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Ware LB, Files DC, Fowler A, Aboodi MS, Aggarwal NR, Brower RG, Chang SY, Douglas IS, Fields S, Foulkes AS, Ginde AA, Harris ES, Hendey GW, Hite RD, Huang W, Lai P, Liu KD, Thompson BT, Matthay MA. Acetaminophen for Prevention and Treatment of Organ Dysfunction in Critically Ill Patients With Sepsis: The ASTER Randomized Clinical Trial. JAMA 2024; 332:390-400. [PMID: 38762798 PMCID: PMC11304120 DOI: 10.1001/jama.2024.8772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 04/25/2024] [Indexed: 05/20/2024]
Abstract
Importance Acetaminophen (paracetamol) has many pharmacological effects that might be beneficial in sepsis, including inhibition of cell-free hemoglobin-induced oxidation of lipids and other substrates. Objective To determine whether acetaminophen increases days alive and free of organ dysfunction in sepsis compared with placebo. Design, Setting, and Participants Phase 2b randomized, double-blind, clinical trial conducted from October 2021 to April 2023 with 90-day follow-up. Adults with sepsis and respiratory or circulatory organ dysfunction were enrolled in the emergency department or intensive care unit of 40 US academic hospitals within 36 hours of presentation. Intervention Patients were randomized to 1 g of acetaminophen intravenously every 6 hours or placebo for 5 days. Main Outcome and Measures The primary end point was days alive and free of organ support (mechanical ventilation, vasopressors, and kidney replacement therapy) to day 28. Treatment effect modification was evaluated for acetaminophen by prerandomization plasma cell-free hemoglobin level higher than 10 mg/dL. Results Of 447 patients enrolled (mean age, 64 [SD, 15] years, 51% female, mean Sequential Organ Failure Assessment [SOFA] score, 5.4 [SD, 2.5]), 227 were randomized to acetaminophen and 220 to placebo. Acetaminophen was safe with no difference in liver enzymes, hypotension, or fluid balance between treatment arms. Days alive and free of organ support to day 28 were not meaningfully different for acetaminophen (20.2 days; 95% CI, 18.8 to 21.6) vs placebo (19.6 days; 95% CI, 18.2 to 21.0; P = .56; difference, 0.6; 95% CI, -1.4 to 2.6). Among 15 secondary outcomes, total, respiratory, and coagulation SOFA scores were significantly lower on days 2 through 4 in the acetaminophen arm as was the rate of development of acute respiratory distress syndrome within 7 days (2.2% vs 8.5% acetaminophen vs placebo; P = .01; difference, -6.3; 95% CI, -10.8 to -1.8). There was no significant interaction between cell-free hemoglobin levels and acetaminophen. Conclusions and Relevance Intravenous acetaminophen was safe but did not significantly improve days alive and free of organ support in critically ill sepsis patients. Trial Registration ClinicalTrials.gov Identifier: NCT04291508.
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Pires Nakama R, Felipe Dos Santos L, Berto-Pereira L, Sobral de Rossi L, Donizette Malvezi A, Isabel Lovo-Martins M, Paula Canizares Cardoso A, Mendes Dionísio de Freitas A, Cardoso Martins-Pinge M, Pinge-Filho P. Metabolic syndrome induces benefits in mice experiencing severe sepsis, comparable to the effects of low-dose aspirin pretreatment in septic mice lacking metabolic syndrome. Int Immunopharmacol 2024; 139:112694. [PMID: 39024746 DOI: 10.1016/j.intimp.2024.112694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Revised: 07/10/2024] [Accepted: 07/12/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND Sepsis is a complex condition characterized by systemic host inflammation caused by an infection. Experimental and observational studies indicate that obesity, one of the components of metabolic syndrome (MetS), or aspirin (ASA) treatment could be associated with sepsis survival. However, the effects of ASA on septic mice with MetS-induced conditions have not been explored. METHODS Swiss mice were administered monosodium glutamate (MSG) (4 mg/kg) during their first 5 days of life for MetS induction, while the control mice received an equimolar saline solution. MetS was validated in male mice on their 60th day of life. ASA treatment was administered for 15 days prior to sepsis (40 mg/kg). On the 75th day, sepsis was induced in MetS and control mice through cecal ligation and puncture (CLP). The effects of ASA on septic mice with MSG-induced MetS were assessed by determining survival rates, quantification of nitric oxide (NO), and cytokine levels in the plasma, while correlating these data with hematological, blood glucose and cardiovascular parameters. RESULTS MetS was validated by Lee-Index (3 body weight/naso-anal length×1000), hypertension, and hyperglycemia in animals receiving MSG as neonates. In control animals, severe sepsis promoted hypoglycemia, which was associated with mortality, as well as increased plasma NO levels, hypotension, hematological alterations, and elevation of proinflammatory cytokines. In contrast, MetS and pre-treatment with ASA were able to prevent sepsis-related alterations. CONCLUSIONS MetS and ASA pre-treatment provided protection against severe sepsis. However, ASA was ineffective in mice with MetS undergoing severe sepsis.
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Affiliation(s)
- Raquel Pires Nakama
- Laboratory of Experimental Immunopathology, Department of Immunology, Parasitology and General Pathology, Center for Biological Sciences, State University of Londrina, PR, Brazil
| | - Lucas Felipe Dos Santos
- Laboratory of Microorganism Molecular Biology, Department of Microbiology, Center for Biological Sciences, State University of Londrina, PR, Brazil
| | - Leonardo Berto-Pereira
- Laboratory of Cardiovascular Physiology and Physiopathology, Department of Physiological Sciences, Center for Biological Sciences, State University of Londrina, PR, Brazil
| | - Lucas Sobral de Rossi
- Laboratory of Experimental Immunopathology, Department of Immunology, Parasitology and General Pathology, Center for Biological Sciences, State University of Londrina, PR, Brazil
| | - Aparecida Donizette Malvezi
- Laboratory of Experimental Immunopathology, Department of Immunology, Parasitology and General Pathology, Center for Biological Sciences, State University of Londrina, PR, Brazil
| | - Maria Isabel Lovo-Martins
- Laboratory of Experimental Immunopathology, Department of Immunology, Parasitology and General Pathology, Center for Biological Sciences, State University of Londrina, PR, Brazil
| | - Ana Paula Canizares Cardoso
- Laboratory of Experimental Immunopathology, Department of Immunology, Parasitology and General Pathology, Center for Biological Sciences, State University of Londrina, PR, Brazil
| | - Andressa Mendes Dionísio de Freitas
- Laboratory of Pharmacology of Inflammation, Department of Physiological Sciences, Center for Biological Sciences, State University of Londrina, PR, Brazil
| | - Marli Cardoso Martins-Pinge
- Laboratory of Experimental Immunopathology, Department of Immunology, Parasitology and General Pathology, Center for Biological Sciences, State University of Londrina, PR, Brazil; Laboratory of Cardiovascular Physiology and Physiopathology, Department of Physiological Sciences, Center for Biological Sciences, State University of Londrina, PR, Brazil
| | - Phileno Pinge-Filho
- Laboratory of Experimental Immunopathology, Department of Immunology, Parasitology and General Pathology, Center for Biological Sciences, State University of Londrina, PR, Brazil; Laboratory of Microorganism Molecular Biology, Department of Microbiology, Center for Biological Sciences, State University of Londrina, PR, Brazil.
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Kasper R, Rodriguez-Alfonso A, Ständker L, Wiese S, Schneider EM. Major endothelial damage markers identified from hemadsorption filters derived from treated patients with septic shock - endoplasmic reticulum stress and bikunin may play a role. Front Immunol 2024; 15:1359097. [PMID: 38698864 PMCID: PMC11063272 DOI: 10.3389/fimmu.2024.1359097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 04/08/2024] [Indexed: 05/05/2024] Open
Abstract
Introduction In septic patients the damage of the endothelial barrier is decisive leading to circulatory septic shock with disseminated vascular coagulation, edema and multiorgan failure. Hemadsorption therapy leads to rapid resolution of clinical symptoms. We propose that the isolation of proteins adsorbed to hemadsorption devices contributes to the identification of mediators responsible for endothelial barrier dysfunction. Material and methods Plasma materials enriched to hemadsorption filters (CytoSorb®) after therapy of patients in septic shock were fractionated and functionally characterized for their effect on cell integrity, viability, proliferation and ROS formation by human endothelial cells. Fractions were further studied for their contents of oxidized nucleic acids as well as peptides and proteins by mass spectrometry. Results Individual fractions exhibited a strong effect on endothelial cell viability, the endothelial layer morphology, and ROS formation. Fractions with high amounts of DNA and oxidized DNA correlated with ROS formation in the target endothelium. In addition, defined proteins such as defensins (HNP-1), SAA1, CXCL7, and the peptide bikunin were linked to the strongest additive effects in endothelial damage. Conclusion Our results indicate that hemadsorption is efficient to transiently remove strong endothelial damage mediators from the blood of patients with septic shock, which explains a rapid clinical improvement of inflammation and endothelial function. The current work indicates that a combination of stressors leads to the most detrimental effects. Oxidized ssDNA, likely derived from mitochondria, SAA1, the chemokine CXCL7 and the human neutrophil peptide alpha-defensin 1 (HNP-1) were unique for their significant negative effect on endothelial cell viability. However, the strongest damage effect occurred, when, bikunin - cleaved off from alpha-1-microglobulin was present in high relative amounts (>65%) of protein contents in the most active fraction. Thus, a relevant combination of stressors appears to be removed by hemadsorption therapy which results in fulminant and rapid, though only transient, clinical restitution.
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Affiliation(s)
- Robin Kasper
- Clinic of Anesthesiology and Intensive Care Medicine, University Hospital Ulm, Ulm, Germany
| | - Armando Rodriguez-Alfonso
- Core Facility Functional Peptidomics, Ulm University Medical Center, Ulm, Germany
- Core Unit Mass Spectrometry and Proteomics (CUMP), Ulm University, Ulm, Germany
| | - Ludger Ständker
- Core Facility Functional Peptidomics, Ulm University Medical Center, Ulm, Germany
| | - Sebastian Wiese
- Core Unit Mass Spectrometry and Proteomics (CUMP), Ulm University, Ulm, Germany
| | - E. Marion Schneider
- Clinic of Anesthesiology and Intensive Care Medicine, University Hospital Ulm, Ulm, Germany
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Ross JT, Robles AJ, Mazer MB, Studer AC, Remy KE, Callcut RA. Cell-Free Hemoglobin in the Pathophysiology of Trauma: A Scoping Review. Crit Care Explor 2024; 6:e1052. [PMID: 38352942 PMCID: PMC10863949 DOI: 10.1097/cce.0000000000001052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024] Open
Abstract
OBJECTIVES Cell-free hemoglobin (CFH) is a potent mediator of endothelial dysfunction, organ injury, coagulopathy, and immunomodulation in hemolysis. These mechanisms have been demonstrated in patients with sepsis, hemoglobinopathies, and those receiving transfusions. However, less is known about the role of CFH in the pathophysiology of trauma, despite the release of equivalent levels of free hemoglobin. DATA SOURCES Ovid MEDLINE, Embase, Web of Science Core Collection, and BIOSIS Previews were searched up to January 21, 2023, using key terms related to free hemoglobin and trauma. DATA EXTRACTION Two independent reviewers selected studies focused on hemolysis in trauma patients, hemoglobin breakdown products, hemoglobin-mediated injury in trauma, transfusion, sepsis, or therapeutics. DATA SYNTHESIS Data from the selected studies and their references were synthesized into a narrative review. CONCLUSIONS Free hemoglobin likely plays a role in endothelial dysfunction, organ injury, coagulopathy, and immune dysfunction in polytrauma. This is a compelling area of investigation as multiple existing therapeutics effectively block these pathways.
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Affiliation(s)
- James T Ross
- Department of Surgery, University of California Davis, Sacramento, CA
- The Blood, Heart, Lung, and Immunology Research Center, Case Western Reserve University, University Hospitals Cleveland, Cleveland, OH
| | - Anamaria J Robles
- Department of Surgery, University of California Davis, Sacramento, CA
| | - Monty B Mazer
- The Blood, Heart, Lung, and Immunology Research Center, Case Western Reserve University, University Hospitals Cleveland, Cleveland, OH
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, UH Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Amy C Studer
- Blaisdell Medical Library, University of California Davis, Sacramento, CA
| | - Kenneth E Remy
- The Blood, Heart, Lung, and Immunology Research Center, Case Western Reserve University, University Hospitals Cleveland, Cleveland, OH
- Division of Pulmonary Critical Care Medicine, Department of Medicine, University Hospitals of Cleveland, Case Western Reserve School of Medicine, Cleveland, OH
| | - Rachael A Callcut
- Department of Surgery, University of California Davis, Sacramento, CA
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Fowler AA. Vitamin C: Rationale for Its Use in Sepsis-Induced Acute Respiratory Distress Syndrome (ARDS). Antioxidants (Basel) 2024; 13:95. [PMID: 38247519 PMCID: PMC10812524 DOI: 10.3390/antiox13010095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 01/08/2024] [Accepted: 01/09/2024] [Indexed: 01/23/2024] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a life-threatening event that occurs in patients suffering from bacterial, fungal, or viral sepsis. Research performed over the last five decades showed that ARDS is a consequence of severe unrestrained systemic inflammation, which leads to injury of the lung's microvasculature and alveolar epithelium. ARDS leads to acute hypoxic/hypercapnic respiratory failure and death in a significant number of patients hospitalized in intensive care units worldwide. Basic and clinical research performed during the time since ARDS was first described has been unable to construct a pharmacological agent that will combat the inflammatory fire leading to ARDS. In-depth studies of the molecular pharmacology of vitamin C indicate that it can serve as a potent anti-inflammatory agent capable of attenuating the pathobiological events that lead to acute injury of the lungs and other body organs. This analysis of vitamin C's role in the treatment of ARDS includes a focused systematic review of the literature relevant to the molecular physiology of vitamin C and to the past performance of clinical trials using the agent.
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Affiliation(s)
- Alpha A Fowler
- Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine, School of Medicine, Virginia Commonwealth University, Richmond, VA 23219, USA
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Bejoy J, Farry JM, Qian ES, Dearing CH, Ware LB, Bastarache JA, Woodard LE. Ascorbate protects human kidney organoids from damage induced by cell-free hemoglobin. Dis Model Mech 2023; 16:dmm050342. [PMID: 37942584 PMCID: PMC10695115 DOI: 10.1242/dmm.050342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 11/02/2023] [Indexed: 11/10/2023] Open
Abstract
Sepsis-associated acute kidney injury is associated with high morbidity and mortality in critically ill patients. Cell-free hemoglobin (CFH) is released into the circulation of patients with severe sepsis and the levels of CFH are independently associated with mortality. CFH treatment increased cytotoxicity in the human tubular epithelial cell line HK-2. To better model the intact kidney, we cultured human kidney organoids derived from induced pluripotent stem cells. We treated human kidney organoids grown using both three-dimensional and transwell protocols with CFH for 48 h. We found evidence for increased tubular toxicity, oxidative stress, mitochondrial fragmentation, endothelial cell injury and injury-associated transcripts compared to those of the untreated control group. To evaluate the protective effect of clinically available small molecules, we co-treated CFH-injured organoids with ascorbate (vitamin C) or acetaminophen for 48 h. We found significantly decreased toxicity, preservation of endothelial cells and reduced mitochondrial fragmentation in the group receiving ascorbate following CFH treatment. This study provides direct evidence that ascorbate or ascorbic acid protects human kidney cells from CFH-induced damage such as that in sepsis-associated acute kidney injury.
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Affiliation(s)
- Julie Bejoy
- Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Justin M. Farry
- Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN 37232, USA
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN 37232, USA
| | - Eddie S. Qian
- Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Curtis H. Dearing
- Vanderbilt Experimental Research Training Inclusion Community Engagement Skills (VERTICES) program, Vanderbilt University, Nashville, TN 37232, USA
| | - Lorraine B. Ware
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Julie A. Bastarache
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN 37232, USA
- Department of Cell Biology, Vanderbilt University Medical Center, Nashville, TN 37232, USA
- U.S. Department of Veterans Affairs, Nashville, TN 37212, USA
| | - Lauren E. Woodard
- Department of Medicine, Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN 37232, USA
- Department of Biomedical Engineering, Vanderbilt University, Nashville, TN 37232, USA
- U.S. Department of Veterans Affairs, Nashville, TN 37212, USA
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Li Y, Chen R, Wang C, Deng J, Luo S. Double-edged functions of hemopexin in hematological related diseases: from basic mechanisms to clinical application. Front Immunol 2023; 14:1274333. [PMID: 38022615 PMCID: PMC10653390 DOI: 10.3389/fimmu.2023.1274333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 10/19/2023] [Indexed: 12/01/2023] Open
Abstract
It is now understood that hemolysis and the subsequent release of heme into circulation play a critical role in driving the progression of various diseases. Hemopexin (HPX), a heme-binding protein with the highest affinity for heme in plasma, serves as an effective antagonist against heme toxicity resulting from severe acute or chronic hemolysis. In the present study, changes in HPX concentration were characterized at different stages of hemolytic diseases, underscoring its potential as a biomarker for assessing disease progression and prognosis. In many heme overload-driven conditions, such as sickle cell disease, transfusion-induced hemolysis, and sepsis, endogenous HPX levels are often insufficient to provide protection. Consequently, there is growing interest in developing HPX therapeutics to mitigate toxic heme exposure. Strategies include HPX supplementation when endogenous levels are depleted and enhancing HPX's functionality through modifications, offering a potent defense against heme toxicity. It is worth noting that HPX may also exert deleterious effects under certain circumstances. This review aims to provide a comprehensive overview of HPX's roles in the progression and prognosis of hematological diseases. It highlights HPX-based clinical therapies for different hematological disorders, discusses advancements in HPX production and modification technologies, and offers a theoretical basis for the clinical application of HPX.
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Affiliation(s)
| | | | | | - Jun Deng
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shanshan Luo
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Marcello M, Virzì GM, Marturano D, de Cal M, Marchionna N, Sgarabotto L, De Rosa S, Ronco C, Zanella M. The Cytotoxic Effect of Septic Plasma on Healthy RBCs: Is Eryptosis a New Mechanism for Sepsis? Int J Mol Sci 2023; 24:14176. [PMID: 37762478 PMCID: PMC10531772 DOI: 10.3390/ijms241814176] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 09/11/2023] [Accepted: 09/14/2023] [Indexed: 09/29/2023] Open
Abstract
Sepsis is a life-threatening multiple-organ dysfunction induced by infection and is one of the leading causes of mortality and critical illness worldwide. The pathogenesis of sepsis involves the alteration of several biochemical pathways such as immune response, coagulation, dysfunction of endothelium and tissue damage through cellular death and/or apoptosis. Recently, in vitro and in vivo studies reported changes in the morphology and in the shape of human red blood cells (RBCs) causing erythrocyte death (eryptosis) during sepsis. Characteristics of eryptosis include cell shrinkage, membrane blebbing, and surface exposure to phosphatidylserine (PS), which attract macrophages. The aim of this study was to evaluate the in vitro induction of eryptosis on healthy RBCs exposed to septic plasma at different time points. Furthermore, we preliminary investigated the in vivo levels of eryptosis in septic patients and its relationship with Endotoxin Activity Assay (EAA), mortality and other biological markers of inflammation and oxidative stress. We enrolled 16 septic patients and 16 healthy subjects (no systemic inflammation in the last 3 months) as a control group. At diagnosis, we measured Interleukin-6 (IL-6) and Myeloperoxidase (MPO). For in vitro study, healthy RBCs were exposed to the plasma of septic patients and CTR for 15 min, 1, 2, 4 and 24 h. Morphological markers of death and eryptosis were evaluated by flow cytometric analyses. The cytotoxic effect of septic plasma on RBCs was studied in vitro at 15 min, 1, 2, 4 and 24 h. Healthy RBCs incubated with plasma from septic patients went through significant morphological changes and eryptosis compared to those exposed to plasma from the control group at all time points (all, p < 0.001). IL-6 and MPO levels were significantly higher in septic patients than in controls (both, p < 0.001). The percentage of AnnexinV-binding RBCs was significantly higher in septic patients with EAA level ≥0.60 (positive EAA: 32.4%, IQR 27.6-36.2) compared to septic patients with EAA level <0.60 (negative EAA: 14.7%, IQR 5.7-30.7) (p = 0.04). Significant correlations were observed between eryptosis and EAA levels (Spearman rho2 = 0.50, p < 0.05), IL-6 (Spearman rho2 = 0.61, p < 0.05) and MPO (Spearman rho2 = 0.70, p < 0.05). In conclusion, we observed a quick and great cytotoxic effect of septic plasma on healthy RBCs and a strong correlation with other biomarkers of severity of sepsis. Based on these results, we confirmed the pathological role of eryptosis in sepsis and we hypothesized its use as a biomarker of sepsis, potentially helping physicians to face important treatment decisions.
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Affiliation(s)
- Matteo Marcello
- Department of Nephrology, Dialysis and Transplant, St Bortolo Hospital, 36100 Vicenza, Italy (M.Z.)
- IRRIV-International Renal Research Institute, 36100 Vicenza, Italy
| | - Grazia Maria Virzì
- Department of Nephrology, Dialysis and Transplant, St Bortolo Hospital, 36100 Vicenza, Italy (M.Z.)
- IRRIV-International Renal Research Institute, 36100 Vicenza, Italy
| | - Davide Marturano
- Department of Nephrology, Dialysis and Transplant, St Bortolo Hospital, 36100 Vicenza, Italy (M.Z.)
- IRRIV-International Renal Research Institute, 36100 Vicenza, Italy
- Nephrology, Dialysis and Transplantation Unit, Department of Medicine, University of Padova, 35100 Padova, Italy
| | - Massimo de Cal
- Department of Nephrology, Dialysis and Transplant, St Bortolo Hospital, 36100 Vicenza, Italy (M.Z.)
- IRRIV-International Renal Research Institute, 36100 Vicenza, Italy
| | - Nicola Marchionna
- Department of Nephrology, Dialysis and Transplant, St Bortolo Hospital, 36100 Vicenza, Italy (M.Z.)
- IRRIV-International Renal Research Institute, 36100 Vicenza, Italy
| | - Luca Sgarabotto
- Department of Nephrology, Dialysis and Transplant, St Bortolo Hospital, 36100 Vicenza, Italy (M.Z.)
- IRRIV-International Renal Research Institute, 36100 Vicenza, Italy
| | - Silvia De Rosa
- Centre for Medical Sciences-CISMed, University of Trento, Via S. Maria Maddalena 1, 38122 Trento, Italy
- Anesthesia and Intensive Care, Santa Chiara Regional Hospital, APSS, 38122 Trento, Italy
| | - Claudio Ronco
- IRRIV-International Renal Research Institute, 36100 Vicenza, Italy
| | - Monica Zanella
- Department of Nephrology, Dialysis and Transplant, St Bortolo Hospital, 36100 Vicenza, Italy (M.Z.)
- IRRIV-International Renal Research Institute, 36100 Vicenza, Italy
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Chen Y, Chen L, Meng Z, Li Y, Tang J, Liu S, Li L, Zhang P, Chen Q, Liu Y. The correlation of hemoglobin and 28-day mortality in septic patients: secondary data mining using the MIMIC-IV database. BMC Infect Dis 2023; 23:417. [PMID: 37340360 DOI: 10.1186/s12879-023-08384-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 06/08/2023] [Indexed: 06/22/2023] Open
Abstract
BACKGROUND Previous studies found minimal evidence and raised controversy about the link between hemoglobin and 28-day mortality in sepsis patients. As a result, the purpose of this study was to examine the association between hemoglobin and 28-day death in sepsis patients by analyzing the Medical Intensive Care IV (MIMIC-IV) database from 2008 to 2019 at an advanced medical center in Boston, Massachusetts. METHODS We extracted 34,916 sepsis patients from the MIMIC-IV retrospective cohort database, using hemoglobin as the exposure variable and 28-day death as the outcome variable, and after adjusting for confounders (demographic indicators, Charlson co-morbidity index, SOFA score, vital signs, medication use status (glucocorticoids, vasoactive drugs, antibiotics, and immunoglobulins, etc.)), we investigated the independent effects of hemoglobin and 28-day risk of death by binary logistic regression as well as two-piecewise linear model, respectively. RESULTS Hemoglobin levels and 28-day mortality were shown to be non-linearly related.The inflection points were 104 g/L and 128 g/L, respectively. When HGB levels were between 41 and 104 g/L, there was a 10% decrease in the risk of 28-day mortality (OR: 0.90; 95% CI: 0.87 to 0.94, p-value = 0.0001). However, in the range of 104-128 g/L, we did not observe a significant association between hemoglobin and 28-day mortality (OR: 1.17; 95% CI: 1.00 to 1.35, P value = 0.0586). When HGB was in the range of 128-207 g/L, there was a 7% increase in the risk of 28-day mortality for every 1 unit increase in HGB (OR: 1.07; 95% CI: 1.01 to 1.15, P value = 0.0424). CONCLUSION In patients with sepsis, baseline hemoglobin was related to a U-shaped risk of 28-day death. When HGB was in the range of 12.8-20.7 g/dL, there was a 7% increase in the risk of 28-day mortality for every 1 unit increase in HGB.
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Affiliation(s)
- Yu Chen
- Clinical Laboratory Center, The Affiliated Hospital of Guizhou Medical University, 28, Guiyi Street, Guiyang, Guizhou, China
| | - Lu Chen
- Department of Clinical Trials Centre, The Affiliated Hospital of Guizhou Medical University, 28, Guiyi Street, Guiyang, Guizhou, China
| | - Zengping Meng
- Clinical Laboratory Center, The Affiliated Hospital of Guizhou Medical University, 28, Guiyi Street, Guiyang, Guizhou, China
| | - Yi Li
- College of Medical Laboratory, Guizhou Medical University, 9 Beijing Road, Guiyang, Guizhou, China
| | - Juan Tang
- College of Medical Laboratory, Guizhou Medical University, 9 Beijing Road, Guiyang, Guizhou, China
| | - Shaowen Liu
- College of Medical Laboratory, Guizhou Medical University, 9 Beijing Road, Guiyang, Guizhou, China
| | - Li Li
- Clinical Laboratory Center, The Affiliated Hospital of Guizhou Medical University, 28, Guiyi Street, Guiyang, Guizhou, China
| | - Peisheng Zhang
- Clinical Laboratory Center, The Affiliated Hospital of Guizhou Medical University, 28, Guiyi Street, Guiyang, Guizhou, China
| | - Qian Chen
- College of Medical Laboratory, Guizhou Medical University, 9 Beijing Road, Guiyang, Guizhou, China
| | - Yongmei Liu
- Clinical Laboratory Center, The Affiliated Hospital of Guizhou Medical University, 28, Guiyi Street, Guiyang, Guizhou, China.
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Costantini S, Belliato M, Ferrari F, Gazzaniga G, Ravasi M, Manera M, De Piero ME, Curcelli A, Cardinale A, Lorusso R. A retrospective analysis of the hemolysis occurrence during extracorporeal membrane oxygenation in a single center. Perfusion 2023; 38:609-621. [PMID: 35225087 DOI: 10.1177/02676591211073768] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Extracorporeal membrane oxygenation (ECMO)-associated hemolysis still represents a serious complication. The present study aimed to investigate those predictive factors, such as flow rates, the use of anticoagulants, and circuit connected dialysis, that might play a pivotal role in hemolysis in adult patients. METHODS This is a retrospective single-center case series of 35 consecutive adult patients undergoing veno-venous ECMO support at our center between April 2014 and February 2020. Daily plasma-free hemoglobin (pfHb) and haptoglobin (Hpt) levels were chosen as hemolysis markers and they were analyzed along with patients' characteristics, daily laboratory findings, and corresponding ECMO system variables, as well as continuous renal replacement therapy (CRRT) when administered, looking for factors influencing their trends over time. RESULTS Among the many settings related to the ECMO support, the presence of CRRT connected to the ECMO circuit has been found associated with both higher daily pfHb levels and lower Hpt levels. After correction for potential confounders, hemolysis was ascribable to circuit-related variables, in particular the membrane oxygenation dead space was associated with an Hpt reduction (B = -215.307, p = 0.004). Moreover, a reduction of ECMO blood flow by 1 L/min has been associated with a daily Hpt consumption of 93.371 mg/dL (p = 0.001). CONCLUSIONS Technical-induced hemolysis during ECMO should be monitored not only when suspected but also during quotidian management and check-ups. While considering the clinical complexity of patients on ECMO support, clinicians should not only be aware of and anticipate possible circuitry malfunctions or inadequate flow settings, but they should also take into account the effects of an ECMO circuit-connected CRRT, as an equally important key factor triggering hemolysis.
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Affiliation(s)
- Silvia Costantini
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, 19001University of Pavia, Pavia, Italy
| | - Mirko Belliato
- UOC Anestesia e Rianimazione II Cardiopolmonare, 18631Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.,Cardio-Thoracic Surgery Department, Heart & Vascular Centre, 199236Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Fiorenza Ferrari
- UOC Anestesia e Rianimazione I, 18631Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Giulia Gazzaniga
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, 19001University of Pavia, Pavia, Italy
| | - Marta Ravasi
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, 19001University of Pavia, Pavia, Italy
| | - Miriam Manera
- UOC Anestesia e Rianimazione II Cardiopolmonare, 18631Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | - Antonio Curcelli
- Cardiac Anesthesia and Intensive Care ICLAS Rapallo, 18591GVM Care & Res, Rapallo, Italy
| | - Alessandra Cardinale
- Department of Statistical Sciences, 9311Sapienza University of Rome, Rome, Italy
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, 199236Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands.,118066Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherland
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11
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De Simone G, Varricchio R, Ruberto TF, di Masi A, Ascenzi P. Heme Scavenging and Delivery: The Role of Human Serum Albumin. Biomolecules 2023; 13:biom13030575. [PMID: 36979511 PMCID: PMC10046553 DOI: 10.3390/biom13030575] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/10/2023] [Accepted: 03/17/2023] [Indexed: 03/30/2023] Open
Abstract
Heme is the reactive center of several metal-based proteins that are involved in multiple biological processes. However, free heme, defined as the labile heme pool, has toxic properties that are derived from its hydrophobic nature and the Fe-atom. Therefore, the heme concentration must be tightly controlled to maintain cellular homeostasis and to avoid pathological conditions. Therefore, different systems have been developed to scavenge either Hb (i.e., haptoglobin (Hp)) or the free heme (i.e., high-density lipoproteins (HDL), low-density lipoproteins (LDL), hemopexin (Hx), and human serum albumin (HSA)). In the first seconds after heme appearance in the plasma, more than 80% of the heme binds to HDL and LDL, and only the remaining 20% binds to Hx and HSA. Then, HSA slowly removes most of the heme from HDL and LDL, and finally, heme transits to Hx, which releases it into hepatic parenchymal cells. The Hx:heme or HSA:heme complexes are internalized via endocytosis mediated by the CD91 and CD71 receptors, respectively. As heme constitutes a major iron source for pathogens, bacteria have evolved hemophores that can extract and uptake heme from host proteins, including HSA:heme. Here, the molecular mechanisms underlying heme scavenging and delivery from HSA are reviewed. Moreover, the relevance of HSA in disease states associated with increased heme plasma concentrations are discussed.
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Affiliation(s)
- Giovanna De Simone
- Department of Sciences, Section of Biomedical Sciences and Technologies, Roma Tre University, 00146 Roma, Italy
| | - Romualdo Varricchio
- Department of Sciences, Section of Biomedical Sciences and Technologies, Roma Tre University, 00146 Roma, Italy
| | - Tommaso Francesco Ruberto
- Department of Sciences, Section of Biomedical Sciences and Technologies, Roma Tre University, 00146 Roma, Italy
| | - Alessandra di Masi
- Department of Sciences, Section of Biomedical Sciences and Technologies, Roma Tre University, 00146 Roma, Italy
- Centro Linceo Interdisciplinare Beniamino Segre, Accademia Nazionale dei Lincei, 00165 Roma, Italy
| | - Paolo Ascenzi
- Department of Sciences, Section of Biomedical Sciences and Technologies, Roma Tre University, 00146 Roma, Italy
- Accademia Nazionale dei Lincei, 00165 Roma, Italy
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12
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Vijayan V, Greite R, Schott S, Doricic J, Madyaningrana K, Pradhan P, Martens J, Blasczyk R, Janciauskiene S, Immenschuh S. Determination of free heme in stored red blood cells with an apo-horseradish peroxidase-based assay. Biol Chem 2022; 403:1091-1098. [PMID: 36054292 DOI: 10.1515/hsz-2022-0184] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 08/15/2022] [Indexed: 12/19/2022]
Abstract
Transfusion effectiveness of red blood cells (RBCs) has been associated with duration of the storage period. Storage-dependent RBC alterations lead to hemolysis and release of toxic free heme, but the increase of free heme levels over time is largely unknown. In the current study, an apo-horseradish peroxidase (apoHRP)-based assay was applied to measure levels of free heme at regular intervals or periodically in supernatants of RBCs until a maximum storage period of 42 days. Free heme levels increased with linear time-dependent kinetics up to day 21 and accelerated disproportionally after day 28 until day 42, as determined with the apoHRP assay. Individual time courses of free heme in different RBC units exhibited high variability. Notably, levels of free hemoglobin, an established indicator of RBC damage, and those of total heme increased with continuous time-dependent linear kinetics over the entire 42 day storage period, respectively. Supernatants from RBC units with high levels of free heme led to inflammatory activation of human neutrophils. In conclusion, determining free heme in stored RBCs with the applied apoHRP assay may become feasible for testing of RBC storage quality in clinical transfusion medicine.
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Affiliation(s)
- Vijith Vijayan
- Institute of Transfusion Medicine and Transplant Engineering, Hannover Medical School, Carl-Neuberg-Str. 1, D-30625 Hannover, Germany
| | - Robert Greite
- Department of Nephrology, Hannover Medical School, D-30625 Hannover, Germany
| | - Sebastian Schott
- Department of Nephrology, Hannover Medical School, D-30625 Hannover, Germany
| | - Julian Doricic
- Department of Nephrology, Hannover Medical School, D-30625 Hannover, Germany
| | - Kukuh Madyaningrana
- Institute of Transfusion Medicine and Transplant Engineering, Hannover Medical School, Carl-Neuberg-Str. 1, D-30625 Hannover, Germany.,Faculty of Biotechnology, Universitas Kristen Duta Wacana, 55224 Yogyakarta, Indonesia
| | - Pooja Pradhan
- Institute of Transfusion Medicine and Transplant Engineering, Hannover Medical School, Carl-Neuberg-Str. 1, D-30625 Hannover, Germany
| | - Jörg Martens
- Institute of Transfusion Medicine and Transplant Engineering, Hannover Medical School, Carl-Neuberg-Str. 1, D-30625 Hannover, Germany
| | - Rainer Blasczyk
- Institute of Transfusion Medicine and Transplant Engineering, Hannover Medical School, Carl-Neuberg-Str. 1, D-30625 Hannover, Germany
| | | | - Stephan Immenschuh
- Institute of Transfusion Medicine and Transplant Engineering, Hannover Medical School, Carl-Neuberg-Str. 1, D-30625 Hannover, Germany
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13
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Greite R, Wang L, Gohlke L, Schott S, Kreimann K, Doricic J, Leffler A, Tudorache I, Salman J, Natanov R, Ius F, Fegbeutel C, Haverich A, Lichtinghagen R, Chen R, Rong S, Haller H, Vijayan V, Gram M, Scheffner I, Gueler F, Gwinner W, Immenschuh S. Cell-Free Hemoglobin in Acute Kidney Injury after Lung Transplantation and Experimental Renal Ischemia/Reperfusion. Int J Mol Sci 2022; 23:ijms232113272. [PMID: 36362059 PMCID: PMC9657083 DOI: 10.3390/ijms232113272] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 10/15/2022] [Accepted: 10/18/2022] [Indexed: 11/06/2022] Open
Abstract
Cell-free hemoglobin (CFH), a pro-oxidant and cytotoxic compound that is released in hemolysis, has been associated with nephrotoxicity. Lung transplantation (LuTx) is a clinical condition with a high incidence of acute kidney injury (AKI). In this study, we investigated the plasma levels of CFH and haptoglobin, a CFH-binding serum protein, in prospectively enrolled LuTx patients (n = 20) with and without AKI. LuTx patients with postoperative AKI had higher CFH plasma levels at the end of surgery compared with no-AKI patients, and CFH correlated with serum creatinine at 48 h. Moreover, CFH levels inversely correlated with haptoglobin levels, which were significantly reduced at the end of surgery in LuTx patients with AKI. Because multiple other factors can contribute to AKI development in the complex clinical setting of LuTx, we next investigated the role of exogenous CFH administration in a mouse model of mild bilateral renal ischemia reperfusion injury (IRI). Exogenous administration of CFH after reperfusion caused overt AKI with creatinine increase, tubular injury, and enhanced markers of renal inflammation compared with vehicle-treated animals. In conclusion, CFH is a possible factor contributing to postoperative AKI after LuTx and promotes AKI in an experimental model of mild transient renal ischemia. Targeting CFH might be a therapeutic option to prevent AKI after LuTx.
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Affiliation(s)
- Robert Greite
- Department of Nephrology and Hypertension, Hannover Medical School, 30625 Hannover, Germany
- Correspondence:
| | - Li Wang
- Department of Nephrology and Hypertension, Hannover Medical School, 30625 Hannover, Germany
| | - Lukas Gohlke
- Department of Nephrology and Hypertension, Hannover Medical School, 30625 Hannover, Germany
| | - Sebastian Schott
- Department of Nephrology and Hypertension, Hannover Medical School, 30625 Hannover, Germany
| | - Kirill Kreimann
- Department of Nephrology and Hypertension, Hannover Medical School, 30625 Hannover, Germany
| | - Julian Doricic
- Department of Nephrology and Hypertension, Hannover Medical School, 30625 Hannover, Germany
| | - Andreas Leffler
- Anaesthesiology, Hannover Medical School, 30625 Hannover, Germany
| | - Igor Tudorache
- Cardiac Surgery, University of Dusseldorf, 40225 Dusseldorf, Germany
| | - Jawad Salman
- Cardiac Surgery, Hannover Medical School, 30625 Hannover, Germany
| | - Ruslan Natanov
- Cardiac Surgery, Hannover Medical School, 30625 Hannover, Germany
| | - Fabio Ius
- Cardiac Surgery, Hannover Medical School, 30625 Hannover, Germany
- German Center for Lung Research (DZL), 35392 Giessen, Germany
| | | | - Axel Haverich
- Cardiac Surgery, Hannover Medical School, 30625 Hannover, Germany
| | | | - Rongjun Chen
- Department of Nephrology and Hypertension, Hannover Medical School, 30625 Hannover, Germany
| | - Song Rong
- Department of Nephrology and Hypertension, Hannover Medical School, 30625 Hannover, Germany
| | - Hermann Haller
- Department of Nephrology and Hypertension, Hannover Medical School, 30625 Hannover, Germany
| | - Vijith Vijayan
- Pediatrics, Stanford University, Stanford, CA 94305, USA
| | - Magnus Gram
- Department of Pediatrics, Clinical Sciences Lund, Lund University, 22220 Lund, Sweden
| | - Irina Scheffner
- Department of Nephrology and Hypertension, Hannover Medical School, 30625 Hannover, Germany
| | - Faikah Gueler
- Department of Nephrology and Hypertension, Hannover Medical School, 30625 Hannover, Germany
| | - Wilfried Gwinner
- Department of Nephrology and Hypertension, Hannover Medical School, 30625 Hannover, Germany
| | - Stephan Immenschuh
- Institute of Transfusion Medicine and Transplant Engineering, Hannover Medical School, 30625 Hannover, Germany
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14
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The Toxic Influence of Excess Free Iron on Red Blood Cells in the Biophysical Experiment: An In Vitro Study. J Toxicol 2022; 2022:7113958. [PMID: 35256882 PMCID: PMC8898121 DOI: 10.1155/2022/7113958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 01/10/2022] [Indexed: 11/18/2022] Open
Abstract
Iron is needed for life-essential processes, but free iron overload causes dangerous clinical consequences. The study of the role of red blood cells (RBCs) in the influence of excess free iron in the blood on the pathological consequences in an organism is relevant. Here, in a direct biophysical experiment in vitro, we studied the action of free iron overload on the packed red blood cell (pRBC) characteristics. In experiments, we incubated pRBCs with the ferrous sulfate solution (Fe2+). Wе used free iron in a wide range of concentrations. High Fe2+ concentrations made us possible to establish the pattern of the toxic effect of excess iron on pRBCs during a reduced incubation time in a biophysical experiment in vitro. It was found that excess free iron causes changes in pRBC morphology, the appearance of bridges between cells, and the formation of clots, increasing the membrane stiffness and methemoglobin concentration. We created a kinetic model of changes in the hemoglobin derivatives. The complex of simultaneous distortions of pRBCs established in our experiments can be taken into account when studying the mechanism of the toxic influence of excess free iron in the blood on pathological changes in an organism.
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15
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Biomarkers Predicting Tissue Pharmacokinetics of Antimicrobials in Sepsis: A Review. Clin Pharmacokinet 2022; 61:593-617. [PMID: 35218003 PMCID: PMC9095522 DOI: 10.1007/s40262-021-01102-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2021] [Indexed: 02/07/2023]
Abstract
The pathophysiology of sepsis alters drug pharmacokinetics, resulting in inadequate drug exposure and target-site concentration. Suboptimal exposure leads to treatment failure and the development of antimicrobial resistance. Therefore, we seek to optimize antimicrobial therapy in sepsis by selecting the right drug and the correct dosage. A prerequisite for achieving this goal is characterization and understanding of the mechanisms of pharmacokinetic alterations. However, most infections take place not in blood but in different body compartments. Since tissue pharmacokinetic assessment is not feasible in daily practice, we need to tailor antibiotic treatment according to the specific patient’s pathophysiological processes. The complex pathophysiology of sepsis and the ineffectiveness of current targeted therapies suggest that treatments guided by biomarkers predicting target-site concentration could provide a new therapeutic strategy. Inflammation, endothelial and coagulation activation markers, and blood flow parameters might be indicators of impaired tissue distribution. Moreover, hepatic and renal dysfunction biomarkers can predict not only drug metabolism and clearance but also drug distribution. Identification of the right biomarkers can direct drug dosing and provide timely feedback on its effectiveness. Therefore, this might decrease antibiotic resistance and the mortality of critically ill patients. This article fills the literature gap by characterizing patient biomarkers that might be used to predict unbound plasma-to-tissue drug distribution in critically ill patients. Although all biomarkers must be clinically evaluated with the ultimate goal of combining them in a clinically feasible scoring system, we support the concept that the appropriate biomarkers could be used to direct targeted antibiotic dosing.
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16
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Graw JA, Hildebrandt P, Krannich A, Balzer F, Spies C, Francis RC, Kuebler WM, Weber-Carstens S, Menk M, Hunsicker O. The role of cell-free hemoglobin and haptoglobin in acute kidney injury in critically ill adults with ARDS and therapy with VV ECMO. Crit Care 2022; 26:50. [PMID: 35193645 PMCID: PMC8864920 DOI: 10.1186/s13054-022-03894-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 01/11/2022] [Indexed: 12/02/2022] Open
Abstract
Background Increased plasma concentrations of circulating cell-free hemoglobin (CFH) are supposed to contribute to the multifactorial etiology of acute kidney injury (AKI) in critically ill patients while the CFH-scavenger haptoglobin might play a protective role. We evaluated the association of CFH and haptoglobin with AKI in patients with an acute respiratory distress syndrome (ARDS) requiring therapy with VV ECMO. Methods Patients with CFH and haptoglobin measurements before initiation of ECMO therapy were identified from a cohort of 1044 ARDS patients and grouped into three CFH concentration groups using a risk stratification. The primary objective was to assess the association of CFH and haptoglobin with KDIGO stage 3 AKI. Further objectives included the identification of a target haptoglobin concentration to protect from CFH-associated AKI. Measurements and main results Two hundred seventy-three patients fulfilled the inclusion criteria. Of those, 154 patients (56.4%) had AKI at ECMO initiation. The incidence of AKI increased stepwise with increasing concentrations of CFH reaching a plateau at 15 mg/dl. Compared to patients with low [< 5 mg/dl] CFH concentrations, patients with moderate [5–14 mg/dl] and high [≥ 15 mg/dl] CFH concentrations had a three- and five-fold increased risk for AKI (adjusted odds ratio [OR] moderate vs. low, 2.69 [95% CI, 1.25–5.95], P = 0.012; and OR high vs. low, 5.47 [2.00–15.9], P = 0.001). Among patients with increased CFH concentrations, haptoglobin plasma levels were lower in patients with AKI compared to patients without AKI. A haptoglobin concentration greater than 2.7 g/l in the moderate and 2.4 g/l in the high CFH group was identified as clinical cutoff value to protect from CFH-associated AKI (sensitivity 89.5% [95% CI, 83–96] and 90.2% [80–97], respectively). Conclusions In critically ill patients with ARDS requiring therapy with VV ECMO, an increased plasma concentration of CFH was identified as independent risk factor for AKI. Among patients with increased CFH concentrations, higher plasma haptoglobin concentrations might protect from CFH-associated AKI and should be subject of future research. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-03894-5.
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17
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Su WL, Chan CY, Cheng CF, Shui HA, Ku HC. Erythrocyte degradation, metabolism, secretion, and communication with immune cells in the blood during sepsis: A review. Tzu Chi Med J 2022; 34:125-133. [PMID: 35465286 PMCID: PMC9020243 DOI: 10.4103/tcmj.tcmj_58_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 04/22/2021] [Accepted: 05/26/2021] [Indexed: 11/04/2022] Open
Abstract
Sepsis is a health issue that affects millions of people worldwide. It was assumed that erythrocytes were affected by sepsis. However, in recent years, a number of studies have shown that erythrocytes affect sepsis as well. When a pathogen invades the human body, it infects the blood and organs, causing infection and sepsis-related symptoms. Pathogens change the internal environment, increasing the levels of reactive oxygen species, influencing erythrocyte morphology, and causing erythrocyte death, i.e., eryptosis. Characteristics of eryptosis include cell shrinkage, membrane blebbing, and surface exposure of phosphatidylserine (PS). Eryptotic erythrocytes increase immune cell proliferation, and through PS, attract macrophages that remove the infected erythrocytes. Erythrocyte-degraded hemoglobin derivatives and heme deteriorate infection; however, they could also be metabolized to a series of derivatives. The result that erythrocytes play an anti-infection role during sepsis provides new perspectives for treatment. This review focuses on erythrocytes during pathogenic infection and sepsis.
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18
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Hu J, Rezoagli E, Zadek F, Bittner EA, Lei C, Berra L. Free Hemoglobin Ratio as a Novel Biomarker of Acute Kidney Injury After On-Pump Cardiac Surgery: Secondary Analysis of a Randomized Controlled Trial. Anesth Analg 2021; 132:1548-1558. [PMID: 33481401 DOI: 10.1213/ane.0000000000005381] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Cardiac surgery with cardiopulmonary bypass (CPB) is associated with a high risk of postoperative acute kidney injury (AKI). Due to limitations of current diagnostic strategies, we sought to determine whether free hemoglobin (fHb) ratio (ie, levels of fHb at the end of CPB divided by baseline fHb) could predict AKI after on-pump cardiac surgery. METHODS This is a secondary analysis of a randomized controlled trial comparing the effect of nitric oxide (intervention) versus nitrogen (control) on AKI after cardiac surgery (NCT01802619). A total of 110 adult patients in the control arm were included. First, we determined whether fHb ratio was associated with AKI via multivariable analysis. Second, we verified whether fHb ratio could predict AKI and incorporation of fHb ratio could improve predictive performance at an early stage, compared with prediction using urinary biomarkers alone. We conducted restricted cubic spline in logistic regression for model development. We determined the predictive performance, including area under the receiver-operating-characteristics curve (AUC) and calibration (calibration plot and accuracy, ie, number of correct predictions divided by total number of predictions). We also used AUC test, likelihood ratio test, and net reclassification index (NRI) to compare the predictive performance between competing models (ie, fHb ratio versus neutrophil gelatinase-associated lipocalin [NGAL], N-acetyl-β-d-glucosaminidase [NAG], and kidney injury molecule-1 [KIM-1], respectively, and incorporation of fHb ratio with NGAL, NAG, and KIM-1 versus urinary biomarkers alone), if applicable. RESULTS Data stratified by median fHb ratio showed that subjects with an fHb ratio >2.23 presented higher incidence of AKI (80.0% vs 49.1%; P = .001), more need of renal replacement therapy (10.9% vs 0%; P = .036), and higher in-hospital mortality (10.9% vs 0%; P = .036) than subjects with an fHb ratio ≤2.23. fHb ratio was associated with AKI after adjustment for preestablished factors. fHb ratio outperformed urinary biomarkers with the highest AUC of 0.704 (95% confidence interval [CI], 0.592-0.804) and accuracy of 0.714 (95% CI, 0.579-0.804). Incorporation of fHb ratio achieved better discrimination (AUC test, P = .012), calibration (likelihood ratio test, P < .001; accuracy, 0.740 [95% CI, 0.617-0.832] vs 0.632 [95% CI, 0.477-0.748]), and significant prediction increment (NRI, 0.638; 95% CI, 0.269-1.008; P < .001) at an early stage, compared with prediction using urinary biomarkers alone. CONCLUSIONS Results from this exploratory, hypothesis-generating retrospective, observational study shows that fHb ratio at the end of CPB might be used as a novel, widely applicable biomarker for AKI. The use of fHb ratio might help for an early detection of AKI, compared with prediction based only on urinary biomarkers.
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Affiliation(s)
- Jie Hu
- From the Department of Critical Care Medicine, Chinese PLA General Hospital, Beijing, China.,Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Emanuele Rezoagli
- School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Francesco Zadek
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Edward A Bittner
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Chong Lei
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Lorenzo Berra
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
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19
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Verma T, Majumdar S, Yadav S, Ahmed SM, Umapathy S, Nandi D. Cell-free hemoglobin is a marker of systemic inflammation in mouse models of sepsis: a Raman spectroscopic study. Analyst 2021; 146:4022-4032. [PMID: 34032232 DOI: 10.1039/d1an00066g] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Sepsis is a life-threatening condition caused by heightened host immune responses post infection. Despite intensive research, most of the existing diagnostic methods remain non-specific, labour-intensive, time-consuming or are not sensitive enough for rapid and timely diagnosis of the onset and progression of sepsis. The present work was undertaken to explore the potential of Raman spectroscopy to identify the biomarkers of sepsis in a label-free and minimally invasive manner using different mouse models of inflammation. The sera of BALB/c mice infected with Salmonella Typhimurium reveal extensive hemolysis, as indicated by the Raman bands that are characteristic of the porphyrin ring of hemoglobin (668, 743, 1050, 1253 and 1397 cm-1) which increase in a kinetic manner. These markers are also observed in a lipopolysaccharide-induced endotoxic shock model, but not in a thioglycollate-induced sterile peritonitis model. These data demonstrate that hemolysis is a signature of systemic, but not localised, inflammation. To further validate our observations, sepsis was induced in the nitric oxide synthase 2 (Nos2-/-) deficient strain which is more sensitive to infection. Interestingly, Nos2-/- mice exhibit a higher degree of hemolysis than C57BL/6 mice. Sepsis-induced hemolysis was also confirmed using resonance Raman spectroscopy with 442 nm excitation which demonstrated a pronounced increase in the resonant Raman bands at 670 and 1350 cm-1 in sera of the infected mice. This is the first study to identify inflammation-induced hemolysis in mouse models of sepsis using Raman spectral signatures for hemoglobin. The possible implications of this method in detecting hemolysis in different inflammatory pathologies, such as the ongoing COVID-19 pandemic, are discussed.
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Affiliation(s)
- Taru Verma
- Centre for BioSystems Science and Engineering, Indian Institute of Science, Bangalore, India.
| | - Shamik Majumdar
- Department of Biochemistry, Indian Institute of Science, Bangalore, India
| | - Shikha Yadav
- Department of Biochemistry, Indian Institute of Science, Bangalore, India
| | - Syed Moiz Ahmed
- Department of Biochemistry, Indian Institute of Science, Bangalore, India
| | - Siva Umapathy
- Centre for BioSystems Science and Engineering, Indian Institute of Science, Bangalore, India. and Department of Inorganic and Physical Chemistry, Indian Institute of Science, Bangalore, India
| | - Dipankar Nandi
- Centre for BioSystems Science and Engineering, Indian Institute of Science, Bangalore, India. and Department of Biochemistry, Indian Institute of Science, Bangalore, India
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20
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Wang J, Applefeld WN, Sun J, Solomon SB, Feng J, Couse ZG, Risoleo TF, Danner RL, Tejero J, Lertora J, Alipour E, Basu S, Sachdev V, Kim-Shapiro DB, Gladwin MT, Klein HG, Natanson C. Mechanistic insights into cell-free hemoglobin-induced injury during septic shock. Am J Physiol Heart Circ Physiol 2021; 320:H2385-H2400. [PMID: 33989079 DOI: 10.1152/ajpheart.00092.2021] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Cell-free hemoglobin (CFH) levels are elevated in septic shock and are higher in nonsurvivors. Whether CFH is only a marker of sepsis severity or is involved in pathogenesis is unknown. This study aimed to investigate whether CFH worsens sepsis-associated injuries and to determine potential mechanisms of harm. Fifty-one, 10-12 kg purpose-bred beagles were randomized to receive Staphylococcus aureus intrapulmonary challenges or saline followed by CFH infusions (oxyhemoglobin >80%) or placebo. Animals received antibiotics and intensive care support for 96 h. CFH significantly increased mean pulmonary arterial pressures and right ventricular afterload in both septic and nonseptic animals, effects that were significantly greater in nonsurvivors. These findings are consistent with CFH-associated nitric oxide (NO) scavenging and were associated with significantly depressed cardiac function, and worsened shock, lactate levels, metabolic acidosis, and multiorgan failure. In septic animals only, CFH administration significantly increased mean alveolar-arterial oxygenation gradients, also to a significantly greater degree in nonsurvivors. CFH-associated iron levels were significantly suppressed in infected animals, suggesting that bacterial iron uptake worsened pneumonia. Notably, cytokine levels were similar in survivors and nonsurvivors and were not predictive of outcome. In the absence and presence of infection, CFH infusions resulted in pulmonary hypertension, cardiogenic shock, and multiorgan failure, likely through NO scavenging. In the presence of infection alone, CFH infusions worsened oxygen exchange and lung injury, presumably by supplying iron that promoted bacterial growth. CFH elevation, a known consequence of clinical septic shock, adversely impacts sepsis outcomes through more than one mechanism, and is a biologically plausible, nonantibiotic, noncytokine target for therapeutic intervention.NEW & NOTEWORTHY Cell-free hemoglobin (CFH) elevations are a known consequence of clinical sepsis. Using a two-by-two factorial design and extensive physiological and biochemical evidence, we found a direct mechanism of injury related to nitric oxide scavenging leading to pulmonary hypertension increasing right heart afterload, depressed cardiac function, worsening circulatory failure, and death, as well as an indirect mechanism related to iron toxicity. These discoveries alter conventional thinking about septic shock pathogenesis and provide novel therapeutic approaches.
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Affiliation(s)
- Jeffrey Wang
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Willard N Applefeld
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Junfeng Sun
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Steve B Solomon
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Jing Feng
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Zoe G Couse
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Thomas F Risoleo
- Department of Biomedical Engineering, Tufts University, Medford, Massachusetts
| | - Robert L Danner
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Jesús Tejero
- Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Juan Lertora
- Pennington Biomedical Research Center, Louisiana State University, Baton Rouge, Louisiana
| | - Elmira Alipour
- Department of Physics, Wake Forest University, Winston-Salem, North Carolina
| | - Swati Basu
- Department of Physics, Wake Forest University, Winston-Salem, North Carolina
| | - Vandana Sachdev
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | | | - Mark T Gladwin
- Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Harvey G Klein
- Department of Transfusion Medicine, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Charles Natanson
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
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21
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Praetorius H. The bacteria and the host: a story of purinergic signaling in urinary tract infections. Am J Physiol Cell Physiol 2021; 321:C134-C146. [PMID: 33979212 DOI: 10.1152/ajpcell.00054.2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The local environment forces a selection of bacteria that might invade the urinary tract, allowing only the most virulent to access the kidney. Quite similar to the diet in setting the stage for the gut microbiome, renal function determines the conditions for bacteria-host interaction in the urinary tract. In the kidney, the term local environment or microenvironment is completely justified because the environment literally changes within a few micrometers. The precise composition of the urine is a function of the epithelium lining the microdomain, and the microenvironment in the kidney shows more variation in the content of nutrients, ion composition, osmolality, and pH than any other site of bacteria-host interaction. This review will cover some of the aspects of bacterial-host interaction in this unique setting and how uropathogenic bacteria can alter the condition for bacteria-host interaction. There will be a particular focus on the recent findings regarding how bacteria specifically trigger host paracrine signaling, via release of extracellular ATP and activation of P2 purinergic receptors. These finding will be discussed from the perspective of severe urinary tract infections, including pyelonephritis and urosepsis.
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22
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Schaer CA, Jeger V, Gentinetta T, Spahn DR, Vallelian F, Rudiger A, Schaer DJ. Haptoglobin treatment prevents cell-free hemoglobin exacerbated mortality in experimental rat sepsis. Intensive Care Med Exp 2021; 9:22. [PMID: 33937959 PMCID: PMC8089067 DOI: 10.1186/s40635-021-00387-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 04/13/2021] [Indexed: 12/31/2022] Open
Affiliation(s)
- Christian A Schaer
- Division of Internal Medicine, University and University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.,Institute of Anesthesiology, University and University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Victor Jeger
- Division of Internal Medicine, University and University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.,Institute of Anesthesiology, University and University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | | | - Donat R Spahn
- Institute of Anesthesiology, University and University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Florence Vallelian
- Division of Internal Medicine, University and University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Alain Rudiger
- Department of Medicine, Hospital Limmattal, Urdorferstrasse 100, 8952, Schlieren, Switzerland
| | - Dominik J Schaer
- Division of Internal Medicine, University and University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.
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23
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Heckl C, Lang A, Rühm A, Sroka R, Duffield T, Vogeser M, Paal M. Spectrophotometric evaluation of hemolysis in plasma by quantification of free oxyhemoglobin, methemoglobin, and methemalbumin in presence of bilirubin. JOURNAL OF BIOPHOTONICS 2021; 14:e202000461. [PMID: 33527705 DOI: 10.1002/jbio.202000461] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 01/28/2021] [Accepted: 01/28/2021] [Indexed: 06/12/2023]
Abstract
Severe intravascular hemolysis leads to the simultaneous presence of free heme pigments (oxyhemoglobin, methemoglobin, and methemalbumin) and bilirubin in human plasma. Standard spectrophotometric methods used to assess in vivo hemolysis inadequately address this complex analytical situation. Thus, we propose a novel quantification algorithm to ensure the highest analytical specificity. A corresponding second-derivative fitting algorithm was validated according to the guideline of bioanalytical method validation from the European Medicines Agency using plasma specimens (n = 1759) spiked with different concentrations of oxyhemoglobin and methemoglobin. The results were compared to standard spectrophotometric quantification methods described by Harboe, Noe, and Fairbanks. Based on the second-derivative method, simultaneous quantification of oxyhemoglobin and methemoglobin/methemalbumin in samples with total bilirubin concentrations ≤4.9 mg/dL (83.8 μmol/L) provided robust results (inaccuracy ≤20%, imprecision ≤16%). Analyzing UV/VIS spectra of plasma from patients with confirmed severe intravascular hemolysis evidenced an underestimation of up to 33% for the combined free heme pigment content. The employed second-derivative algorithm allows for automated and highly specific quantification of the free heme pigment content in diluted human plasma, which cannot be realized with standard spectrophotometric evaluation methods. An Excel-based tool readily applicable to clinical datasets accompanies this manuscript.
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Affiliation(s)
- Christian Heckl
- Laser-Forschungslabor, LIFE-Center, University Hospital, LMU Munich, Germany
- Department of Urology, University Hospital, LMU Munich, Germany
| | - Alexander Lang
- Laser-Forschungslabor, LIFE-Center, University Hospital, LMU Munich, Germany
- Department of Urology, University Hospital, LMU Munich, Germany
| | - Adrian Rühm
- Laser-Forschungslabor, LIFE-Center, University Hospital, LMU Munich, Germany
- Department of Urology, University Hospital, LMU Munich, Germany
| | - Ronald Sroka
- Laser-Forschungslabor, LIFE-Center, University Hospital, LMU Munich, Germany
- Department of Urology, University Hospital, LMU Munich, Germany
| | - Thomas Duffield
- Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Germany
| | - Michael Vogeser
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Germany
| | - Michael Paal
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Germany
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24
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Liu Q, Wu J, Zhang X, Wu X, Zhao Y, Ren J. Iron homeostasis and disorders revisited in the sepsis. Free Radic Biol Med 2021; 165:1-13. [PMID: 33486088 DOI: 10.1016/j.freeradbiomed.2021.01.025] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 12/31/2020] [Accepted: 01/11/2021] [Indexed: 12/26/2022]
Abstract
Sepsis is a life-threatening condition caused by a dysregulated host-response to inflammation, although it currently lacks a fully elucidated pathobiology. Iron is a crucial trace element that is essential for fundamental processes in both humans and bacteria. During sepsis, iron metabolism is altered, including increased iron transport and uptake into cells and decreased iron export. The intracellular sequestration of iron limits its availability to circulating pathogens, which serves as a conservative strategy against the pathogens. Although iron retention has been showed to have protective protect effects, an increase in labile iron may cause oxidative injury and cell death (e.g., pyroptosis, ferroptosis) as the condition progresses. Moreover, iron disorders are substantial and correlate with the severity of sepsis. This also suggests that iron may be useful as a diagnostic marker for evaluating the severity and predicting the outcome of the disease. Further knowledge about these disorders could help in evaluating how drugs targeting iron homeostasis can be optimally applied to improve the treatment of patients with sepsis. Here, we present a comprehensive review of recent advances in the understanding of iron metabolism, focusing on the regulatory mechanisms and iron-mediated injury in sepsis.
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Affiliation(s)
- Qinjie Liu
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, PR China.
| | - Jie Wu
- Department of General Surgery, BenQ Medical Center, The Affiliated BenQ Hospital of Nanjing Medical University, Nanjing, 210002, PR China.
| | - Xufei Zhang
- Research Institute of General Surgery, Jinling Hospital, Nanjing Medical University, Nanjing, 210002, PR China.
| | - Xiuwen Wu
- Research Institute of General Surgery, Jinling Hospital, Nanjing, 210002, PR China.
| | - Yun Zhao
- Department of General Surgery, BenQ Medical Center, The Affiliated BenQ Hospital of Nanjing Medical University, Nanjing, 210002, PR China.
| | - Jianan Ren
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, PR China; Department of General Surgery, BenQ Medical Center, The Affiliated BenQ Hospital of Nanjing Medical University, Nanjing, 210002, PR China; Research Institute of General Surgery, Jinling Hospital, Nanjing Medical University, Nanjing, 210002, PR China.
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25
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Heckl C, Eisel M, Lang A, Homann C, Paal M, Vogeser M, Rühm A, Sroka R. Spectroscopic methods to quantify molecules of the heme‐biosynthesis pathway: A review of laboratory work and point‐of‐care approaches. TRANSLATIONAL BIOPHOTONICS 2021. [DOI: 10.1002/tbio.202000026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Affiliation(s)
- Christian Heckl
- Laser‐Forschungslabor, LIFE Center, Department of Urology University Hospital, LMU Munich Munich Germany
- Department of Urology University Hospital, LMU Munich Munich Germany
| | - Maximilian Eisel
- Laser‐Forschungslabor, LIFE Center, Department of Urology University Hospital, LMU Munich Munich Germany
- Department of Urology University Hospital, LMU Munich Munich Germany
| | - Alexander Lang
- Laser‐Forschungslabor, LIFE Center, Department of Urology University Hospital, LMU Munich Munich Germany
- Department of Urology University Hospital, LMU Munich Munich Germany
| | - Christian Homann
- Laser‐Forschungslabor, LIFE Center, Department of Urology University Hospital, LMU Munich Munich Germany
- Department of Urology University Hospital, LMU Munich Munich Germany
| | - Michael Paal
- Institute of Laboratory Medicine University Hospital, LMU Munich Munich Germany
| | - Michael Vogeser
- Institute of Laboratory Medicine University Hospital, LMU Munich Munich Germany
| | - Adrian Rühm
- Laser‐Forschungslabor, LIFE Center, Department of Urology University Hospital, LMU Munich Munich Germany
- Department of Urology University Hospital, LMU Munich Munich Germany
| | - Ronald Sroka
- Laser‐Forschungslabor, LIFE Center, Department of Urology University Hospital, LMU Munich Munich Germany
- Department of Urology University Hospital, LMU Munich Munich Germany
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26
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Gbotosho OT, Kapetanaki MG, Kato GJ. The Worst Things in Life are Free: The Role of Free Heme in Sickle Cell Disease. Front Immunol 2021; 11:561917. [PMID: 33584641 PMCID: PMC7873693 DOI: 10.3389/fimmu.2020.561917] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 12/04/2020] [Indexed: 12/15/2022] Open
Abstract
Hemolysis is a pathological feature of several diseases of diverse etiology such as hereditary anemias, malaria, and sepsis. A major complication of hemolysis involves the release of large quantities of hemoglobin into the blood circulation and the subsequent generation of harmful metabolites like labile heme. Protective mechanisms like haptoglobin-hemoglobin and hemopexin-heme binding, and heme oxygenase-1 enzymatic degradation of heme limit the toxicity of the hemolysis-related molecules. The capacity of these protective systems is exceeded in hemolytic diseases, resulting in high residual levels of hemolysis products in the circulation, which pose a great oxidative and proinflammatory risk. Sickle cell disease (SCD) features a prominent hemolytic anemia which impacts the phenotypic variability and disease severity. Not only is circulating heme a potent oxidative molecule, but it can act as an erythrocytic danger-associated molecular pattern (eDAMP) molecule which contributes to a proinflammatory state, promoting sickle complications such as vaso-occlusion and acute lung injury. Exposure to extracellular heme in SCD can also augment the expression of placental growth factor (PlGF) and interleukin-6 (IL-6), with important consequences to enthothelin-1 (ET-1) secretion and pulmonary hypertension, and potentially the development of renal and cardiac dysfunction. This review focuses on heme-induced mechanisms that are implicated in disease pathways, mainly in SCD. A special emphasis is given to heme-induced PlGF and IL-6 related mechanisms and their role in SCD disease progression.
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Affiliation(s)
- Oluwabukola T. Gbotosho
- Division of Hematology-Oncology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Maria G. Kapetanaki
- Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Gregory J. Kato
- Division of Hematology-Oncology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
- Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
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27
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Materne LA, Hunsicker O, Menk M, Graw JA. Hemolysis in patients with Extracorporeal Membrane Oxygenation therapy for severe Acute Respiratory Distress Syndrome - a systematic review of the literature. Int J Med Sci 2021; 18:1730-1738. [PMID: 33746589 PMCID: PMC7976579 DOI: 10.7150/ijms.50217] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 12/19/2020] [Indexed: 12/18/2022] Open
Abstract
The Acute Respiratory Distress Syndrome (ARDS) is common in patients on the Intensive Care Unit and associated with significant mortality rates. In situations of severe respiratory insufficiency and failure of all possible conservative therapeutic approaches, veno-venous extracorporeal membrane oxygenation (VV ECMO) is used as a final option for temporary replacement of pulmonary function. ARDS as well as sepsis and VV ECMO treatment are all associated with intravascular hemolysis. The extent and relevance of intravascular hemolysis in the context of ARDS therapy is unclear. This systematic review aims to summarize the current evidence on the incidence and associated complications of intravascular hemolysis in adult patients with ARDS and treatment with VV ECMO. The databases MEDLINE, EMBASE and Web of Science were systematically searched and 19 publications fulfilled inclusion criteria. The incidence of hemolysis in patients with ARDS and treatment with VV ECMO ranged from 0 to 41% with survivors showing lower incidences and less severe hemolysis. A pump head thrombosis and high blood flows (≥3 l/min) as well as use of dual-lumen cannulas but not different pump models were associated with increased hemolysis. In conclusion, intravascular hemolysis in patients with ARDS and treatment with VV ECMO is a common and relevant complication that appears associated with increased mortality. Apart from ECMO hardware-settings, no additional possible causes for increased red cell breakdown such as disease severity, duration of ECMO therapy, or number and quality of red blood cell transfusions were investigated. Further research is needed to determine the origin and relevance of intravascular hemolysis in patients with ARDS and treatment with VV ECMO.
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Affiliation(s)
- Lorenz A Materne
- Department of Anesthesiology and Operative Intensive Care Medicine CCM/CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health
| | - Oliver Hunsicker
- Department of Anesthesiology and Operative Intensive Care Medicine CCM/CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health.,ARDS/ECMO Centrum Charité, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Mario Menk
- Department of Anesthesiology and Operative Intensive Care Medicine CCM/CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health.,ARDS/ECMO Centrum Charité, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
| | - Jan A Graw
- Department of Anesthesiology and Operative Intensive Care Medicine CCM/CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health.,ARDS/ECMO Centrum Charité, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
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28
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In vitro hemocompatibility testing of medical devices. Thromb Res 2020; 195:146-150. [DOI: 10.1016/j.thromres.2020.07.027] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 06/18/2020] [Accepted: 07/10/2020] [Indexed: 12/14/2022]
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29
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Elevated plasma hemoglobin in COVID-19-related illnesses: a critical appraisal. Ann Hematol 2020; 100:2125-2126. [PMID: 32974839 PMCID: PMC7515552 DOI: 10.1007/s00277-020-04281-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 09/21/2020] [Indexed: 11/25/2022]
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30
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Gbotosho OT, Kapetanaki MG, Ghosh S, Villanueva FS, Ofori-Acquah SF, Kato GJ. Heme Induces IL-6 and Cardiac Hypertrophy Genes Transcripts in Sickle Cell Mice. Front Immunol 2020; 11:1910. [PMID: 32973791 PMCID: PMC7473032 DOI: 10.3389/fimmu.2020.01910] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 07/16/2020] [Indexed: 12/11/2022] Open
Abstract
Emerging data indicate that free heme promotes inflammation in many different disease settings, including in sickle cell disease (SCD). Although free heme, proinflammatory cytokines, and cardiac hypertrophy are co-existing features of SCD, no mechanistic links between these features have been demonstrated. We now report significantly higher levels of IL-6 mRNA and protein in hearts of the Townes sickle cell disease (SS) mice (2.9-fold, p ≤ 0.05) than control mice expressing normal human hemoglobin (AA). We find that experimental administration of heme 50 μmoles/kg body weight induces IL-6 expression directly in vivo and induces gene expression markers of cardiac hypertrophy in SS mice. We administered heme intravenously and found that within three hours plasma IL-6 protein significantly increased in SS mice compared to AA mice (3248 ± 275 vs. 2384 ± 255 pg/ml, p ≤ 0.05). In the heart, heme induced a 15-fold increase in IL-6 transcript in SS mice heart compared to controls. Heme simultaneously induced other markers of cardiac stress and hypertrophy, including atrial natriuretic factor (Nppa; 14-fold, p ≤ 0.05) and beta myosin heavy chain (Myh7; 8-fold, p ≤ 0.05) in SS mice. Our experiments in Nrf2-deficient mice indicate that the cardiac IL-6 response to heme does not require Nrf2, the usual mediator of transcriptional response to heme for heme detoxification by heme oxygenase-1. These data are the first to show heme-induced IL-6 expression in vivo, suggesting that hemolysis may play a role in the elevated IL-6 and cardiac hypertrophy seen in patients and mice with SCD. Our results align with published evidence from rodents and humans without SCD that suggest a causal relationship between IL-6 and cardiac hypertrophy.
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Affiliation(s)
- Oluwabukola T Gbotosho
- Division of Hematology-Oncology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States.,Department of Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Maria G Kapetanaki
- Department of Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States.,Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Samit Ghosh
- Division of Hematology-Oncology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States.,Department of Medicine, Center for Translational and International Hematology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Flordeliza S Villanueva
- Center for Ultrasound Molecular Imaging and Therapeutics, Heart and Vascular Institute, Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA, United States
| | - Solomon F Ofori-Acquah
- Division of Hematology-Oncology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States.,Department of Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States.,Department of Medicine, Center for Translational and International Hematology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States.,School of Biomedical and Allied Health Sciences, University of Ghana, Accra, Ghana
| | - Gregory J Kato
- Division of Hematology-Oncology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States.,Department of Medicine, Pittsburgh Heart, Lung, Blood, and Vascular Medicine Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
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31
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Temboot P, Kaewpaiboon S, Tinpun K, Nakpeng T, Khalil R, Ul-Haq Z, Thamlikitkul V, Tiengrim S, Srichana T. Potential of sodium deoxycholate sulfate as a carrier for polymyxin B: Physicochemical properties, bioactivity and in vitro safety. J Drug Deliv Sci Technol 2020. [DOI: 10.1016/j.jddst.2020.101779] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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32
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Patil AS, Ranganath V, Kumar CN, Naik R, John AA, Pharande SB. Evaluation of salivary biomarkers of periodontitis among smokers and nonsmokers: A novel study. J Family Med Prim Care 2020; 9:1136-1142. [PMID: 32318481 PMCID: PMC7113967 DOI: 10.4103/jfmpc.jfmpc_937_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 12/30/2019] [Accepted: 01/21/2020] [Indexed: 01/15/2023] Open
Abstract
Background: The analysis of salivary enzymes contributes to the clarification of pathogenesis and improvement in the diagnosis of periodontal disease. The present study aimed to examine the prospective association between smoking and periodontal disease progression and the effects of smoking on the following salivary biomarkers related to periodontitis: Alkaline phosphatase (ALP), acid phosphatase (ACP), aspartate aminotransferase (AST), alanine aminotransferase (ALT), lactate dehydrogenase (LDH), creatinine (CRE), blood urea nitrogen (BUN), urea (UA), free-hemoglobin (f-Hb), and neopterin. Materials and Methods: A total of 64 male patients aged 21–60 years were recruited and grouped as Group 1: 16 healthy nonsmokers, who had never smoked. Group 2: 16 smokers with gingivitis. Group 3: 16 smokers with moderate periodontitis. Group 4: 16 smokers with severe periodontitis. Stimulated saliva was collected for at least 5 min and clinical measurements; salivary biomarkers were assessed in automated analyzer. Results: Data showed significant correlation among salivary ACP, AST, LDH, CRE, BUN, UA, and f-Hb and neopterin levels showed higher in group 4 compared with other groups. Conclusion: This study indicated that smoking has several detrimental effects on periodontal tissues. A higher level of salivary biomarkers was seen in smokers with severe periodontitis. Hence, these biomarkers are helpful in future for the earlier detection of periodontal diseases progression and can also be used as potential salivary biomarkers for assessing smoking status and severity in chronic periodontitis.
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Affiliation(s)
| | - V Ranganath
- Department of Periodontology, AECS Maaruti Dental College and Hospital, Bengaluru, Karnataka, India
| | - C Naresh Kumar
- Department of Periodontology, Vishnu Dental College, Bhimavaram, Andhra Pradesh, India
| | - Rajesh Naik
- Periodontist at Fresh Breath Dental Clinic, Bengaluru, Karnataka, India
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33
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Buehler PW, Humar R, Schaer DJ. Haptoglobin Therapeutics and Compartmentalization of Cell-Free Hemoglobin Toxicity. Trends Mol Med 2020; 26:683-697. [PMID: 32589936 DOI: 10.1016/j.molmed.2020.02.004] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 02/17/2020] [Accepted: 02/18/2020] [Indexed: 02/06/2023]
Abstract
Hemolysis and accumulation of cell-free hemoglobin (Hb) in the circulation or in confined tissue compartments such as the subarachnoid space is an important driver of disease. Haptoglobin is the Hb binding and clearance protein in human plasma and an efficient antagonist of Hb toxicity resulting from physiological red blood cell turnover. However, endogenous concentrations of haptoglobin are insufficient to provide protection against Hb-driven disease processes in conditions such as sickle cell anemia, sepsis, transfusion reactions, medical-device associated hemolysis, or after a subarachnoid hemorrhage. As a result, there is increasing interest in developing haptoglobin therapeutics to target 'toxic' cell-free Hb exposures. Here, we discuss key concepts of Hb toxicity and provide a perspective on the use of haptoglobin as a therapeutic protein.
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Affiliation(s)
- Paul W Buehler
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, USA; Center for Blood Oxygen Transport and Hemostasis, Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Rok Humar
- Division of Internal Medicine, University Hospital, Zurich, Switzerland
| | - Dominik J Schaer
- Division of Internal Medicine, University Hospital, Zurich, Switzerland.
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Applefeld WN, Wang J, Solomon SB, Sun J, Klein HG, Natanson C. RBC Storage Lesion Studies in Humans and Experimental Models of Shock. APPLIED SCIENCES (BASEL, SWITZERLAND) 2020; 10:1838. [PMID: 38362479 PMCID: PMC10868675 DOI: 10.3390/app10051838] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
The finding of toxicity in a meta-analysis of observational clinical studies of transfused longer stored red blood cells (RBC) and ethical issues surrounding aging blood for human studies prompted us to develop an experimental model of RBC transfusion. Transfusing older RBCs during canine pneumonia increased mortality rates. Toxicity was associated with in vivo hemolysis with release of cell-free hemoglobin (CFH) and iron. CFH can scavenge nitric oxide, causing vasoconstriction and endothelial injury. Iron, an essential bacterial nutrient, can worsen infections. This toxicity was seen at commonly transfused blood volumes (2 units) and was altered by the severity of pneumonia. Washing longer-stored RBCs mitigated these detrimental effects, but washing fresh RBCs actually increased them. In contrast to septic shock, transfused longer stored RBCs proved beneficial in hemorrhagic shock by decreasing reperfusion injury. Intravenous iron was equivalent in toxicity to transfusion of longer stored RBCs and both should be avoided during infection. Storage of longer-stored RBCs at 2 °C instead of higher standard temperatures (4-6 °C) minimized the release of CFH and iron. Haptoglobin, a plasma protein that binds CFH and increases its clearance, minimizes the toxic effects of longer-stored RBCs during infection and is a biologically plausible novel approach to treat septic shock.
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Affiliation(s)
- Willard N. Applefeld
- Critical Care Medicine Department, National Institutes of Health, Bethesda, MD 20892-1662, USA
| | - Jeffrey Wang
- Critical Care Medicine Department, National Institutes of Health, Bethesda, MD 20892-1662, USA
| | - Steven B. Solomon
- Critical Care Medicine Department, National Institutes of Health, Bethesda, MD 20892-1662, USA
| | - Junfeng Sun
- Critical Care Medicine Department, National Institutes of Health, Bethesda, MD 20892-1662, USA
| | - Harvey G. Klein
- Department of Transfusion Medicine, National Institutes of Health, Bethesda, MD 20892-1184, USA
| | - Charles Natanson
- Critical Care Medicine Department, National Institutes of Health, Bethesda, MD 20892-1662, USA
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Abstract
Sepsis is a heterogeneous clinical syndrome that is complicated commonly by acute kidney injury (sepsis-AKI). Currently, no approved pharmacologic therapies exist to either prevent sepsis-AKI or to treat sepsis-AKI once it occurs. A growing body of evidence supports a connection between red blood cell biology and sepsis-AKI. Increased levels of circulating cell-free hemoglobin (CFH) released from red blood cells during hemolysis are common during sepsis and can contribute to sepsis-AKI through several mechanisms including tubular obstruction, nitric oxide depletion, oxidative injury, and proinflammatory signaling. A number of potential pharmacologic therapies targeting CFH in sepsis have been identified including haptoglobin, hemopexin, and acetaminophen, and early phase clinical trials have suggested that acetaminophen may have beneficial effects on lipid peroxidation and kidney function in patients with sepsis. Bedside measurement of CFH levels may facilitate predictive enrichment for future clinical trials of CFH-targeted therapeutics. However, rapid and reliable bedside tests for plasma CFH will be required for such trials to move forward.
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Affiliation(s)
- V Eric Kerchberger
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
| | - Lorraine B Ware
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville TN.
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The Interplay between Molten Globules and Heme Disassociation Defines Human Hemoglobin Disassembly. Biophys J 2020; 118:1381-1400. [PMID: 32075750 DOI: 10.1016/j.bpj.2020.01.031] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 01/22/2020] [Accepted: 01/27/2020] [Indexed: 12/12/2022] Open
Abstract
Hemoglobin functions as a tetrameric oxygen transport protein, with each subunit containing a heme cofactor. Its denaturation, either in vivo or in vitro, involves autoxidation to methemoglobin, followed by cofactor loss and globin unfolding. We have proposed a global disassembly scheme for human methemoglobin, linking hemin (ferric protoporphyrin IX) disassociation and apoprotein unfolding pathways. The model is based on the evaluation of circular dichroism and visible absorbance measurements of guanidine-hydrochloride-induced disassembly of methemoglobin and previous measurements of apohemoglobin unfolding. The populations of holointermediates and equilibrium disassembly parameters were estimated quantitatively for adult and fetal hemoglobins. The key stages are characterized by hexacoordinated hemichrome intermediates, which are important for preventing hemin disassociation from partially unfolded, molten globular species during early disassembly and late-stage assembly events. Both unfolding experiments and independent small angle x-ray scattering measurements demonstrate that heme disassociation leads to the loss of tetrameric structural integrity. Our model predicts that after autoxidation, dimeric and monomeric hemichrome intermediates occur along the disassembly pathway inside red cells, where the hemoglobin concentration is very high. This prediction suggests why misassembled hemoglobins often get trapped as hemichromes that accumulate into insoluble Heinz bodies in the red cells of patients with unstable hemoglobinopathies. These Heinz bodies become deposited on the cell membranes and can lead to hemolysis. Alternatively, when acellular hemoglobin is diluted into blood plasma after red cell lysis, the disassembly pathway appears to be dominated by early hemin disassociation events, which leads to the generation of higher fractions of unfolded apo subunits and free hemin, which are known to damage the integrity of blood vessel walls. Thus, our model provides explanations of the pathophysiology of hemoglobinopathies and other disease states associated with unstable globins and red cell lysis and also insights into the factors governing hemoglobin assembly during erythropoiesis.
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Remy KE, Cortés-Puch I, Sun J, Feng J, Lertora JJ, Risoleo T, Katz J, Basu S, Liu X, Perlegas A, Kim-Shapiro DB, Klein HG, Natanson C, Solomon SB. Haptoglobin therapy has differential effects depending on severity of canine septic shock and cell-free hemoglobin level. Transfusion 2019; 59:3628-3638. [PMID: 31639229 PMCID: PMC8216248 DOI: 10.1111/trf.15567] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 09/12/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND During sepsis, higher plasma cell-free hemoglobin (CFH) levels portend worse outcomes. In sepsis models, plasma proteins that bind CFH improve survival. In our canine antibiotic-treated Staphylococcus aureus pneumonia model, with and without red blood cell (RBC) exchange transfusion, commercial human haptoglobin (Hp) concentrates bound and compartmentalized CFH intravascularly, increased CFH clearance, and lowered iron levels, improving shock, lung injury, and survival. We now investigate in our model how very high CFH levels and treatment time affect Hp's beneficial effects. MATERIALS AND METHODS Two separate canine pneumonia sepsis Hp studies were undertaken: one with exchange transfusion of RBCs after prolonged storage to raise CFH to very high levels and another with rapidly lethal sepsis alone to shorten time to treat. All animals received continuous standard intensive care unit supportive care for 96 hours. RESULTS Older RBCs markedly elevated plasma CFH levels and, when combined with Hp therapy, created supraphysiologic CFH-Hp complexes that did not increase CFH or iron clearance or improve lung injury and survival. In a rapidly lethal bacterial challenge model without RBC transfusion, Hp binding did not increase clearance of complexes or iron or show benefits seen previously in the less lethal model. DISCUSSION High-level CFH-Hp complexes may impair clearance mechanisms and eliminate Hp's beneficial effect during sepsis. Rapidly lethal sepsis narrows the therapeutic window for CFH and iron clearance, also decreasing Hp's beneficial effects. In designing clinical trials, dosing and kinetics may be critical factors if Hp infusion is used to treat sepsis.
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Affiliation(s)
- Kenneth E. Remy
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland;,Department of Pediatrics, Division of Critical Care, Washington University in St. Louis, St. Louis, Missouri
| | - Irene Cortés-Puch
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland;,Division of Pulmonary, Critical Care and Sleep Medicine, University of California Davis, Sacramento, California
| | - Junfeng Sun
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Jing Feng
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Juan J. Lertora
- Pennington Biomedical Research Center, Louisiana State University, Baton Rouge, Louisiana
| | - Thomas Risoleo
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Julia Katz
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Swati Basu
- Department of Biochemistry, Wake Forest University Health Sciences, Winston-Salem, North Carolina
| | - Xiaohua Liu
- Department of Physics, Wake Forest University, Winston-Salem, North Carolina
| | - Andreas Perlegas
- Department of Physics, Wake Forest University, Winston-Salem, North Carolina
| | | | - Harvey G. Klein
- Department of Transfusion Medicine, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Charles Natanson
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
| | - Steven B. Solomon
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland
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38
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The emerging role of red blood cells in cytokine signalling and modulating immune cells. Blood Rev 2019; 41:100644. [PMID: 31812320 DOI: 10.1016/j.blre.2019.100644] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 11/13/2019] [Accepted: 11/22/2019] [Indexed: 02/07/2023]
Abstract
For many years red blood cells have been described as inert bystanders rather than participants in intercellular signalling, immune function, and inflammatory processes. However, studies are now reporting that red blood cells from healthy individuals regulate immune cell activity and maturation, and red blood cells from disease cohorts are dysfunctional. These cells have now been shown to bind more than 50 cytokines and have been described as a sink for these molecules, and the loss of this activity has been correlated with disease progression. In this review, we summarise what is currently understood about the role of red blood cells in cytokine signalling and in modulating the activity of immune cells. We also discuss the implications of these findings for transfusion medicine and in furthering our understanding of anaemia of chronic inflammation. By bringing these disparate units of work together, we aim to shine a light on an area that requires significantly more investigation.
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Kerchberger VE, Bastarache JA, Shaver CM, Nagata H, McNeil JB, Landstreet SR, Putz ND, Yu WK, Jesse J, Wickersham NE, Sidorova TN, Janz DR, Parikh CR, Siew ED, Ware LB. Haptoglobin-2 variant increases susceptibility to acute respiratory distress syndrome during sepsis. JCI Insight 2019; 4:131206. [PMID: 31573976 DOI: 10.1172/jci.insight.131206] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 09/20/2019] [Indexed: 01/15/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) is an inflammatory lung disorder that frequently complicates critical illness and commonly occurs in sepsis. Although numerous clinical and environmental risk factors exist, not all patients with risk factors develop ARDS, raising the possibility of genetic underpinnings for ARDS susceptibility. We have previously reported that circulating cell-free hemoglobin (CFH) is elevated during sepsis, and higher levels predict worse outcomes. Excess CFH is rapidly scavenged by haptoglobin (Hp). A common HP genetic variant, HP2, is unique to humans and is common in many populations worldwide. HP2 haptoglobin has reduced ability to inhibit CFH-mediated inflammation and oxidative stress compared with the alternative HP1. We hypothesized that HP2 increases ARDS susceptibility during sepsis when plasma CFH levels are elevated. In a murine model of sepsis with elevated CFH, transgenic mice homozygous for Hp2 had increased lung inflammation, pulmonary vascular permeability, lung apoptosis, and mortality compared with wild-type mice. We then tested the clinical relevance of our findings in 496 septic critically ill adults, finding that HP2 increased ARDS susceptibility after controlling for clinical risk factors and plasma CFH. These observations identify HP2 as a potentially novel genetic ARDS risk factor during sepsis and may have important implications in the study and treatment of ARDS.
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Affiliation(s)
- V Eric Kerchberger
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine.,Department of Biomedical Informatics
| | - Julie A Bastarache
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine.,Department of Cell and Developmental Biology, and.,Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ciara M Shaver
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine
| | - Hiromasa Nagata
- Department of Anesthesiology, Keio University School of Medicine, Tokyo, Japan
| | - J Brennan McNeil
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine
| | - Stuart R Landstreet
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine
| | - Nathan D Putz
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine
| | - Wen-Kuang Yu
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine.,Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Jordan Jesse
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine
| | - Nancy E Wickersham
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine
| | - Tatiana N Sidorova
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine
| | - David R Janz
- Section of Pulmonary and Critical Care Medicine, Louisiana State University School of Medicine, New Orleans, Louisiana, USA
| | - Chirag R Parikh
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Edward D Siew
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Lorraine B Ware
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine.,Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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40
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Shaver CM, Paul MG, Putz ND, Landstreet SR, Kuck JL, Scarfe L, Skrypnyk N, Yang H, Harrison FE, de Caestecker MP, Bastarache JA, Ware LB. Cell-free hemoglobin augments acute kidney injury during experimental sepsis. Am J Physiol Renal Physiol 2019; 317:F922-F929. [PMID: 31364379 PMCID: PMC6843044 DOI: 10.1152/ajprenal.00375.2018] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 07/09/2019] [Accepted: 07/25/2019] [Indexed: 12/18/2022] Open
Abstract
Acute kidney injury is a common complication of severe sepsis and contributes to high mortality. The molecular mechanisms of acute kidney injury during sepsis are not fully understood. Because hemoproteins, including myoglobin and hemoglobin, are known to mediate kidney injury during rhabdomyolysis, we hypothesized that cell-free hemoglobin (CFH) would exacerbate acute kidney injury during sepsis. Sepsis was induced in mice by intraperitoneal injection of cecal slurry (CS). To mimic elevated levels of CFH observed during human sepsis, mice also received a retroorbital injection of CFH or dextrose control. Four groups of mice were analyzed: sham treated (sham), CFH alone, CS alone, and CS + CFH. The addition of CFH to CS reduced 48-h survival compared with CS alone (67% vs. 97%, P = 0.001) and increased the severity of illness. After 24 and 48 h, CS + CFH mice had a reduced glomerular filtration rate from baseline, whereas sham, CFH, and CS mice maintained baseline glomerular filtration rate. Biomarkers of acute kidney injury, neutrophil gelatinase-associated lipocalin (NGAL) and kidney injury molecule-1 (KIM-1), were markedly elevated in CS+CFH compared with CS (8-fold for NGAL and 2.4-fold for KIM-1, P < 0.002 for each) after 48 h. Histological examination showed a trend toward increased tubular injury in CS + CFH-exposed kidneys compared with CS-exposed kidneys. However, there were similar levels of renal oxidative injury and apoptosis in the CS + CFH group compared with the CS group. Kidney levels of multiple proinflammatory cytokines were similar between CS and CS + CFH groups. Human renal tubule cells (HK-2) exposed to CFH demonstrated increased cytotoxicity. Together, these results show that CFH exacerbates acute kidney injury in a mouse model of experimental sepsis, potentially through increased renal tubular injury.
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Affiliation(s)
- Ciara M Shaver
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Melinda G Paul
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Nathan D Putz
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Stuart R Landstreet
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jamie L Kuck
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lauren Scarfe
- Division of Nephrology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Nataliya Skrypnyk
- Division of Nephrology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Haichun Yang
- Division of Nephrology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Fiona E Harrison
- Division of Diabetes, Endocrinology, and Metabolism, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mark P de Caestecker
- Division of Nephrology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Cell and Developmental Biology, Vanderbilt University, Nashville, Tennessee
| | - Julie A Bastarache
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Cell and Developmental Biology, Vanderbilt University, Nashville, Tennessee
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lorraine B Ware
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
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41
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Multiple biomarkers of sepsis identified by novel time-lapse proteomics of patient serum. PLoS One 2019; 14:e0222403. [PMID: 31568522 PMCID: PMC6768476 DOI: 10.1371/journal.pone.0222403] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Accepted: 08/28/2019] [Indexed: 11/23/2022] Open
Abstract
Serum components of sepsis patients vary with the severity of infection, the resulting inflammatory response, per individual, and even over time. Tracking these changes is crucial in properly treating sepsis. Hence, several blood-derived biomarkers have been studied for their potential in assessing sepsis severity. However, the classical approach of selecting individual biomarkers is problematic in terms of accuracy and efficiency. We therefore present a novel approach for detecting biomarkers using longitudinal proteomics data. This does not require a predetermined set of proteins and can therefore reveal previously unknown related proteins. Our approach involves examining changes over time of both protein abundance and post-translational modifications in serum, using two-dimensional gel electrophoresis (2D-PAGE). 2D-PAGE was conducted using serum from n = 20 patients, collected at five time points, starting from the onset of sepsis. Changes in protein spots were examined using 49 spots for which the signal intensity changed by at least two-fold over time. These were then screened for significant spikes or dips in intensity that occurred exclusively in patients with adverse outcome. Individual level variation was handled by a mixed effects model. Finally, for each time transition, partial correlations between spots were estimated through a Gaussian graphical model (GGM) based on the ridge penalty. Identifications of spots of interest by tandem mass spectrometry revealed that many were either known biomarkers for inflammation (complement components), or had previously been suggested as biomarkers for kidney failure (haptoglobin) or liver failure (ceruloplasmin). The latter two are common complications in severe sepsis. In the GGM, many of the tightly connected spots shared known biological functions or even belonged to the same protein; including hemoglobin chains and acute phase proteins. Altogether, these results suggest that our screening method can successfully identify biomarkers for disease states and cluster biologically related proteins using longitudinal proteomics data derived from 2D-PAGE.
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42
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Englert FA, Seidel RA, Galler K, Gouveia Z, Soares MP, Neugebauer U, Clemens MG, Sponholz C, Heinemann SH, Pohnert G, Bauer M, Weis S. Labile heme impairs hepatic microcirculation and promotes hepatic injury. Arch Biochem Biophys 2019; 672:108075. [DOI: 10.1016/j.abb.2019.108075] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 08/04/2019] [Accepted: 08/10/2019] [Indexed: 12/13/2022]
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Cho NJ, Park S, Islam MI, Song HY, Lee EY, Gil HW. Long-term effect of medium cut-off dialyzer on middle uremic toxins and cell-free hemoglobin. PLoS One 2019; 14:e0220448. [PMID: 31348802 PMCID: PMC6660073 DOI: 10.1371/journal.pone.0220448] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 07/16/2019] [Indexed: 12/22/2022] Open
Abstract
The medium cut-off (MCO) dialyzer has shown good clearance of large middle molecules, but its long-term effects are unclear. We investigated whether MCO hemodialysis (HD) over one year could reduce middle molecule levels and cell-free hemoglobin (CFH), without albumin loss. A prospective cohort study in 57 hemodialysis patients was conducted. The patients were assigned to the MCO dialyzer group or the high-flux dialyzer group, according to the HD machine they used. The reduction ratio (RR) and one-year changes in small and middle molecules and CFH were analyzed. Over a 12-month follow-up, MCO HD did not reduce the serum levels of middle molecules (lambda free light chain [FLC], from 135.7 ± 39.9 to 132.0 ± 39.1 mg/L; kappa FLC, from 168.2 ± 58.5 to 167.7 ± 65.8 mg/L; β2-microglobulin, from 25.6 ± 9.6 to 28.4 ± 4.8 mg/L) or albumin (from 3.96 ± 0.31 to 3.94 ± 0.37 g/dL). MCO HD provided excellent RR of lambda FLC (49.3 ± 10.3%), kappa FLC (69.6 ± 10.4%) and β2-microglobulin (80.9 ± 7.3%), compared to high-flux HD. CFH was also removed well during an MCO HD session (RR of CPH, 85.5 [78.7–97.3] %), but long-term change was not significant (from 57.8 [46.2–79.1] to 62.0 [54.6–116.7] mg/L). The MCO dialyzer can be used effectively and safely in conventional HD settings, but long-term effects on large middle molecules and CFH were not significant. Further studies are needed to verify clinical benefits of the MCO dialyzer.
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Affiliation(s)
- Nam-Jun Cho
- Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Samel Park
- Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Md Imtiazul Islam
- Department of Microbiology and Immunology, School of Medicine, Soonchunhyang University, Cheonan, Korea
| | - Ho-Yeon Song
- Department of Microbiology and Immunology, School of Medicine, Soonchunhyang University, Cheonan, Korea
| | - Eun Young Lee
- Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Hyo-Wook Gil
- Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
- * E-mail:
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44
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Brauckmann S, Effenberger-Neidnicht K, Nagel M, Mayer C, Peters J, Hartmann M. Lipopolysaccharide-Induced Hemolysis Is Abolished by Inhibition of Thrombin Generation but Not Inhibition of Platelet Aggregation. Inflammation 2019; 42:1767-1776. [DOI: 10.1007/s10753-019-01038-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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45
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Pietropaoli AP, Henrichs KF, Cholette JM, Spinelli SL, Phipps RP, Refaai MA, Blumberg N. Total plasma heme concentration increases after red blood cell transfusion and predicts mortality in critically ill medical patients. Transfusion 2019; 59:2007-2015. [PMID: 30811035 DOI: 10.1111/trf.15218] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 01/28/2019] [Accepted: 01/29/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Relationships between red blood cell (RBC) transfusion, circulating cell-free heme, and clinical outcomes in critically ill transfusion recipients are incompletely understood. The goal of this study was to determine whether total plasma heme increases after RBC transfusion and predicts mortality in critically ill patients. STUDY DESIGN AND METHODS This was a prospective cohort study of 111 consecutive medical intensive care patients requiring RBC transfusion. Cell-free heme was measured in RBC units before transfusion and in the patients' plasma before and after transfusion. RESULTS Total plasma heme levels increased in response to transfusion, from a median (interquartile range [IQR]) of 35 (26-76) μmol/L to 47 (35-73) μmol/L (p < 0.001). Posttransfusion total plasma heme was higher in nonsurvivors (54 [35-136] μmol/L) versus survivors (44 [31-65] μmol/L, p = 0.03). Posttransfusion total plasma heme predicted hospital mortality (odds ratio [95% confidence interval] per quartile increase in posttransfusion plasma heme, 1.76 [1.17-2.66]; p = 0.007). Posttransfusion total plasma heme was not correlated with RBC unit storage duration and weakly correlated with RBC unit cell-free heme concentration. CONCLUSIONS Total plasma heme concentration increases in critically ill patients after RBC transfusion and is independently associated with mortality. This transfusion-associated increase in total plasma heme is not fully explained by RBC unit storage age or cell-free heme content. Additional studies are warranted to define mechanisms of transfusion-related plasma heme accumulation and test prevention strategies.
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Affiliation(s)
- Anthony P Pietropaoli
- Department of Medicine, Division of Pulmonary & Critical Care Medicine, University of Rochester Medical Center, Rochester, New York
| | - Kelly F Henrichs
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, New York
| | - Jill M Cholette
- Department of Pediatrics, University of Rochester Medical Center, Rochester, New York
| | - Sherry L Spinelli
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, New York
| | - Richard P Phipps
- Department of Medicine, Division of Pulmonary & Critical Care Medicine, University of Rochester Medical Center, Rochester, New York.,Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, New York.,Department of Microbiology & Immunology, University of Rochester Medical Center, Rochester, New York
| | - Majed A Refaai
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, New York
| | - Neil Blumberg
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, New York
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Minasyan H, Flachsbart F. Blood coagulation: a powerful bactericidal mechanism of human innate immunity. Int Rev Immunol 2019; 38:3-17. [DOI: 10.1080/08830185.2018.1533009] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Hayk Minasyan
- Private laboratory, Immunology Microbiology, Yerevan, Armenia
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Pfeifhofer-Obermair C, Tymoszuk P, Petzer V, Weiss G, Nairz M. Iron in the Tumor Microenvironment-Connecting the Dots. Front Oncol 2018; 8:549. [PMID: 30534534 PMCID: PMC6275298 DOI: 10.3389/fonc.2018.00549] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 11/06/2018] [Indexed: 12/18/2022] Open
Abstract
Iron metabolism and tumor biology are intimately linked. Iron facilitates the production of oxygen radicals, which may either result in iron-induced cell death, ferroptosis, or contribute to mutagenicity and malignant transformation. Once transformed, malignant cells require high amounts of iron for proliferation. In addition, iron has multiple regulatory effects on the immune system, thus affecting tumor surveillance by immune cells. For these reasons, inconsiderate iron supplementation in cancer patients has the potential of worsening disease course and outcome. On the other hand, chronic immune activation in the setting of malignancy alters systemic iron homeostasis and directs iron fluxes into myeloid cells. While this response aims at withdrawing iron from tumor cells, it may impair the effector functions of tumor-associated macrophages and will result in iron-restricted erythropoiesis and the development of anemia, subsequently. This review summarizes our current knowledge of the interconnections of iron homeostasis with cancer biology, discusses current clinical controversies in the treatment of anemia of cancer and focuses on the potential roles of iron in the solid tumor microenvironment, also speculating on yet unknown molecular mechanisms.
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Affiliation(s)
- Christa Pfeifhofer-Obermair
- Department of Internal Medicine II, Infectious Diseases, Immunology, Rheumatology, Pneumology, Medical University of Innsbruck, Innsbruck, Austria
| | - Piotr Tymoszuk
- Department of Internal Medicine II, Infectious Diseases, Immunology, Rheumatology, Pneumology, Medical University of Innsbruck, Innsbruck, Austria
| | - Verena Petzer
- Department of Internal Medicine II, Infectious Diseases, Immunology, Rheumatology, Pneumology, Medical University of Innsbruck, Innsbruck, Austria
| | - Günter Weiss
- Department of Internal Medicine II, Infectious Diseases, Immunology, Rheumatology, Pneumology, Medical University of Innsbruck, Innsbruck, Austria.,Christian Doppler Laboratory for Iron Metabolism and Anemia Research, Medical University of Innsbruck, Innsbruck, Austria
| | - Manfred Nairz
- Department of Internal Medicine II, Infectious Diseases, Immunology, Rheumatology, Pneumology, Medical University of Innsbruck, Innsbruck, Austria
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Aninagyei E, Doku ET, Adu P, Egyir-Yawson A, Acheampong DO. Storage related haematological and biochemical changes in Plasmodium falciparum infected and sickle cell trait donor blood. BMC HEMATOLOGY 2018; 18:30. [PMID: 30450212 PMCID: PMC6220467 DOI: 10.1186/s12878-018-0128-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 10/28/2018] [Indexed: 01/05/2023]
Abstract
Background In sub-Saharan Africa where sickle cell trait (SCT) and malaria is prevalent, significant proportions of blood donors may be affected by one or more of these abnormalities. The haemato-biochemical properties of SCT and asymptomatic malaria in donor blood have not been evaluated. This study evaluated the haemato-biochemical impact of SCT and asymptomatic malaria infections in citrate-phosphate-dextrose-adenine (CPDA-1) stored donor blood units. Methods Fifty-milliliters of sterile CPDA-1 anti-coagulated blood were drained into the sample pouch attached to the main blood bag. Ten units each of sickle cell/malaria negative, sickle cell and malaria positive blood were analyzed. Baseline and weekly haematological profiling and week 1, 3 and 5 concentrations of plasma haemoglobin, % haemolysis, sodium, potassium and chloride and lactate dehydrogenase (LDH) were assayed. Differences between baseline and weekly data were determined using one-way analysis of variance (ANOVA) and Kruskal-Wallis test, whereas differences between baseline parameters and week 1-3 data pairs were determined using paired t-test. P-value < 0.05 was considered statistically significant. Results Storage of SCT and malaria infected blood affected all haematological cell lines. In the SCT donors, red blood cells (RBC) (4.75 × 1012/L ± 1.43baseline to 3.49 × 1012/L ± 1.09week-5), haemoglobin (14.45 g/dl ± 1.63baseline to 11.43 g/dl ± 1.69week-5) and haematocrit (39.96% ± 3.18baseline to 33.22% ± 4.12week-5) were reduced. In the asymptomatic malaria group, reductions were observed in RBC (5.00 × 1012/L ± 0.75baseline to 3.72 × 1012/L ± 0.71week-5), haemoglobin (14.73 g/dl ± 1.67baseline to 11.53 g/dl ± 1.62week-5), haematocrit (42.72% ± 5.16baseline to 33.38% ± 5.80week-5), mean cell haemoglobin concentration (35.48 g/dl ± 1.84baseline to 35.01 g/dl ± 0.64week-5) and red cell distribution width coefficient of variation (14.81% ± 1.54baseline to 16.26% ± 1.37week-5). Biochemically, whereas plasma LDH levels significantly increased in asymptomatic malaria blood donors (319% increase at week 5 compared to baseline), SCT blood donors had the most significant increase in plasma potassium levels at week 5 (382% increase). Sodium ions significantly reduced in SCT/malaria negative and sickle cell trait blood at an average rate of 0.21 mmol/L per day. Moreover, elevations in lymphocytes-to-eosinophils and lymphocytes-to-neutrophils ratios were associated with SCT and malaria positive blood whilst elevation lymphocytes-to-basophils ratio was exclusive to malaria positive blood. Conclusion Severe storage lesions were significant in SCT or malaria positive donor blood units. Proper clinical evaluation must be done in prospective blood donors to ensure deferral of such donors.
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Affiliation(s)
- Enoch Aninagyei
- 1Department of Biomedical Sciences, School of Allied Health Sciences, University of Cape Coast, Cape Coast, Ghana
| | | | - Patrick Adu
- 3Department of Medical Laboratory Technology, University of Cape Coast, Cape Coast, Ghana
| | - Alexander Egyir-Yawson
- 1Department of Biomedical Sciences, School of Allied Health Sciences, University of Cape Coast, Cape Coast, Ghana
| | - Desmond Omane Acheampong
- 1Department of Biomedical Sciences, School of Allied Health Sciences, University of Cape Coast, Cape Coast, Ghana
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Cucchiari D, Reverter E, Blasco M, Molina-Andujar A, Carpio A, Sanz M, Escorsell A, Fernández J, Poch E. High cut-off membrane for in-vivo dialysis of free plasma hemoglobin in a patient with massive hemolysis. BMC Nephrol 2018; 19:250. [PMID: 30286730 PMCID: PMC6172805 DOI: 10.1186/s12882-018-1051-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 09/20/2018] [Indexed: 11/10/2022] Open
Abstract
Background The possibility of clearing Cell-free Plasma Hemoglobin (CPH) from human plasma may appear attractive, especially when considering the noxious effects that CPH has on the immune function and the renal damage caused by its filtration. The existence of the so-called High Cut-Off (HCO) filters, possessing pores as big as 60 kDa, could potentially allow the clearance of the αβ dimers (31.3 kDa), the form in which the α2β2 hemoglobin tetramers (62.6 kDa) physiologically dissociate in plasma. We present herein the first reported case in which such an attempt was made. Case presentation The patient was a 51-year-old man with hemolytic crisis due to glucose-6-phosphate dehydrogenase deficiency, further complicated by pigment-induced nephropathy. He underwent a 48-h CVVHD session, in which a HCO filter was used. The Sieving Coefficient (SC) for CPH was initially 0.08 and decreased to 0.02 after 24 h. This unexpected low SC was due to the initial high concentration of CPH (4.24 g/L). At such concentrations, the α2β2 tetramer poorly dissociates into the αβ dimer; but increases exponentially at concentrations lower than 1 g/L. Conclusions Clearance of CPH through a HCO filter is technically feasible but its performance markedly relies on the initial concentration of CPH. Critically ill patients with smoldering hemolysis, as it happens during septic shock or ECMO treatment, may benefit the most from the use of this membrane in order to clear CPH.
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Affiliation(s)
- David Cucchiari
- Nephrology and Renal Transplant Unit, Hospital Clínic, Carrer Villaroel 170, 08036, Barcelona, Spain.
| | - Enric Reverter
- Liver Intensive Care Unit, Hepatology. Hospital Clínic, Barcelona, Spain
| | - Miquel Blasco
- Nephrology and Renal Transplant Unit, Hospital Clínic, Carrer Villaroel 170, 08036, Barcelona, Spain
| | - Alicia Molina-Andujar
- Nephrology and Renal Transplant Unit, Hospital Clínic, Carrer Villaroel 170, 08036, Barcelona, Spain
| | - Adriá Carpio
- Liver Intensive Care Unit, Hepatology. Hospital Clínic, Barcelona, Spain
| | - Miquel Sanz
- Liver Intensive Care Unit, Hepatology. Hospital Clínic, Barcelona, Spain
| | - Angels Escorsell
- Liver Intensive Care Unit, Hepatology. Hospital Clínic, Barcelona, Spain
| | - Javier Fernández
- Liver Intensive Care Unit, Hepatology. Hospital Clínic, Barcelona, Spain
| | - Esteban Poch
- Nephrology and Renal Transplant Unit, Hospital Clínic, Carrer Villaroel 170, 08036, Barcelona, Spain
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Remy KE, Cortés-Puch I, Solomon SB, Sun J, Pockros BM, Feng J, Lertora JJ, Hantgan RR, Liu X, Perlegas A, Warren HS, Gladwin MT, Kim-Shapiro DB, Klein HG, Natanson C. Haptoglobin improves shock, lung injury, and survival in canine pneumonia. JCI Insight 2018; 3:123013. [PMID: 30232287 PMCID: PMC6237235 DOI: 10.1172/jci.insight.123013] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 08/09/2018] [Indexed: 11/17/2022] Open
Abstract
During the last half-century, numerous antiinflammatory agents were tested in dozens of clinical trials and have proven ineffective for treating septic shock. The observation in multiple studies that cell-free hemoglobin (CFH) levels are elevated during clinical sepsis and that the degree of increase correlates with higher mortality suggests an alternative approach. Human haptoglobin binds CFH with high affinity and, therefore, can potentially reduce iron availability and oxidative activity. CFH levels are elevated over approximately 24-48 hours in our antibiotic-treated canine model of S. aureus pneumonia that simulates the cardiovascular abnormalities of human septic shock. In this 96-hour model, resuscitative treatments, mechanical ventilation, sedation, and continuous care are translatable to management in human intensive care units. We found, in this S. aureus pneumonia model inducing septic shock, that commercial human haptoglobin concentrate infusions over 48-hours bind canine CFH, increase CFH clearance, and lower circulating iron. Over the 96-hour study, this treatment was associated with an improved metabolic profile (pH, lactate), less lung injury, reversal of shock, and increased survival. Haptoglobin binding compartmentalized CFH to the intravascular space. This observation, in combination with increasing CFHs clearance, reduced available iron as a potential source of bacterial nutrition while decreasing the ability for CFH and iron to cause extravascular oxidative tissue injury. In contrast, haptoglobin therapy had no measurable antiinflammatory effect on elevations in proinflammatory C-reactive protein and cytokine levels. Haptoglobin therapy enhances normal host defense mechanisms in contrast to previously studied antiinflammatory sepsis therapies, making it a biologically plausible novel approach to treat septic shock.
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Affiliation(s)
- Kenneth E. Remy
- Critical Care Medicine Department, Clinical Center, NIH, Bethesda, Maryland, USA.,Department of Pediatrics, Division of Critical Care, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Irene Cortés-Puch
- Critical Care Medicine Department, Clinical Center, NIH, Bethesda, Maryland, USA
| | - Steven B. Solomon
- Critical Care Medicine Department, Clinical Center, NIH, Bethesda, Maryland, USA
| | - Junfeng Sun
- Critical Care Medicine Department, Clinical Center, NIH, Bethesda, Maryland, USA
| | - Benjamin M. Pockros
- Critical Care Medicine Department, Clinical Center, NIH, Bethesda, Maryland, USA
| | - Jing Feng
- Critical Care Medicine Department, Clinical Center, NIH, Bethesda, Maryland, USA
| | - Juan J. Lertora
- Clinical Pharmacology Program, Clinical Center, NIH, Bethesda, Maryland, USA
| | - Roy R. Hantgan
- Department of Biochemistry, Wake Forest University Health Sciences, Winston-Salem, North Carolina, USA
| | - Xiaohua Liu
- Department of Physics, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Andreas Perlegas
- Department of Physics, Wake Forest University, Winston-Salem, North Carolina, USA
| | - H. Shaw Warren
- Infectious Disease Unit, Massachusetts General Hospital, and Shriners Hospital for Crippled Children, Boston, Massachusetts, USA
| | - Mark T. Gladwin
- Department of Medicine, The University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Harvey G. Klein
- Department of Transfusion Medicine, Clinical Center, NIH, Bethesda, Maryland, USA
| | - Charles Natanson
- Critical Care Medicine Department, Clinical Center, NIH, Bethesda, Maryland, USA
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