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Chen L, Zhao J, Lu L, Gong Z, Xu S, Yang X, Zhang Y, Feng X. Association between normal saline infusion volume in the emergency department and acute kidney injury in heat stroke patients: a multicenter retrospective study. Ren Fail 2024; 46:2294151. [PMID: 38178374 PMCID: PMC10773613 DOI: 10.1080/0886022x.2023.2294151] [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: 07/31/2023] [Accepted: 12/07/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND Previous studies have shown that intravenous normal saline (NS) may be associated with the incidence of acute kidney injury (AKI). This study aimed to evaluate the association between the volume of NS infusion and AKI in heat stroke (HS) patients. METHODS This multicenter retrospective cohort study included 138 patients with HS. The primary outcome was the incidence of AKI. Secondary outcomes included the need for continuous renal replacement therapy (CRRT), admission to the intensive care unit (ICU), length of stay in the ICU and hospital, and in-hospital mortality. Multivariate regression models, random forest imputation, and genetic and propensity score matching were used to explore the relationship between NS infusion and outcomes. RESULTS The mean volume of NS infusion in the emergency department (ED) was 3.02 ± 1.45 L. During hospitalization, 33 patients (23.91%) suffered from AKI. In the multivariate model, as a continuous variable (per 1 L), the volume of NS infusion was associated with the incidence of AKI (OR, 2.51; 95% CI, 1.43-4.40; p = .001), admission to the ICU (OR, 3.46; 95% CI 1.58-7.54; p = .002), and length of stay in the ICU (β, 1.00 days; 95% CI, 0.44-1.56; p < .001) and hospital (β, 1.41 days; 95% CI, 0.37-2.45; p = .008). These relationships also existed in the forest imputation cohort and matching cohort. There were no differences in the use of CRRT or in-hospital mortality. CONCLUSIONS The volume of NS infusion was associated with a significant increase in the incidence of AKI, admission to the ICU, and length of stay in the ICU and hospital among patients with HS.
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Affiliation(s)
- Lan Chen
- Nursing Department, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Junlu Zhao
- Emergency Department, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua Municipal Central Hospital, Jinhua, China
| | - Liyun Lu
- Emergency Department, Jinhua People’s Hospital, Jinhua, China
| | - Zhumei Gong
- Emergency Department, Yiwu Central Hospital, Yiwu, China
| | - Shuying Xu
- Emergency Department, Dongyang People’s Hospital, Dongyang, China
| | - Xiaoling Yang
- Emergency Department, Lanxi People’s Hospital, Lanxi, China
| | - Yuping Zhang
- Nursing Department, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Xiuqin Feng
- Nursing Department, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
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Wang L, Song Y, Zhang P, Chen W, Xiao F, Zhou P, Yang X, Dai H. Hypoxia-inducible factor prolyl hydroxylase inhibitor alleviates heatstroke-induced acute kidney injury by activating BNIP3-mediated mitophagy. FASEB J 2024; 38:e23723. [PMID: 38865198 DOI: 10.1096/fj.202400047r] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 03/28/2024] [Accepted: 04/08/2024] [Indexed: 06/14/2024]
Abstract
Hypoxia-induced inflammation and apoptosis are important pathophysiological features of heat stroke-induced acute kidney injury (HS-AKI). Hypoxia-inducible factor (HIF) is a key protein that regulates cell adaptation to hypoxia. HIF-prolyl hydroxylase inhibitor (HIF-PHI) stabilizes HIF to increase cell adaptation to hypoxia. Herein, we reported that HIF-PHI pretreatment significantly improved renal function, enhanced thermotolerance, and increased the survival rate of mice in the context of HS. Moreover, HIF-PHI could alleviate HS-induced mitochondrial damage, inflammation, and apoptosis in renal tubular epithelial cells (RTECs) by enhancing mitophagy in vitro and in vivo. By contrast, mitophagy inhibitors Mdivi-1, 3-MA, and Baf-A1 reversed the renoprotective effects of HIF-PHI. Mechanistically, HIF-PHI protects RTECs from inflammation and apoptosis by enhancing Bcl-2 adenovirus E18 19-kDa-interacting protein 3 (BNIP3)-mediated mitophagy, while genetic ablation of BNIP3 attenuated HIF-PHI-induced mitophagy and abolished HIF-PHI-mediated renal protection. Thus, our results indicated that HIF-PHI protects renal function by upregulating BNIP3-mediated mitophagy to improve HS-induced inflammation and apoptosis of RTECs, suggesting HIF-PHI as a promising therapeutic agent to treat HS-AKI.
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Affiliation(s)
- Ling Wang
- Department of Rheumatology and Clinical Immunology, Daping Hospital, Army Medical University, Chongqing, China
| | - Yongwei Song
- Department of Rheumatology and Clinical Immunology, Daping Hospital, Army Medical University, Chongqing, China
| | - Pan Zhang
- Department of Tropical Medicine, Army Medical University, Chongqing, China
- Key Laboratory of Extreme Environmental Medicine, Ministry of Education of China, Army Medical University, Chongqing, China
| | - Wenting Chen
- Department of Rheumatology and Clinical Immunology, Daping Hospital, Army Medical University, Chongqing, China
| | - Fei Xiao
- Department of Rheumatology and Clinical Immunology, Daping Hospital, Army Medical University, Chongqing, China
| | - Ping Zhou
- Department of Rheumatology and Clinical Immunology, Daping Hospital, Army Medical University, Chongqing, China
| | - Xuesen Yang
- Department of Tropical Medicine, Army Medical University, Chongqing, China
- Key Laboratory of Extreme Environmental Medicine, Ministry of Education of China, Army Medical University, Chongqing, China
| | - Huanzi Dai
- Department of Rheumatology and Clinical Immunology, Daping Hospital, Army Medical University, Chongqing, China
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Iba T, Maier CL, Levi M, Levy JH. Thromboinflammation and microcirculation damage in heatstroke. Minerva Med 2024; 115:191-202. [PMID: 38240696 DOI: 10.23736/s0026-4806.23.08919-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2024]
Abstract
Rising temperatures associated with climate change have significantly increased the risk of heatstroke. Unfortunately, the trend is anticipated to persist and increasingly threaten vulnerable populations, particularly older adults. According to Japan's environment ministry, over 1000 people died from heatstroke in 2021, and 86% of deaths occurred in those above 65. Since the precise mechanism of heatstroke is not fully understood, we examined the pathophysiology by focusing on the microcirculatory derangement. Online search of published medical literature through MEDLINE and Web of Science using the term "heatstroke," "heat-related illness," "inflammation," "thrombosis," "coagulation," "fibrinolysis," "endothelial cell," and "circulation." Articles were chosen for inclusion based on their relevance to heatstroke, inflammation, and thrombosis. Reference lists were reviewed to identify additional relevant articles. Other than preexisting conditions (genetic background, age, etc.), factors such as hydration status, acclimatization, dysregulated coagulation, and inflammation are the additional major factors that promote tissue malcirculation in heatstroke. The fundamental pathophysiologic mechanisms significantly overlap with those seen in the systemic inflammatory response to sepsis, and as a result, coagulation-predominant coagulopathy develops during heat stress. Although a bleeding tendency is not common, bleeding frequently occurs in the microcirculation, causing additional injury. Sterile inflammation is mediated by proinflammatory cytokines, chemokines, and other humoral mediators in concert with cellular factors, including monocytes, neutrophils, platelets, and endothelial cells. Excess inflammation results in inflammatory cell death, including pyroptosis and necroptosis, and the release of danger signals that further propagate systemic inflammation and coagulopathy. Consequently, thromboinflammation is the critical factor that induces microcirculatory disturbance in heatstroke.
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Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan -
| | - Cheryl L Maier
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Marcel Levi
- Department of Vascular Medicine, Amsterdam University Medical Center, Amsterdam, the Netherlands
- Department of Medicine, University College London Hospitals NHS Foundation Trust, London, UK
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care and Surgery, Duke University School of Medicine, Durham, NC, USA
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Barletta JF, Palmieri TL, Toomey SA, Harrod CG, Murthy S, Bailey H. Management of Heat-Related Illness and Injury in the ICU: A Concise Definitive Review. Crit Care Med 2024; 52:362-375. [PMID: 38240487 DOI: 10.1097/ccm.0000000000006170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Abstract
OBJECTIVES The increasing frequency of extreme heat events has led to a growing number of heat-related injuries and illnesses in ICUs. The objective of this review was to summarize and critically appraise evidence for the management of heat-related illnesses and injuries for critical care multiprofessionals. DATA SOURCES Ovid Medline, Embase, Cochrane Clinical Trials Register, Cumulative Index to Nursing and Allied Health Literature, and ClinicalTrials.gov databases were searched from inception through August 2023 for studies reporting on heat-related injury and illness in the setting of the ICU. STUDY SELECTION English-language systematic reviews, narrative reviews, meta-analyses, randomized clinical trials, and observational studies were prioritized for review. Bibliographies from retrieved articles were scanned for articles that may have been missed. DATA EXTRACTION Data regarding study methodology, patient population, management strategy, and clinical outcomes were qualitatively assessed. DATA SYNTHESIS Several risk factors and prognostic indicators for patients diagnosed with heat-related illness and injury have been identified and reported in the literature. Effective management of these patients has included various cooling methods and fluid replenishment. Drug therapy is not effective. Multiple organ dysfunction, neurologic injury, and disseminated intravascular coagulation are common complications of heat stroke and must be managed accordingly. Burn injury from contact with hot surfaces or pavement can occur, requiring careful evaluation and possible excision and grafting in severe cases. CONCLUSIONS The prevalence of heat-related illness and injury is increasing, and rapid initiation of appropriate therapies is necessary to optimize outcomes. Additional research is needed to identify effective methods and strategies to achieve rapid cooling, the role of immunomodulators and anticoagulant medications, the use of biomarkers to identify organ failure, and the role of artificial intelligence and precision medicine.
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Affiliation(s)
- Jeffrey F Barletta
- Department of Pharmacy Practice, Midwestern University College of Pharmacy, Glendale Campus, AZ
| | - Tina L Palmieri
- Burn Division, Department of Surgery, Shriners Hospitals for Children Northern California, Sacramento, CA
| | - Shari A Toomey
- Respiratory Department/Sleep Center, Carilion Clinic Children's Hospital, Roanoke, VA
| | | | - Srinivas Murthy
- Department of Pediatrics, BC Children's Hospital, Vancouver, BC, Canada
| | - Heatherlee Bailey
- Department of Emergency Medicine, Durham Veterans Affairs Medical Center, Durham, NC
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Zhong L, Shuai F, Wang C, Han L, Liu Z, Wu M. Serum procalcitonin levels are associated with rhabdomyolysis following exertional heatstroke: an over 10-year intensive care survey. World J Emerg Med 2024; 15:23-27. [PMID: 38188547 PMCID: PMC10765085 DOI: 10.5847/wjem.j.1920-8642.2024.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 11/20/2023] [Indexed: 01/09/2024] Open
Abstract
BACKGROUND Heatstroke has become a common emergency event in hospitals. Procalcitonin (PCT) is used as a biomarker of infection in the emergency department (ED), but its role in rhabdomyolysis (RM) following exertional heatstroke (EHS) remains unclear. METHODS A retrospective cohort study enrolled patients with EHS from the intensive care unit (ICU). We collected RM biomarkers, inflammation markers, critical disease scores at admission, 24 h, 48 h, and discharge, and 90-day mortality. Correlation analysis, linear regression and curve fitting were used to identify the relationship between PCT and RM. RESULTS A total of 162 patients were recruited and divided into RM (n=56) and non-RM (n=106) groups. PCT was positively correlated with myoglobin (Mb), acute hepatic injury, disseminated intravascular coagulation (DIC), Sequential Organ Failure Assessment (SOFA) score, and Acute Physiology and Chronic Health Evaluation II (APACHE II) score, with correlation coefficients of 0.214, 0.237, 0.285, 0.454, and 0.368, respectively (all P<0.05). Interestingly, the results of curve fitting revealed a nonlinear relationship between PCT and RM, and a two-piecewise linear regression model showed that PCT was related to RM with an odds ratio of 1.3 and a cut-off of <4.6 ng/mL. Survival analysis revealed that RM was associated with higher mortality compared to non-RM cases (P=0.0093). CONCLUSION High serum PCT concentrations are associated with RM after EHS in critically ill patients. Elevated PCT concentrations should be interpreted cautiously in patients with EHS in the ED.
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Affiliation(s)
- Li Zhong
- Department of Traditional Chinese Medicine, the First Affiliated Hospital, Guizhou University of Chinese Medicine, Guiyang 550001, China
- Department of Medical Critical Care Medicine, General Hospital of Southern Theatre Command of People’s Liberation Army, Guangzhou 510010, China
| | - Feifei Shuai
- Department of Infection and Critical Care Medicine, Shenzhen Second People’s Hospital & First Affiliated Hospital of Shenzhen University, Health Science Center, Shenzhen 518035, China
- Department of Nosocomial Infection Prevention and Control, Shenzhen Second People’s Hospital, Shenzhen 518035, China
| | - Conglin Wang
- Department of Medical Critical Care Medicine, General Hospital of Southern Theatre Command of People’s Liberation Army, Guangzhou 510010, China
- Key Laboratory of Hot Zone Trauma Care and Tissue Repair of People’s Liberation Army, General Hospital of Southern Theatre Command of People’s Liberation Army, Guangzhou 510010, China
| | - Lipeng Han
- Department of Traditional Chinese Medicine, the First Affiliated Hospital, Guizhou University of Chinese Medicine, Guiyang 550001, China
| | - Zhifeng Liu
- Department of Medical Critical Care Medicine, General Hospital of Southern Theatre Command of People’s Liberation Army, Guangzhou 510010, China
- Key Laboratory of Hot Zone Trauma Care and Tissue Repair of People’s Liberation Army, General Hospital of Southern Theatre Command of People’s Liberation Army, Guangzhou 510010, China
| | - Ming Wu
- Department of Infection and Critical Care Medicine, Shenzhen Second People’s Hospital & First Affiliated Hospital of Shenzhen University, Health Science Center, Shenzhen 518035, China
- Department of Nosocomial Infection Prevention and Control, Shenzhen Second People’s Hospital, Shenzhen 518035, China
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Chen L, Xu S, Yang X, Zhao J, Zhang Y, Feng X. Association between cooling temperature and outcomes of patients with heat stroke. Intern Emerg Med 2023; 18:1831-1842. [PMID: 37133728 PMCID: PMC10504196 DOI: 10.1007/s11739-023-03291-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 04/22/2023] [Indexed: 05/04/2023]
Abstract
This study explored the relationship between body temperature and adverse outcomes in patients with heat stroke to identify the optimal target body temperature within the first 24 h. This retrospective, multicentre study enrolled 143 patients admitted to the emergency department and diagnosed with heat stroke. The primary outcome was the in-hospital mortality rate, while secondary outcomes included the presence and number of damaged organs and neurological sequelae at discharge. A body temperature curve was built using a generalized additive mixed model, and the association between body temperatures and outcomes was established by logistic regression. The threshold and saturation effects were used to explore the targeted body temperature management. Cases were divided into the surviving and non-surviving groups. The cooling rate within the first 2 h was significantly higher in the survival group than the non-survival group (β: 0.47; 95% confidence interval [CI]: 0.09-0.84; P = 0.014), while the non-survival group exhibited a lower body temperature within 24 h (β: - 0.06; 95% CI: - 0.08 to - 0.03; P ≤ 0.001). Body temperature after 2 h (odds ratio [OR]: 2.27; 95% CI: 1.14-4.50; P = 0.019) and lowest temperature within 24 h (OR: 0.18; 95% CI: 0.06-0.55; P = 0.003) were significantly related to in-hospital mortality rate. When the body temperature at 0.5 h was 38.5-40.0 °C, the number of damaged organs was at its lowest. In patients with heat stroke, both hyperthermia and hypothermia were associated with adverse outcomes. Hence, an accurate body temperature management is required during the early stages of care.
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Affiliation(s)
- Lan Chen
- Nursing Department, The Second Affiliated Hospital of Zhejiang University School of Medicine, 88 Jiefang Road, Shangcheng District, Hangzhou, 310009, Zhejiang, China
| | - Shuying Xu
- Emergency Department, Dongyang People's Hospital, Dongyang, Zhejiang Province, China
| | - Xiaoling Yang
- Emergency Department, Lanxi People's Hospital, Lanxi, Zhejiang Province, China
| | - Junlu Zhao
- Emergency Department, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua Municipal Central Hospital, Jinhua, Zhejiang Province, China
| | - Yuping Zhang
- Nursing Department, The Second Affiliated Hospital of Zhejiang University School of Medicine, 88 Jiefang Road, Shangcheng District, Hangzhou, 310009, Zhejiang, China
| | - Xiuqin Feng
- Nursing Department, The Second Affiliated Hospital of Zhejiang University School of Medicine, 88 Jiefang Road, Shangcheng District, Hangzhou, 310009, Zhejiang, China.
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Goto H, Kinoshita M, Oshima N. Heatstroke-induced acute kidney injury and the innate immune system. Front Med (Lausanne) 2023; 10:1250457. [PMID: 37614951 PMCID: PMC10442538 DOI: 10.3389/fmed.2023.1250457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 07/28/2023] [Indexed: 08/25/2023] Open
Abstract
Heatstroke can cause multiple organ failure and systemic inflammatory response syndrome as the body temperature rises beyond the body's ability to regulate temperature in a hot environment. Previous studies have indicated that heatstroke-induced acute kidney injury (AKI) can lead to chronic kidney disease. Therefore, there is an urgent need to elucidate the mechanism of heatstroke-induced AKI and to establish methods for its prevention and treatment. Recent reports have revealed that innate immunity, including neutrophils, macrophages, lymphocytes, and mast cells, is deeply involved in heat-induced AKI. In this review, we will discuss the roles of each immune cell in heat-induced renal injury and their potential therapeutic use.
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Affiliation(s)
- Hiroyasu Goto
- Department of Nephrology and Endocrinology, National Defense Medical College, Tokorozawa, Japan
| | - Manabu Kinoshita
- Department of Immunology and Microbiology, National Defense Medical College, Tokorozawa, Japan
| | - Naoki Oshima
- Department of Nephrology and Endocrinology, National Defense Medical College, Tokorozawa, Japan
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8
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Luan Y, Huang E, Huang J, Yang Z, Zhou Z, Liu Y, Wang C, Wu M. Serum myoglobin modulates kidney injury via inducing ferroptosis after exertional heatstroke. J Transl Int Med 2023; 11:178-188. [PMID: 37408574 PMCID: PMC10318924 DOI: 10.2478/jtim-2023-0092] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023] Open
Abstract
Background and Objectives Myoglobin released by rhabdomyolysis (RM) is considered to be involved in pathogenesis of kidney disease caused by crush injury, but whether high level of serum myoglobin predisposes patients to acute kidney injury (AKI) and its molecular mechanisms are still unclear in exertional heatstroke (EHS). We aimed to determine the association and potential mechanism of myoglobin and AKI, and further investigate the targeted therapeutic agents for myoglobinemia. Methods Serum myoglobin concentrations in patients with EHS were measured at admission, 24 h and 48 h after admission and discharge. The risk of AKI at 48 h was the primary outcome; the secondary outcome was composite outcome events with myoglobin levels and AKI at discharge and death at 90 days. In experimental studies, we further investigated the mechanisms of human kidney proximal tubular (HK-2) cells that were exposed to human myoglobin under heat stress conditions and the effect of baicalein. Results Our measurements showed that the highest myoglobin quartile (vs. the lowest) had an adjusted odds ratio (OR) of 18.95 (95% confidence interval [CI], 6.00-59.83) for AKI and that the OR (vs. quartile 2) was 7.92 (95% CI, 1.62-38.89) for the secondary outcome. The survival rate of HK-2 cells treated with myoglobin under heat stress was significantly decreased, and the production of Fe2+ and reactive oxygen species (ROS) was markedly increased, accompanied by changes in ferroptosis proteins, including increased p53, decreased SLC7A11 and GPX4, and alterations in endoplasmic reticulum stress (ERS) marker proteins. Treatment with baicalein attenuated HK-2 cell ferroptosis induced by myoglobin under heat stress through inhibition of ERS. Conclusions High myoglobin was associated with AKI in the EHS, and its mechanisms involved ERS-associated ferroptosis. Baicalein may be a potential therapeutic drug for the treatment of AKI in patients with high myoglobin induced by rhabdomyolysis following EHS.
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Affiliation(s)
- Yingyi Luan
- Department of Infection and Critical Care Medicine, Shenzhen Second People's Hospital & First Affiliated Hospital of Shenzhen University, Health Science Center, Shenzhen518035, China
- Department of Central Laboratory, Beijing Obstetrics and Gynecology Hospital, Capital Medical University; Beijing Maternal and Child Health Care HospitalBeijing100026, China
| | - Enping Huang
- Department of Forensic Medicine, Southern Medical University, Guangzhou510515, Guangdong Province, China
| | - Jiajia Huang
- Department of Infection and Critical Care Medicine, Shenzhen Second People's Hospital & First Affiliated Hospital of Shenzhen University, Health Science Center, Shenzhen518035, China
- Shantou University Medical College, Shantou515041, Guangdong Province, China
| | - Zhenjia Yang
- Department of Infection and Critical Care Medicine, Shenzhen Second People's Hospital & First Affiliated Hospital of Shenzhen University, Health Science Center, Shenzhen518035, China
- Shantou University Medical College, Shantou515041, Guangdong Province, China
| | - Zhipeng Zhou
- Department of Infection and Critical Care Medicine, Shenzhen Second People's Hospital & First Affiliated Hospital of Shenzhen University, Health Science Center, Shenzhen518035, China
| | - Yan Liu
- Department of Infection and Critical Care Medicine, Shenzhen Second People's Hospital & First Affiliated Hospital of Shenzhen University, Health Science Center, Shenzhen518035, China
| | - Conglin Wang
- Department of critical care medicine, General Hospital of Southern Theatre Command of PLA, Guangzhou510010, Guangdong Province, China
| | - Ming Wu
- Department of Infection and Critical Care Medicine, Shenzhen Second People's Hospital & First Affiliated Hospital of Shenzhen University, Health Science Center, Shenzhen518035, China
- Shantou University Medical College, Shantou515041, Guangdong Province, China
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Li F, Deng J, He Q, Zhong Y. ZBP1 and heatstroke. Front Immunol 2023; 14:1091766. [PMID: 36845119 PMCID: PMC9950778 DOI: 10.3389/fimmu.2023.1091766] [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: 11/09/2022] [Accepted: 01/19/2023] [Indexed: 02/12/2023] Open
Abstract
Heatstroke, which is associated with circulatory failure and multiple organ dysfunction, is a heat stress-induced life-threatening condition characterized by a raised core body temperature and central nervous system dysfunction. As global warming continues to worsen, heatstroke is expected to become the leading cause of death globally. Despite the severity of this condition, the detailed mechanisms that underlie the pathogenesis of heatstroke still remain largely unknown. Z-DNA-binding protein 1 (ZBP1), also referred to as DNA-dependent activator of IFN-regulatory factors (DAI) and DLM-1, was initially identified as a tumor-associated and interferon (IFN)-inducible protein, but has recently been reported to be a Z-nucleic acid sensor that regulates cell death and inflammation; however, its biological function is not yet fully understood. In the present study, a brief review of the main regulators is presented, in which the Z-nucleic acid sensor ZBP1 was identified to be a significant factor in regulating the pathological characteristics of heatstroke through ZBP1-dependent signaling. Thus, the lethal mechanism of heatstroke is revealed, in addition to a second function of ZBP1 other than as a nucleic acid sensor.
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Affiliation(s)
- Fanglin Li
- Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, China,Department of Critical Care Medicine and Hematology, The 3rd Xiangya Hospital, Central South University, Changsha, China
| | - Jiayi Deng
- Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Qiuli He
- Department of Nephrology, The First Affiliated Hospital of Gannan Medical University, Ganzhou, China,*Correspondence: Qiuli He, ; Yanjun Zhong,
| | - Yanjun Zhong
- Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, China,*Correspondence: Qiuli He, ; Yanjun Zhong,
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10
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Sequential organ failure assessment score as a predictor of the outcomes of patients hospitalized for classical or exertional heatstroke. Sci Rep 2022; 12:16373. [PMID: 36180581 PMCID: PMC9525654 DOI: 10.1038/s41598-022-20878-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 09/20/2022] [Indexed: 11/17/2022] Open
Abstract
Heatstroke is a life-threatening event that affects people worldwide. Currently, there are no established tools to predict the outcomes of heatstroke. Although the Sequential Organ Failure Assessment (SOFA) score is a promising tool for judging the severity of critically ill patients. Therefore, in this study, we investigated whether the SOFA score could predict the outcome of patients hospitalized with severe heatstroke, including the classical and exertional types, by using data from a Japanese nationwide multicenter observational registry. We performed retrospective subanalyses of the Japanese Association for Acute Medicine heatstroke registry, 2019. Adults with a SOFA score ≥ 1 hospitalized for heatstroke were analyzed. We analyzed data for 225 patients. Univariate and multivariable analyses showed a significant difference in the SOFA score between non-survivors and survivors in classical and exertional heatstroke cases. The area under the receiver operating characteristic curve were 0.863 (classical) and 0.979 (exertional). The sensitivity and specificity of SOFA scores were 50.0% and 97.5% (classical), 66.7% and 97.5% (exertional), respectively, at a cutoff of 12.5, and 35.0% and 98.8% (classical), 33.3% and 100.0% (exertional), respectively, at a cutoff of 13.5. This study revealed that the SOFA score may predict mortality in patients with heatstroke and might be useful for assessing prognosis.
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11
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Iba T, Connors JM, Levi M, Levy JH. Heatstroke-induced coagulopathy: Biomarkers, mechanistic insights, and patient management. EClinicalMedicine 2022; 44:101276. [PMID: 35128366 PMCID: PMC8792067 DOI: 10.1016/j.eclinm.2022.101276] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 12/27/2021] [Accepted: 01/07/2022] [Indexed: 12/19/2022] Open
Abstract
Heatstroke is increasingly becoming a significant concern due to global warming. Systemic inflammation and coagulopathy are the two major factors that provoke life-threatening organ dysfunction in heatstroke. Dysregulated thermo-control induces cellular injury, damage-associated molecular patterns release, hyperinflammation, and hypercoagulation with suppressed fibrinolysis to produce heatstroke-induced coagulopathy (HSIC). HSIC can progress to disseminated intravascular coagulation and multiorgan failure if severe enough. Platelet count, D-dimer, soluble thrombomodulin, and inflammation biomarkers such as interleukin-6 and histone H3 are promising markers for HSIC. In exertional heatstroke, the measurement of myoglobin is helpful to anticipate renal dysfunction. However, the optimal cutoff for each biomarker has not been determined. Except for initial cooling and hydration, effective therapy continues to be explored, and the use of antiinflammatory and anticoagulant therapies is under investigation. Despite the rapidly increasing risk, our knowledge is limited, and further study is warranted. In this review, we examine current information and what future efforts are needed to better understand and manage HSIC.
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Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo Bunkyo-ku, Tokyo 113-8421, Japan
- Corresponding author.
| | - Jean Marie Connors
- Hematology Division Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Marcel Levi
- Department of Medicine, University College London Hospitals NHS Foundation Trust, and Cardio-metabolic Programme-NIHR UCLH/UCL BRC London, United Kingdom
| | - Jerrold H. Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, NC, United States
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Wu M, Wang C, Zhong L, Liu Z. Serum myoglobin as predictor of acute kidney injury and 90-day mortality in patients with rhabdomyolysis after exertional heatstroke: an over 10-year intensive care survey. Int J Hyperthermia 2022; 39:446-454. [PMID: 35260032 DOI: 10.1080/02656736.2022.2046183] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE Rhabdomyolysis (RM) in exertional heatstroke (EHS) often leads to multiple organ dysfunction including acute kidney injury (AKI). Studies have shown that serum creatine kinase (CK) >1000 U/L as a serological diagnostic criterion for RM does not reflect the risk of AKI or mortality. METHODS This longitudinal cohort study included all patients with EHS who were admitted to intensive care unit between January 2008 and June 2019. Serum myoglobin (sMb) was studied as the serological marker of RM and compared with CK. Outcome events were AKI and 90-day mortality. RESULTS A total of 161 patients were enrolled, of whom 52 (32.3%) had sMb ≥1000 ng/mL. Patients with sMb ≥1000 ng/mL had higher SOFA score, higher APACHE II score, lower GCS score, and higher incidence of disseminated intravascular coagulation, acute myocardial injury, acute liver injury, AKI, and 90-day mortality than patients with sMb <1000 ng/mL. Lymphocytes, neutrophils, D-Dimer were risk factors for AKI in patients with sMb ≥1000 ng/mL. Curve fitting showed a curved relationship between sMb and EHS-induced AKI but not CK. sMb ≥1000 ng/mL showed better predictive ability for AKI (area under curve: 0.786). APACHE II, SOFA, and GCS scores were risk factors for 90-day mortality in patients with sMb ≥1000 ng/mL. CONCLUSION Serum myoglobin is a better predictor of AKI and 90-day mortality than CK in patients with RM after EHS.
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Affiliation(s)
- Ming Wu
- Department of Critical Care Medicine and Hospital Infection Prevention and Control, Shenzhen Second People's Hospital and First Affiliated Hospital of Shenzhen University, Health Science Center, Shenzhen, China
- Shantou University Medical College, Shantou, China
| | - Conglin Wang
- Department of Critical Care Medicine, General Hospital of Southern Theatre Command of Peoples Liberation Army, Guangzhou, China
| | - Li Zhong
- Department of Critical Care Medicine, The First Affiliated Hospital, Guizhou University of Chinese Medicine, Guiyang, China
| | - Zhifeng Liu
- Department of Critical Care Medicine, General Hospital of Southern Theatre Command of Peoples Liberation Army, Guangzhou, China
- Key Laboratory of Hot Zone Trauma Care and Tissue Repair of Peoples Liberation Army, General Hospital of Southern Theatre Command of Peoples Liberation Army, Guangzhou, China
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Wang C, Yu B, Chen R, Su L, Wu M, Liu Z. Association of D-dimer and acute kidney injury associated with rhabdomyolysis in patients with exertional heatstroke: an over 10-year intensive care survey. Ren Fail 2021; 43:1561-1568. [PMID: 34839765 PMCID: PMC8635537 DOI: 10.1080/0886022x.2021.2008975] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Patients with rhabdomyolysis (RM) following exertional heatstroke (EHS) are often accompanied by dysfunction of coagulation and acute kidney injury (AKI). The purpose of this study was to investigate the relationship between D-dimer and AKI in patients with RM following EHS. A retrospective study was performed on patients with EHS admitted to the intensive care unit over 10-year. Data including baseline clinical information at admission, vital organ dysfunction, and 90-day mortality were collected. A total of 84 patients were finally included, of whom 41 (48.8%) had AKI. AKI patients had more severe organ injury and higher 90-day mortality (34.1 vs.0.0%, p < 0.001) than non-AKI patients. Multivariate logistic analysis showed that D-dimer (OR 1.3, 95% CI 1.1–1.7, p = 0.018) was an independent risk factor for AKI with RM following EHS. Curve fitting showed a curve relationship between D-dimer and AKI. Two-piecewise linear regression showed that D-dimer was associated with AKI in all populations (OR 1.3, 95% CI 1.2–1.5, p < 0.001) when D-dimer <10.0 mg/L, in RM group (OR 1.3, 95% CI 1.1–1.5, p < 0.001) when D-dimer >0.4 mg/L, in the non-RM group (OR 6.4, 95% CI 1.7–23.9, p = 0.005) when D-dimer <1.3 mg/L and D-dimer did not increase the incidence of AKI in the non-RM group when D-dimer >1.3 mg/L. AKI is a life-threatening complication of RM following EHS. D-dimer is associated with AKI in critically ill patients with EHS. The relationship between D-dimer and AKI depends on whether RM is present or not.
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Affiliation(s)
- Conglin Wang
- Department of Critical Care Medicine, General Hospital of Southern Theatre Command of Peoples Liberation Army, Guangzhou, China
| | - Baojun Yu
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, China.,Department of Critical Care Medicine, Bao'an People's Hospital, Shenzhen, China
| | - Ronglin Chen
- Department of Critical Care Medicine, General Hospital of Southern Theatre Command of Peoples Liberation Army, Guangzhou, China.,Department of Critical Care Medicine, Central People's Hospital of Longgang, Shenzhen, China
| | - Lei Su
- Department of Critical Care Medicine, General Hospital of Southern Theatre Command of Peoples Liberation Army, Guangzhou, China.,The First School of Clinical Medicine, Southern Medical University, Guangzhou, China.,Key Laboratory of Hot Zone Trauma Care and Tissue Repair of Peoples Liberation Army, General Hospital of Southern Theatre Command of Peoples Liberation Army, Guangzhou, China
| | - Ming Wu
- Department of Critical Care Medicine and Hospital Infection Prevention and Control, The Second People's Hospital of Shenzhen & First Affiliated Hospital of Shenzhen University, Health Science Center, Shenzhen, China
| | - Zhifeng Liu
- Department of Critical Care Medicine, General Hospital of Southern Theatre Command of Peoples Liberation Army, Guangzhou, China.,The First School of Clinical Medicine, Southern Medical University, Guangzhou, China.,Key Laboratory of Hot Zone Trauma Care and Tissue Repair of Peoples Liberation Army, General Hospital of Southern Theatre Command of Peoples Liberation Army, Guangzhou, China
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Wu M, Wang C, Liu Z, Liu Z. Sequential Organ Failure Assessment Score for Prediction of Mortality of Patients With Rhabdomyolysis Following Exertional Heatstroke: A Longitudinal Cohort Study in Southern China. Front Med (Lausanne) 2021; 8:724319. [PMID: 34708052 PMCID: PMC8542709 DOI: 10.3389/fmed.2021.724319] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 09/07/2021] [Indexed: 12/18/2022] Open
Abstract
Background: Heatstroke is a medical emergency that causes multi-organ injury and death without intervention, but limited data are available on the illness scores in predicting the outcomes of exertional heat stroke (EHS) with rhabdomyolysis (RM). The aim of our study was to investigate the Sequential Organ Failure Assessment (SOFA) score in predicting mortality of patients with RM after EHS. Methods: A retrospective cohort study was performed, which included all patients with EHS admitted into the intensive care unit (ICU) of General Hospital of Southern Theater Command of Peoples Liberation Army from January 2008 to June 2019. RM was defined as creatine kinase (CK) > 1,000 U/L. Data, including the baseline data at admission, vital organ function indicators, and 90-day mortality, were reviewed. Results: A total of 176 patients were enrolled; among them, 85 (48.3%) had RM. Patients with RM had a significantly higher SOFA score (4.0 vs. 3.0, p = 0.021), higher occurrence rates of disseminated intravascular coagulation (DIC) (53.1 vs. 18.3%, p < 0.001) and acute liver injury (ALI) (21.4 vs. 5.5%, p = 0.002) than patients with non-RM. RM was positively correlated with ALI and DIC, and the correlation coefficients were 0.236 and 0.365, respectively (both p-values <0.01). Multivariate logistics analysis showed that the SOFA score [odds ratio (OR) 1.7, 95% CI 1.1-2.6, p = 0.024] was the risk factor for 90-day mortality in patients with RM after EHS, with the area under the curve (AUC) 0.958 (95% CI 0.908-1.000, p < 0.001) and the optimal cutoff 7.5 points. Conclusions: Patients with RM after EHS have severe clinical conditions, which are often accompanied by DIC or ALI. The SOFA score could predict the prognosis of patients with RM with EHS. Early treatment strategies based on decreasing the SOFA score at admission may be pivotal to reduce the 90-day mortality of patients with EHS.
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Affiliation(s)
- Ming Wu
- Department of Critical Care Medicine and Hospital Infection Prevention and Control, Health Science Center, The Second People's Hospital of Shenzhen, First Affiliated Hospital of Shenzhen University, Shenzhen, China
- Department of Critical Care Medicine, General Hospital of Southern Theatre Command of Peoples Liberation Army, Guangzhou, China
| | - Conglin Wang
- Department of Critical Care Medicine, General Hospital of Southern Theatre Command of Peoples Liberation Army, Guangzhou, China
| | - Zheying Liu
- Department of Critical Care Medicine, General Hospital of Southern Theatre Command of Peoples Liberation Army, Guangzhou, China
| | - Zhifeng Liu
- Department of Critical Care Medicine, General Hospital of Southern Theatre Command of Peoples Liberation Army, Guangzhou, China
- Key Laboratory of Hot Zone Trauma Care and Tissue Repair of Peoples Liberation Army, General Hospital of Southern Theatre Command of Peoples Liberation Army, Guangzhou, China
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