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Abbasciano RG, Lai FY, Roman MA, Rizzello A, Pathak S, Ramzi J, Lucarelli C, Layton GR, Kumar T, Wozniak MJ, Eagle-Hemming B, Akowuah E, Rogers CA, Angelini GD, Murphy GJ. Activation of the innate immune response and organ injury after cardiac surgery: a systematic review and meta-analysis of randomised trials and analysis of individual patient data from randomised and non-randomised studies. Br J Anaesth 2021; 127:365-375. [PMID: 34229833 DOI: 10.1016/j.bja.2021.04.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 04/14/2021] [Accepted: 04/15/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND It is unclear whether the innate immune response represents a therapeutic target for organ protection strategies in cardiac surgery. METHODS A systematic review of trials of interventions targeting the inflammatory response to cardiac surgery reporting treatment effects on both innate immune system cytokines and organ injury was performed. The protocol was registered at the International Prospective Register of Systematic Reviews: CRD42020187239. Searches of the Cochrane Central Register of Controlled Trials, MEDLINE, and Embase were performed. Random-effects meta-analyses were used for the primary analysis. A separate analysis of individual patient data from six studies (n=785) explored sources of heterogeneity for treatment effects on cytokine levels. RESULTS Searches to May 2020 identified 251 trials evaluating 24 interventions with 20 582 participants for inclusion. Most trials had important limitations. Methodological limitations of the included trials and heterogeneity of the treatment effects on cytokine levels between trials limited interpretation. The primary analysis demonstrated inconsistency in the direction of the treatment effects on innate immunity and organ failure or death between interventions. Analyses restricted to important subgroups or trials with fewer limitations showed similar results. Meta-regression, pooling available data from all trials, demonstrated no association between the direction of the treatment effects on inflammatory cytokines and organ injury or death. The analysis of individual patient data demonstrated heterogeneity in the association between the cytokine response and organ injury after cardiac surgery for people >75 yr old and those with some chronic diseases. CONCLUSIONS The certainty of the evidence for a causal relationship between innate immune system activation and organ injury after cardiac surgery is low.
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Affiliation(s)
| | - Florence Y Lai
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Marius A Roman
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Angelica Rizzello
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Suraj Pathak
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Joussi Ramzi
- Leicester Medical School, University of Leicester, Leicester, UK
| | - Carla Lucarelli
- Department of Cardiac Surgery, University of Verona, Verona, Italy
| | | | - Tracy Kumar
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Marcin J Wozniak
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | | | - Enoch Akowuah
- South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Chris A Rogers
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
| | | | - Gavin J Murphy
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
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2
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Selli AL, Kuzmiszyn AK, Smaglyukova N, Kondratiev TV, Fuskevåg OM, Lyså RA, Ravna AW, Tveita T, Sager G, Dietrichs ES. Treatment of Cardiovascular Dysfunction With PDE5-Inhibitors - Temperature Dependent Effects on Transport and Metabolism of cAMP and cGMP. Front Physiol 2021; 12:695779. [PMID: 34393818 PMCID: PMC8361756 DOI: 10.3389/fphys.2021.695779] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 07/09/2021] [Indexed: 01/24/2023] Open
Abstract
Introduction Cardiovascular dysfunction is a potentially lethal complication of hypothermia. Due to a knowledge gap, pharmacological interventions are not recommended at core temperatures below 30°C. Yet, further cooling is induced in surgical procedures and survival of accidental hypothermia is reported after rewarming from below 15°C, advocating a need for evidence-based treatment guidelines. In vivo studies have proposed vasodilation and afterload reduction through arteriole smooth muscle cGMP-elevation as a favorable strategy to prevent cardiovascular dysfunction in hypothermia. Further development of treatment guidelines demand information about temperature-dependent changes in pharmacological effects of clinically relevant vasodilators. Materials and Methods Human phosphodiesterase-enzymes and inverted erythrocytes were utilized to evaluate how vasodilators sildenafil and vardenafil affected cellular efflux and enzymatic breakdown of cAMP and cGMP, at 37°C, 34°C, 32°C, 28°C, 24°C, and 20°C. The ability of both drugs to reach their cytosolic site of action was assessed at the same temperatures. IC50- and Ki-values were calculated from dose–response curves at all temperatures, to evaluate temperature-dependent effects of both drugs. Results Both drugs were able to reach the intracellular space at all hypothermic temperatures, with no reduction compared to normothermia. Sildenafil IC50 and Ki-values increased during hypothermia for enzymatic breakdown of both cAMP (IC50: 122 ± 18.9 μM at 37°C vs. 269 ± 14.7 μM at 20°C, p < 0.05) and cGMP (IC50: 0.009 ± 0.000 μM at 37°C vs. 0.024 ± 0.004 μM at 32°C, p < 0.05), while no significant changes were detected for vardenafil. Neither of the drugs showed significant hypothermia-induced changes in IC50 and Ki–values for inhibition of cellular cAMP and cGMP efflux. Conclusion Sildenafil and particularly vardenafil were ableto inhibit elimination of cGMP down to 20°C. As the cellular effects of these drugs can cause afterload reduction, they show potential in treating cardiovascular dysfunction during hypothermia. As in normothermia, both drugs showed higher selectivity for inhibition of cGMP-elimination than cAMP-elimination at low core temperatures, indicating that risk for cardiotoxic side effects is not increased by hypothermia.
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Affiliation(s)
- Anders L Selli
- Experimental and Clinical Pharmacology, Department of Medical Biology, UiT - The Arctic University of Norway, Tromsø, Norway
| | - Adrina K Kuzmiszyn
- Experimental and Clinical Pharmacology, Department of Medical Biology, UiT - The Arctic University of Norway, Tromsø, Norway.,Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, Tromsø, Norway
| | - Natalia Smaglyukova
- Experimental and Clinical Pharmacology, Department of Medical Biology, UiT - The Arctic University of Norway, Tromsø, Norway
| | - Timofei V Kondratiev
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT - The Arctic University of Norway, Tromsø, Norway
| | - Ole-Martin Fuskevåg
- Department of Laboratory Medicine, Division of Diagnostic Services, University Hospital of North Norway, Tromsø, Norway
| | - Roy A Lyså
- Experimental and Clinical Pharmacology, Department of Medical Biology, UiT - The Arctic University of Norway, Tromsø, Norway
| | - Aina W Ravna
- Experimental and Clinical Pharmacology, Department of Medical Biology, UiT - The Arctic University of Norway, Tromsø, Norway
| | - Torkjel Tveita
- Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, Tromsø, Norway.,Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT - The Arctic University of Norway, Tromsø, Norway
| | - Georg Sager
- Experimental and Clinical Pharmacology, Department of Medical Biology, UiT - The Arctic University of Norway, Tromsø, Norway
| | - Erik S Dietrichs
- Experimental and Clinical Pharmacology, Department of Medical Biology, UiT - The Arctic University of Norway, Tromsø, Norway.,Center for Psychopharmacology, Diakonhjemmet Hospital, Oslo, Norway
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3
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Abstract
PURPOSE OF REVIEW To describe recent advances in the development of therapeutic agents for acute kidney injury (AKI). RECENT FINDINGS Traditional care for AKI is mostly supportive. At present, no specific therapy has been developed to prevent or treat AKI. However, based on a better understanding of the pathophysiology of AKI, various potential compounds have been recently identified and tested. A variety of pathways has been targeted, including oxidative and mitochondrial stress, cellular metabolism and repair, inflammation, apoptosis and hemodynamics. Many of these potential agents are currently ongoing early-phase clinical trials, and the purpose of this review is to provide a summary of those with the most potential. SUMMARY Despite the lack of therapies specifically approved for AKI, many interesting potential agents are entering clinical trials, with the potential to transform the care of patients with AKI.
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4
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Pathak S, Olivieri G, Mohamed W, Abbasciano R, Roman M, Tomassini S, Lai F, Wozniak M, Murphy GJ. Pharmacological interventions for the prevention of renal injury in surgical patients: a systematic literature review and meta-analysis. Br J Anaesth 2020; 126:131-138. [PMID: 32828488 PMCID: PMC7844346 DOI: 10.1016/j.bja.2020.06.064] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 05/20/2020] [Accepted: 06/19/2020] [Indexed: 10/29/2022] Open
Abstract
BACKGROUND The aim of this systematic review was to summarise the results of randomised controlled trials (RCTs) that have evaluated pharmacological interventions for renoprotection in people undergoing surgery. METHODS Searches were conducted to update a previous review using the Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE to August 23, 2019. RCTs evaluating the use of pharmacological interventions for renal protection in the perioperative period were included. The co-primary outcome measures were 30-day mortality and acute kidney injury (AKI). Pooled effect estimates were expressed as risk ratios (RRs) (95% confidence intervals). RESULTS We included 228 trials enrolling 56 047 patients. Twenty-three trials were considered to be at low risk of bias across all domains. Atrial natriuretic peptides (14 trials; n=2207) reduced 30-day mortality (RR: 0.63 [0.41, 0.97]) and AKI events (RR: 0.43 [0.33, 0.56]) without heterogeneity. These effects were consistent across cardiac surgery and vascular surgery subgroups, and in sensitivity analyses restricted to studies at low risk of bias. Inodilators (13 trials; n=2941) reduced mortality (RR: 0.71 [0.53, 0.94]) and AKI events (RR: 0.65 [0.50, 0.85]) in the primary analysis and in cardiac surgery cohorts. Vasopressors (4 trials; n=1047) reduced AKI (RR: 0.56 [0.36, 0.86]). Nitric oxide donors, alpha-2-agonists, and calcium channel blockers reduced AKI in primary analyses, but not after exclusion of studies at risk of bias. Overall, assessment of the certainty of the effect estimates was low. CONCLUSIONS There are multiple effective pharmacological renoprotective interventions for people undergoing surgery.
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Affiliation(s)
- Suraj Pathak
- Department of Cardiovascular Sciences, National Institute for Health Research Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK.
| | - Guido Olivieri
- Department of Cardiovascular Sciences, National Institute for Health Research Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Walid Mohamed
- Department of Cardiovascular Sciences, National Institute for Health Research Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Riccardo Abbasciano
- Department of Cardiovascular Sciences, National Institute for Health Research Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Marius Roman
- Department of Cardiovascular Sciences, National Institute for Health Research Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Sara Tomassini
- Department of Cardiovascular Sciences, National Institute for Health Research Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Florence Lai
- Department of Cardiovascular Sciences, National Institute for Health Research Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Marcin Wozniak
- Department of Cardiovascular Sciences, National Institute for Health Research Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Gavin J Murphy
- Department of Cardiovascular Sciences, National Institute for Health Research Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
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5
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Kumar T, Aujla H, Woźniak M, Dott W, Sullo N, Joel-David L, Pais P, Smallwood D, Miller D, Eagle-Hemming B, Di Paola AS, Barber S, Brookes C, Brunskill NJ, Murphy GJ. Intravenous sildenafil citrate and post-cardiac surgery acute kidney injury: a double-blind, randomised, placebo-controlled trial. Br J Anaesth 2020; 124:693-701. [PMID: 32245569 PMCID: PMC7271663 DOI: 10.1016/j.bja.2020.01.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 12/09/2019] [Accepted: 01/18/2020] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND This study assessed whether i.v. sildenafil citrate prevented acute kidney injury in at-risk patients undergoing cardiac surgery with cardiopulmonary bypass. METHODS In a double-blind RCT, adults at increased risk of acute kidney injury undergoing cardiac surgery in a single UK tertiary centre were randomised to receive sildenafil citrate 12.5 mg kg-1 i.v. over 150 min or dextrose 5% at the commencement of surgery. The primary outcome was serum creatinine measured at six post-randomisation time points. The primary analysis used a linear mixed-effects model adjusted for the stratification variables, baseline estimated glomerular filtration rate, and surgical procedure. Secondary outcomes considered clinical events and potential disease mechanisms. Effect estimates were expressed as mean differences (MDs) or odds ratios with 95% confidence intervals. RESULTS The analysis population comprised eligible randomised patients that underwent valve surgery or combined coronary artery bypass graft and valve surgery, with cardiopulmonary bypass, between May 2015 and June 2018. There were 60 subjects in the sildenafil group and 69 in the placebo control group. The difference between groups in creatinine concentration was not statistically significant (MD: 0.88 μmol L-1 [-5.82, 7.59]). There was a statistically significant increase in multiple organ dysfunction scores in the sildenafil group (MD: 0.54 [0.02, 1.07]; P=0.044). Secondary outcomes, and biomarkers of kidney injury, endothelial function, and inflammatory cell activation, were not significantly different between the groups. CONCLUSIONS These results do not support the use of i.v. sildenafil citrate for kidney protection in adult cardiac surgery. CLINICAL TRIAL REGISTRATION ISRCTN18386427.
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Affiliation(s)
- Tracy Kumar
- Department of Cardiovascular Sciences and National Institute for Health Research Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester, UK
| | - Hardeep Aujla
- Department of Cardiovascular Sciences and National Institute for Health Research Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester, UK
| | - Marcin Woźniak
- Department of Cardiovascular Sciences and National Institute for Health Research Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester, UK
| | - Will Dott
- Department of Cardiovascular Sciences and National Institute for Health Research Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester, UK
| | - Nikol Sullo
- Department of Cardiovascular Sciences and National Institute for Health Research Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester, UK; University of Nottingham, Royal Derby Hospital, Derby, UK
| | - Lathishia Joel-David
- Department of Cardiovascular Sciences and National Institute for Health Research Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester, UK
| | - Paolo Pais
- Department of Cardiovascular Sciences and National Institute for Health Research Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester, UK
| | - Dawn Smallwood
- Department of Cardiovascular Sciences and National Institute for Health Research Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester, UK; School of Allied Health Sciences, De Montfort University, Leicester, UK
| | - Douglas Miller
- Department of Cardiovascular Sciences and National Institute for Health Research Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester, UK
| | - Bryony Eagle-Hemming
- Department of Cardiovascular Sciences and National Institute for Health Research Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester, UK
| | | | - Shaun Barber
- Leicester Clinical Trials Unit, University of Leicester, Leicester, UK
| | - Cassandra Brookes
- Leicester Clinical Trials Unit, University of Leicester, Leicester, UK
| | - Nigel J Brunskill
- Department of Infection, Immunity and Inflammation, University of Leicester, Leicester, UK
| | - Gavin J Murphy
- Department of Cardiovascular Sciences and National Institute for Health Research Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Clinical Sciences Wing, Glenfield General Hospital, Leicester, UK; Leicester Clinical Trials Unit, University of Leicester, Leicester, UK.
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6
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Zahavi A, Weiss S, Vieyra M, Nicholson JD, Muhsinoglu O, Barinfeld O, Zadok D, Goldenberg-Cohen N. Ocular Effects of Sildenafil in Naïve Mice and a Mouse Model of Optic Nerve Crush. ACTA ACUST UNITED AC 2019; 60:1987-1995. [DOI: 10.1167/iovs.18-26333] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Alon Zahavi
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Ophthalmology, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel
| | - Shirel Weiss
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Krieger Eye Research Laboratory, Felsenstein Medical Research Center, Petach Tikva, Israel
| | - Mark Vieyra
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - James D. Nicholson
- The Krieger Eye Research Laboratory, Felsenstein Medical Research Center, Petach Tikva, Israel
| | - Orkun Muhsinoglu
- Department of Ophthalmology, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel
| | - Orit Barinfeld
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Krieger Eye Research Laboratory, Felsenstein Medical Research Center, Petach Tikva, Israel
| | - David Zadok
- Department of Ophthalmology, Shaare Zedek Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University Medical Center, Jerusalem, Israel
| | - Nitza Goldenberg-Cohen
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Krieger Eye Research Laboratory, Felsenstein Medical Research Center, Petach Tikva, Israel
- Department of Ophthalmology, Bnai Zion Medical Center, Haifa, Israel
- Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
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7
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Aujla H, Kumar T, Woźniak M, Dott W, Sullo N, Joel-David L, Morris T, Brookes C, Barber S, Murphy GJ. Effect of sildenafil (Revatio) on postcardiac surgery acute kidney injury: a randomised, placebo-controlled clinical trial: the REVAKI-2 trial protocol. Open Heart 2018; 5:e000838. [PMID: 30364431 PMCID: PMC6196934 DOI: 10.1136/openhrt-2018-000838] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 06/08/2018] [Accepted: 07/24/2018] [Indexed: 11/22/2022] Open
Abstract
Introduction Acute kidney injury (AKI) is a common and severe complication of cardiac surgery. The administration of pharmacological renoprotective agents during the perioperative period could prevent or reduce the severity of AKI and improve clinical outcomes. Experimental studies suggest that sildenafil may have therapeutic potential for the prevention of AKI. This trial will test the hypothesis that postoperative AKI will be reduced in cardiac surgery patients if they receive sildenafil compared with placebo. Methods and analysis Adult cardiac surgery patients 18 years of age or above undergoing cardiac surgery with cardiopulmonary bypass and cardioplegic arrest at a single tertiary cardiac centre in the UK will be randomised in a 1:1 ratio to receive either sildenafil or placebo. The primary outcome is serum creatinine concentration measured at preoperation and daily for up to 7 days postoperatively. Secondary outcomes will include measures of inflammation, organ injury, volumes of blood transfused and resource use. Allocation concealment, internet-based randomisation stratified by operation type, and blinding of outcome assessors will reduce the risk of bias. A sample size of 112 patients will have a 90% power to detect a mean difference of 10 μmol/L for serum creatinine values between treatment and placebo control groups with an alpha value of 0.05. Ethics and dissemination The trial protocol was approved by a UK ethics committee (reference 15/YH/0489). The trial findings will be disseminated in scientific journals and meetings. Trial registration number ISRCTN18386427.
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Affiliation(s)
- Hardeep Aujla
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, Cardiovascular Theme, University of Leicester, Glenfield Hospital, Leicester, UK
| | - Tracy Kumar
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, Cardiovascular Theme, University of Leicester, Glenfield Hospital, Leicester, UK
| | - Marcin Woźniak
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, Cardiovascular Theme, University of Leicester, Glenfield Hospital, Leicester, UK
| | - William Dott
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, Cardiovascular Theme, University of Leicester, Glenfield Hospital, Leicester, UK
| | - Nikol Sullo
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, Cardiovascular Theme, University of Leicester, Glenfield Hospital, Leicester, UK
| | - Lathishia Joel-David
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, Cardiovascular Theme, University of Leicester, Glenfield Hospital, Leicester, UK
| | - Thomas Morris
- Leicester Clinical Trials Unit, University of Leicester, Leicester General Hospital, Leicester, UK
| | - Cassandra Brookes
- Leicester Clinical Trials Unit, University of Leicester, Leicester General Hospital, Leicester, UK
| | - Shaun Barber
- Leicester Clinical Trials Unit, University of Leicester, Leicester General Hospital, Leicester, UK
| | - Gavin James Murphy
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Centre, Cardiovascular Theme, University of Leicester, Glenfield Hospital, Leicester, UK
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8
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Ring A, Schall R, Loke YK, Day S. Statistical reporting of clinical pharmacology research. Br J Clin Pharmacol 2017; 83:1159-1162. [PMID: 28321897 DOI: 10.1111/bcp.13254] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2017] [Accepted: 01/31/2017] [Indexed: 11/29/2022] Open
Abstract
Research in clinical pharmacology covers a wide range of experiments, trials and investigations: clinical trials, systematic reviews and meta-analyses of drug usage after market approval, the investigation of pharmacokinetic-pharmacodynamic relationships, the search for mechanisms of action or for potential signals for efficacy and safety using biomarkers. Often these investigations are exploratory in nature, which has implications for the way the data should be analysed and presented. Here we summarize some of the statistical issues that are of particular importance in clinical pharmacology research.
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Affiliation(s)
- Arne Ring
- University of the Free State, Bloemfontein, South Africa.,medac GmbH, Wedel, Germany
| | - Robert Schall
- University of the Free State, Bloemfontein, South Africa.,Quintiles Biostatistics, Bloemfontein, South Africa
| | - Yoon K Loke
- Norwich Medical School, University of East Anglia, UK
| | - Simon Day
- Clinical Trials Consulting & Training Limited, Buckingham, UK
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9
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Ring A, Morris T, Wozniak M, Sullo N, Dott W, Verheyden V, Kumar T, Brunskill N, Vaja R, Murphy GJ. A Phase I study to determine the pharmacokinetic profile, safety and tolerability of sildenafil (Revatio ® ) in cardiac surgery: the REVAKI-1 study. Br J Clin Pharmacol 2016; 83:709-720. [PMID: 27779776 DOI: 10.1111/bcp.13162] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 10/03/2016] [Accepted: 10/12/2016] [Indexed: 11/30/2022] Open
Abstract
AIMS Acute kidney injury (AKI) is a common and severe complication of cardiac surgery. There is no effective prevention or treatment. Sildenafil citrate (Revatio® , Pfizer Inc.), a phosphodiesterase type 5 inhibitor, prevents post cardiac surgery AKI in pre-clinical studies, however its use is contraindicated in patients with symptomatic cardiovascular disease. The aim of this study is to assess the safety and pharmacokinetics of intravenous sildenafil in cardiac surgery patients. METHODS We conducted an open label, dose escalation study with six patients per dose level. The six doses were 2.5 mg, 5 mg or 10 mg as a bolus, either alone or followed by an additional 2 h infusion of 2.5 mg sildenafil. RESULTS Thirty-six patients entered the trial, of which 33 completed it. The mean age was 69.9 years. One patient died during surgery, two others were removed from the trial before dosing (all at dose level 5 mg + 2.5 mg). The pharmacokinetic profile of sildenafil was similar to previously published studies. For a dose of 10 mg administered as a bolus followed by 2.5 mg administered over 2 h the results were AUC∞ 537 ng h ml-1 , Cmax 189.4 ng ml-1 and t1/2 10.5 h. The drug was well tolerated with no serious adverse events related to drug administration. Higher sildenafil doses stabilized post-surgery nitric oxide bioavailability. CONCLUSIONS Pharmacokinetics of sildenafil during cardiopulmonary bypass were comparable to those of other patient groups. The drug was well tolerated at therapeutic plasma levels. These results support the further evaluation of sildenafil for the prevention of AKI in cardiac surgery.
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Affiliation(s)
- Arne Ring
- University of the Free State, Bloemfontein, South Africa.,medac GmbH, Wedel, Germany.,Leicester Clinical Trials Unit, Leicester General Hospital, Leicester, UK
| | - Tom Morris
- Leicester Clinical Trials Unit, Leicester General Hospital, Leicester, UK
| | - Marcin Wozniak
- University of Leicester, Cardiovascular Sciences and NIHR Cardiovascular Biomedical Research Unit, Glenfield Hospital, Leicester, UK
| | - Nikol Sullo
- University of Leicester, Cardiovascular Sciences and NIHR Cardiovascular Biomedical Research Unit, Glenfield Hospital, Leicester, UK
| | - William Dott
- University of Leicester, Cardiovascular Sciences and NIHR Cardiovascular Biomedical Research Unit, Glenfield Hospital, Leicester, UK
| | - Veerle Verheyden
- University of Leicester, Cardiovascular Sciences and NIHR Cardiovascular Biomedical Research Unit, Glenfield Hospital, Leicester, UK
| | - Tracy Kumar
- University of Leicester, Cardiovascular Sciences and NIHR Cardiovascular Biomedical Research Unit, Glenfield Hospital, Leicester, UK
| | | | - Rakesh Vaja
- University Hospitals Leicester NHS Trust, Leicester, UK
| | - Gavin J Murphy
- University of Leicester, Cardiovascular Sciences and NIHR Cardiovascular Biomedical Research Unit, Glenfield Hospital, Leicester, UK
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