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Cheema HA, Musheer A, Ejaz A, Paracha AA, Shahid A, Rehman MEU, Hermis AH, Singh H, Duric N, Ahmad F, Ahmad S, Torres A, Szakmany T. Efficacy and safety of corticosteroids for the treatment of community-acquired pneumonia: A systematic review and meta-analysis of randomized controlled trials. J Crit Care 2024; 80:154507. [PMID: 38128217 DOI: 10.1016/j.jcrc.2023.154507] [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: 08/09/2023] [Revised: 10/01/2023] [Accepted: 10/03/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND The role of corticosteroids in the treatment of community-acquired pneumonia (CAP) remains uncertain. We conducted an updated meta-analysis to investigate the effectiveness and potential effect modifiers of adjunctive corticosteroids in patients with CAP. METHODS The protocol of this meta-analysis was registered with PROSPERO (CRD42022354920). We searched MEDLINE, Embase, the Cochrane Library and trial registers from inception till March 2023 to identify randomized controlled trials (RCTs) investigating corticosteroids in adult patients with CAP. Our primary outcome was the risk of all-cause mortality within 30 days after randomization (if not reported at day 30, we extracted the outcome closest to 30 days). Risk ratios (RR) and mean differences (MDs) were pooled under a random-effects model. RESULTS Fifteen RCTs (n = 3252 patients) were included in this review. Corticosteroids reduced the risk of all-cause mortality in CAP patients (RR: 0.69, 95% CI: 0.53-0.89; high certainty). This significant result was restricted to hydrocortisone therapy and patients with severe CAP. Additionally, younger patients demonstrated a greater reduction in mortality. Corticosteroids reduced the incidence of shock and the need for mechanical ventilation (MV), and decreased the length of hospital and ICU stay (moderate certainty). CONCLUSIONS Corticosteroids reduce the risk of all-cause mortality, especially in younger patients receiving hydrocortisone, and probably decrease the need for MV, the incidence of shock, and the length of hospital and ICU stay in patients with CAP. Our findings indicate that patients with CAP, especially severe CAP, will benefit from adjunctive corticosteroid therapy.
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Affiliation(s)
| | - Adeena Musheer
- Department of Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Arooba Ejaz
- Department of Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Anousheh Awais Paracha
- Department of Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Abia Shahid
- Department of Chest Medicine, King Edward Medical University, Lahore, Pakistan
| | | | - Alaa Hamza Hermis
- Nursing College, Al-Mustaqbal University, 51001 Hillah, Babylon, Iraq
| | - Harpreet Singh
- Division of Pulmonary and Critical Care, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Natalie Duric
- Critical Care Directorate, The Grange University Hospital, Aneurin Bevan University Health Board, Cwmbran, United Kingdom
| | - Faran Ahmad
- Infectious Diseases-Critical Care Medicine, Creighton University Medical Center, Omaha, NE, USA; Critical Care Medicine, Veterans Affairs Medical Center, Omaha, NE, USA
| | - Sharjeel Ahmad
- Department of Medicine, Section of Infectious Diseases, University of Illinois College of Medicine at Peoria, Peoria, IL, USA
| | - Antoni Torres
- Department of Pneumology, Respiratory Institute, Hospital Clinic of Barcelona, Barcelona, Spain; CibeRes (Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, 06/06/0028), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; School of Medicine, University of Barcelona, Barcelona, Spain
| | - Tamas Szakmany
- Critical Care Directorate, The Grange University Hospital, Aneurin Bevan University Health Board, Cwmbran, United Kingdom; Department of Anaesthesia, Intensive Care and Pain Medicine, Division of Population Medicine, Cardiff University, Cardiff, United Kingdom.
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2
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Buckel M, Maclean P, Knight JC, Lawler PR, Proudfoot AG. Extending the 'host response' paradigm from sepsis to cardiogenic shock: evidence, limitations and opportunities. Crit Care 2023; 27:460. [PMID: 38012789 PMCID: PMC10683227 DOI: 10.1186/s13054-023-04752-8] [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: 09/18/2023] [Accepted: 11/20/2023] [Indexed: 11/29/2023] Open
Abstract
Recent clinical and research efforts in cardiogenic shock (CS) have largely focussed on the restoration of the low cardiac output state that is the conditio sine qua non of the clinical syndrome. This approach has failed to translate into improved outcomes, and mortality has remained static at 30-50%. There is an unmet need to better delineate the pathobiology of CS to understand the observed heterogeneity of presentation and treatment effect and to identify novel therapeutic targets. Despite data in other critical illness syndromes, specifically sepsis, the role of dysregulated inflammation and immunity is hitherto poorly described in CS. High-dimensional molecular profiling, particularly through leukocyte transcriptomics, may afford opportunity to better characterise subgroups of patients with shared mechanisms of immune dysregulation. In this state-of-the-art review, we outline the rationale for considering molecular subtypes of CS. We describe how high-dimensional molecular technologies can be used to identify these subtypes, and whether they share biological features with sepsis and other critical illness states. Finally, we propose how the identification of molecular subtypes of patients may enrich future clinical trial design and identification of novel therapies for CS.
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Affiliation(s)
- Marie Buckel
- Department of Perioperative Medicine, Bart's Heart Centre, St. Bartholomew's Hospital, London, UK
| | - Patrick Maclean
- Wellcome Centre for Human Genetics, University of Oxford, Oxford, UK
| | - Julian C Knight
- Wellcome Centre for Human Genetics, University of Oxford, Oxford, UK
- Chinese Academy of Medical Sciences Oxford Institute, University of Oxford, Oxford, UK
| | - Patrick R Lawler
- Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, ON, Canada
- McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - Alastair G Proudfoot
- Department of Perioperative Medicine, Bart's Heart Centre, St. Bartholomew's Hospital, London, UK.
- Queen Mary University of London, London, UK.
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3
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Juschten J, Tuinman PR, de Grooth HJ. Harmonization of Reported Baseline Characteristics Is a Prerequisite for Progress in Acute Respiratory Distress Syndrome Research. Ann Am Thorac Soc 2023; 20:947-950. [PMID: 37166835 DOI: 10.1513/annalsats.202212-1038ip] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 02/27/2023] [Indexed: 03/03/2023] Open
Affiliation(s)
- Jenny Juschten
- Department of Anesthesiology and
- Department of Intensive Care, Amsterdam University Medical Center, Location VUmc, Amsterdam, the Netherlands
| | - Pieter R Tuinman
- Department of Intensive Care, Amsterdam University Medical Center, Location VUmc, Amsterdam, the Netherlands
| | - Harm-Jan de Grooth
- Department of Intensive Care, Amsterdam University Medical Center, Location VUmc, Amsterdam, the Netherlands
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4
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Dianti J, McNamee JJ, Slutsky AS, Fan E, Ferguson ND, McAuley DF, Goligher EC. Determinants of Effect of Extracorporeal CO 2 Removal in Hypoxemic Respiratory Failure. NEJM EVIDENCE 2023; 2:EVIDoa2200295. [PMID: 38320056 DOI: 10.1056/evidoa2200295] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
BACKGROUND: Dead space and respiratory system elastance (Ers) may influence the clinical benefit of a ventilation strategy combining very low tidal volume (VT) with extracorporeal carbon dioxide removal (ECCO2R) in patients with acute hypoxemic respiratory failure. We sought to evaluate whether the effect of ECCO2R on mortality varies according to ventilatory ratio (VR; a composite variable reflective of dead space and shunt) and Ers. METHODS: Secondary analysis of a trial of a strategy combining very low VT and low-flow ECCO2R planned before the availability of trial results. Bayesian logistic regression was used to estimate the posterior probability of effect moderation by VR, Ers, and severity of hypoxemia (ratio of arterial partial pressure of oxygen to fraction of inspired oxygen [PaO2:FiO2]) on 90-day mortality. Credibility of effect moderation was appraised according to the Instrument for Assessing the Credibility of Effect Modification Analyses criteria. RESULTS: A total of 405 patients were available for analysis. The effect of the intervention on mortality varied substantially with VR (posterior probability of interaction, 94%; high credibility). Benefit was more probable than harm in patients with VR 3 or higher. In patients with VR less than 3, the probability of increased mortality with intervention was high (>90%). The effect of the intervention also varied with PaO2:FiO2 (posterior probability of interaction, >99%; low credibility). Benefit was more probable than harm in patients with PaO2:FiO2 110 mm Hg or higher. The effect of the intervention did not vary substantially with Ers (posterior probability of interaction, 68%; low credibility). CONCLUSIONS: VR has a highly credible influence on the effect of a strategy combining very low VT and low-flow ECCO2R on mortality. This intervention may reduce mortality in patients with high VR. (Funded by an Early Career Investigator Award from the Canadian Institutes of Health Research to Dr. Goligher.)
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Affiliation(s)
- Jose Dianti
- Department of Medicine, Division of Respirology, University Health Network, University of Toronto, Toronto, ON
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON
| | - James J McNamee
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Science, Queen's University Belfast, Belfast, United Kingdom
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, United Kingdom
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON
| | - Eddy Fan
- Department of Medicine, Division of Respirology, University Health Network, University of Toronto, Toronto, ON
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON
- Toronto General Hospital Research Institute, Toronto, ON
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON
| | - Niall D Ferguson
- Department of Medicine, Division of Respirology, University Health Network, University of Toronto, Toronto, ON
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON
- Toronto General Hospital Research Institute, Toronto, ON
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON
- Department of Physiology, University of Toronto, Toronto, ON
| | - Daniel F McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Science, Queen's University Belfast, Belfast, United Kingdom
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, United Kingdom
| | - Ewan C Goligher
- Department of Medicine, Division of Respirology, University Health Network, University of Toronto, Toronto, ON
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON
- Toronto General Hospital Research Institute, Toronto, ON
- Department of Physiology, University of Toronto, Toronto, ON
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5
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Saha R, Assouline B, Mason G, Douiri A, Summers C, Shankar-Har M. The Impact of Sample Size Misestimations on the Interpretation of ARDS Trials: Systematic Review and Meta-analysis. Chest 2022; 162:1048-1062. [PMID: 35643115 DOI: 10.1016/j.chest.2022.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 04/06/2022] [Accepted: 05/04/2022] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Indeterminate randomized controlled trials (RCTs) in ARDS may arise from sample size misspecification, leading to abandonment of efficacious therapies. RESEARCH QUESTIONS If evidence exists for sample size misspecification in ARDS RCTs, has this led to rejection of potentially beneficial therapies? Does evidence exist for prognostic enrichment in RCTs using mortality as a primary outcome? STUDY DESIGN AND METHODS We identified 150 ARDS RCTs commencing recruitment after the 1994 American European Consensus Conference ARDS definition and published before October 31, 2020. We examined predicted-observed sample size, predicted-observed control event rate (CER), predicted-observed average treatment effect (ATE), and the relationship between observed CER and observed ATE for RCTs with mortality and nonmortality primary outcome measures. To quantify the strength of evidence, we used Bayesian-averaged meta-analysis, trial sequential analysis, and Bayes factors. RESULTS Only 84 of 150 RCTs (56.0%) reported sample size estimations. In RCTs with mortality as the primary outcome, CER was overestimated in 16 of 28 RCTs (57.1%). To achieve predicted ATE, interventions needed to prevent 40.8% of all deaths, compared with the original prediction of 29.3%. Absolute reduction in mortality ≥ 10% was observed in 5 of 28 RCTs (17.9%), but predicted in 21 of 28 RCTs (75%). For RCTs with mortality as the primary outcome, no association was found between observed CER and observed ATE (pooled OR: β = -0.04; 95% credible interval, -0.18 to 0.09). We identified three interventions that are not currently standard of care with a Bayesian-averaged effect size of > 0.20 and moderate strength of existing evidence: corticosteroids, airway pressure release ventilation, and noninvasive ventilation. INTERPRETATION Reporting of sample size estimations was inconsistent in ARDS RCTs, and misspecification of CER and ATE was common. Prognostic enrichment strategies in ARDS RCTs based on all-cause mortality are unlikely to be successful. Bayesian methods can be used to prioritize interventions for future effectiveness RCTs.
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Affiliation(s)
- Rohit Saha
- Critical Care Centre, King's College London, London, United Kingdom; School of Immunology & Microbial Sciences, King's College London, London, United Kingdom
| | - Benjamin Assouline
- Service de Médecine Intensive Réanimation, Faculté de Médecine Sorbonne Université, Hôpital Pitié Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Georgina Mason
- Critical Care Centre, King's College London, London, United Kingdom
| | - Abdel Douiri
- School of Population Health & Environmental Sciences, King's College London, London, United Kingdom; National Institute for Health Research Comprehensive Biomedical Research Centre, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - Charlotte Summers
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Manu Shankar-Har
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, United Kingdom.
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6
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Rochwerg B. Corticosteroids for severe community-acquired pneumonia: a story without an ending. Intensive Care Med 2022; 48:1053-1055. [PMID: 35552779 PMCID: PMC9098255 DOI: 10.1007/s00134-022-06699-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 04/06/2022] [Indexed: 11/12/2022]
Affiliation(s)
- Bram Rochwerg
- Department of Medicine, McMaster University, 1200 Main St W, Hamilton, ON, Canada. .,Department of Health Research Methods, Evidence and Impact, McMaster University, 1200 Main St W, Hamilton, ON, Canada.
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7
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Eckert I, Kumbier MCC, Silva FM, Franzosi OS, de Almeida JC. Association of specialized enteral nutrition with glycemic control and clinical outcomes in critically ill patients: A meta-analysis of randomized controlled trials. Clin Nutr 2021; 40:3940-3949. [PMID: 34139467 DOI: 10.1016/j.clnu.2021.04.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 04/06/2021] [Accepted: 04/19/2021] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To evaluate the association of glycemic-control formulae (GCF) with measurements of glycemic control and clinical outcomes compared to standard enteral formulae (SF) in critically ill patients. DATA SOURCES MEDLINE, EMBASE, Scopus and the Cochrane Central Register of Controlled Trials were searched from inception up to January, 2021. STUDY SELECTION RCTs that assessed the effects of GCF relative to SF in adult critically ill patients. DATA EXTRACTION Measurements of glycemic control were the primary outcomes. Secondary outcomes included insulin requirements, mechanical ventilation (MV), length of intensive care unit (ICU) stay and mortality. Two authors independently extracted data and assessed risk of bias using the Cochrane's RoB 2 tool and the GRADE approach was used to assess the quality of evidence. DATA SYNTHESIS Ten studies (12 reports, 685 patients) were included. The use of GCFs was associated with lower blood glucose (WMD, -16.06 mg/dL; 95% CI -23.48 to -8.63; I2 = 47%) and lower daily administered insulin (WMD, -7.20 IU; 95% CI -13.92 to -0.48; I2 = 53%). Glycemic variability, measured by the coefficient of variation, was also associated with the use of GCFs (WMD, -6.84%; 95% CI, -13.57 to -0.11; I2 = 95%). In contrast, analyses for length of ICU stay (WMD, -0.12, 95% CI -1.77 to 1.52; I2 = 0%), duration of MV (WMD, -0.34 days; 95% CI, -1.72 to 1.04; I2 = 0%) and mortality (RR, 1.13; 95% CI 0.82 to 1.56; I2 = 0%) were not statistically significant. Quality of evidence ranged from low to very low, and only one study was judged as at low risk of bias. CONCLUSIONS In this meta-analysis, GCFs were significantly associated with lower insulin requirements and improved glycemic control. Although results for clinical outcomes were not statistically significant, there is insufficient evidence to confirm or exclude important differences due to serious imprecision in the effect estimates and overall low quality of evidence. The effects of GCFs on clinical outcomes require confirmation in larger randomized trials.
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Affiliation(s)
- Igor Eckert
- Nutrition Undergraduate Program, Federal University of Health Sciences of Porto Alegre (UFCSPA), Rio Grande do Sul, Brazil
| | - Magali C C Kumbier
- Graduate Program on Medical Sciences: Endocrinology, Faculdade de Medicina, Universidade Federal Do Rio Grande Do Sul (UFRGS), Rio Grande do Sul, Brazil
| | - Flávia M Silva
- Department of Nutrition and Postgraduate Program in Nutrition Sciences, Federal University of Health Sciences of Porto Alegre (UFCSPA), Rio Grande do Sul, Brazil.
| | - Oellen S Franzosi
- Nutrition and Dietetic Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Jussara C de Almeida
- Graduate Program on Medical Sciences: Endocrinology, Faculdade de Medicina, Universidade Federal Do Rio Grande Do Sul (UFRGS), Rio Grande do Sul, Brazil; Division of Nutrition and Dietetics, Hospital de Clínicas de Porto Alegre (HCPA), Rio Grande do Sul, Brazil; Department of Nutrition, Faculdade de Medicina, Universidade Federal Do Rio Grande Do Sul, Rio Grande do Sul (UFRGS), Brazil
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8
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Donovan K, Shah A, Day J, McKechnie SR. Adjunctive treatments for the management of septic shock - a narrative review of the current evidence. Anaesthesia 2021; 76:1245-1258. [PMID: 33421029 DOI: 10.1111/anae.15369] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2020] [Indexed: 12/13/2022]
Abstract
Septic shock is a leading cause of death and morbidity worldwide. The cornerstones of management include prompt identification of sepsis, early initiation of antibiotic therapy, adequate fluid resuscitation and organ support. Over the past two decades, there have been considerable improvements in our understanding of the pathophysiology of sepsis and the host response, including regulation of inflammation, endothelial disruption and impaired immunity. This has offered opportunities for innovative adjunctive treatments such as vitamin C, corticosteroids and beta-blockers. Some of these approaches have shown promising results in early phase trials in humans, while others, such as corticosteroids, have been tested in large, international, multicentre randomised controlled trials. Contemporary guidelines make a weak recommendation for the use of corticosteroids to reduce mortality in sepsis and septic shock. Vitamin C, despite showing initial promise in observational studies, has so far not been shown to be clinically effective in randomised trials. Beta-blocker therapy may have beneficial cardiac and non-cardiac effects in septic shock, but there is currently insufficient evidence to recommend their use for this condition. The results of ongoing randomised trials are awaited. Crucial to reducing heterogeneity in the trials of new sepsis treatments will be the concept of enrichment, which refers to the purposive selection of patients with clinical and biological characteristics that are likely to be responsive to the intervention being tested.
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Affiliation(s)
- K Donovan
- Adult Intensive Care Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Adult Intensive Care Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - A Shah
- Adult Intensive Care Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - J Day
- Adult Intensive Care Unit and Nuffield Department of Anaesthesia, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - S R McKechnie
- Adult Intensive Care Unit and Nuffield Department of Anaesthesia, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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9
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Population enrichment for critical care trials: phenotypes and differential outcomes. Curr Opin Crit Care 2020; 25:489-497. [PMID: 31335383 DOI: 10.1097/mcc.0000000000000641] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW Sepsis and acute respiratory distress syndrome (ARDS) are two heterogenous acute illnesses where numerous RCTs have indeterminate results. We present a narrative review on the recent developments in enriching patient populations for future sepsis and ARDS trials. RECENT FINDINGS Many researchers are actively pursuing enrichment strategies to reduce heterogeneity to increase the sensitivity of future trials. Enrichment refers to the use of measurable patient characteristics, known before randomisation, to refine trial populations. Biomarkers could increase the diagnostic certainty of sepsis, whereas chest radiology training to enhance reliability of interpretation and stabilisation period of mechanical ventilation have been considered to increase the diagnostic certainty of ARDS. Clinical and biomarker data analyses identifies four to six sepsis clinical phenotypes and two ARDS clinical phenotypes. Similarly, leukocyte gene expression data identifies two to four sepsis molecular phenotypes. Use of a test-dose identifies ARDS subpopulations who are likely to benefit from higher PEEP. Early-phase trials report how a biomarker that is altered by the intervention, such as lymphocyte count for recombinant interleukin-7 therapy and higher check point inhibitor expression for anti-check point treatments in sepsis, could identify a higher treatment effect population for future trials. SUMMARY Enrichment reduces heterogeneity and will enhance the sensitivity of future trials. However, enrichment, even when it identifies more homogenous populations, may not be efficient to deploy in trials or clinical practice.
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10
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Anderson BJ, Calfee CS, Liu KD, Reilly JP, Kangelaris KN, Shashaty MGS, Lazaar AL, Bayliffe AI, Gallop RJ, Miano TA, Dunn TG, Johansson E, Abbott J, Jauregui A, Deiss T, Vessel K, Belzer A, Zhuo H, Matthay MA, Meyer NJ, Christie JD. Plasma sTNFR1 and IL8 for prognostic enrichment in sepsis trials: a prospective cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:400. [PMID: 31818332 PMCID: PMC6902425 DOI: 10.1186/s13054-019-2684-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 11/22/2019] [Indexed: 01/07/2023]
Abstract
Background Enrichment strategies improve therapeutic targeting and trial efficiency, but enrichment factors for sepsis trials are lacking. We determined whether concentrations of soluble tumor necrosis factor receptor-1 (sTNFR1), interleukin-8 (IL8), and angiopoietin-2 (Ang2) could identify sepsis patients at higher mortality risk and serve as prognostic enrichment factors. Methods In a multicenter prospective cohort study of 400 critically ill septic patients, we derived and validated thresholds for each marker and expressed prognostic enrichment using risk differences (RD) of 30-day mortality as predictive values. We then used decision curve analysis to simulate the prognostic enrichment of each marker and compare different prognostic enrichment strategies. Measurements and main results An admission sTNFR1 concentration > 8861 pg/ml identified patients with increased mortality in both the derivation (RD 21.6%) and validation (RD 17.8%) populations. Among immunocompetent patients, an IL8 concentration > 94 pg/ml identified patients with increased mortality in both the derivation (RD 17.7%) and validation (RD 27.0%) populations. An Ang2 level > 9761 pg/ml identified patients at 21.3% and 12.3% increased risk of mortality in the derivation and validation populations, respectively. Using sTNFR1 or IL8 to select high-risk patients improved clinical trial power and efficiency compared to selecting patients with septic shock. Ang2 did not outperform septic shock as an enrichment factor. Conclusions Thresholds for sTNFR1 and IL8 consistently identified sepsis patients with higher mortality risk and may have utility for prognostic enrichment in sepsis trials.
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Affiliation(s)
- Brian J Anderson
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, 5036 Gates Building, Philadelphia, PA, 19104, USA.
| | - Carolyn S Calfee
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, USA
| | - Kathleen D Liu
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, USA
| | - John P Reilly
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, 5036 Gates Building, Philadelphia, PA, 19104, USA
| | - Kirsten N Kangelaris
- Division of Hospital Medicine, Department of Medicine, University of California San Francisco, San Francisco, USA
| | - Michael G S Shashaty
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, 5036 Gates Building, Philadelphia, PA, 19104, USA.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Aili L Lazaar
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA.,GlaxoSmithKline R&D, Brentford, UK
| | | | - Robert J Gallop
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA.,Department of Mathematics, West Chester University, West Chester, USA
| | - Todd A Miano
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Thomas G Dunn
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, 5036 Gates Building, Philadelphia, PA, 19104, USA
| | - Erik Johansson
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, 5036 Gates Building, Philadelphia, PA, 19104, USA
| | - Jason Abbott
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, USA
| | - Alejandra Jauregui
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, USA
| | - Thomas Deiss
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, USA
| | - Kathryn Vessel
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, USA
| | - Annika Belzer
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, USA
| | - Hanjing Zhuo
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, USA
| | - Michael A Matthay
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, USA
| | - Nuala J Meyer
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, 5036 Gates Building, Philadelphia, PA, 19104, USA
| | - Jason D Christie
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, 5036 Gates Building, Philadelphia, PA, 19104, USA.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
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11
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Kitsios GD, Yang L, Manatakis DV, Nouraie M, Evankovich J, Bain W, Dunlap DD, Shah F, Barbash IJ, Rapport SF, Zhang Y, DeSensi RS, Weathington NM, Chen BB, Ray P, Mallampalli RK, Benos PV, Lee JS, Morris A, McVerry BJ. Host-Response Subphenotypes Offer Prognostic Enrichment in Patients With or at Risk for Acute Respiratory Distress Syndrome. Crit Care Med 2019; 47:1724-1734. [PMID: 31634231 PMCID: PMC6865808 DOI: 10.1097/ccm.0000000000004018] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVES Classification of patients with acute respiratory distress syndrome into hyper- and hypoinflammatory subphenotypes using plasma biomarkers may facilitate more effective targeted therapy. We examined whether established subphenotypes are present not only in patients with acute respiratory distress syndrome but also in patients at risk for acute respiratory distress syndrome (ARFA) and then assessed the prognostic information of baseline subphenotyping on the evolution of host-response biomarkers and clinical outcomes. DESIGN Prospective, observational cohort study. SETTING Medical ICU at a tertiary academic medical center. PATIENTS Mechanically ventilated patients with acute respiratory distress syndrome or ARFA. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We performed longitudinal measurements of 10 plasma biomarkers of host injury and inflammation. We applied unsupervised latent class analysis methods utilizing baseline clinical and biomarker variables and demonstrated that two-class models (hyper- vs hypoinflammatory subphenotypes) offered improved fit compared with one-class models in both patients with acute respiratory distress syndrome and ARFA. Baseline assignment to the hyperinflammatory subphenotype (39/104 [38%] acute respiratory distress syndrome and 30/108 [28%] ARFA patients) was associated with higher severity of illness by Sequential Organ Failure Assessment scores and incidence of acute kidney injury in patients with acute respiratory distress syndrome, as well as higher 30-day mortality and longer duration of mechanical ventilation in ARFA patients (p < 0.0001). Hyperinflammatory patients exhibited persistent elevation of biomarkers of innate immunity for up to 2 weeks postintubation. CONCLUSIONS Our results suggest that two distinct subphenotypes are present not only in patients with established acute respiratory distress syndrome but also in patients at risk for its development. Hyperinflammatory classification at baseline is associated with higher severity of illness, worse clinical outcomes, and trajectories of persistently elevated biomarkers of host injury and inflammation during acute critical illness compared with hypoinflammatory patients. Our findings provide strong rationale for examining treatment effect modifications by subphenotypes in randomized clinical trials to inform precision therapeutic approaches in critical care.
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Affiliation(s)
- Georgios D. Kitsios
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Center for Medicine and the Microbiome, University of Pittsburgh
| | - Libing Yang
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Dimitris V. Manatakis
- Department of Computational and Systems Biology, University of Pittsburgh, Pittsburgh, PA, United States
| | - Mehdi Nouraie
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - John Evankovich
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - William Bain
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Daniel D. Dunlap
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Faraaz Shah
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ian J Barbash
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Sarah F. Rapport
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Yingze Zhang
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Rebecca S. DeSensi
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Nathaniel M. Weathington
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Bill B. Chen
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Prabir Ray
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Rama K. Mallampalli
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Veterans Affairs Pittsburgh Healthcare System
| | - Panayiotis V. Benos
- Department of Computational and Systems Biology, University of Pittsburgh, Pittsburgh, PA, United States
| | - Janet S. Lee
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Alison Morris
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Center for Medicine and the Microbiome, University of Pittsburgh
- Department of Immunology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Bryan J. McVerry
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Center for Medicine and the Microbiome, University of Pittsburgh
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12
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Santhakumaran S, Gordon A, Prevost AT, O'Kane C, McAuley DF, Shankar-Hari M. Heterogeneity of treatment effect by baseline risk of mortality in critically ill patients: re-analysis of three recent sepsis and ARDS randomised controlled trials. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:156. [PMID: 31053084 PMCID: PMC6500045 DOI: 10.1186/s13054-019-2446-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 04/15/2019] [Indexed: 01/15/2023]
Abstract
Background Randomised controlled trials (RCTs) enrolling patients with sepsis or acute respiratory distress syndrome (ARDS) generate heterogeneous trial populations. Non-random variation in the treatment effect of an intervention due to differences in the baseline risk of death between patients in a population represents one form of heterogeneity of treatment effect (HTE). We assessed whether HTE in two sepsis and one ARDS RCTs could explain indeterminate trial results and inform future trial design. Methods We assessed HTE for vasopressin, hydrocortisone and levosimendan in sepsis and simvastatin in ARDS patients, on 28-day mortality, using the total Acute Physiology And Chronic Health Evaluation II (APACHE II) score as the baseline risk measurement, comparing above (high) and below (low) the median score. Secondary risk measures were the acute physiology component of APACHE II and predicted risk of mortality using the APACHE II score. HTE was quantified both in additive (difference in risk difference (RD)) and multiplicative (ratio of relative risks (RR)) scales using estimated treatment differences from a logistic regression model with treatment risk as the interaction term. Results The ratio of the odds of death in the highest APACHE II quartile was 4.9 to 7.4 times compared to the lowest quartile, across the three trials. We did not observe HTE for vasopressin, hydrocortisone and levosimendan in the two sepsis trials. In the HARP-2 trial, simvastatin reduced mortality in the low APACHE II group and increased mortality in the high APACHE II group (difference in RD = 0.34 (0.12, 0.55) (p = 0.02); ratio of RR 3.57 (1.77, 7.17) (p < 0.001). The HTE patterns were inconsistent across the secondary risk measures. The sensitivity analyses of HTE effects for vasopressin, hydrocortisone and levosimendan were consistent with the main analyses and attenuated for simvastatin. Conclusions We assessed HTE in three recent ICU RCTs, using multivariable baseline risk of death models. There was considerable within-trial variation in the baseline risk of death. We observed potential HTE for simvastatin in ARDS, but no evidence of HTE for vasopressin, hydrocortisone or levosimendan in the two sepsis trials. Our findings could be explained either by true lack of HTE (no benefit of vasopressin, hydrocortisone or levosimendan vs comparator for any patient subgroups) or by lack of power to detect HTE. Our results require validation using similar trial databases. Electronic supplementary material The online version of this article (10.1186/s13054-019-2446-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Shalini Santhakumaran
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, W12 7RH, UK
| | - Anthony Gordon
- Section of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London, W2 1NY, UK
| | - A Toby Prevost
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, W12 7RH, UK
| | - Cecilia O'Kane
- Centre for Experimental Medicine, Wellcome-Wolfson Institute for Experimental Medicine, Belfast, BT9 7AE, UK
| | - Daniel F McAuley
- Centre for Experimental Medicine, Wellcome-Wolfson Institute for Experimental Medicine, Belfast, BT9 7AE, UK.,Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, BT12 6BA, UK
| | - Manu Shankar-Hari
- Department of Intensive Care Medicine, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust , Westminster Bridge Road, London, SE1 7EH, UK. .,Peter Gorer Department of Immunobiology, School of Immunology & Microbial Sciences, King's College London, London, SE1 9RT, UK.
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13
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Guervilly C, Parzy G, Papazian L. Acute respiratory distress syndrome phenotyping and latent class analysis, first steps toward precision medicine in critical care illness? J Thorac Dis 2019; 11:S303-S306. [PMID: 30997204 DOI: 10.21037/jtd.2019.01.13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Christophe Guervilly
- Medical Intensive Care Unit, North Hospital, APHM, Marseille, France.,CEReSS, Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France
| | - Gabriel Parzy
- Medical Intensive Care Unit, North Hospital, APHM, Marseille, France
| | - Laurent Papazian
- Medical Intensive Care Unit, North Hospital, APHM, Marseille, France.,CEReSS, Center for Studies and Research on Health Services and Quality of Life EA3279, Aix-Marseille University, Marseille, France
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14
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Shankar-Hari M, Fan E, Ferguson ND. Acute respiratory distress syndrome (ARDS) phenotyping. Intensive Care Med 2018; 45:516-519. [PMID: 30519902 DOI: 10.1007/s00134-018-5480-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 11/21/2018] [Indexed: 01/10/2023]
Affiliation(s)
- M Shankar-Hari
- School of Immunology and Microbial Science, Kings College London, London, SE1 9RT, UK.
- Guy's and St Thomas' NHS Foundation Trust, ICU Support Offices, St Thomas' Hospital, 1st Floor, East Wing, London, SE1 7EH, UK.
| | - E Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- University Health Network and Sinai Health System, 585 University Avenue, PMB 11, Toronto, ON, M5G 2N2, Canada
| | - N D Ferguson
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- University Health Network and Sinai Health System, 585 University Avenue, PMB 11, Toronto, ON, M5G 2N2, Canada
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15
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Uhel F, Peters-Sengers H, van der Poll T. Initiation of renal replacement therapy in patients with sepsis: more to it than meets the eye. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:S130. [PMID: 30740451 DOI: 10.21037/atm.2018.12.36] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Fabrice Uhel
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Hessel Peters-Sengers
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Tom van der Poll
- Center for Experimental and Molecular Medicine, Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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16
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Kesselmeier M, Scherag A. Commentary: Arguing for Adaptive Clinical Trials in Sepsis. Front Immunol 2018; 9:2507. [PMID: 30425717 PMCID: PMC6218887 DOI: 10.3389/fimmu.2018.02507] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 10/10/2018] [Indexed: 01/14/2023] Open
Affiliation(s)
- Miriam Kesselmeier
- Research Group Clinical Epidemiology, Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany
| | - André Scherag
- Research Group Clinical Epidemiology, Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany.,Institute of Medical Statistics, Computer and Data Sciences, Jena University Hospital, Jena, Germany
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17
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Shankar-Hari M, Datta D, Wilson J, Assi V, Stephen J, Weir CJ, Rennie J, Antonelli J, Bateman A, Felton JM, Warner N, Judge K, Keenan J, Wang A, Burpee T, Brown AK, Lewis SM, Mare T, Roy AI, Wright J, Hulme G, Dimmick I, Gray A, Rossi AG, Simpson AJ, Conway Morris A, Walsh TS. Early PREdiction of sepsis using leukocyte surface biomarkers: the ExPRES-sepsis cohort study. Intensive Care Med 2018; 44:1836-1848. [PMID: 30291379 DOI: 10.1007/s00134-018-5389-0] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 09/24/2018] [Indexed: 12/11/2022]
Abstract
PURPOSE Reliable biomarkers for predicting subsequent sepsis among patients with suspected acute infection are lacking. In patients presenting to emergency departments (EDs) with suspected acute infection, we aimed to evaluate the reliability and discriminant ability of 47 leukocyte biomarkers as predictors of sepsis (Sequential Organ Failure Assessment score ≥ 2 at 24 h and/or 72 h following ED presentation). METHODS In a multi-centre cohort study in four EDs and intensive care units (ICUs), we standardised flow-cytometric leukocyte biomarker measurement and compared patients with suspected acute infection (cohort-1) with two comparator cohorts: ICU patients with established sepsis (cohort-2), and ED patients without infection or systemic inflammation but requiring hospitalization (cohort-3). RESULTS Between January 2014 and February 2016, we recruited 272, 59 and 75 patients to cohorts 1, 2, and 3, respectively. Of 47 leukocyte biomarkers, 14 were non-reliable, and 17 did not discriminate between the three cohorts. Discriminant analyses for predicting sepsis within cohort-1 were undertaken for eight neutrophil (cluster of differentiation antigens (CD) CD15; CD24; CD35; CD64; CD312; CD11b; CD274; CD279), seven monocyte (CD35; CD64; CD312; CD11b; HLA-DR; CD274; CD279) and a CD8 T-lymphocyte biomarker (CD279). Individually, only higher neutrophil CD279 [OR 1.78 (95% CI 1.23-2.57); P = 0.002], higher monocyte CD279 [1.32 (1.03-1.70); P = 0.03], and lower monocyte HLA-DR [0.73 (0.55-0.97); P = 0.03] expression were associated with subsequent sepsis. With logistic regression the optimum biomarker combination was increased neutrophil CD24 and neutrophil CD279, and reduced monocyte HLA-DR expression, but no combination had clinically relevant predictive validity. CONCLUSIONS From a large panel of leukocyte biomarkers, immunosuppression biomarkers were associated with subsequent sepsis in ED patients with suspected acute infection. CLINICAL TRIAL REGISTRATION NCT02188992.
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Affiliation(s)
- Manu Shankar-Hari
- School of Immunology & Microbial Sciences, Kings College, London, UK. .,Guy's and St Thomas' NHS Foundation Trust, London, SE17EH, UK.
| | - Deepankar Datta
- MRC Centre for Inflammation Research, University of Edinburgh, 47 Little France Crescent, Edinburgh, UK
| | - Julie Wilson
- School of Immunology & Microbial Sciences, Kings College, London, UK.,Guy's and St Thomas' NHS Foundation Trust, London, SE17EH, UK
| | - Valentina Assi
- Centre for Population Health Sciences, Usher Institute, University of Edinburgh, Edinburgh, UK.,Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | | | - Christopher J Weir
- Centre for Population Health Sciences, Usher Institute, University of Edinburgh, Edinburgh, UK.,Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Jillian Rennie
- MRC Centre for Inflammation Research, University of Edinburgh, 47 Little France Crescent, Edinburgh, UK
| | - Jean Antonelli
- Centre for Population Health Sciences, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Anthony Bateman
- Department of Anaesthesia, Critical Care & Pain Medicine, University of Edinburgh, Edinburgh, UK
| | - Jennifer M Felton
- MRC Centre for Inflammation Research, University of Edinburgh, 47 Little France Crescent, Edinburgh, UK
| | - Noel Warner
- Becton-Dickinson Bioscience, Franklin Lakes, NJ, USA.,Integrated Critical Care Unit, Sunderland Royal Hospital, Sunderland, UK
| | - Kevin Judge
- Becton-Dickinson Bioscience, Franklin Lakes, NJ, USA.,Integrated Critical Care Unit, Sunderland Royal Hospital, Sunderland, UK
| | - Jim Keenan
- Becton-Dickinson Bioscience, Franklin Lakes, NJ, USA.,Integrated Critical Care Unit, Sunderland Royal Hospital, Sunderland, UK
| | - Alice Wang
- Becton-Dickinson Bioscience, Franklin Lakes, NJ, USA.,Integrated Critical Care Unit, Sunderland Royal Hospital, Sunderland, UK
| | - Tony Burpee
- Becton-Dickinson Bioscience, Franklin Lakes, NJ, USA.,Integrated Critical Care Unit, Sunderland Royal Hospital, Sunderland, UK
| | - Alun K Brown
- Guy's and St Thomas' NHS Foundation Trust, London, SE17EH, UK
| | - Sion M Lewis
- Guy's and St Thomas' NHS Foundation Trust, London, SE17EH, UK
| | - Tracey Mare
- Guy's and St Thomas' NHS Foundation Trust, London, SE17EH, UK
| | - Alistair I Roy
- Becton-Dickinson Bioscience, Franklin Lakes, NJ, USA.,Integrated Critical Care Unit, Sunderland Royal Hospital, Sunderland, UK
| | - John Wright
- Emergency Department, Royal Victoria Infirmary, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Gillian Hulme
- Flow Cytometry Core Facility Laboratory, Faculty of Medical Sciences, Centre for Life, Newcastle University, Newcastle upon Tyne, UK
| | - Ian Dimmick
- Flow Cytometry Core Facility Laboratory, Faculty of Medical Sciences, Centre for Life, Newcastle University, Newcastle upon Tyne, UK
| | - Alasdair Gray
- Centre for Population Health Sciences, Usher Institute, University of Edinburgh, Edinburgh, UK.,Department of Emergency Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Adriano G Rossi
- MRC Centre for Inflammation Research, University of Edinburgh, 47 Little France Crescent, Edinburgh, UK
| | - A John Simpson
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Andrew Conway Morris
- University Division of Anesthesia, Department of Medicine, Addenbrooke's Hospital, Hills Road, Cambridge, UK
| | - Timothy S Walsh
- MRC Centre for Inflammation Research, University of Edinburgh, 47 Little France Crescent, Edinburgh, UK.,Centre for Population Health Sciences, Usher Institute, University of Edinburgh, Edinburgh, UK.,Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
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18
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Shankar-Hari M, Harrison DA, Rowan KM, Rubenfeld GD. Estimating attributable fraction of mortality from sepsis to inform clinical trials. J Crit Care 2018; 45:33-39. [DOI: 10.1016/j.jcrc.2018.01.018] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 01/15/2018] [Accepted: 01/17/2018] [Indexed: 11/17/2022]
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19
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Lymphocyte subset expression and serum concentrations of PD-1/PD-L1 in sepsis - pilot study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:95. [PMID: 29661225 PMCID: PMC5902875 DOI: 10.1186/s13054-018-2020-2] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 03/26/2018] [Indexed: 12/27/2022]
Abstract
Background Sepsis remains a major cause of mortality in critical care, for which specific treatments are lacking. The dysregulated response to infection seen in sepsis includes features of lymphocyte dysfunction and exhaustion, suggesting that immune-stimulatory therapy may improve outcomes in certain patient groups. Monoclonal antibodies targeting checkpoint molecules, such as programmed-death 1 protein (PD-1) and its ligand PD-L1, have shown success in stimulating the immune response in patients with cancer, and are being considered for future sepsis trials. The aims of this pilot study were to compare lymphocyte subset expression of PD-1 and its ligands between patients with sepsis and controls; to characterize serum levels of PD-1 and PD-L1 in patients with sepsis and controls, and determine if serum concentrations correlated with cell surface expression. Methods Expression levels of PD-1, PD-L1 and PD-L2 on four lymphocyte subsets (CD27 + CD19+ B cells, CD27-CD19+ B cells, CD27 + CD4+ T cells and CD27-CD4+ T cells) were compared between 22 patients with sepsis (including 11 survivors and 11 non-survivors) and 11 healthy controls using flow cytometry. Levels of soluble PD-1 and PD-L1 were also compared using commercially available ELISA kits. Results Expression of PD-1 and PD-L1 was higher on all lymphocyte subsets in patients with sepsis compared to controls (p < 0.05). PD-L2 expression on CD27+ B cells was also higher in patients with sepsis (p = 0.0317). There was differential expression of PD-1 by CD27 status, with expression being higher in the B and T cell subsets associated with memory status (CD27+ and CD27-, respectively; p < 0.001). Higher PD-1 and PD-L1 expression was not associated with mortality or with a higher risk of nosocomial infection. There were no differences in levels of soluble PD-1 or PD-L1 between patients with sepsis and controls. Conclusions Higher expression of PD-1 by memory subpopulations of B cells and CD4+ T cells, with normal soluble PD-1 and PD-L1 in patients with sepsis, are novel findings. This information may be useful to enrich sepsis populations for trials of PD-1/PD-L1 blockade. Electronic supplementary material The online version of this article (10.1186/s13054-018-2020-2) contains supplementary material, which is available to authorized users.
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20
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Immunoglobulins and sepsis. Intensive Care Med 2018; 44:1923-1925. [DOI: 10.1007/s00134-018-5047-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 01/04/2018] [Indexed: 12/11/2022]
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21
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Vincent JL. In Pursuit of Precision Medicine in the Critically Ill. ANNUAL UPDATE IN INTENSIVE CARE AND EMERGENCY MEDICINE 2018 2018. [PMCID: PMC7121780 DOI: 10.1007/978-3-319-73670-9_48] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Jean-Louis Vincent
- Dept. of Intensive Care Erasme Hospital, Université libre de Bruxelles, Brussels, Belgium
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22
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Can Concurrent Abnormalities in Free Light Chains and Immunoglobulin Concentrations Identify a Target Population for Immunoglobulin Trials in Sepsis?*. Crit Care Med 2017; 45:1829-1836. [DOI: 10.1097/ccm.0000000000002627] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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23
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Shankar-Hari M, Singer M. Caring for Sepsis Patients: An Update. Crit Care Clin 2017; 34:xiii-xv. [PMID: 29149945 DOI: 10.1016/j.ccc.2017.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Manu Shankar-Hari
- Department of Critical Care Medicine, ICU Offices, Guy's and St Thomas' Hospital, NHS Foundation Trust, London SE1 7EH, United Kingdom.
| | - Mervyn Singer
- Intensive Care Medicine, University College London, Cruciform Building, Gower Street, London WC1E 6BT, United Kingdom.
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Shankar-Hari M, Harrison D, Rubenfeld G, Rowan K. Epidemiology of sepsis and septic shock in critical care units: comparison between sepsis-2 and sepsis-3 populations using a national critical care database. Br J Anaesth 2017; 119:626-636. [DOI: 10.1093/bja/aex234] [Citation(s) in RCA: 131] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2017] [Indexed: 12/22/2022] Open
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25
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Shankar-Hari M, McAuley DF. Divide and conquer: identifying acute respiratory distress syndrome subphenotypes. Thorax 2017; 72:867-869. [PMID: 28717034 DOI: 10.1136/thoraxjnl-2017-210422] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- Manu Shankar-Hari
- Department of Critical Care Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Division of Infection and Immunity, King's College London, London, London, UK
| | - Daniel F McAuley
- Centre for Experimental Medicine, Wellcome-Wolfson Institute for Experimental Medicine, Queen's University of Belfast, Belfast, Northern Ireland.,Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, Northern Ireland
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26
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Shankar-Hari M. How could we enhance translation of sepsis immunology to inform immunomodulation trials in sepsis? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:125. [PMID: 28571579 PMCID: PMC5452398 DOI: 10.1186/s13054-017-1715-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 05/10/2017] [Indexed: 12/15/2022]
Abstract
Sepsis results in complex alterations to the immune system. Our understanding of how these alterations in immune responses could help characterize extreme immune phenotypes, identify biomarkers with the ability to stratify patients for therapeutic interventions, surrogates in the causal pathway of clinical end-points, and treatable traits are still rudimentary. A methodologically rigorous, consensus-based approach should enrich sepsis immune subpopulations to increase the probability of successful trials.
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Affiliation(s)
- M Shankar-Hari
- Guy's and St Thomas' NHS Foundation Trust, London, SE17EH, UK. .,Division of Immunology, Infection & Inflammatory Disease, Kings College London, London, SE1 9RT, UK. .,Intensive Care National Audit & Research Centre, Napier House, 24 High Holborn, London, WC1V 6AZ, UK. .,ICU Secretaries Offices, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, SE17EH, UK.
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Perner A, Gordon AC, Angus DC, Lamontagne F, Machado F, Russell JA, Timsit JF, Marshall JC, Myburgh J, Shankar-Hari M, Singer M. The intensive care medicine research agenda on septic shock. Intensive Care Med 2017; 43:1294-1305. [DOI: 10.1007/s00134-017-4821-1] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2016] [Accepted: 04/25/2017] [Indexed: 12/15/2022]
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