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Schaefer M, Stein A, Ruf B, Balling G, Palm J, Simmelbauer A, Cleuziou J, Sander M, Auer J, Borgmann K, Struck J, Hartmann O, Schulte J, Hörer J, Tassani-Prell P, Ewert P, Holdenrieder S, Wolf CM. Bioactive adrenomedullin (bio-ADM) is associated with endothelial dysfunction in infants and children with complex congenital heart disease undergoing open-heart surgery on cardiopulmonary bypass. Clin Chem Lab Med 2024; 62:551-561. [PMID: 37870269 DOI: 10.1515/cclm-2023-0511] [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: 05/15/2023] [Accepted: 10/10/2023] [Indexed: 10/24/2023]
Abstract
OBJECTIVES Children with congenital heart disease (CHD) undergoing cardiac surgery on cardiopulmonary bypass (CPB) are at risk for systemic inflammation leading to endothelial dysfunction associated with increased morbidity. Bioactive adrenomedullin (bio-ADM) is a peptide regulating vascular tone and endothelial permeability. The aim of this study was to evaluate the dynamics of plasma bio-ADM in this patient cohort and its role in capillary leak. METHODS Plasma samples from 73 pediatric CHD patients were collected for bio-ADM measurement at five different timepoints (TP) in the pre-, intra-, and post-operative period. The primary endpoint was a net increase in bio-ADM levels after surgery on CPB. Secondary endpoints included association of bio-ADM levels with clinical signs for endothelial dysfunction. RESULTS Bio-ADM levels increased after surgery on CPB from pre-operative median of 12 pg/mL (IQR [interquartile range] 12.0-14.8 pg/mL) to a maximum post-operative median of 48.8 pg/mL (IQR 34.5-69.6 pg/mL, p<0.001). Bio-ADM concentrations correlated positively with post-operative volume balance, (r=0.341; p=0.005), increased demand for vasoactive medication (duration: r=0.415; p<0.001; quantity: TP3: r=0.415, p<0.001; TP4: r=0.414, p<0.001), and hydrocortisone treatment for vasoplegia (bio-ADM median [IQR]:129.1 [55.4-139.2] pg/mL vs. 37.9 [25.2-64.6] pg/mL; p=0.034). Patients who required pleural effusion drainage revealed higher bio-ADM levels compared to those who did not (median [IQR]: 66.4 [55.4-90.9] pg/mL vs. 40.2 [28.2-57.0] pg/mL; p<0.001). CONCLUSIONS Bio-ADM is elevated in children after cardiac surgery and higher levels correlate with clinical signs of capillary leakage. The peptide should be considered as biomarker for endothelial dysfunction and as potential therapeutic target in this indication.
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Affiliation(s)
- Maike Schaefer
- Department of Congenital Heart Defects and Pediatric Cardiology, German Heart Center Munich, Technical University of Munich, School of Medicine & Health, Munich, Germany
| | - Andreas Stein
- Department of Anesthesiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Bettina Ruf
- Department of Congenital Heart Defects and Pediatric Cardiology, German Heart Center Munich, Technical University of Munich, School of Medicine & Health, Munich, Germany
| | - Gunter Balling
- Department of Congenital Heart Defects and Pediatric Cardiology, German Heart Center Munich, Technical University of Munich, School of Medicine & Health, Munich, Germany
| | - Jonas Palm
- Department of Congenital Heart Defects and Pediatric Cardiology, German Heart Center Munich, Technical University of Munich, School of Medicine & Health, Munich, Germany
| | - Andreas Simmelbauer
- Department of Congenital Heart Defects and Pediatric Cardiology, German Heart Center Munich, Technical University of Munich, School of Medicine & Health, Munich, Germany
| | - Julie Cleuziou
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technical University of Munich, School of Medicine and Health, Munich, Germany
- Division for Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilian Universität München, Munich, Germany
- Institute for Translational Cardiac Surgery (INSURE), German Heart Center Munich, Technical University of Munich, School of Medicine and Health, Munich, Germany
| | - Michaela Sander
- Department of Laboratory Medicine, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Josef Auer
- Department of Congenital Heart Defects and Pediatric Cardiology, German Heart Center Munich, Technical University of Munich, School of Medicine & Health, Munich, Germany
| | - Kristina Borgmann
- Department of Congenital Heart Defects and Pediatric Cardiology, German Heart Center Munich, Technical University of Munich, School of Medicine & Health, Munich, Germany
| | | | | | | | - Jürgen Hörer
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technical University of Munich, School of Medicine and Health, Munich, Germany
- Division for Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilian Universität München, Munich, Germany
| | - Peter Tassani-Prell
- Department of Anesthesiology, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Peter Ewert
- Department of Congenital Heart Defects and Pediatric Cardiology, German Heart Center Munich, Technical University of Munich, School of Medicine & Health, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Stefan Holdenrieder
- Department of Laboratory Medicine, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Cordula M Wolf
- Department of Congenital Heart Defects and Pediatric Cardiology, German Heart Center Munich, Technical University of Munich, School of Medicine & Health, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
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Garduno A, Cusack R, Leone M, Einav S, Martin-Loeches I. Multi-Omics Endotypes in ICU Sepsis-Induced Immunosuppression. Microorganisms 2023; 11:1119. [PMID: 37317092 DOI: 10.3390/microorganisms11051119] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 04/03/2023] [Accepted: 04/21/2023] [Indexed: 06/16/2023] Open
Abstract
It is evident that the admission of some patients with sepsis and septic shock to hospitals is occurring late in their illness, which has contributed to the increase in poor outcomes and high fatalities worldwide across age groups. The current diagnostic and monitoring procedure relies on an inaccurate and often delayed identification by the clinician, who then decides the treatment upon interaction with the patient. Initiation of sepsis is accompanied by immune system paralysis following "cytokine storm". The unique immunological response of each patient is important to define in terms of subtyping for therapy. The immune system becomes activated in sepsis to produce interleukins, and endothelial cells express higher levels of adhesion molecules. The proportions of circulating immune cells change, reducing regulatory cells and increasing memory cells and killer cells, having long-term effects on the phenotype of CD8 T cells, HLA-DR, and dysregulation of microRNA. The current narrative review seeks to highlight the potential application of multi-omics data integration and immunological profiling at the single-cell level to define endotypes in sepsis and septic shock. The review will consider the parallels and immunoregulatory axis between cancer and immunosuppression, sepsis-induced cardiomyopathy, and endothelial damage. Second, the added value of transcriptomic-driven endotypes will be assessed through inferring regulatory interactions in recent clinical trials and studies reporting gene modular features that inform continuous metrics measuring clinical response in ICU, which can support the use of immunomodulating agents.
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Affiliation(s)
- Alexis Garduno
- Department of Clinical Medicine, Trinity College, University of Dublin, D02 PN40 Dublin, Ireland
| | - Rachael Cusack
- Department of Intensive Care Medicine, St. James's Hospital, James's Street, D08 NHY1 Dublin, Ireland
| | - Marc Leone
- Department of Anesthesia, Intensive Care and Trauma Center, Nord University Hospital, Aix Marseille University, APHM, 13015 Marseille, France
| | - Sharon Einav
- General Intensive Care Unit, Shaare Zedek Medical Center, Jerusalem 23456, Israel
- Faculty of Medicine, Hebrew University, Jerusalem 23456, Israel
| | - Ignacio Martin-Loeches
- Department of Clinical Medicine, Trinity College, University of Dublin, D02 PN40 Dublin, Ireland
- Department of Intensive Care Medicine, St. James's Hospital, James's Street, D08 NHY1 Dublin, Ireland
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Hill A, Bergmann D, Schulte J, Zayat R, Marx G, Simon TP, Mossanen J, Brücken A, Stoppe C. Proenkephalin A and bioactive adrenomedullin are useful for risk prognostication in cardiac surgery. Front Cardiovasc Med 2023; 9:1017867. [PMID: 36756642 PMCID: PMC9900105 DOI: 10.3389/fcvm.2022.1017867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 12/28/2022] [Indexed: 01/24/2023] Open
Abstract
Introduction Various clinical scores have been developed to predict organ dysfunction and mortality in patients undergoing cardiac surgery, but outcome prediction may be inaccurate for some patient groups. Proenkephalin A (penKid) and bioactive adrenomedullin (bio-ADM) have emerged as promising biomarkers correlating with shock and organ dysfunction. This imposes the question of whether they can be used as prognostic biomarkers for risk stratification in the perioperative setting of cardiac surgery. Methods Patients undergoing cardiac surgery were prospectively enrolled in this observational study. PenKid and bio-ADM plasma levels, as well as markers evaluating inflammation and organ dysfunction, were measured at five perioperative time points from before the induction of anesthesia to up to 48 h postoperatively. Clinical data regarding organ dysfunction and patient outcomes were recorded during the intensive care unit (ICU)-stay with a special focus on acute kidney injury (AKI). Results In 136 patients undergoing cardiac surgery, the bio-ADM levels increased and the penKid levels decreased significantly over time. PenKid was associated with chronic kidney disease (CKD), the incidence of AKI, and renal replacement therapy (RRT). Bio-ADM was associated with lactate and the need for vasopressors. PenKid was useful to predict an ICU-length of stay (LOS)>1 day and added prognostic value to the European System for Cardiac Operative Risk Evaluation Score (EuroSCORE) II when measured after the end of cardiopulmonary bypass and 24 h after cardiac surgery. For bio-ADM, the same was true when measured 24 h after surgery. PenKid also added prognostic value to the EuroSCORE II for the combined outcome "ICU length of stay >1 day and in-hospital mortality." Conclusion The combination of preoperative EuroSCORE II and intraoperative measurement of penKid may be more useful to predict a prolonged ICU LOS and increased mortality than EuroSCORE II alone. Bio-ADM correlates with markers of shock. More research is encouraged for early risk stratification and validation of penKid and bio-ADM as a tool involved in clinical decisions, which may enable the early initiation of organ protective strategies.
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Affiliation(s)
- Aileen Hill
- Department of Intensive Care and Intermediate Care, Medical Faculty RWTH Aachen, Aachen, Germany
- Department of Anesthesiology, Medical Faculty RWTH Aachen, Aachen, Germany
| | | | | | - Rashad Zayat
- Department of Cardiothoracic Surgery, Medical Faculty RWTH Aachen, Aachen, Germany
| | - Gernot Marx
- Department of Intensive Care and Intermediate Care, Medical Faculty RWTH Aachen, Aachen, Germany
| | - Tim-Philipp Simon
- Department of Intensive Care and Intermediate Care, Medical Faculty RWTH Aachen, Aachen, Germany
| | - Jana Mossanen
- Department of Intensive Care and Intermediate Care, Medical Faculty RWTH Aachen, Aachen, Germany
| | - Anne Brücken
- Department of Intensive Care and Intermediate Care, Medical Faculty RWTH Aachen, Aachen, Germany
| | - Christian Stoppe
- Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Würzburg, Germany
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van Lier D, Picod A, Marx G, Laterre PF, Hartmann O, Knothe C, Azibani F, Struck J, Santos K, Zimmerman J, Bergmann A, Mebazaa A, Pickkers P. Effects of enrichment strategies on outcome of adrecizumab treatment in septic shock: Post-hoc analyses of the phase II adrenomedullin and outcome in septic shock 2 trial. Front Med (Lausanne) 2022; 9:1058235. [PMID: 36530868 PMCID: PMC9751049 DOI: 10.3389/fmed.2022.1058235] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 11/07/2022] [Indexed: 08/19/2023] Open
Abstract
PURPOSE Adrecizumab, a non-neutralizing antibody of adrenomedullin (ADM) was recently investigated regarding its potential to restore endothelial barrier function in septic shock patients with high plasma ADM levels. Circulating dipeptidyl peptidase 3 (cDPP3), a protease involved in the degradation of several cardiovascular mediators, represents another biological pathway strongly associated with outcome in septic shock, although unrelated to ADM. Therefore, the prognosis of patients with elevated cDPP3 may not be influenced by Adrecizumab. Also, time until initiation of treatment may influence efficacy. OBJECTIVE To evaluate effects of cDPP3-based enrichment on treatment efficacy of Adrecizumab. MATERIALS AND METHODS Post-hoc analysis of AdrenOSS-2, a phase-II, double-blind, randomized, placebo-controlled biomarker-guided trial of Adrecizumab. RESULTS Compared to the total study cohort [HR for 28-day mortality of 0.84 (95% CI 0.53;1.31), p = 0.439], therapeutic benefit of Adrecizumab tended to be more pronounced in the subgroup of 249 patients with low cDPP3 (<50 ng/mL); [HR of 0.61 (95% CI 0.34;1.08), p = 0.085]. Median duration to study drug infusion was 8.5 h. In the subgroup of 129 patients with cDPP3 <50 ng/mL and an early start of treatment (<8.5 h after septic shock diagnosis) HR for 28-day mortality vs. placebo was 0.49 (95% CI 0.21-1.18), p = 0.105. In multivariate interaction analyses corrected for baseline disease severity, both cDPP3, as well as the cDPP3 * treatment interaction term were associated with a reduced HR for 28-day mortality in the Adrecizumab treated group; p = 0.015 for cDPP3 in univariate analysis, p = 0.025 for the interaction term between cDPP3 and treatment group. In contrast, treatment timing was not significantly associated with 28-day mortality in multivariate interaction analyses. DISCUSSION In septic shock patients with high ADM levels, a further post-hoc enrichment strategy based on cDPP3 may indicate (with all the caveats to be considered for post-hoc subgroup analyses) that therapeutic efficacy is most pronounced in patients with lower cDPP3 levels.
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Affiliation(s)
- Dirk van Lier
- Department of Intensive Care Medicine and Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, Netherlands
| | - Adrien Picod
- Anesthésie-Réanimation, Hôpital Lariboisière, AP–HP, Paris, France
| | - Gernot Marx
- Klinik fur Operative Intensivmedizin und Intermediate Care, Universitätsklinikum Aachen, Aachen, Germany
| | - Pierre-François Laterre
- Unité de Soins Intensifs, Cliniques Universitaires Saint-Luc (UCL Bruxelles), Brussels, Belgium
| | | | | | - Feriel Azibani
- Anesthésie-Réanimation, Hôpital Lariboisière, AP–HP, Paris, France
| | | | | | | | - Andreas Bergmann
- Sphingotec GmbH, Hennigsdorf, Germany
- Adrenomed AG, Hennigsdorf, Germany
| | - Alexandre Mebazaa
- Anesthésie-Réanimation, Hôpital Lariboisière, AP–HP, Paris, France
- Université de Paris, U942 Inserm, MASCOT, APHP, Fédération Hospitalo-Universitaire PROMICE, Hôpitaux Universitaires Saint-Louis-Lariboisière, Paris, France
| | - Peter Pickkers
- Department of Intensive Care Medicine and Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, Netherlands
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Biomarkers for the Prediction and Judgement of Sepsis and Sepsis Complications: A Step towards precision medicine? J Clin Med 2022; 11:jcm11195782. [PMID: 36233650 PMCID: PMC9571838 DOI: 10.3390/jcm11195782] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 09/19/2022] [Accepted: 09/25/2022] [Indexed: 11/16/2022] Open
Abstract
Sepsis and septic shock are a major public health concern and are still associated with high rates of morbidity and mortality. Whilst there is growing understanding of different phenotypes and endotypes of sepsis, all too often treatment strategies still only employ a “one-size-fits-all” approach. Biomarkers offer a unique opportunity to close this gap to more precise treatment approaches by providing insight into clinically hidden, yet complex, pathophysiology, or by individualizing treatment pathways. Predicting and evaluating systemic inflammation, sepsis or septic shock are essential to improve outcomes for these patients. Besides opportunities to improve patient care, employing biomarkers offers a unique opportunity to improve clinical research in patients with sepsis. The high rate of negative clinical trials in this field may partly be explained by a high degree of heterogeneity in patient cohorts and a lack of understanding of specific endotypes or phenotypes. Moving forward, biomarkers can support the selection of more homogeneous cohorts, thereby potentially improving study conditions of clinical trials. This may finally pave the way to a precision medicine approach to sepsis, septic shock and complication of sepsis in the future.
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6
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Hellenthal KEM, Brabenec L, Wagner NM. Regulation and Dysregulation of Endothelial Permeability during Systemic Inflammation. Cells 2022; 11:cells11121935. [PMID: 35741064 PMCID: PMC9221661 DOI: 10.3390/cells11121935] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/06/2022] [Accepted: 06/09/2022] [Indexed: 12/14/2022] Open
Abstract
Systemic inflammation can be triggered by infection, surgery, trauma or burns. During systemic inflammation, an overshooting immune response induces tissue damage resulting in organ dysfunction and mortality. Endothelial cells make up the inner lining of all blood vessels and are critically involved in maintaining organ integrity by regulating tissue perfusion. Permeability of the endothelial monolayer is strictly controlled and highly organ-specific, forming continuous, fenestrated and discontinuous capillaries that orchestrate the extravasation of fluids, proteins and solutes to maintain organ homeostasis. In the physiological state, the endothelial barrier is maintained by the glycocalyx, extracellular matrix and intercellular junctions including adherens and tight junctions. As endothelial cells are constantly sensing and responding to the extracellular environment, their activation by inflammatory stimuli promotes a loss of endothelial barrier function, which has been identified as a hallmark of systemic inflammation, leading to tissue edema formation and hypotension and thus, is a key contributor to lethal outcomes. In this review, we provide a comprehensive summary of the major players, such as the angiopoietin-Tie2 signaling axis, adrenomedullin and vascular endothelial (VE-) cadherin, that substantially contribute to the regulation and dysregulation of endothelial permeability during systemic inflammation and elucidate treatment strategies targeting the preservation of vascular integrity.
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7
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Safety and tolerability of non-neutralizing adrenomedullin antibody adrecizumab (HAM8101) in septic shock patients: the AdrenOSS-2 phase 2a biomarker-guided trial. Intensive Care Med 2021; 47:1284-1294. [PMID: 34605947 PMCID: PMC8487806 DOI: 10.1007/s00134-021-06537-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 09/09/2021] [Indexed: 11/11/2022]
Abstract
Purpose Investigate safety and tolerability of adrecizumab, a humanized monoclonal adrenomedullin antibody, in septic shock patients with high adrenomedullin. Methods Phase-2a, double-blind, randomized, placebo-controlled biomarker-guided trial with a single infusion of adrecizumab (2 or 4 mg/kg b.w.) compared to placebo. Patients with adrenomedullin above 70 pg/mL, < 12 h of vasopressor start for septic shock were eligible. Randomization was 1:1:2. Primary safety (90-day mortality, treatment emergent adverse events (TEAE)) and tolerability (drug interruption, hemodynamics) endpoints were recorded. Efficacy endpoints included the Sepsis Support Index (SSI, reflecting ventilator- and shock-free days alive), change in Sequential-related Organ Failure Assessment (SOFA) and 28-day mortality. Results 301 patients were enrolled (median time of 8.5 h after vasopressor start). Adrecizumab was well tolerated (one interruption, no hemodynamic alteration) with no differences in frequency and severity in TEAEs between treatment arms (TEAE of grade 3 or higher: 70.5% in the adrecizumab group and 71.1% in the placebo group) nor in 90-day mortality. Difference in change in SSI between adrecizumab and placebo was 0.72 (CI −1.93–0.49, p = 0.24). Among various secondary endpoints, delta SOFA score (defined as maximum versus minimum SOFA) was more pronounced in the adrecizumab combined group compared to placebo [difference at 0.76 (95% CI 0.18–1.35); p = 0.007]. 28-day mortality in the adrecizumab group was 23.9% and 27.7% in placebo with a hazard ratio of 0.84 (95% confidence interval 0.53–1.31, log-rank p = 0.44). Conclusions Overall, we successfully completed a randomized trial evaluating selecting patients for enrolment who had a disease-related biomarker. There were no overt signals of harm with using two doses of the adrenomedullin antibody adrecizumab; however, further randomized controlled trials are required to confirm efficacy and safety of this agent in septic shock patients. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-021-06537-5.
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8
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Meijers WC, Bayes-Genis A, Mebazaa A, Bauersachs J, Cleland JGF, Coats AJS, Januzzi JL, Maisel AS, McDonald K, Mueller T, Richards AM, Seferovic P, Mueller C, de Boer RA. Circulating heart failure biomarkers beyond natriuretic peptides: review from the Biomarker Study Group of the Heart Failure Association (HFA), European Society of Cardiology (ESC). Eur J Heart Fail 2021; 23:1610-1632. [PMID: 34498368 PMCID: PMC9292239 DOI: 10.1002/ejhf.2346] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 08/13/2021] [Accepted: 09/07/2021] [Indexed: 12/18/2022] Open
Abstract
New biomarkers are being evaluated for their ability to advance the management of patients with heart failure. Despite a large pool of interesting candidate biomarkers, besides natriuretic peptides virtually none have succeeded in being applied into the clinical setting. In this review, we examine the most promising emerging candidates for clinical assessment and management of patients with heart failure. We discuss high-sensitivity cardiac troponins (Tn), procalcitonin, novel kidney markers, soluble suppression of tumorigenicity 2 (sST2), galectin-3, growth differentiation factor-15 (GDF-15), cluster of differentiation 146 (CD146), neprilysin, adrenomedullin (ADM), and also discuss proteomics and genetic-based risk scores. We focused on guidance and assistance with daily clinical care decision-making. For each biomarker, analytical considerations are discussed, as well as performance regarding diagnosis and prognosis. Furthermore, we discuss potential implementation in clinical algorithms and in ongoing clinical trials.
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Affiliation(s)
- Wouter C Meijers
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Antoni Bayes-Genis
- Heart Institute, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, CIBERCV, Barcelona, Spain
| | - Alexandre Mebazaa
- Inserm U942-MASCOT; Université de Paris; Department of Anesthesia and Critical Care, Hôpitaux Saint Louis & Lariboisière; FHU PROMICE, Paris, France.,Université de Paris, Paris, France.,Department of Anesthesia and Critical Care, Hôpitaux Saint Louis & Lariboisière, Paris, France.,FHU PROMICE, Paris, France
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - John G F Cleland
- Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow; National Heart & Lung Institute, Imperial College London, London, UK
| | - Andrew J S Coats
- Monash University, Melbourne, Australia.,University of Warwick, Coventry, UK
| | | | | | | | - Thomas Mueller
- Department of Clinical Pathology, Hospital of Bolzano, Bolzano, Italy
| | - A Mark Richards
- Christchurch Heart Institute, Christchurch, New Zealand.,Cardiovascular Research Institute, National University of Singapore, Singapore
| | - Petar Seferovic
- Faculty of Medicine, Belgrade University, Belgrade, Serbia.,Serbian Academy of Sciences and Arts, Belgarde, Serbia
| | | | - Rudolf A de Boer
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
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9
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van Lier D, Kox M, Pickkers P. Promotion of vascular integrity in sepsis through modulation of bioactive adrenomedullin and dipeptidyl peptidase 3. J Intern Med 2021; 289:792-806. [PMID: 33381880 PMCID: PMC8246835 DOI: 10.1111/joim.13220] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 11/07/2020] [Accepted: 11/10/2020] [Indexed: 12/19/2022]
Abstract
Sepsis represents one of the major medical challenges of the 21st century. Despite substantial improvements in the knowledge on pathophysiological mechanisms, this has so far not translated into novel adjuvant treatment strategies for sepsis. In sepsis, both vascular tone and vascular integrity are compromised, and contribute to the development of shock, which is strongly related to the development of organ dysfunction and mortality. In this review, we focus on dipeptidyl peptidase 3 (DPP3) and adrenomedullin (ADM), two molecules that act on the vasculature and are involved in the pathophysiology of sepsis and septic shock. DPP3 is an ubiquitous cytosolic enzyme involved in the degradation of several important signalling molecules essential for regulation of vascular tone, including angiotensin II. ADM is a key hormone involved in the regulation of vascular tone and endothelial barrier function. Previous studies have shown that circulating concentrations of both DPP3 and ADM are independently associated with the development of organ failure and adverse outcome in sepsis. We now discuss new evidence illustrating that these molecules indeed represent two distinct pathways involved in the development of septic shock. Recently, both ADM-enhancing therapies aimed at improving endothelial barrier function and vascular tone and DPP3-blocking therapies aimed at restoring systemic angiotensin responses have been shown to improve outcome in various preclinical sepsis models. Given the current lack of effective adjuvant therapies in sepsis, additional research on the therapeutic application of these peptides in humans is highly warranted.
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Affiliation(s)
- D van Lier
- From the, Department of Intensive Care Medicine and Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands
| | - M Kox
- From the, Department of Intensive Care Medicine and Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands
| | - P Pickkers
- From the, Department of Intensive Care Medicine and Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands
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10
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Deniau B, Takagi K, Asakage A, Mebazaa A. Adrecizumab: an investigational agent for the biomarker-guided treatment of sepsis. Expert Opin Investig Drugs 2020; 30:95-102. [PMID: 33256482 DOI: 10.1080/13543784.2021.1857365] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Introduction: Sepsis is a major health problem with a high incidence and mortality. ADM, a free-circulating peptide mainly expressed and secreted by vascular endothelial cells, shows vasodilatory properties and causes hypotension when present in higher concentrations during sepsis. Areas covered: Adrecizumab (ADZ) (HAM 8101) is a humanized targeted therapy directed against the N-terminus of adrenomedullin (ADM). ADZ inhibits excessive circulating sepsis-induced ADM and stimulates protective effects on the endothelial barrier, and decreases interstitial vasodilatory effects. ADZ demonstrated a promising safety profile in healthy subjects in phase I studies. According to these results, a phase II proof of concept study enrolling 300 septic patients is currently in course (NCT03085758). Expert opinion: ADZ is the first humanized antibody directed against ADM. The main interest of ADZ is its potential use as a 'biomarker-guided therapy' in septic patients with high circulating ADM. ADZ is increasingly seen as a potential adjunct therapy to restore endothelial function in septic shock. A positive pivotal phase III trial is indeed needed to convince the intensive care community to prescribe ADZ in septic shock patients. Further, it would be of interest to see whether ADZ might also benefit other critical diseases such as cardiogenic shock where endothelial dysfunction has also been described.
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Affiliation(s)
- Benjamin Deniau
- Department of Anesthesiology and Critical Care and Burn Unit, Assistance Publique - Hôpitaux De Paris (AP-HP), Groupe Hospitalier St Louis-Lariboisière , Paris, France.,Université de Paris, FHU PROMICE , Paris, France.,INSERM UMR-S 942 MASCOT, Lariboisière Hospital, Institut National de la Santé et de la Recherche Médicale , Paris, France
| | - Koji Takagi
- INSERM UMR-S 942 MASCOT, Lariboisière Hospital, Institut National de la Santé et de la Recherche Médicale , Paris, France
| | - Ayu Asakage
- INSERM UMR-S 942 MASCOT, Lariboisière Hospital, Institut National de la Santé et de la Recherche Médicale , Paris, France
| | - Alexandre Mebazaa
- Department of Anesthesiology and Critical Care and Burn Unit, Assistance Publique - Hôpitaux De Paris (AP-HP), Groupe Hospitalier St Louis-Lariboisière , Paris, France.,Université de Paris, FHU PROMICE , Paris, France.,INSERM UMR-S 942 MASCOT, Lariboisière Hospital, Institut National de la Santé et de la Recherche Médicale , Paris, France
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11
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Abstract
Adrenomedullin (ADM) is a 52 amino acid containing free circulating vasoactive peptide hormone found to be active in various pathophysiological states including sepsis. High ADM levels at admission have been correlated with vasopressor requirements, organ dysfunction, and mortality in sepsis patients. ADM stimulation results in vasodilation and loss of vascular resistance in humans resulting in hypotension with the potential for negative impact in septic shock. However, in vitro human and animal experiments have shown that ADM decreases hyperpermeability and capillary leak, thus having an endothelial barrier stabilizing effect during septic shock. Adrenomedullin thus appears to be a double-edged weapon. This editorial critically reviews the article by Daga et al. who evaluated serum ADM as a prognostic marker to review the gender-related difference in mortality pattern, and also the correlation of ADM level to APACHE II and SOFA scores. The role of adrenomedullin in sepsis and the potential developments in the future have been discussed concisely. How to cite this article: Ajith Kumar AK. Adrenomedullin in Sepsis: Finally, a Friend or an Enemy? Indian J Crit Care Med 2020;24(12):1151-1153.
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Affiliation(s)
- AK Ajith Kumar
- Department of Critical Care, Manipal Hospitals, Bengaluru, Karnataka, India
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12
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Russell JA, Gordon AC, Williams MD, Boyd JH, Walley KR, Kissoon N. Vasopressor Therapy in the Intensive Care Unit. Semin Respir Crit Care Med 2020; 42:59-77. [PMID: 32820475 DOI: 10.1055/s-0040-1710320] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
After fluid administration for vasodilatory shock, vasopressors are commonly infused. Causes of vasodilatory shock include septic shock, post-cardiovascular surgery, post-acute myocardial infarction, postsurgery, other causes of an intense systemic inflammatory response, and drug -associated anaphylaxis. Therapeutic vasopressors are hormones that activate receptors-adrenergic: α1, α2, β1, β2; angiotensin II: AG1, AG2; vasopressin: AVPR1a, AVPR1B, AVPR2; dopamine: DA1, DA2. Vasopressor choice and dose vary widely because of patient and physician practice heterogeneity. Vasopressor adverse effects are excessive vasoconstriction causing organ ischemia/infarction, hyperglycemia, hyperlactatemia, tachycardia, and tachyarrhythmias. To date, no randomized controlled trial (RCT) of vasopressors has shown a decreased 28-day mortality rate. There is a need for evidence regarding alternative vasopressors as first-line vasopressors. We emphasize that vasopressors should be administered simultaneously with fluid replacement to prevent and decrease duration of hypotension in shock with vasodilation. Norepinephrine is the first-choice vasopressor in septic and vasodilatory shock. Interventions that decrease norepinephrine dose (vasopressin, angiotensin II) have not decreased 28-day mortality significantly. In patients not responsive to norepinephrine, vasopressin or epinephrine may be added. Angiotensin II may be useful for rapid resuscitation of profoundly hypotensive patients. Inotropic agent(s) (e.g., dobutamine) may be needed if vasopressors decrease ventricular contractility. Dopamine has fallen to almost no-use recommendation because of adverse effects; angiotensin II is available clinically; there are potent vasopressors with scant literature (e.g., methylene blue); and the novel V1a agonist selepressin missed on its pivotal RCT primary outcome. In pediatric septic shock, vasopressors, epinephrine, and norepinephrine are recommended equally because there is no clear evidence that supports the use of one vasoactive agent. Dopamine is recommended when epinephrine or norepinephrine is not available. New strategies include perhaps patients will be started on several vasopressors with complementary mechanisms of action, patients may be selected for particular vasopressors according to predictive biomarkers, and novel vasopressors may emerge with fewer adverse effects.
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Affiliation(s)
- James A Russell
- Department of Medicine, Centre for Heart Lung Innovation, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada.,Division of Critical Care Medicine, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Anthony C Gordon
- Department of Surgery and Cancer, Division of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London, United Kingdom.,Department of Surgery and Cancer, Intensive Care Unit, Imperial College Healthcare NHS Trust, St Mary's Hospital, London, United Kingdom
| | - Mark D Williams
- Department of Medicine, Indiana University Health Methodist Hospital, Indiana University School of Medicine, Indianapolis, Indiana
| | - John H Boyd
- Department of Medicine, Centre for Heart Lung Innovation, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada.,Division of Critical Care Medicine, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Keith R Walley
- Department of Medicine, Centre for Heart Lung Innovation, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada.,Division of Critical Care Medicine, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Niranjan Kissoon
- Department of Pediatrics, British Columbia Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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The Effects of Genetic 3-Mercaptopyruvate Sulfurtransferase Deficiency in Murine Traumatic-Hemorrhagic Shock. Shock 2020; 51:472-478. [PMID: 29668565 DOI: 10.1097/shk.0000000000001165] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Hemorrhagic shock is a major cause of death after trauma. An additional blunt chest trauma independently contributes to mortality upon the development of an acute lung injury (ALI) by aggravating pathophysiological consequences of hemorrhagic shock. The maintenance of hydrogen sulfide availability is known to play an important role during hemorrhage and ALI. We therefore tested the impact of a genetic 3-mercaptopyruvate sulfurtransferase mutation (Δ3-MST) in a resuscitated murine model of traumatic-hemorrhagic shock. METHODS Anesthetized wild-type (WT) and Δ3-MST mice underwent hemorrhagic shock with/without blunt chest trauma. Hemorrhagic shock was implemented for 1 h followed by retransfusion of shed blood and intensive care therapy for 4 h, including lung-protective mechanical ventilation, fluid resuscitation, and noradrenaline titrated to maintain a mean arterial pressure at least 50 mmHg. Systemic hemodynamics, metabolism, and acid-base status were assessed together with lung mechanics and gas exchange. Postmortem tissue samples were analyzed for immunohistological protein expression and mitochondrial oxygen consumption. RESULTS 3-MST-deficient mice showed similar results in parameters of hemodynamics, gas exchange, metabolism, acid base status, and survival compared with the respective WT controls. Renal albumin extravasation was increased in Δ3-MST mice during hemorrhagic shock, together with a decrease of LEAK respiration in heart tissue. In contrast, mitochondrial oxygen consumption in the uncoupled state was increased in kidney and liver tissue of Δ3-MST mice subjected to the combined trauma. CONCLUSIONS In summary, in a resuscitated murine model of traumatic-hemorrhagic shock, 3-MST deficiency had no physiologically relevant impact on hemodynamics and metabolism, which ultimately lead to unchanged mortality regardless of an additional blunt chest trauma.
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In-Depth Characterization of the Effects of Cigarette Smoke Exposure on the Acute Trauma Response and Hemorrhage in Mice. Shock 2020; 51:68-77. [PMID: 29424792 DOI: 10.1097/shk.0000000000001115] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Hemorrhagic shock accounts for a large amount of trauma-related mortality. The severity of trauma can be further aggravated by an additional blunt chest trauma (TxT), which independently contributes to mortality upon the development of an acute lung injury (ALI). Besides, cigarette smoke (CS) exposure before TxT enhanced posttraumatic inflammation, thereby aggravating ALI. We therefore aimed to characterize the impact of an acute and/or chronic lung injury on organ dysfunction in a murine model of traumatic hemorrhagic shock (HS). METHODS After 3 weeks of CS exposure, anesthetized mice underwent HS with/without TxT. Hemorrhagic shock was implemented for 1 h followed by retransfusion of shed blood and intensive care therapy for 4 h including lung-protective mechanical ventilation, fluid resuscitation, and noradrenaline titrated to maintain mean arterial pressure ≥50 mmHg. Lung mechanics and gas exchange were assessed together with systemic hemodynamics, metabolism, and acid-base status. Postmortem blood and tissue samples were analyzed for cytokine and chemokine levels, protein expression, mitochondrial respiration, and histological changes. RESULTS CS exposure and HS alone coincided with increased inflammation, decreased whole blood sulfide concentrations, and decreased diaphragmatic mitochondrial respiration. CS-exposed mice, which were subjected to TxT and subsequent HS, showed hemodynamic instability, acute kidney injury, and high mortality. CONCLUSIONS Chronic CS exposure per se had the strongest impact on inflammatory responses. The degree of inflammation was similar upon an additional TxT, however, mice presented with organ dysfunction and increased mortality rates. Hence, in mice the degree of inflammation may be dissociated from the severity of organ dysfunction or injury.
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Abstract
Sepsis, a life threating syndrome characterized by organ failure after infection, is the most common cause of death in hospitalized patients. The treatment of sepsis is generally supportive in nature, involving the administration of intravenous fluids, vasoactive substances and oxygen plus antibiotics to eliminate the pathogen. No drugs have been approved specifically for the treatment of sepsis, and clinical trials of potential therapies have failed to reduce mortality - suggesting that new approaches are needed. Abnormalities in the immune response elicited by the pathogen, ranging from excessive inflammation to immunosuppression, contribute to disease pathogenesis. Although hundreds of immunomodulatory agents are potentially available, it remains unclear which patient benefits from which immune therapy at a given time point. Results indicate the importance of personalized therapy, specifically the need to identify the type of intervention required by each individual patient at a given point in the disease process. To address this issue will require using biomarkers to stratify patients based on their individual immune status. This article reviews recent and ongoing clinical investigations using immunostimulatory or immunosuppressive therapies against sepsis including non-pharmacological and novel preclinical approaches.
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Abstract
BACKGROUND Vasopressors are administered to critically ill patients with vasodilatory shock not responsive to volume resuscitation, and less often in cardiogenic shock, and hypovolemic shock. OBJECTIVES The objectives are to review safety and efficacy of vasopressors, pathophysiology, agents that decrease vasopressor dose, predictive biomarkers, β1-blockers, and directions for research. METHODS The quality of evidence was evaluated using Grading of Recommendations Assessment, Development, and Evaluation (GRADE). RESULTS Vasopressors bind adrenergic: α1, α2, β1, β2; vasopressin: AVPR1a, AVPR1B, AVPR2; angiotensin II: AG1, AG2; and dopamine: DA1, DA2 receptors inducing vasoconstriction. Vasopressor choice and dose vary because of patients and physician practice. Adverse effects include excessive vasoconstriction, organ ischemia, hyperglycemia, hyperlactatemia, tachycardia, and tachyarrhythmias. No randomized controlled trials of vasopressors showed a significant difference in 28-day mortality rate. Norepinephrine is the first-choice vasopressor in vasodilatory shock after adequate volume resuscitation. Some strategies that decrease norepinephrine dose (vasopressin, angiotensin II) have not decreased 28-day mortality while corticosteroids have decreased 28-day mortality significantly in some (two large trials) but not all trials. In norepinephrine-refractory patients, vasopressin or epinephrine may be added. A new vasopressor, angiotensin II, may be useful in profoundly hypotensive patients. Dobutamine may be added because vasopressors may decrease ventricular contractility. Dopamine is recommended only in bradycardic patients. There are potent vasopressors with limited evidence (e.g. methylene blue, metaraminol) and novel vasopressors in development (selepressin). CONCLUSIONS Norepinephrine is first choice followed by vasopressin or epinephrine. Angiotensin II and dopamine have limited indications. In future, predictive biomarkers may guide vasopressor selection and novel vasopressors may emerge.
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Affiliation(s)
- James A Russell
- Centre for Heart Lung Innovation, St. Paul's Hospital, University of British Columbia, 1081 Burrard Street, Vancouver, BC, Canada.
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17
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Russell JA. Vasopressor therapy in critically ill patients with shock. Intensive Care Med 2019; 45:1503-1517. [PMID: 31646370 DOI: 10.1007/s00134-019-05801-z] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 09/24/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Vasopressors are administered to critically ill patients with vasodilatory shock not responsive to volume resuscitation, and less often in cardiogenic shock, and hypovolemic shock. OBJECTIVES The objectives are to review safety and efficacy of vasopressors, pathophysiology, agents that decrease vasopressor dose, predictive biomarkers, β1-blockers, and directions for research. METHODS The quality of evidence was evaluated using Grading of Recommendations Assessment, Development, and Evaluation (GRADE). RESULTS Vasopressors bind adrenergic: α1, α2, β1, β2; vasopressin: AVPR1a, AVPR1B, AVPR2; angiotensin II: AG1, AG2; and dopamine: DA1, DA2 receptors inducing vasoconstriction. Vasopressor choice and dose vary because of patients and physician practice. Adverse effects include excessive vasoconstriction, organ ischemia, hyperglycemia, hyperlactatemia, tachycardia, and tachyarrhythmias. No randomized controlled trials of vasopressors showed a significant difference in 28-day mortality rate. Norepinephrine is the first-choice vasopressor in vasodilatory shock after adequate volume resuscitation. Some strategies that decrease norepinephrine dose (vasopressin, angiotensin II) have not decreased 28-day mortality while corticosteroids have decreased 28-day mortality significantly in some (two large trials) but not all trials. In norepinephrine-refractory patients, vasopressin or epinephrine may be added. A new vasopressor, angiotensin II, may be useful in profoundly hypotensive patients. Dobutamine may be added because vasopressors may decrease ventricular contractility. Dopamine is recommended only in bradycardic patients. There are potent vasopressors with limited evidence (e.g. methylene blue, metaraminol) and novel vasopressors in development (selepressin). CONCLUSIONS Norepinephrine is first choice followed by vasopressin or epinephrine. Angiotensin II and dopamine have limited indications. In future, predictive biomarkers may guide vasopressor selection and novel vasopressors may emerge.
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Affiliation(s)
- James A Russell
- Centre for Heart Lung Innovation, St. Paul's Hospital, University of British Columbia, 1081 Burrard Street, Vancouver, BC, Canada.
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18
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Effects of the Humanized Anti-Adrenomedullin Antibody Adrecizumab (HAM8101) on Vascular Barrier Function and Survival in Rodent Models of Systemic Inflammation and Sepsis. Shock 2019; 50:648-654. [PMID: 29324627 DOI: 10.1097/shk.0000000000001102] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Adrenomedullin (ADM) is an important regulator of endothelial barrier function during sepsis. Administration of a murine antibody targeted against the N-terminus of ADM (HAM1101) resulted in improved outcome in models of murine sepsis. We studied the effects of a humanized form of this antibody (HAM8101, also known as Adrecizumab) on vascular barrier dysfunction and survival in rodent models of systemic inflammation and sepsis. METHODS Rats (n=48) received different dosages of HAM8101 or placebo (n = 8 per group), directly followed by administration of lipopolysaccharide (5 mg/kg). Twenty-four hours later, Evans Blue dye was administered to assess vascular leakage in kidney and liver tissue. Furthermore, mice (n = 24) were administered different dosages of HAM8101 or placebo (n = 6 per group), immediately followed by cecal ligation and puncture (CLP). Eighteen hours later, albumin, vascular endothelial growth factor (VEGF), and angiopoietin-1 were analyzed in the kidney. Finally, effects of single and repeated dose administration of HAM1101, HAM8101 and placebo on survival were assessed in CLP-induced murine sepsis (n = 60, n = 10 per group). RESULTS Dosages of 0.1 and 2.5 mg/kg HAM8101 attenuated renal albumin leakage in endotoxemic rats. Dosages of 0.1, 2.0, and 20 mg/kg HAM8101 reduced renal concentrations of albumin and the detrimental protein VEGF in septic mice, whereas concentrations of the protective protein angiopoietin-1 were augmented. Both single and repeated administration of both HAM1101 and HAM8101 resulted in improved survival during murine sepsis. CONCLUSIONS Pretreatment with the humanized anti-ADM antibody HAM8101 improved vascular barrier function and survival in rodent models of systemic inflammation and sepsis.
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19
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Abstract
Sepsis remains a major scientific and medical challenge, for which, apart from significant refinements in supportive therapy, treatment has barely changed over the last few decades. During sepsis, both vascular tone and vascular integrity are compromised, and contribute to the development of shock. The free circulating peptide adrenomedullin (ADM) is involved in the regulation of the endothelial barrier function and tone of blood vessels. Several animal studies have shown that ADM administration improves outcome of sepsis. However, in higher dosages, ADM administration may cause hypotension, limiting its clinical applicability. Moreover, ADM has a very short half-life and easily adheres to surfaces, further hampering its clinical use. The non-neutralizing anti-ADM antibody Adrecizumab (HAM8101) which causes a long-lasting increase of plasma ADM has shown promising results in animal models of systemic inflammation and sepsis; it reduced inflammation, attenuated vascular leakage, and improved hemodynamics, kidney function, and survival. Combined with an excellent safety profile derived from animal and phase I human studies, Adrecizumab represents a promising candidate drug for the adjunctive treatment of sepsis. In this review, we first provide a brief overview of the currently available data on the role of adrenomedullin in sepsis and describe its effects on endothelial barrier function and vasodilation. Furthermore, we provide a novel hypothesis concerning the mechanisms of action through which Adrecizumab may exert its beneficial effects in sepsis.
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20
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Blet A, Deniau B, Geven C, Sadoune M, Caillard A, Kounde PR, Polidano E, Pickkers P, Samuel JL, Mebazaa A. Adrecizumab, a non-neutralizing anti-adrenomedullin antibody, improves haemodynamics and attenuates myocardial oxidative stress in septic rats. Intensive Care Med Exp 2019; 7:25. [PMID: 31093784 PMCID: PMC6520420 DOI: 10.1186/s40635-019-0255-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 05/03/2019] [Indexed: 12/12/2022] Open
Abstract
Background Sepsis still represents a major health issue, with persistent high morbidity and mortality rates. Cardiovascular dysfunction occurs frequently during sepsis. Adrenomedullin has been identified as a key mediator in vascular tone regulation. A non-neutralizing anti-adrenomedullin antibody, Adrecizumab, may improve haemodynamic dysfunction during caecal ligation and puncture-induced septic shock in a murine model. Our objective was to determine the role of Adrecizumab on haemodynamics in a rat model of sepsis. Methods For the induction of sepsis, caecal ligation and puncture were performed in Wistar male rats. Single blinded administration of Adrecizumab (2 mg/kg) or placebo was injected i.v. 24 h after the surgery, and norepinephrine was infused as the standard of care. There were > 7 animals per group. Invasive blood pressure and cardiac function (by echocardiography) were assessed until 3 h after Adrecizumab injection. Results A single therapeutic injection of Adrecizumab in septic rats induced rapid haemodynamic benefits with an increase in systolic blood pressure in septic-Adrecizumab rats versus untreated-septic rats (p = 0.049). The shortening fraction did not differ between the untreated-septic and septic-Adrecizumab groups. However, cardiac output increased during the 3 h after a single dose of Adrecizumab compared to untreated septic rats (p = 0.006). A single dose of Adrecizumab resulted in similar haemodynamics to the continuous administration of norepinephrine. Three hours after a single injection of Adrecizumab, there was no change in the inflammatory phenotype (TNFα, IL-10) in the hearts of the septic rats. By contrast, 3 h after a single Adrecizumab injection, free-radical production decreased in the hearts of septic-Adrecizumab vs untreated septic rats (p < 0.05). Conclusions In a rat model of sepsis, a single therapeutic injection of Adrecizumab rapidly restored haemodynamic parameters and blunted myocardial oxidative stress. Currently, a proof-of-concept and dose-finding phase II trial (Adrenoss-2) is ongoing in patients with septic shock and elevated concentrations of circulating bio-adrenomedullin. Electronic supplementary material The online version of this article (10.1186/s40635-019-0255-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Alice Blet
- Department of Anesthesia, Burn and Critical Care, University Hospitals Saint-Louis - Lariboisière, AP-HP, Paris, France. .,UMR-S 942, Inserm, Paris, France.
| | - Benjamin Deniau
- Department of Anesthesia, Burn and Critical Care, University Hospitals Saint-Louis - Lariboisière, AP-HP, Paris, France.,UMR-S 942, Inserm, Paris, France.,Paris Diderot University, Sorbonne Paris Cité, Paris, France
| | - Christopher Geven
- Department of Intensive Care Medicine, Radboud Center for Infectious Diseases (RCI), Radboud University Medical center, HP: 710, PO Box 9101, 6500, HB, Nijmegen, The Netherlands
| | | | - Anaïs Caillard
- Department of Anesthesia, Burn and Critical Care, University Hospitals Saint-Louis - Lariboisière, AP-HP, Paris, France.,UMR-S 942, Inserm, Paris, France.,Paris Diderot University, Sorbonne Paris Cité, Paris, France
| | - Paul-Robert Kounde
- Department of Anesthesia, Burn and Critical Care, University Hospitals Saint-Louis - Lariboisière, AP-HP, Paris, France.,UMR-S 942, Inserm, Paris, France.,Paris Diderot University, Sorbonne Paris Cité, Paris, France
| | | | - Peter Pickkers
- Department of Intensive Care Medicine, Radboud Center for Infectious Diseases (RCI), Radboud University Medical center, HP: 710, PO Box 9101, 6500, HB, Nijmegen, The Netherlands
| | | | - Alexandre Mebazaa
- Department of Anesthesia, Burn and Critical Care, University Hospitals Saint-Louis - Lariboisière, AP-HP, Paris, France.,UMR-S 942, Inserm, Paris, France.,Paris Diderot University, Sorbonne Paris Cité, Paris, France
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21
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Preclinical safety evaluation of the adrenomedullin-binding antibody Adrecizumab in rodents, dogs and non-human primates. Toxicol Appl Pharmacol 2019; 369:1-16. [PMID: 30822437 DOI: 10.1016/j.taap.2019.02.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 02/15/2019] [Accepted: 02/25/2019] [Indexed: 12/22/2022]
Abstract
Adrenomedullin (ADM) is a vasoactive peptide in sepsis. The non-neutralizing ADM-binding antibody Adrecizumab improved outcome in animal models of systemic inflammation and sepsis. Herein, we evaluated the preclinical safety of Adrecizumab in various animal species. First, Wistar rats received vehicle, 100, 200 or 400 mg/kg/day of Adrecizumab intravenously (n = 20 each) on days 1, 4, 8 and 14. An additional set of rats received vehicle or 400 mg/kg/day (n = 10 each) on the same days and were followed for 42 days. For toxicokinetics, satellite animals received vehicle (n = 6), 100, 200, or 400 mg/kg/day Adrecizumab intravenously (n = 18 each). A hemodynamic study was performed in Beagle dogs (n = 3) receiving vehicle (day 1), 2 mg/kg (day 3), 10 mg/kg (day 5), 50 mg/kg (day 8) and 10 mg/kg Adrecizumab intravenously (day 29). In final experiments, cynomolgus monkeys received vehicle, 25, 50 or 100 mg/kg/day Adrecizumab intravenously (n = 6 each) on days 1, 4, 8 and 14. Additional groups of monkeys received vehicle or 100 mg/kg/day Adrecizumab intravenously (n = 4 each) on the same days and were followed for 42 days. No mortality or moribund conditions occurred and no toxicologically relevant effects were attributed to Adrecizumab. Adrecizumab significantly increased circulating concentrations of its target peptide ADM, consistent with previous studies and mechanistically relevant. Toxicokinetic analyses showed immediate and dose-dependent peak concentrations, slow elimination and no gender differences. In conclusion, intravenous, repeated administration of high doses of Adrecizumab appeared well-tolerated across species. These results pave the way for further investigation of Adrecizumab in humans (intended dose of 2 mg/kg).
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Geven C, Blet A, Kox M, Hartmann O, Scigalla P, Zimmermann J, Marx G, Laterre PF, Mebazaa A, Pickkers P. A double-blind, placebo-controlled, randomised, multicentre, proof-of-concept and dose-finding phase II clinical trial to investigate the safety, tolerability and efficacy of adrecizumab in patients with septic shock and elevated adrenomedullin concentration (AdrenOSS-2). BMJ Open 2019; 9:e024475. [PMID: 30782906 PMCID: PMC6377571 DOI: 10.1136/bmjopen-2018-024475] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 09/14/2018] [Accepted: 12/31/2018] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Sepsis remains a major health problem with an increasing incidence, high morbidity and high mortality. Apart from treatment with antibiotics and organ support, no approved specific adjunct therapies currently exist. Adrenomedullin (ADM) is a vasoactive peptide. High plasma concentrations of ADM correlate with worse outcome in sepsis patients. Preclinical work with the non-neutralising ADM-binding antibody adrecizumab showed promising effects in animal models of septic shock, including improved vascular barrier function, reduced vasopressor demand and organ dysfunction and increased survival. Therapeutic use of adrecizumab may therefore improve outcome in critically ill patients with septic shock and high ADM plasma concentrations. Phase I studies in healthy volunteers did not reveal any safety concerns. In this biomarker-guided trial, the safety and efficacy of adrecizumab will be investigated in patients with septic shock. METHODS AND ANALYSIS We describe a phase II, randomised, double-blind, placebo-controlled, biomarker-guided, proof-of-concept and dose-finding clinical trial in patients with early septic shock and high concentration of circulating ADM. A total of 300 patients will be enrolled at approximately 30 sites within the European Union. Patients are randomised to receive active treatment (2 and 4 mg/kg adrecizumab) or placebo, in a 1:1:2 ratio. Patient selection is guided by clinical parameters, and biomarker-guided by measurement of circulating biologically active ADM concentration at admission. Primary endpoint is safety and tolerability of adrecizumab over a 90-day period. A key secondary endpoint is the Sepsis Severity Index over a 14-day period. ETHICS AND DISSEMINATION This study is approved by relevant institutional review boards/independent ethics committees and is conducted in accordance with the ethical principles of the Declaration of Helsinki, the European Medicines Agency guidelines of Good Clinical Practice and all other applicable regulations. Results of this study will be published in a peer-reviewed scientific journal. TRIAL REGISTRATION NUMBER NCT03085758; Pre-results.
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Affiliation(s)
- Christopher Geven
- Department of Intensive Care Medicine, Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Alice Blet
- Department of Anesthesia, Burn and Critical Care, University Hospitals Saint-Louis—Lariboisière, Paris, France
- UMR-S 942, Inserm, Paris, France
- Paris Diderot University, Paris, France
| | - Matthijs Kox
- Department of Intensive Care Medicine, Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands
| | | | | | | | - Gernot Marx
- Department of Intensive Care Medicine and Intermediate Care, RWTH University Hospital Aachen, Aachen, Germany
| | - Pierre-François Laterre
- Department of Critical Care Medicine, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain (UCL), Brussels, Belgium
| | - Alexandre Mebazaa
- Department of Anesthesia, Burn and Critical Care, University Hospitals Saint-Louis—Lariboisière, Paris, France
- UMR-S 942, Inserm, Paris, France
- Paris Diderot University, Paris, France
| | - Peter Pickkers
- Department of Intensive Care Medicine, Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands
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23
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Geven C, van Lier D, Blet A, Peelen R, ten Elzen B, Mebazaa A, Kox M, Pickkers P. Safety, tolerability and pharmacokinetics/pharmacodynamics of the adrenomedullin antibody adrecizumab in a first-in-human study and during experimental human endotoxaemia in healthy subjects. Br J Clin Pharmacol 2018; 84:2129-2141. [PMID: 29856470 PMCID: PMC6089825 DOI: 10.1111/bcp.13655] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 05/18/2018] [Accepted: 05/27/2018] [Indexed: 12/29/2022] Open
Abstract
AIMS Adrenomedullin (ADM) is an important regulator of endothelial barrier function and vascular tone, and may represent a novel treatment target in sepsis. The non-neutralizing ADM antibody adrecizumab has shown promising results in preclinical sepsis models. In the present study, we investigated the safety, tolerability and pharmacokinetics (PK)/pharmacodynamics of adrecizumab in a first-in-man study and in a second study during experimental human endotoxaemia. METHODS Forty-eight healthy male volunteers were enrolled in two randomized, double-blind, placebo-controlled phase I studies. In both studies, subjects received placebo or one of three doses of adrecizumab (n = 6 per group). In the second study, a bolus of 1 ng kg-1 endotoxin was followed by infusion of 1 ng kg-1 h-1 endotoxin for 3 h to induce systemic inflammation, and the study medication infusion started 1 h after endotoxin bolus administration. RESULTS Adrecizumab showed an excellent safety profile in both studies. PK analyses showed proportional increases in the maximum plasma concentration of adrecizumab with increasing doses, a small volume of distribution, a low clearance rate and a terminal half-life of ~14 days. adrecizumab elicited a pronounced increase in plasma ADM levels, whereas levels of mid-regional pro-adrenomedullin remained unchanged, indicating that de novo synthesis of ADM was not influenced. In the second study, no effects of adrecizumab on cytokine clearance were observed, whereas endotoxin-induced flu-like symptoms resolved more rapidly. CONCLUSIONS Administration of adrecizumab is safe and well tolerated in humans, both in the absence and presence of systemic inflammation. These findings pave the way for further investigation of adrecizumab in sepsis patients.
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Affiliation(s)
- Christopher Geven
- Department of Intensive Care Medicine, Radboud Center for Infectious Diseases (RCI)Radboud University Medical CenterHP: 710, PO Box 91016500HBNijmegenThe Netherlands
| | - Dirk van Lier
- Department of Intensive Care Medicine, Radboud Center for Infectious Diseases (RCI)Radboud University Medical CenterHP: 710, PO Box 91016500HBNijmegenThe Netherlands
| | - Alice Blet
- Department of Anesthesia, Burn and Critical CareUniversity Hospitals Saint‐Louis – Lariboisière, AP‐HPParisFrance
- UMR‐S 942, InsermParisFrance
- Sorbonne Paris CitéParis Diderot UniversityParisFrance
| | - Roel Peelen
- Department of Intensive Care Medicine, Radboud Center for Infectious Diseases (RCI)Radboud University Medical CenterHP: 710, PO Box 91016500HBNijmegenThe Netherlands
| | - Bas ten Elzen
- Department of Intensive Care Medicine, Radboud Center for Infectious Diseases (RCI)Radboud University Medical CenterHP: 710, PO Box 91016500HBNijmegenThe Netherlands
| | - Alexandre Mebazaa
- Department of Anesthesia, Burn and Critical CareUniversity Hospitals Saint‐Louis – Lariboisière, AP‐HPParisFrance
- UMR‐S 942, InsermParisFrance
- Sorbonne Paris CitéParis Diderot UniversityParisFrance
| | - Matthijs Kox
- Department of Intensive Care Medicine, Radboud Center for Infectious Diseases (RCI)Radboud University Medical CenterHP: 710, PO Box 91016500HBNijmegenThe Netherlands
| | - Peter Pickkers
- Department of Intensive Care Medicine, Radboud Center for Infectious Diseases (RCI)Radboud University Medical CenterHP: 710, PO Box 91016500HBNijmegenThe Netherlands
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Abstract
Fundamental features of septic shock are vasodilation, increased permeability, hypovolemia, and ventricular dysfunction. Vasodilation owing to increased nitric oxide and prostaglandins is treated with vasopressors (norepinephrine first). Increased permeability relates to several pathways (Slit/Robo4, vascular endothelial growth factor, angiopoietin 1 and 2/Tie2 pathway, sphingosine-1-phosphate, and heparin-binding protein), some of which are targets for therapies. Hypovolemia is common and crystalloid is recommended for fluid resuscitation. Cardiomyocyte-inflammatory interactions decrease contractility and dobutamine is recommended to increase cardiac output. There is benefit in decreasing heart rate in selected patients with esmolol. Ivabradine is a novel agent for heart rate reduction without decreasing contractility.
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Affiliation(s)
- James A Russell
- Department of Medicine, Centre for Heart Lung Innovation, St. Paul's Hospital, 1081 Burrard Street, Vancouver, British Columbia V6Z 1Y6, Canada.
| | - Barret Rush
- Division of Critical Care Medicine, St. Paul's Hospital, 1081 Burrard Street, Vancouver, British Columbia V6Z 1Y6, Canada
| | - John Boyd
- Department of Medicine, Centre for Heart Lung Innovation, St. Paul's Hospital, 1081 Burrard Street, Vancouver, British Columbia V6Z 1Y6, Canada
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Mr-Proadm Elevation Upon Icu Admission Predicts the Outcome of Septic Patients and is Correlated with Upcoming Fluid Overload. Shock 2018; 48:418-426. [PMID: 28414691 DOI: 10.1097/shk.0000000000000877] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Among septic patients admitted to the intensive care unit (ICU), early recognition of those with the highest risk of death is of paramount importance. We evaluated the prognostic value of Procalcitonin (PCT), mid regional-proadrenomedullin (MR-proADM), copeptine and CT-proendothelin 1 (CT-ProET 1) concentrations. METHODS This was a prospective cohort study, which included 173 septic patient admitted to one ICU. Blood samples for biomarker measurements were obtained upon admission and on day 5. The predictive value of each biomarker regarding the risk of death at day 28 was assessed. The fluid balance was evaluated from admission to day 5. RESULTS All cause ICU mortality was 36.4%. All the biomarkers except CT-ProET-1 were significantly more elevated in the non-survivors than in the survivors upon day 1. This was especially true for MR-proADM (8.6 [5.9] vs. 4.4 [3.9] nmol/L; P < 0.0001) and for the CT-proET-1/MR-proADM ratio (52.9 [22.4] vs. 31.3 [26.6] arbitrary units; P < 0.0001). The best AUROCC values on day 1 were obtained with MR-ProADM and the CT-proET-1/MR-proADM ratio as well (0.75 [0.67-0.85] and 0.82 [0.75-0.89]; 95% CI, respectively). An improved accuracy was achieved on day 5. Moreover, MR-ProADM baseline levels and fluid balance over the 5-day period following ICU admission were strongly correlated (Rho = 0.41; P < 0.001). CONCLUSIONS In patients admitted to the ICU with sepsis, MR-ProADM on admission was the best predictor of short-term clinical outcome if compared with others. This could be related to its ability to predict fluid sequestration.
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Vasoplegia treatments: the past, the present, and the future. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:52. [PMID: 29486781 PMCID: PMC6389278 DOI: 10.1186/s13054-018-1967-3] [Citation(s) in RCA: 116] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 01/26/2018] [Indexed: 12/20/2022]
Abstract
Vasoplegia is a ubiquitous phenomenon in all advanced shock states, including septic, cardiogenic, hemorrhagic, and anaphylactic shock. Its pathophysiology is complex, involving various mechanisms in vascular smooth muscle cells such as G protein-coupled receptor desensitization (adrenoceptors, vasopressin 1 receptors, angiotensin type 1 receptors), alteration of second messenger pathways, critical illness-related corticosteroid insufficiency, and increased production of nitric oxide. This review, based on a critical appraisal of the literature, discusses the main current treatments and future approaches. Our improved understanding of these mechanisms is progressively changing our therapeutic approach to vasoplegia from a standardized to a personalized multimodal treatment with the prescription of several vasopressors. While norepinephrine is confirmed as first line therapy for the treatment of vasoplegia, the latest Surviving Sepsis Campaign guidelines also consider that the best therapeutic management of vascular hyporesponsiveness to vasopressors could be a combination of multiple vasopressors, including norepinephrine and early prescription of vasopressin. This new approach is seemingly justified by the need to limit adrenoceptor desensitization as well as sympathetic overactivation given its subsequent deleterious impacts on hemodynamics and inflammation. Finally, based on new pathophysiological data, two potential drugs, selepressin and angiotensin II, are currently being evaluated.
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27
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Abstract
Both acute and chronic lung injury are associated with up-regulation of the pulmonary expression of the purinergic receptors P2XR4 and P2XR7. Genetic deletion or blockade of P2XR7 attenuated pulmonary hyperinflammation, but simultaneous P2XR4 up-regulation compensated for P2XR7 deletion. Therefore, we tested the hypothesis whether genetic P2XR4 deletion would attenuate the pulmonary inflammatory response and thereby improve organ function after blunt chest trauma in mice with and without pretraumatic cigarette smoke (CS) exposure.After 3 weeks to 4 weeks of exposure to CS, anesthetized wildtype or P2XR4 mice (n = 32) underwent a blast wave-induced blunt chest trauma followed by 4 h of lung-protective mechanical ventilation, fluid resuscitation, and noradrenaline support to maintain mean arterial pressure >55 mm Hg. Hemodynamics, lung mechanics, gas exchange, and acid-base status were measured together with blood and tissue cytokine and chemokine concentrations, heme oxygenase-1, B-cell lymphoma-extra large (Bcl-xL), endogenous nuclear factor-κB inhibitor (IκBα) expression, nitrotyrosine formation, purinergic receptor expression, and histological scoring.Despite a significant increase in the histopathology score in both CS-exposed groups, neither CS exposure nor P2XR4 deletion had any significant effect on post-traumatic pulmonary function and inflammatory response. However, P2XR4 deletion was associated with attenuated impairment of glucose homeostasis and acid-base-status after CS exposure and chest trauma.In conclusion, genetic P2XR4 deletion failed to attenuate the acute post-traumatic pulmonary inflammatory response. The improved glucose homeostasis and acid-base-status after CS exposure in the P2XR4 group was possibly due to less alveolar hypoxia-induced right ventricular remodeling resulting in preserved liver metabolic capacity.
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28
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Geven C, Kox M, Pickkers P. Adrenomedullin and Adrenomedullin-Targeted Therapy As Treatment Strategies Relevant for Sepsis. Front Immunol 2018; 9:292. [PMID: 29520277 PMCID: PMC5827550 DOI: 10.3389/fimmu.2018.00292] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 02/01/2018] [Indexed: 12/29/2022] Open
Abstract
Sepsis remains a major medical challenge, for which, apart from improvements in supportive care, treatment has not relevantly changed over the last few decades. Vasodilation and vascular leakage play a pivotal role in the development of septic shock, with vascular leakage being caused by disrupted endothelial integrity. Adrenomedullin (ADM), a free circulating peptide involved in regulation of endothelial barrier function and vascular tone, is implicated in the pathophysiology of sepsis. ADM levels are increased during sepsis, and correlate with extent of vasodilation, as well as with disease severity and mortality. In vitro and preclinical in vivo data show that administration of ADM exerts anti-inflammatory, antimicrobial, and protective effects on endothelial barrier function during sepsis, but other work suggests that it may also decrease blood pressure, which could be detrimental for patients with septic shock. Work has been carried out to negate ADMs putative negative effects, while preserving or even potentiating its beneficial actions. Preclinical studies have demonstrated that the use of antibodies that bind to the N-terminus of ADM results in an overall increase of circulating ADM levels and improves sepsis outcome. Similar beneficial effects were obtained using coadministration of ADM and ADM-binding protein-1. It is hypothesized that the mechanism behind the beneficial effects of ADM binding involves prolongation of its half-life and a shift of ADM from the interstitium to the circulation. This in turn results in increased ADM activity in the blood compartment, where it exerts beneficial endothelial barrier-stabilizing effects, whereas its detrimental vasodilatory effects in the interstitium are reduced. Up till now, in vivo data on ADM-targeted treatments in humans are lacking; however, the first study in septic patients with an N-terminus antibody (Adrecizumab) is currently being conducted.
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Affiliation(s)
- Christopher Geven
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, Netherlands
- Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, Netherlands
| | - Matthijs Kox
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, Netherlands
- Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, Netherlands
| | - Peter Pickkers
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, Netherlands
- Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, Netherlands
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29
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Association of Kidney Tissue Barrier Disrupture and Renal Dysfunction in Resuscitated Murine Septic Shock. Shock 2018; 46:398-404. [PMID: 26926005 DOI: 10.1097/shk.0000000000000599] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Septic shock-related kidney failure is characterized by almost normal morphological appearance upon pathological examination. Endothelial barrier disrupture has been suggested to be of crucial importance for septic shock-induced organ dysfunction. Therefore, in murine resuscitated cecal ligation and puncture (CLP)-induced septic shock, we tested the hypothesis whether there is a direct relationship between the kidney endothelial barrier injury and renal dysfunction. Anesthetized mice underwent CLP, and 15 h later, were anesthetized again and surgically instrumented for a 5-h period of intensive care comprising lung-protective mechanical ventilation, fluid resuscitation, continuous i.v. norepinephrine to maintain target hemodynamics, and measurement of creatinine clearance (CrCl). Animals were stratified according to low or high CrCl. Nitrotyrosine formation, expression of the inducible isoform of the nitric oxide synthase, and blood cytokine (tumor necrosis factor, interleukin-6, interleukin-10) and chemokine (monocyte chemoattractant protein-1, keratinocyte-derived chemokine) levels were significantly higher in animals with low CrCl. When plotted against CrCl and neutrophil gelatinase-associated lipocalin levels, extravascular albumin accumulation, and tissue expression of the vascular endothelial growth factor and angiopoietin-1 showed significant mathematical relationships related to kidney (dys)function. Preservation of the constitutive expression of the hydrogen sulfide producing enzyme cystathione-γ-lyase was associated with maintenance of organ function. The direct quantitative relation between microvascular leakage and kidney (dys)function may provide a missing link between near-normal tissue morphology and septic shock-related renal failure, thus further highlighting the important role of vascular integrity in septic shock-related renal failure.
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30
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Merz T, Vogt JA, Wachter U, Calzia E, Szabo C, Wang R, Radermacher P, McCook O. Impact of hyperglycemia on cystathionine-γ-lyase expression during resuscitated murine septic shock. Intensive Care Med Exp 2017; 5:30. [PMID: 28616781 PMCID: PMC5471286 DOI: 10.1186/s40635-017-0140-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 05/15/2017] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Cystathionine-γ-lyase (CSE) was shown to have a regulatory role in glucose metabolism. Circulatory shock can induce metabolic stress, thereby leading to hyperglycemia and mitochondrial dysfunction. In vitro data suggest an effect of high glucose on CSE expression. Therefore, the aim of this study was to investigate the effects of hyperglycemia on CSE expression in resuscitated murine septic shock. METHODS Normo- (80-150 mg/dl) and hyperglycemic (>200 mg/dl) male C57/BL6J mice (n = 5-6 per group) underwent cecal ligation and puncture (CLP)-induced polymicrobial sepsis or sham procedure (n = 6 per group) and, 15 h afterwards, were anesthetized again, surgically instrumented and received intensive care treatment, including antibiotics, lung protective mechanical ventilation, circulatory support, and intravenous (i.v.) glucose infusion (50% as stable-isotope labeled 1,2,3,4,5,6-13C6 glucose). Blood and breath gas were sampled hourly to quantify parameters of glucose metabolism. 5 h later, mice were sacrificed and organs were harvested. The liver mitochondrial respiratory activity was determined via high resolution respirometry; CSE, peroxisome proliferator-activated receptor gamma coactivator 1-alpha (PGC1α), and adipocyte differentiation-related protein (ADRP) expression was immunohistochemically investigated. RESULTS In sepsis combined with hyperglycemia the least CSE and PGC1α expression could be detected, along with reduced mitochondrial respiratory activity, and enhanced ADRP expression, a marker of lipid droplet formation, in the liver. A novel in vivo finding is the CSE translocation from the cytosol to the nucleus triggered by metabolic stress. CONCLUSIONS A relationship between CSE and glucose metabolism was established, which, when dysregulated, may contribute to fatty liver disease and hepatic steatosis.
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Affiliation(s)
- Tamara Merz
- Institute of Anesthesiological Pathophysiology and Process Engineering, University Medical School, Helmholtzstrasse 8-1, 89081 Ulm, Germany
| | - Josef A. Vogt
- Institute of Anesthesiological Pathophysiology and Process Engineering, University Medical School, Helmholtzstrasse 8-1, 89081 Ulm, Germany
- Department of Anesthesiology, University Hospital, Ulm, Germany
| | - Ulrich Wachter
- Institute of Anesthesiological Pathophysiology and Process Engineering, University Medical School, Helmholtzstrasse 8-1, 89081 Ulm, Germany
- Department of Anesthesiology, University Hospital, Ulm, Germany
| | - Enrico Calzia
- Institute of Anesthesiological Pathophysiology and Process Engineering, University Medical School, Helmholtzstrasse 8-1, 89081 Ulm, Germany
| | - Csaba Szabo
- Department of Anesthesiology, University of Texas Medical Branch, Galveston, TX USA
| | - Rui Wang
- Department of Biology, Laurentian University, Sudbury, ON Canada
| | - Peter Radermacher
- Institute of Anesthesiological Pathophysiology and Process Engineering, University Medical School, Helmholtzstrasse 8-1, 89081 Ulm, Germany
| | - Oscar McCook
- Institute of Anesthesiological Pathophysiology and Process Engineering, University Medical School, Helmholtzstrasse 8-1, 89081 Ulm, Germany
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31
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Caironi P, Latini R, Struck J, Hartmann O, Bergmann A, Maggio G, Cavana M, Tognoni G, Pesenti A, Gattinoni L, Masson S, Masson S, Caironi P, Spanuth E. Circulating Biologically Active Adrenomedullin (bio-ADM) Predicts Hemodynamic Support Requirement and Mortality During Sepsis. Chest 2017; 152:312-320. [DOI: 10.1016/j.chest.2017.03.035] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 01/30/2017] [Accepted: 03/20/2017] [Indexed: 12/29/2022] Open
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32
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Weber J, Sachse J, Bergmann S, Sparwaßer A, Struck J, Bergmann A. Sandwich Immunoassay for Bioactive Plasma Adrenomedullin. ACTA ACUST UNITED AC 2017; 2:222-233. [DOI: 10.1373/jalm.2017.023655] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 05/05/2017] [Indexed: 11/06/2022]
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García-Ponce A, Chánez Paredes S, Castro Ochoa KF, Schnoor M. Regulation of endothelial and epithelial barrier functions by peptide hormones of the adrenomedullin family. Tissue Barriers 2016; 4:e1228439. [PMID: 28123925 DOI: 10.1080/21688370.2016.1228439] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 08/15/2016] [Accepted: 08/17/2016] [Indexed: 01/16/2023] Open
Abstract
The correct regulation of tissue barriers is of utmost importance for health. Barrier dysfunction accompanies inflammatory disorders and, if not controlled properly, can contribute to the development of chronic diseases. Tissue barriers are formed by monolayers of epithelial cells that separate organs from their environment, and endothelial cells that cover the vasculature, thus separating the blood stream from underlying tissues. Cells within the monolayers are connected by intercellular junctions that are linked by adaptor molecules to the cytoskeleton, and the regulation of these interactions is critical for the maintenance of tissue barriers. Many endogenous and exogenous molecules are known to regulate barrier functions in both ways. Proinflammatory cytokines weaken the barrier, whereas anti-inflammatory mediators stabilize barriers. Adrenomedullin (ADM) and intermedin (IMD) are endogenous peptide hormones of the same family that are produced and secreted by many cell types during physiologic and pathologic conditions. They activate certain G-protein-coupled receptor complexes to regulate many cellular processes such as cytokine production, actin dynamics and junction stability. In this review, we summarize current knowledge about the barrier-stabilizing effects of ADM and IMD in health and disease.
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Affiliation(s)
- Alexander García-Ponce
- Department of Molecular Biomedicine, Center for Investigation and Advanced Studies of the National Polytechnic Institute (CINVESTAV-IPN) , Mexico City, Mexico
| | - Sandra Chánez Paredes
- Department of Molecular Biomedicine, Center for Investigation and Advanced Studies of the National Polytechnic Institute (CINVESTAV-IPN) , Mexico City, Mexico
| | - Karla Fabiola Castro Ochoa
- Department of Molecular Biomedicine, Center for Investigation and Advanced Studies of the National Polytechnic Institute (CINVESTAV-IPN) , Mexico City, Mexico
| | - Michael Schnoor
- Department of Molecular Biomedicine, Center for Investigation and Advanced Studies of the National Polytechnic Institute (CINVESTAV-IPN) , Mexico City, Mexico
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Lundberg OHM, Bergenzaun L, Rydén J, Rosenqvist M, Melander O, Chew MS. Adrenomedullin and endothelin-1 are associated with myocardial injury and death in septic shock patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:178. [PMID: 27282767 PMCID: PMC4899903 DOI: 10.1186/s13054-016-1361-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 05/27/2016] [Indexed: 01/28/2023]
Abstract
Background Adrenomedullin and endothelin-1 are hormones with opposing effects on the cardiovascular system. Adrenomedullin acts as a vasodilator and seems to be important for the initiation and continuation of the hyperdynamic circulatory response in sepsis. Endothelin-1 is a vasoconstrictor and has been linked to decreased cardiac performance. Few studies have studied the relationship between adrenomedullin and endothelin-1, and morbidity and mortality in septic shock patients. High-sensitivity troponin T (hsTNT) is normally used to diagnose acute cardiac injury but is also prognostic for outcome in intensive care. We investigated the relationship between mid-regional pro-adrenomedullin (MR-proADM), C-terminal pro-endothelin-1 (CT-proET-1), and myocardial injury, measured using transthoracic echocardiography and hsTNT in septic shock patients. We were also interested in the development of different biomarkers throughout the ICU stay, and how early measurements were related to mortality. Further, we assessed if a positive biomarker panel, consisting of MR-proADM, CT-proET-1, and hsTNT changed the odds for mortality. Methods A cohort of 53 consecutive patients with septic shock had their levels of MR-proADM, CT-proET-1, hsTNT, and left ventricular systolic functions prospectively measured over 7 days. The relationship between day 1 levels of MR-proADM/CT-proET-1 and myocardial injury was studied. We also investigated the relationship between biomarkers and early (7-day) and later (28-day) mortality. Likelihood ratios, and pretest and posttest odds for mortality were calculated. Results Levels of MR-proADM and CT-proET-1 were significantly higher among patients with myocardial injury and were correlated with left ventricular systolic dysfunction. MR-proADM and hsTNT were significantly higher among 7-day and 28-day non-survivors. CT-proET-1 was also significantly higher among 28-day but not 7-day non-survivors. A positive biomarker panel consisting of the three biomarkers increased the odds for mortality 13-fold to 20-fold. Conclusions MR-proADM and CT-proET-1 are associated with myocardial injury. A biomarker panel combining MR-proADM, CT-proET-1, and hsTNT increases the odds ratio for death, and may improve currently available scoring systems in critical care.
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Affiliation(s)
- Oscar H M Lundberg
- Department of Intensive- and perioperative care, Skåne University Hospital Malmö, Inga Marie Nilssons gata 47, S-205 02, Malmö, Sweden.
| | - Lill Bergenzaun
- Department of Intensive- and perioperative care, Skåne University Hospital Malmö, Inga Marie Nilssons gata 47, S-205 02, Malmö, Sweden
| | - Jörgen Rydén
- Department of Intensive- and perioperative care, Skåne University Hospital Malmö, Inga Marie Nilssons gata 47, S-205 02, Malmö, Sweden
| | - Mari Rosenqvist
- Department of Infectious diseases, Skåne University Hospital Malmö, Ruth Lundskogs gata 3, S-205 02, Malmö, Sweden
| | - Olle Melander
- Department of Internal medicine, Skåne University Hospital Malmö, 205 02, Malmö, Sweden.,Lund University Institute of Clinical Sciences, Malmö, Sweden
| | - Michelle S Chew
- Lund University Institute of Clinical Sciences, Malmö, Sweden.,Department of Anesthesiology and Intensive Care, Linköping University, S-58185, Linköping, Sweden.,Department of Medical and Health Sciences, Linköping University, S-58185, Linköping, Sweden
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35
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Wagner K, Gröger M, McCook O, Scheuerle A, Asfar P, Stahl B, Huber-Lang M, Ignatius A, Jung B, Duechs M, Möller P, Georgieff M, Calzia E, Radermacher P, Wagner F. Blunt Chest Trauma in Mice after Cigarette Smoke-Exposure: Effects of Mechanical Ventilation with 100% O2. PLoS One 2015. [PMID: 26225825 PMCID: PMC4520521 DOI: 10.1371/journal.pone.0132810] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Cigarette smoking (CS) aggravates post-traumatic acute lung injury and increases ventilator-induced lung injury due to more severe tissue inflammation and apoptosis. Hyper-inflammation after chest trauma is due to the physical damage, the drop in alveolar PO2, and the consecutive hypoxemia and tissue hypoxia. Therefore, we tested the hypotheses that 1) CS exposure prior to blunt chest trauma causes more severe post-traumatic inflammation and thereby aggravates lung injury, and that 2) hyperoxia may attenuate this effect. Immediately after blast wave-induced blunt chest trauma, mice (n=32) with or without 3-4 weeks of CS exposure underwent 4 hours of pressure-controlled, thoraco-pulmonary compliance-titrated, lung-protective mechanical ventilation with air or 100 % O2. Hemodynamics, lung mechanics, gas exchange, and acid-base status were measured together with blood and tissue cytokine and chemokine concentrations, heme oxygenase-1 (HO-1), activated caspase-3, and hypoxia-inducible factor 1-α (HIF-1α) expression, nuclear factor-κB (NF-κB) activation, nitrotyrosine formation, purinergic receptor 2X4 (P2XR4) and 2X7 (P2XR7) expression, and histological scoring. CS exposure prior to chest trauma lead to higher pulmonary compliance and lower PaO2 and Horovitz-index, associated with increased tissue IL-18 and blood MCP-1 concentrations, a 2-4-fold higher inflammatory cell infiltration, and more pronounced alveolar membrane thickening. This effect coincided with increased activated caspase-3, nitrotyrosine, P2XR4, and P2XR7 expression, NF-κB activation, and reduced HIF-1α expression. Hyperoxia did not further affect lung mechanics, gas exchange, pulmonary and systemic cytokine and chemokine concentrations, or histological scoring, except for some patchy alveolar edema in CS exposed mice. However, hyperoxia attenuated tissue HIF-1α, nitrotyrosine, P2XR7, and P2XR4 expression, while it increased HO-1 formation in CS exposed mice. Overall, CS exposure aggravated post-traumatic inflammation, nitrosative stress and thereby organ dysfunction and injury; short-term, lung-protective, hyperoxic mechanical ventilation have no major beneficial effect despite attenuation of nitrosative stress, possibly due to compensation of by regional alveolar hypoxia and/or consecutive hypoxemia, resulting in down-regulation of HIF-1α expression.
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MESH Headings
- Acute Lung Injury/etiology
- Acute Lung Injury/physiopathology
- Acute Lung Injury/therapy
- Animals
- Disease Models, Animal
- Female
- Hyperoxia/complications
- Hyperoxia/pathology
- Hyperoxia/physiopathology
- Hypoxia-Inducible Factor 1, alpha Subunit/metabolism
- Lung/pathology
- Lung/physiopathology
- Male
- Mice
- Mice, Inbred C57BL
- Oxidative Stress
- Pulmonary Disease, Chronic Obstructive/etiology
- Pulmonary Disease, Chronic Obstructive/physiopathology
- Pulmonary Disease, Chronic Obstructive/therapy
- Reactive Nitrogen Species/metabolism
- Receptors, Purinergic P2X/metabolism
- Respiration, Artificial/adverse effects
- Smoking/adverse effects
- Thoracic Injuries/complications
- Thoracic Injuries/physiopathology
- Thoracic Injuries/therapy
- Wounds, Nonpenetrating/complications
- Wounds, Nonpenetrating/physiopathology
- Wounds, Nonpenetrating/therapy
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Affiliation(s)
- Katja Wagner
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Ulm, Germany
- Klinik für Anästhesiologie, Universitätsklinikum, Ulm, Germany
| | - Michael Gröger
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Ulm, Germany
| | - Oscar McCook
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Ulm, Germany
| | | | - Pierre Asfar
- Laboratoire HIFIH, UPRES EA 3859, PRES l’UNAM, IFR 132, CNRS UMR 6214, INSERM U1083, Université Angers, Département de Réanimation Médicale et de Médecine Hyperbare, Centre Hospitalier Universitaire, Angers, France
| | - Bettina Stahl
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Ulm, Germany
| | - Markus Huber-Lang
- Klinik für Unfall-, Hand-, Plastische und Wiederherstellungschirurgie, Universitätsklinikum, Ulm, Germany
| | - Anita Ignatius
- Institut für Unfallchirurgische Forschung und Biomechanik, Universitätsklinikum, Ulm, Germany
| | - Birgit Jung
- Abteilung Respiratory Diseases Research, Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach/Riss, Germany
| | - Matthias Duechs
- Abteilung Respiratory Diseases Research, Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach/Riss, Germany
| | - Peter Möller
- Institut für Pathologie, Universitätsklinikum, Ulm, Germany
| | | | - Enrico Calzia
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Ulm, Germany
| | - Peter Radermacher
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Ulm, Germany
- * E-mail:
| | - Florian Wagner
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Ulm, Germany
- Klinik für Anästhesiologie, Universitätsklinikum, Ulm, Germany
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Legrand M, Jacquemod A, Gayat E, Collet C, Giraudeaux V, Launay JM, Payen D. Failure of renal biomarkers to predict worsening renal function in high-risk patients presenting with oliguria. Intensive Care Med 2014; 41:68-76. [PMID: 25465906 DOI: 10.1007/s00134-014-3566-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2014] [Accepted: 11/12/2014] [Indexed: 02/07/2023]
Abstract
PURPOSE Oliguria is a common symptom in critically ill patients and puts patients in a high risk category for further worsening renal function (WRF). We performed this study to explore the predictive value of biomarkers to predict WRF in oliguric intensive care unit (ICU) patients. PATIENTS AND METHODS Single-center prospective observational study. ICU patients were included when they presented a first episode of oliguria. Plasma and urine biomarkers were measured: plasma and urine neutrophil gelatinase-associated lipocalin (pNGAL and uNGAL), urine α1-microglobulin, urine γ-glutamyl transferase, urine indices of tubular function, cystatin C, C terminal fragment of pro-arginine vasopressin (CT-ProAVP), and proadrenomedullin (MR-ProADM). RESULTS One hundred eleven patients formed the cohort, of whom 41 [corrected] had worsening renal function. Simplified Acute Physiology Score (SAPS) II was 41 (31-51). WRF was associated with increased mortality (hazard ratio 8.65 [95 % confidence interval (CI) 3.0-24.9], p = 0.0002). pNGAL, MR-ProADM, and cystatin C had the best odds ratio and area under the receiver-operating characteristic curve (AUC-ROC: 0.83 [0.75-0.9], 0.82 [0.71-0.91], and 0.83 [0.74-0.90]), but not different from serum creatinine (Screat, 0.80 [0.70-0.88]). A clinical model that included age, sepsis, SAPS II, and Screat had AUC-ROC of 0.79 [0.69-0.87]; inclusion of pNGAL increased the AUC-ROC to 0.86 (p = 0.03). The category-free net reclassification index improved with pNGAL (total net reclassification index for events to higher risk 61 % and nonevents to lower 82 %). CONCLUSIONS All episodes of oliguria do not carry the same risk. No biomarker further improved prediction of WRF compared with Screat in this selected cohort of patients at increased risk defined by oliguria.
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Affiliation(s)
- Matthieu Legrand
- Department of Anesthesiology and Critical Care and SMUR and Burn Unit, Assistance Publique-Hopitaux de Paris, AP-HP, GH St-Louis-Lariboisière, University of Paris 7 Denis Diderot, 1 rue Claude Vellefaux, 75010, Paris, France,
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Pugin J. Adrenomedullin: a vasodilator to treat sepsis? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:152. [PMID: 25041977 PMCID: PMC4075119 DOI: 10.1186/cc13924] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Adrenomedullin is a vasodilatory polypeptide with pleiotropic effects secreted by various organs. Adrenomedullin is produced first as a prepropeptide, and then cleaved into mature adrenomedullin and mid-regional proadrenomedullin. Whereas levels of the latter have been shown to correlate with severity of sepsis and carry prognostic value, adrenomedullin plays a role in vascular tone homeostasis. In the previous issue of Critical Care, the infusion of exogenous adrenomedullin is suggested to protect against increased lung endothelial permeability and end-organ dysfunction in a model of pneumococcal pneumonia in mechanically ventilated mice, possibly by stabilizing vascular endothelia. Since adrenomedullin is a strong vasodilatory molecule, further studies are needed to evaluate its potential as a future treatment of sepsis.
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Vogt JA, Wachter U, Wagner K, Calzia E, Gröger M, Weber S, Stahl B, Georgieff M, Asfar P, Fontaine E, Radermacher P, Leverve XM, Wagner F. Effects of glycemic control on glucose utilization and mitochondrial respiration during resuscitated murine septic shock. Intensive Care Med Exp 2014; 2:19. [PMID: 26266919 PMCID: PMC4678133 DOI: 10.1186/2197-425x-2-19] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Accepted: 04/08/2014] [Indexed: 12/13/2022] Open
Abstract
Background This study aims to test the hypothesis whether lowering glycemia improves mitochondrial function and thereby attenuates apoptotic cell death during resuscitated murine septic shock. Methods Immediately and 6 h after cecal ligation and puncture (CLP), mice randomly received either vehicle or the anti-diabetic drug EMD008 (100 μg · g-1). At 15 h post CLP, mice were anesthetized, mechanically ventilated, instrumented and rendered normo- or hyperglycemic (target glycemia 100 ± 20 and 180 ± 50 mg · dL-1, respectively) by infusing stable, non-radioactive isotope-labeled 13C6-glucose. Target hemodynamics was achieved by colloid fluid resuscitation and continuous i.v. noradrenaline, and mechanical ventilation was titrated according to blood gases and pulmonary compliance measurements. Gluconeogenesis and glucose oxidation were derived from blood and expiratory glucose and 13CO2 isotope enrichments, respectively; mathematical modeling allowed analyzing isotope data for glucose uptake as a function of glycemia. Postmortem liver tissue was analyzed for HO-1, AMPK, caspase-3, and Bax (western blotting) expression as well as for mitochondrial respiratory activity (high-resolution respirometry). Results Hyperglycemia lowered mitochondrial respiratory capacity; EMD008 treatment was associated with increased mitochondrial respiration. Hyperglycemia decreased AMPK phosphorylation, and EMD008 attenuated both this effect as well as the expression of activated caspase-3 and Bax. During hyperglycemia EMD008 increased HO-1 expression. During hyperglycemia, maximal mitochondrial oxidative phosphorylation rate was directly related to HO-1 expression, while it was unrelated to AMPK activation. According to the mathematical modeling, EMD008 increased the slope of glucose uptake plotted as a function of glycemia. Conclusions During resuscitated, polymicrobial, murine septic shock, glycemic control either by reducing glucose infusion rates or EMD008 improved glucose uptake and thereby liver tissue mitochondrial respiratory activity. EMD008 effects were more pronounced during hyperglycemia and coincided with attenuated markers of apoptosis. The effects of glucose control were at least in part due to the up-regulation of HO-1 and activation of AMPK. Electronic supplementary material The online version of this article (doi:10.1186/2197-425X-2-19) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Josef A Vogt
- Sektion Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Klinik für Anästhesiologie, Universitätsklinikum, Helmhotzstrasse 8-1, Ulm, 89081, Germany,
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Kox M, Pickkers P. Adrenomedullin: its double-edged sword during sepsis slices yet again. Intensive Care Med Exp 2014; 2:1. [PMID: 26266901 PMCID: PMC4513021 DOI: 10.1186/2197-425x-2-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Accepted: 12/10/2013] [Indexed: 11/25/2022] Open
Affiliation(s)
- Matthijs Kox
- Intensive Care Medicine, Radboud University Medical Centre, Nijmegen, 6500, HB, the Netherlands,
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