Experimental and clinical results in shock lung treatment with vitamin E

Could Vitamins Help in the Fight Against COVID-19?

There are limited proven therapeutic options for the prevention and treatment of COVID-19. The role of vitamin and mineral supplementation or "immunonutrition" has previously been explored in a number of clinical trials in intensive care settings, and there are several hypotheses to support their routine use. The aim of this narrative review was to investigate whether vitamin supplementation is beneficial in COVID-19. A systematic search strategy with a narrative literature summary was designed, using the Medline, EMBASE, Cochrane Trials Register, WHO International Clinical Trial Registry, and Nexis media databases. The immune-mediating, antioxidant and antimicrobial roles of vitamins A to E were explored and their potential role in the fight against COVID-19 was evaluated. The major topics extracted for narrative synthesis were physiological and immunological roles of each vitamin, their role in respiratory infections, acute respiratory distress syndrome (ARDS), and COVID-19. Vitamins A to E highlighted potentially beneficial roles in the fight against COVID-19 via antioxidant effects, immunomodulation, enhancing natural barriers, and local paracrine signaling. Level 1 and 2 evidence supports the use of thiamine, vitamin C, and vitamin D in COVID-like respiratory diseases, ARDS, and sepsis. Although there are currently no published clinical trials due to the novelty of SARS-CoV-2 infection, there is pathophysiologic rationale for exploring the use of vitamins in this global pandemic, supported by early anecdotal reports from international groups. The final outcomes of ongoing trials of vitamin supplementation are awaited with interest.

Oxygen free radicals in nephrology

For living creatures with an aerobic metabolism, the univalent reduction of oxygen can lead to formation within the cell of intermediate products with marked chemical instability and strong potential toxicity. These are the free radicals (FR) superoxide and hydroxyl, hydrogen peroxide and the singlet 1O2. Their toxicity is primarily expressed through the peroxidation of membrane lipids, resulting in mitochondrial, lysosomal and parietal damage. It is enhanced by the presence of metals in trace amounts. Imbalance between the production of FR and the availability of FR scavengers (superoxide dismutase, catalase, glutathione peroxidase, etc.) may underlie different human pathologies. FR have been thought to play a part in inflammation; the aging process, carcinomatous transformations, damage due to recirculation and autoimmune diseases. As far as the kidney is concerned, the intervention of FR has been demonstrated or can be postulated in various contexts in the light of what has been observed in other pathologies: immunological nephritis, toxic nephropathies, microthrombotic and microangiopathic processes, damage caused by post-ischemic reflow, and problems in the preservation and rejection of transplants. FR have also been incriminated in lung lesions following intradialytic leukostasis and some aspects of toxicity ascribable to uremia. Subject to the precautions imposed by the need for theoretical, experimental and clinical verification, FR biochemistry offers new keys to the interpretation of a variety of kidney pathologies and opens up new prospects for treatment, both through a better understanding of the mechanism of action of drugs already known and employed, and with regard to the practical possibility of using alternative or combined forms of therapy.

Aerosol-administered alpha-tocopherol attenuates lung inflammation in rats given lipopolysaccharide intratracheally

Intrapulmonary administration of bacterial lipopolysaccharide (LPS) induces a well-characterized lung inflammatory response involving alveolar macrophage activation, proinflammatory cytokine elaboration, and neutrophil influx. Vitamin E, a lipophilic antioxidant consisting of a family that includes tocopherols and tocotrienols, has previously been shown to have a variety of anti-inflammatory effects, raising interest in its possible uses in disease prevention or therapy. Because aerosol delivery is a specific and rapid way to administer agents to the lungs, the authors undertook to determine whether inhaled vitamin E aerosols would have an anti-inflammatory effect in the lungs. Using a rat model of acute lung inflammation caused by intratracheally administered LPS (10 microg Pseudomonas aeruginosa LPS), the authors examined the effect of aerosol-administered vitamin E, in this case alpha-tocopherol, on several indices of lung inflammation which are increased by LPS treatment. It was found that inhaled alpha-tocopherol aerosol, but not inhaled alpha-tocopherol acetate aerosol, decreased tumor necrosis factor alpha (TNFalpha) and cytokine-induced neutrophil chemoattractant-1 (CINC-1) mRNA levels in lung tissue, TNFalpha and CINC-1 immunoreactive protein levels in lung lavage, and the number of neutrophils recoverable by lung lavage from rats given LPS intratracheally. These results contribute to the increasing body of work describing immunomodulatory functions of alpha-tocopherol, and support the idea that direct aerosol administration of alpha-tocopherol may play a beneficial role in strategies to control inflammatory lung illnesses.

Pharmacologic adjuncts to mechanical ventilation in acute respiratory distress syndrome

This article reviews pharmacologic approaches to treating acute respiratory distress syndrome (ARDS). The authors discuss the therapeutic effects of ketoconazole, antioxidants, corticosteroids, surfactant, ketanserin, pentoxifylline, bronchodilators, and almitrine in ARDS. Current animal data and proposed mechanics which may foster future pharmacologic therapies are also examined.

The American-European Consensus Conference on ARDS, part 2: Ventilatory, pharmacologic, supportive therapy, study design strategies, and issues related to recovery and remodeling. Acute respiratory distress syndrome

The acute respiratory distress syndrome (ARDS) continues as a contributor to the morbidity and mortality of patients in intensive care units throughout the world, imparting tremendous human and financial costs. During the last 10 years there has been a decline in ARDS mortality without a clear explanation. The American-European Consensus Committee on ARDS was formed to re-evaluate the standards for the ICU care of patients with acute lung injury (ALI), with regard to ventilatory strategies, the more promising pharmacologic agents, and the definition and quantification of pathologic features of ALI that require resolution. It was felt that the definition of strategies for the clinical design and coordination of studies between centers and continents was becoming increasingly important to facilitate the study of various new therapies for ARDS.

The American-European Consensus Conference on ARDS, part 2. Ventilatory, pharmacologic, supportive therapy, study design strategies and issues related to recovery and remodeling

The acute respiratory distress syndrome (ARDS) continues as a contributor to the morbidity and mortality of patients in intensive care units throughout the world, imparting tremendous human and financial costs. During the last ten years there has been a decline in ARDS mortality without a clear explanation. The American-European Consensus Committee on ARDS was formed to re-evaluate the standards for the ICU care of patients with acute lung injury (ALI), with regard to ventilatory strategies, the more promising pharmacologic agents, and the definition and quantification of pathological features of ALI that require resolution. It was felt that the definition of strategies for the clinical design and coordination of studies between centers and continents was becoming increasingly important to facilitate the study of various new therapies for ARDS.

Supercritical fluid-aerosolized vitamin E pretreatment decreases leak in isolated oxidant-perfused rat lungs

We hypothesized that direct pulmonary administration of supercritical fluid-aerosolized (SFA) vitamin E would decrease acute oxidative lung injury. We previously reported that rapid expansion of supercritical CO2 formed respirable particles of vitamin E and that administering SFA vitamin E to rats increased lung vitamin E levels and decreased neutrophil-mediated lung leak. In the present investigation, we found that pretreatment with SFA vitamin E protected isolated rat lungs against the oxidant-induced lung leak caused by perfusion with xanthine oxidase (XO) and purine, an enzyme system that generates superoxide union (O2-.) and hydrogen peroxide. SFA vitamin E droplets were 0.7-3 microns in diameter, and inhalation of the airborne droplets for 30 min deposited approximately 55 micrograms of vitamin E in rat lungs. Isolated rat lungs perfused with XO (0.02 U/ml) and purine (10 mM) gained more weight (1.75 +/- 0.12 g, n = 8), retained more Ficoll (11.5 +/- 1.2 mg/left lung, n = 7), and accumulated more Ficoll in their lung lavages (700 +/- 146 micrograms/ml, n = 8) than control lungs [0.25 +/- 0.06 g (n = 10), 6.2 +/- 1.2 mg/left lung (n = 9), and 141 +/- 31 micrograms/ml (n = 8), respectively, P < 0.05]. In contrast, isolated lungs from rats that were pretreated with SFA vitamin E had decreased (P < 0.05) weight gains (0.32 +/- 0.06 g, n = 7), Ficoll retentions (3.3 +/- 1.1 mg/left lung, n = 7), and lung lavage Ficoll concentrations (91 +/- 26 micrograms/ml, n = 6) after perfusion with XO and purine compared with isolated lungs from control rats perfused with XO and purine. This protective effect was not observed in rat lungs given sham treatments (CO2 alone or vitamin E acetate aerosolized with supercritical CO2). Our results suggest that direct pulmonary supplementation of vitamin E decreases susceptibility to vascular leakage caused by XO-derived oxidants.

Chemiluminescence response and adherence of neutrophils to cultured endothelial cells--influence of immunoglobulin G

The effect of different concentrations (0.8, 4.35, 8.7, 17.5, 25 and 35 mg/mL) of intravenous immunoglobulin G (Endobulin) on neutrophil-endothelial cell interaction was studied using an in vitro model of human umbilical cord vein endothelial cells and human neutrophils. Because adherence of neutrophils to endothelial cells is an essential component in inflammatory processes leading to endothelial cell injury the influence of immunoglobulin G on adherence has been investigated. A second aim of the present study was to determine changes in chemiluminescence response of neutrophils during adherence to endothelial cells. Production of oxygen-derived metabolites, measured by chemiluminescence response of neutrophils, decreased significantly in the presence of 8.7 mg immunoglobulin/mL test during coincubation of neutrophils and endothelial cells (p < 0.025). The adherence of neutrophils to endothelial cells was significantly decreased at a concentration of 8.7 mg immunoglobulin/mL test (p < 0.025). The present results indicate that this preparation of immunoglobulin G might exert a protective effect on neutrophil-endothelial cell interaction by decreasing adherence of neutrophils to endothelial cells and by scavenging reactive oxygen metabolites. metabolites. Therefore, the current investigation points to a probable protective effect of immunoglobulin G in oxidative diseases, such as the adult respiratory distress syndrome.

Vitamin E supplementation in the critically ill patient: too narrow a view?

Oxidative stress plays an important contributory role in a number of diseases. In critically ill patients, oxidative stress is a major problem that results from a number of compounding factors such as supportive oxygen therapy, pulmonary inflammation, and the nutritional inadequacies of these patients. It has been known for some time that the circulating concentration of vitamin E, the primary lipid-soluble antioxidant, is low in critically ill patients. However, supplementation with vitamin E by oral loading has not been successful in improving clinical status. A better understanding of the bioavailability of vitamin E in these patients and of the synergistic action of other antioxidant nutrients such as vitamin C and glutathione with vitamin E has provided new opportunities to reexamine the use of antioxidant supplementation for the critically ill.

In vitro effect of ascorbic acid on neutrophil-endothelial cell interaction

The effect of different concentrations (0.06, 0.6 and 6.0 mmol/L) of ascorbic acid on neutrophil-endothelial interaction was studied using an in vitro model of human umbilical cord vein endothelial cells and human neutrophils. The aim of the study was to determine changes in chemiluminescence response of neutrophils during adherence to endothelial cells. Because adherence of neutrophils to endothelial cells is an essential component in inflammatory processes leading to endothelial cell injury, the influence of ascorbic acid on adherence and endothelial cell injury have been investigated. Production of oxygen-derived metabolites, measured by chemiluminescence response of neutrophils, decreased significantly in the presence of 6 mmol/L ascorbic acid during coincubation of neutrophils and endothelial cells (p < 0.025). The adherence of neutrophils to endothelial cells was significantly decreased at a concentration of 6 mmol/L (p < 0.0005). The inhibition of neutrophil adherence to endothelial cells was correlated with a diminished neutrophil-mediated endothelial cell injury during incubation with 6 mmol/L ascorbic acid (p < 0.0005). The present results indicate that ascorbic acid might exert a protective effect on neutrophil-mediated endothelial cell injury by decreasing adherence of neutrophils to endothelial cells and by scavenging reactive oxygen metabolites. Moreover, the current investigation points to probable protective effect of ascorbic acid on oxidant-mediated cell damage in diseases (e.g., Adult Respiratory Distress Syndrome).

Effect of antioxidants on hypoxia/reoxygenation-induced injury in isolated perfused rat liver

Isolated perfused livers from rats fasted overnight were subjected to 30 min. of hypoxia followed by reoxygenation for 60 min., resulting in marked cytotoxicity as evidenced by an enhanced release of cytosolic enzymes (lactate dehydrogenase: 14-fold over controls, glutamate-pyruvate-transaminase: 12-fold over controls) and glutathione (twofold over controls) into the perfusate, by calcium accumulation (by a factor of 1.4) in the tissue and by an 80% inhibition of bile secretion. Virtually no mitochondrial injury became apparent and no evidence for lipid peroxidation could be found. In the presence of ascorbate, an augmentation of hepatic injury was observed. This might be due to the pro-oxidant activity of ascorbate in the presence of ionized iron, which is easily released from high molecular weight stores under reductive (e.g. hypoxic) conditions. The water soluble vitamin E analogue trolox C as well as propyl gallate clearly protected the liver against hypoxia/reoxygenation injury, yielding further evidence for a causative role of oxidative stress in this model. Due to their water solubility and their high efficacy as free radical scavengers, these antioxidants might be of therapeutic value.

Induction of stress proteins in SV-40 transformed human RPE-derived cells by organic oxidants

The expression and induction of heat shock proteins (HSPs) were examined in cultured SV-40-transformed human retinal pigment epithelial (RPE)-derived cells following exposure to chemical oxidants. Concentrations of hydrogen peroxide and the organic oxidants tert-butyl hydroperoxide, cumene hydroperoxide and linoleic acid hydroperoxide were used under conditions where cell viability was between 75% and 90% as determined by the trypan blue exclusion tests. The types of HSPs that are either induced and/or elevated from constitutive levels in cultured transformed cells were separated both by SDS-PAGE and by two-dimensional gel electrophoresis. Subsequent immunoblotting was performed with both a monoclonal antibody (MAb C92) specific for only the stress-inducible form of HSP 70, namely HSP 72, and with a monoclonal antibody (MAb N27) specific for both the stress-inducible HSP 72 and its constitutive form, HSP 73. As positive controls for comparison, other types of stressing agents were used that included heat shock at 41 degrees C for various times and exposure to the proline analogue, azetidine-2-carboxylic acid (AzC). Protein immunoblotting analysis demonstrate that: (a) Stress-inducible HSP 72 is present at low levels in non-stressed cultured transformed RPE-derived cells and in fresh bovine retina and RPE, but is not detectable in non-stressed cultured lung fibroblasts until induction with heat shock; and (b) Stress-inducible HSP 72 is elevated from constitutive levels in RPE-derived cultured cells after exposure to various oxidants. After cellular exposure to both organic oxidants and to AzC in the presence of L-[35-S]-methionine, two-dimensional gel electrophoresis confirmed the elevation of newly synthesized HSP 72. Thus, these results indicate that cultured human SV-40-transformed RPE-derived cells are capable of elevated HSP 72 biosynthesis under conditions of oxidative stress produced by organic oxidants.

Comparison of vitamin E levels in plasma, bronchoalveolar lavage, and lung tissues of adult pulmonary patients

Plasma, bronchoalveolar lavage fluids (BAL), and lung parenchyma were analyzed for vitamin E and polyunsaturated fatty acid (PUFA) concentrations in three groups of patients routinely receiving oxygen therapy--two with adult respiratory distress syndrome (ARDS and SARDS), a third with pneumonia (PNEU), as well as a fourth group of patients receiving little or no oxygen therapy (OTHER). Only plasma alpha- and gamma-tocopherols were significantly lower in patients receiving oxygen therapy compared to those not requiring oxygen. Among diagnosis groups, PNEU patients exhibited highest levels of alpha-tocopherol in BAL, though all groups on oxygen had greater amounts of alpha-tocopheryl quinone in BAL as compared to those of the OTHER group. No significant differences in BAL measures were observed between oxygen and non-oxygen groups, however. No statistical tests on lung measures could be performed between these groups because of insufficient sampling for the OTHER group. A highly significant relationship was observed (r = +0.73, p less than 0.004) between plasma vitamin E and lung vitamin E when expressed in terms of PUFA, whereas no significant relationship was observed if plasma vitamin E and lung vitamin E levels were compared directly. No relationship was obtained for BAL alpha-tocopherol (expressed per number of cells) and lung alpha-tocopherol. These findings support previous reports that in an appropriate setting plasma vitamin E:PUFA ratios along with smoking status may be used to evaluate lung vitamin E levels when also expressed in terms of PUFA.

The suppression of granulocyte functions by lipophilic antioxidants

The effects of several antioxidants on the three major functions of human neutrophils--oxidative burst, secretion and leukotriene formation--were investigated with special emphasis on the lipophilicity. The most striking differences were obtained when ascorbate and the lipophilic ester ascorbyl palmitate were compared. As expected, the luminol- and lucigenin-dependent chemiluminescence was inhibited by all antioxidants to a different degree. Ascorbyl palmitate was able to block the biphasic luminol-dependent response completely with IC50 values of 10 and 25 microM for the first and second phase, respectively. In contrast, ascorbate only blocked efficiently the first phase of the response. The secretion of elastase was inhibited by ascorbyl palmitate dose-dependently with an IC50 value of around 200 microM, whereas ascorbate was completely inactive. Electron microscopy supported the assumption that inhibition was due to a block in degranulation and not to enzyme inactivation. This was further supported by a parallel, although somewhat lower, inhibition of other secretory enzymes like myeloperoxidase, beta-glucuronidase or lysozyme. Cells treated with the Ca2+-ionophore A23187 responded by LTB4-synthesis which was also inhibited by ascorbyl palmitate. A very efficient inhibition was observed in cell homogenates with an IC50 value of 1.5 microM. No inhibition by ascorbate was detected in both systems. Concomitant with the inhibition of 5-lipoxygenase the activity of 15-lipoxygenase increased. We conclude that cellular reductants may control neutrophil functions and that the inhibition by ascorbyl palmitate of the three processes relevant for inflammatory responses could be of therapeutic importance.

Serum alpha-tocopherol levels after high-dose enteral vitamin E administration in patients with acute respiratory failure

Serum levels of tocopherols were measured in 5 healthy volunteers and in 14 patients with acute respiratory failure before and after onset of high-dose enteral vitamin E administration. The initial alpha-tocopherol levels did not differ between both groups (12.1 +/- 2.7 micrograms/ml in the volunteers and 11.3 +/- 3.5 micrograms/ml in the patients; mean +/- SD). After oral administration of 1 g d,l-alpha-tocopherylacetate per day the serum levels more than doubled within 1 day and reached a plateau between 22 and 30 micrograms/ml after 3 days in the volunteers. In contrast, application of even 3 g vitamin E/day by gastric tube in the patients with respiratory failure caused only a delayed increase of the serum levels with values nearly doubling after 5-10 days (6 patients), or there was no increase at all (8 patients). Serum alpha-tocopherol did not rise in patients without accompanying highmolecular weight formula diet and in patients with prolonged hemodynamic insufficiency and metabolic acidosis. The age of the patients, the fact of severe blood losses, hemodialysis and hemofiltration and the final outcome of death or survival appeared to be without influence on the response to enteral vitamin application. Neither in the volunteers nor in the patients with acute respiratory failure were there any detectable amounts of beta-, gamma- or delta-tocopherol or of alpha-tocopherolquinone or alpha-tocotrienol.

Vitamin E and vitamin C inhibit arachidonate-induced aggregation of human peripheral blood leukocytes in vitro

Arachidonate induces aggregation of human polymorphonuclear (PMN) and mononuclear (MNL) blood leukocytes. This is mediated by the lipoxygenase pathway, as it is prevented by lipoxygenase inhibitors and can also be induced by leukotriene B4 (LTB4). Vitamin E and vitamin C have profound effects on the functional state of leukocytes, some of which may involve the lipoxygenase pathway. This study shows that both vitamins inhibit arachidonate-induced aggregation of PMN and MNL, in a concentration-dependent way. BW-755, previously shown to inhibit arachidonate-induced PMN and NML aggregation, was found to potentiate the inhibitory activity of both vitamins. When LTB4 was used as an aggregating agent, vitamin E markedly inhibited PMN and MNL aggregation, whereas vitamin C was ineffective. The prevention of PMN and MNL aggregation by vitamin E might account, at least partially, for the reported beneficial effects of vitamin E supplementation in some experimental syndromes characterized by leukocyte activation.

The adult respiratory distress syndrome

The adult respiratory distress syndrome (ARDS) is a common form of acute respiratory failure that has been increasingly reported as associated with a wide variety of medical conditions. Unlike other identifiable pathological events causing severe lung injury, it is now recognized that ARDS is not a single disease, but a complex interaction of pathophysiological events that result in diffuse injury to lung parenchyma. Only through a thorough understanding of ARDS pathophysiology, pathogenesis, and clinical course can medical intervention be instituted in a judicious and timely manner. This review article is intended to provide an overview of the suspected precipitating causes, discrete pathophysiologic changes, and monitorable clinical events associated with ARDS. With mortality from ARDS high, significant attention is being given to improving therapeutic intervention with such conventional measures as mechanical ventilation, positive end-expiratory pressure, and fluid management, along with corticosteroids and several new experimental pharmacologic approaches.