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Rugg C, Schmid S, Zipperle J, Kreutziger J. Stress hyperglycaemia following trauma - a survival benefit or an outcome detriment? Curr Opin Anaesthesiol 2024; 37:131-138. [PMID: 38390910 DOI: 10.1097/aco.0000000000001350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
PURPOSE OF REVIEW Stress hyperglycaemia occur often in critically injured patients. To gain new consideration about it, this review compile current as well as known immunological and biochemical findings about causes and emergence. RECENT FINDINGS Glucose is the preferred energy substrate for fending immune cells, reparative tissue and the cardiovascular system following trauma. To fulfil these energy needs, the liver is metabolically reprogrammed to rebuild glucose from lactate and glucogenic amino acids (hepatic insulin resistance) at the expenses of muscles mass and - to a less extent - fat tissue (proteolysis, lipolysis, peripheral insulin resistance). This inevitably leads to stress hyperglycaemia, which is evolutionary preserved and seems to be an essential and beneficial survival response. It is initiated by damage-associated molecular patterns (DAMPs) and pathogen-associated molecular patterns (PAMPs), intensified by immune cells itself and mainly ruled by tumour necrosis factor (TNF)α and catecholamines with lactate and hypoxia inducible factor (HIF)-1α as intracellular signals and lactate as an energy shuttle. Important biochemical mechanisms involved in this response are the Warburg effect as an efficient metabolic shortcut and the extended Cori cycle. SUMMARY Stress hyperglycaemia is beneficial in an acute life-threatening situation, but further research is necessary, to prevent trauma patients from the detrimental effects of persisting hyperglycaemia.
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Affiliation(s)
- Christopher Rugg
- Department of Anaesthesia and Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Stefan Schmid
- Department of Anaesthesia and Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Johannes Zipperle
- Johannes Zipperle, Ludwig Boltzmann Institute for Traumatology, The Research Center in Cooperation with AUVA, Vienna, Austria
| | - Janett Kreutziger
- Department of Anaesthesia and Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
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2
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Fitzgerald O, Perez-Concha O, Gallego-Luxan B, Rudd L, Jorm L. The relationship between hyperglycaemia on admission and patient outcome is modified by hyperlactatemia and diabetic status: a retrospective analysis of the eICU collaborative research database. Sci Rep 2023; 13:15692. [PMID: 37735615 PMCID: PMC10514185 DOI: 10.1038/s41598-023-43044-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 09/18/2023] [Indexed: 09/23/2023] Open
Abstract
Both blood glucose and lactate are well-known predictors of organ dysfunction and mortality in critically ill patients. Previous research has shown that concurrent adjustment for glucose and lactate modifies the relationship between these variables and patient outcomes, including blunting of the association between blood glucose and patient outcome. We aim to investigate the relationship between ICU admission blood glucose and hospital mortality while accounting for lactate and diabetic status. Across 43,250 ICU admissions, weighted to account for missing data, we assessed the predictive ability of several logistic regression and generalised additive models that included blood glucose, blood lactate and diabetic status. We found that inclusion of blood glucose marginally improved predictive performance in all patients: AUC-ROC 0.665 versus 0.659 (p = 0.005), with a greater degree of improvement seen in non-diabetics: AUC-ROC 0.675 versus 0.663 (p < 0.001). Inspection of the estimated risk profiles revealed the standard U-shaped risk profile for blood glucose was only present in non-diabetic patients after controlling for blood lactate levels. Future research should aim to utilise observational data to estimate whether interventions such as insulin further modify this effect, with the goal of informing future RCTs of interventions targeting glycaemic control in the ICU.
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Affiliation(s)
- Oisin Fitzgerald
- Centre for Big Data Research in Health, Level 2, AGSM Building, UNSW Sydney, Kensington, NSW, 2052, Australia.
| | - Oscar Perez-Concha
- Centre for Big Data Research in Health, Level 2, AGSM Building, UNSW Sydney, Kensington, NSW, 2052, Australia
| | - Blanca Gallego-Luxan
- Centre for Big Data Research in Health, Level 2, AGSM Building, UNSW Sydney, Kensington, NSW, 2052, Australia
| | - Lachlan Rudd
- Data and Analytics, eHealth NSW, 1 Reserve Road, St Leonards, NSW, 2065, Australia
| | - Louisa Jorm
- Centre for Big Data Research in Health, Level 2, AGSM Building, UNSW Sydney, Kensington, NSW, 2052, Australia
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3
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Liu T, Wen Z, Shao L, Cui Y, Tang X, Miao H, Shi J, Jiang L, Feng S, Zhao Y, Zhang H, Liang Q, Chen D, Zhang Y, Wang C. ATF4 knockdown in macrophage impairs glycolysis and mediates immune tolerance by targeting HK2 and HIF-1α ubiquitination in sepsis. Clin Immunol 2023; 254:109698. [PMID: 37481013 DOI: 10.1016/j.clim.2023.109698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 06/30/2023] [Accepted: 07/18/2023] [Indexed: 07/24/2023]
Abstract
Strengthened glycolysis is crucial for the macrophage pro-inflammatory response during sepsis. Activating transcription factor 4 (ATF4) plays an important role in regulating glucose and lipid metabolic homeostasis in hepatocytes and adipocytes. However, its immunometabolic role in macrophage during sepsis remains largely unknown. In the present study, we found that the expression of ATF4 in peripheral blood mononuclear cells (PBMCs) was increased and associated with glucose metabolism in septic patients. Atf4 knockdown specifically decreased LPS-induced spleen macrophages and serum pro-inflammatory cytokines levels in mice. Moreover, Atf4 knockdown partially blocked LPS-induced pro-inflammatory cytokines, lactate accumulation and glycolytic capacity in RAW264.7. Mechanically, ATF4 binds to the promoter region of hexokinase II (HK2), and interacts with hypoxia inducible factor-1α (HIF-1α) and stabilizes HIF-1α through ubiquitination modification in response to LPS. Furthermore, ATF4-HIF-1α-HK2-glycolysis axis launches pro-inflammatory response in macrophage depending on the activation of mammalian target of rapamycin (mTOR). Importantly, Atf4 overexpression improves the decreased level of pro-inflammatory cytokines and lactate secretion and HK2 expression in LPS-induced tolerant macrophages. In conclusion, we propose a novel function of ATF4 as a crucial glycolytic activator contributing to pro-inflammatory response and improving immune tolerant in macrophage involved in sepsis. So, ATF4 could be a potential new target for immunotherapy of sepsis.
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Affiliation(s)
- Tiantian Liu
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine, 200062 Shanghai, China; Laboratory of Critical Care Translational Medicine, Institute of Pediatric Infection, Immunity, and Critical Care Medicine, Shanghai Jiao Tong University School of Medicine, 200062 Shanghai, China
| | - Zhenliang Wen
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 200025 Shanghai, China
| | - Lujing Shao
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine, 200062 Shanghai, China; Laboratory of Critical Care Translational Medicine, Institute of Pediatric Infection, Immunity, and Critical Care Medicine, Shanghai Jiao Tong University School of Medicine, 200062 Shanghai, China
| | - Yun Cui
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine, 200062 Shanghai, China; Laboratory of Critical Care Translational Medicine, Institute of Pediatric Infection, Immunity, and Critical Care Medicine, Shanghai Jiao Tong University School of Medicine, 200062 Shanghai, China; Institute of Pediatric Critical Care, Shanghai Jiao Tong University, 200062, Shanghai, China
| | - Xiaomeng Tang
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine, 200062 Shanghai, China; Laboratory of Critical Care Translational Medicine, Institute of Pediatric Infection, Immunity, and Critical Care Medicine, Shanghai Jiao Tong University School of Medicine, 200062 Shanghai, China
| | - Huijie Miao
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine, 200062 Shanghai, China; Laboratory of Critical Care Translational Medicine, Institute of Pediatric Infection, Immunity, and Critical Care Medicine, Shanghai Jiao Tong University School of Medicine, 200062 Shanghai, China; Institute of Pediatric Critical Care, Shanghai Jiao Tong University, 200062, Shanghai, China
| | - Jingyi Shi
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine, 200062 Shanghai, China; Laboratory of Critical Care Translational Medicine, Institute of Pediatric Infection, Immunity, and Critical Care Medicine, Shanghai Jiao Tong University School of Medicine, 200062 Shanghai, China; Institute of Pediatric Critical Care, Shanghai Jiao Tong University, 200062, Shanghai, China
| | - Linlin Jiang
- Department of Clinical Laboratory, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200062, China
| | - Shuyun Feng
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine, 200062 Shanghai, China; Laboratory of Critical Care Translational Medicine, Institute of Pediatric Infection, Immunity, and Critical Care Medicine, Shanghai Jiao Tong University School of Medicine, 200062 Shanghai, China
| | - Yilin Zhao
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine, 200062 Shanghai, China; Laboratory of Critical Care Translational Medicine, Institute of Pediatric Infection, Immunity, and Critical Care Medicine, Shanghai Jiao Tong University School of Medicine, 200062 Shanghai, China
| | - Hong Zhang
- Department of Clinical Laboratory, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200062, China
| | - Qiming Liang
- Research Center of Translational Medicine, Shanghai Institute of Immunology, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Dechang Chen
- Department of Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 200025 Shanghai, China..
| | - Yucai Zhang
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine, 200062 Shanghai, China; Laboratory of Critical Care Translational Medicine, Institute of Pediatric Infection, Immunity, and Critical Care Medicine, Shanghai Jiao Tong University School of Medicine, 200062 Shanghai, China; Institute of Pediatric Critical Care, Shanghai Jiao Tong University, 200062, Shanghai, China.
| | - Chunxia Wang
- Department of Critical Care Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University School of Medicine, 200062 Shanghai, China; Laboratory of Critical Care Translational Medicine, Institute of Pediatric Infection, Immunity, and Critical Care Medicine, Shanghai Jiao Tong University School of Medicine, 200062 Shanghai, China; Institute of Pediatric Critical Care, Shanghai Jiao Tong University, 200062, Shanghai, China.
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Pari B, Gallucci M, Ghigo A, Brizzi MF. Insight on Infections in Diabetic Setting. Biomedicines 2023; 11:971. [PMID: 36979949 PMCID: PMC10046483 DOI: 10.3390/biomedicines11030971] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/08/2023] [Accepted: 03/16/2023] [Indexed: 03/30/2023] Open
Abstract
The correlation between diabetes mellitus and infectious diseases is widely recognized. DM patients are characterized by the impaired function of the immune system. This translates into the occurrence of a variety of infections, including urinary tract, skin and surgical site infections, pneumonia, tuberculosis, and, more recently, SARS-CoV-2. Hyperglycemia has been identified as a relevant factor contributing to unfavorable outcomes in hospitalized patients including SARS-CoV-2 patients. Several studies have been performed proving that to maintain the proper and stringent monitoring of glycemia, a balanced diet and physical activity is mandatory to reduce the risk of infections and their associated complications. This review is focused on the mechanisms accounting for the increased susceptibility of DM patients to infections, with particular attention to the impact of newly introduced hypoglycemic drugs in sepsis management.
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Affiliation(s)
| | | | | | - Maria Felice Brizzi
- Department of Medical Sciences, University of Turin, Corso Dogliotti 14, 10126 Turin, Italy
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5
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Jovanovic L, Rajkovic M, Subota V, Subotic B, Dzudovic B, Matijasevic J, Benic M, Salinger S, Simovic S, Miloradovic V, Kovacevic TP, Kos L, Neskovic A, Kafedzic S, Nikolic NM, Bozovic B, Bulatovic N, Obradovic S. Predictive value of admission glycemia in diabetics with pulmonary embolism compared to non-diabetic patients. Acta Diabetol 2022; 59:653-659. [PMID: 35094143 DOI: 10.1007/s00592-021-01843-2] [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: 11/21/2021] [Accepted: 12/19/2021] [Indexed: 11/01/2022]
Abstract
AIMS To examine the relationship between admission glucose (AG) level and short-term in-hospital mortality and to investigate the association between hyperglycemia and major bleeding in PE patients with and without DMT2. METHODS We evaluated 1165 patients with diagnosed acute PE with multi-detector computed tomography pulmonary angiography (MDCT-PA) enrolled in the Regional multicenter PE registry (REPER). The study population was classified to patients with diabetes mellitus type 2 (DMT2) and those without diabetes. According to quartiles of AG patients, both groups separately were categorized into four subgroups (DMT2 I: < 7.5 mmol/L; II: 7.5-10.0 mmol/L; III: 10.0-15.7 mmol/L; IV: > 15.7 mmol/L and (non-DMT2 I: < 5.5 mmol/L; II: 5.5-6.3 mmol/L; III: 6.3-7.9 mmol/L; IV: > 7.9 mmol/L). RESULTS All-cause mortality was higher in the DMT2 group (9.5% vs. 18.2%, p < 0.001), and PE-cause mortality was 6% for the patients without DMT2 and 12.4% for DMT2 patients (p = 0.02). The patients in the fourth AG quartiles in both groups, without DMT2 and with DMT2, had significantly higher all-cause and PE-cause in-hospital mortality compared with the first quartile. Rates of major bleeding were similar between the groups. On the multivariable analysis, after adjusting for age, gender and mortality risk, the adherence in the fourth AG quartile had an independent predictive value for all-cause death (HR 2.476, 95% CI 1.017-6.027) only in DM patients. CONCLUSION In our cohort of patients with acute PE, diabetes was associated with increased rates for all-cause and PE-cause mortality.
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Affiliation(s)
- Ljiljana Jovanovic
- Institute of Medical Biochemistry, Military Medical Academy, Belgrade, Serbia
| | - Milena Rajkovic
- Institute of Medical Biochemistry, Military Medical Academy, Belgrade, Serbia
| | - Vesna Subota
- Institute of Medical Biochemistry, Military Medical Academy, Belgrade, Serbia
| | - Bojana Subotic
- Clinic of Cardiology and Emergency Internal Medicine, Military Medical Academy, School of Medicine, University of Defense, Belgrade, Serbia
| | - Boris Dzudovic
- Clinic of Cardiology and Emergency Internal Medicine, Military Medical Academy, School of Medicine, University of Defense, Belgrade, Serbia
| | - Jovan Matijasevic
- Institute for Pulmonary Diseases of Vojvodina, Sremska Kamenica, Serbia
- School of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - Marija Benic
- Institute for Pulmonary Diseases of Vojvodina, Sremska Kamenica, Serbia
| | - Sonja Salinger
- Clinic of Cardiology, Clinical Center Nis, University of Nis, Nis, Serbia
| | - Stefan Simovic
- Clinic of Cardiology, Clinical Center Kragujevac, School of Medicine, University of Kragujevac, Kragujevac, Serbia
| | - Vladimir Miloradovic
- Clinic of Cardiology, Clinical Center Kragujevac, School of Medicine, University of Kragujevac, Kragujevac, Serbia
| | - Tamara Preradovic Kovacevic
- Clinic of Cardiology, Clinical Center Banja Luka, School of Medicine, University of Banja Luka, Banja Luka, Republic of Srpska, Bosnia and Herzegovina
| | - Ljiljana Kos
- Clinic of Cardiology, Clinical Center Banja Luka, School of Medicine, University of Banja Luka, Banja Luka, Republic of Srpska, Bosnia and Herzegovina
| | - Aleksandar Neskovic
- Department of Cardiology, Clinical Hospital Center Zemun, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Srdjan Kafedzic
- Department of Cardiology, Clinical Hospital Center Zemun, Belgrade, Serbia
| | - Natasa Markovic Nikolic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- University Clinical Center Zvezdara, School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Bjanka Bozovic
- Clinic of Cardiology, Clinical Center Podgorica, School of Medicine, University of Podgorica, Podgorica, Montenegro
| | - Nebojsa Bulatovic
- Clinic of Cardiology, Clinical Center Podgorica, School of Medicine, University of Podgorica, Podgorica, Montenegro
- School of Medicine, University of Defense, Belgrade, Serbia
| | - Slobodan Obradovic
- Clinic of Cardiology and Emergency Internal Medicine, Military Medical Academy, School of Medicine, University of Defense, Belgrade, Serbia.
- School of Medicine, University of Defense, Belgrade, Serbia.
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6
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Lin S, Lai D, He W. Association between hyperglycemia and adverse clinical outcomes of sepsis patients with diabetes. Front Endocrinol (Lausanne) 2022; 13:1046736. [PMID: 36699043 PMCID: PMC9868443 DOI: 10.3389/fendo.2022.1046736] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 12/22/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Hyperglycemia is one of the poor prognostic factors in critical ill sepsis patients with diabetes. We aimed to assess the interaction between admission glucose level and clinical endpoints in sepsis patients with diabetes admitted in the intensive care unit (ICU). METHODS Data from the Medical Information Mart Intensive Care III database were used in this study. The study primary endpoint was 28-day mortality after ICU admission. Multivariate Cox regression models were used to explore the association between admission glucose level and the primary endpoint. RESULTS We included 3,500 sepsis patients with diabetes. Of participants with no hyperglycemia, mild hyperglycemia, and severe hyperglycemia, no differences were evident in hospital mortality, ICU mortality, or 28-day mortality (all P >0.05). The multivariable Cox regression analysis demonstrated that severe hyperglycemia did not increase the risk of 28-day mortality (hazard ratio [HR]=1.06, 95% confidence interval [CI]: 0.86-1.31, P=0.5880). Threshold effects analysis identified the inflection points for 28-day mortality as 110 mg/dl and 240 mg/dl. The HRs for 28-day mortality were 0.980 in the <110 mg/dl and 1.008 in the >240 mg/dl. A short-term survival advantage was observed in the 110-240 mg/dl group compared with that in the <110 mg/dl group; meanwhile, no adverse hazard was detected in the >240 mg/dl group. In the stratified analyses, the association effect between the three glucose groups (<110 mg/dl, 110-240 mg/dl, and ≥240 mg/dl) and 28-day mortality was consistent in terms of different sequential organ failure assessment (SOFA) scores and infection sites. The 28-day mortality of the 110-240 mg/dl group with a SOFA score of ≥10 was lower than that of the <110 mg/dl group (HR=0.61, 95% CI: 0.38-0.98). CONCLUSION Admission hyperglycemia was not a risk factor for short-term prognosis in critical ill sepsis patients with diabetes; a lower admission blood glucose level was associated with increased risk of poor prognosis. The potential benefit of higher admission glucose level on 28-day mortality in patients with a more severe condition remains a concern.
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Affiliation(s)
- Shan Lin
- Department of Respiratory and Critical Care Medicine, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
- Department of Medical Intensive Care Unit, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
- *Correspondence: Shan Lin,
| | - Dingfeng Lai
- Department of Medical Intensive Care Unit, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Wanmei He
- Department of Medical Intensive Care Unit, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
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7
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Doola R, Deane AM, Barrett HL, Okano S, Tolcher DM, Gregory K, Coombes JS, Schalkwijk C, Todd AS, Forbes JM, Sturgess DJ. The impact of a modified carbohydrate formula, and its constituents, on glycaemic control and inflammatory markers: A nested mechanistic sub-study. J Hum Nutr Diet 2021; 35:455-465. [PMID: 34743379 DOI: 10.1111/jhn.12959] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 10/11/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Hyperglycaemia occurs frequently in the critically ill. Dietary intake of advanced glycation end-products (AGEs), specifically Nε-(carboxymethyl)lysine (CML), may exacerbate hyperglycaemia through perturbation of insulin sensitivity. The present study aimed to determine whether the use of nutritional formulae, with varying AGE loads, affects the amount of insulin administered and inflammation. METHODS Exclusively tube fed patients (n = 35) were randomised to receive Nutrison Protein Plus Multifibre®, Diason® or Glucerna Select®. Insulin administration was standardised according to protocol based on blood glucose (<10 mmol L-1 ). Samples were obtained at randomisation and 48 h later. AGEs in nutritional formula, plasma and urine were measured using mass spectrometry. Plasma inflammatory markers were measured using an enzyme-linked immunosorbent assay and multiplex bead-based assays. RESULTS AGE concentrations of CML in nutritional formulae were greatest with delivery of Nutrison Protein Plus® (mean [SD]; 6335 pmol mol-1 [2436]) compared to Diason® (4836 pmol mol-1 [1849]) and Glucerna Select® (4493 pmol mol-1 [1829 pmol mol-1 ]) despite patients receiving similar amounts of energy (median [interquartile range]; 12 MJ [8.2-13.7 MJ], 11.5 MJ [8.3-14.5 MJ], 11.5 MJ [8.3-14.5 MJ]). More insulin was administered with Nutrison Protein Plus® (2.47 units h-1 [95% confidence interval (CI) = 1.57-3.37 units h-1 ]) compared to Diason® (1.06 units h-1 [95% CI = 0.24-1.89 units h-1 ]) or Glucerna Select® (1.11 units h-1 [95% CI = 0.25-1.97 units h-1 ]; p = 0.04). Blood glucose concentrations were similar. There were associations between greater insulin administration and reductions in circulating interleukin-6 (r = -0.46, p < 0.01), tumour necrosis factor-α (r = -0.44, p < 0.05), high sensitivity C-reactive protein (r = -0.42, p < 0.05) and soluble receptor for advanced glycation end-products (r = -0.45, p < 0.01) concentrations. CONCLUSIONS The administration of greater AGE load in nutritional formula potentially increases the amount of insulin required to maintain blood glucose within a normal range during critical illness. There was an inverse relationship between exogenous insulin and plasma inflammatory markers.
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Affiliation(s)
- Ra'eesa Doola
- Princess Alexandra Hospital, Mater Research Institute, The University of Queensland, Brisbane, QLD, Australia
| | - Adam M Deane
- The Royal Melbourne Hospital, The University of Melbourne and Mater Research Institute - The University of Queensland, Brisbane, QLD, Australia
| | - Helen L Barrett
- Mater Health Services, Mater Research Institute - The University of Queensland, Brisbane, QLD, Australia
| | - Satomi Okano
- Mater Research Institute - Statistics Unit, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
| | - Debbie M Tolcher
- System Planning Branch, Strategy Policy and Planning Division, Brisbane, QLD, Australia
| | - Kye Gregory
- SHECC IMT, Queensland Health, Brisbane, QLD, Australia
| | - Jeff S Coombes
- School of Human Movement and Nutrition Sciences, Faculty of Health and Behavioural Sciences, The University of Queensland, Brisbane, QLD, Australia
| | - Casper Schalkwijk
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Maastricht University Medical Centre, Netherlands, The Netherlands
| | - Alwyn S Todd
- Mater Research Institute - The University of Queensland and Menzies Health Institute Brisbane, Griffith University, Brisbane, QLD, Australia
| | - Josephine M Forbes
- Mater Research Institute - The University of Queensland, Brisbane, QLD, Australia
| | - David J Sturgess
- Mater Research Institute - The University of Queensland, Brisbane, QLD, Australia
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8
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Wentowski C, Ingles DP, Nielsen ND. Sepsis 2021: a review. ANAESTHESIA & INTENSIVE CARE MEDICINE 2021. [DOI: 10.1016/j.mpaic.2021.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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9
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Mirzaei F, Khodadadi I, Vafaei SA, Abbasi-Oshaghi E, Tayebinia H, Farahani F. Importance of hyperglycemia in COVID-19 intensive-care patients: Mechanism and treatment strategy. Prim Care Diabetes 2021; 15:409-416. [PMID: 33436320 PMCID: PMC7834268 DOI: 10.1016/j.pcd.2021.01.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 01/03/2021] [Accepted: 01/04/2021] [Indexed: 12/15/2022]
Abstract
This review reported that coronavirus disease 2019 (COVID-19) infected patients with short time bed rest or quarantine and airway inflammation are at more risk of developing hyperglycemia and insulin resistance. This condition can induce oxidative stress, decrease immune system function, impair endothelial function, induce apoptosis, and reduce antioxidant in the lungs. We provide a possible mechanism in severe COVID-19 patients and recommend treatment strategy to reduce mortality rate and prevent adverse outcomes after intensive care unit (ICU).
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Affiliation(s)
- Fatemeh Mirzaei
- Research Center for Molecular Medicine, Hamadan University of Medical Sciences, Hamadan, Iran; Department of Anatomical Sciences, School of Medicine, Hamadan University of Medical Sciences, Hamadan, Iran.
| | - Iraj Khodadadi
- Department of Clinical Biochemistry, Hamadan University of Medical Sciences, Hamadan, Iran.
| | | | - Ebrahim Abbasi-Oshaghi
- Research Center for Molecular Medicine, Hamadan University of Medical Sciences, Hamadan, Iran; Department of Clinical Biochemistry, Hamadan University of Medical Sciences, Hamadan, Iran.
| | - Heidar Tayebinia
- Department of Clinical Biochemistry, Hamadan University of Medical Sciences, Hamadan, Iran.
| | - Farhad Farahani
- Hearing Impairment Research Center, Hamadan University of Medical Sciences, Hamadan, Iran.
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10
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Bajgar A, Krejčová G, Doležal T. Polarization of Macrophages in Insects: Opening Gates for Immuno-Metabolic Research. Front Cell Dev Biol 2021; 9:629238. [PMID: 33659253 PMCID: PMC7917182 DOI: 10.3389/fcell.2021.629238] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 01/11/2021] [Indexed: 12/14/2022] Open
Abstract
Insulin resistance and cachexia represent severe metabolic syndromes accompanying a variety of human pathological states, from life-threatening cancer and sepsis to chronic inflammatory states, such as obesity and autoimmune disorders. Although the origin of these metabolic syndromes has not been fully comprehended yet, a growing body of evidence indicates their possible interconnection with the acute and chronic activation of an innate immune response. Current progress in insect immuno-metabolic research reveals that the induction of insulin resistance might represent an adaptive mechanism during the acute phase of bacterial infection. In Drosophila, insulin resistance is induced by signaling factors released by bactericidal macrophages as a reflection of their metabolic polarization toward aerobic glycolysis. Such metabolic adaptation enables them to combat the invading pathogens efficiently but also makes them highly nutritionally demanding. Therefore, systemic metabolism has to be adjusted upon macrophage activation to provide them with nutrients and thus support the immune function. That anticipates the involvement of macrophage-derived systemic factors mediating the inter-organ signaling between macrophages and central energy-storing organs. Although it is crucial to coordinate the macrophage cellular metabolism with systemic metabolic changes during the acute phase of bacterial infection, the action of macrophage-derived factors may become maladaptive if chronic or in case of infection by an intracellular pathogen. We hypothesize that insulin resistance evoked by macrophage-derived signaling factors represents an adaptive mechanism for the mobilization of sources and their preferential delivery toward the activated immune system. We consider here the validity of the presented model for mammals and human medicine. The adoption of aerobic glycolysis by bactericidal macrophages as well as the induction of insulin resistance by macrophage-derived factors are conserved between insects and mammals. Chronic insulin resistance is at the base of many human metabolically conditioned diseases such as non-alcoholic steatohepatitis, atherosclerosis, diabetes, and cachexia. Therefore, revealing the original biological relevance of cytokine-induced insulin resistance may help to develop a suitable strategy for treating these frequent diseases.
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Affiliation(s)
- Adam Bajgar
- Department of Molecular Biology and Genetics, University of South Bohemia, Ceske Budejovice, Czechia
| | - Gabriela Krejčová
- Department of Molecular Biology and Genetics, University of South Bohemia, Ceske Budejovice, Czechia
| | - Tomáš Doležal
- Department of Molecular Biology and Genetics, University of South Bohemia, Ceske Budejovice, Czechia
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11
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Lin S, Ge S, He W, Zeng M. Association between comorbid diabetes mellitus and prognosis of patients with sepsis in the intensive care unit: a retrospective cohort study. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:22. [PMID: 33553315 PMCID: PMC7859737 DOI: 10.21037/atm-20-4360] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Background Sepsis patients hospitalized in the intensive care unit (ICU) often have comorbid diabetes mellitus (DM). However, the clinical impact of DM on the clinical outcomes of critically ill sepsis patients has yet to be determined. Therefore, the current study aimed to analyze the association of comorbid DM with the prognosis of sepsis patients in the ICU. Methods Data of patients with sepsis and comorbid DM were obtained from a large-scale intensive care database. The primary outcome was 28-day mortality after ICU admission. Associations of comorbid DM with the primary outcome were assessed using a multivariable Cox regression model. Different adjusted models, such as the propensity score method, were used to determine the prognosis of the patients. Results Overall, 12,321 sepsis patients were enrolled, including 3,509 (28.48%) with comorbid DM. After adjusting and matching, we found that comorbid DM was not an independent risk factor for 28-day mortality in critically ill sepsis patients and was even associated with lower mortality. Propensity score matching showed a dramatically lower 28-day mortality for sepsis patients with comorbid DM in comparison to patients without comorbid DM [hazard ratio (HR): 0.86, 95% confidence interval (CI): 0.77–0.97, P=0.0167]. The relationship of comorbid DM with 28-day mortality was broadly consistent for all subgroup variables. In the stratified analysis, a significant interaction was observed only for glucose concentration (P<0.0001). Patients with comorbid DM and a glucose level of 140–200 mg/dL (7.8–11.1 mmol/L) or ≥200 mg/dL (11.1 mmol/L) had a significantly lower 28-day mortality rate (HR 0.83, 95% CI: 0.71–0.98, P=0.0250 and HR: 0.49, 95% CI: 0.38–0.64, P<0.0001, respectively). Conclusions Critically ill patients with sepsis and comorbid DM were not found to have increased 28-day mortality compared to those without comorbid DM, and may even have a lower risk of mortality. Notably, this association remained in the setting of hyperglycemia.
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Affiliation(s)
- Shan Lin
- Department of Medical Intensive Care Unit, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Shanhui Ge
- Department of Medical Intensive Care Unit, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Wanmei He
- Department of Medical Intensive Care Unit, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Mian Zeng
- Department of Medical Intensive Care Unit, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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12
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Lin S, He W, Zeng M. Association of Diabetes and Admission Blood Glucose Levels with Short-Term Outcomes in Patients with Critical Illnesses. J Inflamm Res 2020; 13:1151-1166. [PMID: 33376380 PMCID: PMC7764887 DOI: 10.2147/jir.s287510] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 12/04/2020] [Indexed: 12/16/2022] Open
Abstract
Background Association of diabetes and admission glucose on the short-term prognosis in patients with critical illnesses are currently ambiguous. We aimed to determine whether diabetes and admission glucose affects short-term prognosis of critically ill patients. Methods We performed a retrospective analysis of data on 46,476 critically ill patients from the critical care database. Association of diabetes with 28-day mortality was assessed by inverse probability weighting based on the propensity score. Smoothing splines and threshold effect analysis were applied to explore the relationship between admission glucose and clinical outcomes. Results Of the 33,680 patients enrolled in the study, 8,701 (25.83%) had diabetes. In the main analysis, the 28-day mortality was reduced by 29% (hazard ratio (HR)=0.71, 95% confidence interval (CI) 0.67–0.76) in patients with diabetes compared to those without diabetes. The E-value of 2.17 indicated robustness to unmeasured confounders. Significant interactions were observed for glucose at ICU admission, admission type, and insulin use (Interaction P <0.05). A V-shaped relationship was observed between admission glucose and 28-day mortality in non-diabetic patients, with the lowest 28-day mortality corresponding to a glucose level of 101.75 mg/dl (95% CI 94.64–105.80 mg/dl), and admission hypoglycemia or hyperglycemia should be avoided, especially in patients admitted to the surgical intensive care unit (SICU), cardiac surgery recovery unit (CSRU), and coronary care unit (CCU); for diabetic patients, elevated admission glucose does not appear to be associated with a poor prognosis and perhaps may be beneficial except for CCU and CSRU. Conclusion The non-detrimental effect of diabetes on the short-term prognosis of critically ill patients was further confirmed, which would reduce 28-day mortality by approximately 29%. For non-diabetic patients, the admission glucose level corresponding to the lowest 28-day mortality was 101.75 mg/dl (95% CI 94.64–105.80 mg/dl); however, for diabetics, the appropriate admission glucose threshold remains unresolved.
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Affiliation(s)
- Shan Lin
- Department of Medical Intensive Care Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Wanmei He
- Department of Medical Intensive Care Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Mian Zeng
- Department of Medical Intensive Care Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
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13
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van Niekerk G, Christowitz C, Conradie D, Engelbrecht AM. Insulin as an immunomodulatory hormone. Cytokine Growth Factor Rev 2019; 52:34-44. [PMID: 31831339 DOI: 10.1016/j.cytogfr.2019.11.006] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 11/26/2019] [Accepted: 11/28/2019] [Indexed: 12/11/2022]
Abstract
Insulin plays an indispensable role in the management of hyperglycaemia that arises in a variety of settings, including Type I and II diabetes, gestational diabetes, as well as is in hyperglycaemia following a severe inflammatory insult. However, insulin receptors are also expressed on a range of cells that are not canonically implicated in glucose homeostasis. This includes immune cells, where the anti-inflammatory effects of insulin have been repeatedly reported. However, recent findings have also implicated a more involved role for insulin in shaping the immune response during an infection. This includes the ability of insulin to modulate immune cell differentiation and polarisation as well as the modulation of effector functions such as biocidal ROS production. Finally, inflammatory mediators can through both direct and indirect mechanisms also regulate serum insulin levels, suggesting that insulin may be co-opted by the immune system during an infection to direct immunological operations. Collectively, these observations implicate insulin as a bona fide immune-modulating hormone and suggest that a better understanding of insulin's immunological function may aid in optimising insulin therapy in a range of clinical settings.
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Affiliation(s)
- Gustav van Niekerk
- Department of Physiological Sciences, Stellenbosch University, Stellenbosch, South Africa.
| | - Claudia Christowitz
- Department of Physiological Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Daleen Conradie
- Department of Physiological Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Anna-Mart Engelbrecht
- Department of Physiological Sciences, Stellenbosch University, Stellenbosch, South Africa
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14
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Karampela I, Christodoulatos GS, Dalamaga M. The Role of Adipose Tissue and Adipokines in Sepsis: Inflammatory and Metabolic Considerations, and the Obesity Paradox. Curr Obes Rep 2019; 8:434-457. [PMID: 31637623 DOI: 10.1007/s13679-019-00360-2] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE Sepsis has become a global health problem with rising incidence and high mortality, creating a substantial social and economic burden. Early diagnosis and treatment can improve outcome, but reliable sepsis biomarkers are lacking. This review summarizes current evidence of the pathophysiological mechanisms linking adipose tissue to sepsis and presents experimental and clinical data on adipokines and sepsis along with important insights into the obesity paradox in sepsis survival. RECENT FINDINGS Sepsis is characterized by significant alterations in circulating cytokines and adipokines, biologically active molecules produced by the adipose tissue, being implicated in metabolic and inflammatory processes. Although data are inconclusive regarding classic adipokines such as leptin and adiponectin, recent evidence have highlighted the striking elevation of resistin and visfatin in critical illness and sepsis as well as their association with sepsis severity and outcomes. Given that inflammatory and metabolic pathways are involved in sepsis, studying adipokines presents an attractive, innovative, and promising research field that may provide more powerful diagnostic and prognostic biomarkers as well as novel therapeutic targets, empowering the therapeutic armamentarium for sepsis management in order to improve survival.
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Affiliation(s)
- Irene Karampela
- Second Department of Critical Care, Attikon General University Hospital, Medical School, National and Kapodistrian University of Athens, 1 Rimini St, Haidari, 12462, Athens, Greece.
- Department of Biological Chemistry, Medical School, National and Kapodistrian University of Athens, Mikras Asias 75, Goudi, 11527, Athens, Greece.
| | - Gerasimos Socrates Christodoulatos
- Department of Biological Chemistry, Medical School, National and Kapodistrian University of Athens, Mikras Asias 75, Goudi, 11527, Athens, Greece
| | - Maria Dalamaga
- Department of Biological Chemistry, Medical School, National and Kapodistrian University of Athens, Mikras Asias 75, Goudi, 11527, Athens, Greece
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15
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Okada G, Momoki C, Habu D, Kambara C, Fujii T, Matsuda Y, Lee S, Osugi H. Effect of Postoperative Oral Intake on Prognosis for Esophageal Cancer. Nutrients 2019; 11:nu11061338. [PMID: 31207910 PMCID: PMC6627190 DOI: 10.3390/nu11061338] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 06/07/2019] [Accepted: 06/12/2019] [Indexed: 12/25/2022] Open
Abstract
Background: Patients undergoing surgery for esophageal cancer are at risk of prolonged hospital stay for postoperative malnutrition. Postoperative early oral feeing is a part of the “enhanced recovery after surgery protocol” for coping with this risk. However, the usefulness of early oral intake during perioperatively is questionable. Methods: In total, 117 patients treated surgically for esophageal cancer were analyzed in the study. We assessed the oral energy sufficiency rate per nutritional requirement (oral-E/NR) at the fourth week postoperatively and classified the patients into two groups: Poor oral intake group (POI group; <25% oral-E/NR) and the control group (≥25% oral-E/NR). We analyzed the relationship among postoperative oral intake and prognoses. Results: The POI group had worse postoperative nutritional status and a lower survival rate than the control group. In a multivariate analysis, <25% oral-E/NR was one of the independent factors contributing to negative outcomes postoperatively (adjusted hazard ratio: 2.70, 95% confidence interval: 1.30–5.61). Conclusions: In patients undergoing surgery for esophageal cancer, poor postoperative oral intake negatively affected not only on their postoperative nutritional status but also their overall prognosis. It is necessary to improve the adequacy of oral intake postoperatively for patients with esophageal cancer.
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Affiliation(s)
- Genya Okada
- Department of Health Sciences, Prefectural University of Hiroshima, 1-1-71 Ujina-higashi, Minami-ku, Hiroshima 734-8558, Japan.
- Department of Nutritional Medicine, Graduate School of Human Life Science, Osaka City University, 3-3-138 Sugimoto-cho, Sumiyoshi-ku, Osaka 558-8585, Japan.
| | - Chika Momoki
- Department of Nutritional Medicine, Graduate School of Human Life Science, Osaka City University, 3-3-138 Sugimoto-cho, Sumiyoshi-ku, Osaka 558-8585, Japan.
- Department of Food and Nutrition, Faculty of Contemporary Human Life Science, Tezukayama University, 3-1-3 Gakuenminami, Nara 631-8585, Japan.
| | - Daiki Habu
- Department of Nutritional Medicine, Graduate School of Human Life Science, Osaka City University, 3-3-138 Sugimoto-cho, Sumiyoshi-ku, Osaka 558-8585, Japan.
| | - Chisako Kambara
- Department of Health Sciences, Prefectural University of Hiroshima, 1-1-71 Ujina-higashi, Minami-ku, Hiroshima 734-8558, Japan.
| | - Tamotsu Fujii
- Department of Health Sciences, Prefectural University of Hiroshima, 1-1-71 Ujina-higashi, Minami-ku, Hiroshima 734-8558, Japan.
| | - Yasunori Matsuda
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka City University, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan.
| | - Shigeru Lee
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka City University, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan.
| | - Harushi Osugi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka City University, 1-4-3 Asahi-machi, Abeno-ku, Osaka 545-8585, Japan.
- Institute of Gastroenterology, Tokyo Women's Medical University, 8-1 Kawada-cho, Sinjuku-ku, Tokyo 162-8666, Japan.
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16
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van Niekerk G, Davis T, Patterton HG, Engelbrecht AM. How Does Inflammation-Induced Hyperglycemia Cause Mitochondrial Dysfunction in Immune Cells? Bioessays 2019; 41:e1800260. [PMID: 30970156 DOI: 10.1002/bies.201800260] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 02/26/2019] [Indexed: 12/15/2022]
Abstract
Inflammatory mediators have an established role in inducing insulin resistance and promoting hyperglycemia. In turn, hyperglycemia has been argued to drive immune cell dysfunction as a result of mitochondrial dysfunction. Here, the authors review the evidence challenging this view. First, it is pointed out that inflammatory mediators are known to induce altered mitochondrial function. In this regard, critical care patients suffer both an elevated inflammatory tone as well as hyperglycemia, rendering it difficult to distinguish between the effects of inflammation and hyperglycemia. Second, emerging evidence indicates that a decrease in mitochondrial respiration and an increase in reactive oxygen species (ROS) production are not necessarily manifestations of pathology, but adaptations taking shape as the mitochondria is abdicating its adenosine triphosphate (ATP)-producing function (which is taken over by glycolysis) and instead becomes "retooled" for an immunological role. Collectively, these observations challenge the commonly held belief that acute hyperglycemia induces mitochondrial damage leading to immune cell dysfunction.
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Affiliation(s)
- Gustav van Niekerk
- Department of Physiological Sciences, Stellenbosch University, 7602, Stellenbosch, South Africa
| | - Tanja Davis
- Department of Physiological Sciences, Stellenbosch University, 7602, Stellenbosch, South Africa
| | - Hugh-George Patterton
- Centre for Bioinformatics and Computational Biology, Stellenbosch University, 7602, Stellenbosch, South Africa
| | - Anna-Mart Engelbrecht
- Department of Physiological Sciences, Stellenbosch University, 7602, Stellenbosch, South Africa
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17
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Bar-Or D, Rael LT, Madayag RM, Banton KL, Tanner A, Acuna DL, Lieser MJ, Marshall GT, Mains CW, Brody E. Stress Hyperglycemia in Critically Ill Patients: Insight Into Possible Molecular Pathways. Front Med (Lausanne) 2019; 6:54. [PMID: 30972338 PMCID: PMC6445875 DOI: 10.3389/fmed.2019.00054] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 03/05/2019] [Indexed: 01/08/2023] Open
Abstract
Severe sepsis, systemic inflammatory response syndrome (SIRS), and traumatic brain injury are frequently associated with hyperglycemia in non-diabetic patients. In patients suffering from any of these conditions, hyperglycemia at admission to an intensive care unit (ICU) is directly correlated with increased mortality or morbidity. Although there was initial enthusiasm for insulin treatment to blood glucose levels below 110 mg/dL in these patients, recent understanding suggests that the potential for hypoglycemic complications make this approach potentially dangerous. More moderate glucose control seems to be more beneficial than the aggressive glucose lowering initially suggested. An important publication has shown that hyperlactatemia accompanying hyperglycemia could be the real culprit in bad outcomes. This suggests that coupling moderate glucose lowering with therapeutic agents which might treat the underlying metabolic disturbances in these conditions may be a better strategy. The key metabolic disturbance in these three conditions seems to be persistent glycolysis as an energy source even in the presence of adequate tissue oxygenation (the Warburg Effect). We look at recent advances in understanding aerobic glycolysis and possibly the action of DPP4 on incretins resulting in insulin dysregulation and suggest key metabolic pathways involved in hyperglycemia regulation.
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Affiliation(s)
- David Bar-Or
- Trauma Research Laboratory, Swedish Medical Center, Englewood, CO, United States.,St. Anthony Hospital, Lakewood, CO, United States.,Penrose Hospital, Colorado Springs, CO, United States.,Wesley Medical Center, Wichita, KS, United States.,Research Medical Center, Kansas City, MO, United States.,Medical City Plano Hospital, Plano, TX, United States
| | - Leonard T Rael
- Trauma Research Laboratory, Swedish Medical Center, Englewood, CO, United States
| | | | - Kaysie L Banton
- Trauma Research Laboratory, Swedish Medical Center, Englewood, CO, United States
| | - Allen Tanner
- Penrose Hospital, Colorado Springs, CO, United States
| | | | - Mark J Lieser
- Research Medical Center, Kansas City, MO, United States
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18
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Knopp Nee Dickson JL, Lynn AM, Shaw GM, Chase JG. Safe and effective glycaemic control in premature infants: observational clinical results from the computerised STAR-GRYPHON protocol. Arch Dis Child Fetal Neonatal Ed 2019; 104:F205-F211. [PMID: 29930148 DOI: 10.1136/archdischild-2017-314072] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 04/29/2018] [Accepted: 05/12/2018] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Previous studies examine clinical outcomes of insulin therapy in neonatal intensive care units (NICUs), without first developing safe and effective control protocols. This research quantifies the safety and performance of a computerised model-based control algorithmSTAR-GRYPHON (Stochastic TARgeted Glucose Regulation sYstem to Prevent Hyper- and hypO-glycaemia in Neonates). DESIGN Retrospective observational study of glycaemic control in very/extremely low birthweight infants treated with insulin from Christchurch Women's Hospital NICU between January 2013 and June 2017. Blood glucose (BG) outcomes and control performance is compared with retrospective data (n=22) and literature. INTERVENTIONS Insulin infusion doses were calculated from 3 to 4 hourly BG measurements using a computerised model-based control algorithm, STAR-GRYPHON. MAIN OUTCOME MEASURES Mean BG, time in targeted range and incidence of hypoglycaemia. RESULTS STAR-GRYPHON (n=35) had lower mean BG concentration (7.0mmol/L vs 7.9 mmol/L), higher %BG within the 4.0-8.0 mmol/L target range (71.1% vs 50.9%) and lower %BG <4.0 mmol/L (0.6% vs 2.1%). There were only 2 BG <2.6 mmol/L (over n=2, 5.5% of patients, 0.03% of all BG outcomes), one of which may be attributed to clinical error. These results show better control to target and lower incidence of hypoglycaemia than most literature results from intensive insulin therapy protocols or study groups in children and infants. CONCLUSIONS Model-based protocols can safely and effectively control BG in very premature infants and should be used in future studies to determine the effect of insulin therapy on clinical outcomes.
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Affiliation(s)
| | - Adrienne M Lynn
- Neonatal Intensive Care Unit, Christchurch Women's Hospital, Christchurch, New Zealand
| | - Geoffrey M Shaw
- Intensive Care Unit, Christchurch Hospital, Christchurch, New Zealand
| | - J Geoffrey Chase
- Department of Mechanical Engineering, University of Canterbury, Christchurch, New Zealand
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19
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Wentowski C, Mewada N, Nielsen ND. Sepsis in 2018: a review. ANAESTHESIA AND INTENSIVE CARE MEDICINE 2019. [DOI: 10.1016/j.mpaic.2018.11.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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20
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van Niekerk G, Mitchell M, Engelbrecht AM. Bone resorption: supporting immunometabolism. Biol Lett 2018; 14:rsbl.2017.0783. [PMID: 29491030 DOI: 10.1098/rsbl.2017.0783] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 02/01/2018] [Indexed: 12/21/2022] Open
Abstract
Activation of the immune system is associated with an increase in the breakdown of various peripheral tissues, including bone. Despite the widely appreciated role of inflammatory mediators in promoting bone resorption, the functional value behind this process is not completely understood. Recent advances in the field of immunometabolism have highlighted the metabolic reprogramming that takes place in activated immune cells. It is now believed that the breakdown of peripheral tissue provides metabolic substrates to fuel metabolic anabolism in activated immune cells. We argue that phosphate, liberated by bone resorption, plays an indispensable role in sustaining immune cell metabolism. The liberated phosphate is then incorporated into macromolecules such as nucleotides and phospholipids, and is also used for the phosphorylation of metabolites (e.g. glycolytic intermediates). In addition, magnesium, also liberated during the breakdown of bone, is an essential cofactor required by various metabolic enzymes which are upregulated in activated immune cells. Finally, calcium activates various additional molecules involved in immune cell migration. Taken together, these factors suggest a key role for bone resorption during infection.
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Affiliation(s)
- Gustav van Niekerk
- Department of Physiological Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Megan Mitchell
- Department of Physiological Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Anna-Mart Engelbrecht
- Department of Physiological Sciences, Stellenbosch University, Stellenbosch, South Africa
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21
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Merz T, Wepler M, Nußbaum B, Vogt J, Calzia E, Wang R, Szabo C, Radermacher P, McCook O. Cystathionine-γ-lyase expression is associated with mitochondrial respiration during sepsis-induced acute kidney injury in swine with atherosclerosis. Intensive Care Med Exp 2018; 6:43. [PMID: 30343340 PMCID: PMC6195873 DOI: 10.1186/s40635-018-0208-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 10/07/2018] [Indexed: 02/06/2023] Open
Abstract
Background Sepsis is associated with disturbed glucose metabolism and reduced mitochondrial activity and biogenesis, ultimately leading to multiple organ dysfunction, e.g., acute kidney injury (AKI). Cystathionine-γ-lyase (CSE), the major cardiovascular source of endogenous H2S release, is implicated in the regulation of glucose metabolism and mitochondrial activity through a PGC1α-dependent mechanism, and critical for kidney function. Atherosclerosis is associated with mitochondrial dysfunction and reduced CSE expression. Thus, the aim of this post hoc study was to test the hypothesis whether there is an interplay between CSE expression and kidney dysfunction, mitochondrial activity, and oxidative/nitrosative stress in porcine septic AKI with underlying coronary artery disease. Methods This study is a post hoc analysis of material from anesthetized and instrumented swine with a high fat diet-induced hypercholesterolemia and atherosclerosis undergoing faecal peritonitis-induced septic shock or sham procedure and intensive care (comprising fluid resuscitation and continuous i.v. noradrenaline (NoA) infusion) for 24 h. Glucose metabolism was quantified from blood 13C6-glucose and expiratory 13CO2/12CO2 isotope enrichment during 13C6-glucose infusion. Mitochondrial activity was determined by high-resolution respirometry. CSE and PGC1α expression, as well as nitrotyrosine formation and albumin extravasation, were quantified by immunohistochemistry of formalin-fixed kidney paraffin sections. Results Sepsis was associated with lactic acidosis (p = 0.004) and AKI (50% fall of creatinine clearance (CrCl), p = 0.019). While both whole-body glucose production (p = 0.004) and oxidation (p = 0.006) were increased, kidney tissue mitochondrial respiration was reduced (p = 0.028), coinciding with decreased CSE (p = 0.003) and PGC1α (p = 0.003) expression. Albumin extravasation (p = 0.011) and nitrotyrosine formation (p = 0.008) were increased in septic kidneys. Conclusions Sepsis-induced AKI is associated with disturbed mitochondrial respiration and biogenesis, which may be aggravated by oxidative and nitrosative stress. Our results confirm previous data in murine septic shock and porcine hemorrhage and resuscitation on the crucial role of CSE for barrier integrity and kidney function. Electronic supplementary material The online version of this article (10.1186/s40635-018-0208-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tamara Merz
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Helmholtzstrasse 8-1, 89081, Ulm, Germany.
| | - Martin Wepler
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Helmholtzstrasse 8-1, 89081, Ulm, Germany.,Klinik für Anästhesiologie, Universitätsklinikum Ulm, Ulm, Germany
| | - Benedikt Nußbaum
- Klinik für Anästhesiologie, Universitätsklinikum Ulm, Ulm, Germany
| | - Josef Vogt
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Helmholtzstrasse 8-1, 89081, Ulm, Germany
| | - Enrico Calzia
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Helmholtzstrasse 8-1, 89081, Ulm, Germany
| | - Rui Wang
- Department of Biology, Laurentian University, Sudbury, ON, Canada
| | - Csaba Szabo
- Department of Anesthesiology, The University of Texas Medical Branch at Galveston, 601 Harborside Drive, Galveston, TX, 77555, USA.,Department of Oncology, Microbiology and Immunology, Faculty of Science and Medicine, University of Fribourg, Fribourg, Switzerland
| | - Peter Radermacher
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Helmholtzstrasse 8-1, 89081, Ulm, Germany
| | - Oscar McCook
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Helmholtzstrasse 8-1, 89081, Ulm, Germany
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22
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Zhang J, Tian J, Sun H, Digvijay K, Neri M, Bhargava V, Yin Y, Ronco C. How Does Continuous Renal Replacement Therapy Affect Septic Acute Kidney Injury? Blood Purif 2018; 46:326-331. [PMID: 30173223 DOI: 10.1159/000492026] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 07/10/2018] [Indexed: 12/26/2022]
Abstract
Sepsis is the leading cause of acute kidney injury (AKI) in the intensive care unit. As the most common treatment of septic AKI, it is believed that continuous renal replacement therapy (CRRT) can not only maintain the water balance and excrete the metabolic products but also regulate the inflammation and promote kidney recovery. CRRT can remove the inflammatory cytokines to regulate the metabolic adaption in kidney and restore the kidney recovery to protect the kidney in septic AKI. Second, CRRT can provide extra energy supply in septic AKI to improve the kidney energy balance in septic AKI. Third, the anticoagulant used in CRRT also regulates the inflammation in septic AKI. CRRT is not only a treatment to deal with the water balance and metabolic products, but also a method to regulate the inflammation in septic AKI.
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Affiliation(s)
- Jingxiao Zhang
- Department of Emergency and Critical Care, The Second Hospital of Jilin University, Changchun, China.,International Renal Research Institute of Vicenza (IRRIV), Vicenza, Italy
| | - Jiakun Tian
- Department of Emergency and Critical Care, The Second Hospital of Jilin University, Changchun, China
| | - Hongzhi Sun
- Department of Emergency and Critical Care, The Second Hospital of Jilin University, Changchun, China
| | - Kumar Digvijay
- International Renal Research Institute of Vicenza (IRRIV), Vicenza, Italy.,Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy.,Department of Nephrology and Research, Sir Ganga Ram Hospital, New Delhi, India
| | - Mauro Neri
- International Renal Research Institute of Vicenza (IRRIV), Vicenza, Italy.,Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy
| | - Vinant Bhargava
- Department of Nephrology and Research, Sir Ganga Ram Hospital, New Delhi, India
| | - Yongjie Yin
- Department of Emergency and Critical Care, The Second Hospital of Jilin University, Changchun, China
| | - Claudio Ronco
- International Renal Research Institute of Vicenza (IRRIV), Vicenza, Italy.,Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy
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23
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van Niekerk G, Engelbrecht AM. Inflammation-induced metabolic derangements or adaptation: An immunometabolic perspective. Cytokine Growth Factor Rev 2018; 43:47-53. [PMID: 29970338 DOI: 10.1016/j.cytogfr.2018.06.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 06/27/2018] [Accepted: 06/27/2018] [Indexed: 02/08/2023]
Abstract
Inflammatory mediators have a well-established role in mediating metabolic disturbances. Chronic low-grade inflammation is implicated in the pathogenesis of obesity and the development of metabolic syndrome. This phenomenon is even more pronounced in severe inflammatory states such as in critically ill patients where hyperglycaemia invariably manifests. Similarly, though inflammatory mediators have a well-established role in promoting bone resorption, the adaptive function of this process remains unknown. Here we review emerging evidence from the field of immunometabolism suggesting that these two processes serve a common goal, namely, to sustain the rapid proliferation of immune cells during an infection. Activated immune cells exhibit an increased demand for glucose which not only provides energy, but also glycolytic intermediates which are fluxed into biosynthetic processes. Similarly, phosphate liberated from bone is consumed during the phosphorylation of glycolytic intermediates, which plays a critical role in the synthesis of nucleotides and phospholipids. Taken together, these considerations suggest that metabolic alterations induced by inflammatory mediators do not manifest as an inability to maintain homeostatic levels of metabolites but represent an adaptive shift in the homeostatic set point during an infection.
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Affiliation(s)
- Gustav van Niekerk
- Department of Physiological Sciences, Stellenbosch University, Stellenbosch, South Africa.
| | - Anna-Mart Engelbrecht
- Department of Physiological Sciences, Stellenbosch University, Stellenbosch, South Africa
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24
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Caldwell A, Morick JN, Jentsch AM, Wegner A, Pavlovic D, Al-Banna N, Lehmann C. Impact of insulin on the intestinal microcirculation in a model of sepsis-related hyperglycemia. Microvasc Res 2018; 119:117-128. [PMID: 29778648 DOI: 10.1016/j.mvr.2018.05.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 03/22/2018] [Accepted: 05/13/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Sepsis involves dysfunctional glucose metabolism. Among patients with sepsis, hyperglycemia is frequent and insulin administration has been evaluated for glycemic control to improve patient outcomes. Only few studies have examined the hyperglycemic microcirculation and the impact of insulin on the microvasculature in sepsis. OBJECTIVE To study the functional capillary density (FCD) and leukocyte activation within the intestinal microcirculation in endotoxin-induced experimental sepsis. METHODS In 50 male Lewis rats, endotoxemia was induced with lipopolysaccharide (LPS; 5 mg/kg). Low dose (LD) glucose was administered to avoid insulin-induced hypoglycemia. High dose (HD) glucose was administered to model sepsis-related hyperglycemia. Animals in LD and HD glucose groups received an insulin bolus (1.4 IU/kg). Two hours after LPS administration, intravital microscopy (IVM) of the terminal ileum was performed, and FCD and leukocyte adherence were measured in a blinded fashion. Blood glucose levels were measured every 30 min following the onset of endotoxemia. Plasma samples were collected 3 h after the onset of endotoxemia to measure IFN-γ, TNF-α, IL-1α, IL-4, GM-CSF and MCP-1 levels using multiplex bead immunoassay. RESULTS Endotoxemia significantly reduced FCD and increased leukocyte adherence within the intestinal microvasculature. LD and HD glucose administration combined with insulin improved the FCD and decreased the adherence of leukocytes in endotoxemic animals as did HD glucose administration alone. Consistent with these results, IL-4, IL-1α, GM-CSF and IFN-γ levels were decreased following combined HD glucose and insulin administration in endotoxemic animals. CONCLUSIONS Insulin administration, as well as an endogenous insulin response triggered by HD glucose administration, improved the FCD and decreased leukocyte activation in endotoxemic rats. The results of this study give insight into the immune and vaso-modulatory role of insulin administration during experimental endotoxemia, and may be extrapolated for clinical sepsis and other critical illnesses with marked microcirculatory dysfunction.
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Affiliation(s)
- Alexa Caldwell
- Department of Pharmacology, Dalhousie University, Sir Charles Tupper Medical Building, 5850 College St, Halifax, NS B3H 4R2, Canada
| | - Jan Niklas Morick
- Department of Anesthesia and Intensive Care Medicine, University of Greifswald, Ferdinand-Sauerbruch, 17475 Greifswald, Germany
| | - Anne-Marie Jentsch
- Department of Anesthesia and Intensive Care Medicine, University of Greifswald, Ferdinand-Sauerbruch, 17475 Greifswald, Germany
| | - Annette Wegner
- Department of Anesthesia and Intensive Care Medicine, University of Greifswald, Ferdinand-Sauerbruch, 17475 Greifswald, Germany
| | - Dragan Pavlovic
- Department of Anesthesia and Intensive Care Medicine, University of Greifswald, Ferdinand-Sauerbruch, 17475 Greifswald, Germany
| | - Nadia Al-Banna
- Department of Anesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Sir Charles Tupper Medical Building, 5850 College St, Halifax, NS B3H 4R2, Canada
| | - Christian Lehmann
- Department of Pharmacology, Dalhousie University, Sir Charles Tupper Medical Building, 5850 College St, Halifax, NS B3H 4R2, Canada; Department of Anesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Sir Charles Tupper Medical Building, 5850 College St, Halifax, NS B3H 4R2, Canada; Department of Microbiology and Immunology, Dalhousie University, Sir Charles Tupper Medical Building, 5850 College St, Halifax, NS B3H 4R2, Canada; Department of Physiology and Biophysics, Dalhousie University, Sir Charles Tupper Medical Building, 5850 College St, Halifax, NS B3H 4R2, Canada.
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