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Lazzeri C, Bonizzoli M, Guetti C, Fulceri GE, Peris A. Hemodynamic management in brain dead donors. World J Transplant 2021; 11:410-420. [PMID: 34722170 PMCID: PMC8529942 DOI: 10.5500/wjt.v11.i10.410] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 07/22/2021] [Accepted: 09/10/2021] [Indexed: 02/06/2023] Open
Abstract
Donor management is the key in the complex donation process, since up to 20% of organs of brain death donors (DBD) are lost due to hemodynamic instability. This challenge is made more difficult due to the lack of strong recommendations on therapies for hemodynamic management in DBDs and more importantly to the epidemiologic changes in these donors who are becoming older and with more comorbidities (marginal donors). In the present manuscript we aimed at summarizing the available evidence on therapeutic strategies for hemodynamic management (focusing on vasoactive drugs) and monitoring (therapeutic goals). Evidence on management in elderly DBDs is also summarized. Donor management continues critical care but with different and specific therapeutic goals since the number of donor goals met is related to the number of organs retrieved and transplanted. Careful monitoring of selected parameters (possibly including serial echocardiography) is the clinical tool able to guarantee the achievement and maintaining of therapeutic goals. Despide worldwide differences, norepinephrine is the vasoactive of choice in most countries but, whenever higher doses (> 0.2 mcg/kg/min) are needed, a second vasoactive drug (vasopressin) is advisable. Hormonal therapy (desmopressin, corticosteroid and thyroid hormone) are suggested in all DBDs independently of hemodynamic instability. In the single patient, therapeutic regimen (imprimis vasoactive drugs) should be chosen also according to the potential organs retrievable (i.e. heart vs liver and kidneys).
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Affiliation(s)
- Chiara Lazzeri
- Intensive Care Unit and Regional ECMO Referral Centre, Azienda Ospedaliero Universitaria Careggi, Florence 50134, Italy
| | - Manuela Bonizzoli
- Intensive Care Unit and Regional ECMO Referral Centre, Azienda Ospedaliero Universitaria Careggi, Florence 50134, Italy
| | - Cristiana Guetti
- Intensive Care Unit and Regional ECMO Referral Centre, Azienda Ospedaliero Universitaria Careggi, Florence 50134, Italy
| | - Giorgio Enzo Fulceri
- Intensive Care Unit and Regional ECMO Referral Centre, Azienda Ospedaliero Universitaria Careggi, Florence 50134, Italy
| | - Adriano Peris
- Intensive Care Unit and Regional ECMO Referral Centre, Azienda Ospedaliero Universitaria Careggi, Florence 50134, Italy
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Frenette AJ, Williamson D, Williams V, Lagacé AM, Charbonney E, Serri K. A Pilot Randomized Controlled Trial Comparing Levothyroxine to Placebo in Neurologically Deceased Donors. Prog Transplant 2019; 29:261-268. [PMID: 31179831 DOI: 10.1177/1526924819855083] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Although commonly prescribed, the efficacy of levothyroxine to improve heart function in neurologically deceased donors is unclear. We evaluated the feasibility of a randomized controlled trial to compare levothyroxine to placebo on the variation of left ventricular ejection fraction, in hemodynamically unstable donors. METHODS We conducted a pilot, double-blinded, randomized controlled trial. Deceased donors with reduced left ventricular ejection fraction or needing vasopressors were included. We randomized participants to a 20 μg bolus followed by a 20 μg/h infusion of levothyroxine or an identically appearing placebo. We report the proportion of recruited participants, the time to the administration of the study drug, and protocol violations. RESULTS Twenty-four participants (N = 24/104; 23.1%) were eligible. Five of them (N = 5/24; 20.8%) were excluded by the attending physician. Four others were not included, due to family refusal for research (n = 2/24;8.3%) and unavailability of research staff (n = 2/24; 8.3%). Fifteen participants were randomized (N = 15/104; 14.4%). Mean time between the echocardiography and the initiation of the drug was 1.73 hours, and14 (93.3%) of 15 of the participants received the drug within 2 hours after the echocardiography. We report no study violation. The study was stopped prematurely because of low recruitment. CONCLUSION This pilot trial suggests that the success of a definitive randomized control trial to assess the efficacy of levothyroxine in deceased donors could benefit from a multicenter recruitment and education on the evidence surrounding the pharmacological management of organ donors. The need for consent to research interventions in deceased donors should also be clarified.
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Affiliation(s)
- Anne Julie Frenette
- 1 Pharmacy Department, Hôpital du Sacré-Cœur-de-Montréal, Montreal, Quebec, Canada
- 2 Research Center, Hôpital du Sacré-Cœur-de-Montréal, Montreal, Quebec, Canada
- 3 Faculté de pharmacie, Université de Montréal, Montreal, Quebec, Canada
| | - David Williamson
- 1 Pharmacy Department, Hôpital du Sacré-Cœur-de-Montréal, Montreal, Quebec, Canada
- 2 Research Center, Hôpital du Sacré-Cœur-de-Montréal, Montreal, Quebec, Canada
- 3 Faculté de pharmacie, Université de Montréal, Montreal, Quebec, Canada
| | - Virginie Williams
- 2 Research Center, Hôpital du Sacré-Cœur-de-Montréal, Montreal, Quebec, Canada
- 4 Department of Critical Care, Hôpital du Sacré-Coeur-de-Montréal, Montreal, Quebec, Canada
| | - Anne-Marie Lagacé
- 2 Research Center, Hôpital du Sacré-Cœur-de-Montréal, Montreal, Quebec, Canada
- 4 Department of Critical Care, Hôpital du Sacré-Coeur-de-Montréal, Montreal, Quebec, Canada
| | - Emmanuel Charbonney
- 2 Research Center, Hôpital du Sacré-Cœur-de-Montréal, Montreal, Quebec, Canada
- 4 Department of Critical Care, Hôpital du Sacré-Coeur-de-Montréal, Montreal, Quebec, Canada
- 5 Department of Medicine, Faculté de médecine, Université de Montréal, Montreal, Quebec, Canada
| | - Karim Serri
- 2 Research Center, Hôpital du Sacré-Cœur-de-Montréal, Montreal, Quebec, Canada
- 4 Department of Critical Care, Hôpital du Sacré-Coeur-de-Montréal, Montreal, Quebec, Canada
- 5 Department of Medicine, Faculté de médecine, Université de Montréal, Montreal, Quebec, Canada
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Videla LA. Combined docosahexaenoic acid and thyroid hormone supplementation as a protocol supporting energy supply to precondition and afford protection against metabolic stress situations. IUBMB Life 2019; 71:1211-1220. [PMID: 31091354 DOI: 10.1002/iub.2067] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 04/25/2019] [Indexed: 02/06/2023]
Abstract
Liver preconditioning (PC) refers to the development of an enhanced tolerance to injuring stimuli. For example, the protection from ischemia-reperfusion (IR) in the liver that is obtained by previous maneuvers triggering beneficial molecular and functional changes. Recently, we have assessed the PC effects of thyroid hormone (T3; single dose of 0.1 mg/kg) and n-3 long-chain polyunsaturated fatty acids (n-3 LCPUFAs; daily doses of 450 mg/kg for 7 days) that abrogate IR injury to the liver. This feature is also achieved by a combined T3 and the n-3 LCPUFA docosahexaenoic acid (DHA) using a reduced period of supplementation of the FA (daily doses of 300 mg/kg for 3 days) and half of the T3 dosage (0.05 mg/kg). T3 -dependent protective mechanisms include (i) the reactive oxygen species (ROS)-dependent activation of transcription factors nuclear factor-κB (NF-κB), AP-1, signal transducer and activator of transcription 3, and nuclear factor erythroid-2-related factor 2 (Nrf2) upregulating the expression of protective proteins. (ii) ROS-induced endoplasmic reticulum stress affording proper protein folding. (iii) The autophagy response to produce FAs for oxidation and ATP supply and amino acids for protein synthesis. (iv) Downregulation of inflammasome nucleotide-bonding oligomerization domain leucine-rich repeat containing family pyrin containing 3 and interleukin-1β expression to prevent inflammation. N-3 LCPUFAs induce antioxidant responses due to Nrf2 upregulation, with inflammation resolution being related to production of oxidation products and NF-κB downregulation. Energy supply to achieve liver PC is met by the combined DHA plus T3 protocol through upregulation of AMPK coupled to peroxisome proliferator-activated receptor-γ coactivator 1α signaling. In conclusion, DHA plus T3 coadministration favors hepatic bioenergetics and lipid homeostasis that is of crucial importance in acute and clinical conditions such as IR, which may be extended to long-term or chronic situations including steatosis in obesity and diabetes. © 2019 IUBMB Life, 71(9):1211-1220, 2019.
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Affiliation(s)
- Luis A Videla
- Molecular and Clinical Pharmacology Program, Faculty of Medicine, Institute of Biomedical Sciences, University of Chile, Santiago, Chile
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Zhu R, Guo W, Fang H, Cao S, Yan B, Chen S, Zhang K, Zhang S. Kupffer cell depletion by gadolinium chloride aggravates liver injury after brain death in rats. Mol Med Rep 2018; 17:6357-6362. [PMID: 29488608 PMCID: PMC5928625 DOI: 10.3892/mmr.2018.8646] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 02/08/2018] [Indexed: 12/25/2022] Open
Abstract
Brain death (BD) impairs liver function in potential donors, and is associated with hormonal and metabolic changes or molecular effects with pro‑inflammatory activation. Resident macrophages in the liver named Kupffer cells (KCs) undergo pro‑ or anti‑inflammatory pathway activation, which affects liver function. However, the role of the KCs in liver dysfunction following BD has not been fully elucidated. The aim of the present study was to investigate the role of KCs in liver dysfunction in the context of BD and the effects of their inhibition by gadolinium chloride (GdCl3). Rats were randomly divided into the following groups: Control, BD with GdCl3 pretreatment and BD with normal saline pretreatment. Liver function, hepatic pathological histology and cytokine levels in the liver were assessed. Apoptosis and apoptosis‑related proteins [cleaved caspase‑3, caspase‑3 and apoptosis regulator Bcl‑2 (Bcl‑2)] were evaluated. GdCl3 significantly aggravated liver injury by elevating alanine aminotransferase and aspartate aminotransferase levels (P<0.05) by inhibiting KCs. Interleukin (IL)‑1β and tumor necrosis factor α levels in the GdCl3 group were significantly increased compared with those in the control and saline groups (P<0.01). However, IL‑10 levels in the GdCl3 group were significantly reduced compared with those in the saline group (P<0.05). Caspase‑3 and cleaved caspase‑3 activation, and apoptosis induction in the context of BD were also significantly aggravated by the depletion of KCs, whereas Bcl‑2 was significantly suppressed by the administration of GdCl3. The present study indicated that GdCl3 efficiently inhibits the activity of KCs, and is involved in the onset of liver injury through its effects on pro‑inflammatory and anti‑inflammatory activation. KCs are protective in the liver in the context of BD. This protection appears to be due to KCs secretion of the potent anti‑inflammatory cytokine IL‑10, suggesting that KCs are an attractive target for the prevention and treatment of liver injury in the context of BD in rats.
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Affiliation(s)
- Rongtao Zhu
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Weizhi Guo
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Hongbo Fang
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Shengli Cao
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Bing Yan
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Sanyang Chen
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Kaiming Zhang
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
| | - Shuijun Zhang
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, P.R. China
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Barin-Le Guellec C, Largeau B, Bon D, Marquet P, Hauet T. Ischemia/reperfusion-associated tubular cells injury in renal transplantation: Can metabolomics inform about mechanisms and help identify new therapeutic targets? Pharmacol Res 2018; 129:34-43. [PMID: 29309901 DOI: 10.1016/j.phrs.2017.12.032] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 12/29/2017] [Accepted: 12/29/2017] [Indexed: 12/31/2022]
Abstract
Tubular cells are central targets of ischemia-reperfusion (I/R) injury in kidney transplantation. Inflammation and metabolic disturbances occurring within these cells are deleterious by themselves but also favor secondary events, such as activation of immune response. It is critical to have an in depth understanding of the mechanisms governing tubular cells response to I/R if one wants to define pertinent biomarkers or to elaborate targeted therapeutic interventions. As oxidative damage was shown to be central in the patho-physiological mechanisms, the impact of I/R on proximal tubular cells metabolism has been widely studied, contrary to its effects on expression and activity of membrane transporters of the proximal tubular cells. Yet, temporal modulation of transporters over ischemia and reperfusion periods appears to play a central role, not only in the induction of cells injury but also in graft function recovery. Metabolomics in cell models or diverse biofluids has the potential to provide large pictures of biochemical consequences of I/R. Metabolomic studies conducted in experimental models of I/R or in transplanted patients indeed retrieved metabolites belonging to the pathways known to be particularly affected. Interestingly, they also revealed that metabolic disturbances and transporters activities are in very close mutual interplay. As well as helping to select diagnostic biomarkers, such analyses could also contribute to identify new pharmacological targets and to set up innovative nephroprotective strategies for the future. Even if various therapeutic approaches have been evaluated for a long time to prevent or treat I/R injuries, metabolomics has helped identifying new ones, those related to membrane transporters seeming to be of particular interest. However, considering the very complex and multifactorial effects of I/R in the context of kidney transplantation, all tracks must be followed if one wants to prevent or limit its deleterious consequences.
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Affiliation(s)
- Chantal Barin-Le Guellec
- INSERM UMR 1248, IPPRITT, Limoges, France; CHU Tours, Laboratory of Biochemistry and Molecular Biology, Tours, France; FHU SUPORT, Limoges, Poitiers, Tours, France.
| | - Bérenger Largeau
- CHU Tours, Laboratory of Biochemistry and Molecular Biology, Tours, France
| | - Delphine Bon
- FHU SUPORT, Limoges, Poitiers, Tours, France; University of Poitiers, Poitiers, France; INSERM UMR 1082, IRTOMIT, Poitiers, France; CHU Poitiers, Laboratory of Biochemistry, Poitiers, France
| | - Pierre Marquet
- INSERM UMR 1248, IPPRITT, Limoges, France; FHU SUPORT, Limoges, Poitiers, Tours, France; University of Limoges, Faculty of Medicine, Limoges, France; CHU Limoges, Department of Pharmacology, Toxicology & Pharmacovigilance, Limoges, France
| | - Thierry Hauet
- FHU SUPORT, Limoges, Poitiers, Tours, France; University of Poitiers, Poitiers, France; INSERM UMR 1082, IRTOMIT, Poitiers, France; CHU Poitiers, Laboratory of Biochemistry, Poitiers, France
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Thyroid hormone suppresses ischemia-reperfusion-induced liver NLRP3 inflammasome activation: Role of AMP-activated protein kinase. Immunol Lett 2017; 184:92-97. [DOI: 10.1016/j.imlet.2017.01.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 12/28/2016] [Accepted: 01/12/2017] [Indexed: 01/21/2023]
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