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Iba T, Helms J, Maier CL, Levi M, Scarlatescu E, Levy JH. The role of thromboinflammation in acute kidney injury among patients with septic coagulopathy. J Thromb Haemost 2024; 22:1530-1540. [PMID: 38382739 DOI: 10.1016/j.jtha.2024.02.006] [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: 12/01/2023] [Revised: 01/22/2024] [Accepted: 02/07/2024] [Indexed: 02/23/2024]
Abstract
Inflammation and coagulation are critical self-defense mechanisms for mitigating infection that can nonetheless induce tissue injury and organ dysfunction. In severe cases, like sepsis, a dysregulated thromboinflammatory response may result in multiorgan dysfunction. Sepsis-associated acute kidney injury (AKI) is a significant contributor to patient morbidity and mortality. The connection between AKI and thromboinflammation is largely due to unique aspects of the renal vasculature. Specifically, the interaction between blood cells with the endothelial, glomerular, and peritubular capillary systems during thromboinflammation reduces oxygen supply to tubular epithelial cells. Previous studies have focused on tubular epithelial cell damage due to hypoxia, oxidative stress, and nephrotoxins. Although these factors are pivotal in acute tubular injury or necrosis, recent studies have demonstrated that AKI in sepsis encompasses a mixture of tubular and glomerular damage subtypes. In cases of sepsis-induced coagulopathy, thromboinflammation within the glomerulus and peritubular capillaries is an important pathogenic mechanism for AKI. Unfortunately, and despite the use of renal replacement therapy, the development of AKI in sepsis continues to be associated with high morbidity, mortality, and clinical challenges requiring alternative approaches. This review introduces the important role of thromboinflammation in AKI pathogenesis and details innovative vascular-targeting therapeutic strategies.
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Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan.
| | - Julie Helms
- French National Institute of Health and Medical Research, United Medical Resources 1260, Regenerative Nanomedicine, Federation de Medicine Translationnelle de Strasbourg, Strasbourg University Hospital, Medical Intensive Care Unit - NHC, Strasbourg University, Strasbourg, France
| | - Cheryl L Maier
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Marcel Levi
- Department of Vascular Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands; Department of Medicine, University College London Hospitals National Health Service Foundation Trust, Cardio-metabolic Programme-National Institute for Health and Care Research University College London Hospitals/University College London Biomedical Research Centre, London, United Kingdom
| | - Ecaterina Scarlatescu
- University of Medicine and Pharmacy "Carol Davila," Bucharest, Romania; Department of Anaesthesia and Intensive Care, Fundeni Clinical Institute, Bucharest, Romania
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, North Carolina, USA
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Scurt FG, Bose K, Mertens PR, Chatzikyrkou C, Herzog C. Cardiac Surgery-Associated Acute Kidney Injury. KIDNEY360 2024; 5:909-926. [PMID: 38689404 DOI: 10.34067/kid.0000000000000466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 04/26/2024] [Indexed: 05/02/2024]
Abstract
AKI is a common and serious complication of cardiac surgery that has a significant impact on patient morbidity and mortality. The Kidney Disease Improving Global Outcomes definition of AKI is widely used to classify and identify AKI associated with cardiac surgery (cardiac surgery-associated AKI [CSA-AKI]) on the basis of changes in serum creatinine and/or urine output. There are various preoperative, intraoperative, and postoperative risk factors for the development of CSA-AKI which should be recognized and addressed as early as possible to expedite its diagnosis, reduce its occurrence, and prevent or ameliorate its devastating complications. Crucial issues are the inaccuracy of serum creatinine as a surrogate parameter of kidney function in the perioperative setting of cardiothoracic surgery and the necessity to discover more representative markers of the pathophysiology of AKI. However, except for the tissue inhibitor of metalloproteinase-2 and insulin-like growth factor binding protein 7 ratio, other diagnostic biomarkers with an acceptable sensitivity and specificity are still lacking. This article provides a comprehensive review of various aspects of CSA-AKI, including pathogenesis, risk factors, diagnosis, biomarkers, classification, prevention, and treatment management.
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Affiliation(s)
- Florian G Scurt
- Clinic of Nephrology, Hypertension, Diabetes and Endocrinology, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Katrin Bose
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Magdeburg, Magdeburg, Germany
| | - Peter R Mertens
- Clinic of Nephrology, Hypertension, Diabetes and Endocrinology, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Christos Chatzikyrkou
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - Carolin Herzog
- Clinic of Nephrology, Hypertension, Diabetes and Endocrinology, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
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Fang Y, Xiong B, Shang X, Yang F, Yin Y, Sun Z, Wu X, Zhang J, Liu Y. Triglyceride-glucose index predicts sepsis-associated acute kidney injury and length of stay in sepsis: A MIMIC-IV cohort study. Heliyon 2024; 10:e29257. [PMID: 38617935 PMCID: PMC11015450 DOI: 10.1016/j.heliyon.2024.e29257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 03/23/2024] [Accepted: 04/03/2024] [Indexed: 04/16/2024] Open
Abstract
Background Inflammation and stress response may be related to the occurrence of sepsis-associated acute kidney injury (SA-AKI) in patients with sepsis.Insulin resistance (IR) is closely related to the stress response, inflammatory response, immune response and severity of critical diseases. We assume that the triglyceride-glucose (TyG) index, an alternative indicator for IR, is associated with the occurrence of SA-AKI in patients with sepsis. Methods Data were obtained from The Medical Information Mart for Intensive Care-IV(MIMIC-IV) database in this retrospective cohort study. Univariate and multivariate logistic regression analysis and multivariate restricted cubic spline(RCS) regression were conducted to evaluate the association between TyG index and SA-AKI, length of stay (LOS). Subgroup and sensitivity analyses were performed to verify the robustness of the results. Results The study ultimately included data from 1426 patients with sepsis, predominantly of white ethnicity (59.2%) and male sex (56.4%), with an SA-AKI incidence rate of 78.5%. A significant linear association was observed between the TyG index and SA-AKI (OR, 1.40; 95% confidence interval(CI) [1.14-1.73]). Additionally, the TyG index demonstrated a significant correlation with the length of stay (LOS) in both the hospital (β, 1.79; 95% CI [0.80-2.77]) and the intensive care unit (ICU) (β, 1.30; 95% CI [0.80-1.79]). Subgroup and sensitivity analyses confirmed the robustness of these associations. Conclusion This study revealed a strong association between the TyG index and both SA-AKI and length of stay in patients with sepsis. These findings suggest that the TyG index is a potential predictor of SA-AKI and the length of hospitalization in sepsis cases, broadening its application in this context. However, further research is required to confirm whether interventions targeting the TyG index can genuinely enhance the clinical outcomes of patients with sepsis.
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Affiliation(s)
| | | | | | | | - Yuehao Yin
- Department of Anesthesiology, Shanghai Cancer Centre, Fudan University, Shanghai, 200032, China
| | - Zhirong Sun
- Department of Anesthesiology, Shanghai Cancer Centre, Fudan University, Shanghai, 200032, China
| | - Xin Wu
- Department of Anesthesiology, Shanghai Cancer Centre, Fudan University, Shanghai, 200032, China
| | - Jun Zhang
- Department of Anesthesiology, Shanghai Cancer Centre, Fudan University, Shanghai, 200032, China
| | - Yi Liu
- Corresponding author. Department of Anesthesiology, Shanghai Cancer Centre, Fudan University, No. 270 Dong an Road, Shanghai, 200032, China.
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Abbasciano RG, Olivieri GM, Chubsey R, Gatta F, Tyson N, Easwarakumar K, Fudulu DP, Marsico R, Kofler M, Elshafie G, Lai F, Loubani M, Kendall S, Zakkar M, Murphy GJ. Prophylactic corticosteroids for cardiopulmonary bypass in adult cardiac surgery. Cochrane Database Syst Rev 2024; 3:CD005566. [PMID: 38506343 PMCID: PMC10952358 DOI: 10.1002/14651858.cd005566.pub4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
BACKGROUND Cardiac surgery triggers a strong inflammatory reaction, which carries significant clinical consequences. Corticosteroids have been suggested as a potential perioperative strategy to reduce inflammation and help prevent postoperative complications. However, the safety and effectiveness of perioperative corticosteroid use in adult cardiac surgery is uncertain. This is an update of the 2011 review with 18 studies added. OBJECTIVES Primary objective: to estimate the effects of prophylactic corticosteroid use in adults undergoing cardiac surgery with cardiopulmonary bypass on the: - co-primary endpoints of mortality, myocardial complications, and pulmonary complications; and - secondary outcomes including atrial fibrillation, infection, organ injury, known complications of steroid therapy, prolonged mechanical ventilation, prolonged postoperative stay, and cost-effectiveness. SECONDARY OBJECTIVE to explore the role of characteristics of the study cohort and specific features of the intervention in determining the treatment effects via a series of prespecified subgroup analyses. SEARCH METHODS We used standard, extensive Cochrane search methods to identify randomised studies assessing the effect of corticosteroids in adult cardiac surgery. The latest searches were performed on 14 October 2022. SELECTION CRITERIA We included randomised controlled trials in adults (over 18 years, either with a diagnosis of coronary artery disease or cardiac valve disease, or who were candidates for cardiac surgery with the use of cardiopulmonary bypass), comparing corticosteroids with no treatments. There were no restrictions with respect to length of the follow-up period. All selected studies qualified for pooling of results for one or more endpoints. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were all-cause mortality, and cardiac and pulmonary complications. Secondary outcomes were infectious complications, gastrointestinal bleeding, occurrence of new post-surgery atrial fibrillation, re-thoracotomy for bleeding, neurological complications, renal failure, inotropic support, postoperative bleeding, mechanical ventilation time, length of stays in the intensive care unit (ICU) and hospital, patient quality of life, and cost-effectiveness. We used GRADE to assess the certainty of evidence for each outcome. MAIN RESULTS This updated review includes 72 randomised trials with 17,282 participants (all 72 trials with 16,962 participants were included in data synthesis). Four trials (6%) were considered at low risk of bias in all the domains. The median age of participants included in the studies was 62.9 years. Study populations consisted mainly (89%) of low-risk, first-time coronary artery bypass grafting (CABG) or valve surgery. The use of perioperative corticosteroids may result in little to no difference in all-cause mortality (risk with corticosteroids: 25 to 36 per 1000 versus 33 per 1000 with placebo or no treatment; risk ratio (RR) 0.90, 95% confidence interval (CI) 0.75 to 1.07; 25 studies, 14,940 participants; low-certainty evidence). Corticosteroids may increase the risk of myocardial complications (68 to 86 per 1000) compared with placebo or no treatment (66 per 1000; RR 1.16, 95% CI 1.04 to 1.31; 25 studies, 14,766 participants; low-certainty evidence), and may reduce the risk of pulmonary complications (risk with corticosteroids: 61 to 77 per 1000 versus 78 per 1000 with placebo/no treatment; RR 0.88, 0.78 to 0.99; 18 studies, 13,549 participants; low-certainty evidence). Analyses of secondary endpoints showed that corticosteroids may reduce the incidence of infectious complications (risk with corticosteroids: 94 to 113 per 1000 versus 123 per 1000 with placebo/no treatment; RR 0.84, 95% CI 0.76 to 0.92; 28 studies, 14,771 participants; low-certainty evidence). Corticosteroids may result in little to no difference in incidence of gastrointestinal bleeding (risk with corticosteroids: 9 to 17 per 1000 versus 10 per 1000 with placebo/no treatment; RR 1.21, 95% CI 0.87 to 1.67; 6 studies, 12,533 participants; low-certainty evidence) and renal failure (risk with corticosteroids: 23 to 35 per 1000 versus 34 per 1000 with placebo/no treatment; RR 0.84, 95% CI 0.69 to 1.02; 13 studies, 12,799; low-certainty evidence). Corticosteroids may reduce the length of hospital stay, but the evidence is very uncertain (-0.5 days, 0.97 to 0.04 fewer days of length of hospital stay compared with placebo/no treatment; 25 studies, 1841 participants; very low-certainty evidence). The results from the two largest trials included in the review possibly skew the overall findings from the meta-analysis. AUTHORS' CONCLUSIONS A systematic review of trials evaluating the organ protective effects of corticosteroids in cardiac surgery demonstrated little or no treatment effect on mortality, gastrointestinal bleeding, and renal failure. There were opposing treatment effects on cardiac and pulmonary complications, with evidence that corticosteroids may increase cardiac complications but reduce pulmonary complications; however, the level of certainty for these estimates was low. There were minor benefits from corticosteroid therapy for infectious complications, but the evidence on hospital length of stay was very uncertain. The inconsistent treatment effects across different outcomes and the limited data on high-risk groups reduced the applicability of the findings. Further research should explore the role of these drugs in specific, vulnerable cohorts.
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Affiliation(s)
| | | | - Rachel Chubsey
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Francesca Gatta
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Nathan Tyson
- Department of Cardiac Surgery, University Hospitals of Leicester, Leicester, UK
| | | | - Daniel P Fudulu
- Department of Cardiac Surgery, University Hospital Bristol NHS Trust, Bristol, UK
| | | | | | - Ghazi Elshafie
- Department of Cardiothoracic Surgery, Hull and East Yorkshire Hospitals NHS Trust, Hull, UK
| | - Florence Lai
- Leicester Clinical Trials Unit, University of Leicester, Glenfield Hospital, Leicester, UK
| | - Mahmoud Loubani
- Department of Cardiothoracic Surgery, Hull and East Yorkshire Hospitals NHS Trust, Hull, UK
| | | | - Mustafa Zakkar
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Gavin J Murphy
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
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Wang Y, Guo D, Winkler R, Lei X, Wang X, Messina J, Luo J, Lu H. Development of novel liver-targeting glucocorticoid prodrugs. MEDICINE IN DRUG DISCOVERY 2024; 21:100172. [PMID: 38390434 PMCID: PMC10883687 DOI: 10.1016/j.medidd.2023.100172] [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] [Indexed: 02/24/2024] Open
Abstract
Background Glucocorticoids (GCs) are widely used in the treatment of inflammatory liver diseases and sepsis, but GC's various side effects on extrahepatic tissues limit their clinical benefits. Liver-targeting GC therapy may have multiple advantages over systemic GC therapy. The purpose of this study was to develop novel liver-targeting GC prodrugs as improved treatment for inflammatory liver diseases and sepsis. Methods A hydrophilic linker or an ultra-hydrophilic zwitterionic linker carboxylic betaine (CB) was used to bridge cholic acid (CA) and dexamethasone (DEX) to generate transporter-dependent liver-targeting GC prodrugs CA-DEX and the highly hydrophilic CA-CB-DEX. The efficacy of liver-targeting DEX prodrugs and DEX were determined in primary human hepatocytes (PHH), macrophages, human whole blood, and/or mice with sepsis induced by cecal ligation and puncture. Results CA-DEX was moderately water soluble, whereas CA-CB-DEX was highly water soluble. CA-CB-DEX and CA-DEX displayed highly transporter-dependent activities in reporter assays. Data mining found marked dysregulation of many GR-target genes important for lipid catabolism, cytoprotection, and inflammation in patients with severe alcoholic hepatitis. These key GR-target genes were similarly and rapidly (within 6 h) induced or down-regulated by CA-CB-DEX and DEX in PHH. CA-CB-DEX had much weaker inhibitory effects than DEX on endotoxin-induced cytokines in mouse macrophages and human whole blood. In contrast, CA-CB-DEX exerted more potent anti-inflammatory effects than DEX in livers of septic mice. Conclusions CA-CB-DEX demonstrated good hepatocyte-selectivity in vitro and better anti-inflammatory effects in vivo. Further test of CA-CB-DEX as a novel liver-targeting GC prodrug for inflammatory liver diseases and sepsis is warranted.
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Affiliation(s)
- Yazheng Wang
- Department of Pharmacology, SUNY Upstate Medical University, Syracuse, NY 13210, United States
| | - Dandan Guo
- Department of Pharmacology, SUNY Upstate Medical University, Syracuse, NY 13210, United States
| | - Rebecca Winkler
- Department of Pharmacology, SUNY Upstate Medical University, Syracuse, NY 13210, United States
| | - Xiaohong Lei
- Department of Pharmacology, SUNY Upstate Medical University, Syracuse, NY 13210, United States
| | - Xiaojing Wang
- Department of Pharmacology, SUNY Upstate Medical University, Syracuse, NY 13210, United States
| | - Jennifer Messina
- Department of Pharmacology, SUNY Upstate Medical University, Syracuse, NY 13210, United States
| | - Juntao Luo
- Department of Pharmacology, SUNY Upstate Medical University, Syracuse, NY 13210, United States
| | - Hong Lu
- Department of Pharmacology, SUNY Upstate Medical University, Syracuse, NY 13210, United States
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Li L, Ling Z, Wang X, Zhang X, Li Y, Gao G. Proteomics-based screening of AKR1B1 as a therapeutic target and validation study for sepsis-associated acute kidney injury. PeerJ 2024; 12:e16709. [PMID: 38188141 PMCID: PMC10768659 DOI: 10.7717/peerj.16709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 12/01/2023] [Indexed: 01/09/2024] Open
Abstract
Background Sepsis and sepsis-associated acute kidney injury (SA-AKI) pose significant global health challenges, necessitating the development of innovative therapeutic strategies. Dysregulated protein expression has been implicated in the initiation and progression of sepsis and SA-AKI. Identifying potential protein targets and modulating their expression is crucial for exploring alternative therapies. Method We established an SA-AKI rat model using cecum ligation perforation (CLP) and employed differential proteomic techniques to identify protein expression variations in kidney tissues. Aldose reductase (AKR1B1) emerged as a promising target. The SA-AKI rat model received treatment with the aldose reductase inhibitor (ARI), epalrestat. Blood urea nitrogen (BUN) and creatinine (CRE) levels, as well as IL-1β, IL-6 and TNF-α levels in the serum and kidney tissues, were monitored. Hematoxylin-eosin (H-E) staining and a pathological damage scoring scale assessed renal tissue damage, while protein blotting determined PKC (protein kinase C)/NF-κB pathway protein expression. Result Differential proteomics revealed significant downregulation of seven proteins and upregulation of 17 proteins in the SA-AKI rat model renal tissues. AKR1B1 protein expression was notably elevated, confirmed by Western blot. ARI prophylactic administration and ARI treatment groups exhibited reduced renal injury, low BUN and CRE levels and decreased IL-1β, IL-6 and TNF-α levels compared to the CLP group. These changes were statistically significant (P < 0.05). AKR1B1, PKC-α, and NF-κB protein expression levels were also lowered in the ARI prophylactic administration and ARI treatment groups compared to the CLP group (P < 0.05). Conclusions Epalrestat appeared to inhibit the PKC/NF-κB inflammatory pathway by inhibiting AKR1B1, resulting in reduced inflammatory cytokine levels in renal tissues and blood. This mitigated renal tissue injuries and improved the systemic inflammatory response in the severe sepsis rat model. Consequently, AKR1B1 holds promise as a target for treating sepsis-associated acute kidney injuries.
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Affiliation(s)
- Lei Li
- Intensive Care Unit, Shandong Public Health Clinical Center, Shandong University, Jinan, China
| | - Zaiqin Ling
- Department of Tubercular Medicine, Shandong Public Health Clinical Center, Shandong University, Jinan, China
| | - Xingsheng Wang
- Department of Emergency, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Xinxin Zhang
- Department of Emergency Medicine, Fuyang People’s Hospital of Anhui Medical University, Fuyang, China
| | - Yun Li
- Intensive Care Unit, Central Hospital Affliated to Shandong First Medical University, Jinan, China
| | - Guangsheng Gao
- Neurological Intensive Care Unit, Central Hospital Affliated to Shandong First Medical University, Jinan, China
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7
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Tyson LD, Atkinson S, Hunter RW, Allison M, Austin A, Dear JW, Forrest E, Liu T, Lord E, Masson S, Nunes J, Richardson P, Ryder SD, Wright M, Thursz M, Vergis N. In severe alcohol-related hepatitis, acute kidney injury is prevalent, associated with mortality independent of liver disease severity, and can be predicted using IL-8 and micro-RNAs. Aliment Pharmacol Ther 2023; 58:1217-1229. [PMID: 37781965 PMCID: PMC10946848 DOI: 10.1111/apt.17733] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 09/01/2023] [Accepted: 09/18/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND The prevalence, prediction and impact of acute kidney injury (AKI) in alcohol-related hepatitis (AH) is uncertain. AIMS We aimed to determine AKI incidence; association with mortality; evaluate serum biomarkers and the modifying effects of prednisolone and pentoxifylline in the largest AH cohort to date. METHODS Participants in the Steroids or Pentoxifylline for Alcoholic Hepatitis trial with day zero (D0) creatinine available were included. AKI was defined by modified International Club of Ascites criteria; incident AKI as day 7 (D7) AKI without D0-AKI. Survival was compared by Kaplan-Meier; mortality associations by Cox regression; associations with AKI by binary logistic regression; biomarkers by AUROC analyses. RESULTS D0-AKI was present in 198/1051 (19%) participants; incident AKI developed in a further 119/571 (21%) with available data. Participants with D0-AKI had higher 90-day mortality than those without (32% vs. 25%, p = 0.008), as did participants with incident AKI compared to those without D0-AKI or incident AKI (47% vs. 25%, p < 0.001). Incident AKI was associated with D90 mortality adjusted for age and discriminant function (AHR 2.15, 1.56-2.97, p < 0.001); D0-AKI was not. Prednisolone therapy reduced incident AKI (AOR 0.55, 0.36-0.85, p = 0.007) but not mortality. D0 bilirubin and IL-8 combined, miR-6826-5p, and miR-6811-3p predicted incident AKI (AUROCs 0.726, 0.821, 0.770, p < 0.01). CONCLUSIONS Incident AKI is associated with 90-day mortality independent of liver function. Prednisolone therapy was associated with reduced incident AKI. IL-8 and several miRNAs are potential biomarkers to predict AKI. Novel therapies to prevent incident AKI should be evaluated in AH to reduce mortality.
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Affiliation(s)
- Luke D. Tyson
- Department of Metabolism, Digestion and ReproductionImperial College LondonLondonUK
- The Liver UnitSt Mary's HospitalLondonUK
| | - Stephen Atkinson
- Department of Metabolism, Digestion and ReproductionImperial College LondonLondonUK
- The Liver UnitSt Mary's HospitalLondonUK
| | - Robert W. Hunter
- Centre for Cardiovascular ScienceUniversity of EdinburghEdinburghUK
| | - Michael Allison
- Cambridge NIHR Biomedical Research CentreAddenbrooke's HospitalCambridgeUK
| | | | - James W. Dear
- Centre for Cardiovascular ScienceUniversity of EdinburghEdinburghUK
| | - Ewan Forrest
- Department of HepatologyGlasgow Royal InfirmaryGlasgowUK
- University of GlasgowGlasgowUK
| | - Tong Liu
- Department of Metabolism, Digestion and ReproductionImperial College LondonLondonUK
| | - Emma Lord
- Department of Metabolism, Digestion and ReproductionImperial College LondonLondonUK
| | - Steven Masson
- Department of HepatologyNewcastle Freeman HospitalNewcastle upon TyneUK
| | | | - Paul Richardson
- Department of HepatologyThe Royal Liverpool University HospitalLiverpoolUK
| | - Stephen D. Ryder
- NIHR Nottingham Biomedical Research Centre at Nottingham University Hospitals NHS Trust and the University of NottinghamQueens Medical CentreNottinghamUK
| | - Mark Wright
- Department of HepatologyUniversity Hospital Southampton NHS Foundation TrustSouthamptonUK
| | - Mark Thursz
- Department of Metabolism, Digestion and ReproductionImperial College LondonLondonUK
- The Liver UnitSt Mary's HospitalLondonUK
| | - Nikhil Vergis
- Department of Metabolism, Digestion and ReproductionImperial College LondonLondonUK
- The Liver UnitSt Mary's HospitalLondonUK
- GSKBrentfordUK
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8
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Balakrishna A, Walco J, Billings FT, Lopez MG. Perioperative Acute Kidney Injury: Implications, Approach, Prevention. Adv Anesth 2023; 41:205-224. [PMID: 38251619 PMCID: PMC11079993 DOI: 10.1016/j.aan.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
Acute kidney injury remains a common and significant contributor to perioperative morbidity. Acute kidney injury worsens patient outcomes, and anesthesiologists should make significant efforts to prevent, assess, and treat perioperative renal injury. The authors discuss the impact of renal injury on patient outcomes and putative underlying mechanisms, evidence underlying treatments for acute kidney injury, and practices that may prevent the development of perioperative renal injury.
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Affiliation(s)
- Aditi Balakrishna
- Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jeremy Walco
- Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Frederic T Billings
- Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Marcos G Lopez
- Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA.
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Garg AX, Cuerden M, Cata J, Chan MTV, Devereaux PJ, Fleischmann E, Grande AM, Kabon B, Landoni G, Maziak DE, McLean S, Parikh C, Popova E, Reimer C, Trujillo Reyes JC, Roshanov P, Sessler DI, Srinathan S, Sontrop JM, Gonzalez Tallada A, Wang MK, Wells JR, Conen D. Effect of Colchicine on the Risk of Perioperative Acute Kidney Injury: Clinical Protocol of a Substudy of the Colchicine for the Prevention of Perioperative Atrial Fibrillation Randomized Clinical Trial. Can J Kidney Health Dis 2023; 10:20543581231185427. [PMID: 37457622 PMCID: PMC10338661 DOI: 10.1177/20543581231185427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 06/02/2023] [Indexed: 07/18/2023] Open
Abstract
Background Inflammation during and after surgery can lead to organ damage including acute kidney injury. Colchicine, an established inexpensive anti-inflammatory medication, may help to protect the organs from pro-inflammatory damage. This protocol describes a kidney substudy of the colchicine for the prevention of perioperative atrial fibrillation (COP-AF) study, which is testing the effect of colchicine versus placebo on the risk of atrial fibrillation and myocardial injury among patients undergoing thoracic surgery. Objective Our kidney substudy of COP-AF will determine whether colchicine reduces the risk of perioperative acute kidney injury compared with a placebo. We will also examine whether colchicine has a larger absolute benefit in patients with pre-existing chronic kidney disease, the most prominent risk factor for acute kidney injury. Design and Setting Randomized, superiority clinical trial conducted in 40 centers in 11 countries from 2018 to 2023. Patients Patients (~3200) aged 55 years and older having major thoracic surgery. Intervention Patients are randomized 1:1 to receive oral colchicine (0.5 mg tablet) or a matching placebo, given twice daily starting 2 to 4 hours before surgery for a total of 10 days. Patients, health care providers, data collectors, and outcome adjudicators will be blinded to the randomized treatment allocation. Methods Serum creatinine concentrations will be measured before surgery and on postoperative days 1, 2, and 3 (or until hospital discharge). The primary outcome of the substudy is perioperative acute kidney injury, defined as an increase (from the prerandomization value) in serum creatinine concentration of either ≥26.5 μmol/L (≥0.3 mg/dL) within 48 hours of surgery or ≥50% within 7 days of surgery. The primary analysis (intention-to-treat) will examine the relative risk of acute kidney injury in patients allocated to receive colchicine versus placebo. We will repeat the primary analysis using alternative definitions of acute kidney injury and examine effect modification by pre-existing chronic kidney disease, defined as a prerandomization estimated glomerular filtration rate (eGFR) <60 mL/min per 1.73 m2. Limitations The substudy will be underpowered to detect small effects on more severe forms of acute kidney injury treated with dialysis. Results Substudy results will be reported in 2024. Conclusions This substudy will estimate the effect of colchicine on the risk of perioperative acute kidney injury in older adults undergoing major thoracic surgery. Clinical trial registration number NCT03310125.
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Affiliation(s)
| | | | - Juan Cata
- MD Anderson Cancer Center, Houston, TX, USA
| | | | | | | | | | | | | | | | - Sean McLean
- Vancouver Acute Department of Anesthesiology, Vancouver General Hospital, BC, Canada
| | - Chirag Parikh
- Johns Hopkins School of Medicine, Baltimore, MD, USA
| | | | | | | | - Pavel Roshanov
- London Health Sciences Centre, ON, Canada
- Division of Nephrology, Department of Medicine, Western University, London, ON, Canada
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
| | | | | | | | | | | | | | - David Conen
- Population Health Research Institute, Hamilton, ON, Canada
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10
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Sepsis-associated acute kidney injury: consensus report of the 28th Acute Disease Quality Initiative workgroup. Nat Rev Nephrol 2023; 19:401-417. [PMID: 36823168 DOI: 10.1038/s41581-023-00683-3] [Citation(s) in RCA: 78] [Impact Index Per Article: 78.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2023] [Indexed: 02/25/2023]
Abstract
Sepsis-associated acute kidney injury (SA-AKI) is common in critically ill patients and is strongly associated with adverse outcomes, including an increased risk of chronic kidney disease, cardiovascular events and death. The pathophysiology of SA-AKI remains elusive, although microcirculatory dysfunction, cellular metabolic reprogramming and dysregulated inflammatory responses have been implicated in preclinical studies. SA-AKI is best defined as the occurrence of AKI within 7 days of sepsis onset (diagnosed according to Kidney Disease Improving Global Outcome criteria and Sepsis 3 criteria, respectively). Improving outcomes in SA-AKI is challenging, as patients can present with either clinical or subclinical AKI. Early identification of patients at risk of AKI, or at risk of progressing to severe and/or persistent AKI, is crucial to the timely initiation of adequate supportive measures, including limiting further insults to the kidney. Accordingly, the discovery of biomarkers associated with AKI that can aid in early diagnosis is an area of intensive investigation. Additionally, high-quality evidence on best-practice care of patients with AKI, sepsis and SA-AKI has continued to accrue. Although specific therapeutic options are limited, several clinical trials have evaluated the use of care bundles and extracorporeal techniques as potential therapeutic approaches. Here we provide graded recommendations for managing SA-AKI and highlight priorities for future research.
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11
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Sun Q, Zhao Y, Liao B, Mo L, Xu J, Cui Y. Risk factors of perioperative acute kidney injury in elderly patients: a single-center retrospective study. Int Urol Nephrol 2023; 55:459-467. [PMID: 36008696 DOI: 10.1007/s11255-022-03345-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 08/19/2022] [Indexed: 01/25/2023]
Abstract
PURPOSE The elderly are vulnerable to perioperative acute kidney injury. The aim of this study was to determine the risk factors that associated with acute kidney injury among elderly patients. METHODS Clinical data of elderly patients (> 65 years) who underwent noncardiac, nonrenal surgery between Dec 1 2009 and July 1 2016 were collected for this single-centered historical cohort study. Univariate and multivariate analyses were conducted to explore the risk factors that contribute to acute kidney injury, which was defined as a serum creatinine increase >0.3 mg/dL within 48 h or 1.5 times increase in serum creatinine within 7 days after surgery. RESULTS 7775 patients were eligible for the final analysis, among which 511 (6.57%) patients developed acute kidney injury. We observed 21 risk factors being associated with perioperative acute kidney injury, with the most important disposing factors being history of kidney disease (adjusted OR = 2.94, 95% CI 2.25-3.84), operation time > 180 min (aOR = 2.93, 95% CI 2.04-4.24), preoperative eGFR [15, 30) (aOR = 2.43, 95% CI 1.29-4.45), and protective factor being intraoperative use of sufentanil (aOR = 0.35, 95% CI 0.23-0.54). CONCLUSION This study determined risk factors for perioperative acute kidney injury among the elderly in the Second Xiangya Hospital and visualized the risk factors using nomogram and Excel calculator, which may provide some clues to further investigations. Overall, the prevalence of AKI among this large cohort is 6.57%. CLINICAL TRIALS REGISTRATION http://www.chictr.org.cn ; ChiCTR1900027007; October 28, 2019.
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Affiliation(s)
- Qi Sun
- Department of Anesthesiology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China.,Hunan Province Center for Clinical Anesthesia and Anesthesiology, Research Institute of Central South University, Changsha, China
| | - Yujing Zhao
- Department of Anesthesiology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China.,Hunan Province Center for Clinical Anesthesia and Anesthesiology, Research Institute of Central South University, Changsha, China
| | - Binyi Liao
- Department of Anesthesiology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China.,Hunan Province Center for Clinical Anesthesia and Anesthesiology, Research Institute of Central South University, Changsha, China
| | - Lei Mo
- Department of Biostatistics, Le9 Healthcare Technology Co., Ltd., Shanghai, China
| | - Junmei Xu
- Department of Anesthesiology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China. .,Hunan Province Center for Clinical Anesthesia and Anesthesiology, Research Institute of Central South University, Changsha, China.
| | - Yulong Cui
- Department of Anesthesiology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China. .,Hunan Province Center for Clinical Anesthesia and Anesthesiology, Research Institute of Central South University, Changsha, China.
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12
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Pickkers P, Murray PT, Ostermann M. New drugs for acute kidney injury. Intensive Care Med 2022; 48:1796-1798. [PMID: 35999470 PMCID: PMC9705447 DOI: 10.1007/s00134-022-06859-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 08/04/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Peter Pickkers
- Department Intensive Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Marlies Ostermann
- Department of Critical Care, King’s College London, Guy’s and St Thomas’ Hospital, London, UK
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13
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Chen JJ, Lee TH, Kuo G, Huang YT, Chen PR, Chen SW, Yang HY, Hsu HH, Hsiao CC, Yang CH, Lee CC, Chen YC, Chang CH. Strategies for post–cardiac surgery acute kidney injury prevention: A network meta-analysis of randomized controlled trials. Front Cardiovasc Med 2022; 9:960581. [PMID: 36247436 PMCID: PMC9555275 DOI: 10.3389/fcvm.2022.960581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 09/12/2022] [Indexed: 12/05/2022] Open
Abstract
Objects Cardiac surgery is associated with acute kidney injury (AKI). However, the effects of various pharmacological and non-pharmacological strategies for AKI prevention have not been thoroughly investigated, and their effectiveness in preventing AKI-related adverse outcomes has not been systematically evaluated. Methods Studies from PubMed, Embase, and Medline and registered trials from published through December 2021 that evaluated strategies for preventing post–cardiac surgery AKI were identified. The effectiveness of these strategies was assessed through a network meta-analysis (NMA). The secondary outcomes were prevention of dialysis-requiring AKI, mortality, intensive care unit (ICU) length of stay (LOS), and hospital LOS. The interventions were ranked using the P-score method. Confidence in the results of the NMA was assessed using the Confidence in NMA (CINeMA) framework. Results A total of 161 trials (involving 46,619 participants) and 53 strategies were identified. Eight pharmacological strategies {natriuretic peptides [odds ratio (OR): 0.30, 95% confidence interval (CI): 0.19–0.47], nitroprusside [OR: 0.29, 95% CI: 0.12–0.68], fenoldopam [OR: 0.36, 95% CI: 0.17–0.76], tolvaptan [OR: 0.35, 95% CI: 0.14–0.90], N-acetyl cysteine with carvedilol [OR: 0.37, 95% CI: 0.16–0.85], dexmedetomidine [OR: 0.49, 95% CI: 0.32–0.76;], levosimendan [OR: 0.56, 95% CI: 0.37–0.84], and erythropoietin [OR: 0.62, 95% CI: 0.41–0.94]} and one non-pharmacological intervention (remote ischemic preconditioning, OR: 0.76, 95% CI: 0.63–0.92) were associated with a lower incidence of post–cardiac surgery AKI with moderate to low confidence. Among these nine strategies, five (fenoldopam, erythropoietin, natriuretic peptides, levosimendan, and remote ischemic preconditioning) were associated with a shorter ICU LOS, and two (natriuretic peptides [OR: 0.30, 95% CI: 0.15–0.60] and levosimendan [OR: 0.68, 95% CI: 0.49–0.95]) were associated with a lower incidence of dialysis-requiring AKI. Natriuretic peptides were also associated with a lower risk of mortality (OR: 0.50, 95% CI: 0.29–0.86). The results of a sensitivity analysis support the robustness and effectiveness of natriuretic peptides and dexmedetomidine. Conclusion Nine potentially effective strategies were identified. Natriuretic peptide therapy was the most effective pharmacological strategy, and remote ischemic preconditioning was the only effective non-pharmacological strategy. Preventive strategies might also help prevent AKI-related adverse outcomes. Additional studies are required to explore the optimal dosages and protocols for potentially effective AKI prevention strategies.
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Affiliation(s)
- Jia-Jin Chen
- Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | | | - George Kuo
- Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Department of Nephrology, Kidney Research Center, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yen-Ta Huang
- Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Pei-Rung Chen
- Department of Anesthesiology, Mackay Memorial Hospital, Taipei, Taiwan
| | - Shao-Wei Chen
- Department of Cardiothoracic and Vascular Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
| | - Huang-Yu Yang
- Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Department of Nephrology, Kidney Research Center, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Hsiang-Hao Hsu
- Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Department of Nephrology, Kidney Research Center, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ching-Chung Hsiao
- Department of Nephrology, New Taipei Municipal TuCheng Hospital, New Taipei City, Taiwan
| | - Chia-Hung Yang
- Department of Cardiology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Cheng-Chia Lee
- Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Department of Nephrology, Kidney Research Center, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yung-Chang Chen
- Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Department of Nephrology, Kidney Research Center, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chih-Hsiang Chang
- Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Department of Nephrology, Kidney Research Center, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
- *Correspondence: Chih-Hsiang Chang,
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14
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Narrative Review: Glucocorticoids in Alcoholic Hepatitis—Benefits, Side Effects, and Mechanisms. J Xenobiot 2022; 12:266-288. [PMID: 36278756 PMCID: PMC9589945 DOI: 10.3390/jox12040019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 09/03/2022] [Accepted: 09/05/2022] [Indexed: 11/17/2022] Open
Abstract
Alcoholic hepatitis is a major health and economic burden worldwide. Glucocorticoids (GCs) are the only first-line drugs recommended to treat severe alcoholic hepatitis (sAH), with limited short-term efficacy and significant side effects. In this review, I summarize the major benefits and side effects of GC therapy in sAH and the potential underlying mechanisms. The review of the literature and data mining clearly indicate that the hepatic signaling of glucocorticoid receptor (GR) is markedly impaired in sAH patients. The impaired GR signaling causes hepatic down-regulation of genes essential for gluconeogenesis, lipid catabolism, cytoprotection, and anti-inflammation in sAH patients. The efficacy of GCs in sAH may be compromised by GC resistance and/or GC’s extrahepatic side effects, particularly the side effects of intestinal epithelial GR on gut permeability and inflammation in AH. Prednisolone, a major GC used for sAH, activates both the GR and mineralocorticoid receptor (MR). When GC non-responsiveness occurs in sAH patients, the activation of MR by prednisolone might increase the risk of alcohol abuse, liver fibrosis, and acute kidney injury. To improve the GC therapy of sAH, the effort should be focused on developing the biomarker(s) for GC responsiveness, liver-targeting GR agonists, and strategies to overcome GC non-responsiveness and prevent alcohol relapse in sAH patients.
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15
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Feng YL, Yang Y, Chen H. Small molecules as a source for acute kidney injury therapy. Pharmacol Ther 2022; 237:108169. [DOI: 10.1016/j.pharmthera.2022.108169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 02/28/2022] [Accepted: 03/07/2022] [Indexed: 10/18/2022]
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16
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Liu K, Yuan B, Zhang X, Chen W, Patel LP, Hu Y, Liu M. Characterizing the temporal changes in association between modifiable risk factors and acute kidney injury with multi-view analysis. Int J Med Inform 2022; 163:104785. [DOI: 10.1016/j.ijmedinf.2022.104785] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 04/15/2022] [Accepted: 04/24/2022] [Indexed: 12/15/2022]
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17
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Chen L, Xiang F, Hu Y. Corticosteroids in patients undergoing cardiac surgery: A meta-analysis of 12,559 patients. Perfusion 2022; 38:853-859. [PMID: 35657725 DOI: 10.1177/02676591221106324] [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
OBJECTIVE Corticosteroids can attenuate the inflammatory response to cardiopulmonary bypass, but their benefits on clinical outcomes are unclear. We conducted a meta-analysis to evaluate whether corticosteroid therapy affects outcomes in patients undergoing cardiac surgery. METHODS We searched PubMed, Embase, EBSCO and Cochrane databases from 1 January 2010 to 14 March 2022 for randomized controlled trials (RCTs) that assessed corticosteroid versus non- corticosteroid therapy in patients undergoing cardiac surgery. The primary outcome was in-hospital mortality. Secondary outcomes were renal failure, infection, delirium, intensive care unit (ICU) and hospital stay. RESULTS Four RCTs including 12,559 patients (6265 randomized to corticosteroid therapy and 6294 to non-corticosteroid therapy) were included. One-hundred and 92 of 6265 patients (3.1%) randomized to the corticosteroid group versus 221 of 6294 patients (3.5%) randomized to the non-corticosteroid group experienced death during hospitalization. Compared the control group, corticosteroid therapy did not significantly reduce in-hospital mortality, with an RR of 0.87 (0.72-1.06), p = .16. There was no difference in the incidence of infection (RR 0.78 (0.56-1.10), p = .16), delirium during hospitalization (RR 1.01 (0.90-1.14), p = .85), or the length of hospital stay (MD -0.13 (-0.32 to 0.05), p = .17). However, corticosteroid therapy significantly reduced the risk of renal failure ( RR 0.82 (0.67-0.99), p = .04), and the length of ICU stay (MD -0.41 (-0.65 to -0.17), p < .01). CONCLUSIONS Corticosteroids did not significantly reduce the rates of in-hospital mortality, infection, or delirium, but reduce the incidence of renal failure and the length of ICU stay.
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Affiliation(s)
- Lei Chen
- Department of Pharmacy, 26452The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China
| | - Feng Xiang
- Department of Pharmacy, 26452The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China
| | - Yiyi Hu
- Department of Pharmacy, 26452The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China
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18
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Kunkel D, Parker M, Casey C, Krause B, Taylor J, Pearce RA, Lennertz R, Sanders RD. Impact of perioperative inflammation on days alive and at home after surgery. BJA OPEN 2022; 2:100006. [PMID: 37588271 PMCID: PMC10430844 DOI: 10.1016/j.bjao.2022.100006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 03/01/2022] [Indexed: 08/18/2023]
Abstract
Background Perioperative inflammation is associated with perioperative complications, including delirium, that are associated with a reduced number of postoperative days alive and at home at 90 days (DAH90). We tested whether inflammation was associated with DAH90 even when adjusting for perioperative factors, and whether inflammation independently was associated with DAH90 when adjusting for delirium. Methods We conducted a prospective cohort study of major, non-intracranial surgical patients who were older than 65 yr (n=134). We measured postoperative delirium incidence and severity, and changes in interleukin (IL)-8 and IL-10 in blood plasma. Our primary outcome, DAH90, was analysed using quantile regression. Results Before adjusting for delirium, a postoperative day 1 increased IL-8 was associated with fewer DAH90 at the 0.75 quantile (β=-0.082; 95% confidence interval [CI], -0.19 to -0.006) after adjusting for demographic (age and sex) and perioperative factors (cardiovascular surgery, National Surgical Quality Improvement Program risk of death, and operative time). IL-10 was similarly associated with DAH90 at the 0.5 (β=-0.026; 95% CI, -0.19 to -0.001) and 0.75 (β= -0.035; 95% CI, -0.07 to -0.006) quantiles. Neither cytokine was significantly associated with DAH90 once delirium and baseline Trail Making Test B were added to the models. Conclusions Perioperative inflammation predicts DAH90, but when delirium is added to the model inflammation loses significance as a predictor, whereas delirium is significant. Targeting perioperative inflammation may reduce delirium and moderate hospital readmission and mortality. Clinical trial registration NCT03124303.
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Affiliation(s)
- David Kunkel
- Department of Anesthesiology, University of Wisconsin, Madison, WI, USA
| | - Margaret Parker
- Department of Anesthesiology, University of Wisconsin, Madison, WI, USA
| | - Cameron Casey
- Department of Anesthesiology, University of Wisconsin, Madison, WI, USA
| | - Bryan Krause
- Department of Anesthesiology, University of Wisconsin, Madison, WI, USA
| | - Jennifer Taylor
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney Local Health District, Camperdown, NSW, Australia
| | - Robert A. Pearce
- Department of Anesthesiology, University of Wisconsin, Madison, WI, USA
| | - Richard Lennertz
- Department of Anesthesiology, University of Wisconsin, Madison, WI, USA
| | - Robert D. Sanders
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney Local Health District, Camperdown, NSW, Australia
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19
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Ge Y, Behera TR, Yu M, Xie S, Chen Y, Mao H, Xu Q, Zhao Y, Zhang S, Shen Q. Higher Mean Arterial Pressure during Cardiopulmonary Bypass May Not Prevent Acute Kidney Injury in Elderly Patients Undergoing Cardiac Surgery. Int J Clin Pract 2022; 2022:7701947. [PMID: 35685523 PMCID: PMC9159145 DOI: 10.1155/2022/7701947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 03/15/2022] [Accepted: 03/17/2022] [Indexed: 11/17/2022] Open
Abstract
We aimed to evaluate the role of higher mean arterial pressure (MAP) during cardiopulmonary bypass (CPB) in preventing development of acute kidney injury (AKI). Methods. We evaluated a population of elderly individuals >60 years of age undergoing CPB to find correlation of MAP during CPB with development of AKI after the surgery. Patients who experienced sustained low MAP during the CPB defined as that of <65 mmHg were compared with those that had sustained high MAP of >65 mmHg for their outcome with regard to AKI. The KDIGO criteria were used to define presence of acute kidney injury. Results. Of the total 92 patients, 50 were in the low-pressure group and 42 were in the high-pressure group. The MAP was 61.14 ± 5.54 mmHg in the low-pressure group and 68.97 ± 3.65 mmHg in the high-pressure group (p < 0.001). 13 (26%) in the low-pressure group and 17 (40.48%) in the high-pressure group developed AKI (p = 0.140). Male sex was associated with an increased incidence of cardiac surgery-associated AKI (p = 0.034). Conclusions. A higher MAP in the range of 65-75 mmHg during the cardiopulmonary bypass does not significantly prevent acute kidney injury in elderly patients undergoing cardiac valve surgery.
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Affiliation(s)
- Yunfen Ge
- Center for Rehabilitation Medicine, Department of Anesthesiology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, Zhejiang 310014, China
| | | | - Ming Yu
- Department of Anesthesiology, Tiantai People's Hospital, Tiantai, Taizhou, Zhejiang 317299, China
| | - Shuyang Xie
- Department of Anesthesiology, Tiantai People's Hospital, Tiantai, Taizhou, Zhejiang 317299, China
| | - Yue Chen
- Center for Rehabilitation Medicine, Department of Anesthesiology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, Zhejiang 310014, China
| | - Hui Mao
- Center for Rehabilitation Medicine, Department of Anesthesiology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, Zhejiang 310014, China
| | - Qiong Xu
- Center for Rehabilitation Medicine, Department of Anesthesiology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, Zhejiang 310014, China
| | - Yu Zhao
- Geriatric Medicine Center, Department of Endocrinology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, Zhejiang 310014, China
| | - Shuijun Zhang
- Center for Plastic & Reconstructive Surgery, Department of Orthopedics, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, Zhejiang 310014, China
| | - Quanquan Shen
- Urology & Nephrology Center, Department of Nephrology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, Zhejiang 310014, China
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20
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Preservation of Renal Function. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00017-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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21
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Dashti-Khavidaki S, Saidi R, Lu H. Current status of glucocorticoid usage in solid organ transplantation. World J Transplant 2021; 11:443-465. [PMID: 34868896 PMCID: PMC8603633 DOI: 10.5500/wjt.v11.i11.443] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 09/16/2021] [Accepted: 11/03/2021] [Indexed: 02/06/2023] Open
Abstract
Glucocorticoids (GCs) have been the mainstay of immunosuppressive therapy in solid organ transplantation (SOT) for decades, due to their potent effects on innate immunity and tissue protective effects. However, some SOT centers are reluctant to administer GCs long-term because of the various related side effects. This review summarizes the advantages and disadvantages of GCs in SOT. PubMed and Scopus databases were searched from 2011 to April 2021 using search syntaxes covering “transplantation” and “glucocorticoids”. GCs are used in transplant recipients, transplant donors, and organ perfusate solution to improve transplant outcomes. In SOT recipients, GCs are administered as induction and maintenance immunosuppressive therapy. GCs are also the cornerstone to treat acute antibody- and T-cell-mediated rejections. Addition of GCs to organ perfusate solution and pretreatment of transplant donors with GCs are recommended by some guidelines and protocols, to reduce ischemia-reperfusion injury peri-transplant. GCs with low bioavailability and high potency for GC receptors, such as budesonide, nanoparticle-mediated targeted delivery of GCs to specific organs, and combination use of dexamethasone with inducers of immune-regulatory cells, are new methods of GC application in SOT patients to reduce side effects or induce immune-tolerance instead of immunosuppression. Various side effects involving different non-targeted organs/tissues, such as bone, cardiovascular, neuromuscular, skin and gastrointestinal tract, have been noted for GCs. There are also potential drug-drug interactions for GCs in SOT patients.
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Affiliation(s)
- Simin Dashti-Khavidaki
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran 14155, Iran
| | - Reza Saidi
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY 13210, United States
| | - Hong Lu
- Department of Pharmacology, SUNY Upstate Medical University, Syracuse, NY 13210, United States
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22
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Cardiac Surgery Associated AKI Prevention Strategies and Medical Treatment for CSA-AKI. J Clin Med 2021; 10:jcm10225285. [PMID: 34830567 PMCID: PMC8618011 DOI: 10.3390/jcm10225285] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 11/03/2021] [Accepted: 11/08/2021] [Indexed: 12/29/2022] Open
Abstract
Acute kidney injury (AKI) is common after cardiac surgery. To date, there are no specific pharmacological therapies. In this review, we summarise the existing evidence for prevention and management of cardiac surgery-associated AKI and outline areas for future research. Preoperatively, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers should be withheld and nephrotoxins should be avoided to reduce the risk. Intraoperative strategies include goal-directed therapy with individualised blood pressure management and administration of balanced fluids, the use of circuits with biocompatible coatings, application of minimally invasive extracorporeal circulation, and lung protective ventilation. Postoperative management should be in accordance with current KDIGO AKI recommendations.
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23
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Vormann MK, Tool LM, Ohbuchi M, Gijzen L, van Vught R, Hankemeier T, Kiyonaga F, Kawabe T, Goto T, Fujimori A, Vulto P, Lanz HL, Tetsuka K. Modelling and Prevention of Acute Kidney Injury through Ischemia and Reperfusion in a Combined Human Renal Proximal Tubule/Blood Vessel-on-a-Chip. KIDNEY360 2021; 3:217-231. [PMID: 35373131 PMCID: PMC8967632 DOI: 10.34067/kid.0003622021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 10/29/2021] [Indexed: 01/10/2023]
Abstract
Background Renal ischemia/reperfusion injury (rIRI) is one of the major causes of AKI. Although animal models are suitable for investigating systemic symptoms of AKI, they are limited in translatability. Human in vitro models are crucial in giving mechanistic insights into rIRI; however, they miss out on crucial aspects such as reperfusion injury and the multitissue aspect of AKI. Methods We advanced the current renal proximal tubule-on-a-chip model to a coculture model with a perfused endothelial vessel separated by an extracellular matrix. The coculture was characterized for its three-dimensional structure, protein expression, and response to nephrotoxins. Then, rIRI was captured through control of oxygen levels, nutrient availability, and perfusion flow settings. Injury was quantified through morphologic assessment, caspase-3/7 activation, and cell viability. Results The combination of low oxygen, reduced glucose, and interrupted flow was potent to disturb the proximal tubules. This effect was strongly amplified upon reperfusion. Endothelial vessels were less sensitive to the ischemia-reperfusion parameters. Adenosine treatment showed a protective effect on the disruption of the epithelium and on the caspase-3/7 activation. Conclusions A human in vitro rIRI model was developed using a coculture of a proximal tubule and blood vessel on-a-chip, which was used to characterize the renoprotective effect of adenosine. The robustness of the model and assays in combination with the throughput of the platform make it ideal to advance pathophysiological research and enable the development of novel therapeutic modalities.
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Affiliation(s)
| | | | - Masato Ohbuchi
- Analysis and Pharmacokinetics Research Labs, Astellas Pharma, Inc., Ibaraki, Japan
| | | | | | | | - Fumiko Kiyonaga
- Innovation and Incubation Research Labs, Astellas Pharma, Inc., Ibaraki, Japan
| | | | - Takayuki Goto
- Modality Research Labs, Astellas Pharma, Inc., Ibaraki, Japan
| | - Akira Fujimori
- Research Portfolio Planning, Astellas Pharma, Inc., Ibaraki, Japan
| | | | | | - Kazuhiro Tetsuka
- Analysis and Pharmacokinetics Research Labs, Astellas Pharma, Inc., Ibaraki, Japan
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24
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Wang X, Liu Z, Sandoval-Salaiza DA, Afewerki S, Jimenez-Rodriguez MG, Sanchez-Melgar L, Güemes-Aguilar G, Gonzalez-Sanchez DG, Noble O, Lerma C, Parra-Saldivar R, Lemos DR, Llamas-Esperon GA, Shi J, Li L, Lobo AO, Fuentes-Baldemar AA, Bonventre JV, Dong N, Ruiz-Esparza GU. Nanostructured Non-Newtonian Drug Delivery Barrier Prevents Postoperative Intrapericardial Adhesions. ACS APPLIED MATERIALS & INTERFACES 2021; 13:29231-29246. [PMID: 34137251 DOI: 10.1021/acsami.0c20084] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
With the increasing volume of cardiovascular surgeries and the rising adoption rate of new methodologies that serve as a bridge to cardiac transplantation and that require multiple surgical interventions, the formation of postoperative intrapericardial adhesions has become a challenging problem that limits future surgical procedures, causes serious complications, and increases medical costs. To prevent this pathology, we developed a nanotechnology-based self-healing drug delivery hydrogel barrier composed of silicate nanodisks and polyethylene glycol with the ability to coat the epicardial surface of the heart without friction and locally deliver dexamethasone, an anti-inflammatory drug. After the fabrication of the hydrogel, mechanical characterization and responses to shear, strain, and recovery were analyzed, confirming its shear-thinning and self-healing properties. This behavior allowed its facile injection (5.75 ± 0.15 to 22.01 ± 0.95 N) and subsequent mechanical recovery. The encapsulation of dexamethasone within the hydrogel system was confirmed by 1H NMR, and controlled release for 5 days was observed. In vitro, limited cellular adhesion to the hydrogel surface was achieved, and its anti-inflammatory properties were confirmed, as downregulation of ICAM-1 and VCAM-1 was observed in TNF-α activated endothelial cells. In vivo, 1 week after administration of the hydrogel to a rabbit model of intrapericardial injury, superior efficacy was observed when compared to a commercial adhesion barrier, as histological and immunohistochemical examination revealed reduced adhesion formation and minimal immune infiltration of CD3+ lymphocytes and CD68+ macrophages, as well as NF-κβ downregulation. We presented a novel nanostructured drug delivery hydrogel system with unique mechanical and biological properties that act synergistically to prevent cellular infiltration while providing local immunomodulation to protect the intrapericardial space after a surgical intervention.
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Affiliation(s)
- Xichi Wang
- Division of Engineering in Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, United States
- Division of Health Sciences and Technology, Harvard University - Massachusetts Institute of Technology, Cambridge, Massachusetts 02139, United States
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, United States
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Zongtao Liu
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Diego A Sandoval-Salaiza
- Division of Engineering in Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, United States
- Division of Health Sciences and Technology, Harvard University - Massachusetts Institute of Technology, Cambridge, Massachusetts 02139, United States
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, United States
- School of Engineering and Science, Tecnologico de Monterrey, Monterrey, Nuevo Leon 64849, Mexico
| | - Samson Afewerki
- Division of Engineering in Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, United States
- Division of Health Sciences and Technology, Harvard University - Massachusetts Institute of Technology, Cambridge, Massachusetts 02139, United States
- Department of Chemical Engineering and Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, Massachusetts 02139, United States
| | - Mildred G Jimenez-Rodriguez
- Division of Engineering in Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, United States
- Division of Health Sciences and Technology, Harvard University - Massachusetts Institute of Technology, Cambridge, Massachusetts 02139, United States
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, United States
- School of Engineering and Science, Tecnologico de Monterrey, Monterrey, Nuevo Leon 64849, Mexico
| | - Lorena Sanchez-Melgar
- Division of Engineering in Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, United States
- Division of Health Sciences and Technology, Harvard University - Massachusetts Institute of Technology, Cambridge, Massachusetts 02139, United States
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, United States
- School of Engineering and Science, Tecnologico de Monterrey, Monterrey, Nuevo Leon 64849, Mexico
| | - Gabriela Güemes-Aguilar
- Division of Engineering in Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, United States
- Division of Health Sciences and Technology, Harvard University - Massachusetts Institute of Technology, Cambridge, Massachusetts 02139, United States
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, United States
- School of Medicine and Health Science, Tecnologico de Monterrey, Monterrey, Nuevo Leon 64849, Mexico
| | - David G Gonzalez-Sanchez
- Division of Engineering in Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, United States
- Division of Health Sciences and Technology, Harvard University - Massachusetts Institute of Technology, Cambridge, Massachusetts 02139, United States
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, United States
- School of Medicine and Health Science, Tecnologico de Monterrey, Monterrey, Nuevo Leon 64849, Mexico
| | - Oscar Noble
- Division of Engineering in Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, United States
- Division of Health Sciences and Technology, Harvard University - Massachusetts Institute of Technology, Cambridge, Massachusetts 02139, United States
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, United States
- School of Medicine and Health Science, Tecnologico de Monterrey, Monterrey, Nuevo Leon 64849, Mexico
| | - Cecilia Lerma
- Division of Engineering in Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, United States
- Division of Health Sciences and Technology, Harvard University - Massachusetts Institute of Technology, Cambridge, Massachusetts 02139, United States
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, United States
- School of Engineering and Science, Tecnologico de Monterrey, Monterrey, Nuevo Leon 64849, Mexico
| | - Roberto Parra-Saldivar
- Division of Engineering in Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, United States
- Division of Health Sciences and Technology, Harvard University - Massachusetts Institute of Technology, Cambridge, Massachusetts 02139, United States
- School of Engineering and Science, Tecnologico de Monterrey, Monterrey, Nuevo Leon 64849, Mexico
| | - Dario R Lemos
- Division of Engineering in Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, United States
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, United States
| | - Guillermo A Llamas-Esperon
- Department of Interventional Cardiology, Hospital Cardiológica, Aguascalientes, Aguascalientes 20230, Mexico
| | - Jiawei Shi
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Li Li
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, United States
| | - Anderson O Lobo
- LIMAV-Interdisciplinary Laboratory for Advanced Materials, BioMatLab group, Material Science and Engineering Graduate Program, UFPI- Federal University of Piauí, Teresina, Piauí 64049-550, Brazil
| | - Andres A Fuentes-Baldemar
- Division of Engineering in Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, United States
- Division of Health Sciences and Technology, Harvard University - Massachusetts Institute of Technology, Cambridge, Massachusetts 02139, United States
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, United States
| | - Joseph V Bonventre
- Division of Engineering in Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, United States
- Division of Health Sciences and Technology, Harvard University - Massachusetts Institute of Technology, Cambridge, Massachusetts 02139, United States
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, United States
| | - Nianguo Dong
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Guillermo U Ruiz-Esparza
- Division of Engineering in Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, United States
- Division of Health Sciences and Technology, Harvard University - Massachusetts Institute of Technology, Cambridge, Massachusetts 02139, United States
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, United States
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25
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Abstract
To characterize current evidence and current foci of perioperative clinical trials, we systematically reviewed Medline and identified perioperative trials involving 100 or more adult patients undergoing surgery and reporting renal end points that were published in high-impact journals since 2004. We categorized the 101 trials identified based on the nature of the intervention and summarized major trial findings from the five categories most applicable to perioperative management of patients. Trials that targeted ischemia suggested that increasing perioperative renal oxygen delivery with inotropes or blood transfusion does not reliably mitigate acute kidney injury (AKI), although goal-directed therapy with hemodynamic monitors appeared beneficial in some trials. Trials that have targeted inflammation or oxidative stress, including studies of nonsteroidal anti-inflammatory drugs, steroids, N-acetylcysteine, and sodium bicarbonate, have not shown renal benefits, and high-dose perioperative statin treatment increased AKI in some patient groups in two large trials. Balanced crystalloid intravenous fluids appear safer than saline, and crystalloids appear safer than colloids. Liberal compared with restrictive fluid administration reduced AKI in a recent large trial in open abdominal surgery. Remote ischemic preconditioning, although effective in several smaller trials, failed to reduce AKI in two larger trials. The translation of promising preclinical therapies to patients undergoing surgery remains poor, and most interventions that reduced perioperative AKI compared novel surgical management techniques or existing processes of care rather than novel pharmacologic interventions.
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Affiliation(s)
- David R McIlroy
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | - Marcos G Lopez
- Division of Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | - Frederic T Billings
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN; Division of Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN.
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26
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Xie Y, Jiang W, Cao J, Xie H. Dexmedetomidine attenuates acute kidney injury in children undergoing congenital heart surgery with cardiopulmonary bypass by inhibiting the TLR3/NF-κB signaling pathway. Am J Transl Res 2021; 13:2763-2773. [PMID: 34017439 PMCID: PMC8129309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Accepted: 02/06/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To investigate the effect of dexmedetomidine (DMED) on acute kidney injury in children undergoing congenital heart surgery (CHS) with cardiopulmonary bypass (CPB). METHODS The children undergoing CHS with CPB were randomized to the control and the DMED groups. The children in the DMED group were injected with DMED (1 µg/kg) followed by DMED infusion (0.5 µg/kg/h) until 12 h after operation; the controls received normal saline. Markers were detected before operation (T0), 30 min after anesthesia induction (T1), and at 24 h, 48 h, and 72 h after operation (T2, T3, T4). RESULTS The heart rate and mean arterial pressure in the DMED group decreased at T1 and differed from controls at T1-T3 (all P<0.05). No intergroup differences were observed in the central venous pressure and caspase-3 level (all P>0.05). The DMED group had higher central venous pressure at T3 than at T0 (P<0.05). At T2-T4, the DMED group had lower percentages of TLR3+ cells than the controls (all P<0.05). In the DMED group, the percentagesof TLR3+ cells decreased with time; whereas in the control group, the percentage increased with time (all P<0.05). Compared with the controls, the DMED group had lower levels of NF-κB and TLR3 at T2-T4, lower levels of sCr, IL-1β, and TNF-α at T3-T4, and lower incidence of AKI at T3 (all P≤0.01). CONCLUSION DMED can reduce the risk of AKI in children undergoing CHS with CPB, which may be because DMED can inhibit TLR3/NF-κB signaling and its downstream inflammatory mediators.
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Affiliation(s)
- Yang Xie
- Department of Anesthesiology and Critical Care, The Second Affiliated Hospital of Soochow UniversitySuzhou, Jiangsu Province, China
- Department of Anesthesiology, Suzhou Hospital Affiliated to Nanjing Medical University, Suzhou Municipal HospitalSuzhou, Jiangsu Province, China
| | - Wenqiang Jiang
- Department of Anesthesiology, Suzhou Hospital Affiliated to Nanjing Medical University, Suzhou Municipal HospitalSuzhou, Jiangsu Province, China
| | - Jianfang Cao
- Department of Anesthesiology and Critical Care, The Second Affiliated Hospital of Soochow UniversitySuzhou, Jiangsu Province, China
| | - Hong Xie
- Department of Anesthesiology and Critical Care, The Second Affiliated Hospital of Soochow UniversitySuzhou, Jiangsu Province, China
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27
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Belčič Mikič T, Kojc N, Frelih M, Aleš-Rigler A, Večerić-Haler Ž. Management of Anticoagulant-Related Nephropathy: A Single Center Experience. J Clin Med 2021; 10:jcm10040796. [PMID: 33669373 PMCID: PMC7920283 DOI: 10.3390/jcm10040796] [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: 12/31/2020] [Revised: 01/27/2021] [Accepted: 02/03/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Anticoagulant-related nephropathy (ARN) is a form of acute kidney injury that mainly occurs in patients with previously unrecognized glomerular disease in addition to excessive anticoagulation. Since a renal biopsy is not performed in most cases, the diagnosis is often presumptive. METHODS Here, we present the characteristics of a national Slovenian patient cohort with histologically verified ARN, from the first case in 2014 to December 2020, and a review of the current literature (Pubmed database). RESULTS In Slovenia, ARN has been detected in 13 patients, seven of whom were treated with coumarins, and others with direct oral anticoagulants. In seven patients, ARN appeared after excessive anticoagulation. As many as 11 patients had underlying IgA nephropathy. Similar to the global data presented here, the pathohistological impairment associated with pre-existing glomerulopathy was mild and disproportionate to the degree of functional renal impairment. The majority of our patients with ARN experienced severe deterioration of renal function associated with histological signs of accompanying acute tubular injury, interstitial edema, and occlusive red blood cell casts. These patients were treated with corticosteroids, which (in addition to supportive treatment and discontinuation of the anticoagulant drug) led to a further improvement in renal function. CONCLUSIONS Anticoagulant therapy combined with a pre-existing glomerular injury may lead to ARN. In addition to discontinuation of the anticoagulant and supportive care, corticosteroids, which are currently listed in only a few cases in the world literature, may have a positive influence on the course of treatment. However, the benefits of steroid treatment must be weighed against the risk of complications, especially life-threatening infections.
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Affiliation(s)
- Tanja Belčič Mikič
- Department of Nephrology, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia; (T.B.M.); (A.A.-R.)
| | - Nika Kojc
- Institute of Pathology, Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia; (N.K.); (M.F.)
| | - Maja Frelih
- Institute of Pathology, Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia; (N.K.); (M.F.)
| | - Andreja Aleš-Rigler
- Department of Nephrology, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia; (T.B.M.); (A.A.-R.)
| | - Željka Večerić-Haler
- Department of Nephrology, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia; (T.B.M.); (A.A.-R.)
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
- Correspondence: ; Tel.: +386-1-522-1548
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28
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Chang CJ, Taniguchi A. Establishment of a Nanopatterned Renal Disease Model by Mimicking the Physical and Chemical Cues of a Diseased Mesangial Cell Microenvironment. ACS APPLIED BIO MATERIALS 2021; 4:1573-1583. [PMID: 35014506 DOI: 10.1021/acsabm.0c01406] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Modulation of mesangial cell (MC) response by in vitro disease models offers therapeutic strategies for the treatment of several glomerular diseases. However, traditional cell culture models lack the nanostructured extracellular matrix (ECM), which has unique physical and chemical properties, so they poorly reflect the complexities of the native microenvironment. Therefore, a cell disease model with ECM nanostructures is required to better mimic the in vivo diseased nanoenvironment. To establish a renal disease model, we used a titanium dioxide-based disease-mimic nanopattern as the physical cues and transforming growth factor-beta 1 (TGF-β1) as a chemical cue. The effects of this renal disease model on proliferation and mesangial matrix (MM) component changes in the SV40MES13 (MES13) mouse mesangial cell line were evaluated. Our results showed that both the presence of the disease-mimic nanopattern and TGF-β1 intensified proliferation and resulted in increased type I collagen and fibronectin and decreased type IV collagen expressions in MES13 cells. These effects could be involved in increased TGF-β type I receptor expression in MES13 cells. The intracellular reactive oxygen species (ROS) level as a biomarker of this renal disease model indicated that the cells were in a diseased state. A small molecule A83-01 and known drug dexamethasone markedly attenuated the intracellular ROS production in MES13 that was induced by the disease-mimic nanopattern and TGF-β1. These results highlight the significant effects of physical and chemical cues in facilitating disease-like behavior in MES13 cells, providing an important theoretical basis for developing a drug screening platform for glomerular diseases.
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Affiliation(s)
- Chia-Jung Chang
- Research Center for Functional Materials, National Institute for Materials Science, 1-1 Namiki, Tsukuba, Ibaraki 305-0044, Japan.,Department of Nanoscience and Nanoengineering, Graduate School of Advanced Science and Engineering, Waseda University, 3-4-1 Okubo, Shinjuku-ku, Tokyo 169-8555, Japan
| | - Akiyoshi Taniguchi
- Research Center for Functional Materials, National Institute for Materials Science, 1-1 Namiki, Tsukuba, Ibaraki 305-0044, Japan.,Department of Nanoscience and Nanoengineering, Graduate School of Advanced Science and Engineering, Waseda University, 3-4-1 Okubo, Shinjuku-ku, Tokyo 169-8555, Japan
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29
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Perico L, Benigni A, Casiraghi F, Ng LFP, Renia L, Remuzzi G. Immunity, endothelial injury and complement-induced coagulopathy in COVID-19. Nat Rev Nephrol 2021; 17:46-64. [PMID: 33077917 PMCID: PMC7570423 DOI: 10.1038/s41581-020-00357-4] [Citation(s) in RCA: 341] [Impact Index Per Article: 113.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2020] [Indexed: 01/08/2023]
Abstract
In December 2019, a novel coronavirus was isolated from the respiratory epithelium of patients with unexplained pneumonia in Wuhan, China. This pathogen, named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), causes a pathogenic condition that has been termed coronavirus disease 2019 (COVID-19) and has reached pandemic proportions. As of 17 September 2020, more than 30 million confirmed SARS-CoV-2 infections have been reported in 204 different countries, claiming more than 1 million lives worldwide. Accumulating evidence suggests that SARS-CoV-2 infection can lead to a variety of clinical conditions, ranging from asymptomatic to life-threatening cases. In the early stages of the disease, most patients experience mild clinical symptoms, including a high fever and dry cough. However, 20% of patients rapidly progress to severe illness characterized by atypical interstitial bilateral pneumonia, acute respiratory distress syndrome and multiorgan dysfunction. Almost 10% of these critically ill patients subsequently die. Insights into the pathogenic mechanisms underlying SARS-CoV-2 infection and COVID-19 progression are emerging and highlight the critical role of the immunological hyper-response - characterized by widespread endothelial damage, complement-induced blood clotting and systemic microangiopathy - in disease exacerbation. These insights may aid the identification of new or existing therapeutic interventions to limit the progression of early disease and treat severe cases.
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Affiliation(s)
- Luca Perico
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Ariela Benigni
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | | | - Lisa F P Ng
- Infectious Diseases Horizontal Technology Centre (ID HTC), Agency for Science, Technology and Research (A*STAR), Singapore, Singapore
- Immunology Network (SIgN), Agency for Science, Technology and Research (A*STAR), Singapore, Singapore
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
| | - Laurent Renia
- Infectious Diseases Horizontal Technology Centre (ID HTC), Agency for Science, Technology and Research (A*STAR), Singapore, Singapore
- Immunology Network (SIgN), Agency for Science, Technology and Research (A*STAR), Singapore, Singapore
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy.
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy.
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30
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Masum MA, Ichii O, Elewa YHA, Otani Y, Namba T, Kon Y. Vasculature-Associated Lymphoid Tissue: A Unique Tertiary Lymphoid Tissue Correlates With Renal Lesions in Lupus Nephritis Mouse Model. Front Immunol 2020; 11:595672. [PMID: 33384689 PMCID: PMC7770167 DOI: 10.3389/fimmu.2020.595672] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 11/09/2020] [Indexed: 12/30/2022] Open
Abstract
Lupus nephritis (LN) is a common complication in young patients and the most predominant cause of glomerulonephritis. Infiltrating immune cells and presence of immunocomplexes in the kidney are hallmarks of LN, which is closely associated with renal lesions (RLs). However, their regulatory mechanism in the kidney remains unclear, which is valuable for prevention of RL development. Here, we show the development of vasculature-associated lymphoid tissue (VALT) in LN, which is related to renal inflammatory cytokines, indicating that VALT is a unique tertiary lymphoid tissue. Transcriptomic analysis revealed different chemokines and costimulatory molecules for VALT induction and organization. Vascular and perivascular structures showed lymphoid tissue organization through lymphorganogenic chemokine production. Transcriptional profile and intracellular interaction also demonstrated antigen presentation, lymphocyte activity, clonal expansion, follicular, and germinal center activity in VALT. Importantly, VALT size was correlated with infiltrating immune cells in kidney and RLs, indicating its direct correlation with the development of RLs. In addition, dexamethasone administration reduced VALT size. Therefore, inhibition of VALT formation would be a novel therapeutic strategy against LN.
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Affiliation(s)
- Md Abdul Masum
- Laboratory of Anatomy, Department of Basic Veterinary Sciences, Faculty of Veterinary Medicine, Hokkaido University, Sapporo, Japan.,Department of Anatomy, Histology and Physiology, Faculty of Animal Science and Veterinary Medicine, Sher-e-Bangla Agricultural University, Dhaka, Bangladesh
| | - Osamu Ichii
- Laboratory of Anatomy, Department of Basic Veterinary Sciences, Faculty of Veterinary Medicine, Hokkaido University, Sapporo, Japan.,Laboratory of Agrobiomedical Science, Faculty of Agriculture, Hokkaido University, Sapporo, Japan
| | - Yaser Hosny Ali Elewa
- Laboratory of Anatomy, Department of Basic Veterinary Sciences, Faculty of Veterinary Medicine, Hokkaido University, Sapporo, Japan.,Department of Histology, Faculty of Veterinary Medicine, Zagazig University, Zagazig, Egypt
| | - Yuki Otani
- Laboratory of Anatomy, Department of Basic Veterinary Sciences, Faculty of Veterinary Medicine, Hokkaido University, Sapporo, Japan
| | - Takashi Namba
- Laboratory of Anatomy, Department of Basic Veterinary Sciences, Faculty of Veterinary Medicine, Hokkaido University, Sapporo, Japan
| | - Yasuhiro Kon
- Laboratory of Anatomy, Department of Basic Veterinary Sciences, Faculty of Veterinary Medicine, Hokkaido University, Sapporo, Japan
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31
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Del Rio JM, Abernathy JJ, Taylor MA, Habib RH, Fernandez FG, Bollen BA, Lauer RE, Nussmeier NA, Glance LG, Petty JV, Mackensen GB, Vener DF, Kertai MD. The Adult Cardiac Anesthesiology Section of STS Adult Cardiac Surgery Database: 2020 Update on Quality and Outcomes. Anesth Analg 2020; 131:1383-1396. [PMID: 33079860 DOI: 10.1213/ane.0000000000005093] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- J Mauricio Del Rio
- From the Divisions of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
| | - James Jake Abernathy
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mark A Taylor
- Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Robert H Habib
- STS Research Center, The Society of Thoracic Surgeons, Chicago, Illinois
| | - Felix G Fernandez
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Bruce A Bollen
- International Heart Institute of Montana, Missoula Anesthesiology, PC, Missoula, Montana
| | - Ryan E Lauer
- Department of Anesthesiology, Loma Linda University School of Medicine, Loma Linda, California
| | - Nancy A Nussmeier
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Laurent G Glance
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
| | - Joseph V Petty
- CHI Health Clinic Physician Enterprise Anesthesia, CHI Health Nebraska Heart, Omaha, Nebraska
| | - G Burkhard Mackensen
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology & Pain Medicine, University of Washington Medical Center, Seattle, Washington
| | - David F Vener
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Miklos D Kertai
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
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32
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Del Rio JM, Jake Abernathy J, Taylor MA, Habib RH, Fernandez FG, Bollen BA, Lauer RE, Nussmeier NA, Glance LG, Petty JV, Mackensen GB, Vener DF, Kertai MD. The Adult Cardiac Anesthesiology Section of STS Adult Cardiac Surgery Database: 2020 Update on Quality and Outcomes. J Cardiothorac Vasc Anesth 2020; 35:22-34. [PMID: 33008722 DOI: 10.1053/j.jvca.2020.08.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The Society of Cardiovascular Anesthesiologists, in partnership with The Society of Thoracic Surgeons, has developed the Adult Cardiac Anesthesiology Section of the Adult Cardiac Surgery Database. The goal of this landmark collaboration is to advance clinical care, quality, and knowledge, and to demonstrate the value of cardiac anesthesiology in the perioperative care of cardiac surgical patients. Participation in the Adult Cardiac Anesthesiology Section has been optional since its inception in 2014 but has progressively increased. Opportunities for further growth and improvement remain. In this first update report on quality and outcomes of the Adult Cardiac Anesthesiology Section, we present an overview of the clinically significant anesthesia and surgical variables submitted between 2015 and 2018. Our review provides a summary of quality measures and outcomes related to the current practice of cardiothoracic anesthesiology. We also emphasize the potential for addressing high-impact research questions as data accumulate, with the overall goal of elucidating the influence of cardiac anesthesiology contributions to patient outcomes within the framework of the cardiac surgical team.
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Affiliation(s)
- J Mauricio Del Rio
- Divisions of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
| | - James Jake Abernathy
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mark A Taylor
- Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Robert H Habib
- STS Research Center, The Society of Thoracic Surgeons, Chicago, Illinois
| | - Felix G Fernandez
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Bruce A Bollen
- International Heart Institute of Montana, Missoula Anesthesiology, PC, Missoula, Montana
| | - Ryan E Lauer
- Department of Anesthesiology, Loma Linda University School of Medicine, Loma Linda, California
| | - Nancy A Nussmeier
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Laurent G Glance
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
| | - Joseph V Petty
- CHI Health Clinic Physician Enterprise Anesthesia, CHI Health Nebraska Heart, Omaha, Nebraska
| | - G Burkhard Mackensen
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology & Pain Medicine, University of Washington Medical Center, Seattle, Washington
| | - David F Vener
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Miklos D Kertai
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee.
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Del Rio JM, Abernathy JJ, Taylor MA, Habib RH, Fernandez FG, Bollen BA, Lauer RE, Nussmeier NA, Glance LG, Petty JV, Mackensen GB, Vener DF, Kertai MD. The Adult Cardiac Anesthesiology Section of STS Adult Cardiac Surgery Database: 2020 Update on Quality and Outcomes. Ann Thorac Surg 2020; 110:1447-1460. [PMID: 33008569 DOI: 10.1016/j.athoracsur.2020.05.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 05/27/2020] [Accepted: 05/29/2020] [Indexed: 10/23/2022]
Abstract
The Society of Cardiovascular Anesthesiologists, in partnership with The Society of Thoracic Surgeons, has developed the Adult Cardiac Anesthesiology Section of the Adult Cardiac Surgery Database. The goal of this landmark collaboration is to advance clinical care, quality, and knowledge, and to demonstrate the value of cardiac anesthesiology in the perioperative care of cardiac surgical patients. Participation in the Adult Cardiac Anesthesiology Section has been optional since its inception in 2014 but has progressively increased. Opportunities for further growth and improvement remain. In this first update report on quality and outcomes of the Adult Cardiac Anesthesiology Section, we present an overview of the clinically significant anesthesia and surgical variables submitted between 2015 and 2018. Our review provides a summary of quality measures and outcomes related to the current practice of cardiothoracic anesthesiology. We also emphasize the potential for addressing high-impact research questions as data accumulate, with the overall goal of elucidating the influence of cardiac anesthesiology contributions to patient outcomes within the framework of the cardiac surgical team.
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Affiliation(s)
- J Mauricio Del Rio
- Divisions of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
| | - James Jake Abernathy
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mark A Taylor
- Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Robert H Habib
- STS Research Center, The Society of Thoracic Surgeons, Chicago, Illinois
| | - Felix G Fernandez
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Bruce A Bollen
- International Heart Institute of Montana, Missoula Anesthesiology, PC, Missoula, Montana
| | - Ryan E Lauer
- Department of Anesthesiology, Loma Linda University School of Medicine, Loma Linda, California
| | - Nancy A Nussmeier
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Laurent G Glance
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
| | - Joseph V Petty
- CHI Health Clinic Physician Enterprise Anesthesia, CHI Health Nebraska Heart, Omaha, Nebraska
| | - G Burkhard Mackensen
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology & Pain Medicine, University of Washington Medical Center, Seattle, Washington
| | - David F Vener
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Miklos D Kertai
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee.
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Tu H, Zhang D, Wadman MC, Li YL. Dexamethasone ameliorates recovery process of neuromuscular junctions after tourniquet-induced ischemia-reperfusion injuries in mouse hindlimb. Eur J Pharmacol 2020; 883:173364. [DOI: 10.1016/j.ejphar.2020.173364] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 07/07/2020] [Accepted: 07/09/2020] [Indexed: 02/06/2023]
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Venugopal H, Jacob KA, Dieleman JM, Leaf DE. Dexamethasone for Preventing Major Adverse Kidney Events following Cardiac Surgery: Post-Hoc Analysis to Identify Subgroups. KIDNEY360 2020; 1:530-533. [PMID: 35368593 DOI: 10.34067/kid.0000812019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Hema Venugopal
- Department of Cardiothoracic Surgery, University Medical Center, Utrecht, The Netherlands
| | - Kirolos A Jacob
- Department of Cardiothoracic Surgery, University Medical Center, Utrecht, The Netherlands
| | - Jan M Dieleman
- Department of Anaesthesia, Westmead Hospital, Sydney, New South Wales, Australia
| | - David E Leaf
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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Abstract
One of the prominent problems in clinical medicine is medication-induced acute kidney injury (AKI). Avoiding this problem can prevent patient harm and reduce healthcare expenditures. Several researches have been conducted to identify AKI-associated medications using statistical, data mining, and machine learning techniques. However, these studies are limited to assessing the impact of known nephrotoxic medications and do not comprehensively explore the relationship between medication combinations and AKI. In this paper, we present a population-based retrospective cohort study that employs automated data analysis techniques to identify medications and medication combinations that are associated with a higher risk of AKI. By integrating multivariable logistic regression, frequent itemset mining, and stratified analysis, this study is designed to explore the complex relationships between medications and AKI in such a way that has never been attempted before. Through an analysis of prescription records of one million older patients stored in the healthcare administrative dataset at ICES (an independent, non-profit, world-leading research organization that uses population-based health and social data to produce knowledge on a broad range of healthcare issues), we identified 55 AKI-associated medications among 595 distinct medications and 78 AKI-associated medication combinations among 7748 frequent medication combinations. In addition, through a stratified analysis, we identified 37 cases where a particular medication was associated with increasing the risk of AKI when used with another medication. We have shown that our results are consistent with previous studies through consultation with a nephrologist and an electronic literature search. This research demonstrates how automated analysis techniques can be used to accomplish data-driven tasks using massive clinical datasets.
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Hod T, Freedberg KJ, Motwani SS, Chen M, Frendl G, Leaf DE, Gupta S, Mothi SS, Richards WG, Bueno R, Waikar SS. Acute kidney injury after cytoreductive surgery and hyperthermic intraoperative cisplatin chemotherapy for malignant pleural mesothelioma. J Thorac Cardiovasc Surg 2020; 161:1510-1518. [PMID: 32631662 DOI: 10.1016/j.jtcvs.2020.05.033] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 05/06/2020] [Accepted: 05/11/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Cytoreductive surgery with hyperthermic intraoperative chemotherapy with cisplatin has been used successfully to treat malignant pleural mesothelioma, a highly aggressive malignancy that is rapidly fatal in most cases. We hypothesized that the combination of ischemic injury with nephrotoxic injury from cisplatin would result in high rates of acute kidney injury. METHODS We conducted an observational study in 503 patients to study the risks and outcomes of acute kidney injury after surgical resection of malignant pleural mesothelioma. Eligible subjects underwent extrapleural pneumonectomy or pleurectomy/decortication with or without hyperthermic intraoperative chemotherapy. Acute kidney injury was defined as an increase in creatinine of 26.5 μmol/L or greater within 48 hours of surgery or a 50% or greater increase over 7 days. RESULTS Acute kidney injury developed in 243 patients (48.3%). Severe acute kidney injury requiring renal replacement therapy developed in 16 patients (3.2%). Major significant predictors for acute kidney injury included male sex (odds ratio, 2.98; P < .001), intraoperative cisplatin administration (odds ratio, 3.12; P < .001), previous cisplatin exposure (odds ratio, 1.96; P = .02), hypertension (odds ratio, 1.57; P = .02), and longer surgical time (odds ratio, 1.15 per hour; P = .02). Compared with patients without acute kidney injury, those with severe acute kidney injury had longer length of stay (26 vs 13 days) and a 2.71-fold increased risk of death in multivariable-adjusted models. CONCLUSIONS Acute kidney injury is common after cytoreductive surgery with hyperthermic intraoperative chemotherapy with cisplatin and is associated with poor long-term outcomes. Strategies to prevent postoperative acute kidney injury are needed to improve multimodal treatment of malignant pleural mesothelioma.
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Affiliation(s)
- Tammy Hod
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Mass
| | | | - Shveta S Motwani
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Mass; Adult Survivorship Program, Dana-Farber Cancer Institute, Boston, Mass
| | - Margaret Chen
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Gyorgy Frendl
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Mass
| | - David E Leaf
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Shruti Gupta
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Mass
| | | | - William G Richards
- Department of Surgery, Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Raphael Bueno
- Department of Surgery, Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Sushrut S Waikar
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, Mass; Section of Nephrology, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Mass.
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Ostermann M, Cennamo A, Meersch M, Kunst G. A narrative review of the impact of surgery and anaesthesia on acute kidney injury. Anaesthesia 2020; 75 Suppl 1:e121-e133. [PMID: 31903567 DOI: 10.1111/anae.14932] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The epidemiology of peri-operative acute kidney injury varies depending on the definition, type of surgery and acute and chronic comorbidities. Haemodynamic instability, disturbance of the microcirculation, endothelial dysfunction, inflammation and tubular cell injury are the main factors contributing to the pathogenesis. There are no specific therapies. The most effective strategies to protect renal function during the peri-operative period are: the avoidance of nephrotoxic insults; optimisation of haemodynamics; prevention of hypotension; and meticulous fluid management, including avoidance of both hypovolaemia and hypervolaemia. Peri-operative acute kidney injury is associated with an increased risk of short- and long-term postoperative complications, including a longer stay in hospital, development of premature chronic kidney disease and increased mortality. Resource utilisation and healthcare costs are also higher. In future, the development of advanced clinical prediction scores, new imaging and monitoring techniques and the application of new biomarkers for acute kidney injury have the prospect of identifying acute kidney injury earlier and allowing a more personalised management approach with the aim of reducing the global burden of acute kidney injury.
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Affiliation(s)
- M Ostermann
- Department of Critical Care, King's College London, Guy's and St Thomas' Hospital, London, UK
| | - A Cennamo
- Department of Critical Care, Guy's and St Thomas' Hospital, London, UK
| | - M Meersch
- Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Münster, Münster, Germany
| | - G Kunst
- Department of Anaesthesia, King's College London, King's College Hospital, London, UK.,School of Cardiovascular Medicine and Sciences, King's College London, British Heart Foundation Centre of Excellence, London, UK
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Li Y, Luo Q, Wu X, Jia Y, Yan F. Perioperative Corticosteroid Therapy in Children Undergoing Cardiac Surgery: A Systematic Review and Meta-Analysis. Front Pediatr 2020; 8:350. [PMID: 32903325 PMCID: PMC7396528 DOI: 10.3389/fped.2020.00350] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 05/27/2020] [Indexed: 11/25/2022] Open
Abstract
Background: The benefit-risk profile of perioperative corticosteroids in pediatric patients undergoing cardiac surgery remains controversial. Objective: To investigate the influence of perioperative corticosteroids on the postoperative mortality and clinical outcomes in pediatric patients undergoing cardiac surgery with cardiopulmonary bypass. Methods: We conducted a systematic search using MEDLINE, EMBASE, and Cochrane Database through August 31, 2019. We included randomized controlled trials comparing perioperative corticosteroids with other clinical interventions, placebo, or no treatment in children between 0 and 18 years of age undergoing cardiac surgery. The primary outcome of interest was all-cause in-hospital mortality. The secondary outcomes were length of intensive care unit stay (LOIS), duration of mechanical ventilation (DMV), postoperative insulin therapy, postoperative low cardiac output syndrome (LCOS), postoperative infection, maximal temperature (T max) in the first 24 h postoperatively, urine output (UO) in the first 24 h postoperatively, serum lactate at postoperative day (POD) 1, blood glucose at POD 1, vasoactive inotrope score (VIS) at POD 1, and postoperative acute kidney injury (AKI). Study quality was assessed using the Cochrane Risk of Bias Assessment Tool. Results: Our analysis included 17 studies and 848 pediatric patients. The data demonstrated that children receiving corticosteroids showed no significant difference on the all-cause in-hospital mortality with a fixed-effect model (RR = 0.59, 95% CI = 0.28-1.25, P = 0.55) compared with controls. For the secondary outcomes, corticosteroids had a statistically significant reduction on the VIS at POD1 (MD = -2.04, 95% CI = -3.96 -0.12, P = 0.04), while it might be significantly associated with an increased blood glucose at POD1 (MD = 1.38, 95% CI = 0.68-2.09, P = 0.0001) and a 2.69-fold higher risk of postoperative insulin therapy (RR = 2.69, 95% CI = 1.37-5.27, P = 0.004). No statistical significance was shown in other secondary outcomes. Conclusion: Perioperative corticosteroids might not significantly improve clinical outcomes identified as mortality, LOIS, DMV, AKI, and LCOS other than VIS at POD1. However, it might increase the blood glucose and episodes of insulin therapy. Perioperative corticosteroids to attenuate the inflammatory response are not supported by available evidence from our study. Further results from ongoing randomized controlled trials with a larger sample size are required.
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Affiliation(s)
- Yinan Li
- Department of Anesthesiology, National Center of Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qipeng Luo
- Department of Anesthesiology, National Center of Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xie Wu
- Department of Anesthesiology, National Center of Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuan Jia
- Department of Anesthesiology, National Center of Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fuxia Yan
- Department of Anesthesiology, National Center of Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Oyarzábal-Yera A, Rodríguez-Salgueiro S, Merino-García N, Ocaña-Nápoles L, González-Núñez L, Mena-Valdés L, Zamora-Rodríguez Z, A Medina-Pírez J, Jiménez-Despaigne S, Molina-Cuevas V. Protective effects of D-005, a lipid extract from Acrocomia crispa fruits, against ischemia/reperfusion-induced acute kidney injury in rats. Kidney Res Clin Pract 2019; 38:462-471. [PMID: 31826388 PMCID: PMC6913585 DOI: 10.23876/j.krcp.19.053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 08/26/2019] [Accepted: 09/02/2019] [Indexed: 11/04/2022] Open
Abstract
Background Acute kidney injury (AKI) induced by renal ischemia/reperfusion (IR) is associated with enhanced production of reactive oxygen species in renal tissues. D-005, a lipid extract obtained from Acrocomia crispa fruit, has previously shown antioxidant effects. The aim of this work was to evaluate the effects of D-005 on renal IR-induced AKI in rats. Methods Rats were randomized into seven groups including a negative control group (vehicle) without AKI and six groups with renal IR-induced AKI as follows: a positive control (vehicle); D-005 treatment at 25, 100, 200, or 400 mg/kg; and dexamethasone at 3 mg/kg. All treatments were orally administered as single doses 1 hour before AKI induction. Biomarkers (serum creatinine, urea, and uric acid concentrations), oxidative variables, and histopathological AKI changes were evaluated in blood and kidney tissues. Results All D-005 doses protected against IR-induced AKI in rats by significantly decreasing biomarkers and histopathological AKI changes as assessed by reduced serum concentrations of creatinine, urea, and uric acid. In addition, all D-005 doses decreased tubular damage, as shown by fewer detached cells and casts in the tubular lumen. D-005 reversed oxidation disturbance markers by decreasing malondialdehyde and sulfhydryl group concentrations in plasma and in kidney homogenates and by increasing kidney catalase activity. Dexamethasone, the reference substance, protected against IR-induced AKI in rats by reducing biochemical and histological variables of renal damage in a similar manner. Conclusion Administration of single oral doses of D-005 markedly and significantly protected against renal IR-induced AKI, possibly due to its known antioxidant effects.
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Affiliation(s)
- Ambar Oyarzábal-Yera
- Pharmacology Department, Center of Natural Products, National Center for Scientific Research, Havana, Cuba
| | - Sandra Rodríguez-Salgueiro
- Pharmacology Department, Center of Natural Products, National Center for Scientific Research, Havana, Cuba.,Department of Morphological Sciences, Latin American School of Medicine, Havana, Cuba
| | - Nelson Merino-García
- Pharmacology Department, Center of Natural Products, National Center for Scientific Research, Havana, Cuba
| | - Leyanis Ocaña-Nápoles
- Pharmacology Department, Center of Natural Products, National Center for Scientific Research, Havana, Cuba
| | - Lucía González-Núñez
- Department of Morphological Sciences, Latin American School of Medicine, Havana, Cuba
| | - Licet Mena-Valdés
- Pharmacology Department, Center of Natural Products, National Center for Scientific Research, Havana, Cuba
| | - Zullyt Zamora-Rodríguez
- Pharmacology Department, Center of Natural Products, National Center for Scientific Research, Havana, Cuba
| | - José A Medina-Pírez
- Pharmacology Department, Center of Natural Products, National Center for Scientific Research, Havana, Cuba
| | - Sonia Jiménez-Despaigne
- Pharmacology Department, Center of Natural Products, National Center for Scientific Research, Havana, Cuba
| | - Vivian Molina-Cuevas
- Pharmacology Department, Center of Natural Products, National Center for Scientific Research, Havana, Cuba
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41
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Jacob KA, Leaf DE. Prevention of Cardiac Surgery-Associated Acute Kidney Injury: A Review of Current Strategies. Anesthesiol Clin 2019; 37:729-749. [PMID: 31677688 PMCID: PMC7644277 DOI: 10.1016/j.anclin.2019.08.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Acute kidney injury is a common and often severe postoperative complication after cardiac surgery, and is associated with poor short-term and long-term outcomes. Numerous randomized controlled trials have been conducted to investigate various strategies for prevention of cardiac surgery-associated acute kidney injury. Unfortunately, most trials that have been conducted to date have been negative. However, encouraging results have been demonstrated with preoperative administration of corticosteroids, leukocyte filtration, and administration of inhaled nitric oxide intraoperatively, and implementation of a Kidney Disease: Improving Global Outcomes bundle of care approach postoperatively. These findings require validation in large, multicenter trials.
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Affiliation(s)
- Kirolos A Jacob
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Mail Stop E03.511, PO Box 85500, Utrecht 3508 GA, the Netherlands.
| | - David E Leaf
- Division of Renal Medicine, Brigham and Women's Hospital, 75 Francis Street, Medial Research Building Room MR416B, Boston, MA 02115, USA
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42
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Nath KA, Garovic VD, Grande JP, Croatt AJ, Ackerman AW, Farrugia G, Katusic ZS, Belcher JD, Vercellotti GM. Heme oxygenase-2 protects against ischemic acute kidney injury: influence of age and sex. Am J Physiol Renal Physiol 2019; 317:F695-F704. [PMID: 31215802 PMCID: PMC6842883 DOI: 10.1152/ajprenal.00085.2019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 06/13/2019] [Accepted: 06/17/2019] [Indexed: 01/01/2023] Open
Abstract
Heme oxygenase (HO) activity is exhibited by inducible (HO-1) and constitutive (HO-2) proteins. HO-1 protects against ischemic and nephrotoxic acute kidney injury (AKI). We have previously demonstrated that HO-2 protects against heme protein-induced AKI. The present study examined whether HO-2 is protective in ischemic AKI. Renal ischemia was imposed on young and aged HO-2+/+ and HO-2-/- mice. On days 1 and 2 after renal ischemia, there were no significant differences in renal function between young male HO-2+/+ and HO-2-/- mice, between young female HO-2+/+ and HO-2-/- mice, or between aged female HO-2+/+ and HO-2-/- mice. However, in aged male mice, HO-2 deficiency worsened renal function on days 1 and 2 after ischemic AKI, and, on day 2 after ischemia, such deficiency augmented upregulation of injury-related genes and worsened histological injury. Renal HO activity was markedly decreased in unstressed aged male HO-2-/- mice and remained so after ischemia, despite exaggerated HO-1 induction in HO-2-/- mice after ischemia. Such exacerbation of deficiency of HO-2 protein and HO activity may reflect phosphorylated STAT3, as activation of this proinflammatory transcription factor was accentuated early after ischemia in aged male HO-2-/- mice. This exacerbation may not reflect impaired induction of nephroprotectant genes, since the induction of HO-1, sirtuin 1, and β-catenin was accentuated in aged male HO-2-/- mice after ischemia. We conclude that aged male mice are hypersensitive to ischemic AKI and that HO-2 mitigates such sensitivity. We speculate that this protective effect of HO-2 may be mediated, at least in part, by suppression of phosphorylated STAT3-dependent signaling.
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Affiliation(s)
- Karl A Nath
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Vesna D Garovic
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | | | - Anthony J Croatt
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Allan W Ackerman
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Gianrico Farrugia
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | | | - John D Belcher
- Division of Hematology, Oncology, and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Gregory M Vercellotti
- Division of Hematology, Oncology, and Transplantation, University of Minnesota, Minneapolis, Minnesota
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Wang Y, Li Q, Ma T, Liu X, Wang B, Wu Z, Dang S, Lv Y, Wu R. Transfusion of Older Red Blood Cells Increases the Risk of Acute Kidney Injury After Orthotopic Liver Transplantation: A Propensity Score Analysis. Anesth Analg 2019; 127:202-209. [PMID: 28863026 DOI: 10.1213/ane.0000000000002437] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is a common and serious complication of orthotopic liver transplantation (OLT). Transfusion of older red blood cells (RBCs) has been implicated in poor outcomes in trauma, cardiac surgery, and critically ill patients. However, whether transfusion of older RBCs plays any role in post-OLT AKI remained unknown. The aim of this study was to investigate the effect of the age of transfused RBCs on post-OLT AKI. METHODS The clinical data of consecutive adult patients who received donation after cardiac death and underwent OLT from December 2011 to December 2015 were analyzed. These patients were divided into 2 groups: the newer blood group, who received exclusively RBCs that had been stored for <14 days; and the older blood group, who received RBCs that had been stored for 14 days or more. The incidence of post-OLT AKI, severe AKI, lengths of intensive care unit and hospital stay, and in-hospital mortality after OLT were analyzed. RESULTS Postoperative AKI occurred in 65.1% of patients in the older blood group and 40.5% of patients in the newer blood group (P < .01). The incidence of severe AKI after OLT was significantly higher, and the duration of intensive care unit stay was significantly longer, in the older blood group. After adjustment by the multivariable regression logistic analysis, transfusion of older blood was independently associated with post-OLT AKI (odds ratio [OR] = 2.47 [95% confidence interval {CI}, 1.13-5.41]; P = .024) and severe AKI (OR = 5.88 [95% CI, 2.06-16.80]; P = .001). After adjustment by the inverse probability of treatment weighting analysis, patients in the older blood group still had significantly higher incidences of postoperative AKI (OR = 2.13 [95% CI, 1.07-4.22]; P = .030) and severe AKI (OR = 3.34 [95% CI, 1.47-7.60]; P = .003) than those in the newer blood group. CONCLUSIONS Transfusion of older RBCs significantly increased the risk of postoperative AKI in liver transplant recipients.
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Affiliation(s)
- Yue Wang
- From the Shaanxi Provincial Center for Regenerative Medicine and Surgical Engineering, Xi'an, China.,Institute of Advanced Surgical Technology and Engineering, Xi'an, China.,Department of Hepatobiliary Surgery, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Qingshan Li
- From the Shaanxi Provincial Center for Regenerative Medicine and Surgical Engineering, Xi'an, China.,Institute of Advanced Surgical Technology and Engineering, Xi'an, China.,Department of Hepatobiliary Surgery, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Tao Ma
- From the Shaanxi Provincial Center for Regenerative Medicine and Surgical Engineering, Xi'an, China.,Institute of Advanced Surgical Technology and Engineering, Xi'an, China.,Department of Hepatobiliary Surgery, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Xuemin Liu
- Department of Hepatobiliary Surgery, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Bo Wang
- Department of Hepatobiliary Surgery, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Zheng Wu
- Department of Hepatobiliary Surgery, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Shaonong Dang
- Department of Epidemiology and Biostatistics, Xi'an Jiaotong University School of Public Health, Xi'an, Shaanxi Province, China
| | - Yi Lv
- From the Shaanxi Provincial Center for Regenerative Medicine and Surgical Engineering, Xi'an, China.,Institute of Advanced Surgical Technology and Engineering, Xi'an, China.,Department of Hepatobiliary Surgery, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Rongqian Wu
- From the Shaanxi Provincial Center for Regenerative Medicine and Surgical Engineering, Xi'an, China.,Institute of Advanced Surgical Technology and Engineering, Xi'an, China
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Garg AX, Chan MTV, Cuerden MS, Devereaux PJ, Abbasi SH, Hildebrand A, Lamontagne F, Lamy A, Noiseux N, Parikh CR, Perkovic V, Quantz M, Rochon A, Royse A, Sessler DI, Shah PJ, Sontrop JM, Tagarakis GI, Teoh KH, Vincent J, Walsh M, Yared JP, Yusuf S, Whitlock RP. Effect of methylprednisolone on acute kidney injury in patients undergoing cardiac surgery with a cardiopulmonary bypass pump: a randomized controlled trial. CMAJ 2019; 191:E247-E256. [PMID: 30833491 PMCID: PMC6400656 DOI: 10.1503/cmaj.181644] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2019] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Perioperative corticosteroid use may reduce acute kidney injury. We sought to test whether methylprednisolone reduces the risk of acute kidney injury after cardiac surgery. METHODS We conducted a prespecified substudy of a randomized controlled trial involving patients undergoing cardiac surgery with cardiopulmonary bypass (2007-2014); patients were recruited from 79 centres in 18 countries. Eligibility criteria included a moderate-to-high risk of perioperative death based on a preoperative score of 6 or greater on the European System for Cardiac Operative Risk Evaluation I. Patients (n = 7286) were randomly assigned (1:1) to receive intravenous methylprednisolone (250 mg at anesthetic induction and 250 mg at initiation of cardiopulmonary bypass) or placebo. Patients, caregivers, data collectors and outcome adjudicators were unaware of the assigned intervention. The primary outcome was postoperative acute kidney injury, defined as an increase in the serum creatinine concentration (from the preoperative value) of 0.3 mg/dL or greater (≥ 26.5 μmol/L) or 50% or greater in the 14-day period after surgery, or use of dialysis within 30 days after surgery. RESULTS Acute kidney injury occurred in 1479/3647 patients (40.6%) in the methylprednisolone group and in 1426/3639 patients (39.2%) in the placebo group (adjusted relative risk 1.04, 95% confidence interval 0.96 to 1.11). Results were consistent across several definitions of acute kidney injury and in patients with preoperative chronic kidney disease. INTERPRETATION Intraoperative corticosteroid use did not reduce the risk of acute kidney injury in patients with a moderate-to-high risk of perioperative death who had cardiac surgery with cardiopulmonary bypass. Our results do not support the prophylactic use of steroids during cardiopulmonary bypass surgery. Trial registration: ClinicalTrials.gov, no. NCT00427388.
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Affiliation(s)
- Amit X Garg
- Division of Nephrology (Garg, Cuerden, Sontrop), Department of Medicine, London Health Sciences Centre, London, Ont.; Department of Anaesthesia and Intensive Care (Chan), The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Departments of Health Research Methods, Evidence, and Impact, and Medicine (Devereaux, Walsh), McMaster University, Hamilton, Ont.; Tehran Heart Center (Abbasi), Tehran University of Medical Sciences, Tehran, Iran; Division of Nephrology (Hildebrand), Department of Medicine, University of Alberta, Edmonton, Alta.; Département de médecine (Lamontagne), Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Que.; Department of Surgery (Lamy) McMaster University, Hamilton, Ont.; Department of Cardiac Surgery (Noiseux), Université de Montréal, Montréal, Que.; Division of Nephrology, Johns Hopkins School of Medicine (Parikh), Baltimore, Md.; The George Institute for Global Health (Perkovic), Sydney, Australia; Division of Cardiac Surgery (Quantz), London Health Sciences Centre, University Hospital, London, Ont.; Montreal Heart Institute (Rochon), Université de Montréal, Montréal, Que.; Department of Surgery (Royse), University of Melbourne, Melbourne, Australia; Department of Outcomes Research (Sessler), Cleveland Clinic, Cleveland, Ohio; Department of Cardiac Surgery (Shah), Princess Alexandra Hospital, Brisbane, Australia; Department of Cardiovascular and Thoracic Surgery (Tagarakis), Aristotle University of Thessaloniki, Thessaloniki, Greece; Division of Cardiac Surgery (Teoh), Southlake Regional Health Centre, Newmarket, Ont.; Population Health Research Institute (Vincent, Whitlock), Hamilton, Ont.; Department of Cardiothoracic Anesthesiology (Yared), Cleveland Clinic, Cleveland, Ohio; Division of Cardiology (Yusuf), Department of Medicine, McMaster University, Hamilton, Ont.
| | - Matthew T V Chan
- Division of Nephrology (Garg, Cuerden, Sontrop), Department of Medicine, London Health Sciences Centre, London, Ont.; Department of Anaesthesia and Intensive Care (Chan), The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Departments of Health Research Methods, Evidence, and Impact, and Medicine (Devereaux, Walsh), McMaster University, Hamilton, Ont.; Tehran Heart Center (Abbasi), Tehran University of Medical Sciences, Tehran, Iran; Division of Nephrology (Hildebrand), Department of Medicine, University of Alberta, Edmonton, Alta.; Département de médecine (Lamontagne), Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Que.; Department of Surgery (Lamy) McMaster University, Hamilton, Ont.; Department of Cardiac Surgery (Noiseux), Université de Montréal, Montréal, Que.; Division of Nephrology, Johns Hopkins School of Medicine (Parikh), Baltimore, Md.; The George Institute for Global Health (Perkovic), Sydney, Australia; Division of Cardiac Surgery (Quantz), London Health Sciences Centre, University Hospital, London, Ont.; Montreal Heart Institute (Rochon), Université de Montréal, Montréal, Que.; Department of Surgery (Royse), University of Melbourne, Melbourne, Australia; Department of Outcomes Research (Sessler), Cleveland Clinic, Cleveland, Ohio; Department of Cardiac Surgery (Shah), Princess Alexandra Hospital, Brisbane, Australia; Department of Cardiovascular and Thoracic Surgery (Tagarakis), Aristotle University of Thessaloniki, Thessaloniki, Greece; Division of Cardiac Surgery (Teoh), Southlake Regional Health Centre, Newmarket, Ont.; Population Health Research Institute (Vincent, Whitlock), Hamilton, Ont.; Department of Cardiothoracic Anesthesiology (Yared), Cleveland Clinic, Cleveland, Ohio; Division of Cardiology (Yusuf), Department of Medicine, McMaster University, Hamilton, Ont
| | - Meaghan S Cuerden
- Division of Nephrology (Garg, Cuerden, Sontrop), Department of Medicine, London Health Sciences Centre, London, Ont.; Department of Anaesthesia and Intensive Care (Chan), The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Departments of Health Research Methods, Evidence, and Impact, and Medicine (Devereaux, Walsh), McMaster University, Hamilton, Ont.; Tehran Heart Center (Abbasi), Tehran University of Medical Sciences, Tehran, Iran; Division of Nephrology (Hildebrand), Department of Medicine, University of Alberta, Edmonton, Alta.; Département de médecine (Lamontagne), Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Que.; Department of Surgery (Lamy) McMaster University, Hamilton, Ont.; Department of Cardiac Surgery (Noiseux), Université de Montréal, Montréal, Que.; Division of Nephrology, Johns Hopkins School of Medicine (Parikh), Baltimore, Md.; The George Institute for Global Health (Perkovic), Sydney, Australia; Division of Cardiac Surgery (Quantz), London Health Sciences Centre, University Hospital, London, Ont.; Montreal Heart Institute (Rochon), Université de Montréal, Montréal, Que.; Department of Surgery (Royse), University of Melbourne, Melbourne, Australia; Department of Outcomes Research (Sessler), Cleveland Clinic, Cleveland, Ohio; Department of Cardiac Surgery (Shah), Princess Alexandra Hospital, Brisbane, Australia; Department of Cardiovascular and Thoracic Surgery (Tagarakis), Aristotle University of Thessaloniki, Thessaloniki, Greece; Division of Cardiac Surgery (Teoh), Southlake Regional Health Centre, Newmarket, Ont.; Population Health Research Institute (Vincent, Whitlock), Hamilton, Ont.; Department of Cardiothoracic Anesthesiology (Yared), Cleveland Clinic, Cleveland, Ohio; Division of Cardiology (Yusuf), Department of Medicine, McMaster University, Hamilton, Ont
| | - P J Devereaux
- Division of Nephrology (Garg, Cuerden, Sontrop), Department of Medicine, London Health Sciences Centre, London, Ont.; Department of Anaesthesia and Intensive Care (Chan), The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Departments of Health Research Methods, Evidence, and Impact, and Medicine (Devereaux, Walsh), McMaster University, Hamilton, Ont.; Tehran Heart Center (Abbasi), Tehran University of Medical Sciences, Tehran, Iran; Division of Nephrology (Hildebrand), Department of Medicine, University of Alberta, Edmonton, Alta.; Département de médecine (Lamontagne), Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Que.; Department of Surgery (Lamy) McMaster University, Hamilton, Ont.; Department of Cardiac Surgery (Noiseux), Université de Montréal, Montréal, Que.; Division of Nephrology, Johns Hopkins School of Medicine (Parikh), Baltimore, Md.; The George Institute for Global Health (Perkovic), Sydney, Australia; Division of Cardiac Surgery (Quantz), London Health Sciences Centre, University Hospital, London, Ont.; Montreal Heart Institute (Rochon), Université de Montréal, Montréal, Que.; Department of Surgery (Royse), University of Melbourne, Melbourne, Australia; Department of Outcomes Research (Sessler), Cleveland Clinic, Cleveland, Ohio; Department of Cardiac Surgery (Shah), Princess Alexandra Hospital, Brisbane, Australia; Department of Cardiovascular and Thoracic Surgery (Tagarakis), Aristotle University of Thessaloniki, Thessaloniki, Greece; Division of Cardiac Surgery (Teoh), Southlake Regional Health Centre, Newmarket, Ont.; Population Health Research Institute (Vincent, Whitlock), Hamilton, Ont.; Department of Cardiothoracic Anesthesiology (Yared), Cleveland Clinic, Cleveland, Ohio; Division of Cardiology (Yusuf), Department of Medicine, McMaster University, Hamilton, Ont
| | - Seyed Hesameddin Abbasi
- Division of Nephrology (Garg, Cuerden, Sontrop), Department of Medicine, London Health Sciences Centre, London, Ont.; Department of Anaesthesia and Intensive Care (Chan), The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Departments of Health Research Methods, Evidence, and Impact, and Medicine (Devereaux, Walsh), McMaster University, Hamilton, Ont.; Tehran Heart Center (Abbasi), Tehran University of Medical Sciences, Tehran, Iran; Division of Nephrology (Hildebrand), Department of Medicine, University of Alberta, Edmonton, Alta.; Département de médecine (Lamontagne), Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Que.; Department of Surgery (Lamy) McMaster University, Hamilton, Ont.; Department of Cardiac Surgery (Noiseux), Université de Montréal, Montréal, Que.; Division of Nephrology, Johns Hopkins School of Medicine (Parikh), Baltimore, Md.; The George Institute for Global Health (Perkovic), Sydney, Australia; Division of Cardiac Surgery (Quantz), London Health Sciences Centre, University Hospital, London, Ont.; Montreal Heart Institute (Rochon), Université de Montréal, Montréal, Que.; Department of Surgery (Royse), University of Melbourne, Melbourne, Australia; Department of Outcomes Research (Sessler), Cleveland Clinic, Cleveland, Ohio; Department of Cardiac Surgery (Shah), Princess Alexandra Hospital, Brisbane, Australia; Department of Cardiovascular and Thoracic Surgery (Tagarakis), Aristotle University of Thessaloniki, Thessaloniki, Greece; Division of Cardiac Surgery (Teoh), Southlake Regional Health Centre, Newmarket, Ont.; Population Health Research Institute (Vincent, Whitlock), Hamilton, Ont.; Department of Cardiothoracic Anesthesiology (Yared), Cleveland Clinic, Cleveland, Ohio; Division of Cardiology (Yusuf), Department of Medicine, McMaster University, Hamilton, Ont
| | - Ainslie Hildebrand
- Division of Nephrology (Garg, Cuerden, Sontrop), Department of Medicine, London Health Sciences Centre, London, Ont.; Department of Anaesthesia and Intensive Care (Chan), The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Departments of Health Research Methods, Evidence, and Impact, and Medicine (Devereaux, Walsh), McMaster University, Hamilton, Ont.; Tehran Heart Center (Abbasi), Tehran University of Medical Sciences, Tehran, Iran; Division of Nephrology (Hildebrand), Department of Medicine, University of Alberta, Edmonton, Alta.; Département de médecine (Lamontagne), Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Que.; Department of Surgery (Lamy) McMaster University, Hamilton, Ont.; Department of Cardiac Surgery (Noiseux), Université de Montréal, Montréal, Que.; Division of Nephrology, Johns Hopkins School of Medicine (Parikh), Baltimore, Md.; The George Institute for Global Health (Perkovic), Sydney, Australia; Division of Cardiac Surgery (Quantz), London Health Sciences Centre, University Hospital, London, Ont.; Montreal Heart Institute (Rochon), Université de Montréal, Montréal, Que.; Department of Surgery (Royse), University of Melbourne, Melbourne, Australia; Department of Outcomes Research (Sessler), Cleveland Clinic, Cleveland, Ohio; Department of Cardiac Surgery (Shah), Princess Alexandra Hospital, Brisbane, Australia; Department of Cardiovascular and Thoracic Surgery (Tagarakis), Aristotle University of Thessaloniki, Thessaloniki, Greece; Division of Cardiac Surgery (Teoh), Southlake Regional Health Centre, Newmarket, Ont.; Population Health Research Institute (Vincent, Whitlock), Hamilton, Ont.; Department of Cardiothoracic Anesthesiology (Yared), Cleveland Clinic, Cleveland, Ohio; Division of Cardiology (Yusuf), Department of Medicine, McMaster University, Hamilton, Ont
| | - François Lamontagne
- Division of Nephrology (Garg, Cuerden, Sontrop), Department of Medicine, London Health Sciences Centre, London, Ont.; Department of Anaesthesia and Intensive Care (Chan), The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Departments of Health Research Methods, Evidence, and Impact, and Medicine (Devereaux, Walsh), McMaster University, Hamilton, Ont.; Tehran Heart Center (Abbasi), Tehran University of Medical Sciences, Tehran, Iran; Division of Nephrology (Hildebrand), Department of Medicine, University of Alberta, Edmonton, Alta.; Département de médecine (Lamontagne), Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Que.; Department of Surgery (Lamy) McMaster University, Hamilton, Ont.; Department of Cardiac Surgery (Noiseux), Université de Montréal, Montréal, Que.; Division of Nephrology, Johns Hopkins School of Medicine (Parikh), Baltimore, Md.; The George Institute for Global Health (Perkovic), Sydney, Australia; Division of Cardiac Surgery (Quantz), London Health Sciences Centre, University Hospital, London, Ont.; Montreal Heart Institute (Rochon), Université de Montréal, Montréal, Que.; Department of Surgery (Royse), University of Melbourne, Melbourne, Australia; Department of Outcomes Research (Sessler), Cleveland Clinic, Cleveland, Ohio; Department of Cardiac Surgery (Shah), Princess Alexandra Hospital, Brisbane, Australia; Department of Cardiovascular and Thoracic Surgery (Tagarakis), Aristotle University of Thessaloniki, Thessaloniki, Greece; Division of Cardiac Surgery (Teoh), Southlake Regional Health Centre, Newmarket, Ont.; Population Health Research Institute (Vincent, Whitlock), Hamilton, Ont.; Department of Cardiothoracic Anesthesiology (Yared), Cleveland Clinic, Cleveland, Ohio; Division of Cardiology (Yusuf), Department of Medicine, McMaster University, Hamilton, Ont
| | - Andre Lamy
- Division of Nephrology (Garg, Cuerden, Sontrop), Department of Medicine, London Health Sciences Centre, London, Ont.; Department of Anaesthesia and Intensive Care (Chan), The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Departments of Health Research Methods, Evidence, and Impact, and Medicine (Devereaux, Walsh), McMaster University, Hamilton, Ont.; Tehran Heart Center (Abbasi), Tehran University of Medical Sciences, Tehran, Iran; Division of Nephrology (Hildebrand), Department of Medicine, University of Alberta, Edmonton, Alta.; Département de médecine (Lamontagne), Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Que.; Department of Surgery (Lamy) McMaster University, Hamilton, Ont.; Department of Cardiac Surgery (Noiseux), Université de Montréal, Montréal, Que.; Division of Nephrology, Johns Hopkins School of Medicine (Parikh), Baltimore, Md.; The George Institute for Global Health (Perkovic), Sydney, Australia; Division of Cardiac Surgery (Quantz), London Health Sciences Centre, University Hospital, London, Ont.; Montreal Heart Institute (Rochon), Université de Montréal, Montréal, Que.; Department of Surgery (Royse), University of Melbourne, Melbourne, Australia; Department of Outcomes Research (Sessler), Cleveland Clinic, Cleveland, Ohio; Department of Cardiac Surgery (Shah), Princess Alexandra Hospital, Brisbane, Australia; Department of Cardiovascular and Thoracic Surgery (Tagarakis), Aristotle University of Thessaloniki, Thessaloniki, Greece; Division of Cardiac Surgery (Teoh), Southlake Regional Health Centre, Newmarket, Ont.; Population Health Research Institute (Vincent, Whitlock), Hamilton, Ont.; Department of Cardiothoracic Anesthesiology (Yared), Cleveland Clinic, Cleveland, Ohio; Division of Cardiology (Yusuf), Department of Medicine, McMaster University, Hamilton, Ont
| | - Nicolas Noiseux
- Division of Nephrology (Garg, Cuerden, Sontrop), Department of Medicine, London Health Sciences Centre, London, Ont.; Department of Anaesthesia and Intensive Care (Chan), The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Departments of Health Research Methods, Evidence, and Impact, and Medicine (Devereaux, Walsh), McMaster University, Hamilton, Ont.; Tehran Heart Center (Abbasi), Tehran University of Medical Sciences, Tehran, Iran; Division of Nephrology (Hildebrand), Department of Medicine, University of Alberta, Edmonton, Alta.; Département de médecine (Lamontagne), Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Que.; Department of Surgery (Lamy) McMaster University, Hamilton, Ont.; Department of Cardiac Surgery (Noiseux), Université de Montréal, Montréal, Que.; Division of Nephrology, Johns Hopkins School of Medicine (Parikh), Baltimore, Md.; The George Institute for Global Health (Perkovic), Sydney, Australia; Division of Cardiac Surgery (Quantz), London Health Sciences Centre, University Hospital, London, Ont.; Montreal Heart Institute (Rochon), Université de Montréal, Montréal, Que.; Department of Surgery (Royse), University of Melbourne, Melbourne, Australia; Department of Outcomes Research (Sessler), Cleveland Clinic, Cleveland, Ohio; Department of Cardiac Surgery (Shah), Princess Alexandra Hospital, Brisbane, Australia; Department of Cardiovascular and Thoracic Surgery (Tagarakis), Aristotle University of Thessaloniki, Thessaloniki, Greece; Division of Cardiac Surgery (Teoh), Southlake Regional Health Centre, Newmarket, Ont.; Population Health Research Institute (Vincent, Whitlock), Hamilton, Ont.; Department of Cardiothoracic Anesthesiology (Yared), Cleveland Clinic, Cleveland, Ohio; Division of Cardiology (Yusuf), Department of Medicine, McMaster University, Hamilton, Ont
| | - Chirag R Parikh
- Division of Nephrology (Garg, Cuerden, Sontrop), Department of Medicine, London Health Sciences Centre, London, Ont.; Department of Anaesthesia and Intensive Care (Chan), The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Departments of Health Research Methods, Evidence, and Impact, and Medicine (Devereaux, Walsh), McMaster University, Hamilton, Ont.; Tehran Heart Center (Abbasi), Tehran University of Medical Sciences, Tehran, Iran; Division of Nephrology (Hildebrand), Department of Medicine, University of Alberta, Edmonton, Alta.; Département de médecine (Lamontagne), Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Que.; Department of Surgery (Lamy) McMaster University, Hamilton, Ont.; Department of Cardiac Surgery (Noiseux), Université de Montréal, Montréal, Que.; Division of Nephrology, Johns Hopkins School of Medicine (Parikh), Baltimore, Md.; The George Institute for Global Health (Perkovic), Sydney, Australia; Division of Cardiac Surgery (Quantz), London Health Sciences Centre, University Hospital, London, Ont.; Montreal Heart Institute (Rochon), Université de Montréal, Montréal, Que.; Department of Surgery (Royse), University of Melbourne, Melbourne, Australia; Department of Outcomes Research (Sessler), Cleveland Clinic, Cleveland, Ohio; Department of Cardiac Surgery (Shah), Princess Alexandra Hospital, Brisbane, Australia; Department of Cardiovascular and Thoracic Surgery (Tagarakis), Aristotle University of Thessaloniki, Thessaloniki, Greece; Division of Cardiac Surgery (Teoh), Southlake Regional Health Centre, Newmarket, Ont.; Population Health Research Institute (Vincent, Whitlock), Hamilton, Ont.; Department of Cardiothoracic Anesthesiology (Yared), Cleveland Clinic, Cleveland, Ohio; Division of Cardiology (Yusuf), Department of Medicine, McMaster University, Hamilton, Ont
| | - Vlado Perkovic
- Division of Nephrology (Garg, Cuerden, Sontrop), Department of Medicine, London Health Sciences Centre, London, Ont.; Department of Anaesthesia and Intensive Care (Chan), The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Departments of Health Research Methods, Evidence, and Impact, and Medicine (Devereaux, Walsh), McMaster University, Hamilton, Ont.; Tehran Heart Center (Abbasi), Tehran University of Medical Sciences, Tehran, Iran; Division of Nephrology (Hildebrand), Department of Medicine, University of Alberta, Edmonton, Alta.; Département de médecine (Lamontagne), Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Que.; Department of Surgery (Lamy) McMaster University, Hamilton, Ont.; Department of Cardiac Surgery (Noiseux), Université de Montréal, Montréal, Que.; Division of Nephrology, Johns Hopkins School of Medicine (Parikh), Baltimore, Md.; The George Institute for Global Health (Perkovic), Sydney, Australia; Division of Cardiac Surgery (Quantz), London Health Sciences Centre, University Hospital, London, Ont.; Montreal Heart Institute (Rochon), Université de Montréal, Montréal, Que.; Department of Surgery (Royse), University of Melbourne, Melbourne, Australia; Department of Outcomes Research (Sessler), Cleveland Clinic, Cleveland, Ohio; Department of Cardiac Surgery (Shah), Princess Alexandra Hospital, Brisbane, Australia; Department of Cardiovascular and Thoracic Surgery (Tagarakis), Aristotle University of Thessaloniki, Thessaloniki, Greece; Division of Cardiac Surgery (Teoh), Southlake Regional Health Centre, Newmarket, Ont.; Population Health Research Institute (Vincent, Whitlock), Hamilton, Ont.; Department of Cardiothoracic Anesthesiology (Yared), Cleveland Clinic, Cleveland, Ohio; Division of Cardiology (Yusuf), Department of Medicine, McMaster University, Hamilton, Ont
| | - Mackenzie Quantz
- Division of Nephrology (Garg, Cuerden, Sontrop), Department of Medicine, London Health Sciences Centre, London, Ont.; Department of Anaesthesia and Intensive Care (Chan), The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Departments of Health Research Methods, Evidence, and Impact, and Medicine (Devereaux, Walsh), McMaster University, Hamilton, Ont.; Tehran Heart Center (Abbasi), Tehran University of Medical Sciences, Tehran, Iran; Division of Nephrology (Hildebrand), Department of Medicine, University of Alberta, Edmonton, Alta.; Département de médecine (Lamontagne), Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Que.; Department of Surgery (Lamy) McMaster University, Hamilton, Ont.; Department of Cardiac Surgery (Noiseux), Université de Montréal, Montréal, Que.; Division of Nephrology, Johns Hopkins School of Medicine (Parikh), Baltimore, Md.; The George Institute for Global Health (Perkovic), Sydney, Australia; Division of Cardiac Surgery (Quantz), London Health Sciences Centre, University Hospital, London, Ont.; Montreal Heart Institute (Rochon), Université de Montréal, Montréal, Que.; Department of Surgery (Royse), University of Melbourne, Melbourne, Australia; Department of Outcomes Research (Sessler), Cleveland Clinic, Cleveland, Ohio; Department of Cardiac Surgery (Shah), Princess Alexandra Hospital, Brisbane, Australia; Department of Cardiovascular and Thoracic Surgery (Tagarakis), Aristotle University of Thessaloniki, Thessaloniki, Greece; Division of Cardiac Surgery (Teoh), Southlake Regional Health Centre, Newmarket, Ont.; Population Health Research Institute (Vincent, Whitlock), Hamilton, Ont.; Department of Cardiothoracic Anesthesiology (Yared), Cleveland Clinic, Cleveland, Ohio; Division of Cardiology (Yusuf), Department of Medicine, McMaster University, Hamilton, Ont
| | - Antoine Rochon
- Division of Nephrology (Garg, Cuerden, Sontrop), Department of Medicine, London Health Sciences Centre, London, Ont.; Department of Anaesthesia and Intensive Care (Chan), The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Departments of Health Research Methods, Evidence, and Impact, and Medicine (Devereaux, Walsh), McMaster University, Hamilton, Ont.; Tehran Heart Center (Abbasi), Tehran University of Medical Sciences, Tehran, Iran; Division of Nephrology (Hildebrand), Department of Medicine, University of Alberta, Edmonton, Alta.; Département de médecine (Lamontagne), Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Que.; Department of Surgery (Lamy) McMaster University, Hamilton, Ont.; Department of Cardiac Surgery (Noiseux), Université de Montréal, Montréal, Que.; Division of Nephrology, Johns Hopkins School of Medicine (Parikh), Baltimore, Md.; The George Institute for Global Health (Perkovic), Sydney, Australia; Division of Cardiac Surgery (Quantz), London Health Sciences Centre, University Hospital, London, Ont.; Montreal Heart Institute (Rochon), Université de Montréal, Montréal, Que.; Department of Surgery (Royse), University of Melbourne, Melbourne, Australia; Department of Outcomes Research (Sessler), Cleveland Clinic, Cleveland, Ohio; Department of Cardiac Surgery (Shah), Princess Alexandra Hospital, Brisbane, Australia; Department of Cardiovascular and Thoracic Surgery (Tagarakis), Aristotle University of Thessaloniki, Thessaloniki, Greece; Division of Cardiac Surgery (Teoh), Southlake Regional Health Centre, Newmarket, Ont.; Population Health Research Institute (Vincent, Whitlock), Hamilton, Ont.; Department of Cardiothoracic Anesthesiology (Yared), Cleveland Clinic, Cleveland, Ohio; Division of Cardiology (Yusuf), Department of Medicine, McMaster University, Hamilton, Ont
| | - Alistair Royse
- Division of Nephrology (Garg, Cuerden, Sontrop), Department of Medicine, London Health Sciences Centre, London, Ont.; Department of Anaesthesia and Intensive Care (Chan), The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Departments of Health Research Methods, Evidence, and Impact, and Medicine (Devereaux, Walsh), McMaster University, Hamilton, Ont.; Tehran Heart Center (Abbasi), Tehran University of Medical Sciences, Tehran, Iran; Division of Nephrology (Hildebrand), Department of Medicine, University of Alberta, Edmonton, Alta.; Département de médecine (Lamontagne), Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Que.; Department of Surgery (Lamy) McMaster University, Hamilton, Ont.; Department of Cardiac Surgery (Noiseux), Université de Montréal, Montréal, Que.; Division of Nephrology, Johns Hopkins School of Medicine (Parikh), Baltimore, Md.; The George Institute for Global Health (Perkovic), Sydney, Australia; Division of Cardiac Surgery (Quantz), London Health Sciences Centre, University Hospital, London, Ont.; Montreal Heart Institute (Rochon), Université de Montréal, Montréal, Que.; Department of Surgery (Royse), University of Melbourne, Melbourne, Australia; Department of Outcomes Research (Sessler), Cleveland Clinic, Cleveland, Ohio; Department of Cardiac Surgery (Shah), Princess Alexandra Hospital, Brisbane, Australia; Department of Cardiovascular and Thoracic Surgery (Tagarakis), Aristotle University of Thessaloniki, Thessaloniki, Greece; Division of Cardiac Surgery (Teoh), Southlake Regional Health Centre, Newmarket, Ont.; Population Health Research Institute (Vincent, Whitlock), Hamilton, Ont.; Department of Cardiothoracic Anesthesiology (Yared), Cleveland Clinic, Cleveland, Ohio; Division of Cardiology (Yusuf), Department of Medicine, McMaster University, Hamilton, Ont
| | - Daniel I Sessler
- Division of Nephrology (Garg, Cuerden, Sontrop), Department of Medicine, London Health Sciences Centre, London, Ont.; Department of Anaesthesia and Intensive Care (Chan), The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Departments of Health Research Methods, Evidence, and Impact, and Medicine (Devereaux, Walsh), McMaster University, Hamilton, Ont.; Tehran Heart Center (Abbasi), Tehran University of Medical Sciences, Tehran, Iran; Division of Nephrology (Hildebrand), Department of Medicine, University of Alberta, Edmonton, Alta.; Département de médecine (Lamontagne), Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Que.; Department of Surgery (Lamy) McMaster University, Hamilton, Ont.; Department of Cardiac Surgery (Noiseux), Université de Montréal, Montréal, Que.; Division of Nephrology, Johns Hopkins School of Medicine (Parikh), Baltimore, Md.; The George Institute for Global Health (Perkovic), Sydney, Australia; Division of Cardiac Surgery (Quantz), London Health Sciences Centre, University Hospital, London, Ont.; Montreal Heart Institute (Rochon), Université de Montréal, Montréal, Que.; Department of Surgery (Royse), University of Melbourne, Melbourne, Australia; Department of Outcomes Research (Sessler), Cleveland Clinic, Cleveland, Ohio; Department of Cardiac Surgery (Shah), Princess Alexandra Hospital, Brisbane, Australia; Department of Cardiovascular and Thoracic Surgery (Tagarakis), Aristotle University of Thessaloniki, Thessaloniki, Greece; Division of Cardiac Surgery (Teoh), Southlake Regional Health Centre, Newmarket, Ont.; Population Health Research Institute (Vincent, Whitlock), Hamilton, Ont.; Department of Cardiothoracic Anesthesiology (Yared), Cleveland Clinic, Cleveland, Ohio; Division of Cardiology (Yusuf), Department of Medicine, McMaster University, Hamilton, Ont
| | - Pallav J Shah
- Division of Nephrology (Garg, Cuerden, Sontrop), Department of Medicine, London Health Sciences Centre, London, Ont.; Department of Anaesthesia and Intensive Care (Chan), The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Departments of Health Research Methods, Evidence, and Impact, and Medicine (Devereaux, Walsh), McMaster University, Hamilton, Ont.; Tehran Heart Center (Abbasi), Tehran University of Medical Sciences, Tehran, Iran; Division of Nephrology (Hildebrand), Department of Medicine, University of Alberta, Edmonton, Alta.; Département de médecine (Lamontagne), Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Que.; Department of Surgery (Lamy) McMaster University, Hamilton, Ont.; Department of Cardiac Surgery (Noiseux), Université de Montréal, Montréal, Que.; Division of Nephrology, Johns Hopkins School of Medicine (Parikh), Baltimore, Md.; The George Institute for Global Health (Perkovic), Sydney, Australia; Division of Cardiac Surgery (Quantz), London Health Sciences Centre, University Hospital, London, Ont.; Montreal Heart Institute (Rochon), Université de Montréal, Montréal, Que.; Department of Surgery (Royse), University of Melbourne, Melbourne, Australia; Department of Outcomes Research (Sessler), Cleveland Clinic, Cleveland, Ohio; Department of Cardiac Surgery (Shah), Princess Alexandra Hospital, Brisbane, Australia; Department of Cardiovascular and Thoracic Surgery (Tagarakis), Aristotle University of Thessaloniki, Thessaloniki, Greece; Division of Cardiac Surgery (Teoh), Southlake Regional Health Centre, Newmarket, Ont.; Population Health Research Institute (Vincent, Whitlock), Hamilton, Ont.; Department of Cardiothoracic Anesthesiology (Yared), Cleveland Clinic, Cleveland, Ohio; Division of Cardiology (Yusuf), Department of Medicine, McMaster University, Hamilton, Ont
| | - Jessica M Sontrop
- Division of Nephrology (Garg, Cuerden, Sontrop), Department of Medicine, London Health Sciences Centre, London, Ont.; Department of Anaesthesia and Intensive Care (Chan), The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Departments of Health Research Methods, Evidence, and Impact, and Medicine (Devereaux, Walsh), McMaster University, Hamilton, Ont.; Tehran Heart Center (Abbasi), Tehran University of Medical Sciences, Tehran, Iran; Division of Nephrology (Hildebrand), Department of Medicine, University of Alberta, Edmonton, Alta.; Département de médecine (Lamontagne), Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Que.; Department of Surgery (Lamy) McMaster University, Hamilton, Ont.; Department of Cardiac Surgery (Noiseux), Université de Montréal, Montréal, Que.; Division of Nephrology, Johns Hopkins School of Medicine (Parikh), Baltimore, Md.; The George Institute for Global Health (Perkovic), Sydney, Australia; Division of Cardiac Surgery (Quantz), London Health Sciences Centre, University Hospital, London, Ont.; Montreal Heart Institute (Rochon), Université de Montréal, Montréal, Que.; Department of Surgery (Royse), University of Melbourne, Melbourne, Australia; Department of Outcomes Research (Sessler), Cleveland Clinic, Cleveland, Ohio; Department of Cardiac Surgery (Shah), Princess Alexandra Hospital, Brisbane, Australia; Department of Cardiovascular and Thoracic Surgery (Tagarakis), Aristotle University of Thessaloniki, Thessaloniki, Greece; Division of Cardiac Surgery (Teoh), Southlake Regional Health Centre, Newmarket, Ont.; Population Health Research Institute (Vincent, Whitlock), Hamilton, Ont.; Department of Cardiothoracic Anesthesiology (Yared), Cleveland Clinic, Cleveland, Ohio; Division of Cardiology (Yusuf), Department of Medicine, McMaster University, Hamilton, Ont
| | - Georgios I Tagarakis
- Division of Nephrology (Garg, Cuerden, Sontrop), Department of Medicine, London Health Sciences Centre, London, Ont.; Department of Anaesthesia and Intensive Care (Chan), The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Departments of Health Research Methods, Evidence, and Impact, and Medicine (Devereaux, Walsh), McMaster University, Hamilton, Ont.; Tehran Heart Center (Abbasi), Tehran University of Medical Sciences, Tehran, Iran; Division of Nephrology (Hildebrand), Department of Medicine, University of Alberta, Edmonton, Alta.; Département de médecine (Lamontagne), Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Que.; Department of Surgery (Lamy) McMaster University, Hamilton, Ont.; Department of Cardiac Surgery (Noiseux), Université de Montréal, Montréal, Que.; Division of Nephrology, Johns Hopkins School of Medicine (Parikh), Baltimore, Md.; The George Institute for Global Health (Perkovic), Sydney, Australia; Division of Cardiac Surgery (Quantz), London Health Sciences Centre, University Hospital, London, Ont.; Montreal Heart Institute (Rochon), Université de Montréal, Montréal, Que.; Department of Surgery (Royse), University of Melbourne, Melbourne, Australia; Department of Outcomes Research (Sessler), Cleveland Clinic, Cleveland, Ohio; Department of Cardiac Surgery (Shah), Princess Alexandra Hospital, Brisbane, Australia; Department of Cardiovascular and Thoracic Surgery (Tagarakis), Aristotle University of Thessaloniki, Thessaloniki, Greece; Division of Cardiac Surgery (Teoh), Southlake Regional Health Centre, Newmarket, Ont.; Population Health Research Institute (Vincent, Whitlock), Hamilton, Ont.; Department of Cardiothoracic Anesthesiology (Yared), Cleveland Clinic, Cleveland, Ohio; Division of Cardiology (Yusuf), Department of Medicine, McMaster University, Hamilton, Ont
| | - Kevin H Teoh
- Division of Nephrology (Garg, Cuerden, Sontrop), Department of Medicine, London Health Sciences Centre, London, Ont.; Department of Anaesthesia and Intensive Care (Chan), The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Departments of Health Research Methods, Evidence, and Impact, and Medicine (Devereaux, Walsh), McMaster University, Hamilton, Ont.; Tehran Heart Center (Abbasi), Tehran University of Medical Sciences, Tehran, Iran; Division of Nephrology (Hildebrand), Department of Medicine, University of Alberta, Edmonton, Alta.; Département de médecine (Lamontagne), Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Que.; Department of Surgery (Lamy) McMaster University, Hamilton, Ont.; Department of Cardiac Surgery (Noiseux), Université de Montréal, Montréal, Que.; Division of Nephrology, Johns Hopkins School of Medicine (Parikh), Baltimore, Md.; The George Institute for Global Health (Perkovic), Sydney, Australia; Division of Cardiac Surgery (Quantz), London Health Sciences Centre, University Hospital, London, Ont.; Montreal Heart Institute (Rochon), Université de Montréal, Montréal, Que.; Department of Surgery (Royse), University of Melbourne, Melbourne, Australia; Department of Outcomes Research (Sessler), Cleveland Clinic, Cleveland, Ohio; Department of Cardiac Surgery (Shah), Princess Alexandra Hospital, Brisbane, Australia; Department of Cardiovascular and Thoracic Surgery (Tagarakis), Aristotle University of Thessaloniki, Thessaloniki, Greece; Division of Cardiac Surgery (Teoh), Southlake Regional Health Centre, Newmarket, Ont.; Population Health Research Institute (Vincent, Whitlock), Hamilton, Ont.; Department of Cardiothoracic Anesthesiology (Yared), Cleveland Clinic, Cleveland, Ohio; Division of Cardiology (Yusuf), Department of Medicine, McMaster University, Hamilton, Ont
| | - Jessica Vincent
- Division of Nephrology (Garg, Cuerden, Sontrop), Department of Medicine, London Health Sciences Centre, London, Ont.; Department of Anaesthesia and Intensive Care (Chan), The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Departments of Health Research Methods, Evidence, and Impact, and Medicine (Devereaux, Walsh), McMaster University, Hamilton, Ont.; Tehran Heart Center (Abbasi), Tehran University of Medical Sciences, Tehran, Iran; Division of Nephrology (Hildebrand), Department of Medicine, University of Alberta, Edmonton, Alta.; Département de médecine (Lamontagne), Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Que.; Department of Surgery (Lamy) McMaster University, Hamilton, Ont.; Department of Cardiac Surgery (Noiseux), Université de Montréal, Montréal, Que.; Division of Nephrology, Johns Hopkins School of Medicine (Parikh), Baltimore, Md.; The George Institute for Global Health (Perkovic), Sydney, Australia; Division of Cardiac Surgery (Quantz), London Health Sciences Centre, University Hospital, London, Ont.; Montreal Heart Institute (Rochon), Université de Montréal, Montréal, Que.; Department of Surgery (Royse), University of Melbourne, Melbourne, Australia; Department of Outcomes Research (Sessler), Cleveland Clinic, Cleveland, Ohio; Department of Cardiac Surgery (Shah), Princess Alexandra Hospital, Brisbane, Australia; Department of Cardiovascular and Thoracic Surgery (Tagarakis), Aristotle University of Thessaloniki, Thessaloniki, Greece; Division of Cardiac Surgery (Teoh), Southlake Regional Health Centre, Newmarket, Ont.; Population Health Research Institute (Vincent, Whitlock), Hamilton, Ont.; Department of Cardiothoracic Anesthesiology (Yared), Cleveland Clinic, Cleveland, Ohio; Division of Cardiology (Yusuf), Department of Medicine, McMaster University, Hamilton, Ont
| | - Michael Walsh
- Division of Nephrology (Garg, Cuerden, Sontrop), Department of Medicine, London Health Sciences Centre, London, Ont.; Department of Anaesthesia and Intensive Care (Chan), The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Departments of Health Research Methods, Evidence, and Impact, and Medicine (Devereaux, Walsh), McMaster University, Hamilton, Ont.; Tehran Heart Center (Abbasi), Tehran University of Medical Sciences, Tehran, Iran; Division of Nephrology (Hildebrand), Department of Medicine, University of Alberta, Edmonton, Alta.; Département de médecine (Lamontagne), Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Que.; Department of Surgery (Lamy) McMaster University, Hamilton, Ont.; Department of Cardiac Surgery (Noiseux), Université de Montréal, Montréal, Que.; Division of Nephrology, Johns Hopkins School of Medicine (Parikh), Baltimore, Md.; The George Institute for Global Health (Perkovic), Sydney, Australia; Division of Cardiac Surgery (Quantz), London Health Sciences Centre, University Hospital, London, Ont.; Montreal Heart Institute (Rochon), Université de Montréal, Montréal, Que.; Department of Surgery (Royse), University of Melbourne, Melbourne, Australia; Department of Outcomes Research (Sessler), Cleveland Clinic, Cleveland, Ohio; Department of Cardiac Surgery (Shah), Princess Alexandra Hospital, Brisbane, Australia; Department of Cardiovascular and Thoracic Surgery (Tagarakis), Aristotle University of Thessaloniki, Thessaloniki, Greece; Division of Cardiac Surgery (Teoh), Southlake Regional Health Centre, Newmarket, Ont.; Population Health Research Institute (Vincent, Whitlock), Hamilton, Ont.; Department of Cardiothoracic Anesthesiology (Yared), Cleveland Clinic, Cleveland, Ohio; Division of Cardiology (Yusuf), Department of Medicine, McMaster University, Hamilton, Ont
| | - Jean-Pierre Yared
- Division of Nephrology (Garg, Cuerden, Sontrop), Department of Medicine, London Health Sciences Centre, London, Ont.; Department of Anaesthesia and Intensive Care (Chan), The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Departments of Health Research Methods, Evidence, and Impact, and Medicine (Devereaux, Walsh), McMaster University, Hamilton, Ont.; Tehran Heart Center (Abbasi), Tehran University of Medical Sciences, Tehran, Iran; Division of Nephrology (Hildebrand), Department of Medicine, University of Alberta, Edmonton, Alta.; Département de médecine (Lamontagne), Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Que.; Department of Surgery (Lamy) McMaster University, Hamilton, Ont.; Department of Cardiac Surgery (Noiseux), Université de Montréal, Montréal, Que.; Division of Nephrology, Johns Hopkins School of Medicine (Parikh), Baltimore, Md.; The George Institute for Global Health (Perkovic), Sydney, Australia; Division of Cardiac Surgery (Quantz), London Health Sciences Centre, University Hospital, London, Ont.; Montreal Heart Institute (Rochon), Université de Montréal, Montréal, Que.; Department of Surgery (Royse), University of Melbourne, Melbourne, Australia; Department of Outcomes Research (Sessler), Cleveland Clinic, Cleveland, Ohio; Department of Cardiac Surgery (Shah), Princess Alexandra Hospital, Brisbane, Australia; Department of Cardiovascular and Thoracic Surgery (Tagarakis), Aristotle University of Thessaloniki, Thessaloniki, Greece; Division of Cardiac Surgery (Teoh), Southlake Regional Health Centre, Newmarket, Ont.; Population Health Research Institute (Vincent, Whitlock), Hamilton, Ont.; Department of Cardiothoracic Anesthesiology (Yared), Cleveland Clinic, Cleveland, Ohio; Division of Cardiology (Yusuf), Department of Medicine, McMaster University, Hamilton, Ont
| | - Salim Yusuf
- Division of Nephrology (Garg, Cuerden, Sontrop), Department of Medicine, London Health Sciences Centre, London, Ont.; Department of Anaesthesia and Intensive Care (Chan), The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Departments of Health Research Methods, Evidence, and Impact, and Medicine (Devereaux, Walsh), McMaster University, Hamilton, Ont.; Tehran Heart Center (Abbasi), Tehran University of Medical Sciences, Tehran, Iran; Division of Nephrology (Hildebrand), Department of Medicine, University of Alberta, Edmonton, Alta.; Département de médecine (Lamontagne), Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Que.; Department of Surgery (Lamy) McMaster University, Hamilton, Ont.; Department of Cardiac Surgery (Noiseux), Université de Montréal, Montréal, Que.; Division of Nephrology, Johns Hopkins School of Medicine (Parikh), Baltimore, Md.; The George Institute for Global Health (Perkovic), Sydney, Australia; Division of Cardiac Surgery (Quantz), London Health Sciences Centre, University Hospital, London, Ont.; Montreal Heart Institute (Rochon), Université de Montréal, Montréal, Que.; Department of Surgery (Royse), University of Melbourne, Melbourne, Australia; Department of Outcomes Research (Sessler), Cleveland Clinic, Cleveland, Ohio; Department of Cardiac Surgery (Shah), Princess Alexandra Hospital, Brisbane, Australia; Department of Cardiovascular and Thoracic Surgery (Tagarakis), Aristotle University of Thessaloniki, Thessaloniki, Greece; Division of Cardiac Surgery (Teoh), Southlake Regional Health Centre, Newmarket, Ont.; Population Health Research Institute (Vincent, Whitlock), Hamilton, Ont.; Department of Cardiothoracic Anesthesiology (Yared), Cleveland Clinic, Cleveland, Ohio; Division of Cardiology (Yusuf), Department of Medicine, McMaster University, Hamilton, Ont
| | - Richard P Whitlock
- Division of Nephrology (Garg, Cuerden, Sontrop), Department of Medicine, London Health Sciences Centre, London, Ont.; Department of Anaesthesia and Intensive Care (Chan), The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China; Departments of Health Research Methods, Evidence, and Impact, and Medicine (Devereaux, Walsh), McMaster University, Hamilton, Ont.; Tehran Heart Center (Abbasi), Tehran University of Medical Sciences, Tehran, Iran; Division of Nephrology (Hildebrand), Department of Medicine, University of Alberta, Edmonton, Alta.; Département de médecine (Lamontagne), Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, Que.; Department of Surgery (Lamy) McMaster University, Hamilton, Ont.; Department of Cardiac Surgery (Noiseux), Université de Montréal, Montréal, Que.; Division of Nephrology, Johns Hopkins School of Medicine (Parikh), Baltimore, Md.; The George Institute for Global Health (Perkovic), Sydney, Australia; Division of Cardiac Surgery (Quantz), London Health Sciences Centre, University Hospital, London, Ont.; Montreal Heart Institute (Rochon), Université de Montréal, Montréal, Que.; Department of Surgery (Royse), University of Melbourne, Melbourne, Australia; Department of Outcomes Research (Sessler), Cleveland Clinic, Cleveland, Ohio; Department of Cardiac Surgery (Shah), Princess Alexandra Hospital, Brisbane, Australia; Department of Cardiovascular and Thoracic Surgery (Tagarakis), Aristotle University of Thessaloniki, Thessaloniki, Greece; Division of Cardiac Surgery (Teoh), Southlake Regional Health Centre, Newmarket, Ont.; Population Health Research Institute (Vincent, Whitlock), Hamilton, Ont.; Department of Cardiothoracic Anesthesiology (Yared), Cleveland Clinic, Cleveland, Ohio; Division of Cardiology (Yusuf), Department of Medicine, McMaster University, Hamilton, Ont
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Dekker N, van Meurs M, van Leeuwen A, Hofland H, van Slyke P, Vonk A, Boer C, van den Brom C. Vasculotide, an angiopoietin-1 mimetic, reduces pulmonary vascular leakage and preserves microcirculatory perfusion during cardiopulmonary bypass in rats. Br J Anaesth 2018; 121:1041-1051. [DOI: 10.1016/j.bja.2018.05.049] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 04/26/2018] [Accepted: 05/04/2018] [Indexed: 11/16/2022] Open
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McIlroy D, Bellomo R, Billings F, Karkouti K, Prowle J, Shaw A, Myles P. Systematic review and consensus definitions for the Standardised Endpoints in Perioperative Medicine (StEP) initiative: renal endpoints. Br J Anaesth 2018; 121:1013-1024. [DOI: 10.1016/j.bja.2018.08.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 07/21/2018] [Accepted: 08/07/2018] [Indexed: 02/06/2023] Open
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Myles PS, Dieleman JM, Forbes A, Heritier S, Smith JA. Dexamethasone for Cardiac Surgery trial (DECS-II): Rationale and a novel, practice preference-randomized consent design. Am Heart J 2018; 204:52-57. [PMID: 30081275 DOI: 10.1016/j.ahj.2018.06.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 06/14/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND Numerous studies have investigated high-dose corticosteroids in cardiac surgery, but with mixed results leading to ongoing variations in practice around the world. DECS-II is a study comparing high-dose dexamethasone with placebo in patients undergoing cardiac surgery. METHODS We discuss the rationale for conducting DECS-II, a 2800-patient, pragmatic, multicenter, assessor-blinded, randomized trial in cardiac surgery, and the features of the DECS-II study design (objectives, end points, target population, based on practice preference with post-randomization consent, treatments, patient follow-up and analysis). CONCLUSIONS The DECS-II trial will use a novel, efficient trial design to evaluate whether high-dose dexamethasone has a patient-centered benefit of enhancing recovery and increasing the number of days at home after cardiac surgery.
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Affiliation(s)
- Paul S Myles
- Department of Anaesthesia and Perioperative Medicine, Alfred Hospital, Melbourne, Victoria, Australia; Department of Anaesthesia and Perioperative Medicine, Central Clinical School, Monash University, Melbourne, Victoria, Australia; Department of Epidemiology and Preventive Medicine, School of Public Health and Epidemiology, Monash University; Melbourne, Victoria, Australia.
| | - Jan M Dieleman
- Department of Anaesthesia, University Medical Center, Utrecht, The Netherlands
| | - Andrew Forbes
- Department of Epidemiology and Preventive Medicine, School of Public Health and Epidemiology, Monash University; Melbourne, Victoria, Australia
| | - Stephane Heritier
- Department of Epidemiology and Preventive Medicine, School of Public Health and Epidemiology, Monash University; Melbourne, Victoria, Australia
| | - Julian A Smith
- Department of Cardiothoracic Surgery, Monash Health, Melbourne, Victoria, Australia; Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
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Pretreatment of Huaiqihuang extractum protects against cisplatin-induced nephrotoxicity. Sci Rep 2018; 8:7333. [PMID: 29743526 PMCID: PMC5943312 DOI: 10.1038/s41598-018-25610-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 12/18/2017] [Indexed: 12/31/2022] Open
Abstract
Cisplatin is a commonly used chemotherapeutic agent in the treatment of different types of malignant tumors, but nephrotoxicity limits its usage. Therefore, in this study, we aimed to determine the possible protective effect of Huaiqihuang (HQH) extractum, a kind of Chinese herbal complex that consists of Trametes robiniophila Murr., Lycium barbarum and Polygonatum sibiricum, against nephrotoxicity induced by cisplatin in mice. We found that pretreatment with HQH significantly attenuated the cisplatin-induced increase in blood urea nitrogen (BUN), interstitial congestion, acute renal tubular injury and tubular cell apoptosis and necroptosis. It was further shown that HQH administration reduced cisplatin-induced release and nuclear-cytoplasmic translocation of HMGB1 and inactivated its downstream signaling molecules, TLR4 and NFκB, in renal tubular cells; as a result, HQH repressed cisplatin-induced TNF-α production. As dexamethasone (Dex) exerts renoprotective effects in severe Acute kidney injury (AKI), we compared it with HQH and found that HQH showed similar renoprotective effects to dexamethasone via similar mechanisms. Considering the potential side effects of corticosteroids, reducing the effectiveness of treatment and shortening survival in solid tumor patients, we suggest administration of HQH as a potential adjuvant for cisplatin therapy in solid tumor patients to preserve renal function.
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Jahnukainen T, Keski-Nisula J, Tainio J, Valkonen H, Pätilä T, Jalanko H, Suominen P. Efficacy of corticosteroids in prevention of acute kidney injury in neonates undergoing cardiac surgery-A randomized controlled trial. Acta Anaesthesiol Scand 2018; 62:1072-1079. [PMID: 29667173 DOI: 10.1111/aas.13134] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 03/20/2018] [Accepted: 03/21/2018] [Indexed: 01/22/2023]
Abstract
BACKGROUND Heart surgery requiring cardiopulmonary bypass (CPB) causes an inflammatory response which may further induce acute kidney injury (AKI). In the present randomized controlled study we evaluated whether corticosteroids can prevent CPB related AKI in neonates undergoing heart surgery. METHODS Forty neonates were randomized to receive 2 mg/kg methylprednisolone followed by hydrocortisone infusion 0.2 mg/kg/h perioperatively with tapering doses for 5 days, or placebo administered in a similar fashion. The primary outcome was the inflammatory response (plasma concentrations of interleukins 6 and 10). The correspondence of the interleukin concentrations with AKI was analysed as secondary outcome. In addition, plasma and urine neutrophil gelatinase-associated lipocalin (NGAL), plasma cystatin C, and urine kidney injury molecule-1 (KIM-1) levels were measured. RESULTS Six patients (15%) developed post-operative AKI. No significant difference in the AKI occurrence between the treatment (n = 2) and the placebo (n = 4) groups could be found (risk ratio 2.00, 95% confidence interval 0.41-9.71; P = .661) despite significant reduction in inflammatory response in the treatment group. One patient in the treatment group and two patients in the placebo group required acute peritoneal dialysis. Plasma creatinine and cystatin C or urine NGAL and KIM-1 concentrations did not differ between the treatment and the placebo group. CONCLUSIONS Significantly reduced inflammatory reaction induced by corticosteroid treatment in neonates undergoing cardiac surgery did not reduce the incidence of AKI defined by KDIGO classification or decrease the rise of AKI biomarkers.
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Affiliation(s)
- T Jahnukainen
- Department of Pediatric Nephrology and Transplantation, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - J Keski-Nisula
- Department of Anesthesia and Intensive Care, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - J Tainio
- Department of Pediatric Nephrology and Transplantation, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - H Valkonen
- Department of Anesthesia and Intensive Care, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - T Pätilä
- Department of Pediatric Surgery, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - H Jalanko
- Department of Pediatric Nephrology and Transplantation, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - P Suominen
- Department of Anesthesia and Intensive Care, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Mei B, Yang S, Yue Y, Hou J, Wang K, Chen G, Liang M, Wu Z. Acute adrenal cortex injury during cardiopulmonary bypass in a canine model. J Thorac Cardiovasc Surg 2018; 156:696-706. [PMID: 29753511 DOI: 10.1016/j.jtcvs.2018.03.151] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 03/04/2018] [Accepted: 03/05/2018] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Cardiopulmonary bypass (CPB) might induce systemic inflammatory responses that cause acute injuries to multiple organs. However, no direct evidence exists to determine whether CPB leads to adrenal cortex injury or to describe its underlying mechanism. METHODS Twelve healthy adult beagles were randomly assigned into control and CPB groups. After cannulation, mild hypothermia CPB was performed in the CPB group but not in the control group. The serum concentrations of various cytokines, cortisol, and aldosterone were assessed. Adrenal cortex injuries were evaluated using standard histological methods. Steroidogenic enzymes and the nucleotide-binding oligomerization domain-like receptor containing pyrin domain 3 (NLRP3) inflammasome pathway were detected using quantitative polymerase chain reaction and Western blot analysis. RESULTS During CPB, serum interleukin (IL)-6, IL-8, IL-10, tumor necrosis factor α, cortisol, and aldosterone levels were significantly higher in the CPB group. The pathologic study revealed higher injury scores (3.6 ± 0.6 vs 0.7 ± 0.7) and significantly more severe edema, inflammatory cell infiltration (lymphocytes and neutrophils), and apoptosis in the CPB group. The electron microscopic examination showed swollen mitochondria, ruptured mitochondrial cristae, reduced lipid droplets, and increased secondary lysosomes in the CPB group. The mRNA expression levels of NLRP3 and the protein levels of 17α-hydroxylase and IL-1β in adrenal tissue were significantly upregulated in the CPB group. CONCLUSIONS CPB induces significant systemic and local inflammation in the adrenal cortex and results in cytological architectural and ultrastructural alterations in adrenocorticocytes. In addition, the NLRP3 inflammasome pathway might promote adrenal gland injury during CPB and might represent a novel potential therapeutic target.
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Affiliation(s)
- Bo Mei
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China; Key Laboratory on Assisted Circulation, Ministry of Health, Guangzhou, China
| | - Song Yang
- Key Laboratory on Assisted Circulation, Ministry of Health, Guangzhou, China; Department of Cardiosurgery Intensive Care Unit, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Yuan Yue
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China; Key Laboratory on Assisted Circulation, Ministry of Health, Guangzhou, China
| | - Jian Hou
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China; Key Laboratory on Assisted Circulation, Ministry of Health, Guangzhou, China
| | - Keke Wang
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China; Key Laboratory on Assisted Circulation, Ministry of Health, Guangzhou, China
| | - Guangxian Chen
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China; Key Laboratory on Assisted Circulation, Ministry of Health, Guangzhou, China
| | - Mengya Liang
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China; Key Laboratory on Assisted Circulation, Ministry of Health, Guangzhou, China
| | - Zhongkai Wu
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China; Key Laboratory on Assisted Circulation, Ministry of Health, Guangzhou, China.
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