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Antonucci E, Leone M. Sepsis phenotypes in the era of individualized medicine. J Crit Care 2024; 83:154848. [PMID: 38901070 DOI: 10.1016/j.jcrc.2024.154848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/24/2024] [Accepted: 06/14/2024] [Indexed: 06/22/2024]
Affiliation(s)
- Elio Antonucci
- Intermediate Care Unit, Emergency Department, Ospedale Guglielmo da Saliceto, Piacenza, Italy.
| | - Marc Leone
- Service d'anesthésie réanimation, hôpital Nord, Assistance Publique Hôpitaux Universitaires de Marseille, Aix Marseille Université, Marseille, France
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2
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Jariyasakoolroj T, Chattipakorn SC, Chattipakorn N. Potential biomarkers used for risk estimation of pediatric sepsis-associated organ dysfunction and immune dysregulation. Pediatr Res 2024:10.1038/s41390-024-03289-y. [PMID: 38834784 DOI: 10.1038/s41390-024-03289-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 04/03/2024] [Accepted: 05/11/2024] [Indexed: 06/06/2024]
Abstract
Pediatric sepsis is a serious issue globally and is a significant cause of illness and death among infants and children. Refractory septic shock and multiple organ dysfunction syndrome are the primary causes of mortality in children with sepsis. However, there is incomplete understanding of mechanistic insight of sepsis associated organ dysfunction. Biomarkers present during the body's response to infection-related inflammation can be used for screening, diagnosis, risk stratification/prognostication, and/or guidance in treatment decision-making. Research on biomarkers in children with sepsis can provide information about the risk of poor outcomes and sepsis-related organ dysfunction. This review focuses on clinically used biomarkers associated with immune dysregulation and organ dysfunction in pediatric sepsis, which could be useful for developing precision medicine strategies in pediatric sepsis management in the future. IMPACT: Sepsis is a complex syndrome with diverse clinical presentations, where organ dysfunction is a key factor in morbidity and mortality. Early detection of organ complications is vital in sepsis management, and potential biomarkers offer promise for precision medicine in pediatric cases. Well-designed studies are needed to identify phase-specific biomarkers and improve outcomes through more precise management.
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Affiliation(s)
- Theerapon Jariyasakoolroj
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Siriporn C Chattipakorn
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Center of Excellence in Cardiac Electrophysiology Research, Chiang Mai University, Chiang Mai, Thailand
- Department of Oral Biology and Diagnostic Sciences, Faculty of Dentistry, Chiang Mai University, Chiang Mai, Thailand
| | - Nipon Chattipakorn
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
- Center of Excellence in Cardiac Electrophysiology Research, Chiang Mai University, Chiang Mai, Thailand.
- Cardiac Electrophysiology Unit, Department of Physiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
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Sankar J, Agarwal S, Goyal A, Kabra SK, Lodha R. Pediatric Sepsis Phenotypes and Outcome: 5-Year Retrospective Cohort Study in a Single Center in India (2017-2022). Pediatr Crit Care Med 2024; 25:e186-e192. [PMID: 38305702 DOI: 10.1097/pcc.0000000000003449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
OBJECTIVES To describe mortality associated with different clinical phenotypes of sepsis in children. DESIGN Retrospective study. SETTING PICU of a tertiary care center in India from 2017 to 2022. PATIENTS Six hundred twelve children (from 2 mo to 17 yr old) with a retrospectively applied diagnosis of sepsis using 2020 guidance. METHODS The main outcome was mortality associated with sepsis subtypes. Other analyses included assessment of risk factors, requirement for organ support, and PICU resources used by sepsis phenotype. Clinical data were recorded on a predesigned proforma. INTERVENTIONS None. MEASUREMENTS AND RESULTS Of the 612 children identified, there were 382 (62%) with sepsis but no multiple organ failure (NoMOF), 48 (8%) with thrombocytopenia-associated MOF (TAMOF), 140 (23%) with MOF without thrombocytopenia, and 40 (6.5%) with sequential MOF (SMOF). Mortality was higher in the SMOF (20/40 [50%]), MOF (62/140 [44%]) and TAMOF (20/48 [42%]) groups, compared with NoMOF group (82/382 [21%] [ p < 0.001]). The requirement for organ support and PICU resources was higher in all phenotypes with MOF as compared with those without MOF. On multivariable analysis elevated lactate and having MOF were associated with greater odds of mortality. CONCLUSIONS In this single-center experience of sepsis in India, we found that sepsis phenotypes having MOF were associated with mortality and the requirement of PICU resources. Prospective studies in different regions of the world will help identify a classification of pediatric sepsis that is more widely applicable.
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Affiliation(s)
- Jhuma Sankar
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
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4
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Atreya MR, Piraino G, Cvijanovich NZ, Fitzgerald JC, Weiss SL, Bigham MT, Jain PN, Schwarz AJ, Lutfi R, Nowak J, Thomas NJ, Baines T, Haileselassie B, Zingarelli B. SERUM HUMANIN IN PEDIATRIC SEPTIC SHOCK-ASSOCIATED MULTIPLE-ORGAN DYSFUNCTION SYNDROME. Shock 2024; 61:83-88. [PMID: 37917869 PMCID: PMC10842252 DOI: 10.1097/shk.0000000000002266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
ABSTRACT Background: Multiple-organ dysfunction syndrome disproportionately contributes to pediatric sepsis morbidity. Humanin (HN) is a small peptide encoded by mitochondrial DNA and thought to exert cytoprotective effects in endothelial cells and platelets. We sought to test the association between serum HN (sHN) concentrations and multiple-organ dysfunction syndrome in a prospectively enrolled cohort of pediatric septic shock. Methods: Human MT-RNR2 ELISA was used to determine sHN concentrations on days 1 and 3. The primary outcome was thrombocytopenia-associated multiorgan failure (TAMOF). Secondary outcomes included individual organ dysfunctions on day 7. Associations across pediatric sepsis biomarker (PERSEVERE)-based mortality risk strata and correlation with platelet and markers of endothelial activation were tested. Results: One hundred forty subjects were included in this cohort, of whom 39 had TAMOF. The concentration of sHN was higher on day 1 relative to day 3 and among those with TAMOF phenotype in comparison to those without. However, the association between sHN and TAMOF phenotype was not significant after adjusting for age and illness severity in multivariate models. In secondary analyses, sHN was associated with presence of day 7 sepsis-associated acute kidney injury ( P = 0.049). Furthermore, sHN was higher among those with high PERSEVERE-mortality risk strata and correlated with platelet counts and several markers of endothelial activation. Conclusion: Future investigation is necessary to validate the association between sHN and sepsis-associated acute kidney injury among children with septic shock. Furthermore, mechanistic studies that elucidate the role of HN may lead to therapies that promote organ recovery through restoration of mitochondrial homeostasis among those critically ill.
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Affiliation(s)
| | - Giovanna Piraino
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, 45229, OH, USA
| | | | | | - Scott L Weiss
- Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | | | - Parag N Jain
- Texas Children's Hospital and Baylor College of Medicine, Houston, TX 77030, USA
| | - Adam J Schwarz
- Children's Hospital of Orange County, Orange, CA 92868, USA
| | - Riad Lutfi
- Riley Hospital for Children, Indianapolis, IN 46202, USA
| | - Jeffrey Nowak
- Children's Hospital and Clinics of Minnesota, Minneapolis, MN 55404, USA
| | - Neal J Thomas
- Penn State Hershey Children's Hospital, Hershey, PA 17033, USA
| | - Torrey Baines
- University of Florida Health Shands Children's Hospital, Gainesville, FL 32610, USA
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5
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Atreya MR, Banerjee S, Lautz AJ, Alder MN, Varisco BM, Wong HR, Muszynski JA, Hall MW, Sanchez-Pinto LN, Kamaleswaran R. Machine learning-driven identification of the gene-expression signature associated with a persistent multiple organ dysfunction trajectory in critical illness. EBioMedicine 2024; 99:104938. [PMID: 38142638 PMCID: PMC10788426 DOI: 10.1016/j.ebiom.2023.104938] [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: 09/20/2023] [Revised: 12/08/2023] [Accepted: 12/12/2023] [Indexed: 12/26/2023] Open
Abstract
BACKGROUND Multiple organ dysfunction syndrome (MODS) disproportionately drives morbidity and mortality among critically ill patients. However, we lack a comprehensive understanding of its pathobiology. Identification of genes associated with a persistent MODS trajectory may shed light on underlying biology and allow for accurate prediction of those at-risk. METHODS Secondary analyses of publicly available gene-expression datasets. Supervised machine learning (ML) was used to identify a parsimonious set of genes associated with a persistent MODS trajectory in a training set of pediatric septic shock. We optimized model parameters and tested risk-prediction capabilities in independent validation and test datasets, respectively. We compared model performance relative to an established gene-set predictive of sepsis mortality. FINDINGS Patients with a persistent MODS trajectory had 568 differentially expressed genes and characterized by a dysregulated innate immune response. Supervised ML identified 111 genes associated with the outcome of interest on repeated cross-validation, with an AUROC of 0.87 (95% CI: 0.85-0.88) in the training set. The optimized model, limited to 20 genes, achieved AUROCs ranging from 0.74 to 0.79 in the validation and test sets to predict those with persistent MODS, regardless of host age and cause of organ dysfunction. Our classifier demonstrated reproducibility in identifying those with persistent MODS in comparison with a published gene-set predictive of sepsis mortality. INTERPRETATION We demonstrate the utility of supervised ML driven identification of the genes associated with persistent MODS. Pending validation in enriched cohorts with a high burden of organ dysfunction, such an approach may inform targeted delivery of interventions among at-risk patients. FUNDING H.R.W.'s NIHR35GM126943 award supported the work detailed in this manuscript. Upon his death, the award was transferred to M.N.A. M.R.A., N.S.P, and R.K were supported by NIHR21GM151703. R.K. was supported by R01GM139967.
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Affiliation(s)
- Mihir R Atreya
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, Cincinnati, 45229, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, 45267, USA.
| | - Shayantan Banerjee
- Department of Biotechnology, Bhupat and Jyoti Mehta School of Biosciences, Indian Institute of Technology Madras, Chennai, 600 036, India
| | - Andrew J Lautz
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, Cincinnati, 45229, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, 45267, USA
| | - Matthew N Alder
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, Cincinnati, 45229, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, 45267, USA
| | - Brian M Varisco
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, Cincinnati, 45229, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, 45267, USA
| | - Hector R Wong
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, Cincinnati, 45229, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, 45267, USA
| | - Jennifer A Muszynski
- Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, 43205, OH, USA; Department of Pediatrics, Ohio State University, Columbus, 43205, OH, USA
| | - Mark W Hall
- Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, 43205, OH, USA; Department of Pediatrics, Ohio State University, Columbus, 43205, OH, USA
| | - L Nelson Sanchez-Pinto
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, 60611, IL, USA; Department of Health and Biomedical Informatics, Northwestern University Feinberg School of Medicine, Chicago, 60611, IL, USA
| | - Rishikesan Kamaleswaran
- Department of Biomedical Informatics, Emory University School of Medicine, Atlanta, 30322, GA, United States; Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, 30322, GA, United States
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6
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Carcillo JA, Shakoory B. Cytokine Storm and Sepsis-Induced Multiple Organ Dysfunction Syndrome. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024; 1448:441-457. [PMID: 39117832 DOI: 10.1007/978-3-031-59815-9_30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/10/2024]
Abstract
There is extensive overlap of clinical features among familial or primary HLH (pHLH), reactive or secondary hemophagocytic lymphohistiocytosis (sHLH) [including macrophage activation syndrome (MAS) related to rheumatic diseases], and hyperferritinemic sepsis-induced multiple organ dysfunction syndrome (MODS); however, the distinctive pathobiology that causes hyperinflammatory process in each condition requires careful considerations for therapeutic decision-making. pHLH is defined by five or more of eight HLH-2004 criteria [1], where genetic impairment of natural killer (NK) cells or CD8+ cytolytic T cells results in interferon gamma (IFN-γ)-induced hyperinflammation regardless of triggering factors. Cytolytic treatments (e.g., etoposide) or anti-IFN-γ monoclonal antibody (emapalumab) has been effectively used to bridge the affected patients to hematopoietic stem cell transplant. Secondary forms of HLH also have normal NK cell number with decreased cytolytic function of varying degrees depending on the underlying and triggering factors. Although etoposide was uniformly used in sHLH/MAS in the past, the treatment strategy in different types of sHLH/MAS is increasingly streamlined to reflect the triggering/predisposing conditions, severity/progression, and comorbidities. Accordingly, in hyperferritinemic sepsis, the combination of hepatobiliary dysfunction (HBD) and disseminated intravascular coagulation (DIC) reflects reticuloendothelial system dysfunction and defines sepsis-associated MAS. It is demonstrated that as the innate immune response to infectious organism prolongs, it results in reduction in T cells and NK cells with subsequent lymphopenia even though normal cytolytic activity continues (Figs. 30.1, 30.2, 30.3, and 30.4). These changes allow free hemoglobin and pathogens to stimulate inflammasome activation in the absence of interferon-γ (IFN-γ) production that often responds to source control, intravenous immunoglobulin (IVIg), plasma exchange, and interleukin 1 receptor antagonist (IL-1Ra), similar to non-EBV, infection-induced HLH.
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Affiliation(s)
- Joseph A Carcillo
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Bita Shakoory
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
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Podd BS, Banks RK, Reeder R, Telford R, Holubkov R, Carcillo J, Berg RA, Wessel D, Pollack MM, Meert K, Hall M, Newth C, Lin JC, Doctor A, Shanley T, Cornell T, Harrison RE, Zuppa AF, Sward K, Dean JM, Randolph AG. Early, Persistent Lymphopenia Is Associated With Prolonged Multiple Organ Failure and Mortality in Septic Children. Crit Care Med 2023; 51:1766-1776. [PMID: 37462434 DOI: 10.1097/ccm.0000000000005993] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2023]
Abstract
OBJECTIVES Sepsis-associated immune suppression correlates with poor outcomes. Adult trials are evaluating immune support therapies. Limited data exist to support consideration of immunomodulation in pediatric sepsis. We tested the hypothesis that early, persistent lymphopenia predicts worse outcomes in pediatric severe sepsis. DESIGN Observational cohort comparing children with severe sepsis and early, persistent lymphopenia (absolute lymphocyte count < 1,000 cells/µL on 2 d between study days 0-5) to children without. The composite outcome was prolonged multiple organ dysfunction syndrome (MODS, organ dysfunction beyond day 7) or PICU mortality. SETTING Nine PICUs in the National Institutes of Health Collaborative Pediatric Critical Care Research Network between 2015 and 2017. PATIENTS Children with severe sepsis and indwelling arterial and/or central venous catheters. INTERVENTIONS Blood sampling and clinical data analysis. MEASUREMENTS AND MAIN RESULTS Among 401 pediatric patients with severe sepsis, 152 (38%) had persistent lymphopenia. These patients were older, had higher illness severity, and were more likely to have underlying comorbidities including solid organ transplant or malignancy. Persistent lymphopenia was associated with the composite outcome prolonged MODS or PICU mortality (66/152, 43% vs 45/249, 18%; p < 0.01) and its components prolonged MODS (59/152 [39%] vs 43/249 [17%]), and PICU mortality (32/152, 21% vs 12/249, 5%; p < 0.01) versus children without. After adjusting for baseline factors at enrollment, the presence of persistent lymphopenia was associated with an odds ratio of 2.98 (95% CI [1.85-4.02]; p < 0.01) for the composite outcome. Lymphocyte count trajectories showed that patients with persistent lymphopenia generally did not recover lymphocyte counts during the study, had lower nadir whole blood tumor necrosis factor-α response to lipopolysaccharide stimulation, and higher maximal inflammatory markers (C-reactive protein and ferritin) during days 0-3 ( p < 0.01). CONCLUSIONS Children with severe sepsis and persistent lymphopenia are at risk of prolonged MODS or PICU mortality. This evidence supports testing therapies for pediatric severe sepsis patients risk-stratified by early, persistent lymphopenia.
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Affiliation(s)
- Bradley S Podd
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Center for Critical Care Nephrology and Clinical Research Investigation and Systems Modeling of Acute Illness Center, University of Pittsburgh, Pittsburgh, PA
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA
| | - Russell K Banks
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Ron Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Russell Telford
- Department of Statistics, Carnegie Mellon University, Pittsburgh, PA
| | - Richard Holubkov
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Joseph Carcillo
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Center for Critical Care Nephrology and Clinical Research Investigation and Systems Modeling of Acute Illness Center, University of Pittsburgh, Pittsburgh, PA
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA
| | - Robert A Berg
- Department of Anesthesiology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - David Wessel
- Division of Critical Care Medicine, Department of Pediatrics, Children's National Hospital, Washington, DC
| | - Murray M Pollack
- Division of Critical Care Medicine, Department of Pediatrics, Children's National Hospital, Washington, DC
| | - Kathleen Meert
- Division of Critical Care Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI
- Department of Pediatrics, Central Michigan University, Mt. Pleasant, MI
| | - Mark Hall
- Division of Critical Care Medicine, Department of Pediatrics, The Research Institute at Nationwide Children's Hospital Immune Surveillance Laboratory, and Nationwide Children's Hospital, Columbus, OH
| | - Christopher Newth
- Division of Pediatric Critical Care Medicine, Department of Anesthesiology and Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA
| | - John C Lin
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children's Hospital, St. Louis, MO
| | - Allan Doctor
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children's Hospital, St. Louis, MO
| | - Tom Shanley
- Division of Critical Care Medicine, Department of Pediatrics, C. S. Mott Children's Hospital, Ann Arbor, MI
| | - Tim Cornell
- Division of Critical Care Medicine, Department of Pediatrics, C. S. Mott Children's Hospital, Ann Arbor, MI
| | - Rick E Harrison
- Division of Critical Care Medicine, Department of Pediatrics, Mattel Children's Hospital at University of California Los Angeles, Los Angeles, CA
| | - Athena F Zuppa
- Department of Anesthesiology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Katherine Sward
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Adrienne G Randolph
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
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Sanchez-Pinto LN, Bennett TD, Stroup EK, Luo Y, Atreya M, Bubeck Wardenburg J, Chong G, Geva A, Faustino EVS, Farris RW, Hall MW, Rogerson C, Shah SS, Weiss SL, Khemani RG. Derivation, Validation, and Clinical Relevance of a Pediatric Sepsis Phenotype With Persistent Hypoxemia, Encephalopathy, and Shock. Pediatr Crit Care Med 2023; 24:795-806. [PMID: 37272946 PMCID: PMC10540758 DOI: 10.1097/pcc.0000000000003292] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
OBJECTIVES Untangling the heterogeneity of sepsis in children and identifying clinically relevant phenotypes could lead to the development of targeted therapies. Our aim was to analyze the organ dysfunction trajectories of children with sepsis-associated multiple organ dysfunction syndrome (MODS) to identify reproducible and clinically relevant sepsis phenotypes and determine if they are associated with heterogeneity of treatment effect (HTE) to common therapies. DESIGN Multicenter observational cohort study. SETTING Thirteen PICUs in the United States. PATIENTS Patients admitted with suspected infections to the PICU between 2012 and 2018. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We used subgraph-augmented nonnegative matrix factorization to identify candidate trajectory-based phenotypes based on the type, severity, and progression of organ dysfunction in the first 72 hours. We analyzed the candidate phenotypes to determine reproducibility as well as prognostic, therapeutic, and biological relevance. Overall, 38,732 children had suspected infection, of which 15,246 (39.4%) had sepsis-associated MODS with an in-hospital mortality of 10.1%. We identified an organ dysfunction trajectory-based phenotype (which we termed persistent hypoxemia, encephalopathy, and shock) that was highly reproducible, had features of systemic inflammation and coagulopathy, and was independently associated with higher mortality. In a propensity score-matched analysis, patients with persistent hypoxemia, encephalopathy, and shock phenotype appeared to have HTE and benefit from adjuvant therapy with hydrocortisone and albumin. When compared with other high-risk clinical syndromes, the persistent hypoxemia, encephalopathy, and shock phenotype only overlapped with 50%-60% of patients with septic shock, moderate-to-severe pediatric acute respiratory distress syndrome, or those in the top tier of organ dysfunction burden, suggesting that it represents a nonsynonymous clinical phenotype of sepsis-associated MODS. CONCLUSIONS We derived and validated the persistent hypoxemia, encephalopathy, and shock phenotype, which is highly reproducible, clinically relevant, and associated with HTE to common adjuvant therapies in children with sepsis.
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Affiliation(s)
- L Nelson Sanchez-Pinto
- Department of Pediatrics, Northwestern University Feinberg School of Medicine and Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Tellen D Bennett
- Departments of Biomedical Informatics and Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Emily K Stroup
- Department of Pharmacology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Yuan Luo
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Mihir Atreya
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | | | - Grace Chong
- Department of Pediatrics, University of Chicago Pritzker School of Medicine, Chicago, IL
| | - Alon Geva
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
- Computational Health Informatics Program, Boston Children's Hospital, Boston, MA
- Department of Anaesthesia, Harvard Medical School, Boston, MA
| | | | - Reid W Farris
- Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, WA
| | - Mark W Hall
- Department of Pediatrics, The Ohio State University and Nationwide Children's Hospital, Columbus, OH
| | - Colin Rogerson
- Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, IN
| | - Sareen S Shah
- Department of Pediatrics, Cohen Children's Medical Center, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY
| | - Scott L Weiss
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Robinder G Khemani
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Los Angeles, Los Angeles, CA
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Miksa M. Beyond Survival: Insights From the Phenotyping Sepsis-Induced Multiple Organ Failure Study on the Neurological Impact of Pediatric Sepsis. Pediatr Crit Care Med 2023; 24:877-880. [PMID: 38412371 DOI: 10.1097/pcc.0000000000003316] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Affiliation(s)
- Michael Miksa
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children's Hospital at Montefiore, Bronx, NY
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10
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Papathanakos G, Andrianopoulos I, Xenikakis M, Papathanasiou A, Koulenti D, Blot S, Koulouras V. Clinical Sepsis Phenotypes in Critically Ill Patients. Microorganisms 2023; 11:2165. [PMID: 37764009 PMCID: PMC10538192 DOI: 10.3390/microorganisms11092165] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 08/10/2023] [Accepted: 08/24/2023] [Indexed: 09/29/2023] Open
Abstract
Sepsis, defined as the life-threatening dysregulated host response to an infection leading to organ dysfunction, is considered as one of the leading causes of mortality worldwide, especially in intensive care units (ICU). Moreover, sepsis remains an enigmatic clinical syndrome, with complex pathophysiology incompletely understood and a great heterogeneity both in terms of clinical expression, patient response to currently available therapeutic interventions and outcomes. This heterogeneity proves to be a major obstacle in our quest to deliver improved treatment in septic critical care patients; thus, identification of clinical phenotypes is absolutely necessary. Although this might be seen as an extremely difficult task, nowadays, artificial intelligence and machine learning techniques can be recruited to quantify similarities between individuals within sepsis population and differentiate them into distinct phenotypes regarding not only temperature, hemodynamics or type of organ dysfunction, but also fluid status/responsiveness, trajectories in ICU and outcome. Hopefully, we will eventually manage to determine both the subgroup of septic patients that will benefit from a therapeutic intervention and the correct timing of applying the intervention during the disease process.
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Affiliation(s)
- Georgios Papathanakos
- Department of Intensive Care Medicine, University Hospital of Ioannina, 45500 Ioannina, Greece; (I.A.); (M.X.); (A.P.); (V.K.)
| | - Ioannis Andrianopoulos
- Department of Intensive Care Medicine, University Hospital of Ioannina, 45500 Ioannina, Greece; (I.A.); (M.X.); (A.P.); (V.K.)
| | - Menelaos Xenikakis
- Department of Intensive Care Medicine, University Hospital of Ioannina, 45500 Ioannina, Greece; (I.A.); (M.X.); (A.P.); (V.K.)
| | - Athanasios Papathanasiou
- Department of Intensive Care Medicine, University Hospital of Ioannina, 45500 Ioannina, Greece; (I.A.); (M.X.); (A.P.); (V.K.)
| | - Despoina Koulenti
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QL 4029, Australia;
- Second Critical Care Department, Attikon University Hospital, Rimini Street, 12462 Athens, Greece
| | - Stijn Blot
- Department of Internal Medicine & Pediatrics, Ghent University, 9000 Ghent, Belgium;
| | - Vasilios Koulouras
- Department of Intensive Care Medicine, University Hospital of Ioannina, 45500 Ioannina, Greece; (I.A.); (M.X.); (A.P.); (V.K.)
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11
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Lefebvre T, Boutten A, Raulet-Bussian C, Raynor A, Manceau H, Puy H, Moulouel B, Schmitt C, Timsit JF, Lefort A, Weiss E, Lescure FX, Ricard JD, Sonneville R, Peoc'h K. Evaluation of iron metabolism in hospitalized COVID-19 patients. Clin Chim Acta 2023; 548:117509. [PMID: 37549821 DOI: 10.1016/j.cca.2023.117509] [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: 05/11/2023] [Revised: 07/25/2023] [Accepted: 08/04/2023] [Indexed: 08/09/2023]
Abstract
BACKGROUND Iron metabolism dysregulation may play a role in organ failure observed in Coronavirus disease 2019 (COVID-19). This study aimed to explore the whole iron metabolism in hospitalized COVID-19 patients and evaluate the impact of tocilizumab. METHODS We performed an observational multicentric cohort study, including patients with PCR-provenCOVID-19 from the intensive care unit (ICU) (n = 66) and medical ward (n = 38). We measured serum interleukin-6 (IL-6), ferritin, glycosylated ferritin (GF), transferrin, iron, and hepcidin. The primary outcome was death. RESULTS Among the 104 patients, we observed decreased median GF percentage (35 %; IQ 23-51.5), low iron concentration (7.5 μmol/L; IQ 4-14), normal but low transferrin saturation (TSAT; 21%; IQ 11-33) and increased median hepcidin concentration (58.7 ng/mL; IQ 20.1-92.1). IL-6, ferritin, and GF were independently and significantly associated with death (p = 0.026, p = 0.023, and p = 0.009, respectively). Surprisingly, we observed a decorrelation between hepcidin and IL-6 concentrations in some patients. These findings were amplified in tocilizumab-treated patients. CONCLUSION Iron metabolism is profoundly modified in COVID-19. The pattern we observed presents differences with a typical inflammation profile. We observed uncoupled IL-6/hepcidin levels in some patients. The benefit of additive iron chelation therapy should be questionable in this setting.
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Affiliation(s)
- Thibaud Lefebvre
- Centre Français des Porphyries, Hôpital Louis Mourier, DMU BIOGEM, APHP, Colombes, France; Université Paris Cité, Centre de Recherche sur l'Inflammation, INSERM, UMR1149, Laboratoire d'Excellence GR-Ex, Paris, France
| | - Anne Boutten
- Service de Biochimie, Hôpital Bichat, DMU BIOGEM, AP-HP, Paris, France
| | | | - Alexandre Raynor
- Service de Biochimie, Hôpital Bichat, DMU BIOGEM, AP-HP, Paris, France
| | - Hana Manceau
- Université Paris Cité, Centre de Recherche sur l'Inflammation, INSERM, UMR1149, Laboratoire d'Excellence GR-Ex, Paris, France; Service de Biochimie, Hôpital Beaujon, DMU BIOGEM AP-HP, Clichy, France
| | - Hervé Puy
- Centre Français des Porphyries, Hôpital Louis Mourier, DMU BIOGEM, APHP, Colombes, France; Université Paris Cité, Centre de Recherche sur l'Inflammation, INSERM, UMR1149, Laboratoire d'Excellence GR-Ex, Paris, France; Service de Biochimie, Hôpital Bichat, DMU BIOGEM, AP-HP, Paris, France
| | - Boualem Moulouel
- Centre Français des Porphyries, Hôpital Louis Mourier, DMU BIOGEM, APHP, Colombes, France
| | - Caroline Schmitt
- Centre Français des Porphyries, Hôpital Louis Mourier, DMU BIOGEM, APHP, Colombes, France; Université Paris Cité, Centre de Recherche sur l'Inflammation, INSERM, UMR1149, Laboratoire d'Excellence GR-Ex, Paris, France
| | - Jean-François Timsit
- Université Paris Cité, Hôpital Bichat, Service de Médecine Intensive Réanimation, DMU INVICTUS, Paris, IAME, UMR1148, INSERM, Paris, France
| | - Agnès Lefort
- Université Paris Cité, APHP, Service de médecine interne, DMU INVICTUS, Hopital Beaujon, IAME, INSERM UMR 1137, INSERM Paris, France
| | - Emmanuel Weiss
- Université Paris Cité, AP-HP, Hôpital Beaujon, DMU PARABOL, Service de Médecine Intensive Réanimation, Clichy, IAME, UMR1137, INSERM, Paris, France
| | - Francois-Xavier Lescure
- Université Paris Cité, AP-HP, Hôpital Bichat, DMU INVICTUS, Service des Maladies Infectieuses, Paris, IAME, UMR1137, INSERM, Paris, France
| | - Jean-Damien Ricard
- Université Paris Cité, AP-HP, Hôpital Louis Mourier, DMU ESPRIT, Service de Médecine Intensive Réanimation, Colombes, IAME, UMR1137, INSERM, Paris, France
| | - Romain Sonneville
- Université Paris Cité, Hôpital Bichat, Service de Médecine Intensive Réanimation, DMU INVICTUS, Paris, IAME, UMR1148, INSERM, Paris, France
| | - Katell Peoc'h
- Université Paris Cité, Centre de Recherche sur l'Inflammation, INSERM, UMR1149, Laboratoire d'Excellence GR-Ex, Paris, France; Service de Biochimie, Hôpital Bichat, DMU BIOGEM, AP-HP, Paris, France; Service de Biochimie, Hôpital Beaujon, DMU BIOGEM AP-HP, Clichy, France.
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12
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Nguyen TC, Marini JC, Guillory B, Valladolid-Brown C, Martinez-Vargas M, Subramanyam D, Cohen D, Cirlos SC, Lam F, Stoll B, Didelija IC, Vonderohe C, Orellana R, Saini A, Pradhan S, Bashir D, Desai MS, Flores S, Virk M, Tcharmtchi H, Navaei A, Kaplan S, Lamberth L, Hulten KG, Scull BP, Allen CE, Akcan-Arikan A, Vijayan KV, Cruz MA. Pediatric Swine Model of Methicillin-Resistant Staphylococcus aureus Sepsis-Induced Coagulopathy, Disseminated Microvascular Thrombosis, and Organ Injuries. Crit Care Explor 2023; 5:e0916. [PMID: 37255626 PMCID: PMC10226618 DOI: 10.1097/cce.0000000000000916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023] Open
Abstract
Sepsis-induced coagulopathy leading to disseminated microvascular thrombosis is associated with high mortality and has no existing therapy. Despite the high prevalence of Gram-positive bacterial sepsis, especially methicillin-resistant Staphylococcus aureus (MRSA), there is a paucity of published Gram-positive pediatric sepsis models. Large animal models replicating sepsis-induced coagulopathy are needed to test new therapeutics before human clinical trials. HYPOTHESIS Our objective is to develop a pediatric sepsis-induced coagulopathy swine model that last 70 hours. METHODS AND MODELS Ten 3 weeks old piglets, implanted with telemetry devices for continuous hemodynamic monitoring, were IV injected with MRSA (n = 6) (USA300, Texas Children's Hospital 1516 strain) at 1 × 109 colony forming units/kg or saline (n = 4). Fluid resuscitation was given for heart rate greater than 50% or mean arterial blood pressure less than 30% from baseline. Acetaminophen and dextrose were provided as indicated. Point-of-care complete blood count, prothrombin time (PT), activated thromboplastin time, d-dimer, fibrinogen, and specialized coagulation assays were performed at pre- and post-injection, at 0, 24, 48, 60, and 70 hours. Piglets were euthanized and necropsies performed. RESULTS Compared with the saline treated piglets (control), the septic piglets within 24 hours had significantly lower neurologic and respiratory scores. Over time, PT, d-dimer, and fibrinogen increased, while platelet counts and activities of factors V, VII, protein C, antithrombin, and a disintegrin and metalloproteinase with thrombospondin-1 motifs (13th member of the family) (ADAMTS-13) decreased significantly in septic piglets compared with control. Histopathologic examination showed minor focal organ injuries including microvascular thrombi and necrosis in the kidney and liver of septic piglets. INTERPRETATIONS AND CONCLUSIONS We established a 70-hour swine model of MRSA sepsis-induced coagulopathy with signs of consumptive coagulopathy, disseminated microvascular thrombosis, and early organ injuries with histological minor focal organ injuries. This model is clinically relevant to pediatric sepsis and can be used to study dysregulated host immune response and coagulopathy to infection, identify potential early biomarkers, and to test new therapeutics.
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Affiliation(s)
- Trung C Nguyen
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, TX
- Center for Translational Research on Inflammatory Diseases at the Michael E. DeBakey Veteran Administration Medical Center, Houston, TX
- Baylor College of Medicine, Division of Thrombosis Research, Department of Medicine, Houston, TX
| | - Juan C Marini
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, TX
- USDA/Agricultural Research Service, Children's Nutrition Research Center, Houston, TX
| | - Bobby Guillory
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, TX
| | - Christian Valladolid-Brown
- Center for Translational Research on Inflammatory Diseases at the Michael E. DeBakey Veteran Administration Medical Center, Houston, TX
- Baylor College of Medicine, Division of Thrombosis Research, Department of Medicine, Houston, TX
| | - Marina Martinez-Vargas
- Center for Translational Research on Inflammatory Diseases at the Michael E. DeBakey Veteran Administration Medical Center, Houston, TX
- Baylor College of Medicine, Division of Thrombosis Research, Department of Medicine, Houston, TX
| | - Deepika Subramanyam
- Center for Translational Research on Inflammatory Diseases at the Michael E. DeBakey Veteran Administration Medical Center, Houston, TX
- Baylor College of Medicine, Division of Thrombosis Research, Department of Medicine, Houston, TX
| | - Daniel Cohen
- Center for Translational Research on Inflammatory Diseases at the Michael E. DeBakey Veteran Administration Medical Center, Houston, TX
- Baylor College of Medicine, Department of Pathology, Houston, TX
| | - Sonya C Cirlos
- Center for Translational Research on Inflammatory Diseases at the Michael E. DeBakey Veteran Administration Medical Center, Houston, TX
- Baylor College of Medicine, Division of Thrombosis Research, Department of Medicine, Houston, TX
| | - Fong Lam
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, TX
- Center for Translational Research on Inflammatory Diseases at the Michael E. DeBakey Veteran Administration Medical Center, Houston, TX
| | - Barbara Stoll
- USDA/Agricultural Research Service, Children's Nutrition Research Center, Houston, TX
| | - Inka C Didelija
- USDA/Agricultural Research Service, Children's Nutrition Research Center, Houston, TX
| | - Caitlin Vonderohe
- USDA/Agricultural Research Service, Children's Nutrition Research Center, Houston, TX
| | - Renan Orellana
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, TX
| | - Arun Saini
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, TX
- Center for Translational Research on Inflammatory Diseases at the Michael E. DeBakey Veteran Administration Medical Center, Houston, TX
| | - Subhashree Pradhan
- Center for Translational Research on Inflammatory Diseases at the Michael E. DeBakey Veteran Administration Medical Center, Houston, TX
- Baylor College of Medicine, Division of Thrombosis Research, Department of Medicine, Houston, TX
| | - Dalia Bashir
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, TX
| | - Moreshwar S Desai
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, TX
| | - Saul Flores
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, TX
| | - Manpreet Virk
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, TX
| | - Hossein Tcharmtchi
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, TX
| | - Amir Navaei
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, TX
| | - Sheldon Kaplan
- Division of Infectious Diseases, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, TX
| | - Linda Lamberth
- Division of Infectious Diseases, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, TX
| | - Kristina G Hulten
- Division of Infectious Diseases, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, TX
| | - Brooks P Scull
- Division of Hematology and Oncology, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, TX
| | - Carl E Allen
- Division of Hematology and Oncology, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, TX
| | - Ayse Akcan-Arikan
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, TX
- Division of Critical Care & Nephrology, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, TX
| | - K Vinod Vijayan
- Center for Translational Research on Inflammatory Diseases at the Michael E. DeBakey Veteran Administration Medical Center, Houston, TX
- Baylor College of Medicine, Division of Thrombosis Research, Department of Medicine, Houston, TX
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Miguel A Cruz
- Center for Translational Research on Inflammatory Diseases at the Michael E. DeBakey Veteran Administration Medical Center, Houston, TX
- Baylor College of Medicine, Division of Thrombosis Research, Department of Medicine, Houston, TX
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
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13
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Valerie IC, Prabandari AASM, Wati DK. Ferritin in pediatric critical illness: a scoping review. Clin Exp Pediatr 2023; 66:98-109. [PMID: 36229027 PMCID: PMC9989723 DOI: 10.3345/cep.2022.00654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 08/17/2022] [Indexed: 11/27/2022] Open
Abstract
This scoping review aimed to elucidate and summarize the predictive role of serum ferritin in critical pediatric illness. The Preferred Reporting Items for Systematic reviews and Meta-Analyses methodology was employed to conduct a scoping review of 5 databases (MEDLINE, CENTRAL, ProQuest, ScienceDirect, and Epistemonikos) from the date of inception through January 24, 2022. Primary research studies involving subjects aged <18 years and serum ferritin levels were screened and reviewed independently following an a priori defined protocol. Of the 1,580 retrieved studies, 66 were analyzed. Summary statistics of serum ferritin levels for overall and condition-specific studies were reported in 30 (45.4%) and 47 studies (71.2%), respectively. The normal range was defined in 16 studies (24.2%), whereas the threshold was determined in 43 studies (65.1%). A value of <500 ng/mL was most often the upper limit of the normal range. Serum ferritin as a numerical variable (78.9%) was usually significantly higher (80.8%) in the predicted condition than in controls, while as a categorical variable with preset thresholds, ferritin was a significant predictor in 84.6% of studies. A total of 22 predictive thresholds predicted mortality (12 of 46 [26.1%]), morbidity (18 of 46 [39.1%]), and specific (16 of 46 [34.8%]) outcomes in 15 unique conditions. Increased precision in serum ferritin measures followed by close attention to the threshold modeling strategy and reporting can accelerate the translation from evidence to clinical practice.
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Affiliation(s)
- Ivy Cerelia Valerie
- Department of Child Health, Faculty of Medicine, Universitas Udayana/Sanglah General Hospital, Bali, Indonesia
| | | | - Dyah Kanya Wati
- Department of Child Health, Faculty of Medicine, Universitas Udayana/Sanglah General Hospital, Bali, Indonesia
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14
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Commentary: ‘Critical illness subclasses: all roads lead to Rome’. Crit Care 2022; 26:387. [PMCID: PMC9749358 DOI: 10.1186/s13054-022-04265-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 12/02/2022] [Indexed: 12/16/2022] Open
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15
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Abstract
The Collaborative Pediatric Critical Care Research Network (CPCCRN) was established by the Eunice Kennedy Shriver National Institute of Child Health and Human Development in May 2005 to develop an infrastructure for collaborative clinical trials and meaningful descriptive studies in pediatric critical care. This article describes the history of CPCCRN, discusses its financial and organizational structure, illustrates how funds were efficiently used to carry out studies, and describes CPCCRN public use datasets and future directions, concluding with the development of the PeRsonalizEd Immunomodulation in PediatriC SepsIS-InducEd MODS study.
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Affiliation(s)
- J Michael Dean
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
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16
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Horvat CM, Fabio A, Nagin DS, Banks RK, Qin Y, Park HJ, Kernan KF, Canna SW, Berg RA, Wessel D, Pollack MM, Meert K, Hall M, Newth C, Lin JC, Doctor A, Shanley T, Cornell T, Harrison RE, Zuppa AF, Reeder RW, Sward K, Holubkov R, Notterman DA, Dean JM, Carcillo JA. Mortality Risk in Pediatric Sepsis Based on C-reactive Protein and Ferritin Levels. Pediatr Crit Care Med 2022; 23:968-979. [PMID: 36178701 PMCID: PMC9722561 DOI: 10.1097/pcc.0000000000003074] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVES Interest in using bedside C-reactive protein (CRP) and ferritin levels to identify patients with hyperinflammatory sepsis who might benefit from anti-inflammatory therapies has piqued with the COVID-19 pandemic experience. Our first objective was to identify patterns in CRP and ferritin trajectory among critically ill pediatric sepsis patients. We then examined the association between these different groups of patients in their inflammatory cytokine responses, systemic inflammation, and mortality risks. DATA SOURCES A prospective, observational cohort study. STUDY SELECTION Children with sepsis and organ failure in nine pediatric intensive care units in the United States. DATA EXTRACTION Two hundred and fifty-five children were enrolled. Five distinct clinical multi-trajectory groups were identified. Plasma CRP (mg/dL), ferritin (ng/mL), and 31 cytokine levels were measured at two timepoints during sepsis (median Day 2 and Day 5). Group-based multi-trajectory models (GBMTM) identified groups of children with distinct patterns of CRP and ferritin. DATA SYNTHESIS Group 1 had normal CRP and ferritin levels ( n = 8; 0% mortality); Group 2 had high CRP levels that became normal, with normal ferritin levels throughout ( n = 80; 5% mortality); Group 3 had high ferritin levels alone ( n = 16; 6% mortality); Group 4 had very high CRP levels, and high ferritin levels ( n = 121; 11% mortality); and Group 5 had very high CRP and very high ferritin levels ( n = 30; 40% mortality). Cytokine responses differed across the five groups, with ferritin levels correlated with macrophage inflammatory protein 1α levels and CRP levels reflective of many cytokines. CONCLUSIONS Bedside CRP and ferritin levels can be used together to distinguish groups of children with sepsis who have different systemic inflammation cytokine responses and mortality risks. These data suggest future potential value in personalized clinical trials with specific targets for anti-inflammatory therapies.
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Affiliation(s)
- Christopher M. Horvat
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Anthony Fabio
- Department of Statistics, Carnegie Mellon University, Pittsburgh, PA
| | - Daniel S. Nagin
- Department of Statistics, Carnegie Mellon University, Pittsburgh, PA
| | | | - Yidi Qin
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Hyun-Jung Park
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Kate F. Kernan
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Scott W. Canna
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA
| | - Robert A. Berg
- Department of Anesthesiology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - David Wessel
- Division of Critical Care Medicine, Department of Pediatrics, Children’s National Hospital, Washington, DC
| | - Murray M. Pollack
- Division of Critical Care Medicine, Department of Pediatrics, Children’s National Hospital, Washington, DC
| | - Kathleen Meert
- Division of Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Michigan, Detroit, MI., Central Michigan University, Mt Pleasant MI
| | - Mark Hall
- Division of Critical Care Medicine, Department of Pediatrics, The Research Institute at Nationwide Children’s Hospital Immune Surveillance Laboratory, and Nationwide Children’s Hospital, Columbus, OH
| | - Christopher Newth
- Division of Pediatric Critical Care Medicine, Department of Anesthesiology and Pediatrics, Children’s Hospital Los Angeles, Los Angeles, CA
| | - John C. Lin
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children’s Hospital, St. Louis, MO
| | - Allan Doctor
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children’s Hospital, St. Louis, MO
| | - Tom Shanley
- Division of Critical Care Medicine, Department of Pediatrics, C. S. Mott Children’s Hospital, Ann Arbor, MI
| | - Tim Cornell
- Division of Critical Care Medicine, Department of Pediatrics, C. S. Mott Children’s Hospital, Ann Arbor, MI
| | - Rick E. Harrison
- Division of Critical Care Medicine, Department of Pediatrics, Mattel Children’s Hospital at University of California Los Angeles, Los Angeles, CA
| | - Athena F. Zuppa
- Department of Anesthesiology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | | | | | | | | | | | - Joseph A. Carcillo
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
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Kassif Lerner R, Levinkopf D, Zaslavsky Paltiel I, Sadeh T, Rubinstein M, Pessach IM, Keller N, Lerner-Geva L, Paret G. Thrombocytopenia and Bloodstream Infection: Incidence and Implication on Length of Stay in the Pediatric Intensive Care Unit. J Pediatr Intensive Care 2022; 11:209-214. [DOI: 10.1055/s-0040-1722338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 11/26/2020] [Indexed: 10/22/2022] Open
Abstract
AbstractThe incidence and prognosis of thrombocytopenia in critically ill patients with bloodstream infection (BSI) is not well delineated in the pediatric intensive care unit (PICU) setting. We assessed these variables in our PICU and sought to determine whether thrombocytopenia could serve as a prognostic marker for length of stay (LOS). The study was conducted at the medical PICU of a university hospital, on all critically ill pediatric patients consecutively admitted during a 3-year period. Patient surveillance and data collection have been used to identify the risk factors during the study period. The main outcomes were BSI incidence and implication on morbidity and LOS. Data from 2,349 PICU patients was analyzed. The overall incidence of BSI was 3.9% (93/2,349). Overall, 85 of 93 patients (91.4%) with BSI survived and 8 patients died (8.6% mortality rate). The overall incidence of thrombocytopenia among these 93 patients was 54.8% (51/93) and 100% (8/8) for the nonsurvivors. Out of the 85 survivors, 27 thrombocytopenic patients were hospitalized for >14 days versus 14 of nonthrombocytopenic patients (p = 0.007). Thrombocytopenia was associated with borderline significance with an increased LOS (adjusted odds ratio = 3.00, 95% confidence interval: 0.93–9.71, p = 0.066). Thrombocytopenia is common in critically ill pediatric patients with BSI and constitutes a simple and readily available risk marker for PICU LOS.
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Affiliation(s)
- Reut Kassif Lerner
- Department of Pediatric Intensive Care, The Edmond and Lily Safra Children's Hospital, The Chaim Sheba Medical Center, Tel Hashomer, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dana Levinkopf
- Neonatal Intensive Care Unit, The Edmond and Lily Safra Children's Hospital, The Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Inna Zaslavsky Paltiel
- Women and Children's Health Research Unit, The Gertner Institute for Epidemiology and Health Policy Research, The Chain Sheba Medical Center, Tel Hashomer, Israel
| | - Tal Sadeh
- Department of Pediatric Intensive Care, The Edmond and Lily Safra Children's Hospital, The Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Marina Rubinstein
- Department of Pediatric Intensive Care, The Edmond and Lily Safra Children's Hospital, The Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Itai M. Pessach
- Department of Pediatric Intensive Care, The Edmond and Lily Safra Children's Hospital, The Chaim Sheba Medical Center, Tel Hashomer, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nathan Keller
- Tel Aviv University, Sheba Medical Center, Tel Hashomer, Israel
- Ariel University, Israel
| | - Liat Lerner-Geva
- Women and Children's Health Research Unit, The Gertner Institute for Epidemiology and Health Policy Research, The Chain Sheba Medical Center, Tel Hashomer, Israel
- School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Israel
| | - Gideon Paret
- Department of Pediatric Intensive Care, The Edmond and Lily Safra Children's Hospital, The Chaim Sheba Medical Center, Tel Hashomer, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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18
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Mohan A, Paranchothy M, Segaran S, Wong RSC, Chor YK, Podin Y, Ooi MH. Fatal Pediatric Melioidosis and the Role of Hyperferritinemic Sepsis-Induced Multiple-Organ Dysfunction Syndrome. Am J Trop Med Hyg 2022; 107:393-396. [PMID: 35895426 PMCID: PMC9393471 DOI: 10.4269/ajtmh.22-0051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 03/23/2022] [Indexed: 08/03/2023] Open
Abstract
Melioidosis is reported to cause a high fatality rate in children, even in the absence of risk factors for disease. The aim of this study was to identify characteristics of fatal pediatric melioidosis infection. We performed a retrospective analysis of children aged < 15 years with culture-confirmed melioidosis admitted to Bintulu Hospital in Sarawak, Malaysian Borneo, from January 2011 to December 2020. Forty-one children had culture-confirmed melioidosis. Nine (22%) had a fatal outcome; 8 (89%) had no predisposing risk factors. Bacteremia, septic shock, and acute respiratory distress syndrome were present in all fatalities. Demographic characteristics, presenting manifestation, and disseminated infection were not significantly associated with mortality, whereas the presence of splenomegaly, cytopenia, disseminated intravascular coagulation, and hepatobiliary dysfunction, all of which are features of hyperferritinemic sepsis-induced multiple-organ dysfunction syndrome, were associated with mortality. Hyperferritinemic sepsis-induced multiple-organ dysfunction syndrome may be a key component in the pathogenesis of fatal pediatric melioidosis.
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Affiliation(s)
- Anand Mohan
- Department of Pediatrics, Bintulu Hospital, Ministry of Health Malaysia, Bintulu, Sarawak, Malaysia
- Institute of Health and Community Medicine, Universiti Malaysia Sarawak, Kota Samarahan, Sarawak, Malaysia
| | - Malini Paranchothy
- Department of Pediatrics, Bintulu Hospital, Ministry of Health Malaysia, Bintulu, Sarawak, Malaysia
| | - Sakthy Segaran
- Department of Pediatrics, Bintulu Hospital, Ministry of Health Malaysia, Bintulu, Sarawak, Malaysia
| | - Richard Siu-Chiu Wong
- Department of Pediatrics, Bintulu Hospital, Ministry of Health Malaysia, Bintulu, Sarawak, Malaysia
| | - Yek-Kee Chor
- Department of Pediatrics, Sarawak General Hospital, Ministry of Health Malaysia, Kuching, Sarawak, Malaysia
| | - Yuwana Podin
- Institute of Health and Community Medicine, Universiti Malaysia Sarawak, Kota Samarahan, Sarawak, Malaysia
| | - Mong-How Ooi
- Institute of Health and Community Medicine, Universiti Malaysia Sarawak, Kota Samarahan, Sarawak, Malaysia
- Department of Pediatrics, Sarawak General Hospital, Ministry of Health Malaysia, Kuching, Sarawak, Malaysia
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19
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Prout A, Meert KL. Research in Pediatric Intensive Care. Pediatr Clin North Am 2022; 69:607-620. [PMID: 35667764 DOI: 10.1016/j.pcl.2022.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Many important clinical questions remain unanswered in the practice of pediatric intensive care due to the lack of high-quality evidence. Although challenges exist in conducting research in pediatric intensive care units, identification of research priorities, interdisciplinary collaborations, innovative trial designs, and the use of common datasets and outcome measures helps to bring new knowledge to our field. The topic of "Research in PICUs" is extremely broad; therefore, this review focuses on a few common themes receiving increased attention in the literature, including research agendas, core outcome sets, precision medicine, and novel clinical trial strategies.
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Affiliation(s)
- Andrew Prout
- Division of Pediatric Critical Care Medicine, Discipline of Pediatrics, Children's Hospital of Michigan, Floor Carls Building, 3901 Beaubien Boulevard, Detroit, MI, 48201, USA; Central Michigan University, Mt. Pleasant, MI, USA.
| | - Kathleen L Meert
- Central Michigan University, Mt. Pleasant, MI, USA; Discipline of Pediatrics, Children's Hospital of Michigan, Detroit, MI, USA; Children's Hospital of Michigan, Suite H-07, 3901 Beaubien Boulevard, Detroit, MI 48201, USA
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20
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Qin Y, Kernan KF, Fan Z, Park HJ, Kim S, Canna SW, Kellum JA, Berg RA, Wessel D, Pollack MM, Meert K, Hall M, Newth C, Lin JC, Doctor A, Shanley T, Cornell T, Harrison RE, Zuppa AF, Banks R, Reeder RW, Holubkov R, Notterman DA, Michael Dean J, Carcillo JA. Machine learning derivation of four computable 24-h pediatric sepsis phenotypes to facilitate enrollment in early personalized anti-inflammatory clinical trials. Crit Care 2022; 26:128. [PMID: 35526000 PMCID: PMC9077858 DOI: 10.1186/s13054-022-03977-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 04/03/2022] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Thrombotic microangiopathy-induced thrombocytopenia-associated multiple organ failure and hyperinflammatory macrophage activation syndrome are important causes of late pediatric sepsis mortality that are often missed or have delayed diagnosis. The National Institutes of General Medical Science sepsis research working group recommendations call for application of new research approaches in extant clinical data sets to improve efficiency of early trials of new sepsis therapies. Our objective is to apply machine learning approaches to derive computable 24-h sepsis phenotypes to facilitate personalized enrollment in early anti-inflammatory trials targeting these conditions. METHODS We applied consensus, k-means clustering analysis to our extant PHENOtyping sepsis-induced Multiple organ failure Study (PHENOMS) dataset of 404 children. 24-hour computable phenotypes are derived using 25 available bedside variables including C-reactive protein and ferritin. RESULTS Four computable phenotypes (PedSep-A, B, C, and D) are derived. Compared to all other phenotypes, PedSep-A patients (n = 135; 2% mortality) were younger and previously healthy, with the lowest C-reactive protein and ferritin levels, the highest lymphocyte and platelet counts, highest heart rate, and lowest creatinine (p < 0.05); PedSep-B patients (n = 102; 12% mortality) were most likely to be intubated and had the lowest Glasgow Coma Scale Score (p < 0.05); PedSep-C patients (n = 110; mortality 10%) had the highest temperature and Glasgow Coma Scale Score, least pulmonary failure, and lowest lymphocyte counts (p < 0.05); and PedSep-D patients (n = 56, 34% mortality) had the highest creatinine and number of organ failures, including renal, hepatic, and hematologic organ failure, with the lowest platelet counts (p < 0.05). PedSep-D had the highest likelihood of developing thrombocytopenia-associated multiple organ failure (Adj OR 47.51 95% CI [18.83-136.83], p < 0.0001) and macrophage activation syndrome (Adj OR 38.63 95% CI [13.26-137.75], p < 0.0001). CONCLUSIONS Four computable phenotypes are derived, with PedSep-D being optimal for enrollment in early personalized anti-inflammatory trials targeting thrombocytopenia-associated multiple organ failure and macrophage activation syndrome in pediatric sepsis. A computer tool for identification of individual patient membership ( www.pedsepsis.pitt.edu ) is provided. Reproducibility will be assessed at completion of two ongoing pediatric sepsis studies.
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Affiliation(s)
- Yidi Qin
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kate F Kernan
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Center for Critical Care Nephrology and Clinical Research Investigation and Systems Modeling of Acute Illness Center, Faculty Pavilion, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Suite 2000, 4400 Penn Avenue, Pittsburgh, PA, 15421, USA
| | - Zhenjiang Fan
- Department of Computer Sciences, University of Pittsburgh, Pittsburgh, PA, USA
| | - Hyun-Jung Park
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Soyeon Kim
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Scott W Canna
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA
| | - John A Kellum
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Center for Critical Care Nephrology and Clinical Research Investigation and Systems Modeling of Acute Illness Center, Faculty Pavilion, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Suite 2000, 4400 Penn Avenue, Pittsburgh, PA, 15421, USA
| | - Robert A Berg
- Department of Anesthesiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - David Wessel
- Division of Critical Care Medicine, Department of Pediatrics, Children's National Hospital, Washington, DC, USA
| | - Murray M Pollack
- Division of Critical Care Medicine, Department of Pediatrics, Children's National Hospital, Washington, DC, USA
| | - Kathleen Meert
- Division of Critical Care Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI, USA
- Central Michigan University, Mt. Pleasant, MI, USA
| | - Mark Hall
- Division of Critical Care Medicine, Department of Pediatrics, The Research Institute at Nationwide Children's Hospital Immune Surveillance Laboratory, and Nationwide Children's Hospital, Columbus, OH, USA
| | - Christopher Newth
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - John C Lin
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children's Hospital, St. Louis, MO, USA
| | - Allan Doctor
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children's Hospital, St. Louis, MO, USA
| | - Tom Shanley
- Division of Critical Care Medicine, Department of Pediatrics, Mattel Children's Hospital at University of California Los Angeles, Los Angeles, CA, USA
| | | | - Rick E Harrison
- Division of Critical Care Medicine, Department of Pediatrics, C. S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Athena F Zuppa
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Russell Banks
- Division of Critical Care Medicine, Department of Pediatrics, Mattel Children's Hospital at University of California Los Angeles, Los Angeles, CA, USA
| | - Ron W Reeder
- Division of Critical Care Medicine, Department of Pediatrics, Mattel Children's Hospital at University of California Los Angeles, Los Angeles, CA, USA
| | - Richard Holubkov
- Division of Critical Care Medicine, Department of Pediatrics, Mattel Children's Hospital at University of California Los Angeles, Los Angeles, CA, USA
| | - Daniel A Notterman
- University of Utah, Salt Lake City, UT, USA
- Princeton University, Princeton, NJ, USA
| | - J Michael Dean
- Division of Critical Care Medicine, Department of Pediatrics, Mattel Children's Hospital at University of California Los Angeles, Los Angeles, CA, USA
| | - Joseph A Carcillo
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Center for Critical Care Nephrology and Clinical Research Investigation and Systems Modeling of Acute Illness Center, Faculty Pavilion, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Suite 2000, 4400 Penn Avenue, Pittsburgh, PA, 15421, USA.
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21
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Kellum JA, Formeck CL, Kernan KF, Gómez H, Carcillo JA. Subtypes and Mimics of Sepsis. Crit Care Clin 2022; 38:195-211. [DOI: 10.1016/j.ccc.2021.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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22
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NASUTION BB, PUDJIADI AH, DEWI R. Profile of pediatric clinical sepsis with immunoparalysis in Cipto Mangunkusumo Hospital, Jakarta. GAZZETTA MEDICA ITALIANA ARCHIVIO PER LE SCIENZE MEDICHE 2022. [DOI: 10.23736/s0393-3660.20.04313-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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23
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Anderko RR, Gómez H, Canna SW, Shakoory B, Angus DC, Yealy DM, Huang DT, Kellum JA, Carcillo JA, Angus DC, Barnato AE, Eaton TL, Gimbel E, Huang DT, Keener C, Kellum JA, Landis K, Pike F, Stapleton DK, Weissfeld LA, Willochell M, Wofford KA, Yealy DM, Kulstad E, Watts H, Venkat A, Hou PC, Massaro A, Parmar S, Limkakeng AT, Brewer K, Delbridge TR, Mainhart A, Chawla LS, Miner JR, Allen TL, Grissom CK, Swadron S, Conrad SA, Carlson R, LoVecchio F, Bajwa EK, Filbin MR, Parry BA, Ellender TJ, Sama AE, Fine J, Nafeei S, Terndrup T, Wojnar M, Pearl RG, Wilber ST, Sinert R, Orban DJ, Wilson JW, Ufberg JW, Albertson T, Panacek EA, Parekh S, Gunn SR, Rittenberger JS, Wadas RJ, yEdwards AR, Kelly M, Wang HE, Holmes TM, McCurdy MT, Weinert C, Harris ES, Self WH, Phillips CA, Migues RM. Sepsis with liver dysfunction and coagulopathy predicts an inflammatory pattern of macrophage activation. Intensive Care Med Exp 2022; 10:6. [PMID: 35190900 PMCID: PMC8861227 DOI: 10.1186/s40635-022-00433-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 02/07/2022] [Indexed: 12/30/2022] Open
Abstract
Background Interleukin-1 receptor antagonists can reduce mortality in septic shock patients with hepatobiliary dysfunction and disseminated intravascular coagulation (HBD + DIC), an organ failure pattern with inflammatory features consistent with macrophage activation. Identification of clinical phenotypes in sepsis may allow for improved care. We aim to describe the occurrence of HBD + DIC in a contemporary cohort of patients with sepsis and determine the association of this phenotype with known macrophage activation syndrome (MAS) biomarkers and mortality. We performed a retrospective nested case–control study in adult septic shock patients with concurrent HBD + DIC and an equal number of age-matched controls, with comparative analyses of all-cause mortality and circulating biomarkers between the groups. Multiple logistic regression explored the effect of HBD + DIC on mortality and the discriminatory power of the measured biomarkers for HBD + DIC and mortality. Results Six percent of septic shock patients (n = 82/1341) had HBD + DIC, which was an independent risk factor for 90-day mortality (OR = 3.1, 95% CI 1.4–7.5, p = 0.008). Relative to sepsis controls, the HBD + DIC cohort had increased levels of 21 of the 26 biomarkers related to macrophage activation (p < 0.05). This panel was predictive of both HBD + DIC (sensitivity = 82%, specificity = 84%) and mortality (sensitivity = 92%, specificity = 90%). Conclusion The HBD + DIC phenotype identified patients with high mortality and a molecular signature resembling that of MAS. These observations suggest trials of MAS-directed therapies are warranted. Supplementary Information The online version contains supplementary material available at 10.1186/s40635-022-00433-y.
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O’Reilly D, Murphy CA, Drew R, El-Khuffash A, Maguire PB, Ainle FN, Mc Callion N. Platelets in pediatric and neonatal sepsis: novel mediators of the inflammatory cascade. Pediatr Res 2022; 91:359-367. [PMID: 34711945 PMCID: PMC8816726 DOI: 10.1038/s41390-021-01715-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 07/14/2021] [Accepted: 08/16/2021] [Indexed: 02/07/2023]
Abstract
Sepsis, a dysregulated host response to infection, has been difficult to accurately define in children. Despite a higher incidence, especially in neonates, a non-specific clinical presentation alongside a lack of verified biomarkers has prevented a common understanding of this condition. Platelets, traditionally regarded as mediators of haemostasis and thrombosis, are increasingly associated with functions in the immune system with involvement across the spectrum of innate and adaptive immunity. The large number of circulating platelets (approx. 150,000 cells per microlitre) mean they outnumber traditional immune cells and are often the first to encounter a pathogen at a site of injury. There are also well-described physiological differences between platelets in children and adults. The purpose of this review is to place into context the platelet and its role in immunology and examine the evidence where available for its role as an immune cell in childhood sepsis. It will examine how the platelet interacts with both humoral and cellular components of the immune system and finally discuss the role the platelet proteome, releasate and extracellular vesicles may play in childhood sepsis. This review also examines how platelet transfusions may interfere with the complex relationships between immune cells in infection. IMPACT: Platelets are increasingly being recognised as important "first responders" to immune threats. Differences in adult and paediatric platelets may contribute to differing immune response to infections. Adult platelet transfusions may affect infant immune responses to inflammatory/infectious stimuli.
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Affiliation(s)
- Daniel O’Reilly
- grid.416068.d0000 0004 0617 7587Department of Neonatology, Rotunda Hospital, Dublin, Ireland ,grid.7886.10000 0001 0768 2743Conway-SPHERE Research Group, Conway Institute, University College Dublin, Dublin, Ireland
| | - Claire A. Murphy
- grid.416068.d0000 0004 0617 7587Department of Neonatology, Rotunda Hospital, Dublin, Ireland ,grid.7886.10000 0001 0768 2743Conway-SPHERE Research Group, Conway Institute, University College Dublin, Dublin, Ireland ,grid.4912.e0000 0004 0488 7120Department of Paediatrics, Royal College of Surgeons in Ireland, Dubin, Ireland
| | - Richard Drew
- grid.416068.d0000 0004 0617 7587Clinical Innovation Unit, Rotunda Hospital, Dublin, Ireland ,Irish Meningitis and Sepsis Reference Laboratory, Children’s Health Ireland at Temple Street, Dublin, Ireland ,grid.4912.e0000 0004 0488 7120Department of Clinical Microbiology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Afif El-Khuffash
- grid.416068.d0000 0004 0617 7587Department of Neonatology, Rotunda Hospital, Dublin, Ireland ,grid.4912.e0000 0004 0488 7120Department of Paediatrics, Royal College of Surgeons in Ireland, Dubin, Ireland
| | - Patricia B. Maguire
- grid.7886.10000 0001 0768 2743Conway-SPHERE Research Group, Conway Institute, University College Dublin, Dublin, Ireland ,grid.7886.10000 0001 0768 2743School of Biomolecular & Biomedical Science, University College Dublin, Dublin, Ireland
| | - Fionnuala Ni Ainle
- grid.7886.10000 0001 0768 2743Conway-SPHERE Research Group, Conway Institute, University College Dublin, Dublin, Ireland ,grid.7886.10000 0001 0768 2743School of Biomolecular & Biomedical Science, University College Dublin, Dublin, Ireland ,grid.411596.e0000 0004 0488 8430Department of Haematology, Mater Misericordiae University Hospital, Dublin, Ireland ,grid.416068.d0000 0004 0617 7587Department of Haematology, Rotunda Hospital, Dublin, Ireland ,grid.7886.10000 0001 0768 2743School of Medicine, University College Dublin, Dublin, Ireland
| | - Naomi Mc Callion
- grid.416068.d0000 0004 0617 7587Department of Neonatology, Rotunda Hospital, Dublin, Ireland ,grid.4912.e0000 0004 0488 7120Department of Paediatrics, Royal College of Surgeons in Ireland, Dubin, Ireland
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Shald EA, Erdman MJ, Ferreira JA. Impact of Clinical Sepsis Phenotypes on Mortality and Fluid Status in Critically Ill Patients. Shock 2022; 57:57-62. [PMID: 34559746 DOI: 10.1097/shk.0000000000001864] [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: 11/26/2022]
Abstract
BACKGROUND Sepsis is associated with high rates of in-hospital mortality, despite being the focus of medical research and public health initiatives for several years. The primary objective of this study was to determine the influence of septic phenotypes on rates of in-hospital mortality throughout intensive care unit (ICU) admission. PATIENTS AND METHODS Retrospective, single-center cohort study. Medical ICU of an academic medical center. Medical ICU patients admitted between January 2016 and August 2019 with a "sepsis alert" were screened for admitting diagnosis of "sepsis" or "septic shock." Patients were classified into one of four clinical sepsis phenotypes: multi-organ failure (MOF), respiratory dysfunction (RD), neurologic dysfunction (ND), or other patients (OP). RESULTS An analysis of 320 patients was completed. In-hospital mortality was different between groups (P < 0.001). Patients with the MOF phenotype had the highest rate of mortality (48.4%), followed by the ND phenotype (39.7%), RD phenotype (20.8%), and OP phenotype (13.7%). There were differences in volume balances between phenotypes at 48 h (P = 0.001), 72 h (P < 0.001), and 96 h (P < 0.001) after hospital presentation, with the MOF and ND phenotypes having the largest volume balances at these time points. Ventilator-free days (P < 0.001) and ICU length of stay (LOS) (P = 0.030) were different between groups. There was no difference in hospital LOS (P = 0.479). CONCLUSIONS This data supports the presence of marked intra-disease differences in septic patient presentation and correlation with clinical outcomes including mortality. Additionally, significantly more positive fluid balances were observed between survivors and non-survivors in some patient subsets. Using pragmatic clinical variables readily available to providers to classify patients into septic phenotypes has the propensity to guide treatment strategies in the future.
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Weiss SL, Carcillo JA, Leclerc F, Leteurtre S, Schlapbach LJ, Tissieres P, Wynn JL, Lacroix J. Refining the Pediatric Multiple Organ Dysfunction Syndrome. Pediatrics 2022; 149:S13-S22. [PMID: 34970671 PMCID: PMC9084565 DOI: 10.1542/peds.2021-052888c] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/24/2021] [Indexed: 01/05/2023] Open
Abstract
Since its introduction into the medical literature in the 1970s, the term multiple organ dysfunction syndrome (or some variant) has been applied broadly to any patient with >1 concurrent organ dysfunction. However, the epidemiology, mechanisms, time course, and outcomes among children with multiple organ dysfunction vary substantially. We posit that the term pediatric multiple organ dysfunction syndrome (or MODS) should be reserved for patients with a systemic pathologic state resulting from a common mechanism (or mechanisms) that affects numerous organ systems simultaneously. In contrast, children in whom organ injuries are attributable to distinct mechanisms should be considered to have additive organ system dysfunctions but not the syndrome of MODS. Although such differentiation may not always be possible with current scientific knowledge, we make the case for how attempts to differentiate multiple organ dysfunction from other states of additive organ dysfunctions can help to evolve clinical and research priorities in diagnosis, monitoring, and therapy from largely organ-specific to more holistic strategies.
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Affiliation(s)
- Scott L. Weiss
- Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Pennsylvania
| | | | - Francis Leclerc
- University of Lille, Centre Hospitalier Universitaire de Lille, ULR 2694–METRICS: Évaluation des technologies de santé et des pratiques médicales, Lille, France
| | - Stephane Leteurtre
- University of Lille, Centre Hospitalier Universitaire de Lille, ULR 2694–METRICS: Évaluation des technologies de santé et des pratiques médicales, Lille, France
| | - Luregn J. Schlapbach
- Paediatric ICU, Queensland Children ’s Hospital, Brisbane, Queensland, Australia,Pediatric and Neonatal Intensive Care Unit, Children’s Research Center, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Pierre Tissieres
- Pediatric Intensive Care, Assistance Publique–Hôpitaux de Paris–Saclay University, Le Kremlin-Bicêtre, France
| | - James L. Wynn
- Department of Pediatrics, University of Florida, Gainesville, Florida,Department of Pathology, Immunology, and Laboratory Medicine, University of Florida, Gainesville, Florida
| | - Jacques Lacroix
- Division of Pediatric Critical Care Medicine, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada
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A specialized multi-disciplinary care program for children with sepsis and multiple organ dysfunction-associated immune dysregulation. Pediatr Res 2022; 91:464-469. [PMID: 35022559 PMCID: PMC8754067 DOI: 10.1038/s41390-021-01891-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 09/10/2021] [Accepted: 11/29/2021] [Indexed: 02/06/2023]
Abstract
The complex physiology and medical requirements of children with sepsis and multiple organ dysfunction syndrome (MODS) challenge traditional care coordination models. While the involvement of multiple clinical subspecialty services is often necessary to support different care processes and individual organ system dysfunctions, it can also delay the diagnostic process, monitoring, and treatment. The logistics of coordinating with many specialty providers for critically ill patients are challenging and time consuming, and often can result in fragmented communication. To address these and other related issues, we developed a new multi-disciplinary consult service focused on streamlining diagnostics, management, and communication for patients with sepsis and MODS-associated immune dysregulation. The service, called the Program in Inflammation, Immunity, and the Microbiome (PrIIMe), is now a hospital-wide clinical consult service at our institution caring for a broad group of patients with immune dysregulation, particularly focusing on patients with sepsis and MODS. In this paper, we summarize the development, structure, and function of the program, as well as the initial impact. This information may be helpful to clinicians and healthcare leaders who are developing multi-disciplinary consult services for children with complex care needs, especially those with sepsis and MODS-associated immune dysregulation. IMPACT: The care of children with sepsis and multiple organ dysfunction-associated immune dysregulation requires rapid and flexible involvement of multiple clinical subspecialists that is difficult to achieve without fragmented care and delayed decision making. In this narrative review we describe the development, structure, and function of a multi-disciplinary consult service at a children's hospital dedicated to helping coordinate management and provide continuity of care for patients with sepsis and multiple organ dysfunction-associated immune dysregulation. This information may be helpful to clinicians and healthcare leaders who are developing multi-disciplinary consult services for children with complex care needs, especially those with sepsis and MODS-associated immune dysregulation.
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28
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Bembea MM, Agus M, Akcan-Arikan A, Alexander P, Basu R, Bennett TD, Bohn D, Brandão LR, Brown AM, Carcillo JA, Checchia P, Cholette J, Cheifetz IM, Cornell T, Doctor A, Eckerle M, Erickson S, Farris RW, Faustino EVS, Fitzgerald JC, Fuhrman DY, Giuliano JS, Guilliams K, Gaies M, Gorga SM, Hall M, Hanson SJ, Hartman M, Hassinger AB, Irving SY, Jeffries H, Jouvet P, Kannan S, Karam O, Khemani RG, Niranjan K, Lacroix J, Laussen P, Leclerc F, Lee JH, Leteurtre S, Lobner K, McKiernan PJ, Menon K, Monagle P, Muszynski JA, Odetola F, Parker R, Pathan N, Pierce RW, Pineda J, Prince JM, Robinson KA, Rowan CM, Ryerson LM, Sanchez-Pinto LN, Schlapbach LJ, Selewski DT, Shekerdemian LS, Simon D, Smith LS, Squires JE, Squires RH, Sutherland SM, Ouellette Y, Spaeder MC, Srinivasan V, Steiner ME, Tasker RC, Thiagarajan R, Thomas N, Tissieres P, Traube C, Tucci M, Typpo KV, Wainwright MS, Ward SL, Watson RS, Weiss S, Whitney J, Willson D, Wynn JL, Yeyha N, Zimmerman JJ. Pediatric Organ Dysfunction Information Update Mandate (PODIUM) Contemporary Organ Dysfunction Criteria: Executive Summary. Pediatrics 2022; 149:S1-S12. [PMID: 34970673 PMCID: PMC9599725 DOI: 10.1542/peds.2021-052888b] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/24/2021] [Indexed: 01/20/2023] Open
Abstract
Prior criteria for organ dysfunction in critically ill children were based mainly on expert opinion. We convened the Pediatric Organ Dysfunction Information Update Mandate (PODIUM) expert panel to summarize data characterizing single and multiple organ dysfunction and to derive contemporary criteria for pediatric organ dysfunction. The panel was composed of 88 members representing 47 institutions and 7 countries. We conducted systematic reviews of the literature to derive evidence-based criteria for single organ dysfunction for neurologic, cardiovascular, respiratory, gastrointestinal, acute liver, renal, hematologic, coagulation, endocrine, endothelial, and immune system dysfunction. We searched PubMed and Embase from January 1992 to January 2020. Study identification was accomplished using a combination of medical subject headings terms and keywords related to concepts of pediatric organ dysfunction. Electronic searches were performed by medical librarians. Studies were eligible for inclusion if the authors reported original data collected in critically ill children; evaluated performance characteristics of scoring tools or clinical assessments for organ dysfunction; and assessed a patient-centered, clinically meaningful outcome. Data were abstracted from each included study into an electronic data extraction form. Risk of bias was assessed using the Quality in Prognosis Studies tool. Consensus was achieved for a final set of 43 criteria for pediatric organ dysfunction through iterative voting and discussion. Although the PODIUM criteria for organ dysfunction were limited by available evidence and will require validation, they provide a contemporary foundation for researchers to identify and study single and multiple organ dysfunction in critically ill children.
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Affiliation(s)
- Melania M. Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Michael Agus
- Division of Medical Critical Care, Boston Children’s Hospital, Harvard Medical School, Boston Children’s Hospital, Boston, MA
| | - Ayse Akcan-Arikan
- Department of Pediatrics, Sections of Critical Care and Nephrology, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX
| | - Peta Alexander
- Department of Cardiology, Boston Children’s Hospital and Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Rajit Basu
- Division of Pediatric Critical Care, Children’s Healthcare of Atlanta, Emory University, Atlanta, GA
| | - Tellen D. Bennett
- Sections of Informatics and Data Science and Critical Care Medicine, Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO
| | - Desmond Bohn
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto
| | - Leonardo R. Brandão
- Division of Hematology-Oncology, Department of Paediatrics, University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada
| | - Ann-Marie Brown
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA
| | - Joseph A. Carcillo
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA
| | - Paul Checchia
- Section of Critical Care Medicine, Department of Pediatrics, Texas Children’s Hospital and Baylor College of Medicine, Houston, TX
| | - Jill Cholette
- Department of Pediatrics, University of Rochester Golisano Children’s Hospital, Rochester, NY
| | - Ira M. Cheifetz
- Department of Pediatrics, Rainbow Babies and Children’s Hospital, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Timothy Cornell
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Stanford University School of Medicine, Lucile Packard Children’s Hospital Stanford, Palo Alto, CA
| | - Allan Doctor
- University of Maryland School of Medicine, Center for Blood Oxygen Transport and Hemostasis
| | - Michelle Eckerle
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati OH USA and Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati OH
| | - Simon Erickson
- Department of Paediatric Critical Care; Perth Children’s Hospital and University of Western Australia; Perth, Western Australia, Australia
| | - Reid W.D. Farris
- Department of Pediatrics, University of Washington and Seattle Children’s Hospital; Seattle, WA
| | - E. Vincent S. Faustino
- Department of Pediatrics, Section of Pediatric Critical Care Medicine, Yale School of Medicine, New Haven CT
| | - Julie C. Fitzgerald
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine and Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Dana Y. Fuhrman
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA
| | - John S. Giuliano
- Section of Pediatric Critical Care Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Kristin Guilliams
- Department of Neurology, Division of Pediatric and Development Neurology, Department of Pediatrics, Division of Pediatric Critical Care Medicine, Washington University School of Medicine, St. Louis, MI
| | - Michael Gaies
- Department of Pediatrics, University of Michigan, Ann Arbor, MI
| | | | - Mark Hall
- Division of Critical Care Medicine, Department of Pediatrics, The Ohio State University College of Medicine, Nationwide Children’s Hospital, Columbus, OH
| | - Sheila J. Hanson
- Department of Pediatrics, Critical Care Section, Medical College of Wisconsin/Children’s Wisconsin, Milwaukee, WI
| | - Mary Hartman
- Department of Pediatrics, Washington University, St. Louis, MO
| | - Amanda B. Hassinger
- Department of Pediatrics, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, John R. Oishei Children’s Hospital, Buffalo, NY
| | - Sharon Y. Irving
- Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, PA
| | - Howard Jeffries
- Department of Pediatrics, University of Washington School of Medicine, Seattle WA
| | - Philippe Jouvet
- Department of Paediatrics; Sainte-Justine Hospital and University of Montreal; Montreal, Québec, Canada
| | - Sujatha Kannan
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Oliver Karam
- Division of Pediatric Critical Care Medicine, Children’s Hospital of Richmond at VCU, Richmond, VA
| | - Robinder G. Khemani
- Department of Anesthesiology and Critical Care Medicine; Children’s Hospital Los Angeles and University of Southern California Keck School of Medicine; Los Angeles, CA
| | - Kissoon Niranjan
- Division of Critical Care, Department of Pediatrics, University of British Columbia and BC Children’s Hospital
| | - Jacques Lacroix
- Division of Pediatric Critical Care Medicine, Centre Hospitalier Universitaire de Sainte-Justine, Université de Montreal, Canada
| | - Peter Laussen
- Department of Cardiology, Boston Children’s Hospital and Department of Anesthesia, Harvard Medical School, Boston, MA
| | - Francis Leclerc
- Univ. Lille, CHU Lille, ULR 2694 - METRICS : Évaluation des technologies de santé et des pratiques médicales, F-59000 Lille, France
| | - Jan Hau Lee
- Children’s Intensive Care Unit, KK Women’s and Children’s Hospital, and, Duke-NUS Medical School, Singapore
| | - Stephane Leteurtre
- Univ. Lille, CHU Lille, ULR 2694 - METRICS : Évaluation des technologies de santé et des pratiques médicales, F-59000 Lille, France
| | - Katie Lobner
- Welch Medical Library, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Patrick J. McKiernan
- Division of Gastroenterology, Hepatology, and Nutrition, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Kusum Menon
- Division of Pediatric Critical Care, Department of Pediatrics, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
| | - Paul Monagle
- Department of Clinical Haematology, Royal Children’s Hospital, Victoria, Australia, and Haematology Research, Murdoch Children’s Research Institute, Victoria, Australia
| | - Jennifer A. Muszynski
- Division of Critical Care Medicine, Department of Pediatrics, The Ohio State University College of Medicine, Nationwide Children’s Hospital, Columbus, OH
| | | | - Robert Parker
- Department of Pediatrics (Emeritus), Hematology/Oncology, Stony Brook University Renaissance School of Medicine, Stony Brook, NY
| | - Nazima Pathan
- Department of Paediatrics, University of Cambridge; Clinical Research Associate, Kings College, Cambridge, UK
| | - Richard W. Pierce
- Section of Pediatric Critical Care Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Jose Pineda
- Department of Anesthesiology and Critical Care Medicine; Children’s Hospital Los Angeles and University of Southern California Keck School of Medicine; Los Angeles, CA
| | - Jose M. Prince
- Department of Surgery and Pediatrics, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Karen A. Robinson
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Courtney M. Rowan
- Department of Pediatrics, Division of Pediatric Critical Care; Indiana University School of Medicine and Riley Hospital for Children; Indianapolis, IN
| | | | - L. Nelson Sanchez-Pinto
- Departments of Pediatrics (Critical Care) and Preventive Medicine (Health & Biomedical Informatics), Northwestern University Feinberg School of Medicine and Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
| | - Luregn J Schlapbach
- Pediatric and Neonatal Intensive Care Unit, Children`s Research Center, University Children`s Hospital Zurich, Zurich, Switzerland
| | - David T. Selewski
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Lara S. Shekerdemian
- Section of Critical Care Medicine, Department of Pediatrics, Texas Children’s Hospital and Baylor College of Medicine, Houston, TX
| | - Dennis Simon
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA
| | - Lincoln S. Smith
- Department of Pediatrics, University of Washington and Seattle Children’s Hospital; Seattle, WA
| | - James E. Squires
- Division of Gastroenterology, Hepatology, and Nutrition, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Robert H. Squires
- Division of Gastroenterology, Hepatology, and Nutrition, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Scott M. Sutherland
- Department of Pediatrics, Division of Nephrology, Stanford University School of Medicine, Stanford, CA
| | - Yves Ouellette
- Division of Critical Care Medicine, Department of Pediatrics, Mayo Clinic, Rochester, MN
| | | | - Vijay Srinivasan
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine and Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Marie E. Steiner
- Department of Pediatrics, Critical Care Medicine & Hematology, University of Minnesota, Minneapolis, MN
| | - Robert C. Tasker
- Department of Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston MA
| | - Ravi Thiagarajan
- Department of Cardiology, Boston Children’s Hospital and Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Neal Thomas
- Department of Pediatrics and Public Health Science, Division of Pediatric Critical Care Medicine; Penn State Hershey Children’s Hospital; Hershey, PA
| | - Pierre Tissieres
- Pediatric Intensive Care, AP-HP Paris Saclay University, Le Kremlin-Bicêtre, France
| | - Chani Traube
- Department of Pediatrics, Division of Critical Care Medicine, Weill Cornell Medical College, NY
| | - Marisa Tucci
- Division of Pediatric Critical Care Medicine, Centre Hospitalier Universitaire de Sainte-Justine, Université de Montreal, Canada
| | - Katri V. Typpo
- Department of Pediatrics and the Steele Children’s Research Center, University of Arizona College of Medicine, Tucson, AZ
| | - Mark S. Wainwright
- Department of Neurology, Division of Pediatric Neurology, University of Washington, Seattle, WA
| | - Shan L. Ward
- Department of Pediatrics, Division of Critical Care, UCSF Benioff Children’s Hospitals, San Francisco and Oakland, CA
| | - R. Scott Watson
- Department of Pediatrics, University of Washington and Seattle Children’s Hospital; Seattle, WA
| | - Scott Weiss
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine and Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Jane Whitney
- Division of Medical Critical Care, Boston Children’s Hospital, Harvard Medical School, Boston Children’s Hospital, Boston, MA
| | - Doug Willson
- Division of Pediatric Critical Care Medicine, Children’s Hospital of Richmond at VCU, Richmond, VA
| | - James L. Wynn
- Department of Pediatrics and Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, Florida
| | - Nadir Yeyha
- Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine and Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Jerry J. Zimmerman
- Department of Pediatrics, Seattle Children’s Hospital, Seattle Children’s Research Institute, University of Washington School of Medicine, Seattle, WA
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Zhang Y, Cheng J, Su Y, Li M, Wen J, Li S. Cordycepin induces M1/M2 macrophage polarization to attenuate the liver and lung damage and immunodeficiency in immature mice with sepsis via NF-κB/p65 inhibition. J Pharm Pharmacol 2021; 74:227-235. [PMID: 34850068 DOI: 10.1093/jpp/rgab162] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Accepted: 10/29/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVES To explore the impacts of cordycepin and underlying mechanism on the sepsis. METHODS The sepsis mice model was built and treated with different concentrations of cordycepin. Then the liver and lung injury caused by cecal ligation and puncture (CLP) was assessed using H&E staining and TUNEL assay. The expression of relevant genes was detected using qRT-PCR analysis and ELISA assays. Besides, the macrophage polarization was checked by flow cytometry. KEY FINDINGS Cordycepin could significantly improve the liver and lung injury. Moreover, cordycepin increased the distribution of F4/80+ CD206+ M2-like macrophages and F4/80+ iNOS+ M1-like macrophages through down-regulating the expression of relevant genes. More importantly, cordycepin could monitor the protein expression of iNOS, Arg-1, TNF-α, MCP-1, IL-4 and IL-10 in CLP mice. Meanwhile, the elevated level of p65 induced by CLP was also repressed by the increase of the cordycepin. Moreover, cordycepin played a crucial part in CLP mice through modulating the NF-κB/p65 signalling pathway. CONCLUSIONS Cordycepin played an important role in mice with sepsis via reducing the M1/M2 macrophage polarization and modulating the NF-κB/p65 signalling pathway.
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Affiliation(s)
- Yudan Zhang
- Department of Emergency, Xi'an Children's Hospital, Xi'an, Shaanxi, P.R. China
| | - Jing Cheng
- Department of Emergency, Xi'an Children's Hospital, Xi'an, Shaanxi, P.R. China
| | - Yufei Su
- Department of Emergency, Xi'an Children's Hospital, Xi'an, Shaanxi, P.R. China
| | - Mingyue Li
- Department of Emergency, Xi'an Children's Hospital, Xi'an, Shaanxi, P.R. China
| | - Jun Wen
- Department of Emergency, Xi'an Children's Hospital, Xi'an, Shaanxi, P.R. China
| | - Sixiu Li
- Neonatal Intensive Care Unit, Xi'an Children's Hospital, Xi'an, Shaanxi, P.R. China
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Snyder A, Jedreski K, Fitch J, Wijeratne S, Wetzel A, Hensley J, Flowers M, Bline K, Hall MW, Muszynski JA. Transcriptomic Profiles in Children With Septic Shock With or Without Immunoparalysis. Front Immunol 2021; 12:733834. [PMID: 34659221 PMCID: PMC8517409 DOI: 10.3389/fimmu.2021.733834] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 09/14/2021] [Indexed: 12/29/2022] Open
Abstract
Background Severe innate immune suppression, termed immunoparalysis, is associated with increased risks of nosocomial infection and mortality in children with septic shock. Currently, immunoparalysis cannot be clinically diagnosed in children, and mechanisms remain unclear. Transcriptomic studies identify subsets of septic children with downregulation of genes within adaptive immune pathways, but assays of immune function have not been performed as part of these studies, and little is known about transcriptomic profiles of children with immunoparalysis. Methods We performed a nested case-control study to identify differences in RNA expression patterns between children with septic shock with immunoparalysis (defined as lipopolysaccharide (LPS)-induced tumor necrosis factor (TNF)α response < 200 pg/ml) vs those with normal LPS-induced TNFα response. Children were enrolled within 48 hours of the onset of septic shock and divided into two groups based on LPS-induced TNFα response. RNA was extracted from whole blood for RNAseq, differential expression analyses using DESeq2 software, and pathway analyses using Ingenuity Pathway Analysis. Results 32 children were included in analyses. Comparing those with immunoparalysis (n =19) to those with normal TNFα response (n = 13), 2,303 transcripts were differentially expressed with absolute value fold change ≥ 1.5 and false discovery rate ≤ 0.05. The majority of downregulated pathways in children with immunoparalysis were pathways that involved interactions between innate and adaptive immune cells necessary for cell-mediated immunity, crosstalk between dendritic cells and natural killer cells, and natural killer cell signaling pathways. Upregulated pathways included those involved in humoral immunity (T helper cell type 2), corticotropin signaling, platelet activation (GP6 signaling), and leukocyte migration and extravasation. Conclusions Our study suggests that gene expression data might be useful to identify children with immunoparalysis and identifies several key differentially regulated pathways involved in both innate and adaptive immunity. Our ongoing work in this area aims to dissect interactions between innate and adaptive immunity in septic children and to more fully elucidate patient-specific immunologic pathophysiology to guide individualized immunotherapeutic targets.
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Affiliation(s)
- Andrew Snyder
- Center for Clinical and Translational Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, United States
| | - Kathleen Jedreski
- Center for Clinical and Translational Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, United States
| | - James Fitch
- Institute for Genomic Medicine, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, United States
| | - Saranga Wijeratne
- Institute for Genomic Medicine, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, United States
| | - Amy Wetzel
- Institute for Genomic Medicine, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, United States
| | - Josey Hensley
- Center for Clinical and Translational Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, United States
| | - Margaret Flowers
- Center for Clinical and Translational Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, United States
| | - Katherine Bline
- Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH, United States
| | - Mark W Hall
- Center for Clinical and Translational Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, United States.,Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH, United States
| | - Jennifer A Muszynski
- Center for Clinical and Translational Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, United States.,Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH, United States
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Consensus-Based Guidelines for the Recognition, Diagnosis, and Management of Hemophagocytic Lymphohistiocytosis in Critically Ill Children and Adults. Crit Care Med 2021; 50:860-872. [PMID: 34605776 DOI: 10.1097/ccm.0000000000005361] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Hemophagocytic lymphohistiocytosis is a hyperinflammatory syndrome that often requires critical care support and remains difficult to diagnose. These guidelines are meant to aid in the early recognition, diagnosis, supportive care, and treatment of patients with hemophagocytic lymphohistiocytosis in ICUs. DATA SOURCES The literature searches were performed with PubMed (MEDLINE). STUDY SELECTION Keywords and medical subject headings terms for literature search included "macrophage activation syndrome," hemophagocytic lymphohistiocytosis," and "hemophagocytic syndrome." DATA EXTRACTION The Histiocyte Society developed these consensus recommendations on the basis of published reports and expert opinions with level of evidence provided for each recommendation. They were endorsed by the Society of Critical Care Medicine. DATA SYNTHESIS Testing for hemophagocytic lymphohistiocytosis should be initiated promptly in all patients admitted to ICUs with an unexplained or disproportionate inflammatory response, especially those with rapid clinical deterioration. Meeting five or more of eight hemophagocytic lymphohistiocytosis 2004 diagnostic criteria serves as a valuable diagnostic tool for hemophagocytic lymphohistiocytosis. Early aggressive critical care interventions are often required to manage the multisystem organ failure associated with hemophagocytic lymphohistiocytosis. Thorough investigation of the underlying triggers of hemophagocytic lymphohistiocytosis, including infections, malignancies, and autoimmune/autoinflammatory diseases, is essential. Early steroid treatment is indicated for patients with familial hemophagocytic lymphohistiocytosis and is often valuable in patients with acquired hemophagocytic lymphohistiocytosis (i.e., secondary hemophagocytic lymphohistiocytosis) without previous therapy, including macrophage activation syndrome (hemophagocytic lymphohistiocytosis secondary to autoimmune/autoinflammatory disease) without persistent or relapsing disease. Steroid treatment should not be delayed, particularly if organ dysfunction is present. In patients with macrophage activation syndrome, whose disease does not sufficiently respond, interleukin-1 inhibition and/or cyclosporine A is recommended. In familial hemophagocytic lymphohistiocytosis and severe, persistent, or relapsing secondary macrophage activation syndrome, the addition of prompt individualized, age-adjusted etoposide treatment is recommended. CONCLUSIONS Further studies are needed to determine optimal treatment for patients with hemophagocytic lymphohistiocytosis in ICUs, including the use of novel and adjunct therapies.
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Workman JK, Chambers A, Miller C, Larsen GY, Lane RD. Best practices in pediatric sepsis: building and sustaining an evidence-based pediatric sepsis quality improvement program. Hosp Pract (1995) 2021; 49:413-421. [PMID: 34404310 DOI: 10.1080/21548331.2021.1966252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Pediatric sepsis is a common problem worldwide and is associated with significant morbidity and mortality. Best practice recommendations have been published by both the American College of Critical Care Medicine and the Surviving Sepsis Campaign to guide the recognition and treatment of pediatric sepsis. However, implementation of these recommendations can be challenging due to the complexity of the care required and intensity of resources needed to successfully implement programs. This paper outlines the experience with implementation of a pediatric sepsis quality improvement program at Primary Children's Hospital, a free-standing, quaternary care children's hospital in Salt Lake City. The hospital has implemented sepsis projects across multiple care settings. Challenges, lessons learned, and suggestions for implementation are described.PLAIN LANGUAGE SUMMARYSepsis is a life-threatening condition that results from an inappropriate response to an infection by the body's immune system. All children are potentially susceptible to sepsis, with nearly 8,000 children dying from the disease in the US each year. Sepsis is a complicated disease, and several international groups have published guidelines to help hospital teams treat children with sepsis appropriately. However, because recognizing and treating sepsis in children is challenging and takes a coordinated effort from many different types of healthcare team members, following the international sepsis guidelines effectively can be difficult and resource intensive. This paper describes how one children's hospital (Primary Children's Hospital in Salt Lake City, Utah) approached the challenge of implementing pediatric sepsis guidelines, some lessons learned from their experience, and suggestions for others interested in implementing sepsis guidelines for children.
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Affiliation(s)
- Jennifer K Workman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Amber Chambers
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Christopher Miller
- Division of Pediatric Hospital Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Gitte Y Larsen
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Roni D Lane
- Associate Professor of Pediatrics, Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
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Ravikumar N, Bansal A. Serum Thrombomodulin to Predict Severity in Pediatric Sepsis-Fancy or Frenzy? Indian J Pediatr 2021; 88:851-852. [PMID: 34169457 DOI: 10.1007/s12098-021-03839-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 06/03/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Namita Ravikumar
- Department of Pediatrics, All India Institute of Medical Education and Research, New Delhi, India
| | - Arun Bansal
- Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
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Abstract
OBJECTIVE Immune dysregulation is a defining feature of sepsis, but the role for mitochondria in the development of immunoparalysis in pediatric sepsis is not known. We sought to determine if mitochondrial dysfunction measured in peripheral blood mononuclear cells (PBMCs) is associated with immunoparalysis and systemic inflammation in children with sepsis. DESIGN Prospective observational study. SETTING Single-academic pediatric intensive care unit (PICU). PATIENTS One hundred sixty-one children with sepsis/septic shock and 18 noninfected PICU controls. MEASUREMENTS AND MAIN RESULTS Mitochondrial respiration in PBMCs, markers of immune function, and plasma cytokines were measured on days 1 to 2 (T1), 3 to 5 (T2), and 8 to 14 (T3) after sepsis recognition, and once for controls. Immunoparalysis was defined as whole-blood ex vivo lipopolysaccharide-induced tumor necrosis factor-alpha (TNF-α) ≤200 pg/mL or monocyte human leukocyte antigen-DR ≤30%. Mitochondrial respiration was lower in children with versus without immunoparalysis measured at the same timepoint. Mitochondrial respiration measured early (at T1 and T2) was also lower in those with immunoparalysis at T2 and T3, respectively. Although most patients with immunoparalysis exhibited low mitochondrial respiration, this metabolic finding was not specific to the immunoparalysis phenotype. Plasma cytokines, including IL-8, IL-10, TNF-α, and MCP-1, were highest in the subset of sepsis patients with immune paralysis or low mitochondrial respiration at T1. CONCLUSIONS Children with sepsis had lower PBMC mitochondrial respiration when immunoparalysis was present compared with those without immunoparalysis. The subsets with immune paralysis and low mitochondrial respiration exhibited the highest levels of systemic inflammation.
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Fernández-Sarmiento J, de Carvalho WB. Bundle for pediatric COVID-19 sepsis. ACTA ACUST UNITED AC 2021; 67Suppl 1:26-28. [PMID: 34259765 DOI: 10.1590/1806-9282.67.suppl1.20200714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 09/20/2020] [Indexed: 01/08/2023]
Abstract
COVID-19 infection can progress to severe respiratory infection and have high mortality rates. Several pathophysiological factors are observed in fatal cases, with mortality related to multiple organ failure, in addition to the evolution with high levels of serum ferritin, D-dimer, and C-reactive protein. These severe cases often meet the criteria for macrophage activation syndrome with changes in the host's inflammatory response and an inadequate resolution phase. In the present study, the bundle for COVID-19 sepsis is proposed, including early recognition; protection, handwashing and isolation measures; oxygen therapy; early invasive mechanical ventilation; treatment aimed at modifying the clinical course. This strategy may be useful in the control of children with severe COVID-19 cases, as already demonstrated with the implementation of bundles in sepsis and other etiologies.
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Affiliation(s)
- Jaime Fernández-Sarmiento
- Universidad de la Sabana, Fundación Cardioinfantil-Instituto de Cardiologia, Departament of Pediatric Critical Care Medicine - Bogotá, Colombia
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Horvat CM, Simon DW, Aldewereld Z, Evans I, Aneja R, Carcillo JA. Merging Pediatric Index of Mortality (a physiologic instability measure), lactate, and Systemic Inflammation Mortality Risk to better predict outcome in pediatric sepsis. J Pediatr (Rio J) 2021; 97:256-259. [PMID: 33242412 PMCID: PMC9432282 DOI: 10.1016/j.jped.2020.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Christopher M Horvat
- University of Pittsburgh Medical Center (UPMC), Children's Hospital of Pittsburgh, Department of Critical Care Medicine, Pittsburgh, PA, USA
| | - Dennis W Simon
- University of Pittsburgh Medical Center (UPMC), Children's Hospital of Pittsburgh, Department of Critical Care Medicine, Pittsburgh, PA, USA
| | - Zachary Aldewereld
- University of Pittsburgh Medical Center (UPMC), Children's Hospital of Pittsburgh, Department of Critical Care Medicine, Pittsburgh, PA, USA
| | - Idris Evans
- University of Pittsburgh Medical Center (UPMC), Children's Hospital of Pittsburgh, Department of Critical Care Medicine, Pittsburgh, PA, USA
| | - Rajesh Aneja
- University of Pittsburgh Medical Center (UPMC), Children's Hospital of Pittsburgh, Department of Critical Care Medicine, Pittsburgh, PA, USA
| | - Joseph A Carcillo
- University of Pittsburgh Medical Center (UPMC), Children's Hospital of Pittsburgh, Department of Critical Care Medicine, Pittsburgh, PA, USA.
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37
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DeMerle KM, Angus DC, Baillie JK, Brant E, Calfee CS, Carcillo J, Chang CCH, Dickson R, Evans I, Gordon AC, Kennedy J, Knight JC, Lindsell CJ, Liu V, Marshall JC, Randolph AG, Scicluna BP, Shankar-Hari M, Shapiro NI, Sweeney TE, Talisa VB, Tang B, Thompson BT, Tsalik EL, van der Poll T, van Vught LA, Wong HR, Yende S, Zhao H, Seymour CW. Sepsis Subclasses: A Framework for Development and Interpretation. Crit Care Med 2021; 49:748-759. [PMID: 33591001 PMCID: PMC8627188 DOI: 10.1097/ccm.0000000000004842] [Citation(s) in RCA: 74] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Sepsis is defined as a dysregulated host response to infection that leads to life-threatening acute organ dysfunction. It afflicts approximately 50 million people worldwide annually and is often deadly, even when evidence-based guidelines are applied promptly. Many randomized trials tested therapies for sepsis over the past 2 decades, but most have not proven beneficial. This may be because sepsis is a heterogeneous syndrome, characterized by a vast set of clinical and biologic features. Combinations of these features, however, may identify previously unrecognized groups, or "subclasses" with different risks of outcome and response to a given treatment. As efforts to identify sepsis subclasses become more common, many unanswered questions and challenges arise. These include: 1) the semantic underpinning of sepsis subclasses, 2) the conceptual goal of subclasses, 3) considerations about study design, data sources, and statistical methods, 4) the role of emerging data types, and 5) how to determine whether subclasses represent "truth." We discuss these challenges and present a framework for the broader study of sepsis subclasses. This framework is intended to aid in the understanding and interpretation of sepsis subclasses, provide a mechanism for explaining subclasses generated by different methodologic approaches, and guide clinicians in how to consider subclasses in bedside care.
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Affiliation(s)
- Kimberley M DeMerle
- Department of Critical Care Medicine, The Clinical Research, Investigation, and Systems Modeling of Acute illness (CRISMA) Center, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Derek C Angus
- Department of Critical Care Medicine, The Clinical Research, Investigation, and Systems Modeling of Acute illness (CRISMA) Center, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - J Kenneth Baillie
- Anaesthesia, Critical Care, and Pain Medicine, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Emily Brant
- Department of Critical Care Medicine, The Clinical Research, Investigation, and Systems Modeling of Acute illness (CRISMA) Center, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Carolyn S Calfee
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, CA
| | - Joseph Carcillo
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Chung-Chou H Chang
- Department of Critical Care Medicine, The Clinical Research, Investigation, and Systems Modeling of Acute illness (CRISMA) Center, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Robert Dickson
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor, MI
| | - Idris Evans
- Department of Critical Care Medicine, The Clinical Research, Investigation, and Systems Modeling of Acute illness (CRISMA) Center, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Anthony C Gordon
- Division of Anaesthetics, Pain Medicine, and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Jason Kennedy
- Department of Critical Care Medicine, The Clinical Research, Investigation, and Systems Modeling of Acute illness (CRISMA) Center, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Julian C Knight
- Wellcome Centre for Human Genetics, University of Oxford, Oxford, United Kingdom
| | | | - Vincent Liu
- Kaiser Permanente Division of Research, Oakland, CA
| | - John C Marshall
- Keenan Research Centre for Biomedical Science, St Michael's Hospital, Toronto, ON, Canada
| | - Adrienne G Randolph
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Brendon P Scicluna
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Manu Shankar-Hari
- Guy's and St Thomas' NHS Foundation Trust, ICU support Offices, St Thomas' Hospital, London, United Kingdom
- School of Immunology and Microbial Sciences, Kings College London, London, United Kingdom
| | - Nathan I Shapiro
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | | | - Victor B Talisa
- Department of Critical Care Medicine, The Clinical Research, Investigation, and Systems Modeling of Acute illness (CRISMA) Center, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Benjamin Tang
- Department of Intensive Care Medicine, Nepean Hospital, Sydney, NSW, Australia
| | - B Taylor Thompson
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Ephraim L Tsalik
- Department of Medicine, Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, NC
| | - Tom van der Poll
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Lonneke A van Vught
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Hector R Wong
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Research Foundation, Cincinnati, OH
| | - Sachin Yende
- Department of Critical Care Medicine, The Clinical Research, Investigation, and Systems Modeling of Acute illness (CRISMA) Center, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Huiying Zhao
- Department of Critical Care Medicine, Peking University People's Hospital, Beijing, China
| | - Christopher W Seymour
- Department of Critical Care Medicine, The Clinical Research, Investigation, and Systems Modeling of Acute illness (CRISMA) Center, University of Pittsburgh School of Medicine, Pittsburgh, PA
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Zhang C, Chen X, Wang C, Ran Y, Sheng K. Inhibition of XBP1 Alleviates LPS-Induced Cardiomyocytes Injury by Upregulating XIAP through Suppressing the NF-κB Signaling Pathway. Inflammation 2021; 44:974-984. [PMID: 33453047 DOI: 10.1007/s10753-020-01392-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 11/19/2020] [Accepted: 11/30/2020] [Indexed: 12/24/2022]
Abstract
Cardiomyocytes injury caused by sepsis is a complication of common clinical critical illness and an important cause of high mortality in intensive care unit (ICU) patients. Therefore, lipopolysaccharide (LPS)-induced H9c2 cells were used to simulate the cardiomyocytes injury in vitro. The aim of this study was to investigate whether X-box binding protein 1 (XBP1) exacerbated LPS-induced cardiomyocytes injury by downregulating Xlinked inhibitor of apoptosis protein (XIAP) through activating the NF-κB signaling pathway. After transfection or LPS induction, XBP1 expression was detected by RT-qPCR analysis and Western blot analysis. The viability and apoptosis of H9c2 cells was detected by MTT assay and TUNEL assay. The protein expression related to apoptosis and NF-κB signaling pathway was detected by Western blot analysis. The inflammation and oxidative stress in H9c2 cells was evaluated by their commercial kits. Dual-luciferase reporter assay and chromatin immunoprecipitation (CHIP) assay were used to determine the combination of XBP1 and XIAP. As a result, LPS promoted the XBP1 expression in H9c2 cells. XBP1 was combined with XIAP. Inhibition of XBP1 increased viability, and inhibited apoptosis, inflammation, and oxidative stress of LPS-induced H9c2 cells by suppressing the NF-κB signaling pathway, which was partially reversed by the inhibition of XIAP. In conclusion, inhibition of XBP1 alleviates LPS-induced cardiomyocytes injury by upregulating XIAP through suppressing the NF-κB signaling pathway.
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Affiliation(s)
- Chunmei Zhang
- Intensive Medicine, Tianjin Fourth Central Hospital, Tianjin, 300140, China
| | - Xi Chen
- Intensive Medicine, Tianjin Fourth Central Hospital, Tianjin, 300140, China
| | - Chao Wang
- Intensive Medicine, Tianjin Fourth Central Hospital, Tianjin, 300140, China
| | - Yu Ran
- Intensive Medicine, Tianjin Fourth Central Hospital, Tianjin, 300140, China
| | - Kai Sheng
- Cardio Surgery ICU, Lanzhou University Second Hospital, No.82, Cuiyingmen, Chengguan District, Lanzhou, 730030, Gansu, China.
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Baranwal AK, Kumar MP, Gupta PK. Comparison of Ventilator-free Days at 14 and 28 days as a Clinical Trial Outcome in Low- and Middle-income Countries. Indian J Crit Care Med 2020; 24:960-966. [PMID: 33281322 PMCID: PMC7689112 DOI: 10.5005/jp-journals-10071-23568] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Aims and objectives Reporting ventilator-free days (VFDs) with time frame of 28 days is a popular composite outcome measure (COM) in trials. However, early deaths and shorter pediatric intensive care unit (PICU) stay predominate in low- and middle-income countries (LMICs). A shorter time frame may reduce sample size required. We planned to compute sample size requirements for different effect sizes from datasets of previously conducted prospective studies for 28-day and 14-day time frames (VFD28 vs VFD14) to examine the hypothesis. Materials and methods The VFD28 and VFD14 were defined. Datasets of five prospective studies from PICU of our hospital were analyzed to estimate sample sizes for target reductions of 1–9 days in VFDs and other COMs for the two time frames. Reconfirmation of results was done with datasets of two other studies from PICUs of two geographical extremes of the country. Results Time-to-event occurred within 14 days in majority of patients. Sample size required for VFD14 is about one-fifth to one-sixth of what is required for VFD28 for target reductions of 1–9 days for all the enrolled studies. The same was true for other COMs as well. The hypothesis was supported by datasets of two other studies used for reconfirmation. Conclusion Choice of time frame for assessing VFDs and other COMs in clinical trials should be guided by the clinical context. A shorter time frame may be rewarding in terms of smaller sample size in the prevalent clinical setting of LMICs. Further confirmation with more datasets and prospective studies is desirable. How to cite this article Baranwal AK, Kumar MP, Gupta PK. Comparison of Ventilator-free Days at 14 and 28 days as a Clinical Trial Outcome in Low- and Middle-income Countries. Indian J Crit Care Med 2020;24(10):960–966.
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Affiliation(s)
- Arun K Baranwal
- Department of Paediatrics, Advanced Paediatric Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - M Praveen Kumar
- Department of Pharmacology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pramod K Gupta
- Department of Biostatistics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Kang D, Yu J, Xia J, Li X, Wang H, Zhao Y. Effect of norepinephrine combined with sodium phosphocreatine on cardiac function and prognosis of patients with septic shock. Int J Immunopathol Pharmacol 2020; 34:2058738420950583. [PMID: 33206570 PMCID: PMC7683914 DOI: 10.1177/2058738420950583] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Septic shock (SS) leads to a high mortality rate for sepsis patients. Norepinephrine (NE) is a preferred vasoactive agent in SS treatment. This study aimed to assess the effects of NE at different administration time and NE combined with SP treatment on the cardiac function and prognosis of SS. SS patients received NE treatment at different administration time and NE combined with SP treatment were enrolled in this study. The serum levels of cardiac troponin I (cTnI) and B-type natriuretic peptide (BNP), ejection fraction (EF), and pressure-adjusted heart rate (PAR) value were analyzed to evaluate cardiac function. The 28-day survival information was collected and assessed using the Kaplan-Meier method and log-rank test. The cardiac function of SS patients was improved significantly by NE treatment, especially in the patients received NE at 2 h after fluid infusion, which evidenced by the increased BNP and cTnI levels and EF% and the decreased RAP. In the NE-2 h group, SS patients had a better 28-day survival rate compared with those patients in NE-1 h and -3 h groups. Furthermore, the significantly improved cardiac function and survival outcomes were found in patients received NE combined SP treatment. Taken together, this study results show that NE administration at 2 h after fluid infusion may be the optimal time point for the treatment of SS and NE combined with SP treatment can improve early cardiac dysfunction and 28-day survival outcomes in patients with SS.
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Affiliation(s)
- Dawei Kang
- Department of Emergency, Affiliated Hospital of Chengde Medical University, Chengde, Hebei, China
| | - Jian Yu
- Department of Emergency, Affiliated Hospital of Chengde Medical University, Chengde, Hebei, China
| | - Jiading Xia
- Department of Intensive Care, Affiliated Hospital of Chengde Medical University, Chengde, Hebei, China
| | - Xiuhua Li
- Department of Geriatrics, Affiliated Hospital of Chengde Medical University, Chengde, Hebei, China
| | - Huarong Wang
- Department of Emergency, Affiliated Hospital of Chengde Medical University, Chengde, Hebei, China
| | - Yanjun Zhao
- Department of Emergency, Affiliated Hospital of Chengde Medical University, Chengde, Hebei, China
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Ferritin Levels in Children With Sepsis in Low-Middle Income Countries: Do We Need Lower Threshold? Pediatr Crit Care Med 2020; 21:923. [PMID: 33009312 DOI: 10.1097/pcc.0000000000002443] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Canna SW, Cron RQ. Highways to hell: Mechanism-based management of cytokine storm syndromes. J Allergy Clin Immunol 2020; 146:949-959. [PMID: 33007328 PMCID: PMC7522622 DOI: 10.1016/j.jaci.2020.09.016] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 09/23/2020] [Accepted: 09/23/2020] [Indexed: 12/12/2022]
Abstract
Since the first textbook devoted to cytokine storm syndromes (CSSs) was published in 2019, the world has changed dramatically and the term’s visibility has broadened. Herein, we define CSSs broadly to include life/organ-threatening systemic inflammation and immunopathology regardless of the context in which it occurs, recognizing that the indistinct borders of such a definition limit its utility. Nevertheless, we are focused on the pathomechanisms leading to CSSs, including impairment of granule-mediated cytotoxicity, specific viral infections, excess IL-18, and chimeric antigen receptor T-cell therapy. These mechanisms are often reflected in distinct clinical features, functional tests, and/or biomarker assessments. Moreover, these mechanisms often indicate specific, definitive treatments. This mechanism-focused organization is vital to both advancing the field and understanding the complexities in individual patients. However, increasing evidence suggests that these mechanisms interact and overlap. Likewise, the utility of a broad term such as “cytokine storm” is that it reflects a convergence on a systemic inflammatory phenotype that, regardless of cause or context, may be amenable to “inflammo-stabilization.” CSS research must improve our appreciation of its various mechanisms and their interactions and treatments, but it must also identify the signs and interventions that may broadly prevent CSS-induced immunopathology.
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Affiliation(s)
- Scott W Canna
- University of Pittsburgh/UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pa.
| | - Randy Q Cron
- University of Alabama, Birmingham/Children's of Alabama, Birmingham, Ala
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Associations of Plasma Angiopoietins-1 and -2 and Angiopoietin-2/-1 Ratios With Measures of Organ Injury and Clinical Outcomes in Children With Sepsis: A Preliminary Report. Pediatr Crit Care Med 2020; 21:e874-e878. [PMID: 32740186 DOI: 10.1097/pcc.0000000000002508] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Results from preclinical and adult sepsis studies suggest that the balance of circulating angiopoietin-1 and -2 levels, represented as angiopoietin-2/-1 ratios, plays a pivotal role in mediating vascular dysfunction and organ injury during sepsis. However, the relationship of plasma angiopoietins with organ injury and clinical outcomes in children with sepsis remains unknown. We sought to determine whether plasma angiopoietin-1 and -2 levels and angiopoietin-2/-1 ratios in the acute phase of sepsis correlated with measures of organ injury and clinical outcomes in children with sepsis. DESIGN Prospective observational cohort study. SETTING PICU within a tertiary freestanding children's hospital. PATIENTS Children 18 years old or less and greater than 3 kg admitted to the PICU for sepsis. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Plasma angiopoietin-1 and -2 levels were measured in 38 children with sepsis 0-6, 24, 48, and 72 hours following PICU admission. Children with elevated pediatric Sequential Organ Failure Assessment scores on the third day after PICU admission demonstrated significantly higher 24-72-hour angiopoietin-2/-1 ratios predominantly as a function of higher angiopoietin-2 levels. In children with sepsis-induced organ dysfunction, angiopoietin-2/-1 ratios correlated with oxygenation indices and serum levels of creatinine and bilirubin. Forty-eight- and 72-hour angiopoietin-2/-1 ratios correlated with PICU length of stay (Spearman rho = 0.485, p = 0.004 and rho = 0.440, p = 0.015, respectively). CONCLUSIONS In the acute phase of sepsis in children, plasma angiopoietin-2/-1 ratios rise significantly above control levels and correlate with measures of organ injury and worse clinical outcomes after 24 hours. Our findings suggest that angiopoietin dysregulation begins early in sepsis and, if sustained, may promote greater organ injury that can lead to worse clinical outcomes.
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Prokop JW, Shankar R, Gupta R, Leimanis ML, Nedveck D, Uhl K, Chen B, Hartog NL, Van Veen J, Sisco JS, Sirpilla O, Lydic T, Boville B, Hernandez A, Braunreiter C, Kuk CC, Singh V, Mills J, Wegener M, Adams M, Rhodes M, Bachmann AS, Pan W, Byrne-Steele ML, Smith DC, Depinet M, Brown BE, Eisenhower M, Han J, Haw M, Madura C, Sanfilippo DJ, Seaver LH, Bupp C, Rajasekaran S. Virus-induced genetics revealed by multidimensional precision medicine transcriptional workflow applicable to COVID-19. Physiol Genomics 2020; 52:255-268. [PMID: 32437232 PMCID: PMC7303726 DOI: 10.1152/physiolgenomics.00045.2020] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 05/20/2020] [Accepted: 05/20/2020] [Indexed: 12/26/2022] Open
Abstract
Precision medicine requires the translation of basic biological understanding to medical insights, mainly applied to characterization of each unique patient. In many clinical settings, this requires tools that can be broadly used to identify pathology and risks. Patients often present to the intensive care unit with broad phenotypes, including multiple organ dysfunction syndrome (MODS) resulting from infection, trauma, or other disease processes. Etiology and outcomes are unique to individuals, making it difficult to cohort patients with MODS, but presenting a prime target for testing/developing tools for precision medicine. Using multitime point whole blood (cellular/acellular) total transcriptomics in 27 patients, we highlight the promise of simultaneously mapping viral/bacterial load, cell composition, tissue damage biomarkers, balance between syndromic biology versus environmental response, and unique biological insights in each patient using a single platform measurement. Integration of a transcriptome workflow yielded unexpected insights into the complex interplay between host genetics and viral/bacterial specific mechanisms, highlighted by a unique case of virally induced genetics (VIG) within one of these 27 patients. The power of RNA-Seq to study unique patient biology while investigating environmental contributions can be a critical tool moving forward for translational sciences applied to precision medicine.
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Affiliation(s)
- Jeremy W Prokop
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Grand Rapids, Michigan
- Department of Pharmacology and Toxicology, Michigan State University, East Lansing, Michigan
| | - Rama Shankar
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Grand Rapids, Michigan
- Department of Pharmacology and Toxicology, Michigan State University, East Lansing, Michigan
| | - Ruchir Gupta
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Grand Rapids, Michigan
- Department of Pharmacology and Toxicology, Michigan State University, East Lansing, Michigan
| | - Mara L Leimanis
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Grand Rapids, Michigan
- Pediatric Intensive Care Unit, Helen DeVos Children's Hospital, Grand Rapids, Michigan
| | - Derek Nedveck
- Office of Research, Spectrum Health, Grand Rapids, Michigan
| | - Katie Uhl
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Grand Rapids, Michigan
- Department of Pharmacology and Toxicology, Michigan State University, East Lansing, Michigan
| | - Bin Chen
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Grand Rapids, Michigan
- Department of Pharmacology and Toxicology, Michigan State University, East Lansing, Michigan
| | - Nicholas L Hartog
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Grand Rapids, Michigan
- Pediatric Allergy and Immunology, Helen DeVos Children's Hospital, Grand Rapids, Michigan
- Adult Allergy and Immunology, Spectrum Health, Grand Rapids, Michigan
| | - Jason Van Veen
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Grand Rapids, Michigan
- Grand Rapids Community College, Grand Rapids, Michigan
| | - Joshua S Sisco
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Grand Rapids, Michigan
- Grand Rapids Community College, Grand Rapids, Michigan
| | - Olivia Sirpilla
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Grand Rapids, Michigan
- Walsh University, North Canton, Ohio
| | - Todd Lydic
- Department of Physiology, Michigan State University, East Lansing, Michigan
| | - Brian Boville
- Pediatric Intensive Care Unit, Helen DeVos Children's Hospital, Grand Rapids, Michigan
| | - Angel Hernandez
- Pediatric Neurology, Helen DeVos Children's Hospital, Grand Rapids, Michigan
| | - Chi Braunreiter
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Grand Rapids, Michigan
- Pediatric Hematology-Oncology, Helen DeVos Children's Hospital, Grand Rapids, Michigan
| | - ChiuYing Cynthia Kuk
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Grand Rapids, Michigan
| | - Varinder Singh
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Grand Rapids, Michigan
- College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan
| | - Joshua Mills
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Grand Rapids, Michigan
- Grand Rapids Community College, Grand Rapids, Michigan
| | - Marc Wegener
- Genomics Core Facility, Van Andel Institute, Grand Rapids, Michigan
| | - Marie Adams
- Genomics Core Facility, Van Andel Institute, Grand Rapids, Michigan
| | - Mary Rhodes
- Genomics Core Facility, Van Andel Institute, Grand Rapids, Michigan
| | - Andre S Bachmann
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Grand Rapids, Michigan
| | | | | | | | | | | | | | - Jian Han
- iRepertoire Inc., Huntsville, Alabama
- HudsonAlpha Institute for Biotechnology, Huntsville, Alabama
| | - Marcus Haw
- Congenital Heart Center, Helen DeVos Children's Hospital, Grand Rapids, Michigan
| | - Casey Madura
- Pediatric Neurology, Helen DeVos Children's Hospital, Grand Rapids, Michigan
| | - Dominic J Sanfilippo
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Grand Rapids, Michigan
- Pediatric Intensive Care Unit, Helen DeVos Children's Hospital, Grand Rapids, Michigan
| | - Laurie H Seaver
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Grand Rapids, Michigan
- Spectrum Health Medical Genetics, Grand Rapids, Michigan
| | - Caleb Bupp
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Grand Rapids, Michigan
- Spectrum Health Medical Genetics, Grand Rapids, Michigan
| | - Surender Rajasekaran
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Grand Rapids, Michigan
- Pediatric Intensive Care Unit, Helen DeVos Children's Hospital, Grand Rapids, Michigan
- Office of Research, Spectrum Health, Grand Rapids, Michigan
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Cardiac dysfunction and thrombocytopenia-associated multiple organ failure inflammation phenotype in a severe paediatric case of COVID-19. THE LANCET CHILD & ADOLESCENT HEALTH 2020; 4:552-554. [PMID: 32437638 PMCID: PMC7234774 DOI: 10.1016/s2352-4642(20)30163-2] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 05/04/2020] [Accepted: 05/04/2020] [Indexed: 01/13/2023]
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Prediction of Poor Outcomes for Septic Children According to Ferritin Levels in a Middle-Income Setting. Pediatr Crit Care Med 2020; 21:e259-e266. [PMID: 32343115 DOI: 10.1097/pcc.0000000000002273] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To evaluate serum ferritin measured within 48 hours of admission as a prognostic marker and examine the association with unfavorable outcomes in a population of pediatric patients with sepsis and high prevalence of iron deficiency anemia in which this biomarker is routinely measured. DESIGN Retrospective cohort study. SETTING PICU of a tertiary care teaching hospital in a middle-income country in South America. PATIENTS All patients 6 months to 18 years old (n = 350) admitted with a diagnosis of sepsis, suspected or proven, were eligible for inclusion. Exclusion criteria were length of PICU stay less than 8 hours and inherited or acquired disorder of iron metabolism that could interfere with serum ferritin levels. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Three-hundred twelve patients had their ferritin levels measured within 48 hours, and only 38 did not. The prevalence of iron deficiency anemia (hemoglobin < 11 g/dL and mean corpuscular volume < 80 fl was 40.3%. The median of the highest serum ferritin level within 48 hours was 150.5 ng/mL (interquartile range, 82.25-362 ng/mL), being associated with mortality (p < 0.001; Exp(B), 5.170; 95% CI, 2.619-10.205). A 10-fold increase in ferritin level was associated with a five-fold increase in mortality. There was a monotonic increase in mortality with increasing ferritin levels (p < 0.05). Regarding the discriminatory power of ferritin for mortality, the area under the receiver operating characteristic curve was 0.787 (95% CI, 0.737-0.83; p < 0.0001). CONCLUSIONS Serum ferritin at lower thresholds predicts mortality in children with sepsis admitted to the ICU in a middle-income country with high prevalence of iron deficiency anemia.
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Moreira AC, Mesquita G, Gomes MS. Ferritin: An Inflammatory Player Keeping Iron at the Core of Pathogen-Host Interactions. Microorganisms 2020; 8:microorganisms8040589. [PMID: 32325688 PMCID: PMC7232436 DOI: 10.3390/microorganisms8040589] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 04/10/2020] [Accepted: 04/15/2020] [Indexed: 12/14/2022] Open
Abstract
Iron is an essential element for virtually all cell types due to its role in energy metabolism, nucleic acid synthesis and cell proliferation. Nevertheless, if free, iron induces cellular and organ damage through the formation of free radicals. Thus, iron levels must be firmly controlled. During infection, both host and microbe need to access iron and avoid its toxicity. Alterations in serum and cellular iron have been reported as important markers of pathology. In this regard, ferritin, first discovered as an iron storage protein, has emerged as a biomarker not only in iron-related disorders but also in inflammatory diseases, or diseases in which inflammation has a central role such as cancer, neurodegeneration or infection. The basic research on ferritin identification and functions, as well as its role in diseases with an inflammatory component and its potential as a target in host-directed therapies, are the main considerations of this review.
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Affiliation(s)
- Ana C. Moreira
- i3S—Instituto de Investigação e Inovação em Saúde, Universidade do Porto, 4200-135 Porto, Portugal; (G.M.); (M.S.G.)
- IBMC—Instituto de Biologia Molecular e Celular, Universidade do Porto, 4200-135 Porto, Portugal
- ICBAS—Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, 4050-313 Porto, Portugal
- Correspondence:
| | - Gonçalo Mesquita
- i3S—Instituto de Investigação e Inovação em Saúde, Universidade do Porto, 4200-135 Porto, Portugal; (G.M.); (M.S.G.)
- IBMC—Instituto de Biologia Molecular e Celular, Universidade do Porto, 4200-135 Porto, Portugal
| | - Maria Salomé Gomes
- i3S—Instituto de Investigação e Inovação em Saúde, Universidade do Porto, 4200-135 Porto, Portugal; (G.M.); (M.S.G.)
- IBMC—Instituto de Biologia Molecular e Celular, Universidade do Porto, 4200-135 Porto, Portugal
- ICBAS—Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, 4050-313 Porto, Portugal
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The genetics of macrophage activation syndrome. Genes Immun 2020; 21:169-181. [PMID: 32291394 DOI: 10.1038/s41435-020-0098-4] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 03/13/2020] [Accepted: 03/27/2020] [Indexed: 12/12/2022]
Abstract
Macrophage activation syndrome (MAS), or secondary hemophagocytic lymphohistiocytosis (HLH), is a cytokine storm syndrome associated with multi-organ system dysfunction and high mortality rates. Laboratory and clinical features resemble primary HLH, which arises in infancy (1 in 50,000 live births) from homozygous mutations in various genes critical to the perforin-mediated cytolytic pathway employed by NK cells and cytotoxic CD8 T lymphocytes. MAS/secondary HLH is about ten times more common and typically presents beyond infancy extending into adulthood. The genetics of MAS are far less defined than for familial HLH. However, the distinction between familial HLH and MAS/secondary HLH is blurred by the finding of heterozygous perforin-pathway mutations in MAS patients, which may function as hypomorphic or partial dominant-negative alleles and contribute to disease pathogenesis. In addition, mutations in a variety of other pathogenic pathways have been noted in patients with MAS/secondary HLH. Many of these genetically disrupted pathways result in a similar cytokine storm syndrome, and can be broadly categorized as impaired viral control (e.g., SH2P1A), dysregulated inflammasome activity (e.g., NLRC4), other immune defects (e.g., IKBKG), and dysregulated metabolism (e.g., LIPA). Collectively these genetic lesions likely combine with states of chronic inflammation, as seen in various rheumatic diseases (e.g., still disease), with or without identified infections, to result in MAS pathology as explained by the threshold model of disease. This emerging paradigm may ultimately support genetic risk stratification for high-risk chronic and even acute inflammatory disorders. Moving forward, continued whole-exome and -genome sequencing will likely identify novel MAS gene associations, as well as noncoding mutations altering levels of gene expression.
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Lachmann G, Knaak C, Vorderwülbecke G, La Rosée P, Balzer F, Schenk T, Schuster FS, Nyvlt P, Janka G, Brunkhorst FM, Keh D, Spies C. Hyperferritinemia in Critically Ill Patients. Crit Care Med 2020; 48:459-465. [PMID: 32205591 DOI: 10.1097/ccm.0000000000004131] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Hyperferritinemia is frequently seen in critically ill patients. A rather rare though life-threatening condition related to severely elevated ferritin is hemophagocytic lymphohistiocytosis. We analyze ferritin levels to differentiate hemophagocytic lymphohistiocytosis from other causes of hyperferritinemia in a mixed cohort of critically ill patients. DESIGN Retrospective observational study. SETTING Adult surgical, anesthesiologic, and medical ICUs of a university hospital. PATIENTS Critical care patients (≥ 18 yr old) admitted to any of the adult ICUs at Charité - Universitätsmedizin Berlin between January 2006 and August 2018 with at least one ferritin value and hyperferritinemia (≥ 500 µg/L). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Patients were categorized into hemophagocytic lymphohistiocytosis, sepsis, septic shock, and other diagnoses. These were further categorized into 17 subgroups. Hemophagocytic lymphohistiocytosis diagnosis was based on Hemophagocytic Lymphohistiocytosis-2004 criteria and the HScore. Of 2,623 patients with hyperferritinemia, 40 were considered to have hemophagocytic lymphohistiocytosis (1.52%). Maximum ferritin levels were highest in hemophagocytic lymphohistiocytosis patients compared with all other disease groups (each p < 0.001). Sepsis and septic shock patients had higher maximum ferritin levels than patients with other diagnoses (each p < 0.001). A maximum ferritin value of 9,083 µg/L was at 92.5% sensitivity and 91.9% specificity for hemophagocytic lymphohistiocytosis (area under the curve, 0.963; 95% CI, 0.949-0.978). Of all subgroups with other diagnoses, maximum ferritin levels were highest in patients with varicella-zoster virus, hepatitis, or malaria (median, 1,935, 1,928, and 1,587 µg/L, respectively). Maximum ferritin levels were associated with increased in-hospital mortality (odds ratio, 1.518 per log µg/L [95% CI, 1.384-1.665 per log µg/L]; p < 0.001). CONCLUSIONS This is the largest study of patients with ferritin available in a mixed ICU cohort. Ferritin levels in patients with hemophagocytic lymphohistiocytosis, sepsis, septic shock, and other conditions were distinctly different, with the highest ferritin levels observed in hemophagocytic lymphohistiocytosis patients. Maximum ferritin of 9,083 µg/L showed high sensitivity and specificity and, therefore, may contribute to improved diagnosis of hemophagocytic lymphohistiocytosis in ICU. The inclusion of ferritin into the sepsis laboratory panel is warranted.
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Affiliation(s)
- Gunnar Lachmann
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, D-13353 Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
| | - Cornelia Knaak
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, D-13353 Berlin, Germany
| | - Gerald Vorderwülbecke
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, D-13353 Berlin, Germany
| | - Paul La Rosée
- Klinik für Innere Medizin II, Schwarzwald-Baar-Klinikum, Villingen-Schwenningen, Germany
| | - Felix Balzer
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, D-13353 Berlin, Germany
| | - Thomas Schenk
- Department of Hematology and Oncology, Universitätsklinikum Jena, Jena, Germany
| | - Friederike S Schuster
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, D-13353 Berlin, Germany
| | - Peter Nyvlt
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, D-13353 Berlin, Germany
| | - Gritta Janka
- Clinic of Pediatric Hematology and Oncology, University Medical Center Eppendorf, Hamburg, Germany
| | - Frank M Brunkhorst
- Center for Clinical Studies, Department of Anesthesiology and Intensive Care Medicine, Universitätsklinikum Jena, Jena, Germany
| | - Didier Keh
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, D-13353 Berlin, Germany
| | - Claudia Spies
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, D-13353 Berlin, Germany
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