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He Y, Chai L, Chen H, Qi XS. Effect of different infusion approaches on safety and efficacy of terlipressin: Current controversies. Shijie Huaren Xiaohua Zazhi 2023; 31:705-710. [DOI: 10.11569/wcjd.v31.i17.705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 08/30/2023] [Accepted: 09/01/2023] [Indexed: 09/08/2023] Open
Abstract
Terlipressin, a synthetic analog of vasopressin, has been widely used to treat acute variceal bleeding, hepatorenal syndrome, and other complications of cirrhosis. However, among different infusion approaches of terlipressin, its safety and efficacy are also heterogeneous. Previous studies have demonstrated that continuous infusion of terlipressin is more effective with a lower incidence of adverse events than intermittent intravenous infusion. This paper aims to review the relevant literature and summarize the data regarding the safety and effectiveness of different infusion approaches of terlipressin to guide clinical practice.
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Affiliation(s)
- Yong He
- Department of Gastroenter-ology, General Hospital of Northern Theater Command, Shenyang 110840, Liaoning Province, China
- Graduate School of Shenyang Pharmaceutical University, Shenyang 110016, Liaoning Province, China
| | - Lu Chai
- Department of Gastroenter-ology, General Hospital of Northern Theater Command, Shenyang 110840, Liaoning Province, China
- Graduate School of Shenyang Pharmaceutical University, Shenyang 110016, Liaoning Province, China
| | - Han Chen
- Department of Pharmacy, General Hospital of Northern Theater Command, Shenyang 110840, Liaoning Province, China
| | - Xing-Shun Qi
- Department of Gastroenter-ology, General Hospital of Northern Theater Command, Shenyang 110840, Liaoning Province, China
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Dysregulation of the renin-angiotensin system in septic shock: Mechanistic insights and application of angiotensin II in clinical management. Pharmacol Res 2021; 174:105916. [PMID: 34597810 DOI: 10.1016/j.phrs.2021.105916] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 09/18/2021] [Accepted: 09/26/2021] [Indexed: 12/12/2022]
Abstract
Synergistic physiologic mechanisms involving the renin-angiotensin system (RAS), the sympathetic nervous system, and the arginine-vasopressin system play an integral role in blood pressure homeostasis. A subset of patients with sepsis experience septic shock with attendant circulatory, cellular, and metabolic abnormalities. Septic shock is associated with increased mortality because of an inadequacy to maintain mean arterial blood pressure (MAP) despite volume resuscitation and the use of vasopressors. Vasodilatory shock raises the dose of vasopressors required to maintain a MAP of > 65 mm Hg. The diminished response to endogenous angiotensin II in sepsis-induced vasoplegia may be related to the aberrant RAS activation that stimulates a proinflammatory beneficial antibacterial response, increasing the secretion of proinflammatory cytokines that downregulate AT-1 receptors expression. Moreover, excessive systemic upregulation of nitric oxide synthase, stimulation of prostaglandin synthesis, and activation of ATP-sensitive potassium channels followed by reduced vascular entry of calcium ions are putative mechanisms in the reduced responsiveness to vasopressors. However, intravenous angiotensin II in catecholamine-resistant septic shock patients showed substantial evidence of raising the MAP to target hemodynamic levels, thus allowing time to treat underlying conditions. Nevertheless, evidence of catecholamine-sparing effect by adding angiotensin II, aimed at increasing the therapeutic index of vasopressor therapy, does not show an attenuation of end-organ damage. The use of angiotensin II in septic shock has not been evaluated in patients who are not catecholamine resistant. This, in conjunction with an evolving definition of catecholamine resistance, provides an opportunity for further evaluation of exogenous angiotensin II in septic shock.
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Laghlam D, Jozwiak M, Nguyen LS. Renin-Angiotensin-Aldosterone System and Immunomodulation: A State-of-the-Art Review. Cells 2021; 10:cells10071767. [PMID: 34359936 PMCID: PMC8303450 DOI: 10.3390/cells10071767] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 06/30/2021] [Accepted: 07/09/2021] [Indexed: 12/11/2022] Open
Abstract
The renin–angiotensin system (RAS) has long been described in the field of cardiovascular physiology as the main player in blood pressure homeostasis. However, other effects have since been described, and include proliferation, fibrosis, and inflammation. To illustrate the immunomodulatory properties of the RAS, we chose three distinct fields in which RAS may play a critical role and be the subject of specific treatments. In oncology, RAS hyperactivation has been associated with tumor migration, survival, cell proliferation, and angiogenesis; preliminary data showed promise of the benefit of RAS blockers in patients treated for certain types of cancer. In intensive care medicine, vasoplegic shock has been associated with severe macro- and microcirculatory imbalance. A relative insufficiency in angiotensin II (AngII) was associated to lethal outcomes and synthetic AngII has been suggested as a specific treatment in these cases. Finally, in solid organ transplantation, both AngI and AngII have been associated with increased rejection events, with a regional specificity in the RAS activity. These elements emphasize the complexity of the direct and indirect interactions of RAS with immunomodulatory pathways and warrant further research in the field.
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Zhu Y, Huang H, Xi X, Du B. Terlipressin for septic shock patients: a meta-analysis of randomized controlled study. J Intensive Care 2019; 7:16. [PMID: 30923620 PMCID: PMC6419496 DOI: 10.1186/s40560-019-0369-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 02/21/2019] [Indexed: 12/13/2022] Open
Abstract
Background Catecholamines are commonly used in septic shock but face limitations of their hypo-responsiveness and adverse events due to high dose. Terlipressin is a synthetic vasopressin analog with greater selectivity for the V1-receptor. A meta-analysis was conducted to evaluate the efficacy and safety of terlipressin in septic shock. Methods We searched for relevant studies in PubMed, Embase, and the Cochrane database from inception up to July 15, 2018. Randomized controlled trials (RCTs) were included if they reported data on any of the predefined outcomes in patients with septic shock and managed with terlipressin or any catecholamines. Results were expressed as risk ratio (RR) or mean difference (MD) with accompanying 95% confidence interval (CI). Heterogeneity, subgroup analysis, sensitivity analysis, and publication bias were explored. Results Ten studies with 928 patients were included. Despite the shorter duration of mechanical ventilation, use of terlipressin did not reduce the risk of mortality (RR = 0.94; 95% CI, 0.85 to 1.05; I2 = 0%; P = 0.28) when compared with control. This finding was confirmed by further subgroup and sensitivity analyses. In addition, lactate clearance, length of stay in ICU or hospital, total adverse events, digital ischemia, and arrhythmia were also similar between groups, while terlipressin was associated with shorter duration of mechanical ventilation and less norepinephrine requirements. Conclusions Current results suggest terlipressin did not show added survival benefit in septic shock therapy when compared with catecholamines. Electronic supplementary material The online version of this article (10.1186/s40560-019-0369-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yibing Zhu
- 1ICU, Fuxing Hospital, Capital Medical University, Peking, China
| | - Huibin Huang
- 2Medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Peking, China.,3Department of Critical Care Medicine, the First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Xiuming Xi
- 1ICU, Fuxing Hospital, Capital Medical University, Peking, China
| | - Bin Du
- 2Medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Peking, China
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He X, Su F, Taccone FS, Laporte R, Kjølbye AL, Zhang J, Xie K, Moussa MD, Reinheimer TM, Vincent JL. A Selective V(1A) Receptor Agonist, Selepressin, Is Superior to Arginine Vasopressin and to Norepinephrine in Ovine Septic Shock. Crit Care Med 2016; 44:23-31. [PMID: 26496451 PMCID: PMC4684247 DOI: 10.1097/ccm.0000000000001380] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Selective vasopressin V(1A) receptor agonists may have advantages over arginine vasopressin in the treatment of septic shock. We compared the effects of selepressin, a selective V(1A) receptor agonist, arginine vasopressin, and norepinephrine on hemodynamics, organ function, and survival in an ovine septic shock model. DESIGN Randomized animal study. SETTING University hospital animal research laboratory. SUBJECTS Forty-six adult female sheep. INTERVENTIONS Fecal peritonitis was induced in the anesthetized, mechanically ventilated, fluid-resuscitated sheep, and they were randomized in two successive phases. Three late-intervention groups (each n = 6) received IV selepressin (1 pmol/kg/min), arginine vasopressin (0.25 pmol [0.1 mU]/kg/min), or norepinephrine (3 nmol [0.5 μg]/kg/min) when mean arterial pressure remained less than 70 mm Hg despite fluid challenge; study drugs were thereafter titrated to keep mean arterial pressure at 70-80 mm Hg. Three early-intervention groups (each n = 7) received selepressin, arginine vasopressin, or norepinephrine at the same initial infusion rates as for the late intervention, but already when mean arterial pressure had decreased by 10% from baseline; doses were then titrated as for the late intervention. A control group (n = 7) received saline. All animals were observed until death or for a maximum of 30 hours. MEASUREMENTS AND MAIN RESULTS In addition to hemodynamic and organ function assessment, plasma interleukin-6 and nitrite/nitrate levels were measured. In the late-intervention groups, selepressin delayed the decrease in mean arterial pressure and was associated with lower lung wet/dry weight ratios than in the other two groups. In the early-intervention groups, selepressin maintained mean arterial pressure and cardiac index better than arginine vasopressin or norepinephrine, slowed the increase in blood lactate levels, and was associated with less lung edema, lower cumulative fluid balance, and lower interleukin-6 and nitrite/nitrate levels. Selepressin-treated animals survived longer than the other animals. CONCLUSIONS In this clinically relevant model, selepressin, a selective V(1A) receptor agonist, was superior to arginine vasopressin and to norepinephrine in the treatment of septic shock, especially when administered early.
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Affiliation(s)
- Xinrong He
- 1Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, Brussels, Belgium.2Department of Intensive Care, Sun Yat-sen University Cancer Center, Guangzhou, China.3Clinical & Non-Clinical R&D, Ferring Research Institute, San Diego, CA.4Clinical & Non-Clinical R&D, Ferring Pharmaceuticals A/S, Copenhagen, Denmark.5Department of Biochemistry and Nutrition, Université Libre de Bruxelles, Brussels, Belgium
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Chen D, Song MQ, Liu YJ, Xue YK, Cheng P, Zheng H, Chen LB. Inhibition of complement C3 might rescue vascular hyporeactivity in a conscious hemorrhagic shock rat model. Microvasc Res 2015; 105:23-9. [PMID: 26687560 DOI: 10.1016/j.mvr.2015.12.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Revised: 12/08/2015] [Accepted: 12/08/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND Vascular hyporeactivity in severe hemorrhagic shock could induce refractory hypotension and is an important cause of death. The global acute inflammatory response induced in shock triggers the over-expression of reactive oxygen species, NO, ET1 and TNF-α, which play essential roles in the pathology of vascular hyporeactivity. This leads to a hypothesis that inhibition of the complement system, the mediator of the inflammatory cascade, might be a promising therapeutic exploration for vascular hyporeactivity. METHODS We use cobra venom factor (CVF) and the soluble form of CR1 (sCR1) which deplete or inhibit complement C3 respectively to examine its role in vascular hyporeactivity in a conscious hemorrhagic shock rat model. RESULTS We first confirmed the over-activation of C3 during shock and the down-regulation effects of CVF and sCR1 on C3. Then, both CVF and sCR1 could significantly mitigate the over-expression of serum NO, ET-1, TNF-α and reactive oxygen species. Finally, the vascular reactivity of superior mesenteric arteries (SMA) was examined in vitro, which confirmed the massive reduction of vascular reactivity in shock, which was significantly rescued by both CVF and sCR1. CONCLUSIONS Inhibition of C3 might improve the reactivity of SMA to norepinephrine during hemorrhagic shock possibly through the downregulation of NO, ET1, TNF-α and reactive oxygen radicals.
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Affiliation(s)
- Ding Chen
- Department of Emergency, Wuhan Union Hospital affiliated with Tongji Medical College, Huazhong University of Science and Technology, PR China.
| | - Meng-Qi Song
- Department of Emergency, Wuhan Union Hospital affiliated with Tongji Medical College, Huazhong University of Science and Technology, PR China.
| | - Yan-Jun Liu
- Department of Emergency, Wuhan Union Hospital affiliated with Tongji Medical College, Huazhong University of Science and Technology, PR China.
| | - Yin-Kai Xue
- Department of Emergency, Wuhan Union Hospital affiliated with Tongji Medical College, Huazhong University of Science and Technology, PR China.
| | - Ping Cheng
- Department of Emergency, Wuhan Union Hospital affiliated with Tongji Medical College, Huazhong University of Science and Technology, PR China.
| | - Hai Zheng
- Department of Emergency, Wuhan Union Hospital affiliated with Tongji Medical College, Huazhong University of Science and Technology, PR China.
| | - Li-Bo Chen
- Department of Emergency, Wuhan Union Hospital affiliated with Tongji Medical College, Huazhong University of Science and Technology, PR China.
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Wang X, Song R, Bian HN, Brunk UT, Zhao M, Zhao KS. Polydatin, a natural polyphenol, protects arterial smooth muscle cells against mitochondrial dysfunction and lysosomal destabilization following hemorrhagic shock. Am J Physiol Regul Integr Comp Physiol 2012; 302:R805-14. [PMID: 22277937 DOI: 10.1152/ajpregu.00350.2011] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The main objective of this study was to investigate the activity of polydatin on mitochondrial dysfunction and lysosomal stability of arteriolar smooth muscle cells (ASMCs) in severe shock. The experimental animals (rats) were divided into five groups: control, hemorrhagic shock, shock + CsA, shock + Res, and shock + PD (exposed to cyclosporin A, resveratrol, or polydatin following induction of hemorrhagic shock, respectively). The calcein-Co(2+) technique revealed opening of ASMC mitochondrial permeability transition pores (mPTP) after shock with resulting mitochondrial swelling, decreased mitochondrial membrane potential (ΔΨm), and reduced intracellular ATP levels. These alterations were all inhibited by exposure to PD, which was significantly more effective than CsA and Res. PD also preserved lysosomal stability, suppressed activation of K(ATP) channels, ASMC hyperpolarization, and reduced vasoresponsiveness to norepinephrine that normally follows severe shock. The results demonstrate that exposure to PD after initiation of severe shock effectively preserves ASMC mitochondrial integrity and has a significant therapeutic effect in severe shock. The effects may partially result from lysosomal stabilization against shock-induced oxidative stress and depressed relocation of hydrolytic enzymes and redox-active lysosomal iron that, in turn, may induce mPTP opening.
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Affiliation(s)
- Xingmin Wang
- Guangdong Key Laboratory of Shock and Microcirculation Research, Dept. of Pathophysiology, Southern Medical Univ., Guangzhou, P. R. China
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Antonelli M, Bonten M, Chastre J, Citerio G, Conti G, Curtis JR, De Backer D, Hedenstierna G, Joannidis M, Macrae D, Mancebo J, Maggiore SM, Mebazaa A, Preiser JC, Rocco P, Timsit JF, Wernerman J, Zhang H. Year in review in Intensive Care Medicine 2011: I. Nephrology, epidemiology, nutrition and therapeutics, neurology, ethical and legal issues, experimentals. Intensive Care Med 2012; 38:192-209. [PMID: 22215044 PMCID: PMC3291847 DOI: 10.1007/s00134-011-2447-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2011] [Accepted: 12/14/2011] [Indexed: 12/29/2022]
Affiliation(s)
- Massimo Antonelli
- Department of Intensive Care and Anesthesiology, Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168 Rome, Italy.
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Vasopressortherapie des postoperativen vasoplegischen Syndroms. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2011. [DOI: 10.1007/s00398-011-0881-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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Song R, Bian H, Huang X, Zhao KS. Atractyloside induces low contractile reaction of arteriolar smooth muscle through mitochondrial damage. J Appl Toxicol 2011; 32:402-8. [PMID: 21598287 DOI: 10.1002/jat.1688] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2011] [Revised: 03/28/2011] [Accepted: 03/28/2011] [Indexed: 11/08/2022]
Abstract
Atractyloside is the principal naturally occurring active ingredient in ethnomedicines and animal grazing forage. Evidence that atractyloside can induce opening of the mitochondrial permeability transition pore (mPTP) indicates that mitochondrial mechanisms may play an important role in pathophysiological lesions of the heart, liver and kidney after atractyloside poisoning. Therefore, in this study we investigated the association of atractyloside-induced mitochondrial damage in arteriolar smooth muscle cells (ASMCs) with contractile reaction. Atractyloside led to depolarized and swollen or damaged ASMC mitochondria, which might be related to the concentration-dependent induction of mPTP opening. Relative ATP content in ASMCs was significantly reduced by 48%, 63% and 66% of control when cells were treated with 7.5, 10, and 15 µm atractyloside for 10 min, respectively, and ASMCs were hyperpolarized. In addition, the contractile responsiveness of ASMCs was eventually weakened. These results suggest that atractyloside has a toxic effect on vasoreactivity, which is possibly related to mitochondrial damage.
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Affiliation(s)
- Rui Song
- Guangdong Key Laboratory of Shock and Microcirculation Research, Department of Pathophysiology, Southern Medical University, Guangzhou, People's Republic of China
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Collin S, Sennoun N, Dron AG, de la Bourdonnaye M, Montemont C, Asfar P, Lacolley P, Meziani F, Levy B. Vascular ATP-sensitive potassium channels are over-expressed and partially regulated by nitric oxide in experimental septic shock. Intensive Care Med 2011; 37:861-9. [DOI: 10.1007/s00134-011-2169-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2010] [Accepted: 02/08/2011] [Indexed: 10/18/2022]
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Maybauer MO, Maybauer DM. Vasopressin analogues and V1a receptor agonists in septic shock. Inflamm Res 2011; 60:425-7. [DOI: 10.1007/s00011-011-0314-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
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Mitochondrial injury underlies hyporeactivity of arterial smooth muscle in severe shock. Am J Hypertens 2011; 24:45-51. [PMID: 20940715 DOI: 10.1038/ajh.2010.184] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Our previous data showed membrane hyperpolarization of arteriolar smooth muscle cells (ASMCs) caused by adenosine triphosphate (ATP)-sensitive potassium channels (K(ATP)) activation contributed to vascular hyporeactivity in shock. Despite supply of oxygen and nutrients, vascular hyporeactivity to vasoconstrictor agents still remains, which may result from low ATP level. The study was designed to investigate shock-induced mitochondrial changes of rat ASMCs in the genesis and treatment of hypotension in severe shock. METHODS The animals were divided into four groups: controls, hemorrhagic shock, CsA+shock (preadministration of cyclosporin A before bleeding), and ATR+CsA+shock (preadministration of atractyloside, followed by CsA and bleeding). ASMCs were isolated and the ultrastructure and function of ASMC mitochondria and the vasoresponsiveness to norepinephrine (NE) was measured on microcirculatory preparations. RESULTS Ultrastructurally, the hemorrhagic shock group showed swollen mitochondria with poorly defined cristae. In this group, the number of ASMCs with low mitochondrial membrane potential (Δψ(m)) was increased by 49.7%, and the intracellular ATP level was reduced by 82.1%, which led to activation of K(ATP) plasma membrane channels with resultant ASMC hyperpolarization and low vasoreactivity. These changes were reduced in the CsA+shock group. When mitochondrial damage was aggravated by ATR in the ATR+CsA+shock group, the CsA did not protect. Compared to the shock group, vasoresponsiveness to NE was much improved in the CsA+shock group. CONCLUSIONS Mitochondrial ASMC dysfunction is involved in the genesis of reduced vasoreactivity in severe shock. Mitochondrial protection may therefore be a new approach in the treatment of shock-induced hypotension.
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Lange M, Ertmer C, Rehberg S, Morelli A, Köhler G, Kampmeier TG, Van Aken H, Westphal M. Effects of two different dosing regimens of terlipressin on organ functions in ovine endotoxemia. Inflamm Res 2010; 60:429-37. [PMID: 21190124 DOI: 10.1007/s00011-010-0299-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2010] [Revised: 11/22/2010] [Accepted: 12/13/2010] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE AND DESIGN To test the hypothesis that a continuous infusion of the vasopressin analog terlipressin is associated with less organ dysfunction as compared to intermittent bolus infusion in an ovine sepsis model. SUBJECTS Twenty-seven adult female sheep. TREATMENT All sheep were subjected to a Salmonella typhosa endotoxin infusion (10 ng/kg/min). After 16 h of endotoxemia, the surviving animals (n = 24) were randomized to (1) an untreated control group, (2) a continuous terlipressin group (2 mg/24 h), or (3) a terlipressin bolus group (1 mg/6 h). METHODS Hemodynamic variables were measured and blood was withdrawn at specific time points for the assessment of organ functions. RESULTS Continuous terlipressin infusion was associated with improved surrogate parameters of myocardial, renal, and hepatic function as compared with terlipressin bolus infusion. Reduced vascular hyperpermeability was evidenced by an attenuated decrease in plasma protein concentrations in sheep treated with continuous terlipressin infusion as compared to bolus injection or no treatment. CONCLUSIONS Continuous infusion of low-dose terlipressin preserved several surrogate parameters of organ function better than intermittent bolus injections in sheep with systemic inflammation.
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Affiliation(s)
- Matthias Lange
- Department of Anesthesiology and Intensive Care, University of Muenster, Albert-Schweitzer Str. 33, 48149, Muenster, Germany.
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Levy B, Collin S, Sennoun N, Ducrocq N, Kimmoun A, Asfar P, Perez P, Meziani F. Vascular hyporesponsiveness to vasopressors in septic shock: from bench to bedside. Intensive Care Med 2010; 36:2019-29. [PMID: 20862451 DOI: 10.1007/s00134-010-2045-8] [Citation(s) in RCA: 150] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2010] [Accepted: 08/24/2010] [Indexed: 01/20/2023]
Abstract
PURPOSE To delineate some of the characteristics of septic vascular hypotension, to assess the most commonly cited and reported underlying mechanisms of vascular hyporesponsiveness to vasoconstrictors in sepsis, and to briefly outline current therapeutic strategies and possible future approaches. METHODS Source data were obtained from a PubMed search of the medical literature with the following MeSH terms: Muscle, smooth, vascular/physiopathology; hypotension/etiology; shock/physiopathology; vasodilation/physiology; shock/therapy; vasoconstrictor agents. RESULTS Nitric oxide (NO) and peroxynitrite are crucial components implicated in vasoplegia and vascular hyporeactivity. Vascular ATP-sensitive and calcium-activated potassium channels are activated during shock and participate in hypotension. In addition, shock state is characterized by inappropriately low plasma glucocorticoid and vasopressin concentrations, a dysfunction and desensitization of alpha-receptors, and an inactivation of catecholamines by oxidation. Numerous other mechanisms have been individualized in animal models, the great majority of which involve NO: MEK1/2-ERK1/2 pathway, H(2)S, hyperglycemia, and cytoskeleton dysregulation associated with decreased actin expression. CONCLUSIONS Many therapeutic approaches have proven their efficiency in animal models, especially therapies directed against one particular compound, but have otherwise failed when used in human shock. Nevertheless, high doses of catecholamines, vasopressin and terlipressin, hydrocortisone, activated protein C, and non-specific shock treatment have demonstrated a partial efficiency in reversing sepsis-induced hypotension.
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Affiliation(s)
- B Levy
- Groupe Choc, Contrat Avenir INSERM 2006, Faculté de Médecine, Nancy Université, 9 Avenue de la Forêt de Haye, BP 184, Vandœuvre-lès-Nancy Cedex, 54505, France.
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Effects of a single terlipressin administration on cardiac function and perfusion in cirrhosis. Eur J Gastroenterol Hepatol 2010; 22:1085-92. [PMID: 20453655 DOI: 10.1097/meg.0b013e32833a4822] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The vasoconstrictor terlipressin is widely used in the treatment of the hepatorenal syndrome and variceal bleeding. However, terlipressin may compromise cardiac function and induce ischemia. AIM Therefore, we aimed to assess the effects of terlipressin on cardiac function and perfusion. METHODS Twenty-four patients with cirrhosis and ascites participated, including nine with refractory ascites. Gated myocardial perfusion imaging, mean arterial blood pressure (MAP), cardiac output (CO), ejection fraction (EF), end-diastolic volume (EDV), perfusion, and motion of the myocardium were determined before and after a bolus injection of 2 mg terlipressin. RESULTS MAP increased after terlipressin (P value of less than 0.001). EF and CO fell by -16 and -17%, respectively in the terlipressin group versus 1 and -2%, respectively in the placebo group (P value of less than 0.001 and P value of less than 0.01). In the terlipressin group, EDV increased by 18 versus -4% in the placebo group (P value of less than 0.01). Wall motion in the anterior and posterior walls fell by -18 and -22%, respectively after terlipressin treatment versus 0 and 0% in the placebo group (P value of less than 0.01). In contrast, myocardial perfusion and stroke volume were unaltered in both the groups. The change in EF during terlipressin treatment correlated significantly with the change in MAP (r=-0.60, P value <0.002). Patients with refractory ascites had a higher EF and lower EDV and ESV than the patients with nonrefractory ascites, both at baseline and after terlipressin treatment. The decrease in the left ventricular wall thickening and wall motion correlated with the Child--Pugh score, r=-0.59, P=0.005 and r=-0.48, P=0.03. CONCLUSION In advanced cirrhosis, the increase in afterload and EDV after terlipressin treatment result in a decrease in left ventricular wall motion, resulting in reduced CO and EF, but myocardial perfusion is preserved. Alteration in cardiac function at baseline and after terlipressin treatment relates to the stage of decompensation.
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Krag A, Møller S, Henriksen JH, Bendtsen F. Effects of a single dose of terlipressin on transcutaneous oxygen pressures. Scand J Gastroenterol 2010; 45:953-8. [PMID: 20384528 DOI: 10.3109/00365521003797189] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Terlipressin (TP) is a potent vasoconstrictor, which is widely used in the treatment of bleeding esophageal varices and the hepatorenal syndrome. Side effects to TP are often related to skin hypoxaemia. The aim of the study was to investigate the transcutaneous oxygen pressures (TcPO(2) mmHg) after administration of 2 mg of TP. PATIENTS AND METHODS Nineteen patients with cirrhosis and ascites were included. TcPO(2) mmHg were measured continuously measured at the chest, abdominal wall and at the lower extremity at baseline and after 2 mg TP in 15 patients and placebo in 4 patients. RESULTS The mean whole body TcPO(2) decreased after TP by 34% (p < 0.005). The decrease was even more pronounced in the lower extremity: above knee -33% (50 vs. 33 mmHg, p = 0.01) and below knee -52% (52 vs. 26 mmHg, p = 0.001). Levels below 30 mmHg, were found in 60% of the patients after TP compared to 0% in the placebo group, p = 0.005. There were no significant changes in TcPO(2) after placebo. The baseline leg TcPO(2) correlated inversely with the MELD score (r = -0.64 and p < 0.003) and the increase in MAP after TP correlated inversely with TcPO(2) at the thorax (r = -0.60, p = 0.009). CONCLUSIONS Sixty percent of patients with decompensated cirrhosis develop hypoxaemia in the lower limb after one dose of TP.
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Affiliation(s)
- Aleksander Krag
- Department of Clinical Physiology and Nuclear Medicine, Copenhagen University Hospital, Hvidovre, Faculty of Health Sciences, Copenhagen, Denmark.
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Salgado DR, Rocco JR, Silva E, Vincent JL. Modulation of the renin-angiotensin-aldosterone system in sepsis: a new therapeutic approach? Expert Opin Ther Targets 2010; 14:11-20. [PMID: 20001206 DOI: 10.1517/14728220903460332] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE OF THE FIELD Severe sepsis is characterized by relative hypotension associated with a high cardiac output, peripheral vasodilation, and organ dysfunction. The renin-angiotensin-aldosterone system (RAAS) is primarily activated to increase blood pressure, but recently potential pro-inflammatory effects of angiotensin II have attracted interest because of the reported association between angiotensin II levels and organ failure and mortality in sepsis. RAAS antagonists could represent a new therapeutic option in this setting. AREAS COVERED IN THIS REVIEW The role of RAAS activation in severe sepsis and septic shock, and the potential benefits (and risks) of using RAAS antagonists. WHAT THE READER WILL GAIN Insight into RAAS function in severe sepsis and the potential for RAAS inhibitors to be used as an adjunctive therapy in patients with severe sepsis, with discussion of promising results from animal models of sepsis. TAKE HOME MESSAGE Use of RAAS antagonists is an emerging therapeutic option in severe sepsis because these agents may reduce endothelial damage, organ failure, and mortality. However, timing of administration of RAAS antagonists is important because reduced RAAS function may contribute to refractive hypotension later on in septic shock and benefits of RAAS antagonists seem to be restricted to the early phases of sepsis.
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Affiliation(s)
- Diamantino Ribeiro Salgado
- Federal University of Rio de Janeiro, Clementino Fraga Filho University Hospital, Department of Internal Medicine, Cidade Universitària - Ilha do Fundão - Rio de Janeiro, Brazil.
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Morelli A, Ertmer C, Pietropaoli P, Westphal M. Terlipressin: a promising vasoactive agent in hemodynamic support of septic shock. Expert Opin Pharmacother 2009; 10:2569-75. [PMID: 19735216 DOI: 10.1517/14656560903257808] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND At present, terlipressin is predominantly used for the management of bleeding gastric and esophageal varices, as well as hepato-renal syndrome secondary to liver cirrhosis. Owing to its high and relatively selective affinity to vascular V1 receptors, terlipressin is also increasingly used as an adjunct vasopressor agent in the management of vasodilatory hyperdynamic septic shock. OBJECTIVE This review article aims to summarize the available knowledge related to hemodynamic support with terlipressin in septic shock. METHODS For literature search, PubMed and specific keywords from the MeSH Database were used. RESULTS/CONCLUSIONS Terlipressin represents an effective pressor agent in patients with catecholamine-unresponsive septic shock. However, caution should be exercised, as terlipressin may contribute dose-dependently to vasoconstriction and a reflectory decrease in cardiac output. Additional studies are needed to clarify: i) the optimal time of therapy institution; ii) the efficacy and the dosages of continuous infusion versus bolus administration; and iii) the safety and efficacy of this compound in comparison with other nonspecific vasopressinergic drugs, such as arginine vasopressin. Whether or not terlipressin may improve the outcome of septic shock patients compared with standard therapy with catecholamines remains to be determined.
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Affiliation(s)
- Andrea Morelli
- Department of Anesthesiology and Intensive Care, University of Rome - La Sapienza, Rome 00161, Italy.
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Judge SIV, Smith PJ. Patents related to therapeutic activation of K(ATP) and K(2P) potassium channels for neuroprotection: ischemic/hypoxic/anoxic injury and general anesthetics. Expert Opin Ther Pat 2009; 19:433-60. [PMID: 19441925 DOI: 10.1517/13543770902765151] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Mechanisms of neuroprotection encompass energy deficits in brain arising from insufficient oxygen and glucose levels following respiratory failure; ischemia or stroke, which produce metabolic stresses that lead to unconsciousness and seizures; and the effects of general anesthetics. Foremost among those K(+) channels viewed as important for neuroprotection are ATP-sensitive (K(ATP)) channels, which belong to the family of inwardly rectifying K(+) channels (K(ir)) and contain a sulfonylurea subunit (SUR1 or SUR2) combined with either K(ir)6.1 (KCNJ8) or K(ir)6.2 (KCNJ11) channel pore-forming alpha-subunits, and various members of the tandem two-pore or background (K(2P)) K(+) channel family, including K(2P)1.1 (KCNK1 or TWIK1), K(2P)2.1 (KCNK2 or TREK/TREK1), K(2P)3.1 (KCNK3 or TASK), K(2P)4.1 (KCNK4 or TRAAK), and K(2P)10.1 (KCNK10 or TREK2). OBJECTIVES This review covers patents and patent applications related to inventions of therapeutics, compound screening methods and diagnostics, including K(ATP) channel openers and blockers, as well as K(ATP) and K(2P) nucleic/amino acid sequences and proteins, vectors, transformed cells and transgenic animals. Although the focus of this patent review is on brain and neuroprotection, patents covering inventions of K(ATP) channel openers for cardioprotection, diabetes mellitus and obesity, where relevant, are addressed. RESULTS/CONCLUSIONS Overall, an important emerging therapeutic mechanism underlying neuroprotection is activation/opening of K(ATP) and K(2P) channels. To this end substantial progress has been made in identifying and patenting agents that target K(ATP) channels. However, current K(2P) channels patents encompass compound screening and diagnostics methodologies, reflecting an earlier 'discovery' stage (target identification/validation) than K(ATP) in the drug development pipeline; this reveals a wide-open field for the discovery and development of K(2P)-targeting compounds.
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Affiliation(s)
- Susan I V Judge
- University of Maryland School of Medicine, MS Center of Excellence-East, VA Maryland Health Care System, Department of Neurology, BRB 12-040, 655 West Baltimore Street, Baltimore, MD 21201, USA
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Rehberg S, Ertmer C, Köhler G, Spiegel HU, Morelli A, Lange M, Moll K, Schlack K, Van Aken H, Su F, Vincent JL, Westphal M. Role of arginine vasopressin and terlipressin as first-line vasopressor agents in fulminant ovine septic shock. Intensive Care Med 2009; 35:1286-96. [PMID: 19360396 DOI: 10.1007/s00134-009-1470-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2008] [Accepted: 03/15/2009] [Indexed: 10/20/2022]
Abstract
PURPOSE To compare the effects of first-line therapy with low-dose arginine vasopressin (AVP) or terlipressin (TP) on mesenteric blood flow, plasma AVP levels, organ function and mortality in ovine septic shock. METHODS Twenty-four adult ewes were anesthetized and instrumented for chronic hemodynamic monitoring. A flow-probe was placed around the superior mesenteric artery, and feces were extracted from the cecum. Following baseline measurements, feces were injected into the peritoneal cavity. When mean arterial pressure (MAP) decreased to less than 60 mmHg, animals were randomly assigned to receive AVP (0.5 mU kg(-1) min(-1)), TP (1 microg kg(-1) h(-1)) or saline (n = 8 each). A norepinephrine infusion was titrated to maintain MAP at 70 +/- 5 mmHg in all groups. RESULTS Cardiovascular pressures, cardiac output, mesenteric blood flow, and lung tissue concentrations of 3-nitrotyrosine and hemoxygenase-1 were similar among groups throughout the study period. TP infusion resulted in lower plasma AVP concentrations, reduced positive net fluid balance, increased central venous oxygen saturation and slightly prolonged survival compared to control and AVP-treated animals. However, TP treatment was associated with higher liver transaminases and lactate dehydrogenase versus control animals after 12 h. CONCLUSIONS This study provides evidence that the effects of low-dose TP differ from those of AVP, not only as TP has a longer half life, but also because of different mechanisms of action. Although low-dose TP infusion may be superior to sole norepinephrine or AVP therapy in septic shock, the safety of this therapeutic approach should be determined in more detail.
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Affiliation(s)
- Sebastian Rehberg
- Department of Anesthesiology and Intensive Care, University Hospital of Muenster, Albert-Schweitzer-Str. 33, 48149, Muenster, Germany.
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Terlipressin in Septic Shock: When and How Much? Intensive Care Med 2009. [DOI: 10.1007/978-0-387-77383-4_40] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Animal models of sepsis: Why does preclinical efficacy fail to translate to the clinical setting? Crit Care Med 2009; 37:S30-7. [DOI: 10.1097/ccm.0b013e3181922bd3] [Citation(s) in RCA: 192] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ertmer C, Rehberg S, Morelli A, Westphal M. Current place of vasopressin analogues in the treatment of septic shock. Curr Infect Dis Rep 2008; 10:362-7. [DOI: 10.1007/s11908-008-0059-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Lange M, Ertmer C, Westphal M. Vasopressin vs. terlipressin in the treatment of cardiovascular failure in sepsis. Intensive Care Med 2007; 34:821-32. [PMID: 18066524 DOI: 10.1007/s00134-007-0946-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2007] [Accepted: 10/27/2007] [Indexed: 12/23/2022]
Abstract
BACKGROUND Arginine vasopressin (AVP) and terlipressin (TP) are increasingly used as adjunct vasopressors in the treatment of septic shock. Despite important pharmacological differences between the two drugs (e.g., receptor selectivity, effective half-life) the use of either substance is determined mainly by local availability and institutional inventory. We briefly describe the pathophysiology and pharmacology of septic shock relevant to the treatment with vasopressin analogues. In addition, differences in pharmacokinetics and pharmacodynamics between AVP and TP are discussed. DISCUSSION The current literature suggests that neither AVP nor TP should be administered in high doses in patients with septic shock. Furthermore, increasing evidence indicates that early administration of vasopressin analogues may improve outcome as compared to a last-resort treatment. Low-dose infusion of AVP (0.6-2.4 U/h) has been demonstrated to be a safe adjunct in the management of septic shock. The V2 agonistic effects of AVP may exert favorable effects on hepatosplanchnic, renal, pulmonary, and coronary perfusion. However, the higher V1 receptor selectivity of TP may prove more potent in restoring arterial blood pressure and avoiding rebound hypotension, while carrying the risk of sustained global and regional vasoconstriction after bolus injection. CONCLUSIONS Evidence from experimental studies and initial clinical reports suggests that continuous low-dose infusion of TP may stabilize hemodynamics in septic shock with reduced side effects. However, randomized, controlled trials are necessary to determine the role of bolus or continuous infusion of TP in the treatment of septic shock before this approach can be recommended for routine clinical use.
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Affiliation(s)
- Matthias Lange
- Department of Anesthesiology and Intensive Care, University of Münster, Albert-Schweitzer-Strasse 33, 48149 Münster, Germany.
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WHAT'S NEW IN SHOCK, October 2007? Shock 2007. [DOI: 10.1097/shk.0b013e31814a54f8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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