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Lee GT, Ko BS, Kim DS, Kim M, Park JE, Hwang SY, Jeong D, Chung CR, Kang H, Oh J, Lim TH, Chae B, Kim WY, Shin TG. Diagnostic Accuracy of Plasma Renin Concentration and Renin Activity in Predicting Mortality and Kidney Outcomes in Patients With Septic Shock and Hypoperfusion or Hypotension: A Multicenter, Prospective, Observational Study. Ann Lab Med 2024; 44:497-506. [PMID: 38910340 PMCID: PMC11375189 DOI: 10.3343/alm.2023.0425] [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: 10/30/2023] [Revised: 01/22/2024] [Accepted: 03/12/2024] [Indexed: 06/25/2024] Open
Abstract
Background Lactate is a commonly used biomarker for sepsis, although it has limitations in certain cases, suggesting the need for novel biomarkers. We evaluated the diagnostic accuracy of plasma renin concentration and renin activity for mortality and kidney outcomes in patients with sepsis with hypoperfusion or hypotension. Methods This was a multicenter, prospective, observational study of 117 patients with septic shock treated at three tertiary emergency departments between September 2021 and October 2022. The accuracy of renin activity, renin, and lactate concentrations in predicting 28-day mortality, acute kidney injury (AKI), and renal replacement requirement was assessed using the area under the ROC curve (AUC) analysis. Results The AUCs of initial renin activity, renin, and lactate concentrations for predicting 28-day mortality were 0.66 (95% confidence interval [CI], 0.55-0.77), 0.63 (95% CI, 0.52-0.75), and 0.65 (95% CI, 0.53-0.77), respectively, and those at 24 hrs were 0.74 (95% CI, 0.62-0.86), 0.70 (95% CI, 0.56-0.83), and 0.67 (95% CI, 0.54-0.79). Renin concentrations and renin activity outperformed initial lactate concentrations in predicting AKI within 14 days. The AUCs of renin and lactate concentrations were 0.71 (95% CI, 0.61-0.80) and 0.57 (95% CI, 0.46-0.67), respectively (P=0.030). The AUC of renin activity (0.70; 95% CI, 0.60-0.80) was also higher than that of lactate concentration (P=0.044). Conclusions Renin concentration and renin activity show comparable performance to lactate concentration in predicting 28-day mortality in patients with septic shock but superior performance in predicting AKI.
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Affiliation(s)
- Gun Tak Lee
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Department of Emergency Medicine, College of Medicine, Kangwon National University, Chuncheon, Korea
| | - Byuk Sung Ko
- Department of Emergency Medicine, College of Medicine, Hanyang University, Seoul, Korea
| | - Da Seul Kim
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Minha Kim
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong Eun Park
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Department of Emergency Medicine, College of Medicine, Kangwon National University, Chuncheon, Korea
| | - Sung Yeon Hwang
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Daun Jeong
- Department of Critical Care Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Chi Ryang Chung
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyunggoo Kang
- Department of Emergency Medicine, College of Medicine, Hanyang University, Seoul, Korea
| | - Jaehoon Oh
- Department of Emergency Medicine, College of Medicine, Hanyang University, Seoul, Korea
| | - Tae Ho Lim
- Department of Emergency Medicine, College of Medicine, Hanyang University, Seoul, Korea
| | - Bora Chae
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Won Young Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae Gun Shin
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Pi D, Zheng L, Gao C, Xiao C, Yu Z, Fu Y, Li J, Chen C, Liu C, Zou Z, Xu F. RENIN AND ANGIOTENSIN (1-7) OFFER PREDICTIVE VALUE IN PEDIATRIC SEPSIS: FINDINGS FROM PROSPECTIVE OBSERVATIONAL COHORTS. Shock 2024; 62:488-495. [PMID: 39012767 DOI: 10.1097/shk.0000000000002417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2024]
Abstract
ABSTRACT Background: Pediatric sepsis is a common and complex syndrome characterized by a dysregulated immune response to infection. Aberrations in the renin-angiotensin system (RAS) are factors in several infections of adults. However, the precise impact of RAS dysregulation in pediatric sepsis remains unclear. Methods: Serum samples were collected from a derivation cohort (58 patients with sepsis, 14 critically ill control subjects, and 37 healthy controls) and validation cohort (50 patients with sepsis, 37 critically ill control subjects, and 46 healthy controls). Serum RAS levels on day of pediatric intensive care unit admission were determined and compared with survival status and organ dysfunction. Results: In the derivation cohort, the serum renin concentration was significantly higher in patients with sepsis (3,678 ± 4,746) than that in healthy controls (635.6 ± 199.8) ( P < 0.0001). Meanwhile, the serum angiotensin (1-7) was significantly lower in patients with sepsis (89.7 ± 59.7) compared to that in healthy controls (131.4 ± 66.4) ( P < 0.01). These trends were confirmed in a validation cohort. Nonsurvivors had higher levels of renin (8,207 ± 7,903) compared to survivors (2,433 ± 3,193) ( P = 0.0001) and lower levels of angiotensin (1-7) (60.9 ± 51.1) compared to survivors (104.0 ± 85.1) ( P < 0.05). A combination of renin, angiotensin (1-7) and procalcitonin achieved a model for diagnosis with an area under the receiver operating curve of 0.87 (95% CI: 0.81-0.92). Conclusion: Circulating renin and angiotensin (1-7) have predictive value in pediatric sepsis.
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Affiliation(s)
- Dandan Pi
- Department of Intensive Care Unit, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatric Metabolism and Inflammatory Diseases, Chongqing, China
| | - Lijun Zheng
- Molecular Biology Laboratory of Respiratory Disease, Key Laboratory of Clinical Laboratory Diagnostics (Ministry of Education), College of Laboratory Medicine, Chongqing Medical University, Chongqing, China
| | - Caixia Gao
- Molecular Biology Laboratory of Respiratory Disease, Key Laboratory of Clinical Laboratory Diagnostics (Ministry of Education), College of Laboratory Medicine, Chongqing Medical University, Chongqing, China
| | - Changxue Xiao
- Department of Intensive Care Unit, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatric Metabolism and Inflammatory Diseases, Chongqing, China
| | - Zhicai Yu
- Department of Intensive Care Unit, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatric Metabolism and Inflammatory Diseases, Chongqing, China
| | - Yueqiang Fu
- Department of Intensive Care Unit, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatric Metabolism and Inflammatory Diseases, Chongqing, China
| | - Jing Li
- Department of Intensive Care Unit, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatric Metabolism and Inflammatory Diseases, Chongqing, China
| | - Chengzhi Chen
- Department of Occupational and Environmental Health, School of Public Health, Chongqing Medical University, Chongqing, China
| | - Chengjun Liu
- Department of Intensive Care Unit, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatric Metabolism and Inflammatory Diseases, Chongqing, China
| | | | - Feng Xu
- Department of Intensive Care Unit, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatric Metabolism and Inflammatory Diseases, Chongqing, China
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Blankenship CR, Betthauser KD, Hencken LN, Maamari JA, Goetz J, Giacomino BD, Gibson GA. Clinical Response to Third-Line Angiotensin-II vs Epinephrine in Septic Shock: A Propensity-Matched Cohort Study. Ann Pharmacother 2024; 58:1003-1012. [PMID: 38303571 DOI: 10.1177/10600280231226132] [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] [Indexed: 02/03/2024] Open
Abstract
BACKGROUND The appropriate third-line vasopressor in septic shock patients receiving norepinephrine and vasopressin is unknown. Angiotensin-II (AT-II) offers a unique mechanism of action to traditionally used vasopressors in septic shock. OBJECTIVE The objective of this study was to compare the clinical efficacy and safety of third-line AT-II to epinephrine in patients with septic shock. METHODS A single-center, retrospective cohort study of critically ill patients was performed between April 1, 2019 and July 31, 2022. Propensity-matched (2:1) analysis compared adults with septic shock who received third-line AT-II to controls who received epinephrine following norepinephrine and vasopressin. The primary outcome was clinical response 24 hours after third-line vasopressor initiation. Additional efficacy and safety outcomes were investigated. RESULTS Twenty-three AT-II patients were compared with 46 epinephrine patients. 47.8% of AT-II patients observed a clinical response at hour 24 compared with 28.3% of epinephrine patients (P = 0.12). In-hospital mortality (65.2% vs 73.9%, P = 0.45), cardiac arrhythmias (26.1% vs 26.1%, P = 0.21), and thromboembolism (4.3% vs 2.2%, P = 0.61) were not observed to be statistically different between groups. CONCLUSIONS AND RELEVANCE Administration of AT-II as a third-line vasopressor agent in septic shock patients was not associated with significantly improved clinical response at hour 24 compared with epinephrine. Although underpowered to detect meaningful differences, the clinical observations of this study warrant consideration and further investigation of AT-II as a third-line vasopressor in septic shock.
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Affiliation(s)
| | - Kevin D Betthauser
- Department of Pharmacy Practice, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Laura N Hencken
- Department of Pharmacy Practice, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Julie A Maamari
- Department of Pharmacy Practice, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Jenna Goetz
- Department of Pharmacy Practice, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Bria D Giacomino
- Division of Cardiology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Gabrielle A Gibson
- Department of Pharmacy Practice, Barnes-Jewish Hospital, St. Louis, MO, USA
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Kellum JA. The Dubious Ethics of Patient-Level Cost Containment in the ICU. Crit Care Med 2024; 52:1638-1640. [PMID: 38958569 DOI: 10.1097/ccm.0000000000006373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2024]
Affiliation(s)
- John A Kellum
- The Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
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5
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Möller Petrun A, Markota A. Angiotensin II-Real-Life Use and Literature Review. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1483. [PMID: 39336524 PMCID: PMC11433685 DOI: 10.3390/medicina60091483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2024] [Revised: 09/04/2024] [Accepted: 09/09/2024] [Indexed: 09/30/2024]
Abstract
Angiotensin II is a recently introduced vasopressor, which has been available since 2017. The novelty and the relatively high cost of angiotensin II currently limit its broader application. It induces vasoconstriction by activating the renin-angiotensin-aldosterone system and is currently the sole vasopressor functioning through this pathway. Beyond vasoconstriction, angiotensin II also affects various other physiological processes. Current evidence supports its use in managing vasoplegic and cardiogenic shock in patients who are unresponsive to catecholamines and vasopressin. However, due to limited data, the optimal timing for initiating therapy with angiotensin II, strategies for combining it with other vasopressors, and strategies for its discontinuation remain unclear. Ongoing and planned studies aim to address some of these uncertainties. This article reviews the physiological and pathophysiological effects of angiotensin II, describes its pharmacology, and provides a narrative review of the current literature.
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Affiliation(s)
- Andreja Möller Petrun
- Department of Anaesthesiology, Intensive Therapy and Pain Management, University Medical Centre Maribor, 2000 Maribor, Slovenia
- Faculty of Medicine, University of Maribor, 2000 Maribor, Slovenia
| | - Andrej Markota
- Faculty of Medicine, University of Maribor, 2000 Maribor, Slovenia
- Medical Intensive Care Unit, University Medical Centre Maribor, 2000 Maribor, Slovenia
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Jones TW, Hendrick T, Chase AM. Heterogeneity, Bayesian thinking, and phenotyping in critical care: A primer. Am J Health Syst Pharm 2024; 81:812-832. [PMID: 38742459 DOI: 10.1093/ajhp/zxae139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2024] [Indexed: 05/16/2024] Open
Abstract
PURPOSE To familiarize clinicians with the emerging concepts in critical care research of Bayesian thinking and personalized medicine through phenotyping and explain their clinical relevance by highlighting how they address the issues of frequent negative trials and heterogeneity of treatment effect. SUMMARY The past decades have seen many negative (effect-neutral) critical care trials of promising interventions, culminating in calls to improve the field's research through adopting Bayesian thinking and increasing personalization of critical care medicine through phenotyping. Bayesian analyses add interpretive power for clinicians as they summarize treatment effects based on probabilities of benefit or harm, contrasting with conventional frequentist statistics that either affirm or reject a null hypothesis. Critical care trials are beginning to include prospective Bayesian analyses, and many trials have undergone reanalysis with Bayesian methods. Phenotyping seeks to identify treatable traits to target interventions to patients expected to derive benefit. Phenotyping and subphenotyping have gained prominence in the most syndromic and heterogenous critical care disease states, acute respiratory distress syndrome and sepsis. Grouping of patients has been informative across a spectrum of clinically observable physiological parameters, biomarkers, and genomic data. Bayesian thinking and phenotyping are emerging as elements of adaptive clinical trials and predictive enrichment, paving the way for a new era of high-quality evidence. These concepts share a common goal, sifting through the noise of heterogeneity in critical care to increase the value of existing and future research. CONCLUSION The future of critical care medicine will inevitably involve modification of statistical methods through Bayesian analyses and targeted therapeutics via phenotyping. Clinicians must be familiar with these systems that support recommendations to improve decision-making in the gray areas of critical care practice.
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Affiliation(s)
- Timothy W Jones
- Department of Pharmacy, Piedmont Eastside Medical Center, Snellville, GA
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Athens, GA, USA
| | - Tanner Hendrick
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Aaron M Chase
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Athens, GA
- Department of Pharmacy, Augusta University Medical Center, Augusta, GA, USA
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D'Amico F, Landoni G. Protective hemodynamics: a novel strategy to manage blood pressure. Curr Opin Crit Care 2024:00075198-990000000-00208. [PMID: 39248080 DOI: 10.1097/mcc.0000000000001205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/10/2024]
Abstract
PURPOSE OF REVIEW This editorial aims to highlight the evolving concept of protective hemodynamics in the management of critically ill patients. RECENT FINDINGS Recent literature underscores the limitations of rigid blood pressure targets, particularly in the context of critical care and perioperative management. High blood pressure targets, especially when coupled with high-dose vasopressors, can lead to poor outcomes. 'Protective hemodynamics' aims to maintain cardiovascular stability while reducing risks associated with interventions. SUMMARY The implications of adopting protective hemodynamics are profound for both clinical practice and research. Clinically, this approach can reduce iatrogenic harm and improve long-term outcomes for critically ill patients. For research, it opens new avenues for investigating individualized hemodynamic management strategies that prioritize overall patient stability and long-term health over rigid target attainment.
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Affiliation(s)
- Filippo D'Amico
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
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8
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Kotani Y, D'Andria Ursoleo J, Murru CP, Landoni G. Blood Pressure Management for Hypotensive Patients in Intensive Care and Perioperative Cardiovascular Settings. J Cardiothorac Vasc Anesth 2024; 38:2089-2099. [PMID: 38918089 DOI: 10.1053/j.jvca.2024.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Revised: 03/23/2024] [Accepted: 04/08/2024] [Indexed: 06/27/2024]
Abstract
Blood pressure is a critical physiological parameter, particularly in the context of cardiac intensive care and perioperative settings. As a primary indicator of organ perfusion, the maintenance of adequate blood pressure is imperative for the assurance of sufficient tissue oxygen delivery. Among critically ill and major surgery patients, the continuous monitoring of blood pressure is performed as a standard practice for patients. Nonetheless, uncertainties remain regarding blood pressure goals, and there is no consensus regarding blood pressure targets. This review describes the determinants of blood pressure, examine the influence of blood pressure on organ perfusion, and synthesize the current clinical evidence from various intensive care and perioperative settings to provide a concise guidance for daily clinical practice.
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Affiliation(s)
- Yuki Kotani
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy; Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Jacopo D'Andria Ursoleo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Carlotta Pia Murru
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy.
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Zarbock A, Forni LG, Koyner JL, Bell S, Reis T, Meersch M, Bagshaw SM, Fuhmann DY, Liu KD, Pannu N, Arikan AA, Angus DC, Duquette D, Goldstein SL, Hoste E, Joannidis M, Jongs N, Legrand M, Mehta RL, Murray PT, Nadim MK, Ostermann M, Prowle J, See EJ, Selby NM, Shaw AD, Srisawat N, Ronco C, Kellum JA. Recommendations for clinical trial design in acute kidney injury from the 31st acute disease quality initiative consensus conference. A consensus statement. Intensive Care Med 2024; 50:1426-1437. [PMID: 39115567 PMCID: PMC11377501 DOI: 10.1007/s00134-024-07560-y] [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: 04/28/2024] [Accepted: 07/10/2024] [Indexed: 09/06/2024]
Abstract
PURPOSE Novel interventions for the prevention or treatment of acute kidney injury (AKI) are currently lacking. To facilitate the evaluation and adoption of new treatments, the use of the most appropriate design and endpoints for clinical trials in AKI is critical and yet there is little consensus regarding these issues. We aimed to develop recommendations on endpoints and trial design for studies of AKI prevention and treatment interventions based on existing data and expert consensus. METHODS At the 31st Acute Disease Quality Initiative (ADQI) meeting, international experts in critical care, nephrology, involving adults and pediatrics, biostatistics and people with lived experience (PWLE) were assembled. We focused on four main areas: (1) patient enrichment strategies, (2) prevention and attenuation studies, (3) treatment studies, and (4) innovative trial designs of studies other than traditional (parallel arm or cluster) randomized controlled trials. Using a modified Delphi process, recommendations and consensus statements were developed based on existing data, with > 90% agreement among panel members required for final adoption. RESULTS The panel developed 12 consensus statements for clinical trial endpoints, application of enrichment strategies where appropriate, and inclusion of PWLE to inform trial designs. Innovative trial designs were also considered. CONCLUSION The current lack of specific therapy for prevention or treatment of AKI demands refinement of future clinical trial design. Here we report the consensus findings of the 31st ADQI group meeting which has attempted to address these issues including the use of predictive and prognostic enrichment strategies to enable appropriate patient selection.
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Affiliation(s)
- Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital of Münster, Albert-Schweitzer Campus 1, Building A1, 48149, Münster, Germany.
- Outcomes Research Consortium, Cleveland, OH, USA.
| | - Lui G Forni
- Depatment of Critical Care, Royal Surrey Hospital Foundation Trust, Guildford, Surrey, UK
- School of Medicine, Kate Granger Building, University of Surrey, Guildford, Surrey, UK
| | - Jay L Koyner
- Section of Nephrology, University of Chicago, Chicago, IL, USA
| | - Samira Bell
- Division of Population Health and Genomics, University of Dundee, Dundee, UK
| | - Thiago Reis
- Hospital Sírio-Libanês, São Paulo, Brazil
- Fenix Nephrology, São Paulo, Brazil
- Laboratory of Molecular Pharmacology, University of Brasília, Brasília, Brazil
| | - Melanie Meersch
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital of Münster, Albert-Schweitzer Campus 1, Building A1, 48149, Münster, Germany
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, AB, Canada
| | - Dana Y Fuhmann
- UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Suite 2000, Pittsburgh, PA, 15224, USA
- Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kathleen D Liu
- Departments of Medicine and Anesthesia, University of California, San Francisco, San Francisco, CA, USA
| | - Neesh Pannu
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Ayse Akcan Arikan
- Division of Nephrology and Critical Care Medicine, Department of Pediatric, Baylor College of Medicine, Houston, TX, USA
| | - Derek C Angus
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - D'Arcy Duquette
- Critical Care Strategic Clinical Network, Alberta Health Services, Calgary, Canada
| | - Stuart L Goldstein
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, USA
| | - Eric Hoste
- Intensive Care Unit, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Niels Jongs
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Matthieu Legrand
- Department of Anesthesia and Perioperative Care, Division of Critical Care Medicine, UCSF, San Francisco, CA, USA
| | - Ravindra L Mehta
- Department of Medicine, University of California San Diego, La Jolla, San Diego, CA, USA
| | | | - Mitra K Nadim
- Division of Nephrology and Hypertension, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Marlies Ostermann
- Department of Intensive Care, King's College London, Thomas' Hospital, Guy's & St, London, UK
| | - John Prowle
- Faculty of Medicine and Dentistry, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Emily J See
- Department of Critical Care, University of Melbourne, Parkville, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Nephrology, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Nicholas M Selby
- Centre for Kidney Research and Innovation, University of Nottingham, Nottingham, UK
| | - Andrew D Shaw
- Department of Intensive Care and Resuscitation, The Cleveland Clinic, Cleveland, OH, USA
| | - Nattachai Srisawat
- Division of Nephrology, Department of Medicine, Faculty of Medicine, and Center of Excellence in Critical Care Nephrology, Chulalongkorn University, Bangkok, Thailand
| | - Claudio Ronco
- Department of Medicine, University of Padova, Padua, Italy
- International Renal Research Institute of Vicenza (IRRV), Vicenza, Italy
- Department of Nephrology, San Bortolo Hospital, Vicenza, Italy
| | - John A Kellum
- Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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10
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Landoni G, Cortegiani A, Bignami E, De Pascale G, Donadello K, Donati A, Grasselli G, Guarracino F, Monti G, Paternoster G, Tritapepe L, Girardis M. The use of angiotensin II for the management of distributive shock: expert consensus statements. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2024; 4:56. [PMID: 39152516 PMCID: PMC11328364 DOI: 10.1186/s44158-024-00186-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Accepted: 07/22/2024] [Indexed: 08/19/2024]
Abstract
BACKGROUND Despite the growing body of evidence supporting the use of angiotensin II (ATII) in distributive shock, its integration into existing treatment algorithms requires careful consideration of factors related to patient comorbidities, hemodynamic parameters, cost-effectiveness, and risk-benefit balance. Moreover, several questions regarding its use in clinical practice warrant further investigations. To address these challenges, a group of Italian intensive care specialists (the panel) developed a consensus process using a modified Delphi technique. METHODS The panel defined five clinical questions during an online scoping workshop and then provided a short list of statements related to each clinical question based on literature review and clinical experience. A total of 20 statements were collected. Two coordinators screened and selected the final list of statements to be included in the online survey, which consisted of 17 statements. The consensus was reached when ≥ 75% of respondents assigned a score within the 3-point range of 1-3 (disagreement) or 7-9 (agreement). RESULTS Overall, a consensus on agreement was reached on 13 statements defining the existing gaps in scientific evidence, the possibility of evaluating the addition of drugs with different mechanisms of action for the treatment of refractory shock, the utility of ATII in reducing the catecholamine requirements in the treatment of vasopressor-resistant septic shock, and the effectiveness of ATII in treating patients in whom angiotensin-converting enzyme activity is reduced or pharmacologically blocked. It was widely shared that renin concentration can be used to identify patients who most likely benefit from ATII to restore vascular tone. Thus, the patients who might benefit most from using ATII were defined. Lastly, some potential barriers to the use of ATII were described. CONCLUSIONS ATII was recognized as a useful treatment to reduce catecholamine requirements in treating vasopressor-resistant septic shock. At the same time, the need for additional clinical trials to further elucidate the efficacy and safety of ATII, as well as investigations into potential mechanisms of action and optimization of treatment protocols in patients with refractory distributive shock, emerged.
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Affiliation(s)
- Giovanni Landoni
- Anesthesia and Intensive Care Department, IRCCS San Raffaele Scientific Institute, Milan, Italy.
- Vita-Salute San Raffaele University, Milan, Italy.
| | - Andrea Cortegiani
- Department of Precision Medicine in Medical, Surgical and Critical Care (Me.Pre.C.C.), University of Palermo, Palermo, Italy
- Department of Anesthesia Intensive Care and Emergency, University Hospital Policlinico Paolo Giaccone, Palermo, Italy
| | - Elena Bignami
- Anesthesiology, Critical Care and Pain Medicine Division, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Gennaro De Pascale
- Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Katia Donadello
- Department of Surgery, Dentistry, Gynecology and Pediatrics, University of Verona, Verona, Italy
- Anaesthesia and Intensive Care B, University Hospital Integrated Trust of Verona, Verona, Italy
| | - Abele Donati
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
- Anesthesia and Intensive Care, Azienda Ospedaliero Universitaria Delle Marche, Ancona, Italy
| | - Giacomo Grasselli
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Fabio Guarracino
- Department of Anesthesia and Intensive Care, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Gianpaola Monti
- Department of Anesthesia and postsurgical and abdominal transplantation Intensive Care Unit, ASST GOM Niguarda, Milan, Italy
| | | | - Luigi Tritapepe
- Department of Anesthesia and Intensive Care, Sapienza University of Rome, Rome, Italy
- Department of Anesthesia and Intensive Care, San Camillo-Forlanini Hospital, Rome, Italy
| | - Massimo Girardis
- Department of Anesthesia and Intensive Care, University Hospital of Modena, Modena, Italy
- University of Modena and Reggio Emilia, Reggio Emilia, Italy
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11
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Saxena J, Das S, Kumar A, Sharma A, Sharma L, Kaushik S, Kumar Srivastava V, Jamal Siddiqui A, Jyoti A. Biomarkers in sepsis. Clin Chim Acta 2024; 562:119891. [PMID: 39067500 DOI: 10.1016/j.cca.2024.119891] [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: 06/06/2024] [Revised: 07/20/2024] [Accepted: 07/24/2024] [Indexed: 07/30/2024]
Abstract
Sepsis is a life-threatening condition characterized by dysregulated host response to infection leading to organ dysfunction. Despite advances in understanding its pathology, sepsis remains a global health concern and remains a major contributor to mortality. Timely identification is crucial for improving clinical outcomes, as delayed treatment significantly impacts survival. Accordingly, biomarkers play a pivotal role in diagnosis, risk stratification, and management. This review comprehensively discusses various biomarkers in sepsis and their potential application in antimicrobial stewardship and risk assessment. Biomarkers such as white blood cell count, neutrophil to lymphocyte ratio, erythrocyte sedimentation rate, C-reactive protein, interleukin-6, presepsin, and procalcitonin have been extensively studied for their diagnostic and prognostic value as well as in guiding antimicrobial therapy. Furthermore, this review explores the role of biomarkers in risk stratification, emphasizing the importance of identifying high-risk patients who may benefit from specific therapeutic interventions. Moreover, the review discusses the emerging field of transcriptional diagnostics and metagenomic sequencing. Advances in sequencing have enabled the identification of host response signatures and microbial genomes, offering insight into disease pathology and aiding species identification. In conclusion, this review provides a comprehensive overview of the current understanding and future directions of biomarker-based approaches in sepsis diagnosis, management, and personalized therapy.
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Affiliation(s)
- Juhi Saxena
- Department of Biotechnology, Parul Institute of Technology, Parul University, Vadodara, Gujarat, India
| | - Sarvjeet Das
- Department of Life Science, Parul Institute of Applied Science, Parul University, Vadodara, Gujarat, India
| | - Anshu Kumar
- Department of Life Science, Parul Institute of Applied Science, Parul University, Vadodara, Gujarat, India
| | - Aditi Sharma
- Department of Pharmacology, School of Pharmaceutical Sciences, Shoolini University of Biotechnology,and Management Sciences, Solan 173229, Himachal Pradesh, India
| | - Lalit Sharma
- Department of Pharmacology, School of Pharmaceutical Sciences, Shoolini University of Biotechnology,and Management Sciences, Solan 173229, Himachal Pradesh, India
| | - Sanket Kaushik
- Amity Institute of Biotechnology, Amity University Rajasthan, Jaipur, India
| | | | - Arif Jamal Siddiqui
- Department of Biology, College of Science, University of Ha'il, P.O. Box 2440, Ha'il, Saudi Arabia
| | - Anupam Jyoti
- Department of Life Science, Parul Institute of Applied Science, Parul University, Vadodara, Gujarat, India.
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12
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Chiscano-Camón L, Ruiz-Sanmartin A, Bajaña I, Bastidas J, Lopez-Martinez R, Franco-Jarava C, Gonzalez JJ, Larrosa N, Riera J, Nuvials-Casals X, Ruiz-Rodríguez JC, Ferrer R. Current perspectives in the management of sepsis and septic shock. Front Med (Lausanne) 2024; 11:1431791. [PMID: 39211340 PMCID: PMC11358069 DOI: 10.3389/fmed.2024.1431791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2024] [Accepted: 07/24/2024] [Indexed: 09/04/2024] Open
Abstract
Within patients with sepsis, there exists significant heterogeneity, and while all patients should receive conventional therapy, there are subgroups of patients who may benefit from specific therapies, often referred to as rescue therapies. Therefore, the identification of these specific patient subgroups is crucial and lays the groundwork for the application of precision medicine based on the development of targeted interventions. Over the years, efforts have been made to categorize sepsis into different subtypes based on clinical characteristics, biomarkers, or underlying mechanisms. For example, sepsis can be stratified into different phenotypes based on the predominant dysregulated host response. These phenotypes can range from hyperinflammatory states to immunosuppressive states and even mixed phenotypes. Each phenotype may require different therapeutic approaches to improve patient outcomes. Rescue strategies for septic shock may encompass various interventions, such as immunomodulatory therapies, extracorporeal support (e.g., ECMO), or therapies targeted at specific molecular or cellular pathways involved in the pathophysiology of sepsis. In recent years, there has been growing interest in precision medicine approaches to sepsis and phenotype identification. Precision medicine aims to tailor treatments to each individual patient based on their unique characteristics and disease mechanisms.
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Affiliation(s)
- Luis Chiscano-Camón
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Departament de Medicina, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Adolf Ruiz-Sanmartin
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Ivan Bajaña
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Juliana Bastidas
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Rocio Lopez-Martinez
- Immunology Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Clara Franco-Jarava
- Immunology Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Juan José Gonzalez
- Microbiology Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Nieves Larrosa
- Microbiology Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Jordi Riera
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Xavier Nuvials-Casals
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Juan Carlos Ruiz-Rodríguez
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Departament de Medicina, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Ricard Ferrer
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Departament de Medicina, Universitat Autonoma de Barcelona, Barcelona, Spain
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13
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Benken ST, Thomas R, Fraidenburg DR, Benken JJ. Angiotensin II as a Vasopressor for Perioperative Hypotension in Solid Organ Transplant. Biomedicines 2024; 12:1817. [PMID: 39200281 PMCID: PMC11351893 DOI: 10.3390/biomedicines12081817] [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: 07/16/2024] [Revised: 07/29/2024] [Accepted: 08/07/2024] [Indexed: 09/02/2024] Open
Abstract
During the perioperative period of transplantation, patients experience hypotension secondary to the side effects of anesthesia, surgical stress, inflammatory triggering, and intraoperative fluid shifts, among others causes. Vasopressor support, in this context, must reverse systemic hypotension, but ideally, the agents used should benefit allograft function and avoid the adverse events commonly seen after transplantation. Traditional therapies to reverse hypotension include catecholamine vasopressors (norepinephrine, epinephrine, dopamine, and phenylephrine), but their utility is limited when considering allograft complications and adverse events such as arrhythmias with agents with beta-adrenergic properties. Synthetic angiotensin II (AT2S-[Giapreza]) is a novel vasopressor indicated for distributive shock with a unique mechanism of action as an angiotensin receptor agonist restoring balance to an often-disrupted renin angiotensin aldosterone system. Additionally, AT2S provides a balanced afferent and efferent arteriole vasoconstriction at the level of the kidney and could avoid the arrhythmic complications of a beta-adrenergic agonist. While the data, to date, are limited, AT2S has demonstrated safety in case reports, pilot studies, and small series in the kidney, liver, heart, and lung transplant populations. There are physiologic and hemodynamic reasons why AT2S could be a more utilized agent in these populations, but further investigation is warranted.
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Affiliation(s)
- Scott T. Benken
- Department of Pharmacy Practice, University of Illinois Chicago College of Pharmacy, Chicago, IL 60612, USA; (R.T.); (J.J.B.)
| | - Riya Thomas
- Department of Pharmacy Practice, University of Illinois Chicago College of Pharmacy, Chicago, IL 60612, USA; (R.T.); (J.J.B.)
| | - Dustin R. Fraidenburg
- Department of Medicine, Division of Pulmonary, Critical Care, Sleep, and Allergy, University of Illinois Chicago College of Medicine, Chicago, IL 60612, USA;
| | - Jamie J. Benken
- Department of Pharmacy Practice, University of Illinois Chicago College of Pharmacy, Chicago, IL 60612, USA; (R.T.); (J.J.B.)
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14
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Kim ME, Gist KM, Brandewie K, Zang H, Lehenbauer D, Winlaw DS, Morales DLS, Alten JA, Goldstein SL, Cooper DS. Kinetics of Renin Concentrations in Infants Undergoing Congenital Cardiac Surgery. J Intensive Care Med 2024:8850666241268655. [PMID: 39094610 DOI: 10.1177/08850666241268655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
BACKGROUND Elevated renin has been shown to predict poor response to standard vasoactive therapies and is associated with poor outcomes in adults. Similarly, elevated renin was associated with mortality in children with septic shock. Renin concentration profiles after pediatric cardiac surgery are unknown. The purpose of this study was to characterize renin kinetics after pediatric cardiac surgery. METHODS Single-center retrospective study of infants who underwent cardiac surgery with cardiopulmonary bypass (CPB) utilizing serum samples obtained in the perioperative period to measure plasma renin concentrations (pg/mL). Time points included pre-bypass and 1, 4, and 24 h after initiation of CPB. RESULTS Fifty patients (65% male) with a median age 5 months (interquartile range (IQR) 3.5, 6.5) were included. Renin concentrations peaked 4 h after CPB. There was a significant difference in preoperative and 4 h post-CPB renin concentration (4 h post-CPB vs preoperative: mean difference 100.6, 95% confidence interval (CI) 48.9-152.4, P < .001). Median renin concentration at 24 h after CPB was lower than the preoperative baseline. CONCLUSIONS We describe renin kinetics in infants after CPB. Future studies based on these data can now be performed to evaluate the associations of elevated renin concentrations with adverse outcomes.
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Affiliation(s)
- Michael E Kim
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Katja M Gist
- Department of Pediatrics, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Katie Brandewie
- Department of Critical Care Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Huaiyu Zang
- Department of Pediatrics, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David Lehenbauer
- Department of Pediatrics, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David S Winlaw
- Heart Center, Ann and Robert H. Lurie Children's Hospital of Chicago and Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - David L S Morales
- Department of Pediatrics, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Jeffrey A Alten
- Department of Pediatrics, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Stuart L Goldstein
- Division of Nephrology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David S Cooper
- Department of Pediatrics, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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15
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Fisler G, Murphy K, Mastroianni F, Schneider JB, Deutschman CS, Leisman DE, Taylor MD. Kidney Blood Flow and Renin-Angiotensin-Aldosterone System Measurements Associated With Kidney and Cardiovascular Dysfunction in Pediatric Shock. Crit Care Explor 2024; 6:e1134. [PMID: 39110074 PMCID: PMC11309640 DOI: 10.1097/cce.0000000000001134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2024] Open
Abstract
IMPORTANCE Pediatric acute kidney injury (AKI) is a prevalent and morbid complication of shock. Its pathogenesis and early identification remain elusive. OBJECTIVES We aim to determine whether renal blood flow (RBF) measurements by point-of-care ultrasound (POCUS) and renin-angiotensin-aldosterone system (RAAS) hormones in pediatric shock associate with vasoactive requirements and AKI. DESIGN, SETTING, AND PARTICIPANTS This is a single-center prospective, noninterventional observational cohort study in one tertiary PICU in North American from 2020 to 2022 that enrolled children younger than 18 years with shock without preexisting end-stage renal disease. MAIN OUTCOMES AND MEASURES RBF was measured by POCUS on hospital days 1 and 3 and plasma RAAS hormone levels were measured on day 1. The primary outcome was the presence of AKI by Kidney Disease Improving Global Outcomes criteria at first ultrasound with key secondary outcomes of creatinine, blood urea nitrogen (BUN), Vasoactive-Inotrope Score (VIS), and norepinephrine equivalent dosing (NED) 48 hours after first ultrasound. RESULTS Fifty patients were recruited (20 with AKI, mean age 10.5 yr, 48% female). POCUS RBF showed lower qualitative blood flow (power Doppler ultrasound [PDU] score) and higher regional vascular resistance (renal resistive index [RRI]) in children with AKI (p = 0.017 and p = 0.0007). Renin and aldosterone levels were higher in the AKI cohort (p = 0.003 and p = 0.007). Admission RRI and PDU associated with higher day 3 VIS and NED after adjusting for age, day 1 VIS, and RAAS hormones. Admission renin associated with higher day 3 creatinine and BUN after adjusting for age, day 1 VIS, and the ultrasound parameters. CONCLUSIONS AND RELEVANCE In pediatric shock, kidney blood flow was abnormal and renin and aldosterone were elevated in those with AKI. Kidney blood flow abnormalities are independently associated with future cardiovascular dysfunction; renin elevations are independently associated with future kidney dysfunction. Kidney blood flow by POCUS may identify children who will have persistent as opposed to resolving AKI. RAAS perturbations may drive AKI in pediatric shock.
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Affiliation(s)
- Grace Fisler
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Northwell, New Hyde Park, NY
- Feinstein Institutes for Medical Research, Northwell, New Hyde Park, NY
| | - Kristina Murphy
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Northwell, New Hyde Park, NY
| | - Fiore Mastroianni
- Division of Pulmonary and Critical Care Medicine, New York University Grossman Long Island School of Medicine, Mineola, NY
| | - James B. Schneider
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Northwell, New Hyde Park, NY
| | - Clifford S. Deutschman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Northwell, New Hyde Park, NY
- Feinstein Institutes for Medical Research, Northwell, New Hyde Park, NY
| | - Daniel E. Leisman
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Matthew D. Taylor
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Northwell, New Hyde Park, NY
- Feinstein Institutes for Medical Research, Northwell, New Hyde Park, NY
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16
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Xourgia E, Exadaktylos AK, Chalkias A, Ziaka M. ANGIOTENSIN II IN THE TREATMENT OF DISTRIBUTIVE SHOCK: A SYSTEMATIC-REVIEW AND META-ANALYSIS. Shock 2024; 62:155-164. [PMID: 38888542 DOI: 10.1097/shk.0000000000002384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2024]
Abstract
ABSTRACT Objective: While nonnorepinephrine vasopressors are increasingly used as a rescue therapy in cases of norepinephrine-refractory shock, data on their efficacy are limited. This systematic review and meta-analysis aims to synthesize existing literature on the efficacy of angiotensin II (ATII) in distributive shock. Methods: We preregistered our meta-analysis with PROSPERO (CRD42023456136). We searched PubMed, Scopus, and gray literature for studies presenting outcomes on ATII use in distributive shock. The primary outcome of the meta-analysis was all-cause mortality. We used a random effects model to calculate pooled risk ratio (RR) and 95% confidence intervals (CIs). Results: By incorporating data from 1,555 patients included in 10 studies, we found that however, all-cause mortality was similar among patients receiving ATII and controls (RR = 1.02; 95% CI: 0.89 to 1.16, P = 0.81), the reduction in norepinephrine or norepinephrine-equivalent dose at 3 h after treatment initiation was greater among patients receiving ATII (MD = -0.06; 95% CI: -0.11 to -0.02, P = 0.008), while there were no higher rates of adverse events reported among ATII patients. Conclusions: While ATII did not reduce mortality among distributive shock patients, it allowed for significant adjunctive vasopressor reduction at 3 h without an increase in reported adverse events, deeming it a viable alternative for the increasingly adopted multimodal vasopressor for minimizing catecholamine exposure and its adverse events.
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Affiliation(s)
| | - Aristomenis K Exadaktylos
- Department of Emergency Medicine, Inselspital, University Hospital, University of Bern, Bern, Switzerland
| | | | - Mairi Ziaka
- Department of Emergency Medicine, Inselspital, University Hospital, University of Bern, Bern, Switzerland
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17
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See EJ, Chaba A, Spano S, Maeda A, Clapham C, Burrell LM, Liu J, Khasin M, Liskaser G, Eastwood G, Bellomo R. Renin Levels and Angiotensin II Responsiveness in Vasopressor-Dependent Hypotension. Crit Care Med 2024; 52:1218-1227. [PMID: 38511994 DOI: 10.1097/ccm.0000000000006273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024]
Abstract
OBJECTIVES The relationship between renin levels, exposure to renin-angiotensin system (RAS) inhibitors, angiotensin II (ANGII) responsiveness, and outcome in patients with vasopressor-dependent vasodilatory hypotension is unknown. DESIGN We conducted a single-center prospective observational study to explore whether recent RAS inhibitor exposure affected baseline renin levels, whether baseline renin levels predicted ANGII responsiveness, and whether renin levels at 24 hours were associated with clinical outcomes. SETTING An academic ICU in Melbourne, VIC, Australia. PATIENTS Forty critically ill adults who received ANGII as the primary agent for vasopressor-dependent vasodilatory hypotension who were included in the Acute Renal effects of Angiotensin II Management in Shock study. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS After multivariable adjustment, recent exposure to a RAS inhibitor was independently associated with a relative increase in baseline renin levels by 198% (95% CI, 36-552%). The peak amount of ANGII required to achieve target mean arterial pressure was independently associated with baseline renin level (increase by 46% per ten-fold increase; 95% CI, 8-98%). Higher renin levels at 24 hours after ANGII initiation were independently associated with fewer days alive and free of continuous renal replacement therapy (CRRT) (-7 d per ten-fold increase; 95% CI, -12 to -1). CONCLUSIONS In patients with vasopressor-dependent vasodilatory hypotension, recent RAS inhibitor exposure was associated with higher baseline renin levels. Such higher renin levels were then associated with decreased ANGII responsiveness. Higher renin levels at 24 hours despite ANGII infusion were associated with fewer days alive and CRRT-free. These preliminary findings emphasize the importance of the RAS and the role of renin as a biomarker in patients with vasopressor-dependent vasodilatory hypotension.
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Affiliation(s)
- Emily J See
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
- Department of Critical Care, University of Melbourne, Parkville, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Nephrology, Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Medicine, University of Melbourne, Parkville, VIC, Australia
- Institute of Breathing and Sleep, Austin Health, Melbourne, VIC, Australia
- Data Analytics Research and Evaluation Centre, The University of Melbourne and Austin Hospital, Melbourne, VIC, Australia
| | - Anis Chaba
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
| | - Sofia Spano
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
| | - Akinori Maeda
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
| | - Caroline Clapham
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
| | - Louise M Burrell
- Department of Medicine, University of Melbourne, Parkville, VIC, Australia
- Institute of Breathing and Sleep, Austin Health, Melbourne, VIC, Australia
| | - Jasmine Liu
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
| | - Monique Khasin
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
| | - Grace Liskaser
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
| | - Glenn Eastwood
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
| | - Rinaldo Bellomo
- Department of Medicine, University of Melbourne, Parkville, VIC, Australia
- Data Analytics Research and Evaluation Centre, The University of Melbourne and Austin Hospital, Melbourne, VIC, Australia
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18
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Russell JA. Vasopressor Responsiveness 101: Prediction of Responsiveness to Angiotensin II Infusion. Crit Care Med 2024; 52:1310-1313. [PMID: 39008548 DOI: 10.1097/ccm.0000000000006320] [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: 07/17/2024]
Affiliation(s)
- James A Russell
- Centre for Heart Lung Innovation, University of British Columbia, Vancouver, BC, Canada
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
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19
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Lin KM, Su CC, Chen JY, Pan SY, Chuang MH, Lin CJ, Wu CJ, Pan HC, Wu VC. Biomarkers in pursuit of precision medicine for acute kidney injury: hard to get rid of customs. Kidney Res Clin Pract 2024; 43:393-405. [PMID: 38934040 PMCID: PMC11237332 DOI: 10.23876/j.krcp.23.284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 01/08/2024] [Accepted: 02/13/2024] [Indexed: 06/28/2024] Open
Abstract
Traditional acute kidney injury (AKI) classifications, which are centered around semi-anatomical lines, can no longer capture the complexity of AKI. By employing strategies to identify predictive and prognostic enrichment targets, experts could gain a deeper comprehension of AKI's pathophysiology, allowing for the development of treatment-specific targets and enhancing individualized care. Subphenotyping, which is enriched with AKI biomarkers, holds insights into distinct risk profiles and tailored treatment strategies that redefine AKI and contribute to improved clinical management. The utilization of biomarkers such as N-acetyl-β-D-glucosaminidase, tissue inhibitor of metalloprotease-2·insulin-like growth factor-binding protein 7, kidney injury molecule-1, and liver fatty acid-binding protein garnered significant attention as a means to predict subclinical AKI. Novel biomarkers offer promise in predicting persistent AKI, with urinary motif chemokine ligand 14 displaying significant sensitivity and specificity. Furthermore, they serve as predictive markers for weaning patients from acute dialysis and offer valuable insights into distinct AKI subgroups. The proposed management of AKI, which is encapsulated in a structured flowchart, bridges the gap between research and clinical practice. It streamlines the utilization of biomarkers and subphenotyping, promising a future in which AKI is swiftly identified and managed with unprecedented precision. Incorporating kidney biomarkers into strategies for early AKI detection and the initiation of AKI care bundles has proven to be more effective than using care bundles without these novel biomarkers. This comprehensive approach represents a significant stride toward precision medicine, enabling the identification of high-risk subphenotypes in patients with AKI.
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Grants
- MOST 107-2314-B-002-026-MY3, 108-2314B-002-058, 110-2314-B-002-241, 110-2314-B-002-239 Ministry of Science and Technology (MOST) of the Republic of China (Taiwan)
- NSTC 109-2314-B-002-174-MY3, 110-2314-B-002124-MY3, 111-2314-B-002-046, 111-2314-B-002-058 National Science and Technology Council
- PH-102-SP-09 National Health Research Institutes
- 109-S4634, PC-1246, PC-1309, VN109-09, UN109-041, UN110-030, 111-FTN0011 National Taiwan University Hospital
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Affiliation(s)
- Kun-Mo Lin
- Division of Nephrology, Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan
| | - Ching-Chun Su
- Division of Nephrology, Department of Internal Medicine, Chi-Mei Medical Center, Tainan, Taiwan
| | - Jui-Yi Chen
- Division of Nephrology, Department of Internal Medicine, Chi-Mei Medical Center, Tainan, Taiwan
| | - Szu-Yu Pan
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Integrated Diagnostics and Therapeutics, National Taiwan University Hospital, Taipei, Taiwan
| | - Min-Hsiang Chuang
- Division of Nephrology, Department of Internal Medicine, Chi-Mei Medical Center, Tainan, Taiwan
| | - Cheng-Jui Lin
- Division of Nephrology, Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan
| | - Chih-Jen Wu
- Division of Nephrology, Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan
| | - Heng-Chih Pan
- Division of Nephrology, Department of Internal Medicine, Keelung Chang Gung Memorial Hospital, Taiwan
| | - Vin-Cent Wu
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Primary Aldosteronism Center of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- NSARF (National Taiwan University Hospital Study Group of ARF), Taipei, Taiwan
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20
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Sadjadi M, von Groote T, Weiss R, Strauß C, Wempe C, Albert F, Langenkämper M, Landoni G, Bellomo R, Khanna AK, Coulson T, Meersch M, Zarbock A. A Pilot Study of Renin-Guided Angiotensin-II Infusion to Reduce Kidney Stress After Cardiac Surgery. Anesth Analg 2024; 139:165-173. [PMID: 38289858 DOI: 10.1213/ane.0000000000006839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
BACKGROUND Vasoplegia is common after cardiac surgery, is associated with hyperreninemia, and can lead to acute kidney stress. We aimed to conduct a pilot study to test the hypothesis that, in vasoplegic cardiac surgery patients, angiotensin-II (AT-II) may not increase kidney stress (measured by [TIMP-2]*[IGFBP7]). METHODS We randomly assigned patients with vasoplegia (cardiac index [CI] > 2.1l/min, postoperative hypotension requiring vasopressors) and Δ-renin (4-hour postoperative-preoperative value) ≥3.7 µU/mL, to AT-II or placebo targeting a mean arterial pressure ≥65 mm Hg for 12 hours. The primary end point was the incidence of kidney stress defined as the difference between baseline and 12 hours [TIMP-2]*[IGFBP7] levels. Secondary end points included serious adverse events (SAEs). RESULTS We randomized 64 patients. With 1 being excluded, 31 patients received AT-II, and 32 received placebo. No significant difference was observed between AT-II and placebo groups for kidney stress (Δ-[TIMP-2]*[IGFBP7] 0.06 [ng/mL] 2 /1000 [Q1-Q3, -0.24 to 0.28] vs -0.08 [ng/mL] 2 /1000 [Q1-Q3, -0.35 to 0.14]; P = .19; Hodges-Lehmann estimation of the location shift of 0.12 [ng/mL] 2 /1000 [95% confidence interval, CI, -0.1 to 0.36]). AT-II patients received less fluid during treatment than placebo patients (2946 vs 3341 mL, P = .03), and required lower doses of norepinephrine equivalent (0.19 mg vs 4.18mg, P < .001). SAEs were reported in 38.7% of patients in the AT-II group and in 46.9% of patients in the placebo group. CONCLUSIONS The infusion of AT-II for 12 hours appears feasible and did not lead to an increase in kidney stress in a high-risk cohort of cardiac surgery patients. These findings support the cautious continued investigation of AT-II as a vasopressor in hyperreninemic cardiac surgery patients.
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Affiliation(s)
- Mahan Sadjadi
- From the Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Thilo von Groote
- From the Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Raphael Weiss
- From the Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Christian Strauß
- From the Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Carola Wempe
- From the Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Felix Albert
- Institute of Biostatistics and Clinical Research, University of Münster, Münster, Germany
| | - Marie Langenkämper
- From the Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Giovanni Landoni
- Department of Intensive Care and Anesthesia, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Department of Anesthesia and Intensive Care, School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Rinaldo Bellomo
- Department of Critical Care, The University of Melbourne, Melbourne, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Intensive Care, Austin Health, Heidelberg, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, School of Medicine, Wake Forest University, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
- Outcomes Research Consortium, Cleveland, Ohio
- Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, North Carolina
| | - Tim Coulson
- Department of Critical Care, The University of Melbourne, Melbourne, Australia
- Department of Anesthesiology and Perioperative Medicine, The Alfred Hospital, Melbourne, Victoria, Australia; Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia
| | - Melanie Meersch
- From the Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Alexander Zarbock
- From the Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
- Outcomes Research Consortium, Cleveland, Ohio
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21
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Picod A, Garcia B, Van Lier D, Pickkers P, Herpain A, Mebazaa A, Azibani F. Impaired angiotensin II signaling in septic shock. Ann Intensive Care 2024; 14:89. [PMID: 38877367 PMCID: PMC11178728 DOI: 10.1186/s13613-024-01325-y] [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: 12/20/2023] [Accepted: 05/29/2024] [Indexed: 06/16/2024] Open
Abstract
Recent years have seen a resurgence of interest for the renin-angiotensin-aldosterone system in critically ill patients. Emerging data suggest that this vital homeostatic system, which plays a crucial role in maintaining systemic and renal hemodynamics during stressful conditions, is altered in septic shock, ultimately leading to impaired angiotensin II-angiotensin II type 1 receptor signaling. Indeed, available evidence from both experimental models and human studies indicates that alterations in the renin-angiotensin-aldosterone system during septic shock can occur at three distinct levels: 1. Impaired generation of angiotensin II, possibly attributable to defects in angiotensin-converting enzyme activity; 2. Enhanced degradation of angiotensin II by peptidases; and/or 3. Unavailability of angiotensin II type 1 receptor due to internalization or reduced synthesis. These alterations can occur either independently or in combination, ultimately leading to an uncoupling between the renin-angiotensin-aldosterone system input and downstream angiotensin II type 1 receptor signaling. It remains unclear whether exogenous angiotensin II infusion can adequately address all these mechanisms, and additional interventions may be required. These observations open a new avenue of research and offer the potential for novel therapeutic strategies to improve patient prognosis. In the near future, a deeper understanding of renin-angiotensin-aldosterone system alterations in septic shock should help to decipher patients' phenotypes and to implement targeted interventions.
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Affiliation(s)
- Adrien Picod
- INSERM, UMR-S 942 MASCOT-Université Paris-Cité, Paris, France.
| | - Bruno Garcia
- Department of Intensive Care Medicine, Centre Hospitalier Universitaire de Lille, Lille, France
- Experimental Laboratory of Intensive Care, Université Libre de Bruxelles, Brussels, Belgium
| | - Dirk Van Lier
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Peter Pickkers
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Antoine Herpain
- Experimental Laboratory of Intensive Care, Université Libre de Bruxelles, Brussels, Belgium
- Department of Intensive Care Medicine, St. Pierre University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Alexandre Mebazaa
- INSERM, UMR-S 942 MASCOT-Université Paris-Cité, Paris, France
- Department of Anesthesiology, Burns and Critical Care, Hopitaux Saint-Louis-Lariboisière, AP-HP, Paris, France
| | - Feriel Azibani
- INSERM, UMR-S 942 MASCOT-Université Paris-Cité, Paris, France
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22
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Garcia B, Ter Schiphorst B, Santos K, Su F, Dewachter L, Vasques-Nóvoa F, Rocha-Oliveira E, Roncon-Albuquerque R, Uba T, Hartmann O, Picod A, Azibani F, Callebert J, Goldman S, Annoni F, Favory R, Vincent JL, Creteur J, Taccone FS, Mebazaa A, Herpain A. Inhibition of circulating dipeptidyl-peptidase 3 by procizumab in experimental septic shock reduces catecholamine exposure and myocardial injury. Intensive Care Med Exp 2024; 12:53. [PMID: 38849640 PMCID: PMC11161450 DOI: 10.1186/s40635-024-00638-3] [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: 04/22/2024] [Accepted: 05/29/2024] [Indexed: 06/09/2024] Open
Abstract
BACKGROUND Dipeptidyl peptidase 3 (DPP3) is a ubiquitous cytosolic enzyme released into the bloodstream after tissue injury, that can degrade angiotensin II. High concentrations of circulating DPP3 (cDPP3) have been associated with worse outcomes during sepsis. The aim of this study was to assess the effect of Procizumab (PCZ), a monoclonal antibody that neutralizes cDPP3, in an experimental model of septic shock. METHODS In this randomized, open-label, controlled study, 16 anesthetized and mechanically ventilated pigs with peritonitis were randomized to receive PCZ or standard treatment when the mean arterial pressure (MAP) dropped below 50 mmHg. Resuscitation with fluids, antimicrobial therapy, peritoneal lavage, and norepinephrine was initiated one hour later to maintain MAP between 65-75 mmHg for 12 h. Hemodynamic variables, tissue oxygenation indices, and measures of organ failure and myocardial injury were collected. Organ blood flow was assessed using isotopic assessment (99mtechnetium albumin). cDPP3 activity, equilibrium analysis of the renin-angiotensin system and circulating catecholamines were measured. Tissue mRNA expression of interleukin-6 and downregulation of adrenergic and angiotensin receptors were assessed on vascular and myocardial samples. RESULTS PCZ-treated animals had reduced cDPP3 levels and required less norepinephrine and fluid than septic control animals for similar organ perfusion and regional blood flow. PCZ-treated animals had less myocardial injury, and higher PaO2/FiO2 ratios. PCZ was associated with lower circulating catecholamine levels; higher circulating angiotensin II and higher angiotensin II receptor type 1 myocardial protein expression, and with lower myocardial and radial artery mRNA interleukin-6 expression. CONCLUSIONS In an experimental model of septic shock, PCZ administration was associated with reduced fluid and catecholamine requirements, less myocardial injury and cardiovascular inflammation, along with preserved angiotensin II signaling.
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Affiliation(s)
- Bruno Garcia
- Experimental Laboratory of the Department of Intensive Care, Université Libre de Bruxelles (ULB), Brussels, Belgium.
- Department of Intensive Care, Centre Hospitalier Universitaire de Lille, Lille, France.
| | - Benoit Ter Schiphorst
- Experimental Laboratory of the Department of Intensive Care, Université Libre de Bruxelles (ULB), Brussels, Belgium
- Department of Intensive Care, Centre Hospitalier Universitaire de Lille, Lille, France
| | | | - Fuhong Su
- Experimental Laboratory of the Department of Intensive Care, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Laurence Dewachter
- Laboratory of Physiology and Pharmacology, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | | | - Estela Rocha-Oliveira
- Cardiovascular R&D Center, Faculty of Medicine, University of Porto, Porto, Portugal
| | | | - Theo Uba
- 4TEEN4 Pharmaceuticals GmbH, Hennigsdorf, Germany
| | | | - Adrien Picod
- Université Paris Cité, UMR-S 942, INSERM, MASCOT, Paris, France
| | - Feriel Azibani
- Université Paris Cité, UMR-S 942, INSERM, MASCOT, Paris, France
| | - Jacques Callebert
- Université Paris Cité, UMR-S 942, INSERM, MASCOT, Paris, France
- Department of Biochemistry, Assistance Publique Hôpitaux de Paris, Hôpital Lariboisière, Paris, France
| | - Serge Goldman
- Department of Nuclear Medicine, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Filippo Annoni
- Experimental Laboratory of the Department of Intensive Care, Université Libre de Bruxelles (ULB), Brussels, Belgium
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Raphaël Favory
- Department of Intensive Care, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Jean-Louis Vincent
- Experimental Laboratory of the Department of Intensive Care, Université Libre de Bruxelles (ULB), Brussels, Belgium
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Jacques Creteur
- Experimental Laboratory of the Department of Intensive Care, Université Libre de Bruxelles (ULB), Brussels, Belgium
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Fabio Silvio Taccone
- Experimental Laboratory of the Department of Intensive Care, Université Libre de Bruxelles (ULB), Brussels, Belgium
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Alexandre Mebazaa
- Université Paris Cité, UMR-S 942, INSERM, MASCOT, Paris, France
- Department of Anesthesia, Burn and Critical Care, University Hospitals Saint-Louis-Lariboisière, AP-HP, Paris, France
| | - Antoine Herpain
- Experimental Laboratory of the Department of Intensive Care, Université Libre de Bruxelles (ULB), Brussels, Belgium
- Department of Intensive Care, Saint-Pierre University Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
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23
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Antonucci E, Garcia B, Legrand M. Hemodynamic Support in Sepsis. Anesthesiology 2024; 140:1205-1220. [PMID: 38743000 DOI: 10.1097/aln.0000000000004958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
This review discusses recent evidence in managing sepsis-induced hemodynamic alterations and how it can be integrated with previous knowledge for actionable interventions in adult patients.
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Affiliation(s)
- Edoardo Antonucci
- Department of Anesthesia and Perioperative Care, Division of Critical Care Medicine, University of California, San Francisco, San Francisco, California; Department of Anesthesia and Critical Care Medicine, University of Milan, Milan, Italy
| | - Bruno Garcia
- Department of Anesthesia and Perioperative Care, Division of Critical Care Medicine, University of California, San Francisco, San Francisco, California; Department of Intensive Care, Centre Hospitalier Universitaire de Lille, Lille, France; Experimental Laboratory of Intensive Care, Université Libre de Bruxelles, Brussels, Belgium
| | - Matthieu Legrand
- Department of Anesthesia and Perioperative Care, Division of Critical Care Medicine, University of California, San Francisco, San Francisco, California; INI-CRCT (Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists) Network, Nancy, France
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24
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Krzych ŁJ, Nadziakiewicz P, Kucewicz-Czech E. Proposal for the use of angiotensin II in distributive shock after extracorporeal circulation - position paper of the Section of Intensive Care Medicine and the Section of Cardiothoracic Anaesthesiology of the Polish Society of Anaesthesiology and Intensive Therapy. KARDIOCHIRURGIA I TORAKOCHIRURGIA POLSKA = POLISH JOURNAL OF CARDIO-THORACIC SURGERY 2024; 21:96-98. [PMID: 39055252 PMCID: PMC11267642 DOI: 10.5114/kitp.2024.141146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Accepted: 03/17/2024] [Indexed: 07/27/2024]
Abstract
Angiotensin II (AT) is a potent vasoconstrictor and hypertensive drug that is registered for the treatment of severe hypotension in vasoplegic shock. Growing experience with the use of AT in cardiac surgery allows the first therapeutic algorithms to be created. This paper is a proposal for the use of AT in distributive shock after extracorporeal circulation.
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Affiliation(s)
- Łukasz J Krzych
- Department of Anaesthesiology and Intensive Care, Silesian Centre for Heart Diseases, Zabrze, Poland
- Department of Acute Medicine, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
- Section of Intensive Care Medicine, Polish Society of Anaesthesiology and Intensive Therapy
- Department of Cardiac Anaesthesiology and Intensive Care, Faculty of Medical Sciences in Zabrze, Medical University of Silesia in Katowice, Poland
- Section of Cardiothoracic Anaesthesiology, Polish Society of Anaesthesiology and Intensive Therapy
| | - Paweł Nadziakiewicz
- Department of Anaesthesiology and Intensive Care, Silesian Centre for Heart Diseases, Zabrze, Poland
- Department of Cardiac Anaesthesiology and Intensive Care, Faculty of Medical Sciences in Zabrze, Medical University of Silesia in Katowice, Poland
- Section of Cardiothoracic Anaesthesiology, Polish Society of Anaesthesiology and Intensive Therapy
| | - Ewa Kucewicz-Czech
- Department of Anaesthesiology and Intensive Care, Silesian Centre for Heart Diseases, Zabrze, Poland
- Section of Cardiothoracic Anaesthesiology, Polish Society of Anaesthesiology and Intensive Therapy
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25
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Schaich CL, Leisman DE, Goldberg MB, Filbin MR, Khanna AK, Chappell MC. Dysfunction of the renin-angiotensin-aldosterone system in human septic shock. Peptides 2024; 176:171201. [PMID: 38555976 PMCID: PMC11060897 DOI: 10.1016/j.peptides.2024.171201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 03/20/2024] [Accepted: 03/27/2024] [Indexed: 04/02/2024]
Abstract
Sepsis and septic shock are global healthcare problems associated with mortality rates of up to 40% despite optimal standard-of-care therapy and constitute the primary cause of death in intensive care units worldwide. Circulating biomarkers of septic shock severity may represent a clinically relevant approach to individualize those patients at risk for worse outcomes early in the course of the disease, which may facilitate early and more precise interventions to improve the clinical course. However, currently used septic shock biomarkers, including lactate, may be non-specific and have variable impact on prognosis and/or disease management. Activation of the renin-angiotensin-aldosterone system (RAAS) is likely an early event in septic shock, and studies suggest that an elevated level of renin, the early and committed step in the RAAS cascade, is a better predictor of worse outcomes in septic shock, including mortality, than the current standard-of-care measure of lactate. Despite a robust increase in renin, other elements of the RAAS, including endogenous levels of Ang II, may fail to sufficiently increase to maintain blood pressure, tissue perfusion, and protective immune responses in septic shock patients. We review the current clinical literature regarding the dysfunction of the RAAS in septic shock and potential therapeutic approaches to improve clinical outcomes.
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Affiliation(s)
- Christopher L Schaich
- Hypertension & Vascular Research Center, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Daniel E Leisman
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Marcia B Goldberg
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Micheal R Filbin
- Department of Emergency Medicine, Massachusetts General Hospital,Boston, MA, USA
| | - Ashish K Khanna
- Hypertension & Vascular Research Center, Wake Forest University School of Medicine, Winston-Salem, NC, USA; Department of Anesthesiology, Section on Critical Care Medicine, Atrium Health Wake Forest Baptist Medical Center, USA; Outcomes Research Consortium, Cleveland, OH, USA
| | - Mark C Chappell
- Hypertension & Vascular Research Center, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
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26
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Kotani Y, Chappell M, Landoni G, Zarbock A, Bellomo R, Khanna AK. Renin in critically ill patients. Ann Intensive Care 2024; 14:79. [PMID: 38775999 PMCID: PMC11111649 DOI: 10.1186/s13613-024-01304-3] [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: 03/14/2024] [Accepted: 04/28/2024] [Indexed: 05/25/2024] Open
Abstract
The renin-angiotensin system (RAS) constitutes one of the principal mechanisms to maintain hemodynamic and fluid homeostasis. However, most research until now on RAS primarily focuses on its relationship with hypertension and its role in critically ill hypotensive populations is not well understood. With the approval of angiotensin II (Ang II) in the United States and Europe, following a phase 3 randomized controlled trial showing efficacy in catecholamine-resistant vasodilatory shock, there is growing interest in RAS in critically ill patients. Among the fundamental components of RAS, renin acts as the initial stimulus for the entire system. In the context of hypotension, its release increases in response to low blood pressure sensed by renal baroreceptors and attenuated negative Ang II feedback loop. Thus, elevated renin could reflect disease severity and predict poor outcomes. Studies investigating this hypothesis have validated the prognostic accuracy of renin in various critically ill populations, with several reports indicating its superiority to lactate for mortality prediction. Accordingly, renin reduction has been used to assess the effectiveness of Ang II administration. Furthermore, renin holds potential to identify patients who might benefit from Ang II treatment, potentially paving the way for personalized vasopressor management. Despite these promising data, most available evidence is derived from retrospective analysis and necessitates prospective confirmation. The absence of a rapid, point-of-care and reliable renin assay presents another hurdle to its integration into routine clinical practice. This narrative review aims to describe the current understanding and future directions of renin as a biomarker during resuscitation of critically ill patients.
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Affiliation(s)
- Yuki Kotani
- Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Mark Chappell
- Hypertension and Vascular Research Center, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Muenster, Muenster, Germany
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Australia
| | - Ashish K Khanna
- Section On Critical Care Medicine, Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, NC, 27157, USA.
- Perioperative Outcomes and Informatics Collaborative, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC, 27157, USA.
- Outcomes Research Consortium, Cleveland, OH, 44195, USA.
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27
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Kotani Y, Belletti A, Maiucci G, Lodovici M, Fresilli S, Landoni G, Bellomo R, Zarbock A. Renin as a Prognostic Marker in Intensive Care and Perioperative Settings: A Scoping Review. Anesth Analg 2024; 138:929-936. [PMID: 38358109 DOI: 10.1213/ane.0000000000006682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Abstract
Serum renin increases in response to sympathetic nerve activation and hypotension. Recent studies have reported the association of serum renin levels with adverse clinical outcomes in acute care settings. This scoping review aimed to systematically review the available literature on renin as a prognostic marker in intensive care and perioperative patients. We searched for studies published since inception until March 31, 2023, which assessed the association between serum renin levels and clinical outcomes or the effect of synthetic angiotensin II administration on serum renin levels in critically ill and perioperative patients in PubMed, Embase, and the Cochrane Library. The primary outcome was mortality at the longest follow-up; the secondary outcomes were adverse renal outcomes (ie, acute kidney injury, the need for renal replacement therapy, and major adverse kidney events), hemodynamic instability, outcomes to angiotensin II administration, and prognostic performance for mortality when compared with lactate. Among the 2081 studies identified, we included 16 studies with 1573 patients (7 studies on shock, 5 on nonspecific critical illness, 2 on cardiac surgery, 1 on noncardiac surgery, and 1 on coronavirus disease 2019). A significant association between serum renin levels and poor outcomes was identified in 14 studies, with 10 studies demonstrating an association with mortality. One post hoc analysis found that angiotensin II administration reduced mortality in patients with markedly elevated renin values. Two studies showed that renin was superior to lactate as a prognostic marker of mortality. Our scoping review showed that elevated serum renin levels may be associated with clinically relevant outcomes among various perioperative and intensive care populations. Increased serum renin levels may identify patients in which synthetic angiotensin II administration improves clinical outcomes and may outperform serum lactate in predicting mortality.
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Affiliation(s)
- Yuki Kotani
- From the Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
- Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Alessandro Belletti
- From the Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giacomo Maiucci
- From the Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Martina Lodovici
- From the Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Fresilli
- From the Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giovanni Landoni
- From the Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Rinaldo Bellomo
- Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Critical Care, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Muenster, Muenster, Germany
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28
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Leisman DE, Handisides DR, Busse LW, Chappell MC, Chawla LS, Filbin MR, Goldberg MB, Ham KR, Khanna AK, Ostermann M, McCurdy MT, Adams CD, Hodges TN, Bellomo R. ACE inhibitors and angiotensin receptor blockers differentially alter the response to angiotensin II treatment in vasodilatory shock. Crit Care 2024; 28:130. [PMID: 38637829 PMCID: PMC11027368 DOI: 10.1186/s13054-024-04910-6] [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: 02/17/2024] [Accepted: 04/12/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND Angiotensin-converting enzyme inhibitor (ACEi) and angiotensin receptor blockers (ARB) medications are widely prescribed. We sought to assess how pre-admission use of these medications might impact the response to angiotensin-II treatment during vasodilatory shock. METHODS In a post-hoc subgroup analysis of the randomized, placebo-controlled, Angiotensin Therapy for High Output Shock (ATHOS-3) trial, we compared patients with chronic angiotensin-converting enzyme inhibitor (ACEi) use, and patients with angiotensin receptor blocker (ARB) use, to patients without exposure to either ACEi or ARB. The primary outcome was mean arterial pressure after 1-h of treatment. Additional clinical outcomes included mean arterial pressure and norepinephrine equivalent dose requirements over time, and study-drug dose over time. Biological outcomes included baseline RAS biomarkers (renin, angiotensin-I, angiotensin-II, and angiotensin-I/angiotensin-II ratio), and the change in renin from 0 to 3 h. RESULTS We included n = 321 patients, of whom, 270 were ACEi and ARB-unexposed, 29 were ACEi-exposed and 22 ARB-exposed. In ACEi/ARB-unexposed patients, angiotensin-treated patients, compared to placebo, had higher hour-1 mean arterial pressure (9.1 mmHg [95% CI 7.6-10.1], p < 0.0001), lower norepinephrine equivalent dose over 48-h (p = 0.0037), and lower study-drug dose over 48-h (p < 0.0001). ACEi-exposed patients treated with angiotensin-II showed similarly higher hour-1 mean arterial pressure compared to ACEi/ARB-unexposed (difference in treatment-effect: - 2.2 mmHg [95% CI - 7.0-2.6], pinteraction = 0.38), but a greater reduction in norepinephrine equivalent dose (pinteraction = 0.0031) and study-drug dose (pinteraction < 0.0001) over 48-h. In contrast, ARB-exposed patients showed an attenuated effect of angiotensin-II on hour-1 mean arterial pressure versus ACEi/ARB-unexposed (difference in treatment-effect: - 6.0 mmHg [95% CI - 11.5 to - 0.6], pinteraction = 0.0299), norepinephrine equivalent dose (pinteraction < 0.0001), and study-drug dose (pinteraction = 0.0008). Baseline renin levels and angiotensin-I/angiotensin-II ratios were highest in ACEi-exposed patients. Finally, angiotensin-II treatment reduced hour-3 renin in ACEi/ARB-unexposed and ACEi-exposed patients but not in ARB-exposed patients. CONCLUSIONS In vasodilatory shock patients, the cardiovascular and biological RAS response to angiotensin-II differed based upon prior exposure to ACEi and ARB medications. ACEi-exposure was associated with increased angiotensin II responsiveness, whereas ARB-exposure was associated with decreased responsiveness. These findings have clinical implications for patient selection and dosage of angiotensin II in vasodilatory shock. Trial Registration ClinicalTrials.Gov Identifier: NCT02338843 (Registered January 14th 2015).
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Affiliation(s)
- Daniel E Leisman
- Department of Medicine, Massachusetts General Hospital, 55 Fruit St., GRB 7-730, Boston, MA, 02114, USA.
| | - Damian R Handisides
- Innoviva Specialty Therapeutics, Inc - an Affiliate of La Jolla Pharmaceutical Company, Waltham, MA, USA
| | - Laurence W Busse
- Department of Medicine, Emory University, Atlanta, GA, USA
- Emory Critical Care Center, Emory Healthcare, Atlanta, GA, USA
| | - Mark C Chappell
- Hypertension and Vascular Research Center, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Lakhmir S Chawla
- Department of Medicine, Veterans Affairs Medical Center, San Diego, CA, USA
| | - Michael R Filbin
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
- Department of Emergency Medicine, Harvard Medical School, Boston, MA, USA
- Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA, USA
| | - Marcia B Goldberg
- Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, MA, USA
- Division of Infectious Diseases, Department of Medicine, Center for Bacterial Pathogenesis, Massachusetts General Hospital, Boston, MA, USA
- Department of Microbiology, Harvard Medical School, Boston, MA, USA
| | - Kealy R Ham
- Department of Critical Care, Mayo Clinic, Phoenix, AZ, USA
| | - Ashish K Khanna
- Section on Critical Care Medicine, Department of Anesthesiology, Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
- Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA
- Outcomes Research Consortium, Cleveland, OH, USA
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's & St Thomas' Hospital, London, UK
| | - Michael T McCurdy
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Christopher D Adams
- Innoviva Specialty Therapeutics, Inc - an Affiliate of La Jolla Pharmaceutical Company, Waltham, MA, USA
| | - Tony N Hodges
- Innoviva Specialty Therapeutics, Inc - an Affiliate of La Jolla Pharmaceutical Company, Waltham, MA, USA
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Austin Hospital, Melbourne, Australia
- Data Analytics Research and Evaluation (DARE) Centre, Austin Hospital, Melbourne, Australia
- Department of Intensive Care Medicine, Austin Hospital, Melbourne, Australia
- The Australian and New Zealand Intensive Care Society (ANZICS) Centre for Outcome and Resource Evaluation (CORE), Melbourne, Australia
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
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Picod A, Placier S, Genest M, Callebert J, Julian N, Zalc M, Assad N, Nordin H, Santos K, Gaudry S, Chatziantoniou C, Mebazaa A, Azibani F. Circulating Dipeptidyl Peptidase 3 Modulates Systemic and Renal Hemodynamics Through Cleavage of Angiotensin Peptides. Hypertension 2024; 81:927-935. [PMID: 38334001 PMCID: PMC10956665 DOI: 10.1161/hypertensionaha.123.21913] [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: 08/14/2023] [Accepted: 01/25/2024] [Indexed: 02/10/2024]
Abstract
BACKGROUND High circulating DPP3 (dipeptidyl peptidase 3) has been associated with poor prognosis in critically ill patients with circulatory failure. In such situation, DPP3 could play a pathological role, putatively via an excessive angiotensin peptides cleavage. Our objective was to investigate the hemodynamics changes induced by DPP3 in mice and the relation between the observed effects and renin-angiotensin system modulation. METHODS Ten-week-old male C57Bl/6J mice were subjected to intravenous injection of purified human DPP3 or an anti-DPP3 antibody (procizumab). Invasive blood pressure and renal blood flow were monitored throughout the experiments. Circulating angiotensin peptides and catecholamines were measured and receptor blocking experiment performed to investigate the underlying mechanisms. RESULTS DPP3 administration significantly increased renal blood flow, while blood pressure was minimally affected. Conversely, procizumab led to significantly decreased renal blood flow. Angiotensin peptides measurement and an AT1R (angiotensin II receptor type 1) blockade experiment using valsartan demonstrated that the renovascular effect induced by DPP3 is due to reduced AT1R activation via decreased concentrations of circulating angiotensin II, III, and IV. Measurements of circulating catecholamines and an adrenergic receptor blockade by labetalol demonstrated a concomitant catecholamines release that explains blood pressure maintenance upon DPP3 administration. CONCLUSIONS High circulating DPP3 increases renal blood flow due to reduced AT1R activation via decreased concentrations of circulating angiotensin peptides while blood pressure is maintained by concomitant endogenous catecholamines release.
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Affiliation(s)
- Adrien Picod
- Institut National de la Santé et de la Recherche Médicale UMR-S 942 MASCOT – Paris – Cité University, Paris, France (A.P., M.G., J.C., N.J., M.Z., N.A., H.N., A.M., F.A.)
| | - Sandrine Placier
- INSERM UMR-S 1155 CORAKID – Paris – Sorbonne University, France (S.P., S.G., C.C.)
| | - Magali Genest
- Institut National de la Santé et de la Recherche Médicale UMR-S 942 MASCOT – Paris – Cité University, Paris, France (A.P., M.G., J.C., N.J., M.Z., N.A., H.N., A.M., F.A.)
| | - Jacques Callebert
- Institut National de la Santé et de la Recherche Médicale UMR-S 942 MASCOT – Paris – Cité University, Paris, France (A.P., M.G., J.C., N.J., M.Z., N.A., H.N., A.M., F.A.)
- Department of Biochemistry and Molecular Biology, Lariboisière – Saint Louis Hospitals (J.C.), APHP, Paris, France
| | - Nathan Julian
- Institut National de la Santé et de la Recherche Médicale UMR-S 942 MASCOT – Paris – Cité University, Paris, France (A.P., M.G., J.C., N.J., M.Z., N.A., H.N., A.M., F.A.)
- Department of Anesthesiology and Intensive Care, Lariboisière – Saint Louis Hospitals (N.J., A.M.), APHP, Paris, France
| | - Maxime Zalc
- Institut National de la Santé et de la Recherche Médicale UMR-S 942 MASCOT – Paris – Cité University, Paris, France (A.P., M.G., J.C., N.J., M.Z., N.A., H.N., A.M., F.A.)
- Department of Anesthesiology and Intensive Care, Mondor Hospital (M.Z.), APHP, Paris, France
- Paris Est – Créteil University, France (M.Z.)
| | - Noma Assad
- Institut National de la Santé et de la Recherche Médicale UMR-S 942 MASCOT – Paris – Cité University, Paris, France (A.P., M.G., J.C., N.J., M.Z., N.A., H.N., A.M., F.A.)
| | - Hugo Nordin
- Institut National de la Santé et de la Recherche Médicale UMR-S 942 MASCOT – Paris – Cité University, Paris, France (A.P., M.G., J.C., N.J., M.Z., N.A., H.N., A.M., F.A.)
| | - Karine Santos
- 4TEEN4 Pharmaceuticals Gmbh, Hennigsdorf, Germany (K.S.)
| | - Stéphane Gaudry
- INSERM UMR-S 1155 CORAKID – Paris – Sorbonne University, France (S.P., S.G., C.C.)
- Sorbonne – Paris Nord University, France (S.G.)
- Medical and Surgical Intensive Care Unit, Avicenne Hospital, APHP, Bobigny, France (S.G.)
| | | | - Alexandre Mebazaa
- Institut National de la Santé et de la Recherche Médicale UMR-S 942 MASCOT – Paris – Cité University, Paris, France (A.P., M.G., J.C., N.J., M.Z., N.A., H.N., A.M., F.A.)
- Department of Anesthesiology and Intensive Care, Lariboisière – Saint Louis Hospitals (N.J., A.M.), APHP, Paris, France
| | - Feriel Azibani
- Institut National de la Santé et de la Recherche Médicale UMR-S 942 MASCOT – Paris – Cité University, Paris, France (A.P., M.G., J.C., N.J., M.Z., N.A., H.N., A.M., F.A.)
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Legrand M, Bagshaw SM, Bhatraju PK, Bihorac A, Caniglia E, Khanna AK, Kellum JA, Koyner J, Harhay MO, Zampieri FG, Zarbock A, Chung K, Liu K, Mehta R, Pickkers P, Ryan A, Bernholz J, Dember L, Gallagher M, Rossignol P, Ostermann M. Sepsis-associated acute kidney injury: recent advances in enrichment strategies, sub-phenotyping and clinical trials. Crit Care 2024; 28:92. [PMID: 38515121 PMCID: PMC10958912 DOI: 10.1186/s13054-024-04877-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 03/17/2024] [Indexed: 03/23/2024] Open
Abstract
Acute kidney injury (AKI) often complicates sepsis and is associated with high morbidity and mortality. In recent years, several important clinical trials have improved our understanding of sepsis-associated AKI (SA-AKI) and impacted clinical care. Advances in sub-phenotyping of sepsis and AKI and clinical trial design offer unprecedented opportunities to fill gaps in knowledge and generate better evidence for improving the outcome of critically ill patients with SA-AKI. In this manuscript, we review the recent literature of clinical trials in sepsis with focus on studies that explore SA-AKI as a primary or secondary outcome. We discuss lessons learned and potential opportunities to improve the design of clinical trials and generate actionable evidence in future research. We specifically discuss the role of enrichment strategies to target populations that are most likely to derive benefit and the importance of patient-centered clinical trial endpoints and appropriate trial designs with the aim to provide guidance in designing future trials.
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Affiliation(s)
- Matthieu Legrand
- Division of Critical Care Medicine, Department of Anesthesia and Perioperative Care, UCSF, 521 Parnassus Avenue, San Francisco, CA, 94143, USA.
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, Canada
| | - Pavan K Bhatraju
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, USA
- Kidney Research Institute, University of Washington, Seattle, USA
| | - Azra Bihorac
- Department of Medicine, University of Florida, Gainesville, FL, USA
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL, USA
| | - Ellen Caniglia
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
| | - Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
- Outcomes Research Consortium, Cleveland, OH, USA
- Perioperative Outcomes and Informatics Collaborative, Winston-Salem, NC, USA
| | - John A Kellum
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jay Koyner
- University Section of Nephrology, Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Michael O Harhay
- Clinical Trials Methods and Outcomes Lab, Department of Biostatistics, Epidemiology, and Informatics, PAIR (Palliative and Advanced Illness Research) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Fernando G Zampieri
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, Canada
| | | | | | - Kathleen Liu
- Divisions of Nephrology and Critical Care Medicine, Departments of Medicine and Anesthesia, University of California San Francisco, San Francisco, CA, USA
| | - Ravindra Mehta
- Department of Medicine, University of California, San Diego, USA
| | - Peter Pickkers
- Intensive Care Medicine, Radboudumc, Nijmegen, The Netherlands
| | - Abigail Ryan
- Chronic Care Policy Group, Division of Chronic Care Management, Center for Medicare and Medicaid Services, Center for Medicare, Baltimore, MD, USA
| | | | - Laura Dember
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Department of Biostatistics, Epidemiology and Informatics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Martin Gallagher
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Patrick Rossignol
- FCRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
- INSERM CIC-P 1433, CHRU de Nancy, INSERM U1116, Université de Lorraine, Nancy, France
- Medicine and Nephrology-Hemodialysis Departments, Monaco Private Hemodialysis Centre, Princess Grace Hospital, Monaco, Monaco
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's & St Thomas' Hospital, London, UK
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Chakradhar A, Baron RM, Vera MP, Devarajan P, Chawla L, Hou PC. Plasma renin as a novel prognostic biomarker of sepsis-associated acute respiratory distress syndrome. Sci Rep 2024; 14:6667. [PMID: 38509149 PMCID: PMC10954703 DOI: 10.1038/s41598-024-56994-3] [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: 04/12/2023] [Accepted: 03/13/2024] [Indexed: 03/22/2024] Open
Abstract
Sepsis-associated acute respiratory distress syndrome (ARDS) is a life-threatening condition in critical care medicine for which there is a substantial need for early prognostic biomarkers of outcome. The present study seeks to link plasma renin levels and 30-day mortality in sepsis-associated ARDS patients treated at our institution. The Registry of Critical Illness (RoCI) prospectively enrolled patients from the intensive care units (ICU) within a single academic medical center, and a convenience sample of patients with sepsis-associated ARDS was analyzed from this cohort. This study was approved by the Mass General Brigham Institutional Review Boards (IRB) as part of the RoCI, and all procedures performed were in accordance with the ethical standards of the institutional board. From April 2012 to February 2019, a cohort of 32 adult sepsis-associated ARDS patients with 500 µL of plasma samples available on Day 0 and Day 3 of their ICU stay were enrolled. Renin levels were measured twice, on Day 0 and Day 3 via the direct renin enzyme-linked immunosorbent assay (ELISA EIA-525) by DRG diagnostics. Day 0 and Day 3 renin were statistically evaluated via logistic regression to predict 30-day mortality. Direct renin levels of 64 samples were assayed from 32 sepsis-associated ARDS patients (50% male; mean ± SD, 55 ± 13.8 years old). The 30-day hospital mortality rate was 59.4%. Patients who died within 30 days of admission were more likely to have an elevated Day 3 Renin (Odds ratio [OR] = 6, 95% CI 1.25-28.84) and have received vasopressors (OR = 13.33, 95% CI 1.43-123.95). Adjusting for vasopressor use as a proxy for septic shock status, patients with an Elevated Day 3 Renin had a 6.85 (95% CI 1.07-43.75) greater odds of death than those with Low-Normal Day 3 Renin. Patients with sustained Elevated Renin levels from Day 0 to Day 3 had the highest risk of death in a 30-day window. In this study, we found that renin may be a novel biomarker that has prognostic value for patients with sepsis-associated ARDS. Future studies evaluating renin levels in patients with sepsis-associated ARDS are needed to validate these findings.
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Affiliation(s)
- Anjali Chakradhar
- Department of Molecular and Cellular Biology, Harvard University, Cambridge, MA, USA
| | - Rebecca M Baron
- Division of Pulmonary Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Mayra Pinilla Vera
- Division of Pulmonary Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Prasad Devarajan
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Lakhmir Chawla
- Silver Creek Pharmaceuticals, Inc., San Francisco, CA, USA
| | - Peter C Hou
- Division of Emergency Critical Care Medicine, Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA.
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Teixeira JP, Perez Ingles D, Barton JB, Dean JT, Garcia P, Kunkel SJ, Sarangarm P, Weiss NK, Schaich CL, Busse LW, Nielsen ND. The scientific rationale and study protocol for the DPP3, Angiotensin II, and Renin Kinetics in Sepsis (DARK-Sepsis) randomized controlled trial: serum biomarkers to predict response to angiotensin II versus standard-of-care vasopressor therapy in the treatment of septic shock. Trials 2024; 25:182. [PMID: 38475822 DOI: 10.1186/s13063-024-07995-0] [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: 07/16/2023] [Accepted: 02/20/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND Data to support the use of specific vasopressors in septic shock are limited. Since angiotensin II (AT2) was approved by the Food and Drug Administration in 2017, multiple mechanistically distinct vasopressors are available to treat septic shock, but minimal data exist regarding which patients are most likely to benefit from each agent. Renin and dipeptidyl peptidase 3 (DPP3) are components of the renin-angiotensin-aldosterone system which have been shown to outperform lactate in predicting sepsis prognosis, and preliminary data suggest they could prove useful as biomarkers to guide AT2 use in septic shock. METHODS The DARK-Sepsis trial is an investigator-initiated industry-funded, open-label, single-center randomized controlled trial of the use of AT2 versus standard of care (SOC) vasopressor therapy in patients admitted to the intensive care unit (ICU) with vasodilatory shock requiring norepinephrine ≥ 0.1 mcg/kg/min. In both groups, a series of renin and DPP3 levels will be obtained over the first 24 h of treatment with AT2 or SOC. The primary study outcome will be the ability of these biomarkers to predict response to vasopressor therapy, as measured by change in total norepinephrine equivalent dose of vasopressors at 3 h post-drug initiation or the equivalent timepoint in the SOC arm. To determine if the ability to predict vasopressor response is specific to AT2 therapy, the primary analysis will be the ability of baseline renin and DPP3 levels to predict vasopressor response adjusted for treatment arm (AT2 versus control) and Sequential Organ Failure Assessment (SOFA) scores. Secondary outcomes will include rates of acute kidney injury, need for mechanical ventilation and kidney replacement therapy, lengths of stay in the ICU and hospital, ICU and hospital mortality, and rates of prespecified adverse events. DISCUSSION With an armamentarium of mechanistically distinct vasopressor agents now available, sub-phenotyping patients using biomarkers has the potential to improve septic shock outcomes by enabling treatment of the correct patient with the correct vasopressor at the correct time. However, this approach requires validation in a large definitive multicenter trial. The data generated through the DARK-Sepsis study will prove crucial to the optimal design and patient enrichment of such a pivotal trial. TRIAL REGISTRATION ClinicalTrials.gov NCT05824767. Registered on April 24, 2023.
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Affiliation(s)
- J Pedro Teixeira
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA.
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA.
| | - David Perez Ingles
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Jordan B Barton
- Investigational Drug Services Pharmacy, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - James T Dean
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Pablo Garcia
- Division of Nephrology, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Susan J Kunkel
- Investigational Drug Services Pharmacy, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | | | - Natalie K Weiss
- Clinical Trials Unit, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Christopher L Schaich
- Hypertension and Vascular Research Center, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Laurence W Busse
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Nathan D Nielsen
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA
- Section of Transfusion Medicine and Therapeutic Pathology, Department of Pathology, University of New Mexico School of Medicine, Albuquerque, NM, USA
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See EJ, Russell JA, Bellomo R, Lawler PR. Renin as a Prognostic and Predictive Biomarker in Sepsis: More Questions Than Answers? Crit Care Med 2024; 52:509-512. [PMID: 38381014 DOI: 10.1097/ccm.0000000000006133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Affiliation(s)
- Emily J See
- Department of Intensive Care, Royal Melbourne Hospital, Parkville, NSW, Australia
- Department of Critical Care, University of Melbourne, Parkville, NSW, Australia
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
- Department of Critical Care, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- Department of Medicine, Centre for Heart Lung Innovation, University of British Columbia and St Paul's Hospital, Vancouver, BC, Canada
- Department of Medicine, McGill University Health Centre and McGill University, Montreal, QC, Canada
- Division of Cardiology and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - James A Russell
- Department of Medicine, Centre for Heart Lung Innovation, University of British Columbia and St Paul's Hospital, Vancouver, BC, Canada
| | - Rinaldo Bellomo
- Department of Intensive Care, Royal Melbourne Hospital, Parkville, NSW, Australia
- Department of Critical Care, University of Melbourne, Parkville, NSW, Australia
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
- Department of Critical Care, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- Department of Medicine, Centre for Heart Lung Innovation, University of British Columbia and St Paul's Hospital, Vancouver, BC, Canada
- Department of Medicine, McGill University Health Centre and McGill University, Montreal, QC, Canada
- Division of Cardiology and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Patrick R Lawler
- Department of Medicine, McGill University Health Centre and McGill University, Montreal, QC, Canada
- Division of Cardiology and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
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Busse LW, Schaich CL, Chappell MC, McCurdy MT, Staples EM, Ten Lohuis CC, Hinson JS, Sevransky JE, Rothman RE, Wright DW, Martin GS, Khanna AK. Association of Active Renin Content With Mortality in Critically Ill Patients: A Post hoc Analysis of the Vitamin C, Thiamine, and Steroids in Sepsis (VICTAS) Trial. Crit Care Med 2024; 52:441-451. [PMID: 37947484 PMCID: PMC10876175 DOI: 10.1097/ccm.0000000000006095] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
OBJECTIVE Sepsis is a leading cause of mortality. Predicting outcomes is challenging and few biomarkers perform well. Defects in the renin-angiotensin system (RAS) can predict clinical outcomes in sepsis and may outperform traditional biomarkers. We postulated that RAS dysfunction (elevated active renin, angiotensin 1-7 [Ang-(1-7)], and angiotensin-converting enzyme 2 (ACE2) activity with depressed Ang-II and ACE activity) would be associated with mortality in a cohort of septic patients. DESIGN Post hoc analysis of patients enrolled in the Vitamin C, Thiamine, and Steroids in Sepsis (VICTAS) randomized controlled trial. SETTING Forty-three hospitals across the United States. PATIENTS Biorepository samples of 103 patients. INTERVENTIONS We analyzed day 0 (within 24 hr of respiratory failure, septic shock, or both) and day 3 samples ( n = 103 and 95, respectively) for assessment of the RAS. The association of RAS values with 30-day mortality was determined using Cox proportional hazards regression with multivariable adjustments for age, sex, VICTAS treatment arm, systolic blood pressure, Sequential Organ Failure Assessment Score, and vasopressor use. MEASUREMENTS AND MAIN RESULTS High baseline active renin values were associated with higher 30-day mortality when dichotomized to the median of 188.7 pg/mL (hazard ratio [HR] = 2.84 [95% CI, 1.10-7.33], p = 0.031) or stratified into quartiles (Q1 = ref, HR Q2 = 2.01 [0.37-11.04], HR Q3 = 3.22 [0.64-16.28], HR Q4 = 5.58 [1.18-26.32], p for linear trend = 0.023). A 1- sd (593.6 pg/mL) increase in renin from day 0 to day 3 was associated with increased mortality (HR = 3.75 [95% CI, 1.94-7.22], p < 0.001), and patients whose renin decreased had improved survival compared with those whose renin increased (HR 0.22 [95% CI, 0.08-0.60], p = 0.003). Ang-(1-7), ACE2 activity, Ang-II and ACE activity did not show this association. Mortality was attenuated in patients with renin over the median on day 0 who received the VICTAS intervention, but not on day 3 ( p interaction 0.020 and 0.137, respectively). There were no additional consistent patterns of mortality on the RAS from the VICTAS intervention. CONCLUSIONS Baseline serum active renin levels were strongly associated with mortality in critically ill patients with sepsis. Furthermore, a greater relative activation in circulating renin from day 0 to day 3 was associated with a higher risk of death.
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Affiliation(s)
- Laurence W Busse
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University, Atlanta, GA
- Emory Critical Care Center, Emory Healthcare, Atlanta, GA
| | - Christopher L Schaich
- Hypertension and Vascular Research Center, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Mark C Chappell
- Hypertension and Vascular Research Center, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Michael T McCurdy
- Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Erin M Staples
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
| | | | - Jeremiah S Hinson
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Jonathan E Sevransky
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University, Atlanta, GA
- Emory Critical Care Center, Emory Healthcare, Atlanta, GA
| | - Richard E Rothman
- Department of Emergency Medicine, Johns Hopkins University, The Johns Hopkins Hospital, Baltimore, MD
| | - David W Wright
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA
- Grady Marcus Trauma and Emergency Care Center, Atlanta, GA
| | - Greg S Martin
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University, Atlanta, GA
- Emory Critical Care Center, Emory Healthcare, Atlanta, GA
| | - Ashish K Khanna
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University, Atlanta, GA
- Emory Critical Care Center, Emory Healthcare, Atlanta, GA
- Hypertension and Vascular Research Center, Wake Forest University School of Medicine, Winston-Salem, NC
- Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, MD
- Department of Emergency Medicine, Johns Hopkins University, The Johns Hopkins Hospital, Baltimore, MD
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA
- Grady Marcus Trauma and Emergency Care Center, Atlanta, GA
- Department of Anesthesiology, Section of Critical Care Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
- Outcomes Research Consortium, Cleveland, OH
- Perioperative Outcomes and Informatics Collaborative, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC
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35
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Coloretti I, Genovese A, Teixeira JP, Cherian A, Ferrer R, Landoni G, Leone M, Girardis M, Nielsen ND. Angiotensin ii therapy in refractory septic shock: which patient can benefit most? A narrative review. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2024; 4:13. [PMID: 38383521 PMCID: PMC10882873 DOI: 10.1186/s44158-024-00150-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 02/12/2024] [Indexed: 02/23/2024]
Abstract
Patients with septic shock who experience refractory hypotension despite adequate fluid resuscitation and high-dose noradrenaline have high mortality rates. To improve outcomes, evidence-based guidelines recommend starting a second vasopressor, such as vasopressin, if noradrenaline doses exceed 0.5 µg/kg/min. Recently, promising results have been observed in treating refractory hypotension with angiotensin II, which has been shown to increase mean arterial pressure and has been associated with improved outcomes. This narrative review aims to provide an overview of the pathophysiology of the renin-angiotensin system and the role of endogenous angiotensin II in vasodilatory shock with a focus on how angiotensin II treatment impacts clinical outcomes and on identifying the population that may benefit most from its use.
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Affiliation(s)
- Irene Coloretti
- Anesthesia and Intensive Care Medicine, Policlinico Di Modena, University of Modena and Reggio Emilia, Via del Pozzo, Modena, 71. 41124, Italy.
| | - Andrea Genovese
- Anesthesia and Intensive Care Medicine, Policlinico Di Modena, University of Modena and Reggio Emilia, Via del Pozzo, Modena, 71. 41124, Italy
| | - J Pedro Teixeira
- Divisions of Nephrology and Pulmonary, Critical Care, and Sleep Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Anusha Cherian
- Anesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Dhanvantri Nagar, Pondicherry, India
| | - Ricard Ferrer
- Intensive Care Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Giovanni Landoni
- Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marc Leone
- Anesthesia and Intensive Care Medicine, Hôpital Nord, Assistance Publique Hôpitaux de Marseille, Aix Marseille Université, Marseille, France
| | - Massimo Girardis
- Anesthesia and Intensive Care Medicine, Policlinico Di Modena, University of Modena and Reggio Emilia, Via del Pozzo, Modena, 71. 41124, Italy
| | - Nathan D Nielsen
- Division of Pulmonary, Critical Care and Sleep Medicine & Section of Transfusion Medicine and Therapeutic Pathology, University of New Mexico School of Medicine, Albuquerque, NM, USA
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36
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Bellomo R, Zarbock A, Landoni G. Angiotensin II. Intensive Care Med 2024; 50:279-282. [PMID: 38189932 DOI: 10.1007/s00134-023-07290-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 11/20/2023] [Indexed: 01/09/2024]
Affiliation(s)
- Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
- Department of Critical Care, University of Melbourne, Melbourne, Australia.
- Data Analytics Research and Evaluation Centre, Austin Hospital, Melbourne, Australia.
- Department of Intensive Care, Austin Hospital, Heidelberg, Melbourne, VIC, 3084, Australia.
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Australia.
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Giovanni Landoni
- Vita-Salute San Raffaele University, Milan, Italy
- IRCCS San Raffaele Scientific Institute, Milan, Italy
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37
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Suero OR, Park Y, Wieruszewski PM, Chatterjee S. Management of Vasoplegic Shock in the Cardiovascular Intensive Care Unit after Cardiac Surgery. Crit Care Clin 2024; 40:73-88. [PMID: 37973358 DOI: 10.1016/j.ccc.2023.06.002] [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] [Indexed: 11/19/2023]
Abstract
Vasoplegic shock after cardiac surgery is characterized by hypotension, a high cardiac output, and vasodilation. Much of the understanding of this pathologic state is informed by the understanding of septic shock. Adverse outcomes and mortality are increased with vasoplegic shock. Early recognition and a systematic approach to its management are critical. The need for vasopressors to sustain an adequate blood pressure as well as pharmacologic adjuncts to mitigate the inflammatory inciting process are necessary. The rationale behind vasopressor escalation and consideration of adjuncts are discussed.
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Affiliation(s)
- Orlando R Suero
- Baylor St. Lukes Medical Center, 6720 Bertner Avenue, Room 0-520, Houston, TX 77030, USA
| | - Yangseon Park
- Baylor St. Lukes Medical Center, 6720 Bertner Avenue, Room 0-520, Houston, TX 77030, USA
| | - Patrick M Wieruszewski
- Department of Pharmacy, Mayo Clinic, RO_MB_GR_722PH, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Subhasis Chatterjee
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA; Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, TX, USA.
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38
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Zarbock A, Koyner JL, Gomez H, Pickkers P, Forni L. Sepsis-associated acute kidney injury-treatment standard. Nephrol Dial Transplant 2023; 39:26-35. [PMID: 37401137 DOI: 10.1093/ndt/gfad142] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Indexed: 07/05/2023] Open
Abstract
Sepsis is a host's deleterious response to infection, which could lead to life-threatening organ dysfunction. Sepsis-associated acute kidney injury (SA-AKI) is the most frequent organ dysfunction and is associated with increased morbidity and mortality. Sepsis contributes to ≈50% of all AKI in critically ill adult patients. A growing body of evidence has unveiled key aspects of the clinical risk factors, pathobiology, response to treatment and elements of renal recovery that have advanced our ability to detect, prevent and treat SA-AKI. Despite these advancements, SA-AKI remains a critical clinical condition and a major health burden, and further studies are needed to diminish the short and long-term consequences of SA-AKI. We review the current treatment standards and discuss novel developments in the pathophysiology, diagnosis, outcome prediction and management of SA-AKI.
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Affiliation(s)
- Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital of Münster, Münster, Germany and Outcomes Research Consortium, Cleveland, OH, USA
| | - Jay L Koyner
- Section of Nephrology, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Hernando Gomez
- Program for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Peter Pickkers
- Department Intensive Care Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Lui Forni
- Department of Critical Care, Royal Surrey Hospital Foundation Trust, Guildford, UK
- Faculty of Health Sciences, University of Surrey, Guildford, UK
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39
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Leisman DE, Handisides DR, Chawla LS, Albertson TE, Busse LW, Boldt DW, Deane AM, Gong MN, Ham KR, Khanna AK, Ostermann M, McCurdy MT, Thompson BT, Tumlin JS, Adams CD, Hodges TN, Bellomo R. Angiotensin II treatment is associated with improved oxygenation in ARDS patients with refractory vasodilatory shock. Ann Intensive Care 2023; 13:128. [PMID: 38103056 PMCID: PMC10725390 DOI: 10.1186/s13613-023-01227-5] [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: 08/07/2023] [Accepted: 12/10/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND The physiological effects of renin-angiotensin system modulation in acute respiratory distress syndrome (ARDS) remain controversial and have not been investigated in randomized trials. We sought to determine whether angiotensin-II treatment is associated with improved oxygenation in shock-associated ARDS. METHODS Post-hoc subgroup analysis of the Angiotensin Therapy for High Output Shock (ATHOS-3) trial. We studied patients who met modified Berlin ARDS criteria at enrollment. The primary outcome was PaO2/FiO2-ratio (P:F) at 48-h adjusted for baseline P:F. Secondary outcomes included oxygenation index, ventilatory ratio, PEEP, minute-ventilation, hemodynamic measures, patients alive and ventilator-free by day-7, and mortality. RESULTS Of 81 ARDS patients, 34 (42%) and 47 (58%) were randomized to angiotensin-II or placebo, respectively. In angiotensin-II patients, mean P:F increased from 155 mmHg (SD: 69) at baseline to 265 mmHg (SD: 160) at hour-48 compared with no change with placebo (148 mmHg (SD: 63) at baseline versus 164 mmHg (SD: 74) at hour-48)(baseline-adjusted difference: + 98.4 mmHg [95%CI 35.2-161.5], p = 0.0028). Similarly, oxygenation index decreased by - 6.0 cmH2O/mmHg at hour-48 with angiotensin-II versus - 0.4 cmH2O/mmHg with placebo (baseline-adjusted difference: -4.8 cmH2O/mmHg, [95%CI - 8.6 to - 1.1], p = 0.0273). There was no difference in PEEP, minute ventilation, or ventilatory ratio. Twenty-two (64.7%) angiotensin-II patients had sustained hemodynamic response to treatment at hour-3 versus 17 (36.2%) placebo patients (absolute risk-difference: 28.5% [95%CI 6.5-47.0%], p = 0.0120). At day-7, 7/34 (20.6%) angiotensin-II patients were alive and ventilator-free versus 5/47(10.6%) placebo patients. Day-28 mortality was 55.9% in the angiotensin-II group versus 68.1% in the placebo group. CONCLUSIONS In post-hoc analysis of the ATHOS-3 trial, angiotensin-II was associated with improved oxygenation versus placebo among patients with ARDS and catecholamine-refractory vasodilatory shock. These findings provide a physiologic rationale for trials of angiotensin-II as treatment for ARDS with vasodilatory shock. TRIAL REGISTRATION ClinicalTrials.Gov Identifier: NCT02338843 (Registered January 14th 2015).
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Affiliation(s)
- Daniel E Leisman
- Department of Medicine, Massachusetts General Hospital, 55 Fruit St., GRB 7-730, Boston, MA, 02114, USA.
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA.
| | | | - Lakhmir S Chawla
- Department of Medicine, Veterans Affairs Medical Center, San Diego, CA, USA
| | - Timothy E Albertson
- Departments of Medicine, Emergency Medicine and Anesthesiology, School of Medicine, UC Davis, Sacramento, CA, USA
| | - Laurence W Busse
- Department of Medicine, Emory University, Atlanta, GA, USA
- Emory Critical Care Center, Emory Healthcare, Atlanta, GA, USA
| | - David W Boldt
- Division of Critical Care, Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Adam M Deane
- Department of Medicine and Radiology, Royal Melbourne Hospital, The University of Melbourne, Melbourne Medical School, Parkville, Australia
| | - Michelle N Gong
- Division of Critical Care Medicine, Division of Pulmonary Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Kealy R Ham
- Department of Critical Care, Mayo Clinic, Phoenix, AZ, USA
| | - Ashish K Khanna
- Department of Anesthesiology, Section On Critical Care Medicine, Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
- Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA
- Outcomes Research Consortium, Cleveland, OH, USA
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's & St Thomas' Hospital, London, UK
| | - Michael T McCurdy
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - James S Tumlin
- Renal Division, Department of Medicine, Emory University Medical Center, Emory University, Atlanta, GA, USA
| | | | | | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Austin Hospital, Melbourne, Australia
- Data Analytics Research and Evaluation (DARE) Centre, Austin Hospital, Melbourne, Australia
- Department of Intensive Care Medicine, Austin Hospital, Melbourne, Australia
- The Australian and New Zealand Intensive Care Society (ANZICS) Centre for Outcome and Resource Evaluation (CORE), Melbourne, Australia
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
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40
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Smith LM, Mentz GB, Engoren MC. Angiotensin II for the Treatment of Refractory Shock: A Matched Analysis. Crit Care Med 2023; 51:1674-1684. [PMID: 37378469 DOI: 10.1097/ccm.0000000000005975] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Abstract
OBJECTIVES To determine if angiotensin II is associated with improved outcomes as measured by 30- and 90-day mortality as well as other secondary outcomes such as organ dysfunction and adverse events. DESIGN Retrospective, matched analysis of patients receiving angiotensin II compared with both historical and concurrent controls receiving equivalent doses of nonangiotensin II vasopressors. SETTING Multiple ICUs in a large, university-based hospital. PATIENTS Eight hundred thirteen adult patients with shock admitted to an ICU and requiring vasopressor support. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Angiotensin II use had no association with the primary outcome of 30-day mortality (60% vs 56%; p = 0.292). The secondary outcome of 90-day mortality was also similar (65% vs 63%; p = 0.440) as were changes in Sequential Organ Failure Assessment scores over a 5-day monitoring period after enrollment. Angiotensin II was not associated with increased rates of kidney replacement therapy (odds ratio [OR], 1.39; 95% CI, 0.88-2.19; p = 0.158) or receipt of mechanical ventilation (OR, 1.50; 95% CI, 0.41-5.51; p = 0.539) after enrollment, and the rate of thrombotic events was similar between angiotensin II and control patients (OR, 1.02; 95% CI, 0.71-1.48; p = 0.912). CONCLUSIONS In patients with severe shock, angiotensin II was not associated with improved mortality or organ dysfunction and was not associated with an increased rate of adverse events.
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Affiliation(s)
- Lane M Smith
- Department of Anesthesiology, Section of Critical Care, University of Michigan, Ann Arbor, MI
| | - Graciela B Mentz
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI
| | - Milo C Engoren
- Department of Anesthesiology, Section of Critical Care, University of Michigan, Ann Arbor, MI
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41
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Garcia B, Zarbock A, Bellomo R, Legrand M. The role of renin-angiotensin system in sepsis-associated acute kidney injury: mechanisms and therapeutic implications. Curr Opin Crit Care 2023; 29:607-613. [PMID: 37861190 DOI: 10.1097/mcc.0000000000001092] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
PURPOSE OF REVIEW This review aims to explore the relationship between the renin angiotensin system (RAS) and sepsis-associated acute kidney injury (SA-AKI), a common complication in critically ill patients associated with mortality, morbidity, and long-term cardiovascular complications. Additionally, this review aims to identify potential therapeutic approaches to intervene with the RAS and prevent the development of AKI. RECENT FINDINGS Recent studies have provided increasing evidence of RAS alteration during sepsis, with systemic and local RAS disturbance, which can contribute to SA-AKI. Angiotensin II was recently approved for catecholamine resistant vasodilatory shock and has been associated with improved outcomes in selected patients. SUMMARY SA-AKI is a common condition that can involve disturbances in the RAS, particularly the canonical angiotensin-converting enzyme (ACE) angiotensin-II (Ang II)/angiotensin II receptor 1 (AT-1R) axis. Increased renin levels, a key enzyme in the RAS, have been shown to be associated with AKI and may also guide vasopressor therapy in shock. In patients with high renin levels, angiotensin II administration may reduce renin concentration, improve intra-renal hemodynamics, and enhance signaling through the angiotensin II receptor 1. Further studies are needed to explore the role of the RAS in SA-AKI and the potential for targeted therapies.
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Affiliation(s)
- Bruno Garcia
- Department of Anesthesia & Peri-operative Care, Division of Critical Care Medicine, University of California, San Francisco (UCSF), San Francisco, California, USA
- Department of Intensive Care, Centre Hospitalier Universitaire de Lille, Lille, France
- Experimental Laboratory of Intensive Care, Université Libre de Bruxelles, Brussels, Belgium
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital of Münster, Münster, Germany
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital
- Australian and New Zealand Intensive Care Research Centre, Monash University
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, Victoria, Australia
| | - Matthieu Legrand
- Department of Anesthesia & Peri-operative Care, Division of Critical Care Medicine, University of California, San Francisco (UCSF), San Francisco, California, USA
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42
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Garcia B, Zarbock A, Bellomo R, Legrand M. The alternative renin-angiotensin system in critically ill patients: pathophysiology and therapeutic implications. Crit Care 2023; 27:453. [PMID: 37986086 PMCID: PMC10662652 DOI: 10.1186/s13054-023-04739-5] [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: 09/29/2023] [Accepted: 11/14/2023] [Indexed: 11/22/2023] Open
Abstract
The renin-angiotensin system (RAS) plays a crucial role in regulating blood pressure and the cardio-renal system. The classical RAS, mainly mediated by angiotensin I, angiotensin-converting enzyme, and angiotensin II, has been reported to be altered in critically ill patients, such as those in vasodilatory shock. However, recent research has highlighted the role of some components of the counterregulatory axis of the classical RAS, termed the alternative RAS, such as angiotensin-converting Enzyme 2 (ACE2) and angiotensin-(1-7), or peptidases which can modulate the RAS like dipeptidyl-peptidase 3, in many critical situations. In cases of shock, dipeptidyl-peptidase 3, an enzyme involved in the degradation of angiotensin and opioid peptides, has been associated with acute kidney injury and mortality and preclinical studies have tested its neutralization. Angiotensin-(1-7) has been shown to prevent septic shock development and improve outcomes in experimental models of sepsis. In the context of experimental acute lung injury, ACE2 activity has demonstrated a protective role, and its inactivation has been associated with worsened lung function, leading to the use of active recombinant human ACE2, in preclinical and human studies. Angiotensin-(1-7) has been tested in experimental models of acute lung injury and in a recent randomized controlled trial for patients with COVID-19 related hypoxemia. Overall, the alternative RAS appears to have a role in the pathogenesis of disease in critically ill patients, and modulation of the alternative RAS may improve outcomes. Here, we review the available evidence regarding the methods of analysis of the RAS, pathophysiological disturbances of this system, and discuss how therapeutic manipulation may improve outcomes in the critically ill.
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Affiliation(s)
- Bruno Garcia
- Department of Anesthesia and Peri-Operative Care, Division of Critical Care Medicine, University of California, San Francisco (UCSF), San Francisco, CA, USA
- Department of Intensive Care, Centre Hospitalier Universitaire de Lille, Lille, France
- Experimental Laboratory of the Department of Intensive Care, Université Libre de Bruxelles, Brussels, Belgium
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital of Münster, Münster, Germany
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, 3084, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia
| | - Matthieu Legrand
- Department of Anesthesia and Peri-Operative Care, Division of Critical Care Medicine, University of California, San Francisco (UCSF), San Francisco, CA, USA.
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Bokoch MP, Tran AT, Brinson EL, Marcus SG, Reddy M, Sun E, Roll GR, Pardo M, Fields S, Adelmann D, Kothari RP, Legrand M. Angiotensin II in liver transplantation (AngLT-1): protocol of a randomised, double-blind, placebo-controlled trial. BMJ Open 2023; 13:e078713. [PMID: 37984940 PMCID: PMC10660907 DOI: 10.1136/bmjopen-2023-078713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 10/24/2023] [Indexed: 11/22/2023] Open
Abstract
INTRODUCTION Catecholamine vasopressors such as norepinephrine are the standard drugs used to maintain mean arterial pressure during liver transplantation. At high doses, catecholamines may impair organ perfusion. Angiotensin II is a peptide vasoconstrictor that may improve renal perfusion pressure and glomerular filtration rate, a haemodynamic profile that could reduce acute kidney injury. Angiotensin II is approved for vasodilatory shock but has not been rigorously evaluated for treatment of hypotension during liver transplantation. The objective is to assess the efficacy of angiotensin II as a second-line vasopressor infusion during liver transplantation. This trial will establish the efficacy of angiotensin II in decreasing the dose of norepinephrine to maintain adequate blood pressure. Completion of this study will allow design of a follow-up, multicentre trial powered to detect a reduction of organ injury in liver transplantation. METHODS AND ANALYSIS This is a double-blind, randomised clinical trial. Eligible subjects are adults with a Model for End-Stage Liver Disease Sodium Score ≥25 undergoing deceased donor liver transplantation. Subjects are randomised 1:1 to receive angiotensin II or saline placebo as the second-line vasopressor infusion. The study drug infusion is initiated on reaching a norepinephrine dose of 0.05 µg kg-1 min-1 and titrated per protocol. The primary outcome is the dose of norepinephrine required to maintain a mean arterial pressure ≥65 mm Hg. Secondary outcomes include vasopressin or epinephrine requirement and duration of hypotension. Safety outcomes include incidence of thromboembolism within 48 hours of the end of surgery and severe hypertension. An intention-to-treat analysis will be performed for all randomised subjects receiving the study drug. The total dose of norepinephrine will be compared between the two arms by a one-tailed Mann-Whitney U test. ETHICS AND DISSEMINATION The trial protocol was approved by the local Institutional Review Board (#20-30948). Results will be posted on ClinicalTrials.gov and published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER ClinicalTrials.govNCT04901169.
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Affiliation(s)
- Michael P Bokoch
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - Amy T Tran
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - Erika L Brinson
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - Sivan G Marcus
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - Meghana Reddy
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - Elizabeth Sun
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - Garrett R Roll
- Division of Transplant Surgery, University of California San Francisco, San Francisco, California, USA
| | - Manuel Pardo
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - Scott Fields
- Investigational Drug Pharmacy, University of California San Francisco, San Francisco, California, USA
| | - Dieter Adelmann
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - Rishi P Kothari
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
- Department of Anesthesiology and Perioperative Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Matthieu Legrand
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
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44
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Kim ME, Goldstein SL, Chlebowski MM. Recombinant angiotensin II therapy in a child with cardiac dysfunction and Pandoraea and Candida sepsis. Cardiol Young 2023; 33:2393-2394. [PMID: 37212085 DOI: 10.1017/s1047951123001221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Recombinant angiotensin II is an emerging drug therapy for refractory hypotension. Its use is relevant to patients with disruption of the renin-angiotensin-aldosterone system denoted by elevated direct renin levels. We present a child that responded to recombinant angiotensin II in the setting of right ventricular hypertension and multi-organism septic shock.
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Affiliation(s)
- Michael E Kim
- Heart Institute, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH, USA
| | - Stuart L Goldstein
- Department of Pediatrics, Division of Nephrology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, College of Medicine, Cincinnati, OH, USA
| | - Meghan M Chlebowski
- Heart Institute, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH, USA
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45
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Bauer SR, Gellatly RM, Erstad BL. Precision fluid and vasoactive drug therapy for critically ill patients. Pharmacotherapy 2023; 43:1182-1193. [PMID: 36606689 PMCID: PMC10323046 DOI: 10.1002/phar.2763] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 10/03/2022] [Accepted: 10/30/2022] [Indexed: 01/07/2023]
Abstract
There are several clinical practice guidelines concerning the use of fluid and vasoactive drug therapies in critically ill adult patients, but the recommendations in these guidelines are often based on low-quality evidence. Further, some were compiled prior to the publication of landmark clinical trials, particularly in the comparison of balanced crystalloid and normal saline. An important consideration in the treatment of critically ill patients is the application of precision medicine to provide the most effective care to groups of patients most likely to benefit from the therapy. Although not currently widely integrated into these practice guidelines, the utility of precision medicine in critical illness is a recognized research priority for fluid and vasoactive therapy management. The purpose of this narrative review was to illustrate the evaluation and challenges of providing precision fluid and vasoactive therapies to adult critically ill patients. The review includes a discussion of important investigations published after the release of currently available clinical practice guidelines to provide insight into how recommendations and research priorities may change future guidelines and bedside care for critically ill patients.
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Affiliation(s)
- Seth R Bauer
- Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio, USA
| | - Rochelle M Gellatly
- Pharmacy Department, Surrey Memorial Hospital, Surrey, British Columbia, Canada
| | - Brian L Erstad
- Department of Pharmacy Practice and Science, University of Arizona, Tucson, Arizona, USA
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46
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García-Álvarez R, Arboleda-Salazar R. Vasopressin in Sepsis and Other Shock States: State of the Art. J Pers Med 2023; 13:1548. [PMID: 38003863 PMCID: PMC10672256 DOI: 10.3390/jpm13111548] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 10/19/2023] [Accepted: 10/27/2023] [Indexed: 11/26/2023] Open
Abstract
This review of the use of vasopressin aims to be comprehensive and highly practical, based on the available scientific evidence and our extensive clinical experience with the drug. It summarizes controversies about vasopressin use in septic shock and other vasodilatory states. Vasopressin is a natural hormone with powerful vasoconstrictive effects and is responsible for the regulation of plasma osmolality by maintaining fluid homeostasis. Septic shock is defined by the need for vasopressors to correct hypotension and lactic acidosis secondary to infection, with a high mortality rate. The Surviving Sepsis Campaign guidelines recommend vasopressin as a second-line vasopressor, added to norepinephrine. However, these guidelines do not address specific debates surrounding the use of vasopressin in real-world clinical practice.
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Affiliation(s)
- Raquel García-Álvarez
- Department of Anesthesiology and Surgical Intensive Care, University Hospital 12 de Octubre, 28022 Madrid, Spain
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47
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Wieruszewski PM, Coleman PJ, Levine AR, Davison D, Smischney NJ, Kethireddy S, Guo Y, Hecht J, Mazzeffi MA, Chow JH. Trajectory of PaO 2/FiO 2 Ratio in Shock After Angiotensin II. J Intensive Care Med 2023; 38:939-948. [PMID: 37161301 DOI: 10.1177/08850666231174870] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
INTRODUCTION High-dose catecholamines can impair hypoxic pulmonary vasoconstriction and increase shunt fraction. We aimed to determine if Angiotensin II (Ang-2) is associated with improved PaO2/FiO2 and SpO2/FiO2 in patients in shock. METHODS Adult patients at four tertiary care centers and one community hospital in the United States who received Ang-2 from July 2018-September 2020 were included in this retrospective, observational cohort study. PaO2, SpO2, and FiO2 were measured at 13 timepoints during the 48-h before and after Ang-2 initiation. Piecewise linear mixed models of PaO2/FiO2 and SpO2/FiO2 were created to evaluate hourly changes in oxygenation after Ang-2 initiation. The difference in the proportion of patients with PaO2/FiO2 ≤ 300 mm Hg at the time of Ang-2 initiation and 48 h after was also examined. RESULTS The study included 254 patients. In the 48 h prior to Ang-2 initiation, oxygenation was significantly declining (hourly PaO2/FiO2 change -4.7 mm Hg/hr, 95% CI - 6.0 to -3.5, p < .001; hourly SpO2/FiO2 change -3.1/hr, 95% CI-3.7 to -2.4, p < .001). Ang-2 treatment was associated with significant improvements in PaO2/FiO2 and SpO2/FiO2 in the 48-h after initiation (hourly PaO2/FiO2 change +1.5 mm Hg/hr, 95% CI 0.5-2.5, p = .003; hourly SpO2/FiO2 change +0.9/hr, 95% CI 0.5-1.2, p < .001). The difference in the hourly change in oxygenation before and after Ang-2 initiation was also significant (pinteraction < 0.001 for both PaO2/FiO2 and SpO2/FiO2). This improvement was associated with significantly fewer patients having a PaO2/FiO2 ≤ 300 mm Hg at 48 h compared to baseline (mean difference -14.9%, 95% CI -25.3% to -4.6%, p = .011). Subgroup analysis found that patients with either a baseline PaO2/FiO2 ≤ 300 mm Hg or a norepinephrine-equivalent dose requirement >0.2 µg/kg/min had the greatest associations with oxygenation improvement. CONCLUSIONS Ang-2 is associated with improved PaO2/FiO2 and SpO2/FiO2. The mechanisms for this improvement are not entirely clear but may be due to catecholamine-sparing effect or may also be related to improved ventilation-perfusion matching, intrapulmonary shunt, or oxygen delivery.
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Affiliation(s)
- Patrick M Wieruszewski
- Department of Anesthesiology and Pharmacy, Mayo Clinic School of Medicine, Rochester, MN, USA
| | - Patrick J Coleman
- Department of Anesthesiology, Walter Reed National Military Medical Center, Baltimore, MD, USA
| | - Andrea R Levine
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Danielle Davison
- Department of Anesthesiology & Critical Care Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Nathan J Smischney
- Department of Anesthesiology, Division of Critical Care Medicine, Mayo Clinic School of Medicine, Rochester, MN, USA
| | - Shravan Kethireddy
- Department of Medicine, Division of Pulmonary and Critical Care, Cleveland Clinic, Cleveland, OH, USA
| | - Yanglin Guo
- Department of Medicine, Division of Pulmonary & Critical Care, University of Mississippi Medical Center, Jackson, MS, USA
| | - Jason Hecht
- Department of Pharmacy, St. Joseph Mercy Ann Arbor Hospital, Ypsilanti, MI, USA
| | - Michael A Mazzeffi
- Department of Anesthesiology, University of Virginia, Charlottesville, VA, USA
| | - Jonathan H Chow
- Department of Anesthesiology & Critical Care Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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48
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Zhou HX, Yang CF, Wang HY, Teng Y, He HY. Should we initiate vasopressors earlier in patients with septic shock: A mini systemic review. World J Crit Care Med 2023; 12:204-216. [PMID: 37745258 PMCID: PMC10515096 DOI: 10.5492/wjccm.v12.i4.204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 06/28/2023] [Accepted: 07/17/2023] [Indexed: 09/05/2023] Open
Abstract
Septic shock treatment remains a major challenge for intensive care units, despite the recent prominent advances in both management and outcomes. Vasopressors serve as a cornerstone of septic shock therapy, but there is still controversy over the timing of administration. Specifically, it remains unclear whether vasopressors should be used early in the course of treatment. Here, we provide a systematic review of the literature on the timing of vasopressor administration. Research was systematically identified through PubMed, Embase and Cochrane searching according to PRISMA guidelines. Fourteen studies met the eligibility criteria and were included in the review. The pathophysiological basis for early vasopressor use was classified, with the exploration on indications for the early administration of mono-vasopressors or their combination with vasopressin or angiotensinII. We found that mortality was 28.1%-47.7% in the early vasopressors group, and 33.6%-54.5% in the control group. We also investigated the issue of vasopressor responsiveness. Furthermore, we acknowledged the subsequent challenge of administration of high-dose norepinephrine via peripheral veins with early vasopressor use. Based on the literature review, we propose a possible protocol for the early initiation of vasopressors in septic shock resuscitation.
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Affiliation(s)
- Hang-Xiang Zhou
- Department of Critical Care Medicine, Affiliated Hospital of Guizhou Medical University, Guiyang 550004, Guizhou Province, China
- Department of Critical Care Medicine, The Sixth Hospital of Guiyang, Guiyang 550002, Guizhou Province, China
| | - Chun-Fu Yang
- Department of Critical Care Medicine, The Sixth Hospital of Guiyang, Guiyang 550002, Guizhou Province, China
- Department of Respiratory Medicine, The First Affiliated Hospital of Guizhou University of Traditional Chinese Medicine, Guiyang 550002, Guizhou Province, China
| | - He-Yan Wang
- Department of Critical Care Medicine, The Sixth Hospital of Guiyang, Guiyang 550002, Guizhou Province, China
- School of Basic Medicine, Guizhou University of Traditional Chinese Medicine, Guiyang 550002, Guizhou Province, China
| | - Yin Teng
- Department of Thoracic Surgery, Affiliated Hospital of Guizhou Medical University, Guiyang 550004, Guizhou Province, China
| | - Hang-Yong He
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Beijing 100020, China
- Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Beijing 100020, China
- Beijing Key Laboratory of Respiratory and Pulmonary Circulation, Beijing Chao-Yang Hospital, Beijing 100020, China
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49
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Guzzo I, Paglialonga F. Critically ill children with septic shock: time to rediscover renin? Pediatr Nephrol 2023; 38:2907-2910. [PMID: 37087478 DOI: 10.1007/s00467-023-05985-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 04/10/2023] [Accepted: 04/10/2023] [Indexed: 04/24/2023]
Affiliation(s)
- Isabella Guzzo
- Pediatric Nephrology, Dialysis and Transplant Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Fabio Paglialonga
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
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50
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Stanski NL, Pode Shakked N, Zhang B, Cvijanovich NZ, Fitzgerald JC, Jain PN, Schwarz AJ, Nowak J, Weiss SL, Allen GL, Thomas NJ, Haileselassie B, Goldstein SL. Serum renin and prorenin concentrations predict severe persistent acute kidney injury and mortality in pediatric septic shock. Pediatr Nephrol 2023; 38:3099-3108. [PMID: 36939916 PMCID: PMC10588759 DOI: 10.1007/s00467-023-05930-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 02/24/2023] [Accepted: 02/24/2023] [Indexed: 03/21/2023]
Abstract
BACKGROUND Studies in critically ill adults demonstrate associations between serum renin concentrations (a proposed surrogate for renin-angiotensin-aldosterone system dysregulation) and poor outcomes, but data in critically ill children are lacking. We assessed serum renin + prorenin concentrations in children with septic shock to determine their predictive ability for acute kidney injury (AKI) and mortality. METHODS We conducted a secondary analysis of a multicenter observational study of children aged 1 week to 18 years admitted to 14 pediatric intensive care units (PICUs) with septic shock and residual serum available for renin + prorenin measurement. Primary outcomes were development of severe persistent AKI (≥ KDIGO stage 2 for ≥ 48 h) in the first week and 28-day mortality. RESULTS Among 233 patients, day 1 median renin + prorenin concentration was 3436 pg/ml (IQR 1452-6567). Forty-two (18%) developed severe persistent AKI and 32 (14%) died. Day 1 serum renin + prorenin predicted severe persistent AKI with an AUROC of 0.75 (95% CI 0.66-0.84, p < 0.0001; optimal cutoff 6769 pg/ml) and mortality with an AUROC of 0.79 (95% CI 0.69-0.89, p < 0.0001; optimal cutoff 6521 pg/ml). Day 3/day 1 (D3:D1) renin + prorenin ratio had an AUROC of 0.73 (95% CI 0.63-0.84, p < 0.001) for mortality. On multivariable regression, day 1 renin + prorenin > optimal cutoff retained associations with severe persistent AKI (aOR 6.8, 95% CI 3.0-15.8, p < 0.001) and mortality (aOR 6.9, 95% CI 2.2-20.9, p < 0.001). Similarly, D3:D1 renin + prorenin > optimal cutoff was associated with mortality (aOR 7.6, 95% CI 2.5-23.4, p < 0.001). CONCLUSIONS Children with septic shock have very elevated serum renin + prorenin concentrations on PICU admission, and these concentrations, as well as their trend over the first 72 h, predict severe persistent AKI and mortality. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Natalja L Stanski
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA.
- Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH, 45267, USA.
| | - Naomi Pode Shakked
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Bin Zhang
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
| | | | - Julie C Fitzgerald
- The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Parag N Jain
- Texas Children's Hospital and Baylor College of Medicine, 6621 Fannin Street, Houston, TX, 77030, USA
| | - Adam J Schwarz
- Children's Hospital of Orange County, 1201 W La Veta Ave, Orange, CA, 92868, USA
| | - Jeffrey Nowak
- Children's Minnesota, 2525 Chicago Ave, Minneapolis, MN, 55404, USA
| | - Scott L Weiss
- The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Geoffrey L Allen
- Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Neal J Thomas
- Penn State Health Children's Hospital, 600 University Dr, Hershey, PA, 17033, USA
| | | | - Stuart L Goldstein
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH, 45267, USA
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