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Wen TZ, Li TR, Chen XY, Chen HY, Wang S, Fu WJ, Xiao SQ, Luo J, Tang R, Ji JL, Huang JF, He ZC, Luo T, Zhao HL, Chen C, Miao JY, Niu Q, Wang Y, Bian XW, Yao XH. Increased adrenal steroidogenesis and suppressed corticosteroid responsiveness in critical COVID-19. Metabolism 2024:155980. [PMID: 39053691 DOI: 10.1016/j.metabol.2024.155980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 07/01/2024] [Accepted: 07/19/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND The effect of coronavirus disease 2019 (COVID-19) on adrenal endocrine metabolism in critically ill patients remains unclear. This study aimed to investigate the alterations in adrenal steroidogenic activity, elucidate underlying mechanisms, provide in situ histopathological evidence, and examine the clinical implications. METHODS The comparative analyses of the adrenal cortices from 24 patients with fatal COVID-19 and 20 matched controls was performed, excluding patients previously treated with glucocorticoids. Several SARS-CoV-2 and its receptors were identified and pathological alterations were examined. Furthermore, histological examinations, immunohistochemical staining and ultrastructural analyses were performed to assess corticosteroid biosynthesis. The zona glomerulosa (ZG) and zona fasciculata (ZF) were then dissected for proteomic analyses. The biological processes that affected steroidogenesis were analyzed by integrating histological, proteomic, and clinical data. Finally, the immunoreactivity of mineralocorticoids and glucocorticoid receptors in essential tissues were quantitatively measured to evaluate corticosteroid responsiveness. FINDINGS The demographic characteristics of COVID-19 patients were comparable with those of controls, excluding those that affected adrenal function. SARS-CoV-2-like particles were identified in the adrenocortical cells of three patients; however, these particles did not affect cellular morphology or steroid synthesis compared with those in SARS-CoV-2-negative specimens. Although the adrenals exhibited focal necrosis, vacuolization, microthrombi, and inflammation, widespread degeneration was not evident. Notably, corticosteroid biosynthesis was significantly enhanced in both the ZG and ZF of COVID-19 patients. The increase in the inflammatory response and cellular differentiation in the adrenal cortices of patients with critical COVID-19 was positively correlated with heightened steroidogenic activity. Additionally, the appearance of more dual-ZG/ZF identity cells in COVID-19 adrenals was in accordance with the increased steroidogenic function. However, activated mineralocorticoid and glucocorticoid receptors in vital tissues were markedly reduced in patients with critical COVID-19. INTERPRETATION Critical COVID-19 was characterized by potentiated adrenal steroidogenesis, associated with exacerbation of inflammation, differentiation and the presence of dual-ZG/ZF identity cells. These alterations implied the reduced effectiveness of conventional corticosteroid therapy and underscored the need for evaluation of adrenal axis and the corticosteroid sensitivity.
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Affiliation(s)
- Tian-Zi Wen
- Institute of Pathology, Southwest Hospital, Third Military Medical University (Army Medical University), and Key Laboratory of Tumor Immunopathology, Ministry of Education of China, Chongqing, China
| | - Tian-Ran Li
- Institute of Pathology, Southwest Hospital, Third Military Medical University (Army Medical University), and Key Laboratory of Tumor Immunopathology, Ministry of Education of China, Chongqing, China
| | - Xin-Yu Chen
- Institute of Pathology, Southwest Hospital, Third Military Medical University (Army Medical University), and Key Laboratory of Tumor Immunopathology, Ministry of Education of China, Chongqing, China
| | - He-Yuan Chen
- Institute of Pathology, Southwest Hospital, Third Military Medical University (Army Medical University), and Key Laboratory of Tumor Immunopathology, Ministry of Education of China, Chongqing, China
| | - Shuai Wang
- Institute of Pathology, Southwest Hospital, Third Military Medical University (Army Medical University), and Key Laboratory of Tumor Immunopathology, Ministry of Education of China, Chongqing, China
| | - Wen-Juan Fu
- Institute of Pathology, Southwest Hospital, Third Military Medical University (Army Medical University), and Key Laboratory of Tumor Immunopathology, Ministry of Education of China, Chongqing, China
| | - Shi-Qi Xiao
- Institute of Pathology, Southwest Hospital, Third Military Medical University (Army Medical University), and Key Laboratory of Tumor Immunopathology, Ministry of Education of China, Chongqing, China
| | - Jie Luo
- Institute of Pathology, Southwest Hospital, Third Military Medical University (Army Medical University), and Key Laboratory of Tumor Immunopathology, Ministry of Education of China, Chongqing, China
| | - Rui Tang
- Institute of Pathology, Southwest Hospital, Third Military Medical University (Army Medical University), and Key Laboratory of Tumor Immunopathology, Ministry of Education of China, Chongqing, China
| | - Jia-Le Ji
- Institute of Pathology, Southwest Hospital, Third Military Medical University (Army Medical University), and Key Laboratory of Tumor Immunopathology, Ministry of Education of China, Chongqing, China
| | - Jia-Feng Huang
- Institute of Pathology, Southwest Hospital, Third Military Medical University (Army Medical University), and Key Laboratory of Tumor Immunopathology, Ministry of Education of China, Chongqing, China
| | - Zhi-Cheng He
- Institute of Pathology, Southwest Hospital, Third Military Medical University (Army Medical University), and Key Laboratory of Tumor Immunopathology, Ministry of Education of China, Chongqing, China
| | - Tao Luo
- Institute of Pathology, Southwest Hospital, Third Military Medical University (Army Medical University), and Key Laboratory of Tumor Immunopathology, Ministry of Education of China, Chongqing, China
| | - Hong-Liang Zhao
- Institute of Pathology, Southwest Hospital, Third Military Medical University (Army Medical University), and Key Laboratory of Tumor Immunopathology, Ministry of Education of China, Chongqing, China
| | - Cong Chen
- Institute of Pathology, Southwest Hospital, Third Military Medical University (Army Medical University), and Key Laboratory of Tumor Immunopathology, Ministry of Education of China, Chongqing, China
| | - Jing-Ya Miao
- Institute of Pathology, Southwest Hospital, Third Military Medical University (Army Medical University), and Key Laboratory of Tumor Immunopathology, Ministry of Education of China, Chongqing, China
| | - Qin Niu
- Institute of Pathology, Southwest Hospital, Third Military Medical University (Army Medical University), and Key Laboratory of Tumor Immunopathology, Ministry of Education of China, Chongqing, China
| | - Yan Wang
- Institute of Pathology, Southwest Hospital, Third Military Medical University (Army Medical University), and Key Laboratory of Tumor Immunopathology, Ministry of Education of China, Chongqing, China; Jinfeng Laboratory, Chongqing, China
| | - Xiu-Wu Bian
- Institute of Pathology, Southwest Hospital, Third Military Medical University (Army Medical University), and Key Laboratory of Tumor Immunopathology, Ministry of Education of China, Chongqing, China; YuYue Laboratory, Chongqing, China.
| | - Xiao-Hong Yao
- Institute of Pathology, Southwest Hospital, Third Military Medical University (Army Medical University), and Key Laboratory of Tumor Immunopathology, Ministry of Education of China, Chongqing, China.
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2
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Zhang G, Zhang K. Screening and Identification of Neutrophil Extracellular Trap-related Diagnostic Biomarkers for Pediatric Sepsis by Machine Learning. Inflammation 2024:10.1007/s10753-024-02059-6. [PMID: 38795170 DOI: 10.1007/s10753-024-02059-6] [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: 02/20/2024] [Revised: 05/15/2024] [Accepted: 05/20/2024] [Indexed: 05/27/2024]
Abstract
Neutrophil extracellular trap (NET) is released by neutrophils to trap invading pathogens and can lead to dysregulation of immune responses and disease pathogenesis. However, systematic evaluation of NET-related genes (NETRGs) for the diagnosis of pediatric sepsis is still lacking. Three datasets were taken from the Gene Expression Omnibus (GEO) database: GSE13904, GSE26378, and GSE26440. After NETRGs and differentially expressed genes (DEGs) were identified in the GSE26378 dataset, crucial genes were identified by using LASSO regression analysis and random forest analysis on the genes that overlapped in both DEGs and NETRGs. These crucial genes were then employed to build a diagnostic model. The diagnostic model's effectiveness in identifying pediatric sepsis across the three datasets was confirmed through receiver operating characteristic curve (ROC) analysis. In addition, clinical pediatric sepsis samples were collected to measure the expression levels of important genes and evaluate the diagnostic model's performance using qRT-PCR in identifying pediatric sepsis in actual clinical samples. Next, using the CIBERSORT database, the relationship between invading immune cells and diagnostic markers was investigated in more detail. Lastly, to evaluate NET formation, we measured myeloperoxidase (MPO)-DNA complex levels using ELISA. A group of five important genes (MME, BST1, S100A12, FCAR, and ALPL) were found among the 13 DEGs associated with NET formation and used to create a diagnostic model for pediatric sepsis. Across all three cohorts, the sepsis group had consistently elevated expression levels of these five critical genes as compared to the normal group. Area under the curve (AUC) values of 1, 0.932, and 0.966 indicate that the diagnostic model performed exceptionally well in terms of diagnosis. Notably, when applied to the clinical samples, the diagnostic model also showed good diagnostic capacity with an AUC of 0.898, outperforming the effectiveness of traditional inflammatory markers such as PCT, CRP, WBC, and NEU%. Lastly, we discovered that children with high ratings for sepsis also had higher MPO-DNA complex levels. In conclusion, the creation and verification of a five-NETRGs diagnostic model for pediatric sepsis performs better than established markers of inflammation.
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Affiliation(s)
- Genhao Zhang
- Department of Blood Transfusion, Zhengzhou University First Affiliated Hospital, Zhengzhou, China.
| | - Kai Zhang
- Department of Medical Laboratory, Zhengzhou University Third Affiliated Hospital, Zhengzhou, China
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3
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Zheng X, Xu Z, Xu L, Wang L, Qin S, Ying L, Dong S, Tang L. Angiotensin II Type 2 Receptor Inhibits M1 Polarization and Apoptosis of Alveolar Macrophage and Protects Against Mechanical Ventilation-Induced Lung Injury. Inflammation 2024:10.1007/s10753-024-02037-y. [PMID: 38767784 DOI: 10.1007/s10753-024-02037-y] [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: 02/06/2024] [Revised: 04/03/2024] [Accepted: 04/24/2024] [Indexed: 05/22/2024]
Abstract
Angiotensin II (Ang II) is associated with macrophage polarization and apoptosis, but the role of the angiotensin type 2 receptor (AT2R) in these processes remains controversial. However, the effect of AT2Rs on alveolar macrophages and mechanical ventilation-induced lung injury has not been determined. Mechanical ventilation-induced lung injury in Sprague‒Dawley (SD) rats and LPS-stimulated rat alveolar macrophages (NR8383) were used to determine the effects of AT2Rs, selective AT2R agonists and selective AT1Rs or AT2R antagonists. Macrophage polarization, apoptosis, and related signaling pathways were assessed via western blotting, QPCR and flow cytometry. AT2R expression was decreased in LPS-stimulated rat alveolar macrophages (NR8383). Administration of the AT2R agonist CGP-42112 was associated with an increase in AT2R expression and M2 polarization, but no effect was observed upon administration of the AT2R antagonist PD123319 or the AT1R antagonist valsartan. In mechanical ventilation-induced lung injury in Sprague‒Dawley (SD) rats, the administration of the AT2R agonist C21 was associated with attenuation of the pathological damage score, lung wet/dry weight, cell count and protein content in BALF. C21 can significantly reduce proinflammatory factor TNF-α, IL-1β levels, increase anti-inflammatory factor IL-4, IL-10 levels in BALF, compared with the model group (p < 0.01). Similarly, compared with those at the same time points, the M1/M2 ratios in alveolar macrophages and apoptosis in peritoneal macrophages at 4 h, 6 h and 8 h in the mechanical ventilation models were lower after C21 administration. These findings indicated that the expression of AT2Rs in alveolar macrophages mediates M1 macrophage polarization and apoptosis and that AT2Rs play a protective role in mediating mechanical ventilation-induced lung injury.
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Affiliation(s)
- Xuyang Zheng
- Department of Pediatrics, School of Medicine, Zhejiang University, Hangzhou, 310000, Zhejiang, People's Republic of China.
- Department of Pediatrics, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou, 310000, Zhejiang, People's Republic of China.
| | - Zhiguang Xu
- Department of Pediatrics, School of Medicine, Zhejiang University, Hangzhou, 310000, Zhejiang, People's Republic of China
| | - Lihui Xu
- Department of Clinical Laboratory, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou, 310000, Zhejiang, People's Republic of China
| | - Lingqiao Wang
- Department of Pediatrics, School of Medicine, Zhejiang University, Hangzhou, 310000, Zhejiang, People's Republic of China
| | - Siyun Qin
- Department of Pediatrics, School of Medicine, Zhejiang University, Hangzhou, 310000, Zhejiang, People's Republic of China
| | - Liu Ying
- Department of Pediatrics, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou, 310000, Zhejiang, People's Republic of China
| | - Shuangyong Dong
- Department of Emergency, Affiliated Hangzhou First People's Hospital, School of Medicine, Westlake University, Hangzhou, 310000, Zhejiang, People's Republic of China.
| | - Lanfang Tang
- Department of pulmonology, Affiliated Children's Hospital, School of medicine, Zhejiang University, Hangzhou, 310003, Zhejiang, People's Republic of China.
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Shrestha DB, Sedhai YR, Oli PR, Proskuriakova E, Adelkhanova A, Shtembari J, Khan TMA, Singh K, Ahmed MA, Waheed I, Kazimuddin N, Steff R, Acharya R, Patel NK. Prior Use of Angiotensin-converting Enzyme Inhibitors or Angiotensin II Receptor Blockers and Clinical Outcomes of Sepsis and Septic Shock: A Systematic Review and Meta-analysis. J Cardiovasc Pharmacol 2024; 83:16-22. [PMID: 37815234 DOI: 10.1097/fjc.0000000000001491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 09/15/2023] [Indexed: 10/11/2023]
Abstract
ABSTRACT Sepsis and septic shock are life-threatening conditions that are associated with high mortality and considerable health care costs. The association between prior angiotensin-converting enzyme inhibitors (ACEi) or angiotensin II receptor blockers (ARBs) use and outcomes after sepsis is elusive. The aim of this study was to evaluate the role of the prior use of ACEi or ARBs and outcomes after sepsis and septic shock. A relevant literature review was performed in 4 databases from inception until July 2022. Independent reviewers first screened the title, abstract, and full text, and then, data extraction and analysis were performed. One post hoc analysis of a trial and 6 retrospective cohort studies were included in this review. There were 22% lower odds of in-hospital/30-day mortality among patients who have used ACEi/ARBs in the past [23.83% vs. 37.20%; odds ratio (OR), 0.78, 95% confidence interval (CI), 0.64-0.96], and reduced 90-day mortality (OR, 0.80, 95% CI, 0.69-0.92). ACEi/ARBs users were found to have 31% lesser odds of developing acute kidney injury as compared with nonusers (OR, 0.69, 95% CI, 0.63-0.76). There was no significant difference in the length of hospital stay (MD 1.26, 95% CI, ‒7.89 to 10.42), need for renal replacement therapy (OR, 0.71, 95% CI, 0.13-3.92), mechanical ventilation (OR, 1.10, 95% CI, 0.88-1.37) or use of vasopressors (OR, 1.21, 95% CI, 0.91-1.61). Based on this analysis, prior use of ACEi/ARBs lowers the risk of mortality and adverse renal events in patients with sepsis and septic shock.
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Affiliation(s)
| | - Yub Raj Sedhai
- Division of Pulmonary Disease and Critical Care Medicine, University of Kentucky College of Medicine, Bowling Green, KY
| | - Prakash Raj Oli
- Department of Internal Medicine, Province Hospital, Birendranagar, Nepal
| | | | - Alla Adelkhanova
- Department of Internal Medicine, Mount Sinai Hospital, Chicago, IL
| | - Jurgen Shtembari
- Department of Internal Medicine, Mount Sinai Hospital, Chicago, IL
| | - Tahir Muhammad Abdullah Khan
- Division of Pulmonary Disease and Critical Care Medicine, University of Kentucky College of Medicine, Bowling Green, KY
| | - Karan Singh
- Division of Pulmonary Disease and Critical Care Medicine, University of Kentucky College of Medicine, Bowling Green, KY
| | - Muhammad Altaf Ahmed
- Division of Pulmonary Disease and Critical Care Medicine, University of Kentucky College of Medicine, Bowling Green, KY
| | - Irfan Waheed
- Division of Pulmonary Disease and Critical Care Medicine, University of Kentucky College of Medicine, Bowling Green, KY
| | - Nisarfathima Kazimuddin
- Division of Pulmonary Disease and Critical Care Medicine, University of Kentucky College of Medicine, Bowling Green, KY
| | - Rodney Steff
- Division of Pulmonary Disease and Critical Care Medicine, University of Kentucky College of Medicine, Bowling Green, KY
| | - Roshan Acharya
- Department of Internal Medicine, Division of Pulmonary Disease and Critical Care Medicine, Virginia Tech Carilion School of Medicine, Roanoke, VA; and
| | - Nimesh K Patel
- Department of Internal Medicine, Division of Cardiology, Virginia Commonwealth University, School of Medicine, Richmond, VA
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5
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Putowski Z, Pluta MP, Rachfalska N, Krzych ŁJ, De Backer D. Sublingual Microcirculation in Temporary Mechanical Circulatory Support: A Current State of Knowledge. J Cardiothorac Vasc Anesth 2023; 37:2065-2072. [PMID: 37330330 DOI: 10.1053/j.jvca.2023.05.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 05/13/2023] [Accepted: 05/17/2023] [Indexed: 06/19/2023]
Abstract
Cardiogenic shock causes hypoperfusion within the microcirculation, leading to impaired oxygen delivery, cell death, and progression of multiple organ failure. Mechanical circulatory support (MCS) is the last line of treatment for cardiac failure. The goal of MCS is to ensure end-organ perfusion by maintaining perfusion pressure and total blood flow. However, machine-blood interactions and the nonobvious translation of global macrohemodynamics into the microcirculation suggest that the use of MCS may not necessarily be associated with improved capillary flow. With the use of hand-held vital microscopes, it is possible to assess the microcirculation at the bedside. The paucity of literature on the use of microcirculatory assessment suggests the need for an in-depth look into microcirculatory assessment within the context of MCS. The purpose of this review is to discuss the possible interactions between MCS and microcirculation, as well as to describe the research conducted in this area. Regarding sublingual microcirculation, 3 types of MCS will be discussed: venoarterial extracorporeal membrane oxygenation, intra-aortic balloon counterpulsation, and microaxial flow pumps (Impella).
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Affiliation(s)
- Zbigniew Putowski
- University Clinical Center of the Medical University of Silesia in Katowice, Katowice, Poland.
| | - Michał P Pluta
- Department of Anesthesiology and Intensive Care, Faculty of Medical Sciences, Medical University of Silesia, Katowice, Poland
| | - Natalia Rachfalska
- Department of Anesthesiology and Intensive Care, Faculty of Medical Sciences, Medical University of Silesia, Katowice, Poland
| | - Łukasz J Krzych
- Department of Anesthesiology and Intensive Care, Faculty of Medical Sciences, Medical University of Silesia, Katowice, Poland; Department of Cardiac Anaesthesia and Intensive Therapy, Medical University of Silesia, Silesian Center for Heart Diseases, Zabrze, Poland
| | - Daniel De Backer
- Department of Intensive Care, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
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6
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Guzzo I, Paglialonga F. Critically ill children with septic shock: time to rediscover renin? Pediatr Nephrol 2023; 38:2907-2910. [PMID: 37087478 DOI: 10.1007/s00467-023-05985-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 04/10/2023] [Accepted: 04/10/2023] [Indexed: 04/24/2023]
Affiliation(s)
- Isabella Guzzo
- Pediatric Nephrology, Dialysis and Transplant Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Fabio Paglialonga
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
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7
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Lawler PR, Derde LPG, van de Veerdonk FL, McVerry BJ, Huang DT, Berry LR, Lorenzi E, van Kimmenade R, Gommans F, Vaduganathan M, Leaf DE, Baron RM, Kim EY, Frankfurter C, Epelman S, Kwan Y, Grieve R, O'Neill S, Sadique Z, Puskarich M, Marshall JC, Higgins AM, Mouncey PR, Rowan KM, Al-Beidh F, Annane D, Arabi YM, Au C, Beane A, van Bentum-Puijk W, Bonten MJM, Bradbury CA, Brunkhorst FM, Burrell A, Buzgau A, Buxton M, Cecconi M, Cheng AC, Cove M, Detry MA, Estcourt LJ, Ezekowitz J, Fitzgerald M, Gattas D, Godoy LC, Goossens H, Haniffa R, Harrison DA, Hills T, Horvat CM, Ichihara N, Lamontagne F, Linstrum KM, McAuley DF, McGlothlin A, McGuinness SP, McQuilten Z, Murthy S, Nichol AD, Owen DRJ, Parke RL, Parker JC, Pollock KM, Reyes LF, Saito H, Santos MS, Saunders CT, Seymour CW, Shankar-Hari M, Singh V, Turgeon AF, Turner AM, Zarychanski R, Green C, Lewis RJ, Angus DC, Berry S, Gordon AC, McArthur CJ, Webb SA. Effect of Angiotensin-Converting Enzyme Inhibitor and Angiotensin Receptor Blocker Initiation on Organ Support-Free Days in Patients Hospitalized With COVID-19: A Randomized Clinical Trial. JAMA 2023; 329:1183-1196. [PMID: 37039790 PMCID: PMC10326520 DOI: 10.1001/jama.2023.4480] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 03/07/2023] [Indexed: 04/12/2023]
Abstract
IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non-critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support-free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support-free days among critically ill patients was 10 (-1 to 16) in the ACE inhibitor group (n = 231), 8 (-1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support-free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02735707.
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Affiliation(s)
- Patrick R Lawler
- Peter Munk Cardiac Centre at University Health Network, Toronto, Canada
- McGill University Health Centre, Montreal, QC, Canada
| | | | | | | | | | | | | | | | - Frank Gommans
- Radboud University Medical Centre, Nijmegen, Netherlands
| | | | - David E Leaf
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Rebecca M Baron
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Edy Y Kim
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Slava Epelman
- Peter Munk Cardiac Centre at University Health Network, Toronto, Canada
| | - Yvonne Kwan
- Peter Munk Cardiac Centre at University Health Network, Toronto, Canada
| | - Richard Grieve
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Stephen O'Neill
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Zia Sadique
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | | | | | - Paul R Mouncey
- Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | - Kathryn M Rowan
- Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | | | - Djillali Annane
- Hospital Raymond Poincaré (Assistance Publique Hôpitaux de Paris), Garches, France
- Université Versailles SQY - Université Paris Saclay, Montigny-le-Bretonneux, France
| | - Yaseen M Arabi
- King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Carly Au
- Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | - Abi Beane
- University of Oxford, Oxford, England
| | | | | | | | | | | | | | - Meredith Buxton
- Global Coalition for Adaptive Research, Larkspur, California
| | | | | | - Matthew Cove
- Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | | | | | | | | | - David Gattas
- The George Institute for Global Health, Sydney, Australia
| | - Lucas C Godoy
- Peter Munk Cardiac Centre at University Health Network, Toronto, Canada
| | | | - Rashan Haniffa
- University of Oxford, Bangkok, Thailand
- National Intensive Care Surveillance (NICST), Colombo, Sri Lanka
| | - David A Harrison
- Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | - Thomas Hills
- Medical Research Institute of New Zealand (MRINZ), Wellington, New Zealand
| | | | | | | | | | - Daniel F McAuley
- Queen's University Belfast, Belfast, Northern Ireland
- Royal Victoria Hospital, Belfast, Northern Ireland
| | | | - Shay P McGuinness
- Monash University, Melbourne, Australia
- Auckland City Hospital, Auckland, New Zealand
| | | | | | - Alistair D Nichol
- Monash University, Melbourne, Australia
- University College Dublin, Dublin, Ireland
| | - David R J Owen
- Department of Brain Sciences, Imperial College London, London, United Kingdom
- UK Dementia Research Institute of Imperial College London, London, United Kingdom
| | - Rachael L Parke
- Auckland City Hospital, Auckland, New Zealand
- University of Auckland, Auckland, New Zealand
| | | | | | - Luis Felipe Reyes
- Universidad de La Sabana, Chia, Colombia
- Clinica Universidad de La Sabana, Chia, Colombia
| | - Hiroki Saito
- St Marianna University School of Medicine, Yokohama City Seibu Hospital, Yokohama, Japan
| | | | | | | | | | | | - Alexis F Turgeon
- Université Laval, Québec City, Canada
- CHU de Québec-Université Laval Research Center, Québec City, Canada
| | - Anne M Turner
- Medical Research Institute of New Zealand (MRINZ), Wellington, New Zealand
| | | | | | - Roger J Lewis
- Berry Consultants, Austin, Texas
- Harbor-UCLA Medical Center, Torrance, California
- Statistical Editor, JAMA
| | - Derek C Angus
- University of Pittsburgh, Pittsburgh, Pennsylvania
- Senior Editor, JAMA
| | | | - Anthony C Gordon
- Imperial College London, London, United Kingdom
- Imperial College Healthcare NHS Trust, St Mary's Hospital, London, United Kingdom
| | | | - Steve A Webb
- Monash University, Melbourne, Australia
- St John of God Hospital, Subiaco, Australia
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8
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Wu C, Chen Y, Zhou P, Hu Z. Recombinant human angiotensin-converting enzyme 2 plays a protective role in mice with sepsis-induced cardiac dysfunction through multiple signaling pathways dependent on converting angiotensin II to angiotensin 1-7. ANNALS OF TRANSLATIONAL MEDICINE 2023; 11:13. [PMID: 36760245 PMCID: PMC9906207 DOI: 10.21037/atm-22-6016] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 12/29/2022] [Indexed: 01/13/2023]
Abstract
Background Sepsis-induced cardiac dysfunction (SICD) is a common complication of sepsis and contributes to mortality and the complexity of management in patients with sepsis. Recombinant human angiotensin-converting enzyme 2 (rhACE2) has been reported to protect the heart from injury and dysfunction in conditions which involve increased angiotensin II (Ang II). In this study, we aimed to detect the effects of rhACE2 on SICD. Methods A SICD model was developed in male C57/B6 mice by lipopolysaccharide (LPS) intraperitoneal injection. When cardiac dysfunction was confirmed by echocardiography 3 hours after LPS administration, mice were treated with either saline, rhACE2, or rhACE2 + A779. All mice received echocardiographic examination at 6 hours after LPS injection and then were sacrificed for serum and myocardial tissues collection. Angiotensin, cardiac troponin I (cTnI), and inflammatory markers in serum were measured. Histopathology features were examined by hematoxylin and eosin (HE) and terminal deoxynucleotidyl transferase (TdT) dUTP nick-end labeling (TUNEL) staining to evaluate structure injury and cell pyroptosis rate in heart tissue respectively. Pyroptosis-related proteins and signaling pathways involved in nucleotide binding and oligomerization domain-like receptor family pyrin domain-containing 3 (NLRP3) inflammasome activation in heart tissue were investigated by western blot (WB). Results RhACE2 relieved myocardial injury and improved cardiac function in mice with SICD accompanied by decrease of Ang II and increase of angiotensin 1-7 (Ang 1-7) in serum. RhACE2 diminished activation of NLRP3 inflammasome, inflammatory response, and cell pyroptosis induced by LPS. In addition, rhACE2 partly inhibited activation of nuclear factor κB (NF-κB), the p38 mitogen-activated protein kinase (MAPK) pathway, and promoted activation of the AMP-activated protein kinase-α1 (AMPK-α1) pathway in heart tissue. Administration of A779 offset the inhibitive effects of rhACE2 on NLRP3 expression and protective role on cardiac injury and dysfunction in mice with SICD. Conclusions RhACE2 plays a protective role in SICD, ameliorating cardiac injury and dysfunction through NF-κB, p38 MAPK, and the AMPK-α1/NLRP3 inflammasome pathway dependent on converting Ang II to Ang 1-7.
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Affiliation(s)
- Chunxue Wu
- Department of Critical Care Medicine, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China;,Intensive Care Unit of Emergency Department, Neurology Branch of Cangzhou Central Hospital, Cangzhou, China;,Hebei Key Laboratory of Critical Disease Mechanism and Intervention, Shijiazhuang, China
| | - Yuhong Chen
- Department of Critical Care Medicine, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China;,Hebei Key Laboratory of Critical Disease Mechanism and Intervention, Shijiazhuang, China
| | - Pan Zhou
- Department of Critical Care Medicine, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China;,Hebei Key Laboratory of Critical Disease Mechanism and Intervention, Shijiazhuang, China
| | - Zhenjie Hu
- Department of Critical Care Medicine, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China;,Hebei Key Laboratory of Critical Disease Mechanism and Intervention, Shijiazhuang, China
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9
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Chen XS, Cui JR, Meng XL, Wang SH, Wei W, Gao YL, Shou ST, Liu YC, Chai YF. Angiotensin-(1-7) ameliorates sepsis-induced cardiomyopathy by alleviating inflammatory response and mitochondrial damage through the NF-κB and MAPK pathways. J Transl Med 2023; 21:2. [PMID: 36593471 PMCID: PMC9807106 DOI: 10.1186/s12967-022-03842-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 12/20/2022] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND There is no available viable treatment for Sepsis-Induced Cardiomyopathy (SIC), a common sepsis complication with a higher fatality risk. The septic patients showed an abnormal activation of the renin angiotensin (Ang) aldosterone system (RAAS). However, it is not known how the Ang II and Ang-(1-7) affect SIC. METHODS Peripheral plasma was collected from the Healthy Control (HC) and septic patients and Ang II and Ang-(1-7) protein concentrations were measured. The in vitro and in vivo models of SIC were developed using Lipopolysaccharide (LPS) to preliminarily explore the relationship between the SIC state, Ang II, and Ang-(1-7) levels, along with the protective function of exogenous Ang-(1-7) on SIC. RESULTS Peripheral plasma Ang II and the Ang II/Ang-(1-7) levels in SIC-affected patients were elevated compared to the levels in HC and non-SIC patients, however, the HC showed higher Ang-(1-7) levels. Furthermore, peripheral plasma Ang II, Ang II/Ang-(1-7), and Ang-(1-7) levels in SIC patients were significantly correlated with the degree of myocardial injury. Additionally, exogenous Ang-(1-7) can attenuate inflammatory response, reduce oxidative stress, maintain mitochondrial dynamics homeostasis, and alleviate mitochondrial structural and functional damage by inhibiting nuclear factor-kappa B (NF-κB) and mitogen-activated protein kinase (MAPK) signaling pathways, thus alleviating SIC. CONCLUSIONS Plasma Ang-(1-7), Ang II, and Ang II/Ang-(1-7) levels were regarded as significant SIC biomarkers. In SIC, therapeutic targeting of RAAS, for example with Ang-(1-7), may exert protective roles against myocardial damage.
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Affiliation(s)
- Xin-Sen Chen
- grid.412645.00000 0004 1757 9434Department of Emergency Medicine, Tianjin Medical University General Hospital, 154 Anshan Road, Tianjin, 300052 China
| | - Jing-Rui Cui
- grid.412645.00000 0004 1757 9434Department of Emergency Medicine, Tianjin Medical University General Hospital, 154 Anshan Road, Tianjin, 300052 China
| | - Xiang-Long Meng
- grid.412645.00000 0004 1757 9434Department of Emergency Medicine, Tianjin Medical University General Hospital, 154 Anshan Road, Tianjin, 300052 China
| | - Shu-Hang Wang
- grid.412645.00000 0004 1757 9434Department of Emergency Medicine, Tianjin Medical University General Hospital, 154 Anshan Road, Tianjin, 300052 China
| | - Wei Wei
- grid.412645.00000 0004 1757 9434Department of Emergency Medicine, Tianjin Medical University General Hospital, 154 Anshan Road, Tianjin, 300052 China
| | - Yu-Lei Gao
- grid.412645.00000 0004 1757 9434Department of Emergency Medicine, Tianjin Medical University General Hospital, 154 Anshan Road, Tianjin, 300052 China
| | - Song-Tao Shou
- grid.412645.00000 0004 1757 9434Department of Emergency Medicine, Tianjin Medical University General Hospital, 154 Anshan Road, Tianjin, 300052 China
| | - Yan-Cun Liu
- grid.412645.00000 0004 1757 9434Department of Emergency Medicine, Tianjin Medical University General Hospital, 154 Anshan Road, Tianjin, 300052 China
| | - Yan-Fen Chai
- grid.412645.00000 0004 1757 9434Department of Emergency Medicine, Tianjin Medical University General Hospital, 154 Anshan Road, Tianjin, 300052 China
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10
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Wang J, Li J, Lou A, Lin Y, Xu Q, Cui W, Huang W, Wang G, Li Y, Sun J, Gong J, Guo Q, Qiu H, Meng Y, Li X. Sacubitril/valsartan alleviates sepsis-induced acute lung injury via inhibiting GSDMD-dependent macrophage pyroptosis in mice. FEBS J 2022; 290:2180-2198. [PMID: 36471663 DOI: 10.1111/febs.16696] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 10/25/2022] [Accepted: 12/05/2022] [Indexed: 12/12/2022]
Abstract
Sepsis-induced acute lung injury (ALI) is a life-threatening disorder with intricate pathogenesis. Macrophage pyroptosis reportedly plays a vital role in ALI. Although it has been established that angiotensin receptor blockers (ARBs) can reduce sepsis-induced organ injury, the efficacy of sacubitril/valsartan (SV) for sepsis has been largely understudied. Here, we aimed to investigate the role of SV in sepsis-induced ALI. Caecal ligation and puncture (CLP) were used to induce polymicrobial sepsis and related ALI. The therapeutic effects of SV in CLP mice were subsequently assessed. Gasdermin D (GSDMD)-/- mice were used to validate the signalling pathways affected by SV. In vitro, mouse bone marrow-derived macrophages (BMDMs) and Raw264.7 cells were treated with SV following exposure to lipopolysaccharide and adenosine triphosphate. Finally, the serum obtained from 42 septic patients was used for biochemical analysis. Compared to the other ARBs, SV yielded more pronounced anti-inflammatory effects on macrophages. In vivo, SV decreased mortality rates, significantly reduced lung damage and prevented the inflammatory response in CLP mice. In addition, SV suppressed GSDMD-mediated macrophage pyroptosis in mice. In BMDMs and Raw264.7 cells, the anti-inflammatory and anti-pyroptosis properties of SV were verified. SV treatment effectively inhibited NLRP3 inflammasome activation and prevented macrophage pyroptosis in a GSDMD-dependent manner. Furthermore, we found that septic individuals had considerably higher serum angiotensin II levels. Overall, we found that SV might prevent ALI in CLP mice by inhibiting GSDMD-mediated pyroptosis of macrophages. Thus, SV might be a viable drug for sepsis-induced ALI.
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Affiliation(s)
- Jun Wang
- Department of Emergency Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Gastroenterology, Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jierui Li
- Department of Emergency Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Anni Lou
- Department of Emergency Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Ying Lin
- Department of Emergency Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Qihan Xu
- Guangdong Provincial Key Laboratory of Gastroenterology, Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Wanfu Cui
- Department of Emergency Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Weichang Huang
- Department of Emergency Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Guozhen Wang
- Department of Emergency Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yang Li
- Department of Emergency Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jing Sun
- Department of Emergency Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jiacheng Gong
- Guangdong Provincial Key Laboratory of Gastroenterology, Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Qiuping Guo
- Department of Emergency Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Hongshen Qiu
- Guangdong Provincial Key Laboratory of Gastroenterology, Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Ying Meng
- Department of Respiratory and Critical Care Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xu Li
- Department of Emergency Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, China.,Ministry of Education, Key Laboratory of Hainan Trauma and Disaster Rescue, College of Emergency and Trauma, Hainan Medical University, Haikou, China
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11
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Schottelkotte KM, Crone SA. Forebrain control of breathing: Anatomy and potential functions. Front Neurol 2022; 13:1041887. [PMID: 36388186 PMCID: PMC9663927 DOI: 10.3389/fneur.2022.1041887] [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: 09/11/2022] [Accepted: 10/11/2022] [Indexed: 01/25/2023] Open
Abstract
The forebrain plays important roles in many critical functions, including the control of breathing. We propose that the forebrain is important for ensuring that breathing matches current and anticipated behavioral, emotional, and physiological needs. This review will summarize anatomical and functional evidence implicating forebrain regions in the control of breathing. These regions include the cerebral cortex, extended amygdala, hippocampus, hypothalamus, and thalamus. We will also point out areas where additional research is needed to better understand the specific roles of forebrain regions in the control of breathing.
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Affiliation(s)
- Karl M. Schottelkotte
- Department of Pharmacology and Systems Physiology, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Steven A. Crone
- Division of Pediatric Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States,Division of Developmental Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States,Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH, United States,*Correspondence: Steven A. Crone
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12
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Renin as a Marker of Tissue Perfusion, Septic Shock and Mortality in Septic Patients: A Prospective Observational Study. Int J Mol Sci 2022; 23:ijms23169133. [PMID: 36012398 PMCID: PMC9409106 DOI: 10.3390/ijms23169133] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 08/10/2022] [Accepted: 08/12/2022] [Indexed: 11/16/2022] Open
Abstract
Sepsis is a life-threatening organ dysfunction caused by the dysregulation of the host’s response to an infection, where the dominant mechanism is tissue hypoperfusion. Currently, the marker used to define tissue disorders is lactate levels, which may be elevated in other disease states as well. Renin is an essential hormone for the proper functioning of the renin-angiotensin-aldosterone (RASS) system. It is secreted in the glomerular apparatus in response to hypoperfusion. This study aimed to assess the usefulness of renin as a marker of tissue hypoperfusion in patients with sepsis and septic shock. A final group of 48 patients treated for sepsis and septic shock in the intensive care unit was included. Blood samples for renin quantification were collected in the morning as a part of routine blood analysis on the first, third, and fifth days. Sepsis was diagnosed in 19 patients (39.6%), and septic shock was diagnosed in 29 patients (60.4%). There was no significant difference in renin concentration between patients who received and did not receive continuous renal replacement therapy (CRRT) on any study day. Therefore, all samples were analyzed together in subsequent analyses. There was a significant difference in renin concentration between sepsis survivors and non-survivors on the third (31.5 and 119.9 pg/mL, respectively) and fifth (18.2 and 106.7 pg/mL, respectively) days. As a survival marker, renin was characterized by 69% and 71% overall accuracy if determined on the third and fifth days, respectively. There was a significant difference in renin concentration between sepsis and septic shock patients on the first (45.8 and 103.4 pg/mL, respectively) and third (24.7 and 102.1 pg/mL, respectively) days. At an optimal cut-off of 87 pg/mL, renin had very good specificity and a positive likelihood ratio. Renin was a strong predictor of mortality in patients with sepsis and septic shock. Further, the level of renin in patients with septic shock was significantly higher than in patients with sepsis. In combination with the assessment of lactate concentration, renin seems to be the optimal parameter for monitoring tissue hypoperfusion and could be helpful for septic shock diagnosis, as well as for identifying candidate patients for CRRT.
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13
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Owen A, Patel JM, Parekh D, Bangash MN. Mechanisms of Post-critical Illness Cardiovascular Disease. Front Cardiovasc Med 2022; 9:854421. [PMID: 35911546 PMCID: PMC9334745 DOI: 10.3389/fcvm.2022.854421] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 06/22/2022] [Indexed: 11/13/2022] Open
Abstract
Prolonged critical care stays commonly follow trauma, severe burn injury, sepsis, ARDS, and complications of major surgery. Although patients leave critical care following homeostatic recovery, significant additional diseases affect these patients during and beyond the convalescent phase. New cardiovascular and renal disease is commonly seen and roughly one third of all deaths in the year following discharge from critical care may come from this cluster of diseases. During prolonged critical care stays, the immunometabolic, inflammatory and neurohumoral response to severe illness in conjunction with resuscitative treatments primes the immune system and parenchymal tissues to develop a long-lived pro-inflammatory and immunosenescent state. This state is perpetuated by persistent Toll-like receptor signaling, free radical mediated isolevuglandin protein adduct formation and presentation by antigen presenting cells, abnormal circulating HDL and LDL isoforms, redox and metabolite mediated epigenetic reprogramming of the innate immune arm (trained immunity), and the development of immunosenescence through T-cell exhaustion/anergy through epigenetic modification of the T-cell genome. Under this state, tissue remodeling in the vascular, cardiac, and renal parenchymal beds occurs through the activation of pro-fibrotic cellular signaling pathways, causing vascular dysfunction and atherosclerosis, adverse cardiac remodeling and dysfunction, and proteinuria and accelerated chronic kidney disease.
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Affiliation(s)
- Andrew Owen
- Department of Critical Care, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham, United Kingdom
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
| | - Jaimin M. Patel
- Department of Critical Care, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham, United Kingdom
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
| | - Dhruv Parekh
- Department of Critical Care, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham, United Kingdom
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
| | - Mansoor N. Bangash
- Department of Critical Care, Queen Elizabeth Hospital, University Hospitals Birmingham, Birmingham, United Kingdom
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
- *Correspondence: Mansoor N. Bangash
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14
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Camargo RL, Bombassaro B, Monfort-Pires M, Mansour E, Palma AC, Ribeiro LC, Ulaf RG, Bernardes AF, Nunes TA, Agrela MV, Dertkigil RP, Dertkigil SS, Araujo EP, Nadruz W, Moretti ML, Velloso LA, Sposito AC. Plasma Angiotensin II Is Increased in Critical Coronavirus Disease 2019. Front Cardiovasc Med 2022; 9:847809. [PMID: 35811697 PMCID: PMC9263116 DOI: 10.3389/fcvm.2022.847809] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 05/31/2022] [Indexed: 12/24/2022] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) employs angiotensin-converting enzyme 2 (ACE2) as its receptor for cell entrance, and studies have suggested that upon viral binding, ACE2 catalytic activity could be inhibited; therefore, impacting the regulation of the renin-angiotensin-aldosterone system (RAAS). To date, only few studies have evaluated the impact of SARS-CoV-2 infection on the blood levels of the components of the RAAS. The objective of this study was to determine the blood levels of ACE, ACE2, angiotensin-II, angiotensin (1-7), and angiotensin (1-9) at hospital admission and discharge in a group of patients presenting with severe or critical evolution of coronavirus disease 2019 (COVID-19). We showed that ACE, ACE2, angiotensin (1-7), and angiotensin (1-9) were similar in patients with critical and severe COVID-19. However, at admission, angiotensin-II levels were significantly higher in patients presenting as critical, compared to patients presenting with severe COVID-19. We conclude that blood levels of angiotensin-II are increased in hospitalized patients with COVID-19 presenting the critical outcome of the disease. We propose that early measurement of Ang-II could be a useful biomarker for identifying patients at higher risk for extremely severe progression of the disease.
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Affiliation(s)
- Rafael L Camargo
- Obesity and Comorbidities Research Center, University of Campinas, Campinas, Brazil
| | - Bruna Bombassaro
- Obesity and Comorbidities Research Center, University of Campinas, Campinas, Brazil
| | - Milena Monfort-Pires
- Obesity and Comorbidities Research Center, University of Campinas, Campinas, Brazil
| | - Eli Mansour
- Department of Internal Medicine, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Andre C Palma
- Department of Internal Medicine, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Luciana C Ribeiro
- Department of Internal Medicine, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Raisa G Ulaf
- Department of Internal Medicine, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Ana Flavia Bernardes
- Department of Internal Medicine, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Thyago A Nunes
- Department of Internal Medicine, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Marcus V Agrela
- Department of Internal Medicine, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Rachel P Dertkigil
- Department of Radiology, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Sergio S Dertkigil
- Department of Radiology, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Eliana P Araujo
- Obesity and Comorbidities Research Center, University of Campinas, Campinas, Brazil.,School of Nursing, University of Campinas, Campinas, Brazil
| | - Wilson Nadruz
- Obesity and Comorbidities Research Center, University of Campinas, Campinas, Brazil.,Department of Internal Medicine, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Maria Luiza Moretti
- Department of Internal Medicine, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Licio A Velloso
- Obesity and Comorbidities Research Center, University of Campinas, Campinas, Brazil.,Department of Internal Medicine, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Andrei C Sposito
- Obesity and Comorbidities Research Center, University of Campinas, Campinas, Brazil.,Department of Internal Medicine, School of Medical Sciences, University of Campinas, Campinas, Brazil
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15
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Proczka M, Przybylski J, Cudnoch-Jędrzejewska A, Szczepańska-Sadowska E, Żera T. Vasopressin and Breathing: Review of Evidence for Respiratory Effects of the Antidiuretic Hormone. Front Physiol 2021; 12:744177. [PMID: 34867449 PMCID: PMC8637824 DOI: 10.3389/fphys.2021.744177] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 09/27/2021] [Indexed: 12/17/2022] Open
Abstract
Vasopressin (AVP) is a key neurohormone involved in the regulation of body functions. Due to its urine-concentrating effect in the kidneys, it is often referred to as antidiuretic hormone. Besides its antidiuretic renal effects, AVP is a potent neurohormone involved in the regulation of arterial blood pressure, sympathetic activity, baroreflex sensitivity, glucose homeostasis, release of glucocorticoids and catecholamines, stress response, anxiety, memory, and behavior. Vasopressin is synthesized in the paraventricular (PVN) and supraoptic nuclei (SON) of the hypothalamus and released into the circulation from the posterior lobe of the pituitary gland together with a C-terminal fragment of pro-vasopressin, known as copeptin. Additionally, vasopressinergic neurons project from the hypothalamus to the brainstem nuclei. Increased release of AVP into the circulation and elevated levels of its surrogate marker copeptin are found in pulmonary diseases, arterial hypertension, heart failure, obstructive sleep apnoea, severe infections, COVID-19 due to SARS-CoV-2 infection, and brain injuries. All these conditions are usually accompanied by respiratory disturbances. The main stimuli that trigger AVP release include hyperosmolality, hypovolemia, hypotension, hypoxia, hypoglycemia, strenuous exercise, and angiotensin II (Ang II) and the same stimuli are known to affect pulmonary ventilation. In this light, we hypothesize that increased AVP release and changes in ventilation are not coincidental, but that the neurohormone contributes to the regulation of the respiratory system by fine-tuning of breathing in order to restore homeostasis. We discuss evidence in support of this presumption. Specifically, vasopressinergic neurons innervate the brainstem nuclei involved in the control of respiration. Moreover, vasopressin V1a receptors (V1aRs) are expressed on neurons in the respiratory centers of the brainstem, in the circumventricular organs (CVOs) that lack a blood-brain barrier, and on the chemosensitive type I cells in the carotid bodies. Finally, peripheral and central administrations of AVP or antagonists of V1aRs increase/decrease phrenic nerve activity and pulmonary ventilation in a site-specific manner. Altogether, the findings discussed in this review strongly argue for the hypothesis that vasopressin affects ventilation both as a blood-borne neurohormone and as a neurotransmitter within the central nervous system.
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Affiliation(s)
- Michał Proczka
- Department of Experimental and Clinical Physiology, Doctoral School, Medical University of Warsaw, Warsaw, Poland
| | - Jacek Przybylski
- Department of Biophysics, Physiology, and Pathophysiology, Laboratory of Centre for Preclinical Research, Medical University of Warsaw, Warsaw, Poland
| | - Agnieszka Cudnoch-Jędrzejewska
- Department of Experimental and Clinical Physiology, Laboratory of Centre for Preclinical Research, Medical University of Warsaw, Warsaw, Poland
| | - Ewa Szczepańska-Sadowska
- Department of Experimental and Clinical Physiology, Laboratory of Centre for Preclinical Research, Medical University of Warsaw, Warsaw, Poland
| | - Tymoteusz Żera
- Department of Experimental and Clinical Physiology, Laboratory of Centre for Preclinical Research, Medical University of Warsaw, Warsaw, Poland
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16
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Shi S, Pan X, Feng H, Zhang S, Shi S, Lin W. Identification of transcriptomics biomarkers for the early prediction of the prognosis of septic shock from pneumopathies. BMC Infect Dis 2021; 21:1190. [PMID: 34836493 PMCID: PMC8619650 DOI: 10.1186/s12879-021-06888-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 11/19/2021] [Indexed: 11/21/2022] Open
Abstract
Background Identifying the biological subclasses of septic shock might provide specific targeted therapies for the treatment and prognosis of septic shock. It might be possible to find biological markers for the early prediction of septic shock prognosis. Methods The data were obtained from the Gene Expression Omnibus databases (GEO) in NCBI. GO enrichment and KEGG pathway analyses were performed to investigate the functional annotation of up- and downregulated DEGs. ROC curves were drawn, and their areas under the curves (AUCs) were determined to evaluate the predictive value of the key genes. Results 117 DEGs were obtained, including 36 up- and 81 downregulated DEGs. The AUC for the MME gene was 0.879, as a key gene with the most obvious upregulation in septic shock. The AUC for the THBS1 gene was 0.889, as a key downregulated gene with the most obvious downregulation in septic shock. Conclusions The upregulation of MME via the renin-angiotensin system pathway and the downregulation of THBS1 through the PI3K–Akt signaling pathway might have implications for the early prediction of prognosis of septic shock in patients with pneumopathies.
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Affiliation(s)
- Songchang Shi
- Department of Critical Care Medicine, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital South Branch, Fujian Provincial Hospital Jinshan Branch, Fuzhou, 350001, Fujian, People's Republic of China
| | - Xiaobin Pan
- Department of Critical Care Medicine, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital South Branch, Fujian Provincial Hospital Jinshan Branch, Fuzhou, 350001, Fujian, People's Republic of China
| | - Hangwei Feng
- Department of Critical Care Medicine, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital South Branch, Fujian Provincial Hospital Jinshan Branch, Fuzhou, 350001, Fujian, People's Republic of China
| | - Shujuan Zhang
- Department of Critical Care Medicine, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital South Branch, Fujian Provincial Hospital Jinshan Branch, Fuzhou, 350001, Fujian, People's Republic of China
| | - Songjing Shi
- Department of Critical Care Medicine, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, No.134 East Street, Gulou District, Fuzhou, 350001, Fujian, People's Republic of China.
| | - Wei Lin
- Department of Endocrinology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, No.134 East Street, Gulou District, Fuzhou, 350001, Fujian, People's Republic of China.
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17
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Human Ace D/I Polymorphism Could Affect the Clinicobiological Course of COVID-19. J Renin Angiotensin Aldosterone Syst 2021; 2021:5509280. [PMID: 34603503 PMCID: PMC8448604 DOI: 10.1155/2021/5509280] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 07/04/2021] [Accepted: 08/20/2021] [Indexed: 01/13/2023] Open
Abstract
Introduction The coronavirus disease 2019 (COVID-19), that is caused by severe acute respiratory syndrome corona virus 2 (SARS-CoV-2), has spread rapidly worldwide since December 2019. The SARS-CoV-2 virus has a great affinity for the angiotensin-converting enzyme-2 (ACE-2) receptor, which is an essential element of the renin-angiotensin system (RAS). This study is aimed at assessing the impact of the angiotensin-converting enzyme (ACE) gene insertion (I)/deletion (D) polymorphisms, on the susceptibility and clinical outcomes of the COVID-19 immunoinflammatory syndrome. Patients and Methods. A total of 112 patients diagnosed with COVID-19 between 1 and 15 May 2020 were enrolled in the study. ACE gene allele frequencies were compared to the previously reported Turkish population comprised of 300 people. Results The most common genotype in the patients and control group was DI with 53% and II with 42%, respectively. The difference in the presence of the D allele between the patient and control groups was statistically significant (67% vs. 42%, respectively, p < 0.0001). Severe pneumonia was observed more in patients with DI allele (31%) than DD (8%) and II (0%) (p = 0.021). The mortality rate, time to defervescence, and the hospitalization duration were not different between the genotype groups. Conclusion Genotype DI of ACE I/D polymorphism is associated with the infectious rate particularly severe pneumonia in this study conducted in the Turkish population. Therefore, ACE D/I polymorphism could affect the clinical course of COVID-19.
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Patel JS, Colon Hidalgo D, Capistrano I, Mancl E, Rech MA. Antihypertensive Medications Prior to Shock Onset Do Not Impact Initial Vasopressor Requirements in Patients With Shock. J Pharm Pract 2021; 36:342-349. [PMID: 34601987 DOI: 10.1177/08971900211048623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: The effect of the use of antihypertensive agents in patients prior to the development of shock is unclear. The purpose of this study was to determine the impact of antihypertensive agents on vasopressor dose and duration in shock. Materials and Methods: This retrospective, single-center study included patients with shock who received at least one vasopressor for at least 24 hours after shock onset from January 1 to June 30, 2017. Patients taking an antihypertensive agent(s) were compared to those who were not. The primary outcome was the number of vasopressor-free hours at 72 hours. Secondary outcomes included maximum and cumulative vasopressor doses, intensive care unit length of stay, and 30-day mortality. Results: One hundred and sixty-eight patients were included and 99 (59%) were on antihypertensives. Distributive shock was the most common type of shock (75.5%) and more patients taking antihypertensives had hypertension, coronary artery disease, and dyslipidemia at baseline. There was no difference in the number of vasopressor-free hours at 72 hours between patients taking an antihypertensive medication(s) and the control group (2 hours vs 1 hour; P = .11). No difference was found between any of the secondary outcomes. Conclusion: Patients taking antihypertensive agents prior to shock onset did not require increased vasopressor doses or duration.
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Affiliation(s)
- Jaimini S Patel
- Department of Pharmacy, Cleveland Clinic Akron General Medical Center, OH, USA
| | | | - Irene Capistrano
- Department of Pharmacy, 25815Loyola University Medical Center, IL, USA
| | - Erin Mancl
- Department of Pharmacy, 25815Loyola University Medical Center, IL, USA
| | - Megan A Rech
- Department of Pharmacy, 25815Loyola University Medical Center, IL, USA.,Department of Emergency Medicine, Stritch School of Medicine, Loyola University Chicago, IL, USA
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Dysregulation of the renin-angiotensin system in septic shock: Mechanistic insights and application of angiotensin II in clinical management. Pharmacol Res 2021; 174:105916. [PMID: 34597810 DOI: 10.1016/j.phrs.2021.105916] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 09/18/2021] [Accepted: 09/26/2021] [Indexed: 12/12/2022]
Abstract
Synergistic physiologic mechanisms involving the renin-angiotensin system (RAS), the sympathetic nervous system, and the arginine-vasopressin system play an integral role in blood pressure homeostasis. A subset of patients with sepsis experience septic shock with attendant circulatory, cellular, and metabolic abnormalities. Septic shock is associated with increased mortality because of an inadequacy to maintain mean arterial blood pressure (MAP) despite volume resuscitation and the use of vasopressors. Vasodilatory shock raises the dose of vasopressors required to maintain a MAP of > 65 mm Hg. The diminished response to endogenous angiotensin II in sepsis-induced vasoplegia may be related to the aberrant RAS activation that stimulates a proinflammatory beneficial antibacterial response, increasing the secretion of proinflammatory cytokines that downregulate AT-1 receptors expression. Moreover, excessive systemic upregulation of nitric oxide synthase, stimulation of prostaglandin synthesis, and activation of ATP-sensitive potassium channels followed by reduced vascular entry of calcium ions are putative mechanisms in the reduced responsiveness to vasopressors. However, intravenous angiotensin II in catecholamine-resistant septic shock patients showed substantial evidence of raising the MAP to target hemodynamic levels, thus allowing time to treat underlying conditions. Nevertheless, evidence of catecholamine-sparing effect by adding angiotensin II, aimed at increasing the therapeutic index of vasopressor therapy, does not show an attenuation of end-organ damage. The use of angiotensin II in septic shock has not been evaluated in patients who are not catecholamine resistant. This, in conjunction with an evolving definition of catecholamine resistance, provides an opportunity for further evaluation of exogenous angiotensin II in septic shock.
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20
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Flannery AH, Ortiz-Soriano V, Li X, Gianella FG, Toto RD, Moe OW, Devarajan P, Goldstein SL, Neyra JA. Serum renin and major adverse kidney events in critically ill patients: a multicenter prospective study. Crit Care 2021; 25:294. [PMID: 34391450 PMCID: PMC8364694 DOI: 10.1186/s13054-021-03725-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 08/04/2021] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Preliminary studies have suggested that the renin-angiotensin system is activated in critical illness and associated with mortality and kidney outcomes. We sought to assess in a larger, multicenter study the relationship between serum renin and Major Adverse Kidney Events (MAKE) in intensive care unit (ICU) patients. METHODS Prospective, multicenter study at two institutions of patients with and without acute kidney injury (AKI). Blood samples were collected for renin measurement a median of 2 days into the index ICU admission and 5-7 days later. The primary outcome was MAKE at hospital discharge, a composite of mortality, kidney replacement therapy, or reduced estimated glomerular filtration rate to ≤ 75% of baseline. RESULTS Patients in the highest renin tertile were more severely ill overall, including more AKI, vasopressor-dependence, and severity of illness. MAKE were significantly greater in the highest renin tertile compared to the first and second tertiles. In multivariable logistic regression, this initial measurement of renin remained significantly associated with both MAKE as well as the individual component of mortality. The association of renin with MAKE in survivors was not statistically significant. Renin measurements at the second time point were also higher in patients with MAKE. The trajectory of the renin measurements between time 1 and 2 was distinct when comparing death versus survival, but not when comparing MAKE versus those without. CONCLUSIONS In a broad cohort of critically ill patients, serum renin measured early in the ICU admission is associated with MAKE at discharge, particularly mortality.
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Affiliation(s)
- Alexander H Flannery
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY, USA
- Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, KY, USA
| | - Victor Ortiz-Soriano
- Department of Internal Medicine, Division of Nephrology, Bone, and Mineral Metabolism, University of Kentucky College of Medicine, Lexington, KY, 40536, USA
| | - Xilong Li
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Fabiola G Gianella
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Robert D Toto
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Department of Internal Medicine, Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Orson W Moe
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Department of Internal Medicine, Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Prasad Devarajan
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Stuart L Goldstein
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, OH, USA
| | - Javier A Neyra
- Department of Internal Medicine, Division of Nephrology, Bone, and Mineral Metabolism, University of Kentucky College of Medicine, Lexington, KY, 40536, USA.
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, TX, USA.
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21
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Laghlam D, Jozwiak M, Nguyen LS. Renin-Angiotensin-Aldosterone System and Immunomodulation: A State-of-the-Art Review. Cells 2021; 10:cells10071767. [PMID: 34359936 PMCID: PMC8303450 DOI: 10.3390/cells10071767] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 06/30/2021] [Accepted: 07/09/2021] [Indexed: 12/11/2022] Open
Abstract
The renin–angiotensin system (RAS) has long been described in the field of cardiovascular physiology as the main player in blood pressure homeostasis. However, other effects have since been described, and include proliferation, fibrosis, and inflammation. To illustrate the immunomodulatory properties of the RAS, we chose three distinct fields in which RAS may play a critical role and be the subject of specific treatments. In oncology, RAS hyperactivation has been associated with tumor migration, survival, cell proliferation, and angiogenesis; preliminary data showed promise of the benefit of RAS blockers in patients treated for certain types of cancer. In intensive care medicine, vasoplegic shock has been associated with severe macro- and microcirculatory imbalance. A relative insufficiency in angiotensin II (AngII) was associated to lethal outcomes and synthetic AngII has been suggested as a specific treatment in these cases. Finally, in solid organ transplantation, both AngI and AngII have been associated with increased rejection events, with a regional specificity in the RAS activity. These elements emphasize the complexity of the direct and indirect interactions of RAS with immunomodulatory pathways and warrant further research in the field.
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Preadmission Antihypertensive Drug Use and Sepsis Outcome: Impact of Angiotensin-Converting Enzyme Inhibitors (ACEIs) and Angiotensin Receptor Blockers (ARBs). Shock 2021; 53:407-415. [PMID: 31135703 DOI: 10.1097/shk.0000000000001382] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Several studies have reported improved sepsis outcomes when certain preadmission antihypertensive drugs, namely, calcium channel blockers (CCBs), are used. This study aims to determine whether preadmission antihypertensive drug use, especially angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs), is associated with decreased total hospital mortality in sepsis. METHODS This study was conducted using the unique database of a sepsis cohort from the National Health Insurance Research Database in Taiwan. Frequency matching for age and sex between preadmission antihypertensive drug users (study cohort) and nonusers (comparison cohort) was conducted. The primary outcome was total hospital mortality. Logistic regression analyses were performed to calculate the odds ratios (ORs) of important variables. Further joint effect analyses were carried out to examine the impacts of different combinations of antihypertensive drugs. RESULTS A total of 33,213 sepsis antihypertensive drug use patients were retrieved as the study cohort, and an equal number of matched sepsis patients who did not use antihypertensive drugs were identified as the comparison cohort. The study cohort had a higher incidence rate of being diagnosed with septic shock compared with the comparison cohort (4.36%-2.31%, P < 0.001) and a higher rate of total hospital mortality (38.42%-24.57%, P < 0.001). In the septic shock condition, preadmission antihypertensive drug use was associated with a decreased adjusted OR (OR = 0.66, 95% confidence interval [CI], 0.55-0.80) for total hospital mortality, which was not observed for the nonseptic shock condition. Compared with antihypertensive drug nonusers, both ACEI and ARB users had decreased adjusted ORs for total hospital mortality in sepsis (adjusted OR = 0.93, 95% CI, 0.88-0.98 and adjusted OR = 0.85, 95% CI, 0.81-0.90); however, CCB, beta-blocker, and diuretic users did not. In the septic shock condition, ACEI, ARB, CCB, and beta-blocker users all had decreased ORs for total hospital mortality. Joint effect analysis showed ACEI use, except in combination with diuretics, to be associated with a decreased adjusted OR for total hospital mortality in sepsis. Similar results were observed for ARB users. CONCLUSIONS Preadmission ACEI or ARB use is associated with a decreased risk of total hospital mortality, regardless of a nonshock or septic shock condition.
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23
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Fernandes D, Pacheco LK, Sordi R, Scheschowitsch K, Ramos GC, Assreuy J. Angiotensin II receptor type 1 blockade improves hyporesponsiveness to vasopressors in septic shock. Eur J Pharmacol 2021; 897:173953. [PMID: 33617825 DOI: 10.1016/j.ejphar.2021.173953] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 02/04/2021] [Accepted: 02/15/2021] [Indexed: 11/30/2022]
Abstract
Sepsis activates the renin-angiotensin system and the production of angiotensin II, which has a key role in the regulation of blood pressure through AT1 receptors. However, excessive activation of AT1 receptor is associated with deleterious effects. We investigated the consequences of a differential blockade of AT1 receptor caused by two doses of losartan (0.25 mg/kg or 15 mg/kg, s.c), a selective AT1 receptor antagonist on sepsis outcome. These doses reduced the effect of angiotensin II in normal rats by 30% and >90% 8 h after administration, respectively, but only the higher dose maintained its inhibitory effect (~70%) 24 h after injection. Sepsis was induced by cecal ligation and puncture (CLP). Losartan was injected 2 h after CLP and parameters were evaluated 6 and 24 h after CLP. Septic rats developed hypotension and hyporesponsiveness to vasoconstrictors, an intense inflammatory process and increase in plasma markers of organ dysfunction. The lower dose of losartan improved the vasoconstrictive response to phenylephrine and angiotensin II, reduced lung myeloperoxidase and prevented leukopenia 24 h after CLP, but it did not reduce NOS-2 expression, plasma IL-6 levels or organ injury parameters of septic rats. On the other hand, the higher dose of losartan worsened the response to vasoconstrictors, potentiated the hypotension and increased further levels of creatine, urea and lactate in septic rats. Therefore, an early and partial blockade of AT1 receptor with a low dose of losartan may counteract sepsis-induced refractoriness to vasoconstrictors thus providing an opportunity to improve the outcome of this condition.
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MESH Headings
- Angiotensin II/metabolism
- Angiotensin II Type 1 Receptor Blockers/pharmacology
- Animals
- Arterial Pressure/drug effects
- Disease Models, Animal
- Dose-Response Relationship, Drug
- Female
- Hypotension/drug therapy
- Hypotension/metabolism
- Hypotension/microbiology
- Hypotension/physiopathology
- Inflammation Mediators/blood
- Losartan/pharmacology
- Rats, Wistar
- Receptor, Angiotensin, Type 2/drug effects
- Receptor, Angiotensin, Type 2/metabolism
- Renin-Angiotensin System/drug effects
- Shock, Septic/drug therapy
- Shock, Septic/metabolism
- Shock, Septic/microbiology
- Shock, Septic/physiopathology
- Vasoconstriction/drug effects
- Vasoconstrictor Agents/pharmacology
- Rats
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Affiliation(s)
- Daniel Fernandes
- Department of Pharmacology, Universidade Federal de Santa Catarina, Florianópolis, Brazil
| | - Letícia Kramer Pacheco
- Department of Pharmacology, Universidade Federal de Santa Catarina, Florianópolis, Brazil
| | - Regina Sordi
- Department of Pharmacology, Universidade Federal de Santa Catarina, Florianópolis, Brazil
| | - Karin Scheschowitsch
- Department of Pharmacology, Universidade Federal de Santa Catarina, Florianópolis, Brazil
| | - Gustavo Campos Ramos
- Department of Pharmacology, Universidade Federal de Santa Catarina, Florianópolis, Brazil
| | - Jamil Assreuy
- Department of Pharmacology, Universidade Federal de Santa Catarina, Florianópolis, Brazil.
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Oz M, Lorke DE. Multifunctional angiotensin converting enzyme 2, the SARS-CoV-2 entry receptor, and critical appraisal of its role in acute lung injury. Biomed Pharmacother 2021; 136:111193. [PMID: 33461019 PMCID: PMC7836742 DOI: 10.1016/j.biopha.2020.111193] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 12/15/2020] [Accepted: 12/26/2020] [Indexed: 12/11/2022] Open
Abstract
The recent emergence of coronavirus disease-2019 (COVID-19) as a pandemic affecting millions of individuals has raised great concern throughout the world, and the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) was identified as the causative agent for COVID-19. The multifunctional protein angiotensin converting enzyme 2 (ACE2) is accepted as its primary target for entry into host cells. In its enzymatic function, ACE2, like its homologue ACE, regulates the renin-angiotensin system (RAS) critical for cardiovascular and renal homeostasis in mammals. Unlike ACE, however, ACE2 drives an alternative RAS pathway by degrading Ang-II and thus operates to balance RAS homeostasis in the context of hypertension, heart failure, and cardiovascular as well as renal complications of diabetes. Outside the RAS, ACE2 hydrolyzes key peptides, such as amyloid-β, apelin, and [des-Arg9]-bradykinin. In addition to its enzymatic functions, ACE2 is found to regulate intestinal amino acid homeostasis and the gut microbiome. Although the non-enzymatic function of ACE2 as the entry receptor for SARS-CoV-2 has been well established, the contribution of enzymatic functions of ACE2 to the pathogenesis of COVID-19-related lung injury has been a matter of debate. A complete understanding of this central enzyme may begin to explain the various symptoms and pathologies seen in SARS-CoV-2 infected individuals, and may aid in the development of novel treatments for COVID-19.
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Affiliation(s)
- Murat Oz
- Department of Pharmacology and Therapeutics, Faculty of Pharmacy, Kuwait University, Safat 13110, Kuwait.
| | - Dietrich Ernst Lorke
- Department of Anatomy and Cellular Biology, Khalifa University, Abu Dhabi, United Arab Emirates; Center for Biotechnology, Khalifa University of Science and Technology, Abu Dhabi, United Arab Emirates
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25
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Belyea BC, Santiago AE, Vasconez WA, Nagalakshmi VK, Xu F, Mehalic TC, Sequeira-Lopez MLS, Gomez RA. A primitive type of renin-expressing lymphocyte protects the organism against infections. Sci Rep 2021; 11:7251. [PMID: 33790364 PMCID: PMC8012387 DOI: 10.1038/s41598-021-86629-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 03/02/2021] [Indexed: 12/11/2022] Open
Abstract
The hormone renin plays a crucial role in the regulation of blood pressure and fluid-electrolyte homeostasis. Normally, renin is synthesized by juxtaglomerular (JG) cells, a specialized group of myoepithelial cells located near the entrance to the kidney glomeruli. In response to low blood pressure and/or a decrease in extracellular fluid volume (as it occurs during dehydration, hypotension, or septic shock) JG cells respond by releasing renin to the circulation to reestablish homeostasis. Interestingly, renin-expressing cells also exist outside of the kidney, where their function has remained a mystery. We discovered a unique type of renin-expressing B-1 lymphocyte that may have unrecognized roles in defending the organism against infections. These cells synthesize renin, entrap and phagocyte bacteria and control bacterial growth. The ability of renin-bearing lymphocytes to control infections-which is enhanced by the presence of renin-adds a novel, previously unsuspected dimension to the defense role of renin-expressing cells, linking the endocrine control of circulatory homeostasis with the immune control of infections to ensure survival.
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Affiliation(s)
- Brian C Belyea
- Department of Pediatrics, Child Health Research Center, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Araceli E Santiago
- Department of Pediatrics, Child Health Research Center, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Wilson A Vasconez
- Department of Pediatrics, Child Health Research Center, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Vidya K Nagalakshmi
- Department of Pediatrics, Child Health Research Center, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Fang Xu
- Department of Pediatrics, Child Health Research Center, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Theodore C Mehalic
- Department of Pediatrics, Child Health Research Center, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Maria Luisa S Sequeira-Lopez
- Department of Pediatrics, Child Health Research Center, University of Virginia School of Medicine, Charlottesville, VA, USA.
| | - R Ariel Gomez
- Department of Pediatrics, Child Health Research Center, University of Virginia School of Medicine, Charlottesville, VA, USA.
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Razeghian-Jahromi I, Zibaeenezhad MJ, Lu Z, Zahra E, Mahboobeh R, Lionetti V. Angiotensin-converting enzyme 2: a double-edged sword in COVID-19 patients with an increased risk of heart failure. Heart Fail Rev 2021; 26:371-380. [PMID: 32844337 PMCID: PMC7447089 DOI: 10.1007/s10741-020-10016-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The coronavirus disease (COVID-19) pandemic is a global health priority. Given that cardiovascular diseases (CVD) are the leading cause of morbidity around the world and that several trials have reported severe cardiovascular damage in patients infected with SARS-CoV-2, a substantial number of COVID-19 patients with underlying cardiovascular diseases need to continue their medications in order to improve myocardial contractility and to prevent the onset of major adverse cardiovascular events (MACEs), including heart failure. Some of the current life-saving medications may actually simultaneously expose patients to a higher risk of severe COVID-19. Angiotensin-converting enzyme 2 (ACE2), a key counter regulator of the renin-angiotensin system (RAS), is the main entry gate of SARS-CoV-2 into human host cells and an established drug target to prevent heart failure. In fact, ACE inhibitors, angiotensin II receptor blockers, and mineralocorticoid antagonists may augment ACE2 levels to protect organs from angiotensin II overload. Elevated ACE2 expression on the host cell surface might facilitate viral entrance, at the same time sudden nonadherence to these medications triggers MACEs. Hence, safety issues in the use of RAS inhibitors in COVID-19 patients with cardiac dysfunction remain an unsolved dilemma and need paramount attention. Although ACE2 generally plays an adaptive role in both healthy subjects and patients with systolic and/or diastolic dysfunction, we conducted a literature appraisal on its maladaptive role. Understanding the exact role of ACE2 in COVID-19 patients at risk of heart failure is needed to safely manage RAS inhibitors in frail and non-frail critically ill patients.
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Affiliation(s)
| | | | - Zhibing Lu
- Department of Cardiology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Elyaspour Zahra
- Cardiovascular Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Razmkhah Mahboobeh
- Shiraz Institute for Cancer Research, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Vicenzo Lionetti
- Unit of Translational Critical Care Medicine, Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy. .,UOS Anesthesiology and Intensive Care Medicine, Fondazione Toscana G. Monasterio, Pisa, Italy.
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27
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Lee HW, Suh JK, Jang E, Lee SM. Effect of angiotensin converting enzyme inhibitor and angiotensin II receptor blocker on the patients with sepsis. Korean J Intern Med 2021; 36:371-381. [PMID: 32264653 PMCID: PMC7969078 DOI: 10.3904/kjim.2019.262] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 11/25/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND/AIMS Inhibitors of the renin-angiotensin system, angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs), reportedly have anti-inflammatory effects. This study assessed the association of prior use of ACE inhibitors and ARBs with sepsis-related clinical outcomes. METHODS A population-based observational study was conducted using the Health Insurance Review and Assessment Service claims data. Among the adult patients hospitalized with new onset of sepsis in 2012, patients who took ARBs or ACE inhibitors at least 30 days prior to hospitalization were analyzed. Generalized linear models and logistic regression were used to examine the relation between the prior use of medication and clinical outcomes, such as in-hospital mortality, mechanical ventilation, and length of stay. RESULTS Of a total of 27,628 patients who were hospitalized for sepsis, the ACE inhibitor, ARB, and non-user groups included 1,214 (4.4%), 3,951 (14.4%), and 22,463 (82.1%) patients, respectively. As the patients in the ACE inhibitor and ARB groups had several comorbid conditions, higher rates of intensive care unit admission, hemodialysis, and mechanical ventilation were observed. However, after covariate adjustment, the use of ACE inhibitor (odds ratio [OR], 0.752; 95% confidence interval [CI], 0.661 to 0.855) or ARB (OR, 0.575; 95% CI, 0.532 to 0.621) was significantly associated with a lower rate of in-hospital mortality. CONCLUSION Pre-hospitalization use of ACE inhibitors or ARBs for sepsis was an independent factor for a lower rate of in-hospital mortality.
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Affiliation(s)
- Hyun Woo Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jae Kyung Suh
- National Evidence-Based Healthcare Collaborating Agency, Seoul, Korea
| | - Eunjin Jang
- Department of Information Statistics, Andong National University, Andong, Korea
| | - Sang-Min Lee
- National Evidence-Based Healthcare Collaborating Agency, Seoul, Korea
- Correspondence to Sang-Min Lee, Ph.D. Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea Tel: +82-2-2072-0833 Fax: +82-2-764-2199 E-mail:
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28
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Xu JY, Chang W, Sun Q, Peng F, Yang Y. Pulmonary midkine inhibition ameliorates sepsis induced lung injury. J Transl Med 2021; 19:91. [PMID: 33639987 PMCID: PMC7913048 DOI: 10.1186/s12967-021-02755-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 02/16/2021] [Indexed: 02/08/2023] Open
Abstract
Background Midkine is a multi-functional molecule participating in a various key pathological process. We aimed to evaluate the change of midkine in sepsis and its association with angiotensin-converting enzyme (ACE) system, as well as the mechanism by which midkine induced in sepsis and lung injury. Methods The peripheral blood sample of septic patients on admission was obtained and measured for midkine, ACE and angiotensin II. Cecal ligation and puncture (CLP) mouse model was used, and adeno-associated virus (AAV) was stilled trans-trachea for regional targeting midkine expression, comparing the severity of lung injury. Furthermore, we studied the in vitro mechanism of midkine activates ACE system by using inhibitors targeting candidate receptors of midkine, and its effects on the vascular endothelial cells. Results Plasma midkine was significantly elevated in sepsis, and was closely associated with ACE system. Both circulating and lung midkine was increased in CLP mouse, and was related to severe lung injury. Regional interfering midkine expression in lung tissue by AAV could alleviate acute lung injury in CLP model. In vitro study elucidated that Notch 2 participated in the activation of ACE system and angiotensin II release, induced by midkine and triggered vascular endothelial injury by angiotensin II induced reactive oxygen species production. Conclusions Midkine inhibition ameliorates sepsis induced lung injury, which might via ACE/Ang II pathway and the participation of Notch 2 in the stimulation of ACE. Trial registration Clinicaltrials.gov NCT02605681. Registered 12 November 2015
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Affiliation(s)
- Jing-Yuan Xu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, 87 Dingjiaqiao Rd., Nanjing, 210009, People's Republic of China
| | - Wei Chang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, 87 Dingjiaqiao Rd., Nanjing, 210009, People's Republic of China
| | - Qin Sun
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, 87 Dingjiaqiao Rd., Nanjing, 210009, People's Republic of China
| | - Fei Peng
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, 87 Dingjiaqiao Rd., Nanjing, 210009, People's Republic of China
| | - Yi Yang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, 87 Dingjiaqiao Rd., Nanjing, 210009, People's Republic of China.
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29
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Xu DF, Liu YJ, Mao YF, Wang Y, Xu CF, Zhu XY, Jiang L. Elevated angiotensin II induces platelet apoptosis through promoting oxidative stress in an AT1R-dependent manner during sepsis. J Cell Mol Med 2021; 25:4124-4135. [PMID: 33624364 PMCID: PMC8051711 DOI: 10.1111/jcmm.16382] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 01/18/2021] [Accepted: 01/28/2021] [Indexed: 12/18/2022] Open
Abstract
Thrombocytopenia is independently related with increased mortality in severe septic patients. Renin‐angiotensin system (RAS) is elevated in septic subjects; accumulating studies show that angiotensin II (Ang II) stimulate the intrinsic apoptosis pathway by promoting reactive oxygen species (ROS) production. However, the mechanisms underlying the relationship of platelet apoptosis and RAS system in sepsis have not been fully elucidated. The present study aimed to elucidate whether the RAS was involved in the pathogenesis of sepsis‐associated thrombocytopenia and explore the underlying mechanisms. We found that elevated plasma Ang II was associated with decreased platelet count in both patients with sepsis and experimental animals exposed to lipopolysaccharide (LPS). Besides, Ang II treatment induced platelet apoptosis in a concentration‐dependent manner in primary isolated platelets, which was blocked by angiotensin II type 1 receptor (AT1R) antagonist losartan, but not by angiotensin II type 2 receptor (AT2R) antagonist PD123319. Moreover, inhibiting AT1R by losartan attenuated LPS‐induced platelet apoptosis and alleviated sepsis‐associated thrombocytopenia. Furthermore, Ang II treatment induced oxidative stress level in a concentration‐dependent manner in primary isolated platelets, which was partially reversed by the AT1R antagonist losartan. The present study demonstrated that elevated Ang II directly stimulated platelet apoptosis through promoting oxidative stress in an AT1R‐dependent manner in sepsis‐associated thrombocytopenia. The results would helpful for understanding the role of RAS system in sepsis‐associated thrombocytopenia.
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Affiliation(s)
- Dun-Feng Xu
- Department of Anesthesiology and Surgical Intensive Care Unit, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,School of Kinesiology, The Key Laboratory of Exercise and Health Sciences of Ministry of Education, Shanghai University of Sport, Shanghai, China
| | - Yu-Jian Liu
- School of Kinesiology, The Key Laboratory of Exercise and Health Sciences of Ministry of Education, Shanghai University of Sport, Shanghai, China
| | - Yan-Fei Mao
- Department of Anesthesiology and Surgical Intensive Care Unit, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yan Wang
- Department of Anesthesiology and Surgical Intensive Care Unit, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chu-Fan Xu
- Department of Anesthesiology and Surgical Intensive Care Unit, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,School of Kinesiology, The Key Laboratory of Exercise and Health Sciences of Ministry of Education, Shanghai University of Sport, Shanghai, China
| | - Xiao-Yan Zhu
- Department of Physiology, Navy Medical University, Shanghai, China
| | - Lai Jiang
- Department of Anesthesiology and Surgical Intensive Care Unit, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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30
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Ning L, Rong J, Zhang Z, Xu Y. Therapeutic approaches targeting renin-angiotensin system in sepsis and its complications. Pharmacol Res 2021; 167:105409. [PMID: 33465472 DOI: 10.1016/j.phrs.2020.105409] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 11/28/2020] [Accepted: 12/22/2020] [Indexed: 01/08/2023]
Abstract
Sepsis, caused by the inappropriate host response to infection, is characterized by excessive inflammatory response and organ dysfunction, thus becomes a critical clinical problem. Commonly, sepsis may progress to septic shock and severe complications, including acute kidney injury (AKI), acute respiratory distress syndrome (ARDS), sepsis-induced myocardial dysfunction (SIMD), liver dysfunction, cerebral dysfunction, and skeletal muscle atrophy, which predominantly contribute to high mortality. Additionally, the global pandemic of coronavirus disease 2019 (COVID-19) raised the concern of development of effectve therapeutic strategies for viral sepsis. Renin-angiotensin system (RAS) may represent as a potent therapeutic target for sepsis therapy. The emerging role of RAS in the pathogenesis of sepsis has been investigated and several preclinical and clinical trials targeting RAS for sepsis treatment revealed promising outcomes. Herein, we attempt to review the effects and mechanisms of RAS manipulation on sepsis and its complications and provide new insights into optimizing RAS interventions for sepsis treatment.
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Affiliation(s)
- Le Ning
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009, China
| | - Jiabing Rong
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009, China
| | - Zhaocai Zhang
- Department of Intensive Care Unit, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009, China.
| | - Yinchuan Xu
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009, China.
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31
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Miners S, Kehoe PG, Love S. Cognitive impact of COVID-19: looking beyond the short term. Alzheimers Res Ther 2020; 12:170. [PMID: 33380345 PMCID: PMC7772800 DOI: 10.1186/s13195-020-00744-w] [Citation(s) in RCA: 120] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 12/07/2020] [Indexed: 02/07/2023]
Abstract
COVID-19 is primarily a respiratory disease but up to two thirds of hospitalised patients show evidence of central nervous system (CNS) damage, predominantly ischaemic, in some cases haemorrhagic and occasionally encephalitic. It is unclear how much of the ischaemic damage is mediated by direct or inflammatory effects of virus on the CNS vasculature and how much is secondary to extracranial cardiorespiratory disease. Limited data suggest that the causative SARS-CoV-2 virus may enter the CNS via the nasal mucosa and olfactory fibres, or by haematogenous spread, and is capable of infecting endothelial cells, pericytes and probably neurons. Extracranially, SARS-CoV-2 targets endothelial cells and pericytes, causing endothelial cell dysfunction, vascular leakage and immune activation, sometimes leading to disseminated intravascular coagulation. It remains to be confirmed whether endothelial cells and pericytes in the cerebral vasculature are similarly targeted. Several aspects of COVID-19 are likely to impact on cognition. Cerebral white matter is particularly vulnerable to ischaemic damage in COVID-19 and is also critically important for cognitive function. There is accumulating evidence that cerebral hypoperfusion accelerates amyloid-β (Aβ) accumulation and is linked to tau and TDP-43 pathology, and by inducing phosphorylation of α-synuclein at serine-129, ischaemia may also increase the risk of development of Lewy body disease. Current therapies for COVID-19 are understandably focused on supporting respiratory function, preventing thrombosis and reducing immune activation. Since angiotensin-converting enzyme (ACE)-2 is a receptor for SARS-CoV-2, and ACE inhibitors and angiotensin receptor blockers are predicted to increase ACE-2 expression, it was initially feared that their use might exacerbate COVID-19. Recent meta-analyses have instead suggested that these medications are protective. This is perhaps because SARS-CoV-2 entry may deplete ACE-2, tipping the balance towards angiotensin II-ACE-1-mediated classical RAS activation: exacerbating hypoperfusion and promoting inflammation. It may be relevant that APOE ε4 individuals, who seem to be at increased risk of COVID-19, also have lowest ACE-2 activity. COVID-19 is likely to leave an unexpected legacy of long-term neurological complications in a significant number of survivors. Cognitive follow-up of COVID-19 patients will be important, especially in patients who develop cerebrovascular and neurological complications during the acute illness.
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Affiliation(s)
- Scott Miners
- Dementia Research Group, Bristol Medical School (THS), University of Bristol, Learning & Research level 1, Southmead Hospital, Bristol, BS10 5NB, UK.
| | - Patrick G Kehoe
- Dementia Research Group, Bristol Medical School (THS), University of Bristol, Learning & Research level 1, Southmead Hospital, Bristol, BS10 5NB, UK
| | - Seth Love
- Dementia Research Group, Bristol Medical School (THS), University of Bristol, Learning & Research level 1, Southmead Hospital, Bristol, BS10 5NB, UK.
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32
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Vieweg R, Järemo M, Steinvall I, Elmasry M, Abdelrahman I, Sjöberg F. Renin signals renal hypoperfusion during Parkland fluid resuscitation of severe burns - a prospective longitudinal cohort study. INTERNATIONAL JOURNAL OF BURNS AND TRAUMA 2020; 10:331-337. [PMID: 33500845 PMCID: PMC7811941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 11/23/2020] [Indexed: 06/12/2023]
Abstract
INTRODUCTION Previous investigations have shown that fluid resuscitation of burns using the Parkland formula results in controlled hypovolaemia and that kidney injury is a common complication. Enhancing monitoring of tissue perfusion might reduce complications. Plasma renin has recently been suggested to be a promising marker for tissue hypoperfusion in intensive care patients. The aim of this study was to explore plasma renin levels during the first 48 hours after major burns in patients resuscitated using the Parkland formula. MATERIALS AND METHODS Patients 18 years or older of age with 10% or more total body surface area (TBSA) burned, admitted to Linköping Burn Intensive Care Unit, and resuscitated using the Parkland formula were included. Samples for plasma renin were drawn at admission and eight-hourly thereafter for 48 hours. RESULTS Fifteen patients were included. Median TBSA burned was 36% and age 53 years. The fluid volumes provided were in accordance with the Parkland formula. Mean arterial pressure, urinary output, and lactate remained within reference ranges during the first 48 hours. At eight hours after burn median plasma renin was elevated to more than 25 times the upper reference value, decreasing to about four times the upper reference at 48 hours. Renin concentration was associated with lactate levels and TBSA burned. CONCLUSION During Parkland fluid resuscitation of severe burns, plasma renin levels were extremely elevated. The fact that the traditionally used endpoints for Parkland fluid resuscitation remained within the reference range raises concerns about whether the increased renin concentrations may signal a relative renal hypoperfusion.
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Affiliation(s)
- Rosa Vieweg
- Department of Anaesthesiology and Intensive Care in Linköping, Department of Biomedical and Clinical Sciences, Linköping UniversityLinköping, Sweden
| | - Mikael Järemo
- Department of Biomedical and Clinical Sciences, Linköping UniversityLinköping, Sweden
| | - Ingrid Steinvall
- Department of Hand Surgery, Plastic Surgery and Burns in Linköping, Department of Biomedical and Clinical Sciences, Linköping UniversityLinköping, Sweden
| | - Moustafa Elmasry
- Department of Hand Surgery, Plastic Surgery and Burns in Linköping, Department of Biomedical and Clinical Sciences, Linköping UniversityLinköping, Sweden
| | - Islam Abdelrahman
- Department of Hand Surgery, Plastic Surgery and Burns in Linköping, Department of Biomedical and Clinical Sciences, Linköping UniversityLinköping, Sweden
| | - Folke Sjöberg
- Department of Anaesthesiology and Intensive Care in Linköping, Department of Biomedical and Clinical Sciences, Linköping UniversityLinköping, Sweden
- Department of Hand Surgery, Plastic Surgery and Burns in Linköping, Department of Biomedical and Clinical Sciences, Linköping UniversityLinköping, Sweden
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33
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Vasanthakumar N. Beta-Adrenergic Blockers as a Potential Treatment for COVID-19 Patients. Bioessays 2020; 42:e2000094. [PMID: 32815593 PMCID: PMC7460992 DOI: 10.1002/bies.202000094] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 07/28/2020] [Indexed: 12/19/2022]
Abstract
More than 15 million people have been affected by coronavirus disease 2019 (COVID-19) and it has caused 640 016 deaths as of July 26, 2020. Currently, no effective treatment option is available for COVID-19 patients. Though many drugs have been proposed, none of them has shown particular efficacy in clinical trials. In this article, the relationship between the Adrenergic system and the renin-angiotensin-aldosterone system (RAAS) is focused in COVID-19 and a vicious circle consisting of the Adrenergic system-RAAS-Angiotensin converting enzyme 2 (ACE2)-severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (which is referred to as the "ARAS loop") is proposed. Hyperactivation of the ARAS loop may be the underlying pathophysiological mechanism in COVID-19, and beta-adrenergic blockers are proposed as a potential treatment option. Beta-adrenergic blockers may decrease the SARS-CoV-2 cellular entry by decreasing ACE2 receptors expression and cluster of differentiation 147 (CD147) in various cells in the body. Beta-adrenergic blockers may decrease the morbidity and mortality in COVID-19 patients by preventing or reducing acute respiratory distress syndrome (ARDS) and other complications. Retrospective and prospective clinical trials should be conducted to check the validity of the hypothesis. Also see the video abstract here https://youtu.be/uLoy7do5ROo.
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Affiliation(s)
- Natesan Vasanthakumar
- School of Chemical and BiotechnologySASTRA Deemed UniversityThanjavurTamil Nadu613401India
- Present address:
Abel ClinicUthangaraiTamil Nadu635207India
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34
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COVID-19 and Microvascular Disease: Pathophysiology of SARS-CoV-2 Infection With Focus on the Renin-Angiotensin System. Heart Lung Circ 2020; 29:1596-1602. [PMID: 32972810 PMCID: PMC7467122 DOI: 10.1016/j.hlc.2020.08.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/26/2020] [Accepted: 08/14/2020] [Indexed: 02/08/2023]
Abstract
The recently described severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has infected millions of people, with thousands of fatalities. It has prompted global efforts in research, with focus on the pathophysiology of coronavirus disease-19 (COVID-19), and a rapid surge of publications. COVID-19 has been associated with a myriad of clinical manifestations, including the lungs, heart, kidneys, central nervous system, gastrointestinal system, skin, and blood coagulation abnormalities. The endothelium plays a key role in organ dysfunction associated with severe infection, and current data suggest that it is also involved in SARS-CoV-2-induced sepsis. This critical review aimed to address a possible unifying mechanism underlying the diverse complications of COVID-19: microvascular dysfunction, with emphasis on the renin-angiotensin system. In addition, research perspectives are suggested in order to expand understanding of the pathophysiology of the infection.
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35
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Zheng H, Cao JJ. Angiotensin-Converting Enzyme Gene Polymorphism and Severe Lung Injury in Patients with Coronavirus Disease 2019. THE AMERICAN JOURNAL OF PATHOLOGY 2020; 190:2013-2017. [PMID: 32735889 PMCID: PMC7387924 DOI: 10.1016/j.ajpath.2020.07.009] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 07/15/2020] [Accepted: 07/20/2020] [Indexed: 12/21/2022]
Abstract
Coronavirus disease 2019 has markedly varied clinical presentations, with most patients being asymptomatic or having mild symptoms. However, severe acute respiratory disease, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is common and associated with mortality in patients who require hospitalization. The etiology of susceptibility to severe lung injury remains unclear. Angiotensin II, converted by angiotensin-converting enzyme (ACE) from angiotensin I and metabolized by ACE 2 (ACE2), plays a pivotal role in the pathogenesis of lung injury. ACE2 is identified as an essential receptor for SARS-CoV-2 to enter the cell. The binding of ACE2 and SARS-CoV-2 leads to the exhaustion and down-regulation of ACE2. The interaction and imbalance between ACE and ACE2 result in an unopposed angiotensin II. Considering that the ACE insertion (I)/deletion (D) gene polymorphism contributes to the ACE level variability in general population, in which mean ACE level in DD carriers is approximately twice that in II carriers, we propose a hypothesis of genetic predisposition to severe lung injury in patients with coronavirus disease 2019. It is plausible that the ACE inhibitors and ACE receptor blockers may have the potential to prevent and to treat the acute lung injury after SARS-CoV-2 infection, especially for those with the ACE genotype associated with high ACE level.
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Affiliation(s)
- Haoyi Zheng
- St. Francis Hospital, The Heart Center, Roslyn, New York.
| | - J Jane Cao
- St. Francis Hospital, The Heart Center, Roslyn, New York
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36
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Leisman DE, Fernandes TD, Bijol V, Abraham MN, Lehman JR, Taylor MD, Capone C, Yaipan O, Bellomo R, Deutschman CS. Impaired angiotensin II type 1 receptor signaling contributes to sepsis-induced acute kidney injury. Kidney Int 2020; 99:148-160. [PMID: 32882263 DOI: 10.1016/j.kint.2020.07.047] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 07/16/2020] [Accepted: 07/24/2020] [Indexed: 12/26/2022]
Abstract
In sepsis-induced acute kidney injury, kidney blood flow may increase despite decreased glomerular filtration. Normally, angiotensin-II reduces kidney blood flow to maintain filtration. We hypothesized that sepsis reduces angiotensin type-1 receptor (AT1R) expression to account for this observation and tested this hypothesis in a patient case-control study and studies in mice. Seventy-three mice underwent cecal ligation and puncture (a sepsis model) or sham operation. Additionally, 94 septic mice received losartan (selective AT1R antagonist), angiotensin II without or with losartan, or vehicle. Cumulative urine output, kidney blood flow, blood urea nitrogen, and creatinine were measured. AT1R expression was assessed using ELISA, qPCR, and immunofluorescence. A blinded pathologist evaluated tissue for ischemic injury. AT1R expression was compared in autopsy tissue from seven patients with sepsis to that of the non-involved portion of kidney from ten individuals with kidney cancer and three non-infected but critically ill patients. By six hours post ligation/puncture, kidney blood flow doubled, blood urea nitrogen rose, and urine output fell. Concurrently, AT1R expression significantly fell 2-fold in arterioles and the macula densa. Creatinine significantly rose by 24 hours and sham operation did not alter measurements. Losartan significantly exacerbated ligation/puncture-induced changes in kidney blood flow, blood urea nitrogen, creatinine, and urine output. There was no histologic evidence of cortical ischemia. Significantly, angiotensin II prevented changes in kidney blood flow, creatinine, and urine output compared to vehicle. Co-administering losartan with angiotensin-II reversed this protection. Relative to both controls, patients with sepsis had low AT1R expression in arterioles and macula densa. Thus, murine cecal ligation/puncture and clinical sepsis decrease renal AT1R expression. Angiotensin II prevents functional changes while AT1R-blockade exacerbates them independent of ischemia in mice.
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Affiliation(s)
- Daniel E Leisman
- Icahn School of Medicine at Mount Sinai, New York, New York, USA; Sepsis Research Laboratory, Feinstein Institute for Medical Research, Manhasset, New York, USA; Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA; Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.
| | - Tiago D Fernandes
- Sepsis Research Laboratory, Feinstein Institute for Medical Research, Manhasset, New York, USA; Department of Pediatrics, Cohen Children's Medical Center, New Hyde Park, New York, USA
| | - Vanesa Bijol
- Department of Pathology, North Shore University Hospital, Manhasset, New York, USA; Zucker School of Medicine at Hofstra-Northwell, Hempstead, New York, USA
| | - Mabel N Abraham
- Sepsis Research Laboratory, Feinstein Institute for Medical Research, Manhasset, New York, USA; Department of Pediatrics, Cohen Children's Medical Center, New Hyde Park, New York, USA
| | - Jake R Lehman
- Sepsis Research Laboratory, Feinstein Institute for Medical Research, Manhasset, New York, USA; Zucker School of Medicine at Hofstra-Northwell, Hempstead, New York, USA
| | - Matthew D Taylor
- Sepsis Research Laboratory, Feinstein Institute for Medical Research, Manhasset, New York, USA; Department of Pediatrics, Cohen Children's Medical Center, New Hyde Park, New York, USA; Zucker School of Medicine at Hofstra-Northwell, Hempstead, New York, USA
| | - Christine Capone
- Sepsis Research Laboratory, Feinstein Institute for Medical Research, Manhasset, New York, USA; Department of Pediatrics, Cohen Children's Medical Center, New Hyde Park, New York, USA; Zucker School of Medicine at Hofstra-Northwell, Hempstead, New York, USA
| | - Omar Yaipan
- Sepsis Research Laboratory, Feinstein Institute for Medical Research, Manhasset, New York, USA; Department of Pediatrics, Cohen Children's Medical Center, New Hyde Park, New York, USA
| | - Rinaldo Bellomo
- Data Analytics, Research and Evaluation (DARE) Centre, Austin Hospital, University of Melbourne, Melbourne, Australia; Department of Intensive Care, Austin Hospital, Melbourne, Australia; Centre of Integrated Critical Care, University of Melbourne, Melbourne, Australia; School of Medicine, University of Melbourne, Melbourne, Australia
| | - Clifford S Deutschman
- Sepsis Research Laboratory, Feinstein Institute for Medical Research, Manhasset, New York, USA; Department of Pediatrics, Cohen Children's Medical Center, New Hyde Park, New York, USA; Zucker School of Medicine at Hofstra-Northwell, Hempstead, New York, USA
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37
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Zheng H, Cao JJ. Angiotensin-Converting Enzyme Gene Polymorphism and Severe Lung Injury in Patients with Coronavirus Disease 2019. THE AMERICAN JOURNAL OF PATHOLOGY 2020. [PMID: 32735889 DOI: 10.1016/j.ajpath.2020.07.009.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 09/30/2022]
Abstract
Coronavirus disease 2019 has markedly varied clinical presentations, with most patients being asymptomatic or having mild symptoms. However, severe acute respiratory disease, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is common and associated with mortality in patients who require hospitalization. The etiology of susceptibility to severe lung injury remains unclear. Angiotensin II, converted by angiotensin-converting enzyme (ACE) from angiotensin I and metabolized by ACE 2 (ACE2), plays a pivotal role in the pathogenesis of lung injury. ACE2 is identified as an essential receptor for SARS-CoV-2 to enter the cell. The binding of ACE2 and SARS-CoV-2 leads to the exhaustion and down-regulation of ACE2. The interaction and imbalance between ACE and ACE2 result in an unopposed angiotensin II. Considering that the ACE insertion (I)/deletion (D) gene polymorphism contributes to the ACE level variability in general population, in which mean ACE level in DD carriers is approximately twice that in II carriers, we propose a hypothesis of genetic predisposition to severe lung injury in patients with coronavirus disease 2019. It is plausible that the ACE inhibitors and ACE receptor blockers may have the potential to prevent and to treat the acute lung injury after SARS-CoV-2 infection, especially for those with the ACE genotype associated with high ACE level.
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Affiliation(s)
- Haoyi Zheng
- St. Francis Hospital, The Heart Center, Roslyn, New York.
| | - J Jane Cao
- St. Francis Hospital, The Heart Center, Roslyn, New York
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38
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Plasma Renin Concentration is Associated With Hemodynamic Deficiency and Adverse Renal Outcome in Septic Shock. Shock 2020; 52:e22-e30. [PMID: 30407370 DOI: 10.1097/shk.0000000000001285] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND In septic shock, both systemic vasodilatation and glomerular arteriole dilatation are responsible for the drop in glomerular filtration observed in early acute kidney injury. Angiotensin II has been shown to act on both mechanisms. Our objective was to evaluate the impact of renin angiotensin system activation, on hemodynamic deficiency and renal outcome in patient with septic shock and to assess whether urinary sodium could be a reliable test for high plasma renin concentration screening. METHODS This was a prospective and observational study. Inclusion criteria were early septic shock (first episode), dose of norepinephrine ≥ 0.25 μg/kg/min, before the start of substitutive corticosteroids. Plasma renin concentration, plasma aldosterone concentration, and urinary sodium were measured at inclusion. Renal outcome, organ deficiency, and 28-day survival were followed. RESULTS Plasma renin concentration was associated with worse hemodynamic deficiency and adverse renal outcome. Natriuresis was associated with shock severity but was not associated with renal outcome. Low natriuresis (< 20 mM) was associated with higher renin concentration. Those two variables were only weakly correlated. CONCLUSION Plasma renin concentration is associated with adverse renal outcome, probably through shock severity and insufficient glomerular efferent arterioles vasoconstriction. An association was observed between low natriuresis and high plasma renin concentration.
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39
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Bui AD, Helgeson SA, Guru PK, Sanghavi DK. Angiotensin II for the treatment of septic shock in a neutropenic patient with T-cell acute lymphoblastic leukaemia. BMJ Case Rep 2020; 13:13/6/e233432. [PMID: 32595128 DOI: 10.1136/bcr-2019-233432] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Mortality remains high in septic shock with few new treatment options. Angiotensin II has been recently approved for use in septic shock due to promising results in the ATHOS-3 trial. However, patients with neutropenia were excluded in the trial. This patient population is becoming increasingly common in the intensive care unit as there is an increase in novel biologic therapies and stem cell transplantations for haematological and solid organ malignancies. We present a case of a patient with T-cell acute lymphoblastic leukaemia who received chemotherapy, resulting in neutropenia and septic shock. There was persistent hypotension despite initiating multiple conventional vasopressors. Angiotensin II was attempted with immediate improvement in the blood pressure which resulted in weaning of other vasopressors. This positive haemodynamic response suggests that angiotensin II can successfully be used in neutropenic patients without increasing the overall catecholamine burden of septic shock.
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Affiliation(s)
- Albert D Bui
- Critical Care, Mayo Clinic Florida, Jacksonville, Florida, USA.,Ohio University Heritage College of Osteopathic Medicine, Athens, Ohio, USA
| | | | - Pramod K Guru
- Critical Care, Mayo Clinic Florida, Jacksonville, Florida, USA
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40
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Lumlertgul N, Ostermann M. Roles of angiotensin II as vasopressor in vasodilatory shock. Future Cardiol 2020; 16:569-583. [PMID: 32462921 DOI: 10.2217/fca-2020-0019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Shock is an acute condition of circulatory failure resulting in life-threatening organ dysfunction, high morbidity and high mortality. Current management includes fluid and catecholamine therapy to maintain adequate mean arterial pressure and organ perfusion. Norepinephrine is recommended as first-line vasopressor, but other agents are available. Angiotensin II is an alternative potent vasoconstrictor without chronotropic or inotropic properties. Several studies, including a large randomized controlled trial have demonstrated its ability to increase blood pressure with catecholamine-sparing effects. Angiotensin II was consequently approved by the US FDA in 2017 and the EU in 2019 as an add-on vasopressor in vasodilatory shock. This review aims to discuss its basic pharmacology, clinical efficacy, safety and future perspectives.
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Affiliation(s)
- Nuttha Lumlertgul
- Department of Critical Care, Guy's & St. Thomas' Hospital, London SE1 7EH, UK.,Division of Nephrology, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Bangkok 10330, Thailand.,Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok 10330, Thailand.,Critical Care Nephrology Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
| | - Marlies Ostermann
- Department of Critical Care, Guy's & St. Thomas' Hospital, London SE1 7EH, UK
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41
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Busse LW, Ostermann M. Vasopressor Therapy and Blood Pressure Management in the Setting of Acute Kidney Injury. Semin Nephrol 2020; 39:462-472. [PMID: 31514910 DOI: 10.1016/j.semnephrol.2019.06.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Acute kidney injury (AKI) is common in the setting of shock. Hemodynamic instability is a risk factor for the development of AKI, and pathophysiological mechanisms include loss of renal perfusion pressure and impaired microcirculation. Although restoration of mean arterial pressure (MAP) may mitigate the risk of AKI to some extent, evidence on this is conflicting. Also debatable is the optimal blood pressure needed to minimize the risk of kidney injury. A MAP of 65 mm Hg traditionally has been considered adequate to maintain renal perfusion pressure, and studies have failed to consistently show improved outcomes at higher levels of MAP. Therapeutic options to support renal perfusion consist of catecholamines, vasopressin, and angiotensin II. Although catecholamines are the most studied, they are associated with adverse events at higher doses, including AKI. Vasopressin and angiotensin II are noncatecholamine options to support blood pressure and may improve microcirculatory hemodynamics through unique mechanisms, including differential vasoconstriction of efferent and afferent arterioles within the nephron. Future areas of study include methods by which clinicians can measure renal blood flow in a macrocirculatory and microcirculatory way, a personalized approach to blood pressure management in septic shock using patient-specific measures of perfusion adequacy, and novel agents that may improve the microcirculation within the kidneys without causing adverse microcirculatory effects in other organs.
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Affiliation(s)
- Laurence W Busse
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA.
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's and St Thomas' National Health Service Foundation Hospital, London, United Kingdom
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Brojakowska A, Narula J, Shimony R, Bander J. Clinical Implications of SARS-CoV-2 Interaction With Renin Angiotensin System: JACC Review Topic of the Week. J Am Coll Cardiol 2020; 75:3085-3095. [PMID: 32305401 PMCID: PMC7161517 DOI: 10.1016/j.jacc.2020.04.028] [Citation(s) in RCA: 113] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 04/09/2020] [Accepted: 04/13/2020] [Indexed: 01/03/2023]
Abstract
Severe acute respiratory-syndrome coronavirus-2 (SARS-CoV-2) host cell infection is mediated by binding to angiotensin-converting enzyme 2 (ACE2). Systemic dysregulation observed in SARS-CoV was previously postulated to be due to ACE2/angiotensin 1-7 (Ang1-7)/Mas axis downregulation; increased ACE2 activity was shown to mediate disease protection. Because angiotensin II receptor blockers, ACE inhibitors, and mineralocorticoid receptor antagonists increase ACE2 receptor expression, it has been tacitly believed that the use of these agents may facilitate viral disease; thus, they should not be used in high-risk patients with cardiovascular disease. Based on the anti-inflammatory benefits of the upregulation of the ACE2/Ang1-7/Mas axis and previously demonstrated benefits of lung function improvement in SARS-CoV infections, it has been hypothesized that the benefits of treatment with renin-angiotensin system inhibitors in SARS-CoV-2 may outweigh the risks and at the very least should not be withheld.
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Affiliation(s)
- Agnieszka Brojakowska
- Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jagat Narula
- Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Rony Shimony
- Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jeffrey Bander
- Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York.
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Renin aldosterone vasopressin and copeptin kinetics in patients with septic shock, a post-hoc Hyper2S randomized trial analysis. Intensive Care Med 2020; 46:808-810. [DOI: 10.1007/s00134-019-05912-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2019] [Indexed: 10/25/2022]
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Knotzer H, Poidinger B, Kleinsasser A. Pharmacologic Agents for the Treatment of Vasodilatory Shock. Curr Pharm Des 2020; 25:2133-2139. [PMID: 31272348 DOI: 10.2174/1381612825666190704101907] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 06/20/2019] [Indexed: 01/05/2023]
Abstract
Vasodilatory shock is a life-threatening syndrome in critically ill patients and is characterized by severe hypotension and resultant tissue hypoperfusion. This shock state requires the use of vasopressor agents to restore adequate vascular tone. Norepinephrine is still recommended as first-line vasopressor in the management of critically ill patients suffering from severe vasodilation. In the recent time, catecholaminergic vasopressor drugs have been associated with possible side effects at higher dosages. This so-called catecholamine toxicity has focused on alternative noncatecholaminergic vasopressors or the use of moderate doses of multiple vasopressors with complementary mechanisms of action. Besides vasopressin and terlipressin, angiotensin II may be a promising drug for the management of vasodilatory shock. In addition, adjunctive drugs, such as hydrocortisone, methylene blue or ascorbic acid can be added to conventional vasopressor therapy. The objective of this review is to give an overview of the current available vasopressor agents used in vasodilatory shock. A thorough search of PubMed was conducted in order to identify the majority of studies related to the subject. Data on the outcome of several drugs and future perspective of possible management strategies for the therapy of vasodilatory shock are discussed.
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Affiliation(s)
- Hans Knotzer
- Institute of Anesthesiology and Critical Care Medicine II, Klinikum Wels, Wels, Austria
| | - Bernhard Poidinger
- Institute of Anesthesiology and Critical Care Medicine II, Klinikum Wels, Wels, Austria
| | - Axel Kleinsasser
- Department of Anesthesiology and Critical Care Medicine, Medical University Innsbruck, Innsbruck, Austria
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Wang D, Chai XQ, Magnussen CG, Zosky GR, Shu SH, Wei X, Hu SS. Renin-angiotensin-system, a potential pharmacological candidate, in acute respiratory distress syndrome during mechanical ventilation. Pulm Pharmacol Ther 2019; 58:101833. [PMID: 31376462 PMCID: PMC7110665 DOI: 10.1016/j.pupt.2019.101833] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Revised: 06/24/2019] [Accepted: 07/31/2019] [Indexed: 02/06/2023]
Abstract
While effective treatments for acute respiratory distress syndrome (ARDS) are lacking, mechanical lung ventilation can sustain adequate gas exchange in critically ill patients with respiratory failure due to ARDS. However, as a result of the phenomenon of ventilator-induced lung injury (VILI), there is an increasing need to seek beneficial pharmacological therapies for ARDS. Recent studies have suggested the renin-angiotensin system (RAS), which consists of the ACE/Ang-II/AT1R axis and ACE2/Ang-(1-7)/MasR axis, plays a dual role in the pathogenesis of ARDS and VILI. This review highlights the deleterious action of ACE/Ang-II/AT1R axis and the beneficial role of ACE2/Ang-(1-7)/MasR axis, as well as AT2R, in VILI and ARDS, and also discusses the possibility of targeting RAS components with pharmacological interventions to improve outcomes in ARDS.
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Affiliation(s)
- Di Wang
- Department of Anesthesiology and Pain Medicine, Anhui Provincial Hospital, First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China (USTC), Hefei, 230001, Anhui, China
| | - Xiao-Qing Chai
- Department of Anesthesiology and Pain Medicine, Anhui Provincial Hospital, First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China (USTC), Hefei, 230001, Anhui, China.
| | - Costan G Magnussen
- Menzies Institute for Medical Research, College of Health and Medicine, University of Tasmania, Hobart, 7001, Tasmania, Australia; Research Centre of Applied and Preventive Cardiovascular Research, University of Turku, Turku, 20520, Finland
| | - Graeme R Zosky
- Menzies Institute for Medical Research, College of Health and Medicine, University of Tasmania, Hobart, 7001, Tasmania, Australia; School of Medicine, College of Health and Medicine, University of Tasmania, Hobart, 7001, Tasmania, Australia
| | - Shu-Hua Shu
- Department of Anesthesiology and Pain Medicine, Anhui Provincial Hospital, First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China (USTC), Hefei, 230001, Anhui, China
| | - Xin Wei
- Department of Anesthesiology and Pain Medicine, Anhui Provincial Hospital, First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China (USTC), Hefei, 230001, Anhui, China
| | - Shan-Shan Hu
- Institute of Clinical Pharmacology, Anhui Medical University, Hefei, 230032, Anhui, China
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Kobayashi D, Kuriyama N, Yanase F, Takahashi O, Aoki K, Komatsu Y. Angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker use prior to medical intensive care unit admission and in-hospital mortality: propensity score-matched cohort study. J Nephrol 2019; 32:595-603. [PMID: 30937855 DOI: 10.1007/s40620-019-00603-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 03/26/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND The aim of this study was to evaluate whether angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker (ACEI/ARB) use prior to medical intensive care unit (ICU) admission was associated with in-hospital mortality and length of ICU stay. METHODS A propensity score-matched cohort study was conducted at single center from 2004 to 2016. We included all adult patients who were admitted to the ICU due to internal medicine-related conditions. We compared patients who had used ACEIs/ARBs prior to ICU admission to patients who had not. Our primary and secondary outcomes were in-hospital mortality and length of stay among survivors and the deceased. Propensity scores were calculated via logistic regression analyses with forward stepwise selection. An odds ratio (OR) for primary outcome was calculated via logistic regression. Sensitivity analyses were performed using conditional logistic regression models including different sets of covariates to confirm our results. RESULTS 3095 patients were admitted to the ICU. Overall, 693 patients were identified via matching, 231 of whom had used ACEIs/ARBs and 462 of whom had not. None of the baseline characteristics differed significantly between groups. Among them, 131 (18.9%) died. Those who had used ACEIs/ARBs had a lower rate of mortality (p < 0.01). Length of ICU stay did not differ significantly between those with ACEIs/ARBs and those without among survivors (p = 0.43) and the deceased (p = 0.14). The OR for mortality was 0.51 (95% confidence interval 0.32-0.79). The results of the sensitivity analyses confirmed the results (ORs 0.4 6-0.53; all were statistically significant). CONCLUSION Prior ACEI/ARB use may be related to in-hospital mortality among medical ICU patients.
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Affiliation(s)
- Daiki Kobayashi
- Division of General Internal Medicine, Department of Medicine, St. Luke's International Hospital, Tokyo, Japan. .,Fujita Health University, Toyoake, Japan.
| | - Nagato Kuriyama
- Department of Epidemiology for Community Health and Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Fumitaka Yanase
- Department of Intensive Care Unit, Saitama Medical Center Jichi Medical University, Omiya, Japan
| | - Osamu Takahashi
- Division of General Internal Medicine, Department of Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Kazuhiro Aoki
- Department of Anesthesia and Intensive Care Unit, St. Luke's International Hospital, Tokyo, Japan
| | - Yasuhiro Komatsu
- Division of Nephrology, Department of Medicine, St. Luke's International Hospital, Tokyo, Japan
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Abstract
Classic and nonclassic renin-angiotensin systems (RAS) are 2 sides of an ubiquitous endocrine/paracrine cascade regulating blood pressure and homeostasis. Angiotensin II and angiotensin-converting enzyme (ACE) levels are associated with severity of disease in the critically ill, and are central to the physiology and the pathogenesis of circulatory shock. Angiotensin (1-7) and ACE2 act as an endogenous counterregulatory arm to the angiotensin II/ACE axis. The tissue-based RAS has paracrine effects dissociated from those of the circulating RAS. Exogenous angiotensin II or ACE2 may improve the outcome of septic shock and acute respiratory distress syndrome, respectively.
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Affiliation(s)
- Laurent Bitker
- Department of Intensive Care, ICU Research Office, Austin Hospital, 145 Studley Road, Heidelberg, Victoria 3084, Australia.
| | - Louise M Burrell
- Department of Medicine, University of Melbourne, Austin Health, Austin Hospital, 145 Studley Road, Heidelberg, Victoria 3084, Australia
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Jadhav AP, Sadaka FG. Angiotensin II in septic shock. Am J Emerg Med 2019; 37:1169-1174. [PMID: 30935784 DOI: 10.1016/j.ajem.2019.03.026] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 03/13/2019] [Accepted: 03/18/2019] [Indexed: 01/21/2023] Open
Abstract
Septic shock is a life threatening condition and a medical emergency. It is associated with organ dysfunction and hypotension despite optimal volume resuscitation. Refractory septic shock carries a very high rate of mortality and is associated with ischemic and arrhythmogenic complications from high dose vasopressors. Angiotensin II (AT-II) is a product of the renin-angiotensin-aldosterone system. It is a vasopressor agent that has been recently approved by FDA to be used in conjunction with other vasopressors (catecholamines) in refractory shock and to reduce catecholamine requirements. We have reviewed the physiology and current literature on AT-II in refractory septic/vasodilatory shock. Larger trials with longer duration of follow-up are warranted to address the questions which are unanswered by the ATHOS-3 trial, especially pertaining to its effects on lungs, brain, microcirculation, inflammation, and venous thromboembolism risk.
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Affiliation(s)
- Amar P Jadhav
- Intensivist, SSM St. Mary's Hospital, Richmond Heights, St. Louis, United States of America..
| | - Farid G Sadaka
- Clinical Associate Professor, Critical care/Neurocritical care, Mercy Hospital St.Louis, St. Louis University School of Medicine Program, United States of America
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Tsai HJ, Liao MH, Shih CC, Ka SM, Tsao CM, Wu CC. Angiotensin-(1-7) attenuates organ injury and mortality in rats with polymicrobial sepsis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:269. [PMID: 30367644 PMCID: PMC6204017 DOI: 10.1186/s13054-018-2210-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 09/25/2018] [Indexed: 11/14/2022]
Abstract
Background Sepsis and related multiple organ dysfunction result in high morbidity and mortality. Angiotensin (Ang)-(1–7), a biologically active peptide, has various opposing effects of Ang II. Because the effect of Ang-(1–7) on sepsis is unknown, in this study we aimed to determine the impact of Ang-(1–7) on pathophysiologic changes in a clinically relevant model of polymicrobial sepsis induced by cecal ligation and puncture (CLP). Methods Sepsis was induced by CLP in rats under anesthesia. Rats were randomized to one of the following five groups: (1) sham-operated group, (2) Ang-(1–7) (1 mg/kg intravenously infused for 1 h) at 3 h and 6 h after sham operation, (3) CLP, (4) Ang-(1–7) at 3 h after CLP, and (5) Ang-(1–7) at 3 h and 6 h after CLP. Rats were observed for 24 h after CLP surgery and then killed for subsequent histological examination. Results Ang-(1–7) significantly improved the survival of septic rats (83.3% vs. 36.4% at 24 h following CLP; p = 0.009). Ang-(1–7) attenuated the CLP-induced decreased arterial pressure and organ dysfunction, indicated by diminished biochemical variables and fewer histological changes. Ang-(1–7) significantly reduced the level of plasma interleukin-6 and pulmonary superoxide production (p < 0.05). Moreover, caspase-3 and cytoplasmic IκB expression in liver was significantly lower in the Ang-(1–7)-treated CLP rats (p < 0.05). Conclusions In this clinically relevant model of sepsis, Ang-(1–7) ameliorates CLP-induced organ dysfunction and improves survival, possibly through suppressing the inflammatory response, oxidative stress, and apoptosis, suggesting that Ang-(1–7) could be a potential novel therapeutic approach to treatment of peritonitis and polymicrobial sepsis.
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Affiliation(s)
- Hsin-Jung Tsai
- Department of Anesthesiology, Taipei Veterans General Hospital and National Yang-Ming University, No. 201, Sec. 2, Shipai Road, Beitou District, Taipei, 11217, Taiwan, Republic of China
| | - Mei-Hui Liao
- Department of Pharmacology, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Chih-Chin Shih
- Department of Pharmacology, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Shuk-Man Ka
- Graduate Institute of Aerospace and Undersea Medicine, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Cheng-Ming Tsao
- Department of Anesthesiology, Taipei Veterans General Hospital and National Yang-Ming University, No. 201, Sec. 2, Shipai Road, Beitou District, Taipei, 11217, Taiwan, Republic of China. .,Department of Anesthesiology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China.
| | - Chin-Chen Wu
- Department of Pharmacology, National Defense Medical Center, Taipei, Taiwan, Republic of China
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