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Yang X, Zhu L, Pan H, Yang Y. Cardiopulmonary bypass associated acute kidney injury: better understanding and better prevention. Ren Fail 2024; 46:2331062. [PMID: 38515271 PMCID: PMC10962309 DOI: 10.1080/0886022x.2024.2331062] [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: 10/17/2023] [Accepted: 03/11/2024] [Indexed: 03/23/2024] Open
Abstract
Cardiopulmonary bypass (CPB) is a common technique in cardiac surgery but is associated with acute kidney injury (AKI), which carries considerable morbidity and mortality. In this review, we explore the range and definition of CPB-associated AKI and discuss the possible impact of different disease recognition methods on research outcomes. Furthermore, we introduce the specialized equipment and procedural intricacies associated with CPB surgeries. Based on recent research, we discuss the potential pathogenesis of AKI that may result from CPB, including compromised perfusion and oxygenation, inflammatory activation, oxidative stress, coagulopathy, hemolysis, and endothelial damage. Finally, we explore current interventions aimed at preventing and attenuating renal impairment related to CPB, and presenting these measures from three perspectives: (1) avoiding CPB to eliminate the fundamental impact on renal function; (2) optimizing CPB by adjusting equipment parameters, optimizing surgical procedures, or using improved materials to mitigate kidney damage; (3) employing pharmacological or interventional measures targeting pathogenic factors.
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Affiliation(s)
- Xutao Yang
- The Fourth Affiliated Hospital of School of Medicine, and International School of Medicine, International Institutes of Medicine, Zhejiang University, Yiwu, China
| | - Li Zhu
- The Fourth Affiliated Hospital of School of Medicine, and International School of Medicine, International Institutes of Medicine, Zhejiang University, Yiwu, China
- The Jinhua Affiliated Hospital of Zhejiang University School of Medicine, Yiwu, China
| | - Hong Pan
- The Fourth Affiliated Hospital of School of Medicine, and International School of Medicine, International Institutes of Medicine, Zhejiang University, Yiwu, China
| | - Yi Yang
- The Fourth Affiliated Hospital of School of Medicine, and International School of Medicine, International Institutes of Medicine, Zhejiang University, Yiwu, China
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Engoren M, Janda A, Heung M, Sturmer D, Likosky DS, Hawkins RB, Do-Nguyen CC, Mathis M. The Association of Oxygen Delivery and Transfusion on Cardiopulmonary Bypass with Acute Kidney Injury. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00275-1. [PMID: 38890088 DOI: 10.1053/j.jvca.2024.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 03/22/2024] [Accepted: 04/14/2024] [Indexed: 06/20/2024]
Abstract
OBJECTIVES To estimate whether the association of transfusion and acute kidney injury (AKI) has a threshold of oxygen delivery below which transfusion is beneficial but above which it is harmful. DESIGN Retrospective study SETTING: Cardiovascular operating room and intensive care unit PARTICIPANTS: Patients undergoing cardiac surgery with continuous oxygen delivery monitoring during cardiopulmonary bypass INTERVENTIONS: None MEASUREMENTS AND MAIN RESULTS: Logistic regression was used to estimate the associations between oxygen delivery (mean, cumulative deficit, and bands of oxygen delivery), transfusion, and their interaction and AKI. A subgroup analysis of transfused and nontransfused patients with exact matching on cumulative oxygen deficit and time on bypass with adjustment for propensity to receive a transfusion using logistic regression. Nine hundred ninety-one of 4,203 patients developed AKI within 7 days. After adjustment for confounders, lower mean oxygen delivery (odds ratio [OR], 0.968; 95% confidence interval [CI], 0.949-0.988; p = 0.002) and transfusions (OR, 1.442; 95% CI, 1.077, 1.932; p = 0.014) were associated with increased odds of AKI by 7 days. As oxygen delivery decreased, the risk of AKI increased, with the slope of the OR steeper at <160 mL/m2/min. In the subgroup analysis, matched transfused patients were more likely than matched nontransfused patients to develop AKI (45% [n = 145] v 31% [n = 101]; p < 0.001). However, after propensity score adjustment, the difference was nonsignificant (OR, 1.181; 95% CI, 0.796-1.752; p = 0.406). CONCLUSIONS We found a nonlinear relationship between oxygen delivery and AKI. We found no level of oxygen delivery at which transfusion was associated with a decreased risk of AKI.
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Affiliation(s)
- Milo Engoren
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI.
| | - Allison Janda
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI
| | - Michael Heung
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - David Sturmer
- Department of Perfusion, University of Michigan, Ann Arbor, MI
| | - Donald S Likosky
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI
| | - Robert B Hawkins
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI
| | - Chi Chi Do-Nguyen
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI
| | - Michael Mathis
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI
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Young AM, Strobel RJ, Rotar EP, Kleiman A, McNeil JS, Teman NR, Hawkins RB, Raphael J, Mehaffey JH. Perioperative acetaminophen is associated with reduced acute kidney injury after cardiac surgery. J Thorac Cardiovasc Surg 2024; 167:1372-1380. [PMID: 36207161 DOI: 10.1016/j.jtcvs.2022.09.005] [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: 05/14/2022] [Revised: 08/19/2022] [Accepted: 09/03/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Cardiac surgery-associated acute kidney injury (AKI) is associated with increased postoperative morbidity and mortality. Evidence suggests an association between perioperative acetaminophen administration and decreased incidence of postoperative AKI in pediatric cardiac surgery patients; however, an effect in adults is unknown. METHODS All patients (n = 6192) undergoing coronary and/or valve surgery with a recorded Society of Thoracic Surgeons (STS) risk score at our institution between 2010 and 2018 were stratified by acetaminophen exposure on the day of surgery using institutional pharmacy records. AKI was determined using the Kidney Disease: Improving Global Outcomes (KDIGO) staging criteria. Logistic regression was used to analyze the association between perioperative acetaminophen and postoperative kidney injury or STS major morbidity. A sensitivity analysis using propensity score matching on the STS predicted risk of renal failure and cardiopulmonary bypass time was performed to account for time bias. RESULTS Perioperative acetaminophen exposure was associated with lower odds of stage 1 to 3 acute kidney injury (odds ratio [OR], 0.68; 95% CI, 0.56-0.83; P < .001) and decreased prolonged postoperative ventilation (OR, 0.53; 95% CI, 0.37-0.76; P < .001). A sensitivity analysis provided well-balanced (standard mean difference <0.10) groups of 401 pairs, in which acetaminophen was associated with a decreased incidence of postoperative AKI (OR, 0.7; 95% CI, 0.52-0.94; P = .016). CONCLUSIONS Exposure to acetaminophen on the day of surgery was associated with a decreased incidence of AKI in our patients undergoing cardiac surgery. These data serve as a measure of effect size to further explore the therapeutic potential of acetaminophen to reduce postoperative AKI after cardiac surgery and to elucidate the mechanisms involved.
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Affiliation(s)
- Andrew M Young
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, University of Virginia, Charlottesville, Va
| | - Raymond J Strobel
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, University of Virginia, Charlottesville, Va
| | - Evan P Rotar
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, University of Virginia, Charlottesville, Va
| | - Amanda Kleiman
- Department of Anesthesiology, University of Virginia, Charlottesville, Va
| | - John S McNeil
- Department of Anesthesiology, University of Virginia, Charlottesville, Va
| | - Nicholas R Teman
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, University of Virginia, Charlottesville, Va
| | - Robert B Hawkins
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Jacob Raphael
- Department of Anesthesiology, University of Virginia, Charlottesville, Va
| | - J Hunter Mehaffey
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WVa.
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Legrand M, Clark AT, Neyra JA, Ostermann M. Acute kidney injury in patients with burns. Nat Rev Nephrol 2024; 20:188-200. [PMID: 37758939 DOI: 10.1038/s41581-023-00769-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2023] [Indexed: 09/29/2023]
Abstract
Burn injury is associated with a high risk of acute kidney injury (AKI) with a prevalence of AKI among patients with burns of 9-50%. Despite an improvement in burn injury survival in the past decade, AKI in patients with burns is associated with an extremely poor short-term and long-term prognosis, with a mortality of >80% among those with severe AKI. Factors that contribute to the development of AKI in patients with burns include haemodynamic alterations, burn-induced systemic inflammation and apoptosis, haemolysis, rhabdomyolysis, smoke inhalation injury, drug nephrotoxicity and sepsis. Early and late AKI after burn injury differ in their aetiologies and outcomes. Sepsis is the main driver of late AKI in patients with burns and late AKI has been associated with higher mortality than early AKI. Prevention of early AKI involves correction of hypovolaemia and avoidance of nephrotoxic drugs (for example, hydroxocobalamin), whereas prevention of late AKI involves prevention and early recognition of sepsis as well as avoidance of nephrotoxins. Treatment of AKI in patients with burns remains supportive, including prevention of fluid overload, treatment of electrolyte disturbance and use of kidney replacement therapy when indicated.
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Affiliation(s)
- Matthieu Legrand
- Department of Anaesthesia and Perioperative Care, Division of Critical Care Medicine, University of California San Francisco, San Francisco, CA, USA.
| | - Audra T Clark
- Department of General Surgery, Division of Burn, Trauma, Critical Care, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Javier A Neyra
- Department of Internal Medicine, Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Marlies Ostermann
- Department of Critical Care & Nephrology, King's College London, Guy's & St Thomas' Hospital, London, UK
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Barrett LDG, Ryckman KK, Goedken AM, Steinbach EJ, van der Plas E, Beasley G, Khan RS, Exil V, Axelrod DA, Harshman LA. Subsequent kidney transplant after pediatric heart transplant: Prevalence and risk factors. Am J Transplant 2024:S1600-6135(24)00169-2. [PMID: 38431077 DOI: 10.1016/j.ajt.2024.02.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 02/22/2024] [Accepted: 02/25/2024] [Indexed: 03/05/2024]
Abstract
Pediatric heart failure and transplantation carry associated risks for kidney failure and potential need for kidney transplant following pediatric heart transplantation (KT/pHT). This retrospective, United Network of Organ Sharing study of 10,030 pediatric heart transplants (pHTs) from 1987 to 2020 aimed to determine the incidence of waitlisting for and completion of KT/pHT, risk factors for KT/pHT, and risk factors for nonreceipt of a KT/pHT. Among pHT recipients, 3.4% were waitlisted for KT/pHT (median time of 14 years after pHT). Among those waitlisted, 70% received a KT/pHT, and 18% died on the waitlist at a median time of 0.8 years from KT/pHT waitlisting (median age of 20 years). Moderate-high sensitization at KT/pHT waitlisting (calculated panel reactive antibody, ≥ 20%) was associated with a lower likelihood of KT/pHT (adjusted hazard ratio, 0.67; 95% confidence interval, 0.47-0.95). Waitlisting for heart transplantation simultaneously with kidney transplant (adjusted hazard ratio, 3.73; 95% confidence interval, 2.01-6.92) was associated with increased risk of death on the KT/pHT waitlist. While the prevalence of KT/pHT is low, there is substantial mortality among those waitlisted for KT/pHT. These findings suggest a need to consider novel risk factors for nonreceipt of KT/pHT and death on the waitlist in prioritizing criteria/guidelines for simultaneous heart-kidney transplantation.
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Affiliation(s)
- Lucas D G Barrett
- Medical Scientist Training Program, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA; Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA; University of Iowa Stead Family Children's Hospital, Iowa City, Iowa, USA
| | - Kelli K Ryckman
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA; Department of Epidemiology and Biostatistics, Indiana University School of Public Health - Bloomington, Bloomington, Indiana, USA
| | - Amber M Goedken
- University of Iowa College of Pharmacy, Iowa City, Iowa, USA
| | - Emily J Steinbach
- University of Iowa Stead Family Children's Hospital, Iowa City, Iowa, USA
| | - Ellen van der Plas
- Psychiatry Department, University of Iowa Hospitals & Clinics, Iowa City, Iowa, USA; Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA; Department of Hematology/Oncology, Arkansas Children's Hospital, Little Rock, Arkansas, USA
| | - Gary Beasley
- University of Iowa Stead Family Children's Hospital, Iowa City, Iowa, USA
| | - Rabia S Khan
- University of Iowa Stead Family Children's Hospital, Iowa City, Iowa, USA; Division of Pediatric Cardiology, Department of Pediatrics, University of California, Los Angeles Health Sciences, Los Angeles, California, USA
| | - Vernat Exil
- Division of Pediatrics, Cardiology, Saint Louis University, St. Louis, Missouri, USA
| | - David A Axelrod
- Department of Surgery, University of Iowa, Iowa City, Iowa, USA
| | - Lyndsay A Harshman
- University of Iowa Stead Family Children's Hospital, Iowa City, Iowa, USA.
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Cheruku SR, Raphael J, Neyra JA, Fox AA. Acute Kidney Injury after Cardiac Surgery: Prediction, Prevention, and Management. Anesthesiology 2023; 139:880-898. [PMID: 37812758 PMCID: PMC10841304 DOI: 10.1097/aln.0000000000004734] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Abstract
Acute kidney injury (AKI) is a common complication in cardiac surgery patients, with a reported incidence of 20 to 30%. The development of AKI is associated with worse short- and long-term mortality, and longer hospital length of stay. The pathogenesis of cardiac surgery-associated AKI is poorly understood but likely involves an interplay between preoperative comorbidities and perioperative stressors. AKI is commonly diagnosed by using increases in serum creatinine or decreased urine output and staged using a standardized definition such as the Kidney Disease Improving Global Outcomes classification. Novel biomarkers under investigation may provide earlier detection and better prediction of AKI, enabling mitigating therapies early in the perioperative period. Recent clinical trials of cardiac surgery patients have demonstrated the benefit of goal-directed oxygen delivery, avoidance of hyperthermic perfusion and specific fluid and medication strategies. This review article highlights both advances and limitations regarding the prevention, prediction, and treatment of cardiac surgery-associated AKI.
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Affiliation(s)
- Sreekanth R Cheruku
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jacob Raphael
- Department of Anesthesiology and Perioperative Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Javier A Neyra
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas; Department of Medicine, Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Amanda A Fox
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas; McDermott Center for Human Growth and Development, University of Texas Southwestern Medical Center, Dallas, Texas
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Dony CA, Illipparambil LC, Maeda T, Mroczek SK, Rovitelli A, Wexler O, Malnoske M, Bice T, Fe AZ, Storms CR, Zhang J, Schultz RD, Pietropaoli AP. Plasma Nitric Oxide Consumption Is Elevated and Associated With Adverse Outcomes in Critically Ill Patients. Crit Care Med 2023; 51:1706-1715. [PMID: 37607081 PMCID: PMC10645105 DOI: 10.1097/ccm.0000000000006006] [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: 08/24/2023]
Abstract
OBJECTIVES Impaired nitric oxide (NO) bioavailability may contribute to microvascular dysfunction in sepsis. Excessive plasma NO consumption has been attributed to scavenging by circulating cell-free hemoglobin. This may be a mechanism for NO deficiency in sepsis and critical illness. We hypothesized that plasma NO consumption is high in critically ill patients, particularly those with sepsis, acute respiratory distress syndrome (ARDS), shock, and in hospital nonsurvivors. We further hypothesized that plasma NO consumption is correlated with plasma cell-free hemoglobin concentration. DESIGN Retrospective cohort study. SETTING Adult ICUs of an academic medical center. PATIENTS AND SUBJECTS Three hundred sixty-two critically ill patients and 46 healthy control subjects. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Plasma NO consumption was measured using reductive chemiluminescence and cell-free hemoglobin was measured with a colorimetric assay. Mean (95% CI) plasma NO consumption (µM) was higher in critically ill patients versus healthy control subjects (3.9 [3.7-4.1] vs 2.1 [1.8-2.5]), septic versus nonseptic patients (4.1 [3.8-4.3] vs 3.6 [3.3-3.8]), ARDS versus non-ARDS patients (4.4 [4.0-4.9] vs 3.7 [3.6-3.9]), shock vs nonshock patients (4.4 [4.0-4.8] vs 3.6 [3.4-3.8]), and hospital nonsurvivors versus survivors (5.3 [4.4-6.4] vs 3.7 [3.6-3.9]). These relationships remained significant in multivariable analyses. Plasma cell-free hemoglobin was weakly correlated with plasma NO consumption. CONCLUSIONS Plasma NO consumption is elevated in critically ill patients and independently associated with sepsis, ARDS, shock, and hospital death. These data suggest that excessive intravascular NO scavenging characterizes sepsis and adverse outcomes of critical illness.
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Affiliation(s)
- Christina A Dony
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Rochester Medical Center, Rochester, NY
| | - Lijo C Illipparambil
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Rochester Medical Center, Rochester, NY
| | - Tetsuro Maeda
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Rochester Medical Center, Rochester, NY
| | - Susan K Mroczek
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Rochester Medical Center, Rochester, NY
| | - Amy Rovitelli
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Rochester Medical Center, Rochester, NY
| | - Orren Wexler
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Rochester Medical Center, Rochester, NY
| | | | - Tristan Bice
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Rochester Medical Center, Rochester, NY
| | - Alex Z Fe
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Rochester Medical Center, Rochester, NY
| | - Casey R Storms
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Rochester Medical Center, Rochester, NY
| | - Jimmy Zhang
- Division of Pulmonary, Critical Care, and Sleep Medicine, Mount Sinai Hospital, New York, NY
| | - Rebecca D Schultz
- Department of Respiratory Care, Division of Pulmonary and Critical Care Medicine, University of Rochester Medical Center, Rochester, NY
| | - Anthony P Pietropaoli
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Rochester Medical Center, Rochester, NY
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Abouzid M, Roshdy Y, Daniel JM, Rzk FM, Ismeal AAA, Hendawy M, Tanashat M, Elnagar M, Daoud N, Ramadan A. The beneficial use of nitric oxide during cardiopulmonary bypass on postoperative outcomes in children and adult patients: a systematic review and meta-analysis of 2897 patients. Eur J Clin Pharmacol 2023; 79:1425-1442. [PMID: 37650923 PMCID: PMC10618325 DOI: 10.1007/s00228-023-03554-9] [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: 05/16/2023] [Accepted: 08/13/2023] [Indexed: 09/01/2023]
Abstract
PURPOSE Investigate inhaled nitric oxide's influence on mortality rates, mechanical ventilation and cardiopulmonary bypass duration, and length of stay in the intensive care unit and hospital when administered during cardiopulmonary bypass. METHODS Following the PRISMA guidelines, we searched four electronic databases (PubMed, EMBASE, Cochrane Library, and Web of Science) up to 4th March 2023. The protocol was registered in the PROSPERO database with ID: CRD42023423007. Using Review Manager software, we reported outcomes as risk ratios (RRs) or mean difference (MD) and confidence intervals (CIs). RESULTS The meta-analysis included a total of 17 studies with 2897 patients. Overall, there were no significant differences in using nitric oxide over control concerning mortality (RR = 1.03, 95% CI 0.73 to 1.45; P = 0.88) or cardiopulmonary bypass duration (MD = -0.14, 95% CI - 0.96 to 0.69; P = 0.74). The intensive care unit days were significantly lower in the nitric oxide group than control (MD = -0.80, 95% CI - 1.31 to -0.29; P = 0.002). Difference results were obtained in terms of the length of stay in the hospital according to sensitivity analysis (without sensitivity [MD = -0.41, 95% CI - 0.79 to -0.02; P = 0.04] vs. with sensitivity [MD = -0.31, 95% CI - 0.69 to 0.07; P = 0.11]. Subgroup analysis shows that, in children, nitric oxide was favored over control in significantly reducing the duration of mechanical ventilation (MD = -4.58, 95% CI - 5.63 to -3.53; P < 0.001). CONCLUSION Using inhaled nitric oxide during cardiopulmonary bypass reduces the length of stay in the intensive care unit, and for children, it reduces the duration of mechanical ventilation.
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Affiliation(s)
- Mohamed Abouzid
- Department of Physical Pharmacy and Pharmacokinetics, Faculty of Pharmacy, Poznan University of Medical Sciences, Rokietnicka 3 St., 60-806, Poznan, Poland.
- Doctoral School, Poznan University of Medical Sciences, 60-812, Poznan, Poland.
| | - Yara Roshdy
- Faculty of Medicine, South Valley University, Qena, Egypt
| | | | | | | | - Mohamed Hendawy
- Faculty of Pharmacy, Alexandria University, Alexandria, Egypt
| | | | | | - Nada Daoud
- Faculty of Medicine, University of Tripoli, Tripoli, Libya
| | - Alaa Ramadan
- Faculty of Medicine, South Valley University, Qena, Egypt
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9
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Jiang Y, Song Y. Analysis of Risk Factors and Intervention Strategies for Acute Kidney Injury After Cardiac Valve Replacement. J Inflamm Res 2023; 16:3523-3529. [PMID: 37614810 PMCID: PMC10443686 DOI: 10.2147/jir.s425485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 08/11/2023] [Indexed: 08/25/2023] Open
Abstract
Objective To investigate the risk factors and intervention strategies for the development of acute kidney injury (AKI) after cardiac valve replacement with extracorporeal circulation. Methods Retrospective analysis of the clinical data of a total of 106 patients diagnosed with heart valve disease and undergoing extracorporeal circulation heart valve replacement surgery from January 2021 to December 2021 in the Department of Cardiac and Major Vascular Surgery of our hospital. The two groups were divided into AKI and non-AKI groups according to whether acute kidney injury occurred after surgery, and the preoperative, intraoperative and postoperative clinical data were compared. Single-factor analysis and multi-factor logistic regression analysis were used to explore the risk factors for acute kidney injury after extracorporeal heart valve replacement, and to improve the prognosis by giving kidney function protection strategies as early as possible. Results Univariate analysis showed that age, preoperative blood creatinine >130umol/L, LVEF <45%, presence of subacute infective endocarditis (SIE), concurrent coronary artery bypass grafting (CABG), time to extracorporeal circulation, time to surgery, MAP <70mmHg, urine output <0.5mL/(kg-h), pulmonary infection, low cardiac output, and bacteraemia were risk factors for postoperative AKI. Multi-factor regression analysis showed that preoperative blood creatinine >130umol/l, LVEF <45%, combined infective endocarditis, extracorporeal circulation time >2h, intraoperative and postoperative hypotension, low cardiac output, and postoperative bacteremia were independent risk factors for postoperative AKI. Conclusion Active intervention strategies in the perioperative period can reduce the occurrence of postoperative AKI and improve patient prognosis.
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Affiliation(s)
- Yi Jiang
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, 710000, People’s Republic of China
| | - Yanyan Song
- Department of Cardiovascular Surgery, General Hospital of Ningxia Medical University, Yinchuan, 750004, People’s Republic of China
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Pires IS, Berthiaume F, Palmer AF. Engineering Therapeutics to Detoxify Hemoglobin, Heme, and Iron. Annu Rev Biomed Eng 2023; 25:1-21. [PMID: 37289555 DOI: 10.1146/annurev-bioeng-081622-031203] [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: 06/10/2023]
Abstract
Hemolysis (i.e., red blood cell lysis) can increase circulatory levels of cell-free hemoglobin (Hb) and its degradation by-products, namely heme (h) and iron (Fe). Under homeostasis, minor increases in these three hemolytic by-products (Hb/h/Fe) are rapidly scavenged and cleared by natural plasma proteins. Under certain pathophysiological conditions, scavenging systems become overwhelmed, leading to the accumulation of Hb/h/Fe in the circulation. Unfortunately, these species cause various side effects such as vasoconstriction, hypertension, and oxidative organ damage. Therefore, various therapeutics strategies are in development, ranging from supplementation with depleted plasma scavenger proteins to engineered biomimetic protein constructs capable of scavenging multiple hemolytic species. In this review, we briefly describe hemolysis and the characteristics of the major plasma-derived protein scavengers of Hb/h/Fe. Finally, we present novel engineering approaches designed to address the toxicity of these hemolytic by-products.
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Affiliation(s)
- Ivan S Pires
- William G. Lowrie Department of Chemical and Biomolecular Engineering, The Ohio State University, Columbus, Ohio, USA;
| | - François Berthiaume
- Department of Biomedical Engineering, Rutgers University, Piscataway, New Jersey, USA
| | - Andre F Palmer
- William G. Lowrie Department of Chemical and Biomolecular Engineering, The Ohio State University, Columbus, Ohio, USA;
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11
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Seika P, Janikova M, Asokan S, Janovicova L, Csizmadia E, O’Connell M, Robson SC, Glickman J, Wegiel B. Free heme exacerbates colonic injury induced by anti-cancer therapy. Front Immunol 2023; 14:1184105. [PMID: 37342339 PMCID: PMC10277564 DOI: 10.3389/fimmu.2023.1184105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 05/22/2023] [Indexed: 06/22/2023] Open
Abstract
Gastrointestinal inflammation and bleeding are commonly induced by cancer radiotherapy and chemotherapy but mechanisms are unclear. We demonstrated an increased number of infiltrating heme oxygenase-1 positive (HO-1+) macrophages (Mø, CD68+) and the levels of hemopexin (Hx) in human colonic biopsies from patients treated with radiation or chemoradiation versus non-irradiated controls or in the ischemic intestine compared to matched normal tissues. The presence of rectal bleeding in these patients was also correlated with higher HO-1+ cell infiltration. To functionally assess the role of free heme released in the gut, we employed myeloid-specific HO-1 knockout (LysM-Cre : Hmox1flfl), hemopexin knockout (Hx-/-) and control mice. Using LysM-Cre : Hmox1flfl conditional knockout (KO) mice, we showed that a deficiency of HO-1 in myeloid cells led to high levels of DNA damage and proliferation in colonic epithelial cells in response to phenylhydrazine (PHZ)-induced hemolysis. We found higher levels of free heme in plasma, epithelial DNA damage, inflammation, and low epithelial cell proliferation in Hx-/- mice after PHZ treatment compared to wild-type mice. Colonic damage was partially attenuated by recombinant Hx administration. Deficiency in Hx or Hmox1 did not alter the response to doxorubicin. Interestingly, the lack of Hx augmented abdominal radiation-mediated hemolysis and DNA damage in the colon. Mechanistically, we found an altered growth of human colonic epithelial cells (HCoEpiC) treated with heme, corresponding to an increase in Hmox1 mRNA levels and heme:G-quadruplex complexes-regulated genes such as c-MYC, CCNF, and HDAC6. Heme-treated HCoEpiC cells exhibited growth advantage in the absence or presence of doxorubicin, in contrast to poor survival of heme-stimulated RAW247.6 Mø. In summary, our data indicate that accumulation of heme in the colon following hemolysis and/or exposure to genotoxic stress amplifies DNA damage, abnormal proliferation of epithelial cells, and inflammation as a potential etiology for gastrointestinal syndrome (GIS).
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Affiliation(s)
- Philippa Seika
- Department of Surgery, Division of Surgical Sciences, Cancer Research Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Monika Janikova
- Department of Surgery, Division of Surgical Sciences, Cancer Research Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
- Institute of Molecular Biomedicine, Faculty of Medicine, Comenius University, Bratislava, Slovakia
| | - Sahana Asokan
- Department of Surgery, Division of Surgical Sciences, Cancer Research Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
- Division of Microbiome and Cancer, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Faculty of Biosciences, Heidelberg University, Heidelberg, Germany
| | - Lubica Janovicova
- Department of Surgery, Division of Surgical Sciences, Cancer Research Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
- Institute of Molecular Biomedicine, Faculty of Medicine, Comenius University, Bratislava, Slovakia
| | - Eva Csizmadia
- Department of Surgery, Division of Surgical Sciences, Cancer Research Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Mckenzie O’Connell
- Department of Surgery, Division of Surgical Sciences, Cancer Research Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Simon C. Robson
- Department of Anesthesia, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Jonathan Glickman
- Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Barbara Wegiel
- Department of Surgery, Division of Surgical Sciences, Cancer Research Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
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12
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Bünger V, Hunsicker O, Krannich A, Balzer F, Spies CD, Kuebler WM, Weber-Carstens S, Menk M, Graw JA. Potential of cell-free hemoglobin and haptoglobin as prognostic markers in patients with ARDS and treatment with veno-venous ECMO. J Intensive Care 2023; 11:15. [PMID: 37081577 PMCID: PMC10116665 DOI: 10.1186/s40560-023-00664-5] [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: 02/06/2023] [Accepted: 04/10/2023] [Indexed: 04/22/2023] Open
Abstract
BACKGROUND Hemolysis is associated with increased mortality in patients with sepsis, ARDS, or therapy with extracorporeal membrane oxygenation (ECMO). To quantify a critical threshold of hemolysis in patients with ARDS and treatment with veno-venous ECMO, we aimed to identify cutoff values for cell-free hemoglobin (CFH) and haptoglobin (Hp) plasma concentrations associated with a significant increase in ICU mortality. METHODS Patients with ARDS admitted to a tertiary ARDS referral center between 01/2007 and 12/2018 and treatment with veno-venous ECMO were included. Cutoff values for mean CFH (mCFH) and mean Hp (mHp) plasma concentrations dividing the cohort into groups with significantly different ICU mortalities were calculated and patient characteristics were compared. A multiple logistic regression model with stepwise backward variable selection was included. In addition, cutoff values for vulnerable relative timespans for the respective CFH and Hp concentrations were calculated. RESULTS A quantitative cutoff value of 11 mg/dl for mCFH separated the cohort (n = 442) regarding ICU mortality (mCFH ≤ 11 mg/dl: 38%, [95%-CI: 32.22-43.93] (n = 277) vs. mCFH > 11 mg/dl: 70%, [61.99-76.47] (n = 165), p < 0.001). Analogously, a mHp cutoff value ≤ 0.39 g/l was associated with a significant increase in ICU mortality (mHp ≤ 0.39 g/l: 68.7%, [60.91-75.61] (n = 163) vs. mHp > 0.39 g/l: 38.7%, [33.01-44.72] (n = 279), p < 0.001). The independent association of ICU mortality with CFH and Hp cutoff values was confirmed by logistic regression adjusting for confounders (CFH Grouping: OR 3.77, [2.51-5.72], p < 0.001; Hp Grouping: OR 0.29, [0.19-0.43], p < 0.001). A significant increase in ICU mortality was observed when CFH plasma concentration exceeded the limit of 11 mg/dl on 13.3% of therapy days (≤ 13.3% of days with CFH > 11 mg/dl: 33%; [26.81-40.54] (n = 192) vs. > 13.3% of days with CFH > 11 mg/dl: 62%; [56.05-68.36] (n = 250), p < 0.001). Analogously, a mortality increase was detected when Hp plasma concentration remained ≤ 0.39 g/l for > 18.2% of therapy days (≤ 18.2% days with Hp ≤ 0.39 g/l: 27%; [19.80-35.14] (n = 138) vs. > 18.2% days with Hp ≤ 0.39 g/l: 60%; [54.43-65.70] (n = 304), p < 0.001). CONCLUSIONS Moderate hemolysis with mCFH-levels as low as 11 mg/dl impacts mortality in patients with ARDS and therapy with veno-venous ECMO. Furthermore, a cumulative dose effect should be considered indicated by the relative therapy days with CFH-concentrations > 11 mg/dl. In addition, also Hp plasma concentrations need consideration when the injurious effect of elevated CFH is evaluated.
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Affiliation(s)
- Victoria Bünger
- Department of Anesthesiology and Intensive Care Medicine CCM / CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
- ARDS/ECMO Centrum Charité, Charité - Universitätsmedizin Berlin, Berlin, Germany.
| | - Oliver Hunsicker
- Department of Anesthesiology and Intensive Care Medicine CCM / CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
- ARDS/ECMO Centrum Charité, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Alexander Krannich
- Clinical Trial Office, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Department Analytics, TCC GmbH, Hamburg, Germany
| | - Felix Balzer
- Institute of Medical Informatics, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Claudia D Spies
- Department of Anesthesiology and Intensive Care Medicine CCM / CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
- ARDS/ECMO Centrum Charité, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Wolfgang M Kuebler
- Institute of Physiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Steffen Weber-Carstens
- Department of Anesthesiology and Intensive Care Medicine CCM / CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
- ARDS/ECMO Centrum Charité, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Mario Menk
- Department of Anesthesiology and Intensive Care Medicine CCM / CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
- ARDS/ECMO Centrum Charité, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Department of Anesthesiology and Intensive Care Medicine, University Hospital "Carl Gustav Carus", Technische Universität Dresden, Dresden, Germany
| | - Jan A Graw
- Department of Anesthesiology and Intensive Care Medicine CCM / CVK, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
- ARDS/ECMO Centrum Charité, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Department of Anesthesiology and Intensive Care Medicine, Universitätsklinikum Ulm, Ulm University, Ulm, Germany
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13
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Xiong C, Jia Y, Wu X, Zhao Y, Yuan S, Yan F, Sessler DI. Early Postoperative Acetaminophen Administration and Severe Acute Kidney Injury After Cardiac Surgery. Am J Kidney Dis 2022; 81:675-683.e1. [PMID: 36586561 DOI: 10.1053/j.ajkd.2022.11.009] [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: 05/25/2022] [Accepted: 11/02/2022] [Indexed: 12/29/2022]
Abstract
RATIONALE & OBJECTIVE Oxidative stress may contribute to the development of acute kidney injury (AKI) after cardiac surgery. Acetaminophen can be considered an antioxidant because it inhibits hemoprotein-catalyzed lipid peroxidation. We hypothesized that perioperative acetaminophen administration is associated with reduced AKI after cardiac surgery. STUDY DESIGN Retrospective observational cohort study. SETTING & PARTICIPANTS Patients aged≥18 years who had cardiac surgery were identified from 2 publicly available clinical registries: the Medical Information Mart for Intensive Care III (MIMIC-III) and the eICU Collaborative Research Database (eICU). EXPOSURE Administration of acetaminophen in the first 48 hours after surgery. OUTCOME Severe AKI in the first 7 days after surgery, defined as stage 2 or stage 3 AKI according to KDIGO criteria. ANALYTICAL APPROACH Multivariable cause-specific hazards regression analysis. RESULTS We identified 5,791 patients from the MIMIC-III and 3,840 patients from the eICU registries. The overall incidence of severe AKI was 58% (3,390 patients) in the MIMIC-III cohort and 37% (1,431 patients) in the eICU cohort. Acetaminophen was administered in the early postoperative period to 4,185 patients (72%) and 2,737 patients (71%) in these 2 cohorts, respectively. In multivariable regression models, early postoperative use of acetaminophen was associated with a lower risk of severe AKI in both the MIMIC-III (adjusted hazard ratio [AHR], 0.86 [95% CI, 0.79-0.94]) and eICU (AHR, 0.84 [95% CI, 0.72-0.97]) cohorts. The benefit was consistent across sensitivity and subgroup analyses. LIMITATIONS No data on acetaminophen dose. CONCLUSIONS Early postoperative acetaminophen administration was independently associated with a lower risk of severe AKI in adults recovering from cardiac surgery. Prospective trials are warranted to assess the extent to which the observed association is causal and estimate the extent to which acetaminophen administration might prevent or reduce the severity of AKI.
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Affiliation(s)
- Chao Xiong
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Yuan Jia
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Xie Wu
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Yanyan Zhao
- Department of Medical Research & Biometrics Center, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Su Yuan
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.
| | - Fuxia Yan
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.
| | - Daniel I Sessler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
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14
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Balakhnin DG, Chermnykh II, Ivkin AA, Borisenko DV, Grigoryev EV. The Issue of Acute Kidney Injury in Patients after Cardiac Surgery. MESSENGER OF ANESTHESIOLOGY AND RESUSCITATION 2022. [DOI: 10.21292/2078-5658-2022-19-5-93-101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Cardiac surgery associated acute kidney injury (CSA-AKI) is a common complication of cardiac surgery resulting from the patient's exposure to a complex combination of factors in the perioperative period. Current diagnostic criteria for AKI may underestimate the incidence of this complication due to certain specific features of cardiac surgery patients. The introduction of new diagnostic biomarkers of kidney injury into clinical practice has shown the prospective of identifying patients in the early stages of CSA-AKI development. Accurate and timely identification of patients at high risk of developing CSA-AKI can also allow performing comprehensive interventions to prevent it. When diagnosed, CSA-AKI management limited to symptomatic treatment.
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15
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Beukers AM, de Ruijter JAC, Loer SA, Vonk A, Bulte CSE. Effects of crystalloid and colloid priming strategies for cardiopulmonary bypass on colloid oncotic pressure and haemostasis: a meta-analysis. Interact Cardiovasc Thorac Surg 2022; 35:6581082. [PMID: 35512381 PMCID: PMC9419694 DOI: 10.1093/icvts/ivac127] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 04/11/2022] [Accepted: 05/02/2022] [Indexed: 11/14/2022] Open
Affiliation(s)
- Anne Maria Beukers
- Amsterdam UMC Location Vrije Universiteit Amsterdam, Department of Anaesthesiology , Amsterdam, Netherlands
| | | | - Stephan Alexander Loer
- Amsterdam UMC Location Vrije Universiteit Amsterdam, Department of Anaesthesiology , Amsterdam, Netherlands
| | - Alexander Vonk
- Amsterdam UMC Location University of Amsterdam, Department of Cardiothoracic Surgery , Amsterdam, Netherlands
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16
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Cell-Free Hemoglobin Concentration in Blood Prime Solution Is a Major Determinant of Cell-Free Hemoglobin Exposure during Cardiopulmonary Bypass Circulation in the Newborn. J Clin Med 2022; 11:jcm11144071. [PMID: 35887835 PMCID: PMC9317140 DOI: 10.3390/jcm11144071] [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: 06/01/2022] [Revised: 07/04/2022] [Accepted: 07/06/2022] [Indexed: 11/17/2022] Open
Abstract
Exposure to circulating cell-free hemoglobin is a ubiquitous feature of open-heart surgery on cardiopulmonary bypass circulation. This study aims to determine the origins and dynamics of circulating cell-free hemoglobin and its major scavenger proteins haptoglobin and hemopexin during neonatal cardiopulmonary bypass. Forty neonates with an isolated critical congenital heart defect were included in a single-center prospective observational study. Blood samples were obtained preoperatively, hourly during bypass circulation, after bypass separation, at admission to the pediatric intensive care unit, and at postoperative days 1–3. Concentrations of cell-free hemoglobin, haptoglobin and hemopexin were determined using ELISA. Neonates were exposed to significantly elevated plasma concentrations of cell-free hemoglobin and a concomitant depletion of scavenger protein supplies during open-heart surgery. The main predictor of cell-free hemoglobin exposure was the concentration of cell-free hemoglobin in blood prime solution. Concentrations of haptoglobin and hemopexin in prime solution were important determinants for intra- and postoperative circulating scavenger protein resources.
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17
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Signori D, Magliocca A, Hayashida K, Graw JA, Malhotra R, Bellani G, Berra L, Rezoagli E. Inhaled nitric oxide: role in the pathophysiology of cardio-cerebrovascular and respiratory diseases. Intensive Care Med Exp 2022; 10:28. [PMID: 35754072 PMCID: PMC9234017 DOI: 10.1186/s40635-022-00455-6] [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: 12/27/2021] [Accepted: 06/08/2022] [Indexed: 11/23/2022] Open
Abstract
Nitric oxide (NO) is a key molecule in the biology of human life. NO is involved in the physiology of organ viability and in the pathophysiology of organ dysfunction, respectively. In this narrative review, we aimed at elucidating the mechanisms behind the role of NO in the respiratory and cardio-cerebrovascular systems, in the presence of a healthy or dysfunctional endothelium. NO is a key player in maintaining multiorgan viability with adequate organ blood perfusion. We report on its physiological endogenous production and effects in the circulation and within the lungs, as well as the pathophysiological implication of its disturbances related to NO depletion and excess. The review covers from preclinical information about endogenous NO produced by nitric oxide synthase (NOS) to the potential therapeutic role of exogenous NO (inhaled nitric oxide, iNO). Moreover, the importance of NO in several clinical conditions in critically ill patients such as hypoxemia, pulmonary hypertension, hemolysis, cerebrovascular events and ischemia-reperfusion syndrome is evaluated in preclinical and clinical settings. Accordingly, the mechanism behind the beneficial iNO treatment in hypoxemia and pulmonary hypertension is investigated. Furthermore, investigating the pathophysiology of brain injury, cardiopulmonary bypass, and red blood cell and artificial hemoglobin transfusion provides a focus on the potential role of NO as a protective molecule in multiorgan dysfunction. Finally, the preclinical toxicology of iNO and the antimicrobial role of NO-including its recent investigation on its role against the Sars-CoV2 infection during the COVID-19 pandemic-are described.
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Affiliation(s)
- Davide Signori
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Aurora Magliocca
- Department of Medical Physiopathology and Transplants, University of Milan, Milan, Italy
| | - Kei Hayashida
- Laboratory for Critical Care Physiology, Feinstein Institutes for Medical Research, Northwell Health System, Manhasset, NY, USA
- Department of Emergency Medicine, North Shore University Hospital, Northwell Health System, Manhasset, NY, USA
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Jan A Graw
- Department of Anesthesiology and Operative Intensive Care Medicine, CCM/CVK Charité, Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
- ARDS/ECMO Centrum Charité, Charité, Universitätsmedizin Berlin, Berlin, Germany
| | - Rajeev Malhotra
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Giacomo Bellani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy
| | - Lorenzo Berra
- Harvard Medical School, Boston, MA, USA
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
- Respiratory Care Department, Massachusetts General Hospital, Boston, MA, USA
| | - Emanuele Rezoagli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.
- Department of Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy.
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de Oliveira J, Denadai MB, Costa DL. Crosstalk between Heme Oxygenase-1 and Iron Metabolism in Macrophages: Implications for the Modulation of Inflammation and Immunity. Antioxidants (Basel) 2022; 11:861. [PMID: 35624725 PMCID: PMC9137896 DOI: 10.3390/antiox11050861] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 04/21/2022] [Accepted: 04/22/2022] [Indexed: 12/16/2022] Open
Abstract
Heme oxygenase-1 (HO-1) is an enzyme that catalyzes the degradation of heme, releasing equimolar amounts of carbon monoxide (CO), biliverdin (BV), and iron. The anti-inflammatory and antioxidant properties of HO-1 activity are conferred in part by the release of CO and BV and are extensively characterized. However, iron constitutes an important product of HO-1 activity involved in the regulation of several cellular biological processes. The macrophage-mediated recycling of heme molecules, in particular those contained in hemoglobin, constitutes the major mechanism through which living organisms acquire iron. This process is finely regulated by the activities of HO-1 and of the iron exporter protein ferroportin. The expression of both proteins can be induced or suppressed in response to pro- and anti-inflammatory stimuli in macrophages from different tissues, which alters the intracellular iron concentrations of these cells. As we discuss in this review article, changes in intracellular iron levels play important roles in the regulation of cellular oxidation reactions as well as in the transcriptional and translational regulation of the expression of proteins related to inflammation and immune responses, and therefore, iron metabolism represents a potential target for the development of novel therapeutic strategies focused on the modulation of immunity and inflammation.
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Affiliation(s)
- Joseana de Oliveira
- Departamento de Bioquímica e Imunologia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirao Preto 14049-900, Brazil; (J.d.O.); (M.B.D.)
- Programa de Pós-Graduação em Imunologia Básica e Aplicada, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirao Preto 14049-900, Brazil
| | - Marina B. Denadai
- Departamento de Bioquímica e Imunologia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirao Preto 14049-900, Brazil; (J.d.O.); (M.B.D.)
- Programa de Pós-Graduação em Imunologia Básica e Aplicada, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirao Preto 14049-900, Brazil
| | - Diego L. Costa
- Departamento de Bioquímica e Imunologia, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirao Preto 14049-900, Brazil; (J.d.O.); (M.B.D.)
- Programa de Pós-Graduação em Imunologia Básica e Aplicada, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirao Preto 14049-900, Brazil
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19
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Graw JA, Hildebrandt P, Krannich A, Balzer F, Spies C, Francis RC, Kuebler WM, Weber-Carstens S, Menk M, Hunsicker O. The role of cell-free hemoglobin and haptoglobin in acute kidney injury in critically ill adults with ARDS and therapy with VV ECMO. Crit Care 2022; 26:50. [PMID: 35193645 PMCID: PMC8864920 DOI: 10.1186/s13054-022-03894-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 01/11/2022] [Indexed: 12/02/2022] Open
Abstract
Background Increased plasma concentrations of circulating cell-free hemoglobin (CFH) are supposed to contribute to the multifactorial etiology of acute kidney injury (AKI) in critically ill patients while the CFH-scavenger haptoglobin might play a protective role. We evaluated the association of CFH and haptoglobin with AKI in patients with an acute respiratory distress syndrome (ARDS) requiring therapy with VV ECMO. Methods Patients with CFH and haptoglobin measurements before initiation of ECMO therapy were identified from a cohort of 1044 ARDS patients and grouped into three CFH concentration groups using a risk stratification. The primary objective was to assess the association of CFH and haptoglobin with KDIGO stage 3 AKI. Further objectives included the identification of a target haptoglobin concentration to protect from CFH-associated AKI. Measurements and main results Two hundred seventy-three patients fulfilled the inclusion criteria. Of those, 154 patients (56.4%) had AKI at ECMO initiation. The incidence of AKI increased stepwise with increasing concentrations of CFH reaching a plateau at 15 mg/dl. Compared to patients with low [< 5 mg/dl] CFH concentrations, patients with moderate [5–14 mg/dl] and high [≥ 15 mg/dl] CFH concentrations had a three- and five-fold increased risk for AKI (adjusted odds ratio [OR] moderate vs. low, 2.69 [95% CI, 1.25–5.95], P = 0.012; and OR high vs. low, 5.47 [2.00–15.9], P = 0.001). Among patients with increased CFH concentrations, haptoglobin plasma levels were lower in patients with AKI compared to patients without AKI. A haptoglobin concentration greater than 2.7 g/l in the moderate and 2.4 g/l in the high CFH group was identified as clinical cutoff value to protect from CFH-associated AKI (sensitivity 89.5% [95% CI, 83–96] and 90.2% [80–97], respectively). Conclusions In critically ill patients with ARDS requiring therapy with VV ECMO, an increased plasma concentration of CFH was identified as independent risk factor for AKI. Among patients with increased CFH concentrations, higher plasma haptoglobin concentrations might protect from CFH-associated AKI and should be subject of future research. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-03894-5.
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Gretchen C, Bayir H, Kochanek PM, Ruppert K, Viegas M, Palmer D, Kim-Campbell N. Association Between Hyperoxemia and Increased Cell-Free Plasma Hemoglobin During Cardiopulmonary Bypass in Infants and Children. Pediatr Crit Care Med 2022; 23:e111-e119. [PMID: 34560775 PMCID: PMC8816845 DOI: 10.1097/pcc.0000000000002814] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To determine potential risk factors for severe hemolysis during pediatric cardiopulmonary bypass and examine whether supraphysiologic levels of oxygen and cardiopulmonary bypass duration are associated with hemolysis. DESIGN Prospective observational study. SETTING Cardiac ICU in a university-affiliated children's hospital. PATIENTS Greater than 1 month to less than 18 years old patients undergoing cardiopulmonary bypass for cardiac surgery. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Plasma samples from 100 patients to assess cell-free plasma hemoglobin levels were obtained at start cardiopulmonary bypass, at the end of cardiopulmonary bypass, and 2 and 24 hours after reperfusion. Arterial blood gas samples were obtained before and every 30 minutes during cardiopulmonary bypass. Patient demographics and laboratory data were collected from the electronic medical record. Plasma hemoglobin levels peaked at the end of cardiopulmonary bypass and haptoglobin levels continued to fall throughout all time points. There were 44 patients with severe hemolysis (change in cell-free plasma hemoglobin > 50 mg/dL). Younger age (odds ratio/sd 0.45 [95% CI, 0.25-0.81]) and higher mean Pao2 × cardiopulmonary bypass duration (31.11 [1.46-664.64]) were identified as risk factors for severe hemolysis in multivariable analysis. Severe hemolysis was associated with longer hospital and ICU lengths of stay as well as acute kidney injury. CONCLUSIONS We observed younger age and the exposure to both oxygen and duration of cardiopulmonary bypass as risk factors for hemolysis. Oxygen delivery through the cardiopulmonary bypass circuit is an easily modifiable risk factor. Its role in the production of reactive oxygen species that could alter the erythrocyte membrane deserves further examination in larger prospective studies.
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Affiliation(s)
- Catherine Gretchen
- Department of Critical Care Medicine, University of Pittsburgh; Pittsburgh, PA
- Department of Pediatrics, Division of Critical Care Medicine, Ochsner Hospital for Children; New Orleans, LA
| | - Hϋlya Bayir
- Department of Critical Care Medicine, University of Pittsburgh; Pittsburgh, PA
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA
- Department of Environmental and Occupational Health, University of Pittsburgh, Pittsburgh, PA
- UPMC Children’s Hospital of Pittsburgh
| | - Patrick M. Kochanek
- Department of Critical Care Medicine, University of Pittsburgh; Pittsburgh, PA
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA
- UPMC Children’s Hospital of Pittsburgh
| | - Kristine Ruppert
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Melita Viegas
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA
- UPMC Children’s Hospital of Pittsburgh
| | | | - Nahmah Kim-Campbell
- Department of Critical Care Medicine, University of Pittsburgh; Pittsburgh, PA
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA
- UPMC Children’s Hospital of Pittsburgh
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21
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Graw JA, Bünger V, Materne LA, Krannich A, Balzer F, Francis RCE, Pruß A, Spies CD, Kuebler WM, Weber-Carstens S, Menk M, Hunsicker O. Age of Red Cells for Transfusion and Outcomes in Patients with ARDS. J Clin Med 2022; 11:jcm11010245. [PMID: 35011986 PMCID: PMC8745782 DOI: 10.3390/jcm11010245] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 12/23/2021] [Accepted: 12/29/2021] [Indexed: 12/12/2022] Open
Abstract
Packed red blood cells (PRBCs), stored for prolonged intervals, might contribute to adverse clinical outcomes in critically ill patients. In this study, short-term outcome after transfusion of PRBCs of two storage duration periods was analyzed in patients with Acute Respiratory Distress Syndrome (ARDS). Patients who received transfusions of PRBCs were identified from a cohort of 1044 ARDS patients. Patients were grouped according to the mean storage age of all transfused units. Patients transfused with PRBCs of a mean storage age ≤ 28 days were compared to patients transfused with PRBCs of a mean storage age > 28 days. The primary endpoint was 28-day mortality. Secondary endpoints included failure-free days composites. Two hundred and eighty-three patients were eligible for analysis. Patients in the short-term storage group had similar baseline characteristics and received a similar amount of PRBC units compared with patients in the long-term storage group (five units (IQR, 3-10) vs. four units (2-8), p = 0.14). The mean storage age in the short-term storage group was 20 (±5.4) days compared with 32 (±3.1) days in the long-term storage group (mean difference 12 days (95%-CI, 11-13)). There was no difference in 28-day mortality between the short-term storage group compared with the long-term storage group (hazard ratio, 1.36 (95%-CI, 0.84-2.21), p = 0.21). While there were no differences in ventilator-free, sedation-free, and vasopressor-free days composites, patients in the long-term storage group compared with patients in the short-term storage group had a 75% lower chance for successful weaning from renal replacement therapy (RRT) within 28 days after ARDS onset (subdistribution hazard ratio, 0.24 (95%-CI, 0.1-0.55), p < 0.001). Further analysis indicated that even a single PRBC unit stored for more than 28 days decreased the chance for successful weaning from RRT. Prolonged storage of PRBCs was not associated with a higher mortality in adults with ARDS. However, transfusion of long-term stored PRBCs was associated with prolonged dependence of RRT in critically ill patients with an ARDS.
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Affiliation(s)
- Jan A. Graw
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM/CVK), Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany; (V.B.); (L.A.M.); (R.C.E.F.); (C.D.S.); (S.W.-C.); (M.M.); (O.H.)
- ARDS/ECMO Centrum Charité, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany
- Berlin Institute of Health (BIH), Charitéplatz 1, 10117 Berlin, Germany
- Correspondence:
| | - Victoria Bünger
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM/CVK), Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany; (V.B.); (L.A.M.); (R.C.E.F.); (C.D.S.); (S.W.-C.); (M.M.); (O.H.)
| | - Lorenz A. Materne
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM/CVK), Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany; (V.B.); (L.A.M.); (R.C.E.F.); (C.D.S.); (S.W.-C.); (M.M.); (O.H.)
| | - Alexander Krannich
- Experimental and Clinical Research Center (ECRC), Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany;
| | - Felix Balzer
- Institute of Medical Informatics, Charité-Universitätsmedizin Berlin, 10115 Berlin, Germany;
| | - Roland C. E. Francis
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM/CVK), Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany; (V.B.); (L.A.M.); (R.C.E.F.); (C.D.S.); (S.W.-C.); (M.M.); (O.H.)
- ARDS/ECMO Centrum Charité, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany
| | - Axel Pruß
- Institute of Transfusion Medicine, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany;
| | - Claudia D. Spies
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM/CVK), Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany; (V.B.); (L.A.M.); (R.C.E.F.); (C.D.S.); (S.W.-C.); (M.M.); (O.H.)
- ARDS/ECMO Centrum Charité, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany
| | - Wolfgang M. Kuebler
- Institute of Physiology, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany;
| | - Steffen Weber-Carstens
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM/CVK), Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany; (V.B.); (L.A.M.); (R.C.E.F.); (C.D.S.); (S.W.-C.); (M.M.); (O.H.)
- ARDS/ECMO Centrum Charité, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany
| | - Mario Menk
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM/CVK), Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany; (V.B.); (L.A.M.); (R.C.E.F.); (C.D.S.); (S.W.-C.); (M.M.); (O.H.)
- ARDS/ECMO Centrum Charité, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany
| | - Oliver Hunsicker
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM/CVK), Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany; (V.B.); (L.A.M.); (R.C.E.F.); (C.D.S.); (S.W.-C.); (M.M.); (O.H.)
- ARDS/ECMO Centrum Charité, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany
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22
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Lewin D, Nersesian G, Roehrich L, Mueller M, Mulzer J, Stein J, Kukucka M, Starck C, Schoenrath F, Falk V, Ott S, Potapov EV. Impact of left ventricular inspection employing cardiopulmonary bypass on outcome after implantation of left ventricular assist device. Artif Organs 2021; 46:908-921. [PMID: 34904259 DOI: 10.1111/aor.14145] [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: 08/18/2021] [Revised: 10/18/2021] [Accepted: 12/06/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Cardiopulmonary bypass (CPB) during left ventricular assist device (LVAD) implantation provides circulatory support and allows for safe inspection of the left ventricle (LV), whereas circulatory support by veno-arterial extracorporeal life support (va-ECLS) or off-pump implantation may reduce postoperative bleeding and inflammatory response. METHODS Retrospective analysis of 616 consecutive adult patients who received an LVAD via median sternotomy between January 1, 2015 and December 31, 2019. All patients undergoing concomitant intracardiac procedures other than closure of persistent foramen ovale or atrial septal defect and redo surgeries were excluded from the analysis. The remaining patients (n = 222) were divided into two groups and 1:1 propensity score-matched regarding preoperative parameters: patients who underwent LVAD implantation with LV inspection employing CPB (CPB group, n = 62) and without LV inspection on va-ECLS or off-pump (non-CPB group, n = 62). RESULTS The groups were well balanced with regard to preoperative baseline characteristics (standard difference <0.1). Patients in the CPB group required more blood transfusions (median 2 vs. 0 units, p = 0.031) during surgery and in the first 24 h afterwards. The median intensive care unit stay was longer in the CPB group (18 vs. 11 days, p = 0.021). The CPB group showed an absence of perioperative stroke and a smaller number of events per patient-year for postoperative ischemic stroke (0.02 vs. 0.12, p = 0.003). 30-day survival (87% vs. 87.1%) and 1-year survival (80.3% vs. 74%) were similar in both groups (p = 0.78). CONCLUSION Visual LV inspection on CPB may reduce the risk of postoperative ischemic stroke. Despite the negative effects of employing CPB in lieu of other intraoperative strategies, survival was similar in both groups.
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Affiliation(s)
- Daniel Lewin
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Gaik Nersesian
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Luise Roehrich
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany.,German Heart Foundation, Frankfurt am Main, Germany
| | - Marcus Mueller
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Johanna Mulzer
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Julia Stein
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Marian Kukucka
- Department of Cardiac Anesthesiology and Intensive Care Medicine, Berlin, Germany
| | - Christoph Starck
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Felix Schoenrath
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany.,Department of Cardiovascular Surgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany.,Translational Cardiovascular Technologies, Department of Health Sciences and Technology, Institute of Translational Medicine, Swiss Federal Institute of Technology (ETH) Zurich, Zurich, Switzerland
| | - Sascha Ott
- Department of Cardiac Anesthesiology and Intensive Care Medicine, Berlin, Germany
| | - Evgenij V Potapov
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
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23
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Hu J, Rezoagli E, Zadek F, Bittner EA, Lei C, Berra L. Free Hemoglobin Ratio as a Novel Biomarker of Acute Kidney Injury After On-Pump Cardiac Surgery: Secondary Analysis of a Randomized Controlled Trial. Anesth Analg 2021; 132:1548-1558. [PMID: 33481401 DOI: 10.1213/ane.0000000000005381] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Cardiac surgery with cardiopulmonary bypass (CPB) is associated with a high risk of postoperative acute kidney injury (AKI). Due to limitations of current diagnostic strategies, we sought to determine whether free hemoglobin (fHb) ratio (ie, levels of fHb at the end of CPB divided by baseline fHb) could predict AKI after on-pump cardiac surgery. METHODS This is a secondary analysis of a randomized controlled trial comparing the effect of nitric oxide (intervention) versus nitrogen (control) on AKI after cardiac surgery (NCT01802619). A total of 110 adult patients in the control arm were included. First, we determined whether fHb ratio was associated with AKI via multivariable analysis. Second, we verified whether fHb ratio could predict AKI and incorporation of fHb ratio could improve predictive performance at an early stage, compared with prediction using urinary biomarkers alone. We conducted restricted cubic spline in logistic regression for model development. We determined the predictive performance, including area under the receiver-operating-characteristics curve (AUC) and calibration (calibration plot and accuracy, ie, number of correct predictions divided by total number of predictions). We also used AUC test, likelihood ratio test, and net reclassification index (NRI) to compare the predictive performance between competing models (ie, fHb ratio versus neutrophil gelatinase-associated lipocalin [NGAL], N-acetyl-β-d-glucosaminidase [NAG], and kidney injury molecule-1 [KIM-1], respectively, and incorporation of fHb ratio with NGAL, NAG, and KIM-1 versus urinary biomarkers alone), if applicable. RESULTS Data stratified by median fHb ratio showed that subjects with an fHb ratio >2.23 presented higher incidence of AKI (80.0% vs 49.1%; P = .001), more need of renal replacement therapy (10.9% vs 0%; P = .036), and higher in-hospital mortality (10.9% vs 0%; P = .036) than subjects with an fHb ratio ≤2.23. fHb ratio was associated with AKI after adjustment for preestablished factors. fHb ratio outperformed urinary biomarkers with the highest AUC of 0.704 (95% confidence interval [CI], 0.592-0.804) and accuracy of 0.714 (95% CI, 0.579-0.804). Incorporation of fHb ratio achieved better discrimination (AUC test, P = .012), calibration (likelihood ratio test, P < .001; accuracy, 0.740 [95% CI, 0.617-0.832] vs 0.632 [95% CI, 0.477-0.748]), and significant prediction increment (NRI, 0.638; 95% CI, 0.269-1.008; P < .001) at an early stage, compared with prediction using urinary biomarkers alone. CONCLUSIONS Results from this exploratory, hypothesis-generating retrospective, observational study shows that fHb ratio at the end of CPB might be used as a novel, widely applicable biomarker for AKI. The use of fHb ratio might help for an early detection of AKI, compared with prediction based only on urinary biomarkers.
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Affiliation(s)
- Jie Hu
- From the Department of Critical Care Medicine, Chinese PLA General Hospital, Beijing, China.,Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Emanuele Rezoagli
- School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Francesco Zadek
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Edward A Bittner
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Chong Lei
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Lorenzo Berra
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
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24
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Baek JH, Shin HKH, Koo SM, Gao Y, Qu H, Feng X, Xu X, Pinto J, Katneni U, Kimchi-Sarfaty C, Buehler PW. Polyethylene Oxide Molecular Size Determines the Severity of Atypical Thrombotic Microangiopathy in a Guinea Pig Model of Acute Intravenous Exposure. Toxicol Sci 2021; 177:235-247. [PMID: 32579216 DOI: 10.1093/toxsci/kfaa099] [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: 11/13/2022] Open
Abstract
In 2017, Opana ER was voluntarily removed from the U.S. market based on concerns that its risks outweighed its therapeutic benefits. The data that supported this conclusion were based on postmarketing evaluation that demonstrated increased intravenous abuse associated outbreaks of HIV, hepatitis C, and uniquely, a thrombotic thrombocytopenic purpura (TTP)-like syndrome. In 2017, the cause was mechanistically linked to intravenous exposure of the high-molecular weight polyethylene oxide (PEO), an excipient component of the drug product. However, it was unknown how differing PEO preparations might alter this response in vivo. Knowing the likelihood of a PEO driven atypical thrombotic microangiopathy with hemolytic uremic syndrome (TMA-HUS), this study was specifically designed with the primary objective focused on understanding the impact of PEO molecular weight on TMA-HUS in a guinea pig model of acute repeat PEO (1, 4, and 7 MDa) dosing. Results from this analysis suggest that repeated dosing with PEO 4 and 7 MDa, but not 1 MDa induced a marked intravascular hemolysis with schistocytes, mild anemia, thrombocytopenia, hemoglobinuria, and kidney injury, consistent with observations of a TMA-HUS-like syndrome. Nonetheless, observations of tissue microthrombi, complement or altered von Willebrand factor involvement were not observed, which would be consistent with a definitive TMA. Further, only 7 MDa PEO dosing was associated with marked renal hypoxia. Taken together, this study defines renal injury risk with PEO formulations >1 MDa that is driven by a robust intravascular hemolysis and potentially, tissue hypoxia.
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Affiliation(s)
- Jin Hyen Baek
- Laboratory of Biochemistry and Vascular Biology, Division of Blood Components and Devices, Office of Blood Research and Review; Center for Drug Evaluation and Review, FDA, Silver Spring, Maryland
| | - Hye Kyung H Shin
- Laboratory of Biochemistry and Vascular Biology, Division of Blood Components and Devices, Office of Blood Research and Review; Center for Drug Evaluation and Review, FDA, Silver Spring, Maryland
| | - Soo Min Koo
- Laboratory of Biochemistry and Vascular Biology, Division of Blood Components and Devices, Office of Blood Research and Review; Center for Drug Evaluation and Review, FDA, Silver Spring, Maryland
| | - Yamei Gao
- Division of Viral Products, Office of Vaccines, Center for Biologics Evaluation and Research (CBER), FDA, Silver Spring, Maryland
| | - Haiou Qu
- Division of Product Quality Research, Office of Testing and Research, Office of Pharmaceutical Quality; Center for Drug Evaluation and Review, FDA, Silver Spring, Maryland
| | - Xin Feng
- Division of Product Quality Research, Office of Testing and Research, Office of Pharmaceutical Quality; Center for Drug Evaluation and Review, FDA, Silver Spring, Maryland
| | - Xiaoming Xu
- Division of Product Quality Research, Office of Testing and Research, Office of Pharmaceutical Quality; Center for Drug Evaluation and Review, FDA, Silver Spring, Maryland
| | - Julia Pinto
- Division of New Drug Product II, Office of New Drug Products, Office of Pharmaceutical Quality, Center for Drug Evaluation and Research (CDER), FDA, Silver Spring Maryland
| | - Upendra Katneni
- Division of Plasma Protein Therapeutics, Office of Tissues and Advanced Therapies, Center for Biologics Evaluation and Research (CBER), FDA, Silver Spring Maryland
| | - Chava Kimchi-Sarfaty
- Division of Plasma Protein Therapeutics, Office of Tissues and Advanced Therapies, Center for Biologics Evaluation and Research (CBER), FDA, Silver Spring Maryland
| | - Paul W Buehler
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland.,The Center for Blood Oxygen Transport and Hemostasis, Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland
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25
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Meegan JE, Bastarache JA, Ware LB. Toxic effects of cell-free hemoglobin on the microvascular endothelium: implications for pulmonary and nonpulmonary organ dysfunction. Am J Physiol Lung Cell Mol Physiol 2021; 321:L429-L439. [PMID: 34009034 DOI: 10.1152/ajplung.00018.2021] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Levels of circulating cell-free hemoglobin are elevated during hemolytic and inflammatory diseases and contribute to organ dysfunction and severity of illness. Though several studies have investigated the contribution of hemoglobin to tissue injury, the precise signaling mechanisms of hemoglobin-mediated endothelial dysfunction in the lung and other organs are not yet completely understood. The purpose of this review is to highlight the knowledge gained thus far and the need for further investigation regarding hemoglobin-mediated endothelial inflammation and injury to develop novel therapeutic strategies targeting the damaging effects of cell-free hemoglobin.
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Affiliation(s)
- Jamie E Meegan
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Julie A Bastarache
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Cell and Developmental Biology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lorraine B Ware
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
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26
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Legrand M, Bokoch MP. The Yin and Yang of the Renin-Angiotensin-Aldosterone System in Acute Kidney Injury. Am J Respir Crit Care Med 2021; 203:1053-1055. [PMID: 33357099 PMCID: PMC8314897 DOI: 10.1164/rccm.202012-4419ed] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Affiliation(s)
- Matthieu Legrand
- Department of Anesthesia and Perioperative Care
- Division of Critical Care Medicine University of California San Francisco, California
- F-CRIN INI-CRCT Network Nancy, France and
| | - Michael P Bokoch
- Department of Anesthesia and Perioperative Care University of California San Francisco, California
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27
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Hokka M, Egi M, Kubota K, Mizobuchi S. Perioperative Serum Free Hemoglobin and Haptoglobin Levels in Valvular and Aortic Surgery With Cardiopulmonary Bypass: Their Associations With Postoperative Kidney Injury. J Cardiothorac Vasc Anesth 2021; 35:3207-3214. [PMID: 34052069 DOI: 10.1053/j.jvca.2021.04.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 04/16/2021] [Accepted: 04/19/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To observe the perioperative free hemoglobin and haptoglobin levels and to assess their associations with the risk of postoperative acute kidney injury (pAKI) in adult patients undergoing valvular and aortic surgery requiring cardiopulmonary bypass (CPB). DESIGN A single-center, prospective, observational study. SETTING Public teaching hospital. PARTICIPANTS The study comprised 74 adult patients without chronic renal failure who underwent cardiovascular surgery requiring CPB from 2014 to 2020. MEASUREMENTS AND MAIN RESULTS Perioperative free hemoglobin and haptoglobin levels during the study period were obtained from study participants. The primary outcome was pAKI defined by the Kidney Disease: Improving Global Outcomes criteria. Of the 74 patients in this study, pAKI occurred in 25 patients (33.8%). The free hemoglobin level began to increase after the initiation of CPB and reached a peak level at 30 minutes after weaning from CPB. It returned to the baseline level on postoperative day one. Haptoglobin levels were the highest after anesthesia induction and decreased continuously until postoperative day one. In the multivariate analysis, maximum free hemoglobin and minimum haptoglobin were associated independently with increased risk of pAKI (adjusted odds ratio 1.33 [95% confidence interval 1.12-1.58; p = 0.001] and 0.95 [95% confidence interval 0.91-1.00; p = 0.03], respectively). The free hemoglobin level began to have an independent association with pAKI at one hour after commencement of CPB, and the independent association disappeared at postoperative day one. CONCLUSIONS This study found that the perioperative increase of the free hemoglobin level and the decrease of the haptoglobin level had independent associations with the risk of pAKI.
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Affiliation(s)
- Mai Hokka
- Department of Anesthesiology, Kobe University Hospital, Kobe, Hyogo Japan
| | - Moritoki Egi
- Department of Anesthesiology, Kobe University Hospital, Kobe, Hyogo Japan.
| | - Kenta Kubota
- Department of Anesthesiology, Kobe University Hospital, Kobe, Hyogo Japan
| | - Satoshi Mizobuchi
- Department of Anesthesiology, Kobe University Hospital, Kobe, Hyogo Japan
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28
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Djordjević A, Šušak S, Velicki L, Antonič M. ACUTE KIDNEY INJURY AFTER OPEN-HEART SURGERY PROCEDURES. Acta Clin Croat 2021; 60:120-126. [PMID: 34588731 PMCID: PMC8305357 DOI: 10.20471/acc.2021.60.01.17] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 08/18/2020] [Indexed: 12/26/2022] Open
Abstract
Cardiac surgery-associated acute kidney injury (CS-AKI) is a major complication associated with increased morbidity and mortality. There are multiple diagnostic criteria for CS-AKI. Despite many new investigations available for improved AKI diagnostics, creatinine and urea remain the cornerstone of diagnostics in everyday clinical practice. There are three major pathophysiological mechanisms that contribute to kidney injury, i.e. renal hypoperfusion, inflammation with oxidative stress, and use of nephrotoxic agents. Some risk factors have been identified that can be modified during the course of treatment (use of nephrotoxic agents, duration of cardiopulmonary bypass, type of extracorporeal circulation, postoperative low cardiac output or hypotension). The aim of AKI prevention should always be to prevent aggravation of renal failure and, if possible, to avoid progression to renal replacement therapy, which in turn brings worse long-term outcomes.
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Affiliation(s)
| | - Stamenko Šušak
- 1Maribor University Medical Center, Department of Cardiac Surgery, Maribor, Slovenia; 2Institute of Cardiovascular Diseases of Vojvodina, Department of Cardiovascular Surgery, Sremska Kamenica, Serbia; 3University of Novi Sad, Faculty of Medicine, Novi Sad, Serbia; 4University of Maribor, Faculty of Medicine, Maribor, Slovenia
| | - Lazar Velicki
- 1Maribor University Medical Center, Department of Cardiac Surgery, Maribor, Slovenia; 2Institute of Cardiovascular Diseases of Vojvodina, Department of Cardiovascular Surgery, Sremska Kamenica, Serbia; 3University of Novi Sad, Faculty of Medicine, Novi Sad, Serbia; 4University of Maribor, Faculty of Medicine, Maribor, Slovenia
| | - Miha Antonič
- 1Maribor University Medical Center, Department of Cardiac Surgery, Maribor, Slovenia; 2Institute of Cardiovascular Diseases of Vojvodina, Department of Cardiovascular Surgery, Sremska Kamenica, Serbia; 3University of Novi Sad, Faculty of Medicine, Novi Sad, Serbia; 4University of Maribor, Faculty of Medicine, Maribor, Slovenia
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29
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Seilitz J, Edström M, Kasim A, Jansson K, Axelsson B, Nilsson KF. Intestinal fatty acid-binding protein and acute gastrointestinal injury grade in postoperative cardiac surgery patients. J Card Surg 2021; 36:1850-1857. [PMID: 33616277 DOI: 10.1111/jocs.15430] [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: 12/20/2020] [Revised: 01/29/2021] [Accepted: 02/04/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND AND AIM Gastrointestinal complications post cardiac surgery are infrequent but difficult to diagnose and carry a high mortality. Plasma intestinal fatty acid-binding protein (I-FABP) concentrations and the relationship between I-FABP, gastrointestinal dysfunction, and postoperative outcomes were investigated in patients who developed gastrointestinal dysfunction (acute gastrointestinal injury [AGI] grade ≥2) and those with normal gastrointestinal function. METHODS Patients with (AGI 2 group, n = 11) and without (matched controls, AGI 0 group, n = 22) early postoperative gastrointestinal dysfunction were extracted from a larger single-center prospective observational study, including adults undergoing elective cardiac surgery with extracorporeal circulation, and investigated in this nested case-control analysis. RESULTS Both groups displayed variations in I-FABP concentrations with higher I-FABP on postoperative Day 1 compared to baseline and postoperative Days 2 and 3 (p < .001 and p = .005, respectively). The AGI 2 group had higher I-FABP concentrations on Day 2 compared to the AGI 0 group (p = .024). I-FABP on Day 2 correlated positively with AGI grade over the first 3 days (p = .036, p = .021 and p = .018, respectively). High I-FABP (defined as fourth quartile concentrations) on Day 1 was associated with more prolonged surgical procedures (p < .05). Furthermore, fourth quartile I-FABP on Day 1 and early gastrointestinal dysfunction were associated with higher frequencies of postoperative organ dysfunction (p < .05) and gastrointestinal complications (p < .05), and higher 365-day mortality. CONCLUSION The present study indicates an association between intraoperative gastrointestinal injury, postoperative gastrointestinal dysfunction and gastrointestinal complications. A high-powered study is needed to further explore this relationship and the interpretation of I-FABP concentrations in individual cardiac surgery patients.
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Affiliation(s)
- Jenny Seilitz
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Måns Edström
- Department of Anesthesiology and Intensive Care, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Alhamsa Kasim
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Kjell Jansson
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Birger Axelsson
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Kristofer F Nilsson
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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Silicone Oil Decreases Biofilm Formation in a Capacitance-Based Automatic Urine Measurement System. SENSORS 2021; 21:s21020445. [PMID: 33435177 PMCID: PMC7826702 DOI: 10.3390/s21020445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 01/02/2021] [Accepted: 01/07/2021] [Indexed: 11/17/2022]
Abstract
Capacitance-based automatic urine measurement is a validated technique already implemented in clinical practice. However, albuminuria and free hemoglobinuria cause progressive biofilm buildup on the capacitance sensors of the urinometers. The aim of this experimental study is to investigate the influence of albumin and free hemoglobin on the capacitance signal of an automatic urinometer with and without the addition of silicone oil. A solution of Ringer’s acetate mixed with either albumin or free hemoglobin was run through an automatic urinometer containing either a water-soluble capsule with silicone oil or not. In total, around 500 capacitance measurements were retrieved from the albumin and free hemoglobin group, respectively. The mean increase in capacitance in the albumin 3 g/L group was 257 ± 100 pF without and 105 ± 30 pF with silicone oil, respectively, during 24 h. After ten hours of recording, differences between the two albumin groups reached statistical significance. For the free hemoglobin groups (0.01 g/L), the mean increase in capacitance was 190 ± 170 pF with silicone oil, and 324 ± 80 pF without, with a significant difference between the groups after 20 h and onwards. Coating of the capacitance measurement membrane of the automatic urinometer by albumin or free hemoglobin was significantly decreased by silicone oil, prolonging the functionality of the device.
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Chen X, Bai M, Zhao L, Yu Y, Yue Y, Sun S, Chen X. Time to peak bilirubin concentration and advanced AKI were associated with increased mortality in rheumatic heart valve replacement surgery patients with severe postoperative hyperbilirubinemia: a retrospective cohort study. BMC Cardiovasc Disord 2021; 21:16. [PMID: 33407165 PMCID: PMC7789141 DOI: 10.1186/s12872-020-01830-5] [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: 07/28/2020] [Accepted: 12/20/2020] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Hyperbilirubinemia after heart valve surgery (HVS) with cardiopulmonary bypass is frequently observed and associated with worse outcomes. We investigated the characteristics and prognosis of patients with severe hyperbilirubinemia after HVS for rheumatic heart disease (RHD) to identify the clinical outcomes and potential risk factors. METHODS Between 2015 and 2018, patients who underwent HVS in the cardiac surgery intensive care unit of our hospital were retrospectively screened. Risk factors for acute kidney injury (AKI), the requirement for continuous renal replacement therapy (CRRT), and in-hospital and long-term mortality were identified by univariate and multivariate analyses. The patient survival proportion was graphically presented with the Kaplan-Meier method. RESULTS A total of 149 patients who underwent HVS for RHD and had severe postoperative hyperbilirubinemia were included. Of the included patients, 80.5% developed postoperative AKI, and 18.1% required CRRT. The in-hospital mortality was 30.2%. Backward logistic regression analysis showed that the time to peak TB concentration (odds ratio [OR] 1.557, 95% confidence interval [CI] 1.259-1.926; P < 0.001) and advanced AKI (stage 2 and 3 AKI) (OR 19.408, 95% CI 6.553-57.482; P < 0.001) were independent predictors for in-hospital mortality. The cutoff value of the time to peak TB levels for predicting in-hospital mortality was 5 postoperative days. CONCLUSIONS Severe postoperative hyperbilirubinemia is a life-threatening complication in patients who undergo HVS for RHD. Patients whose bilirubin levels continued to increase past the 5th postoperative day and who had advanced AKI (stages 2 and 3) were associated with a higher risk of mortality.
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Affiliation(s)
- Xiaolan Chen
- The Nephrology Department of Xijing Hospital, The Fourth Military Medical University, No. 127 Changle West, Road, Xi'an, 710032, China
| | - Ming Bai
- The Nephrology Department of Xijing Hospital, The Fourth Military Medical University, No. 127 Changle West, Road, Xi'an, 710032, China.
| | - Lijuan Zhao
- The Nephrology Department of Xijing Hospital, The Fourth Military Medical University, No. 127 Changle West, Road, Xi'an, 710032, China
| | - Yan Yu
- The Nephrology Department of Xijing Hospital, The Fourth Military Medical University, No. 127 Changle West, Road, Xi'an, 710032, China
| | - Yuan Yue
- The Nephrology Department of Xijing Hospital, The Fourth Military Medical University, No. 127 Changle West, Road, Xi'an, 710032, China
| | - Shiren Sun
- The Nephrology Department of Xijing Hospital, The Fourth Military Medical University, No. 127 Changle West, Road, Xi'an, 710032, China.
| | - Xiangmei Chen
- The Nephrology Department of Xijing Hospital, The Fourth Military Medical University, No. 127 Changle West, Road, Xi'an, 710032, China. .,State Key Laboratory of Kidney Disease, Department of Nephrology, Chinese People's Liberation Army General Hospital and Military Medical Postgraduate College, 28th Fuxing Road, Beijing, 100853, China.
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Pat B, Oh JY, Masjoan Juncos JX, Powell PC, Collawn JF, Patel RP, Dell'Italia LJ. Red blood cell exosome hemoglobin content increases after cardiopulmonary bypass and mediates acute kidney injury in an animal model. J Thorac Cardiovasc Surg 2020; 164:e289-e308. [PMID: 33451850 DOI: 10.1016/j.jtcvs.2020.11.102] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 10/22/2020] [Accepted: 11/13/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Hemolysis, characterized by formation of free hemoglobin (Hb), occurs in patients undergoing cardiopulmonary bypass (CPB). However, there is no study of the dynamic changes in red blood cell (RBC)-derived exosomes (Exos) released during CPB, nor whether these particles mediate acute kidney injury (AKI). METHODS This study is a comprehensive time-course analysis, at baseline, 30 minutes, to 24 hours post-crossclamp release (XCR) to determine (1) Exos Hb content; (2) free Hb/heme, haptoglobin, hemopexin; and (3) urinary markers of AKI over the same time period. In addition, we developed a model system in Sprague-Dawley rats to test for AKI after intravenous injection of Exos Hb released during CPB. RESULTS In 30 patients undergoing CPB, there is a significant increase in plasma Hb-positive Exos but not microvesicles 30 minutes post-XCR versus other time points, with a simultaneous decrease in the haptoglobin/Hb ratio. These changes presage a significant increase in urine neutrophil gelatinase-associated lipocalin and kidney injury molecule-1 at 24 hours. Intravenous injection of plasma Exos (109-10 particles obtained 30 minutes post-XCR) into rats causes AKI at 72 hours, manifested by multifocal degeneration of proximal tubular epithelium. At 21 days, there is persistent tubular injury and interstitial fibrosis. Intravenous injection of Exos from 35-day-old stored RBCs into rats results in glomerular-tubular injury, increased kidney ferritin and hemoxygenase-1 expression, and significant elevation of kidney injury molecule-1 and proteinuria at 72 hours. CONCLUSIONS These combined studies raise the potential for RBC-derived Exos, released during CPB, to target the kidney and mediate AKI.
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Affiliation(s)
- Betty Pat
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham (UAB) Cardiovascular Institute, University of Alabama at Birmingham, Birmingham, Ala
| | - Joo-Yeun Oh
- Department of Pathology and Center for Free Radical Biology, University of Alabama at Birmingham, Birmingham, Ala
| | - Juan Xavier Masjoan Juncos
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Ala
| | - Pamela C Powell
- Department of Veterans Affairs Medical Center, Birmingham, Ala
| | - James F Collawn
- UAB Department of Cell, Developmental, and Integrative Biology, University of Alabama at Birmingham, Birmingham, Ala
| | - Rakesh P Patel
- Department of Pathology and Center for Free Radical Biology, University of Alabama at Birmingham, Birmingham, Ala
| | - Louis J Dell'Italia
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham (UAB) Cardiovascular Institute, University of Alabama at Birmingham, Birmingham, Ala; Department of Veterans Affairs Medical Center, Birmingham, Ala.
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Hong MH, Jin XJ, Yoon JJ, Lee YJ, Oh HC, Lee HS, Kim HY, Kang DG. Antihypertensive Effects of Gynura divaricata (L.) DC in Rats with Renovascular Hypertension. Nutrients 2020; 12:E3321. [PMID: 33138042 PMCID: PMC7692656 DOI: 10.3390/nu12113321] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 10/19/2020] [Accepted: 10/22/2020] [Indexed: 12/15/2022] Open
Abstract
Gynura divaricata (L.) DC (Compositae) (GD) could be found in various parts of Asia. It has been used as a traditional medicine to treat diabetes, high blood pressure, and other diseases, but its effects have not yet been scientifically confirmed. Therefore, we aimed at determining whether GD could affect renal function regulation, blood pressure, and the renin-angiotensin-aldosterone system (RAAS). Cardio-renal syndrome (CRS) is a disease caused by the interaction between the kidney and the cardiovascular system, where the acute or chronic dysfunction in one organ might induce acute or chronic dysfunction of the other. This study investigated whether GD could improve cardio-renal mutual in CRS type 4 model animals, two-kidney one-clip (2K1C) renal hypertensive rats. The experiments were performed on the following six experimental groups: control rats (CONT); 2K1C rats (negative control); OMT (Olmetec, 10 mg/kg/day)-treated 2K1C rats (positive control); and 2K1C rats treated with GD extracts in three different doses (50, 100, and 200 mg/kg/day) for three weeks by oral intake. Each group consisted of 10 rats. We measured the systolic blood pressure weekly using the tail-cuff method. Urine was also individually collected from the metabolic cage to investigate the effect of GD on the kidney function, monitoring urine volume, electrolyte, osmotic pressure, and creatinine levels from the collected urine. We observed that kidney weight and urine volume, which would both display typically increased values in non-treated 2K1C animals, significantly decreased following the GD treatment (###p < 0.001 vs. 2K1C). Osmolality and electrolytes were measured in the urine to determine how renal excretory function, which is reduced in 2K1C rats, could be affected. We found that the GD treatment improved renal excretory function. Moreover, using periodic acid-Schiff staining, we confirmed that the GD treatment significantly reduced fibrosis, which is typically increased in 2K1C rats. Thus, we confirmed that the GD treatment improved kidney function in 2K1C rats. Meanwhile, we conducted blood pressure and vascular relaxation studies to determine if the GD treatment could improve cardiovascular function in 2K1C rats. The heart weight percentages of the left atrium and ventricle were significantly lower in GD-treated 2K1C rats than in non-treated 2K1C rats. These results showed that GD treatment reduced cardiac hypertrophy in 2K1C rats. Furthermore, the acetylcholine-, sodium nitroprusside-, and atrial natriuretic peptide-mediated reduction of vasodilation in 2K1C rat aortic rings was also ameliorated by GD treatment (GD 200 mg/kg/day; p < 0.01, p < 0.05, and p < 0.05 vs. 2K1C for vasodilation percentage in case of each compound). The mRNA expression in the 2K1C rat heart tissue showed that the GD treatment reduced brain-type natriuretic peptide and troponin T levels (p < 0.001 and p < 0.001 vs. 2K1C). In conclusion, this study showed that GD improved the cardiovascular and renal dysfunction observed in an innovative hypertension model, highlighting the potential of GD as a therapeutic agent for hypertension. These findings indicate that GD shows beneficial effects against high blood pressure by modulating the RAAS in the cardio-renal syndrome. Thus, it should be considered an effective traditional medicine in hypertension treatment.
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Affiliation(s)
- Mi Hyeon Hong
- College of Oriental Medicine and Professional Graduate School of Oriental Medicine, Wonkwang University, Iksan, Jeonbuk 54538, Korea; (M.H.H.); (X.J.J.); (J.J.Y.); (Y.J.L.); (H.S.L.)
- Hanbang Cardio-renal Research Center & Professional Graduate School of Oriental Medicine, Wonkwang University, Iksan, Jeonbuk 54538, Korea
| | - Xian Jun Jin
- College of Oriental Medicine and Professional Graduate School of Oriental Medicine, Wonkwang University, Iksan, Jeonbuk 54538, Korea; (M.H.H.); (X.J.J.); (J.J.Y.); (Y.J.L.); (H.S.L.)
| | - Jung Joo Yoon
- College of Oriental Medicine and Professional Graduate School of Oriental Medicine, Wonkwang University, Iksan, Jeonbuk 54538, Korea; (M.H.H.); (X.J.J.); (J.J.Y.); (Y.J.L.); (H.S.L.)
- Hanbang Cardio-renal Research Center & Professional Graduate School of Oriental Medicine, Wonkwang University, Iksan, Jeonbuk 54538, Korea
| | - Yun Jung Lee
- College of Oriental Medicine and Professional Graduate School of Oriental Medicine, Wonkwang University, Iksan, Jeonbuk 54538, Korea; (M.H.H.); (X.J.J.); (J.J.Y.); (Y.J.L.); (H.S.L.)
- Hanbang Cardio-renal Research Center & Professional Graduate School of Oriental Medicine, Wonkwang University, Iksan, Jeonbuk 54538, Korea
| | - Hyun Cheol Oh
- College of Pharmacy, Wonkwang University, Iksan 54538, Korea;
| | - Ho Sub Lee
- College of Oriental Medicine and Professional Graduate School of Oriental Medicine, Wonkwang University, Iksan, Jeonbuk 54538, Korea; (M.H.H.); (X.J.J.); (J.J.Y.); (Y.J.L.); (H.S.L.)
- Hanbang Cardio-renal Research Center & Professional Graduate School of Oriental Medicine, Wonkwang University, Iksan, Jeonbuk 54538, Korea
| | - Hye Yoom Kim
- College of Oriental Medicine and Professional Graduate School of Oriental Medicine, Wonkwang University, Iksan, Jeonbuk 54538, Korea; (M.H.H.); (X.J.J.); (J.J.Y.); (Y.J.L.); (H.S.L.)
- Hanbang Cardio-renal Research Center & Professional Graduate School of Oriental Medicine, Wonkwang University, Iksan, Jeonbuk 54538, Korea
| | - Dae Gill Kang
- College of Oriental Medicine and Professional Graduate School of Oriental Medicine, Wonkwang University, Iksan, Jeonbuk 54538, Korea; (M.H.H.); (X.J.J.); (J.J.Y.); (Y.J.L.); (H.S.L.)
- Hanbang Cardio-renal Research Center & Professional Graduate School of Oriental Medicine, Wonkwang University, Iksan, Jeonbuk 54538, Korea
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Borawski B, Malyszko J. Iron, ferroptosis, and new insights for prevention in acute kidney injury. Adv Med Sci 2020; 65:361-370. [PMID: 32592957 DOI: 10.1016/j.advms.2020.06.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 05/06/2020] [Accepted: 06/14/2020] [Indexed: 01/01/2023]
Abstract
Acute kidney injury (AKI) is a very common condition with high morbidity and mortality, which can be seen in 5-7% of all hospitalized patients and in up to 57% of all intensive care unit admissions. Despite recent advances in clinical care, the prevalence of AKI has been shown to increase with virtually no change in mortality. AKI is a complex syndrome occurring in a variety of clinical settings. Early detection is crucial to prevent irreversible loss of renal function. The pathogenesis of AKI is highly multifactorial and complex, including vasoconstriction, reactive oxygen species formation, cell death, abnormal immune modulators and growth factors. Emerging evidence from both human and animal studies suggests that dysregulation of iron metabolism may play a potentially important role in AKI. Therefore, targeting the iron homeostasis may provide a new therapeutic intervention for AKI. New therapeutic strategies including iron chelation therapy, targeting iron metabolism related proteins and direct inhibitors of ferroptosis are imperative to improve the outcomes of patients. Taking into consideration the complexity of AKI, one intervention may not be enough for therapeutic success. Future preclinical studies in animal disease models followed by well-designed clinical trials should be conducted to extend findings from animal AKI models to humans.
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Biomarkers of Inflammation and Lung Recovery in Extracorporeal Membrane Oxygenation Patients With Persistent Pulmonary Hypertension of the Newborn: A Feasibility Study. Pediatr Crit Care Med 2020; 21:363-372. [PMID: 31725531 DOI: 10.1097/pcc.0000000000002173] [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] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Extracorporeal membrane oxygenation is a treatment for Persistent Pulmonary Hypertension of the Newborn with high mortality. HYPOTHESIS the extracorporeal membrane oxygenation circuit results in inflammatory responses that mitigate against successful weaning. DESIGN Single-center prospective observational feasibility study. SETTING PICU. PATIENTS Twenty-four neonates requiring extracorporeal membrane oxygenation support for Persistent Pulmonary Hypertension of the Newborn. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The reference outcome was death or more than 7 days of extracorporeal membrane oxygenation support. Other outcomes included serial measures of plasma-free hemoglobin and markers of its metabolism, leucocyte, platelet and endothelial activation, and biomarkers of inflammation. Of 24 participants recruited between February 2016 and June 2017, 10 died or required prolonged extracorporeal membrane oxygenation support. These patients were sicker at baseline with higher levels of plasma-free hemoglobin within 12 hours of cannulation (geometric mean ratio, 1.92; 95% CIs, 1.00-3.67; p = 0.050) but not thereafter, versus those requiring less than 7 days extracorporeal membrane oxygenation. Serum haptoglobin concentrations were significantly elevated in both groups. Patients who died or required prolonged extracorporeal membrane oxygenation support demonstrated elevated levels of platelet-leucocyte aggregation, but decreased concentrations of mediators of the inflammatory response: interleukin-8, C-reactive protein, and tumor necrosis factor α. CONCLUSIONS Clinical status at baseline and not levels of plasma-free hemoglobin or the systemic inflammatory response may determine the requirement for prolonged extracorporeal membrane oxygenation support in neonates.
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Khorashadi M, Bokoch MP, Legrand M. Is nitric oxide the forgotten nephroprotective treatment during cardiac surgery? Ann Intensive Care 2020; 10:22. [PMID: 32052208 PMCID: PMC7016086 DOI: 10.1186/s13613-020-0631-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 01/23/2020] [Indexed: 12/26/2022] Open
Affiliation(s)
- Mina Khorashadi
- Department of Anesthesiology and Peri-Operative Medicine, University of California - UCSF Medical Center, 500 Parnassus Ave, San Francisco, CA, 94143, USA
| | - Michael P Bokoch
- Department of Anesthesiology and Peri-Operative Medicine, University of California - UCSF Medical Center, 500 Parnassus Ave, San Francisco, CA, 94143, USA
| | - Matthieu Legrand
- Department of Anesthesiology and Peri-Operative Medicine, University of California - UCSF Medical Center, 500 Parnassus Ave, San Francisco, CA, 94143, USA. .,Institute National de la Santé et de la Recherche Médicale (INSERM) 942, Lariboisière Hospital & F-CRIN INI-CRCT, Paris, France.
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Natanov R, Khalikov A, Gueler F, Maus U, Boyle EC, Haverich A, Kühn C, Madrahimov N. Four hours of veno-venous extracorporeal membrane oxygenation using bi-caval cannulation affects kidney function and induces moderate lung damage in a mouse model. Intensive Care Med Exp 2019; 7:72. [PMID: 31845103 PMCID: PMC6915191 DOI: 10.1186/s40635-019-0285-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 11/27/2019] [Indexed: 12/15/2022] Open
Abstract
Background Improvement of single site cannulation for extracorporeal membrane oxygenation (ECMO) therapy is pivotal for reduction of patient morbidity and mortality in respiratory failure. To further improve the cardiopulmonary outcomes and reduce end organ damage, we established a murine model for single site cannulation with a double lumen cannula. Results We created a hemodynamically stable double lumen cannula and successfully implanted it through the jugular vein into the upper and lower vena cava. This allowed adequate drainage of the blood. Blood gas analysis showed excellent oxygenation and CO2 reduction. There was no excessive bleeding. No signs of right heart congestion were present which was confirmed in the histological analysis of the liver. Histology demonstrated moderate lung damage and mild acute kidney injury. Neutrophil infiltration was similar in ECMO and sham kidneys. Conclusions Veno-venous extracorporeal circulation deteriorates kidney function and promotes moderate pulmonary damage.
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Affiliation(s)
- Ruslan Natanov
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Abdurasul Khalikov
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Faikah Gueler
- Department of Nephrology, Hannover Medical School, Hannover, Germany
| | - Ulrich Maus
- Department of Pneumology, Hannover Medical School, Hannover, Germany
| | - Erin C Boyle
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Axel Haverich
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Christian Kühn
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Nodir Madrahimov
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany. .,Clinic of Cardiothoracic Surgery, University Clinic of Würzburg, Oberdürrbacher Strasse 6, 97080, Würzburg, Germany.
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Hu J, Spina S, Zadek F, Kamenshchikov NO, Bittner EA, Pedemonte J, Berra L. Effect of nitric oxide on postoperative acute kidney injury in patients who underwent cardiopulmonary bypass: a systematic review and meta-analysis with trial sequential analysis. Ann Intensive Care 2019; 9:129. [PMID: 31754841 PMCID: PMC6872705 DOI: 10.1186/s13613-019-0605-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 11/13/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The effect of nitric oxide (NO) on renal function is controversial in critical illness. We performed a systematic meta-analysis and trial sequential analysis to determine the effect of NO gas on renal function and other clinical outcomes in patients requiring cardiopulmonary bypass (CPB). The primary outcome was the relative risk (RR) of acute kidney injury (AKI), irrespective of the AKI stage. The secondary outcome was the mean difference (MD) in the length of ICU and hospital stay, the RR of postoperative hemorrhage, and the MD in levels of methemoglobin. Trial sequential analysis (TSA) was performed for the primary outcome. RESULTS 54 trials were assessed for eligibility and 5 studies (579 patients) were eligible for meta-analysis. NO was associated with reduced risk of AKI (RR 0.76, 95% confidential interval [CI], 0.62 to 0.93, I2 = 0%). In the subgroup analysis by NO initiation timing, NO did not decrease the risk of AKI when started at the end of CPB (RR 1.20, 95% CI 0.52-2.78, I2 = 0%). However, NO did significantly reduce the risk of AKI when started from the beginning of CPB (RR 0.71, 95% CI 0.54-0.94, I2 = 10%). We conducted TSA based on three trials (400 patients) using KDIGO criteria and with low risk of bias. TSA indicated a CI of 0.50-1.02 and an optimal information size of 589 patients, suggesting a lack of definitive conclusion. Furthermore, NO does not affect the length of ICU and hospital stay or the risk of postoperative hemorrhage. NO slightly increased the level of methemoglobin at the end of CPB (MD 0.52%, 95% CI 0.27-0.78%, I2 = 90%), but it was clinically negligible. CONCLUSIONS NO appeared to reduce the risk of postoperative AKI in patients undergoing CPB. Additional studies are required to ascertain the finding and further determine the dosage, timing and duration of NO administration.
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Affiliation(s)
- Jie Hu
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, USA
- Department of Critical Care Medicine, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, China
| | - Stefano Spina
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, USA
| | - Francesco Zadek
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, USA
| | - Nikolay O Kamenshchikov
- Department of Anesthesia and Critical Care Medicine, Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, 111a Kievskaya St., Tomsk, 634012, Russia
| | - Edward A Bittner
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, USA
| | - Juan Pedemonte
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, USA
- División de Anestesiología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Lorenzo Berra
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, USA.
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Ganushchak YM, Kurniawati ER, Maessen JG, Weerwind PW. Peripheral cannulae selection for veno-arterial extracorporeal life support: a paradox. Perfusion 2019; 35:331-337. [PMID: 31709887 PMCID: PMC7263036 DOI: 10.1177/0267659119885586] [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] [Indexed: 11/17/2022]
Abstract
Explosive penetration of veno-arterial extracorporeal life support in everyday practice has drawn awareness to complications of peripheral cannulation, resulting in recommendations to use smaller size cannulae. However, using smaller cannulae may limit the effectiveness of extracorporeal support and thereby the specific needs of the patient. Selection of proper size cannulae may therefore pose a dilemma, especially since pressure-flow characteristics at different hematocrits are lacking. This study evaluates the precision of cannula pressure drop prediction with increase of fluid viscosity from water flow-pressure charts by M-number, dynamic similarity law, and via fitted parabolic equation. Thirteen commercially available peripheral cannulae were used in this in vitro study. Pressure drop and flow were recorded using water and a water-glycerol solution as a surrogate for blood, at ambient temperature. Subsequently, pressure-flow curves were modeled with increased fluid viscosity (0.0031 N s m-2), and then compared by M-number, dynamic similarity law, and fitted parabolic equation. The agreement of predicted and measured values were significantly higher when the M-number (concordance correlation = 0.948), and the dynamic similarity law method (concordance correlation = 0.947) was used in comparison to the fitted parabolic equation (concordance correlation = 0.898, p < 0.01). The M-number and dynamic similarity based model allow for reliable prediction of peripheral cannula pressure drop with changes of fluid viscosity and could therefore aid in well-thought-out selection of cannulae for extracorporeal life support.
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Affiliation(s)
- Yuri M Ganushchak
- Department of Cardiothoracic Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Eva R Kurniawati
- Department of Cardiothoracic Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Jos G Maessen
- Department of Cardiothoracic Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Patrick W Weerwind
- Department of Cardiothoracic Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht, Maastricht University Medical Center+, Maastricht, The Netherlands
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Baek JH, Yalamanoglu A, Brown RP, Saylor DM, Malinauskas RA, Buehler PW. Renal Toxicodynamic Effects of Extracellular Hemoglobin After Acute Exposure. Toxicol Sci 2019; 166:180-191. [PMID: 30085279 DOI: 10.1093/toxsci/kfy193] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Plasma hemoglobin (Hb) is elevated in some hematologic disease states, during exposures to certain toxicants, and with the use of some medical devices. Exposure to free Hb can precipitate oxidative reactions within tissues and alter the normal physiological function of critical organ systems. As kidney structures can be highly sensitive to Hb exposures, we evaluated the acute dose dependent renal toxicologic response to purified Hb isolated from RBCs. Male Hartley guinea pigs (n = 5 per group) were dosed with 0.9% saline (2 ml), 15, 75, 150, or 300 mg of purified Hb, infused over a 2-h period. The primary endpoints of this study were to define toxicokinetic parameters after increasing doses of purified Hb, identify clinically recognized and experimental markers of acute kidney injury (AKI), and determine relevant toxicological parameters and potential causes of renal toxicity in this model. Experimental findings demonstrated a dose dependent increase in Cmax after a 2-h infusion, which correlated with an elevation in serum creatinine, renal Kim-1 mRNA expression and increased urinary Kim-1. Renal NGAL mRNA expression and urinary NGAL excretion were also increased in several groups, but these parameters did not correlate with exposure. Iron increased in the renal cortex as Hb exposure increased and its deposition colocalized with 4-hydroxy-nonenal and 8-Oxo-2-deoxyguanosine immune reactivity, suggesting oxidative stressors may contribute to AKI in animals exposed to Hb. The results presented here suggest that Cmax may effectively predict the risk of AKI in normal healthy animals exposed to Hb.
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Affiliation(s)
| | | | - Ronald P Brown
- Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, Maryland 20993
| | - David M Saylor
- Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, Maryland 20993
| | - Richard A Malinauskas
- Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, Maryland 20993
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Girgis A, Millar J, Butt W, d'Udekem Y, Namachivayam SP. Peak Creatinine, Cardiopulmonary Bypass, and Mortality After Stage 1 Single-Ventricle Reconstruction. Ann Thorac Surg 2019; 109:1488-1494. [PMID: 31614137 DOI: 10.1016/j.athoracsur.2019.09.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 08/21/2019] [Accepted: 09/06/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Serum creatinine is the most commonly used marker to diagnose acute kidney injury. Studies exploring creatinine patterns in the single-ventricle population are scarce. We studied serum creatinine up to 5 postoperative days after the stage 1 operation and assessed its relationship with outcomes. METHODS Neonates who underwent a first-stage single-ventricle operation (Norwood or a Damus-Kaye-Stansel) between 2005 and 2017 were retrospectively analyzed. Peak percentage creatinine change (PPCC) was defined as the difference between the baseline (preoperative) and the peak postoperative level (within 5 postoperative days), expressed as a percentage of the baseline level. RESULTS Among 187 neonates included, the median PPCC was 38.7% (interquartile range, 14.1%-73.1%), and in-hospital mortality was 17% (31 of 187). A controlled analysis showed that for every 10-minute increase in cardiopulmonary bypass duration (CPB), the PPCC increased by 1.8% (95% confidence interval [CI], 0.7%-2.9%; P = .002). Risk of in-hospital death increased log-linearly with PPCC. The adjusted odds ratios for death in the hospital associated with a 50%, 100%, and 200%, increase in peak percentage creatinine change were 1.85 (95% CI, 1.23-2.78), 3.41 (95% CI, 1.15-7.72), and 11.66 (95% CI, 2.28-59.63), respectively. In-hospital death was also associated with CPB duration (adjusted odds ratio, 1.13 per 10-minute increase; 95% CI, 1.05-1.22; P = .001). CONCLUSIONS Increase in CPB duration has a strong linear association with increase in PPCC after stage 1 single-ventricle reconstruction. Increase in PPCC and CPB duration has a strong linear association with hospital mortality. It is important to identify therapies that minimize complications associated with prolonged CPB duration in high-risk populations.
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Affiliation(s)
- Andrew Girgis
- Intensive Care Unit, Royal Children's Hospital, Melbourne, Victoria, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Johnny Millar
- Intensive Care Unit, Royal Children's Hospital, Melbourne, Victoria, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia; Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Warwick Butt
- Intensive Care Unit, Royal Children's Hospital, Melbourne, Victoria, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia; Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Yves d'Udekem
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia; Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Cardiac Surgery, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Siva P Namachivayam
- Intensive Care Unit, Royal Children's Hospital, Melbourne, Victoria, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia; Murdoch Children's Research Institute, Melbourne, Victoria, Australia.
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Zadek F, Spina S, Hu J, Berra L. Nitric Oxide Treatment for Lungs and Beyond. Novel Insights from Recent Literature. Am J Respir Crit Care Med 2019; 200:628-630. [PMID: 31185176 DOI: 10.1164/rccm.201901-0037rr] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Francesco Zadek
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Stefano Spina
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Jie Hu
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Lorenzo Berra
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
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Spina S, Lei C, Pinciroli R, Berra L. Hemolysis and Kidney Injury in Cardiac Surgery: The Protective Role of Nitric Oxide Therapy. Semin Nephrol 2019; 39:484-495. [DOI: 10.1016/j.semnephrol.2019.06.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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45
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Van Avondt K, Nur E, Zeerleder S. Mechanisms of haemolysis-induced kidney injury. Nat Rev Nephrol 2019; 15:671-692. [PMID: 31455889 DOI: 10.1038/s41581-019-0181-0] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2019] [Indexed: 12/16/2022]
Abstract
Intravascular haemolysis is a fundamental feature of chronic hereditary and acquired haemolytic anaemias, including those associated with haemoglobinopathies, complement disorders and infectious diseases such as malaria. Destabilization of red blood cells (RBCs) within the vasculature results in systemic inflammation, vasomotor dysfunction, thrombophilia and proliferative vasculopathy. The haemoprotein scavengers haptoglobin and haemopexin act to limit circulating levels of free haemoglobin, haem and iron - potentially toxic species that are released from injured RBCs. However, these adaptive defence systems can fail owing to ongoing intravascular disintegration of RBCs. Induction of the haem-degrading enzyme haem oxygenase 1 (HO1) - and potentially HO2 - represents a response to, and endogenous defence against, large amounts of cellular haem; however, this system can also become saturated. A frequent adverse consequence of massive and/or chronic haemolysis is kidney injury, which contributes to the morbidity and mortality of chronic haemolytic diseases. Intravascular destruction of RBCs and the resulting accumulation of haemoproteins can induce kidney injury via a number of mechanisms, including oxidative stress and cytotoxicity pathways, through the formation of intratubular casts and through direct as well as indirect proinflammatory effects, the latter via the activation of neutrophils and monocytes. Understanding of the detailed pathophysiology of haemolysis-induced kidney injury offers opportunities for the design and implementation of new therapeutic strategies to counteract the unfavourable and potentially fatal effects of haemolysis on the kidney.
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Affiliation(s)
- Kristof Van Avondt
- Department of Immunopathology, Sanquin Research, and Landsteiner Laboratory, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands. .,Institute for Cardiovascular Prevention (IPEK), Ludwig Maximilian University of Munich, Munich, Germany.
| | - Erfan Nur
- Department of Haematology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Sacha Zeerleder
- Department of Immunopathology, Sanquin Research, and Landsteiner Laboratory, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands. .,Department of Haematology and Central Haematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland. .,Department for BioMedical Research, University of Bern, Bern, Switzerland.
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Marrazzo F, Spina S, Zadek F, Lama T, Xu C, Larson G, Rezoagli E, Malhotra R, Zheng H, Bittner EA, Shelton K, Melnitchouk S, Roy N, Sundt TM, Riley WD, Williams P, Fisher D, Kacmarek RM, Thompson TB, Bonventre J, Zapol W, Ichinose F, Berra L. Protocol of a randomised controlled trial in cardiac surgical patients with endothelial dysfunction aimed to prevent postoperative acute kidney injury by administering nitric oxide gas. BMJ Open 2019; 9:e026848. [PMID: 31278097 PMCID: PMC6615910 DOI: 10.1136/bmjopen-2018-026848] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Revised: 06/02/2019] [Accepted: 06/06/2019] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION Postoperative acute kidney injury (AKI) is a common complication in cardiac surgery. Levels of intravascular haemolysis are strongly associated with postoperative AKI and with prolonged (>90 min) use of cardiopulmonary bypass (CPB). Ferrous plasma haemoglobin released into the circulation acts as a scavenger of nitric oxide (NO) produced by endothelial cells. Consequently, the vascular bioavailability of NO is reduced, leading to vasoconstriction and impaired renal function. In patients with cardiovascular risk factors, the endothelium is dysfunctional and cannot replenish the NO deficit. A previous clinical study in young cardiac surgical patients with rheumatic fever, without evidence of endothelial dysfunction, showed that supplementation of NO gas decreases AKI by converting ferrous plasma haemoglobin to ferric methaemoglobin, thus preserving vascular NO. In this current trial, we hypothesised that 24 hours administration of NO gas will reduce AKI following CPB in patients with endothelial dysfunction. METHODS This is a single-centre, randomised (1:1) controlled, parallel-arm superiority trial that includes patients with endothelial dysfunction, stable kidney function and who are undergoing cardiac surgery procedures with an expected CPB duration >90 min. After randomisation, 80 parts per million (ppm) NO (intervention group) or 80 ppm nitrogen (N2, control group) are added to the gas mixture. Test gases (N2 or NO) are delivered during CPB and for 24 hours after surgery. The primary study outcome is the occurrence of AKI among study groups. Key secondary outcomes include AKI severity, occurrence of renal replacement therapy, major adverse kidney events at 6 weeks after surgery and mortality. We are recruiting 250 patients, allowing detection of a 35% AKI relative risk reduction, assuming a two-sided error of 0.05. ETHICS AND DISSEMINATION The Partners Human Research Committee approved this trial. Recruitment began in February 2017. Dissemination plans include presentations at scientific conferences, scientific publications and advertising flyers and posters at Massachusetts General Hospital. TRIAL REGISTRATION NUMBER NCT02836899.
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Affiliation(s)
- Francesco Marrazzo
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Stefano Spina
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Francesco Zadek
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Tenzing Lama
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Changhan Xu
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Grant Larson
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Emanuele Rezoagli
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Rajeev Malhotra
- Department of Medicine, Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Hui Zheng
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Edward A Bittner
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kenneth Shelton
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Serguei Melnitchouk
- Department of Cardiac surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nathalie Roy
- Department of Cardiac surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Thoralf M Sundt
- Department of Cardiac surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - William D Riley
- Department of Surgery, Cardiac Surgery, Perfusion Services, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Purris Williams
- Respiratory Care Services, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Daniel Fisher
- Respiratory Care Services, Boston Medical Center, Boston, Massachusetts, USA
| | - Robert M Kacmarek
- Department of Respiratory Care, Massachusetts General Hospital, Boston, USA
- Department of Anesthesiology, Harvard University, Boston, USA
| | - Taylor B Thompson
- Department of Medicine, Pulmonary and Critical Care Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Joseph Bonventre
- Department of Medicine, Division of Renal Medicine, Brigham and Women’s Hospital Department of Medicine, Boston, Massachusetts, USA
| | - Warren Zapol
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Fumito Ichinose
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lorenzo Berra
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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Oda T, Yamaguchi A, Ishida R, Nikai T, Shimizu K, Matsumoto KI. Plasma proteomic changes during therapeutic hypothermia in resuscitated patients after cardiac arrest. Exp Ther Med 2019; 18:1069-1080. [PMID: 31316602 PMCID: PMC6601400 DOI: 10.3892/etm.2019.7649] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 05/02/2019] [Indexed: 12/29/2022] Open
Abstract
Hypothermia is used for several h during cardiac and aortic surgery to protect ischemic organs. Therapeutic hypothermia (TH) is used for ≤24 h as a treatment for comatose patients after the return of spontaneous circulation (ROSC) following cardiac arrest. The proteomic approach may provide unbiased data on alterations in the abundance of proteins during TH. The objective of this study was to assess the effects of cooling/rewarming on the plasma proteome during TH after ROSC and to identify the mechanism underlying its therapeutic effects. A total of nine comatose adult patients, resuscitated shortly after cardiac arrest, were cooled to 34°C for 24 h and slowly rewarmed to 36°C. A quantitative gel-free proteomic analysis was performed using the isobaric tag for relative and absolute quantification labeling tandem mass spectrometry. Plasma samples were obtained prior to cooling and rewarming, and immediately after rewarming, from all patients during TH after ROSC. A total of 92 high-confidence proteins were identified. Statistically significant alterations were observed (>1.2-fold increase or <0.833-fold decrease) in the levels of 15 of those proteins (P=0.003–0.047), mainly proteins belonging to the acute-phase response or platelet degranulation. Unexpectedly, the levels of free hemoglobin (hemoglobin subunits α and β) were significantly downregulated during TH (P<0.05). The level of the terminal complement complex (SC5b-9) showed significant reduction after cooling (P=0.023). Although the acute-phase response proteins were upregulated, the abundance of complement proteins did not change, and the levels of SC5b-9 and free hemoglobin decreased during TH in patients after ROSC.
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Affiliation(s)
- Teiji Oda
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Shimane University Faculty of Medicine, Izumo, Shimane 693-8501, Japan
| | - Akane Yamaguchi
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Shimane University Faculty of Medicine, Izumo, Shimane 693-8501, Japan
| | - Ryosuke Ishida
- Department of Emergency and Critical Care Medicine, Shimane Prefectural Central Hospital, Izumo, Shimane 693-8555, Japan
| | - Tetsuro Nikai
- Department of Anesthesiology, Shimane University Faculty of Medicine, Izumo, Shimane 693-8501, Japan
| | - Koji Shimizu
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Shimane University Faculty of Medicine, Izumo, Shimane 693-8501, Japan
| | - Ken-Ichi Matsumoto
- Department of Biosignaling and Radioisotope Experiment, Interdisciplinary Center for Science Research, Organization for Research, Shimane University, Izumo, Shimane 693-8501, Japan
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Gleason TG, Argenziano M, Bavaria JE, Kane LC, Coselli JS, Engelman RM, Tanaka KA, Awad A, Sekela ME, Zwischenberger JB. Hemoadsorption to Reduce Plasma-Free Hemoglobin During Cardiac Surgery: Results of REFRESH I Pilot Study. Semin Thorac Cardiovasc Surg 2019; 31:783-793. [DOI: 10.1053/j.semtcvs.2019.05.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 05/08/2019] [Indexed: 12/15/2022]
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McVey MJ, Kuebler WM. Extracellular vesicles: biomarkers and regulators of vascular function during extracorporeal circulation. Oncotarget 2018; 9:37229-37251. [PMID: 30647856 PMCID: PMC6324688 DOI: 10.18632/oncotarget.26433] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Accepted: 11/26/2018] [Indexed: 12/12/2022] Open
Abstract
Extracellular vesicles (EVs) are generated at increased rates from parenchymal and circulating blood cells during exposure of the circulation to abnormal flow conditions and foreign materials associated with extracorporeal circuits (ExCors). This review describes types of EVs produced in different ExCors and extracorporeal life support (ECLS) systems including cardiopulmonary bypass circuits, extracorporeal membrane oxygenation (ECMO), extracorporeal carbon dioxide removal (ECCO2R), apheresis, dialysis and ventricular assist devices. Roles of EVs not only as biomarkers of adverse events during ExCor/ECLS use, but also as mediators of vascular dysfunction are explored. Manipulation of the number or subtypes of circulating EVs may prove a means of improving vascular function for individuals requiring ExCor/ECLS support. Strategies for therapeutic manipulation of EVs during ExCor/ECLS use are discussed such as accelerating their clearance, preventing their genesis or pharmacologic options to reduce or select which and how many EVs circulate. Strategies to reduce or select for specific types of EVs may prove beneficial in preventing or treating other EV-related diseases such as cancer.
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Affiliation(s)
- Mark J McVey
- Keenan Research Centre for Biomedical Science, St Michael's Hospital, Toronto, ON, Canada.,Department of Physiology, University of Toronto, Toronto, ON, Canada.,Department of Anesthesia, University of Toronto, Toronto, ON, Canada.,Department of Anesthesia and Pain Medicine, SickKids, Toronto, ON, Canada
| | - Wolfgang M Kuebler
- Keenan Research Centre for Biomedical Science, St Michael's Hospital, Toronto, ON, Canada.,Department of Physiology, University of Toronto, Toronto, ON, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada.,Institute of Physiology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,German Heart Institute, Berlin, Germany
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50
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Dhir A, Tempe DK. Anemia and Patient Blood Management in Cardiac Surgery—Literature Review and Current Evidence. J Cardiothorac Vasc Anesth 2018; 32:2726-2742. [DOI: 10.1053/j.jvca.2017.11.043] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Indexed: 12/24/2022]
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