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Xourgia E, Exadaktylos AK, Chalkias A, Ziaka M. ANGIOTENSIN II IN THE TREATMENT OF DISTRIBUTIVE SHOCK: A SYSTEMATIC-REVIEW AND META-ANALYSIS. Shock 2024; 62:155-164. [PMID: 38888542 DOI: 10.1097/shk.0000000000002384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2024]
Abstract
ABSTRACT Objective: While nonnorepinephrine vasopressors are increasingly used as a rescue therapy in cases of norepinephrine-refractory shock, data on their efficacy are limited. This systematic review and meta-analysis aims to synthesize existing literature on the efficacy of angiotensin II (ATII) in distributive shock. Methods: We preregistered our meta-analysis with PROSPERO (CRD42023456136). We searched PubMed, Scopus, and gray literature for studies presenting outcomes on ATII use in distributive shock. The primary outcome of the meta-analysis was all-cause mortality. We used a random effects model to calculate pooled risk ratio (RR) and 95% confidence intervals (CIs). Results: By incorporating data from 1,555 patients included in 10 studies, we found that however, all-cause mortality was similar among patients receiving ATII and controls (RR = 1.02; 95% CI: 0.89 to 1.16, P = 0.81), the reduction in norepinephrine or norepinephrine-equivalent dose at 3 h after treatment initiation was greater among patients receiving ATII (MD = -0.06; 95% CI: -0.11 to -0.02, P = 0.008), while there were no higher rates of adverse events reported among ATII patients. Conclusions: While ATII did not reduce mortality among distributive shock patients, it allowed for significant adjunctive vasopressor reduction at 3 h without an increase in reported adverse events, deeming it a viable alternative for the increasingly adopted multimodal vasopressor for minimizing catecholamine exposure and its adverse events.
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Affiliation(s)
| | - Aristomenis K Exadaktylos
- Department of Emergency Medicine, Inselspital, University Hospital, University of Bern, Bern, Switzerland
| | | | - Mairi Ziaka
- Department of Emergency Medicine, Inselspital, University Hospital, University of Bern, Bern, Switzerland
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Siti-Zubaidah MZ, Harafinova HS, Liba AN, Nordin ML, Hambali KA, Siti HN. Exploring bradykinin: A common mediator in the pathophysiology of sepsis and atherosclerotic cardiovascular disease. Vascul Pharmacol 2024; 156:107414. [PMID: 39089528 DOI: 10.1016/j.vph.2024.107414] [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: 04/13/2024] [Revised: 07/16/2024] [Accepted: 07/29/2024] [Indexed: 08/04/2024]
Abstract
Sepsis and atherosclerotic cardiovascular disease (ASCVD) are major health challenges involving complex processes like inflammation, renin-angiotensin system (RAS) dysregulation, and thrombosis. Despite distinct clinical symptoms, both conditions share mechanisms mediated by bradykinin. This review explores bradykinin's role in inflammation, RAS modulation, and thrombosis in sepsis and ASCVD. In sepsis, variable kininogen-bradykinin levels may correlate with disease severity and progression, though the effect of bradykinin receptor modulation on inflammation remains uncertain. RAS activation is present in both diseases, with sepsis showing variable or low levels of Ang II, ACE, and ACE2, while ASCVD consistently exhibits elevated levels. Bradykinin may act as a mediator for ACE2 and AT2 receptor effects in RAS regulation. It may influence clotting and fibrinolysis in sepsis-associated coagulopathy, but evidence for an antithrombotic effect in ASCVD is insufficient. Understanding bradykinin's role in these shared pathologies could guide therapeutic and monitoring strategies and inform future research.
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Affiliation(s)
- Mohd Zahari Siti-Zubaidah
- Department of Anaesthesia and Intensive Care, National Heart Institute, Jalan Tun Razak, 50400 Kuala Lumpur, Malaysia.
| | - Harman-Shah Harafinova
- Department of Internal Medicine, Faculty of Medicine, Universiti Sultan Zainal Abidin, Jalan Sultan Mahmud, 20400 Kuala Terengganu, Terengganu, Malaysia.
| | - Abdullahi Nuradeen Liba
- Department of Veterinary Clinical Studies, Faculty of Veterinary Medicine, Universiti Malaysia Kelantan, Pengkalan Chepa, Kota Bharu, 16100, Kelantan, Malaysia
| | - Muhammad Luqman Nordin
- Department of Veterinary Clinical Studies, Faculty of Veterinary Medicine, Universiti Malaysia Kelantan, Pengkalan Chepa, Kota Bharu, 16100, Kelantan, Malaysia; Department of Pharmaceutical Technology, Faculty of Pharmacy, Universiti Malaya, 50603 Kuala Lumpur, Malaysia.
| | - Kamarul Ariffin Hambali
- Faculty of Earth Science, Universiti Malaysia Kelantan, Jeli, 17600, Kelantan, Malaysia; Animal and Wildlife Research Group, Faculty of Earth Science, Jeli Campus, Universiti Malaysia Kelantan, 17600, Kelantan, Malaysia.
| | - Hawa Nordin Siti
- Department of Pharmacology, Faculty of Medicine, Universiti Sultan Zainal Abidin, Jalan Sultan Mahmud, 20400 Kuala Terengganu, Terengganu, Malaysia.
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Schaich CL, Leisman DE, Goldberg MB, Filbin MR, Khanna AK, Chappell MC. Dysfunction of the renin-angiotensin-aldosterone system in human septic shock. Peptides 2024; 176:171201. [PMID: 38555976 PMCID: PMC11060897 DOI: 10.1016/j.peptides.2024.171201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 03/20/2024] [Accepted: 03/27/2024] [Indexed: 04/02/2024]
Abstract
Sepsis and septic shock are global healthcare problems associated with mortality rates of up to 40% despite optimal standard-of-care therapy and constitute the primary cause of death in intensive care units worldwide. Circulating biomarkers of septic shock severity may represent a clinically relevant approach to individualize those patients at risk for worse outcomes early in the course of the disease, which may facilitate early and more precise interventions to improve the clinical course. However, currently used septic shock biomarkers, including lactate, may be non-specific and have variable impact on prognosis and/or disease management. Activation of the renin-angiotensin-aldosterone system (RAAS) is likely an early event in septic shock, and studies suggest that an elevated level of renin, the early and committed step in the RAAS cascade, is a better predictor of worse outcomes in septic shock, including mortality, than the current standard-of-care measure of lactate. Despite a robust increase in renin, other elements of the RAAS, including endogenous levels of Ang II, may fail to sufficiently increase to maintain blood pressure, tissue perfusion, and protective immune responses in septic shock patients. We review the current clinical literature regarding the dysfunction of the RAAS in septic shock and potential therapeutic approaches to improve clinical outcomes.
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Affiliation(s)
- Christopher L Schaich
- Hypertension & Vascular Research Center, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Daniel E Leisman
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Marcia B Goldberg
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Micheal R Filbin
- Department of Emergency Medicine, Massachusetts General Hospital,Boston, MA, USA
| | - Ashish K Khanna
- Hypertension & Vascular Research Center, Wake Forest University School of Medicine, Winston-Salem, NC, USA; Department of Anesthesiology, Section on Critical Care Medicine, Atrium Health Wake Forest Baptist Medical Center, USA; Outcomes Research Consortium, Cleveland, OH, USA
| | - Mark C Chappell
- Hypertension & Vascular Research Center, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
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Kotani Y, Chappell M, Landoni G, Zarbock A, Bellomo R, Khanna AK. Renin in critically ill patients. Ann Intensive Care 2024; 14:79. [PMID: 38775999 PMCID: PMC11111649 DOI: 10.1186/s13613-024-01304-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 04/28/2024] [Indexed: 05/25/2024] Open
Abstract
The renin-angiotensin system (RAS) constitutes one of the principal mechanisms to maintain hemodynamic and fluid homeostasis. However, most research until now on RAS primarily focuses on its relationship with hypertension and its role in critically ill hypotensive populations is not well understood. With the approval of angiotensin II (Ang II) in the United States and Europe, following a phase 3 randomized controlled trial showing efficacy in catecholamine-resistant vasodilatory shock, there is growing interest in RAS in critically ill patients. Among the fundamental components of RAS, renin acts as the initial stimulus for the entire system. In the context of hypotension, its release increases in response to low blood pressure sensed by renal baroreceptors and attenuated negative Ang II feedback loop. Thus, elevated renin could reflect disease severity and predict poor outcomes. Studies investigating this hypothesis have validated the prognostic accuracy of renin in various critically ill populations, with several reports indicating its superiority to lactate for mortality prediction. Accordingly, renin reduction has been used to assess the effectiveness of Ang II administration. Furthermore, renin holds potential to identify patients who might benefit from Ang II treatment, potentially paving the way for personalized vasopressor management. Despite these promising data, most available evidence is derived from retrospective analysis and necessitates prospective confirmation. The absence of a rapid, point-of-care and reliable renin assay presents another hurdle to its integration into routine clinical practice. This narrative review aims to describe the current understanding and future directions of renin as a biomarker during resuscitation of critically ill patients.
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Affiliation(s)
- Yuki Kotani
- Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Mark Chappell
- Hypertension and Vascular Research Center, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Muenster, Muenster, Germany
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Australia
| | - Ashish K Khanna
- Section On Critical Care Medicine, Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, NC, 27157, USA.
- Perioperative Outcomes and Informatics Collaborative, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC, 27157, USA.
- Outcomes Research Consortium, Cleveland, OH, 44195, USA.
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Kotani Y, Belletti A, Maiucci G, Lodovici M, Fresilli S, Landoni G, Bellomo R, Zarbock A. Renin as a Prognostic Marker in Intensive Care and Perioperative Settings: A Scoping Review. Anesth Analg 2024; 138:929-936. [PMID: 38358109 DOI: 10.1213/ane.0000000000006682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Abstract
Serum renin increases in response to sympathetic nerve activation and hypotension. Recent studies have reported the association of serum renin levels with adverse clinical outcomes in acute care settings. This scoping review aimed to systematically review the available literature on renin as a prognostic marker in intensive care and perioperative patients. We searched for studies published since inception until March 31, 2023, which assessed the association between serum renin levels and clinical outcomes or the effect of synthetic angiotensin II administration on serum renin levels in critically ill and perioperative patients in PubMed, Embase, and the Cochrane Library. The primary outcome was mortality at the longest follow-up; the secondary outcomes were adverse renal outcomes (ie, acute kidney injury, the need for renal replacement therapy, and major adverse kidney events), hemodynamic instability, outcomes to angiotensin II administration, and prognostic performance for mortality when compared with lactate. Among the 2081 studies identified, we included 16 studies with 1573 patients (7 studies on shock, 5 on nonspecific critical illness, 2 on cardiac surgery, 1 on noncardiac surgery, and 1 on coronavirus disease 2019). A significant association between serum renin levels and poor outcomes was identified in 14 studies, with 10 studies demonstrating an association with mortality. One post hoc analysis found that angiotensin II administration reduced mortality in patients with markedly elevated renin values. Two studies showed that renin was superior to lactate as a prognostic marker of mortality. Our scoping review showed that elevated serum renin levels may be associated with clinically relevant outcomes among various perioperative and intensive care populations. Increased serum renin levels may identify patients in which synthetic angiotensin II administration improves clinical outcomes and may outperform serum lactate in predicting mortality.
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Affiliation(s)
- Yuki Kotani
- From the Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
- Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Japan
| | - Alessandro Belletti
- From the Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giacomo Maiucci
- From the Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Martina Lodovici
- From the Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Fresilli
- From the Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giovanni Landoni
- From the Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Rinaldo Bellomo
- Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Critical Care, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Muenster, Muenster, Germany
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Chakradhar A, Baron RM, Vera MP, Devarajan P, Chawla L, Hou PC. Plasma renin as a novel prognostic biomarker of sepsis-associated acute respiratory distress syndrome. Sci Rep 2024; 14:6667. [PMID: 38509149 PMCID: PMC10954703 DOI: 10.1038/s41598-024-56994-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 03/13/2024] [Indexed: 03/22/2024] Open
Abstract
Sepsis-associated acute respiratory distress syndrome (ARDS) is a life-threatening condition in critical care medicine for which there is a substantial need for early prognostic biomarkers of outcome. The present study seeks to link plasma renin levels and 30-day mortality in sepsis-associated ARDS patients treated at our institution. The Registry of Critical Illness (RoCI) prospectively enrolled patients from the intensive care units (ICU) within a single academic medical center, and a convenience sample of patients with sepsis-associated ARDS was analyzed from this cohort. This study was approved by the Mass General Brigham Institutional Review Boards (IRB) as part of the RoCI, and all procedures performed were in accordance with the ethical standards of the institutional board. From April 2012 to February 2019, a cohort of 32 adult sepsis-associated ARDS patients with 500 µL of plasma samples available on Day 0 and Day 3 of their ICU stay were enrolled. Renin levels were measured twice, on Day 0 and Day 3 via the direct renin enzyme-linked immunosorbent assay (ELISA EIA-525) by DRG diagnostics. Day 0 and Day 3 renin were statistically evaluated via logistic regression to predict 30-day mortality. Direct renin levels of 64 samples were assayed from 32 sepsis-associated ARDS patients (50% male; mean ± SD, 55 ± 13.8 years old). The 30-day hospital mortality rate was 59.4%. Patients who died within 30 days of admission were more likely to have an elevated Day 3 Renin (Odds ratio [OR] = 6, 95% CI 1.25-28.84) and have received vasopressors (OR = 13.33, 95% CI 1.43-123.95). Adjusting for vasopressor use as a proxy for septic shock status, patients with an Elevated Day 3 Renin had a 6.85 (95% CI 1.07-43.75) greater odds of death than those with Low-Normal Day 3 Renin. Patients with sustained Elevated Renin levels from Day 0 to Day 3 had the highest risk of death in a 30-day window. In this study, we found that renin may be a novel biomarker that has prognostic value for patients with sepsis-associated ARDS. Future studies evaluating renin levels in patients with sepsis-associated ARDS are needed to validate these findings.
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Affiliation(s)
- Anjali Chakradhar
- Department of Molecular and Cellular Biology, Harvard University, Cambridge, MA, USA
| | - Rebecca M Baron
- Division of Pulmonary Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Mayra Pinilla Vera
- Division of Pulmonary Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Prasad Devarajan
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Lakhmir Chawla
- Silver Creek Pharmaceuticals, Inc., San Francisco, CA, USA
| | - Peter C Hou
- Division of Emergency Critical Care Medicine, Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA.
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See EJ, Russell JA, Bellomo R, Lawler PR. Renin as a Prognostic and Predictive Biomarker in Sepsis: More Questions Than Answers? Crit Care Med 2024; 52:509-512. [PMID: 38381014 DOI: 10.1097/ccm.0000000000006133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Affiliation(s)
- Emily J See
- Department of Intensive Care, Royal Melbourne Hospital, Parkville, NSW, Australia
- Department of Critical Care, University of Melbourne, Parkville, NSW, Australia
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
- Department of Critical Care, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- Department of Medicine, Centre for Heart Lung Innovation, University of British Columbia and St Paul's Hospital, Vancouver, BC, Canada
- Department of Medicine, McGill University Health Centre and McGill University, Montreal, QC, Canada
- Division of Cardiology and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - James A Russell
- Department of Medicine, Centre for Heart Lung Innovation, University of British Columbia and St Paul's Hospital, Vancouver, BC, Canada
| | - Rinaldo Bellomo
- Department of Intensive Care, Royal Melbourne Hospital, Parkville, NSW, Australia
- Department of Critical Care, University of Melbourne, Parkville, NSW, Australia
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
- Department of Critical Care, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- Department of Medicine, Centre for Heart Lung Innovation, University of British Columbia and St Paul's Hospital, Vancouver, BC, Canada
- Department of Medicine, McGill University Health Centre and McGill University, Montreal, QC, Canada
- Division of Cardiology and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Patrick R Lawler
- Department of Medicine, McGill University Health Centre and McGill University, Montreal, QC, Canada
- Division of Cardiology and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
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Busse LW, Schaich CL, Chappell MC, McCurdy MT, Staples EM, Ten Lohuis CC, Hinson JS, Sevransky JE, Rothman RE, Wright DW, Martin GS, Khanna AK. Association of Active Renin Content With Mortality in Critically Ill Patients: A Post hoc Analysis of the Vitamin C, Thiamine, and Steroids in Sepsis (VICTAS) Trial. Crit Care Med 2024; 52:441-451. [PMID: 37947484 PMCID: PMC10876175 DOI: 10.1097/ccm.0000000000006095] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
OBJECTIVE Sepsis is a leading cause of mortality. Predicting outcomes is challenging and few biomarkers perform well. Defects in the renin-angiotensin system (RAS) can predict clinical outcomes in sepsis and may outperform traditional biomarkers. We postulated that RAS dysfunction (elevated active renin, angiotensin 1-7 [Ang-(1-7)], and angiotensin-converting enzyme 2 (ACE2) activity with depressed Ang-II and ACE activity) would be associated with mortality in a cohort of septic patients. DESIGN Post hoc analysis of patients enrolled in the Vitamin C, Thiamine, and Steroids in Sepsis (VICTAS) randomized controlled trial. SETTING Forty-three hospitals across the United States. PATIENTS Biorepository samples of 103 patients. INTERVENTIONS We analyzed day 0 (within 24 hr of respiratory failure, septic shock, or both) and day 3 samples ( n = 103 and 95, respectively) for assessment of the RAS. The association of RAS values with 30-day mortality was determined using Cox proportional hazards regression with multivariable adjustments for age, sex, VICTAS treatment arm, systolic blood pressure, Sequential Organ Failure Assessment Score, and vasopressor use. MEASUREMENTS AND MAIN RESULTS High baseline active renin values were associated with higher 30-day mortality when dichotomized to the median of 188.7 pg/mL (hazard ratio [HR] = 2.84 [95% CI, 1.10-7.33], p = 0.031) or stratified into quartiles (Q1 = ref, HR Q2 = 2.01 [0.37-11.04], HR Q3 = 3.22 [0.64-16.28], HR Q4 = 5.58 [1.18-26.32], p for linear trend = 0.023). A 1- sd (593.6 pg/mL) increase in renin from day 0 to day 3 was associated with increased mortality (HR = 3.75 [95% CI, 1.94-7.22], p < 0.001), and patients whose renin decreased had improved survival compared with those whose renin increased (HR 0.22 [95% CI, 0.08-0.60], p = 0.003). Ang-(1-7), ACE2 activity, Ang-II and ACE activity did not show this association. Mortality was attenuated in patients with renin over the median on day 0 who received the VICTAS intervention, but not on day 3 ( p interaction 0.020 and 0.137, respectively). There were no additional consistent patterns of mortality on the RAS from the VICTAS intervention. CONCLUSIONS Baseline serum active renin levels were strongly associated with mortality in critically ill patients with sepsis. Furthermore, a greater relative activation in circulating renin from day 0 to day 3 was associated with a higher risk of death.
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Affiliation(s)
- Laurence W Busse
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University, Atlanta, GA
- Emory Critical Care Center, Emory Healthcare, Atlanta, GA
| | - Christopher L Schaich
- Hypertension and Vascular Research Center, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Mark C Chappell
- Hypertension and Vascular Research Center, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Michael T McCurdy
- Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Erin M Staples
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
| | | | - Jeremiah S Hinson
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Jonathan E Sevransky
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University, Atlanta, GA
- Emory Critical Care Center, Emory Healthcare, Atlanta, GA
| | - Richard E Rothman
- Department of Emergency Medicine, Johns Hopkins University, The Johns Hopkins Hospital, Baltimore, MD
| | - David W Wright
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA
- Grady Marcus Trauma and Emergency Care Center, Atlanta, GA
| | - Greg S Martin
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University, Atlanta, GA
- Emory Critical Care Center, Emory Healthcare, Atlanta, GA
| | - Ashish K Khanna
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University, Atlanta, GA
- Emory Critical Care Center, Emory Healthcare, Atlanta, GA
- Hypertension and Vascular Research Center, Wake Forest University School of Medicine, Winston-Salem, NC
- Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, MD
- Department of Emergency Medicine, Johns Hopkins University, The Johns Hopkins Hospital, Baltimore, MD
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA
- Grady Marcus Trauma and Emergency Care Center, Atlanta, GA
- Department of Anesthesiology, Section of Critical Care Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
- Outcomes Research Consortium, Cleveland, OH
- Perioperative Outcomes and Informatics Collaborative, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC
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Zhu B, Zhou R, Qin J, Li Y. Hierarchical Capability in Distinguishing Severities of Sepsis via Serum Lactate: A Network Meta-Analysis. Biomedicines 2024; 12:447. [PMID: 38398049 PMCID: PMC10886935 DOI: 10.3390/biomedicines12020447] [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: 01/15/2024] [Revised: 01/30/2024] [Accepted: 02/01/2024] [Indexed: 02/25/2024] Open
Abstract
Background: Blood lactate is a potentially useful biomarker to predict the mortality and severity of sepsis. The purpose of this study is to systematically review the ability of lactate to predict hierarchical sepsis clinical outcomes and distinguish sepsis, severe sepsis and septic shock. Methods: We conducted an exhaustive search of the PubMed, Embase and Cochrane Library databases for studies published before 1 October 2022. Inclusion criteria mandated the presence of case-control, cohort studies and randomized controlled trials that established the association between before-treatment blood lactate levels and the mortality of individuals with sepsis, severe sepsis or septic shock. Data was analyzed using STATA Version 16.0. Results: A total of 127 studies, encompassing 107,445 patients, were ultimately incorporated into our analysis. Meta-analysis of blood lactate levels at varying thresholds revealed a statistically significant elevation in blood lactate levels predicting mortality (OR = 1.57, 95% CI 1.48-1.65, I2 = 92.8%, p < 0.00001). Blood lactate levels were significantly higher in non-survivors compared to survivors in sepsis patients (SMD = 0.77, 95% CI 0.74-0.79, I2 = 83.7%, p = 0.000). The prognostic utility of blood lactate in sepsis mortality was validated through hierarchical summary receiver operating characteristic curve (HSROC) analysis, yielding an area under the curve (AUC) of 0.72 (95% CI 0.68-0.76), accompanied by a summary sensitivity of 0.65 (95% CI 0.59-0.7) and a summary specificity of 0.7 (95% CI 0.64-0.75). Unfortunately, the network meta-analysis could not identify any significant differences in average blood lactate values' assessments among sepsis, severe sepsis and septic shock patients. Conclusions: This meta-analysis demonstrated that high-level blood lactate was associated with a higher risk of sepsis mortality. Lactate has a relatively accurate predictive ability for the mortality risk of sepsis. However, the network analysis found that the levels of blood lactate were not effective in distinguishing between patients with sepsis, severe sepsis and septic shock.
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Affiliation(s)
| | | | | | - Yifei Li
- Department of Pediatrics, West China Second University Hospital, Sichuan University, No. 20, 3rd Section, South Renmin Road, Chengdu 610041, China; (B.Z.); (R.Z.); (J.Q.)
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10
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Guzzo I, Paglialonga F. Critically ill children with septic shock: time to rediscover renin? Pediatr Nephrol 2023; 38:2907-2910. [PMID: 37087478 DOI: 10.1007/s00467-023-05985-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 04/10/2023] [Accepted: 04/10/2023] [Indexed: 04/24/2023]
Affiliation(s)
- Isabella Guzzo
- Pediatric Nephrology, Dialysis and Transplant Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Fabio Paglialonga
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
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11
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Stanski NL, Pode Shakked N, Zhang B, Cvijanovich NZ, Fitzgerald JC, Jain PN, Schwarz AJ, Nowak J, Weiss SL, Allen GL, Thomas NJ, Haileselassie B, Goldstein SL. Serum renin and prorenin concentrations predict severe persistent acute kidney injury and mortality in pediatric septic shock. Pediatr Nephrol 2023; 38:3099-3108. [PMID: 36939916 PMCID: PMC10588759 DOI: 10.1007/s00467-023-05930-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 02/24/2023] [Accepted: 02/24/2023] [Indexed: 03/21/2023]
Abstract
BACKGROUND Studies in critically ill adults demonstrate associations between serum renin concentrations (a proposed surrogate for renin-angiotensin-aldosterone system dysregulation) and poor outcomes, but data in critically ill children are lacking. We assessed serum renin + prorenin concentrations in children with septic shock to determine their predictive ability for acute kidney injury (AKI) and mortality. METHODS We conducted a secondary analysis of a multicenter observational study of children aged 1 week to 18 years admitted to 14 pediatric intensive care units (PICUs) with septic shock and residual serum available for renin + prorenin measurement. Primary outcomes were development of severe persistent AKI (≥ KDIGO stage 2 for ≥ 48 h) in the first week and 28-day mortality. RESULTS Among 233 patients, day 1 median renin + prorenin concentration was 3436 pg/ml (IQR 1452-6567). Forty-two (18%) developed severe persistent AKI and 32 (14%) died. Day 1 serum renin + prorenin predicted severe persistent AKI with an AUROC of 0.75 (95% CI 0.66-0.84, p < 0.0001; optimal cutoff 6769 pg/ml) and mortality with an AUROC of 0.79 (95% CI 0.69-0.89, p < 0.0001; optimal cutoff 6521 pg/ml). Day 3/day 1 (D3:D1) renin + prorenin ratio had an AUROC of 0.73 (95% CI 0.63-0.84, p < 0.001) for mortality. On multivariable regression, day 1 renin + prorenin > optimal cutoff retained associations with severe persistent AKI (aOR 6.8, 95% CI 3.0-15.8, p < 0.001) and mortality (aOR 6.9, 95% CI 2.2-20.9, p < 0.001). Similarly, D3:D1 renin + prorenin > optimal cutoff was associated with mortality (aOR 7.6, 95% CI 2.5-23.4, p < 0.001). CONCLUSIONS Children with septic shock have very elevated serum renin + prorenin concentrations on PICU admission, and these concentrations, as well as their trend over the first 72 h, predict severe persistent AKI and mortality. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Natalja L Stanski
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA.
- Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH, 45267, USA.
| | - Naomi Pode Shakked
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Bin Zhang
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
| | | | - Julie C Fitzgerald
- The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Parag N Jain
- Texas Children's Hospital and Baylor College of Medicine, 6621 Fannin Street, Houston, TX, 77030, USA
| | - Adam J Schwarz
- Children's Hospital of Orange County, 1201 W La Veta Ave, Orange, CA, 92868, USA
| | - Jeffrey Nowak
- Children's Minnesota, 2525 Chicago Ave, Minneapolis, MN, 55404, USA
| | - Scott L Weiss
- The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Geoffrey L Allen
- Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Neal J Thomas
- Penn State Health Children's Hospital, 600 University Dr, Hershey, PA, 17033, USA
| | | | - Stuart L Goldstein
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH, 45267, USA
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12
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Pode-Shakked N, Ceschia G, Rose JE, Goldstein SL, Stanski NL. Increasing angiotensin-converting enzyme concentrations and absent angiotensin-converting enzyme activity are associated with adverse kidney outcomes in pediatric septic shock. Crit Care 2023; 27:230. [PMID: 37308975 PMCID: PMC10259008 DOI: 10.1186/s13054-023-04518-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 06/02/2023] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND Sepsis-induced endothelial dysfunction is proposed to cause angiotensin-converting enzyme (ACE) dysfunction and renin-angiotensin-aldosterone system (RAAS) derangement, exacerbating vasodilatory shock and acute kidney injury (AKI). Few studies test this hypothesis directly, including none in children. We measured serum ACE concentrations and activity, and assessed their association with adverse kidney outcomes in pediatric septic shock. METHODS A pilot study of 72 subjects aged 1 week-18 years from an existing multicenter, observational study. Serum ACE concentrations and activity were measured on Day 1; renin + prorenin concentrations were available from a previous study. The associations between individual RAAS components and a composite outcome (Day 1-7 severe persistent AKI, kidney replacement therapy use, or mortality) were assessed. RESULTS 50/72 subjects (69%) had undetectable ACE activity (< 2.41 U/L) on Day 1 and 27/72 (38%) developed the composite outcome. Subjects with undetectable ACE activity had higher Day 1 renin + prorenin compared to those with activity (4533 vs. 2227 pg/ml, p = 0.017); ACE concentrations were no different between groups. Children with the composite outcome more commonly had undetectable ACE activity (85% vs. 65%, p = 0.025), and had higher Day 1 renin + prorenin (16,774 pg/ml vs. 3037 pg/ml, p < 0.001) and ACE concentrations (149 vs. 96 pg/ml, p = 0.019). On multivariable regression, increasing ACE concentrations (aOR 1.01, 95%CI 1.002-1.03, p = 0.015) and undetectable ACE activity (aOR 6.6, 95%CI 1.2-36.1, p = 0.031) retained associations with the composite outcome. CONCLUSIONS ACE activity is diminished in pediatric septic shock, appears uncoupled from ACE concentrations, and is associated with adverse kidney outcomes. Further study is needed to validate these findings in larger cohorts.
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Affiliation(s)
- Naomi Pode-Shakked
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45208, USA
- Sackler Faculty of Medicine, Tel-Aviv University, P.O. Box 39040, 6997801, Tel Aviv, Israel
| | - Giovanni Ceschia
- Pediatric Nephrology Unit, Department of Women's and Children's Health, University-Hospital of Padova, Via Giustiniani 3, 35128, Padua, Italy
| | - James E Rose
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45208, USA
| | - Stuart L Goldstein
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45208, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH, 45267, USA
| | - Natalja L Stanski
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45208, USA.
- Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH, 45267, USA.
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13
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Hasegawa D, Lee YI, Prasitlumkum N, Chopra L, Nishida K, Smith RL, Sato R. Premorbid angiotensin converting enzyme inhibitors or angiotensin II receptor blockers in patients with sepsis. Am J Emerg Med 2022; 62:69-77. [DOI: 10.1016/j.ajem.2022.10.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 10/03/2022] [Accepted: 10/05/2022] [Indexed: 11/05/2022] Open
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14
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Louvet L, Lenglet G, Krautzberger AM, Mentaverri R, Hague F, Kowalewski C, Mahtal N, Lesieur J, Bonnet A, Andrique C, Gaucher C, Gomila C, Schrewe H, Tharaux P, Kamel S, Chaussain C, Six I. Vasorin plays a critical role in vascular smooth muscle cells and arterial functions. J Cell Physiol 2022; 237:3845-3859. [PMID: 35892191 PMCID: PMC9796581 DOI: 10.1002/jcp.30838] [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: 02/05/2022] [Revised: 07/07/2022] [Accepted: 07/12/2022] [Indexed: 01/01/2023]
Abstract
Within the cardiovascular system, the protein vasorin (Vasn) is predominantly expressed by vascular smooth muscle cells (VSMCs) in the coronary arteries and the aorta. Vasn knockout (Vasn-/- ) mice die within 3 weeks of birth. In the present study, we investigated the role of vascular Vasn expression on vascular function. We used inducible Vasn knockout mice (VasnCRE-ERT KO and VasnSMMHC-CRE-ERT2 KO , in which respectively all cells or SMCs only are targeted) to analyze the consequences of total or selective Vasn loss on vascular function. Furthermore, in vivo effects were investigated in vitro using human VSMCs. The death of VasnCRE-ERT KO mice 21 days after tamoxifen injection was concomitant with decreases in blood pressure, angiotensin II levels, and vessel contractibility to phenylephrine. The VasnSMMHC-CRE-ERT2 KO mice displayed concomitant changes in vessel contractibility in response to phenylephrine and angiotensin II levels. In vitro, VASN deficiency was associated with a shift toward the SMC contractile phenotype, an increase in basal intracellular Ca2+ levels, and a decrease in the SMCs' ability to generate a calcium signal in response to carbachol or phenylephrine. Additionally, impaired endothelium-dependent relaxation (due to changes in nitric oxide signaling) was observed in all Vasn knockout mice models. Our present findings highlight the role played by Vasn SMC expression in the maintenance of vascular functions. The mechanistic experiments suggested that these effects are mediated by SMC phenotype switching and changes in intracellular calcium homeostasis, angiotensin II levels, and NO signaling.
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Affiliation(s)
- Loïc Louvet
- UR 7517 UPJV, Pathophysiological Mechanisms and Consequences of Cardiovascular Calcifications (MP3CV)Picardie Jules Verne UniversityAmiensFrance
| | - Gaëlle Lenglet
- UR 7517 UPJV, Pathophysiological Mechanisms and Consequences of Cardiovascular Calcifications (MP3CV)Picardie Jules Verne UniversityAmiensFrance
| | | | - Romuald Mentaverri
- UR 7517 UPJV, Pathophysiological Mechanisms and Consequences of Cardiovascular Calcifications (MP3CV)Picardie Jules Verne UniversityAmiensFrance,Amiens University HospitalHuman Biology CenterAmiensFrance
| | - Frédéric Hague
- UR EA4667, UPJV, Laboratoire de Physiologie Cellulaire et MoléculairePicardie Jules Verne UniversityAmiensFrance
| | - Clara Kowalewski
- UR 7517 UPJV, Pathophysiological Mechanisms and Consequences of Cardiovascular Calcifications (MP3CV)Picardie Jules Verne UniversityAmiensFrance
| | - Nassim Mahtal
- Université Paris Cité, Paris Cardiovascular CenterINSERMParisFrance
| | - Julie Lesieur
- Université Paris Cité, URP2496F‐92120MontrougeFrance
| | - Anne‐Laure Bonnet
- Université Paris Cité, URP2496F‐92120MontrougeFrance,AP‐HP, FHU DDS‐net, Services de médecine bucco‐dentaire (GH Sorbonne Université, GH Paris Nord Université de Paris, GH Henri Mondor)ParisFrance
| | | | - Céline Gaucher
- Université Paris Cité, URP2496F‐92120MontrougeFrance,AP‐HP, FHU DDS‐net, Services de médecine bucco‐dentaire (GH Sorbonne Université, GH Paris Nord Université de Paris, GH Henri Mondor)ParisFrance
| | - Cathy Gomila
- UR 7517 UPJV, Pathophysiological Mechanisms and Consequences of Cardiovascular Calcifications (MP3CV)Picardie Jules Verne UniversityAmiensFrance
| | - Heinrich Schrewe
- Department of Developmental GeneticsMax Planck Institute for Molecular GeneticsBerlinGermany
| | | | - Said Kamel
- UR 7517 UPJV, Pathophysiological Mechanisms and Consequences of Cardiovascular Calcifications (MP3CV)Picardie Jules Verne UniversityAmiensFrance,Amiens University HospitalHuman Biology CenterAmiensFrance
| | - Catherine Chaussain
- Université Paris Cité, URP2496F‐92120MontrougeFrance,AP‐HP, FHU DDS‐net, Services de médecine bucco‐dentaire (GH Sorbonne Université, GH Paris Nord Université de Paris, GH Henri Mondor)ParisFrance
| | - Isabelle Six
- UR 7517 UPJV, Pathophysiological Mechanisms and Consequences of Cardiovascular Calcifications (MP3CV)Picardie Jules Verne UniversityAmiensFrance
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15
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Jozwiak M. Alternatives to norepinephrine in septic shock: Which agents and when? JOURNAL OF INTENSIVE MEDICINE 2022; 2:223-232. [PMID: 36788938 PMCID: PMC9924015 DOI: 10.1016/j.jointm.2022.05.001] [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: 03/04/2022] [Revised: 04/28/2022] [Accepted: 05/07/2022] [Indexed: 10/18/2022]
Abstract
Vasopressors are the cornerstone of hemodynamic management in patients with septic shock. Norepinephrine is currently recommended as the first-line vasopressor in these patients. In addition to norepinephrine, there are many other potent vasopressors with specific properties and/or advantages that act on vessels through different pathways after activation of specific receptors; these could be of interest in patients with septic shock. Dopamine is no longer recommended in patients with septic shock because its use is associated with a higher rate of cardiac arrhythmias without any benefit in terms of mortality or organ dysfunction. Epinephrine is currently considered as a second-line vasopressor therapy, because of the higher rate of associated metabolic and cardiac adverse effects compared with norepinephrine; however, it may be considered in settings where norepinephrine is unavailable or in patients with refractory septic shock and myocardial dysfunction. Owing to its potential effects on mortality and renal function and its norepinephrine-sparing effect, vasopressin is recommended as second-line vasopressor therapy instead of norepinephrine dose escalation in patients with septic shock and persistent arterial hypotension. However, two synthetic analogs of vasopressin, namely, terlipressin and selepressin, have not yet been employed in the management of patients with septic shock, as their use is associated with a higher rate of digital ischemia. Finally, angiotensin Ⅱ also appears to be a promising vasopressor in patients with septic shock, especially in the most severe cases and/or in patients with acute kidney injury requiring renal replacement therapy. Nevertheless, due to limited evidence and concerns regarding safety (which remains unclear because of potential adverse effects related to its marked vasopressor activity), angiotensin Ⅱ is currently not recommended in patients with septic shock. Further studies are needed to better define the role of these vasopressors in the management of these patients.
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Affiliation(s)
- Mathieu Jozwiak
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire l'Archet 1, 151 route Saint Antoine de Ginestière, 06200 Nice, France,Equipe 2 CARRES UR2CA – Unité de Recherche Clinique Côte d'Azur, Université Côte d'Azur UCA, 06103 Nice, France
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16
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Krenn K, Tretter V, Kraft F, Ullrich R. The Renin-Angiotensin System as a Component of Biotrauma in Acute Respiratory Distress Syndrome. Front Physiol 2022; 12:806062. [PMID: 35498160 PMCID: PMC9043684 DOI: 10.3389/fphys.2021.806062] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 12/29/2021] [Indexed: 12/13/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a major concern in critical care medicine with a high mortality of over 30%. Injury to the lungs is caused not only by underlying pathological conditions such as pneumonia, sepsis, or trauma, but also by ventilator-induced lung injury (VILI) resulting from high positive pressure levels and a high inspiratory oxygen fraction. Apart from mechanical factors that stress the lungs with a specific physical power and cause volutrauma and barotrauma, it is increasingly recognized that lung injury is further aggravated by biological mediators. The COVID-19 pandemic has led to increased interest in the role of the renin-angiotensin system (RAS) in the context of ARDS, as the RAS enzyme angiotensin-converting enzyme 2 serves as the primary cell entry receptor for severe acute respiratory syndrome (SARS) coronavirus (CoV)-2. Even before this pandemic, studies have documented the involvement of the RAS in VILI and its dysregulation in clinical ARDS. In recent years, analytical tools for RAS investigation have made major advances based on the optimized precision and detail of mass spectrometry. Given that many clinical trials with pharmacological interventions in ARDS were negative, RAS-modifying drugs may represent an interesting starting point for novel therapeutic approaches. Results from animal models have highlighted the potential of RAS-modifying drugs to prevent VILI or treat ARDS. While these drugs have beneficial pulmonary effects, the best targets and application forms for intervention still have to be determined to avoid negative effects on the circulation in clinical settings.
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17
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Meersch M, Weiss R, Massoth C, Küllmar M, Saadat-Gilani K, Busen M, Chawla L, Landoni G, Bellomo R, Gerss J, Zarbock A. The Association Between Angiotensin II and Renin Kinetics in Patients After Cardiac Surgery. Anesth Analg 2022; 134:1002-1009. [PMID: 35171852 DOI: 10.1213/ane.0000000000005953] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Hyperreninemia after cardiac surgery is associated with cardiovascular instability. Angiotensin II (AT-II) could potentially attenuate hyperreninemia while maintaining target blood pressure. This study assesses the association between AT-II usage and renin levels in cardiac surgery patients with postoperative hyperreninemia and vasoplegia. METHODS Between September 2020 and March 2021, we retrospectively identified 40 cardiac surgery patients with high Δ-renin levels (4 hours after cardiopulmonary bypass [CPB] minus preoperative levels) (defined as higher than 3.7 µU/mL) and vasopressor use who received a vasopressor therapy with either AT-II or continued norepinephrine alone. The primary outcome was the renin plasma level at 12 hours after surgery, adjusted by the renin plasma level at 4 hours after surgery. RESULTS Overall, the median renin plasma concentration increased from a baseline with median of 44.3 µU/mL (Q1-Q3, 14.6-155.5) to 188.6 µU/mL (Q1-Q3, 29.8-379.0) 4 hours after CPB. High Δ-renin (difference between postoperation and preoperation) patients (higher than 3.7 µU/mL) were then treated with norepinephrine alone (median dose of 3.25 mg [Q1-Q3, 1.00-4.75]) or with additional AT-II (norepinephrine dose: 1.33 mg [Q1-Q3, 0.78-2.04]; AT-II dose: 0.34 mg [Q1-Q3, 0.29-0.78]). At 12 hours after surgery, AT-II patients had lower renin levels than standard of care patients (71.7 µU/mL [Q1-Q3, 21.9-211.4] vs 130.6 µU/mL [Q1-Q3, 62.9-317.0]; P = .034 adjusting for the renin plasma level at 4 hours after surgery). CONCLUSIONS In cardiac surgery patients with hypotonia and postoperative high Δ-renin levels, AT-II was associated with reduced renin plasma levels for at 12 hours and significantly decreased norepinephrine use, while norepinephrine alone was associated with increased renin levels. Further studies of AT-II in cardiac surgery appear justified.
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Affiliation(s)
- Melanie Meersch
- From the Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Raphael Weiss
- From the Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Christina Massoth
- From the Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Mira Küllmar
- From the Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Khaschayar Saadat-Gilani
- From the Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Manuel Busen
- From the Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Lakhmir Chawla
- Department of Medicine, Veterans Affairs Medical Center, San Diego, California
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, Scientific Institute for Research, Hospitalization and Healthcare (IRCCS), San Raffaele Scientific Institute, Milan, Italy.,School of Medicine, Vita-Salute San Raffaele University
| | - Rinaldo Bellomo
- Department of Critical Care, the University of Melbourne, Melbourne, Australia.,Department of Intensive Care, Royal Melbourne Hospital, Parkville, Victoria, Australia.,Department of Intensive Care, Austin Health, Heidelberg, Australia.,Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Joachim Gerss
- Institute of Biostatistics and Clinical Research, University of Münster, Münster, Germany
| | - Alexander Zarbock
- From the Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
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18
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Effectiveness of Angiotensin II for Catecholamine Refractory Septic or Distributive Shock on Mortality: A Propensity Score Weighted Analysis of Real-World Experience in the Medical ICU. Crit Care Explor 2022; 4:e0623. [PMID: 35072084 PMCID: PMC8769135 DOI: 10.1097/cce.0000000000000623] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Supplemental Digital Content is available in the text. Angiotensin II (ATII) was approved for septic or other distributive shock due to its property of increasing blood pressure within 3 hours. Limited data exist regarding its effectiveness when used in real-world clinical practice.
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19
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Tavares LP, Melo EM, Sousa LP, Teixeira MM. Pro-resolving therapies as potential adjunct treatment for infectious diseases: Evidence from studies with annexin A1 and angiotensin-(1-7). Semin Immunol 2022; 59:101601. [PMID: 35219595 DOI: 10.1016/j.smim.2022.101601] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 02/06/2022] [Accepted: 02/17/2022] [Indexed: 01/15/2023]
Abstract
Infectious diseases, once believed to be an eradicable public health threat, still represent a leading cause of death worldwide. Environmental and social changes continuously favor the emergence of new pathogens and rapid dissemination around the world. The limited availability of anti-viral therapies and increased antibiotic resistance has made the therapeutic management of infectious disease a major challenge. Inflammation is a primordial defense to protect the host against invading microorganisms. However, dysfunctional inflammatory responses contribute to disease severity and mortality during infections. In recent years, a few studies have examined the relevance of resolution of inflammation in the context of infections. Inflammation resolution is an active integrated process transduced by several pro-resolving mediators, including Annexin A1 and Angiotensin-(1-7). Here, we examine some of the cellular and molecular circuits triggered by pro-resolving molecules and that may be beneficial in the context of infectious diseases.
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Affiliation(s)
- Luciana Pádua Tavares
- Pulmonary and Critical Care Medicine Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, 02115, USA
| | - Eliza Mathias Melo
- Immunopharmacology Laboratory, Departamento de Bioquímica e Imunologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Lirlândia Pires Sousa
- Signaling in Inflammation Laboratory, Departamento de Análises Clínicas e Toxicológicas, Faculdade de Farmácia, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.
| | - Mauro Martins Teixeira
- Immunopharmacology Laboratory, Departamento de Bioquímica e Imunologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil.
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20
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Gallo CG, Fiorino S, Posabella G, Antonacci D, Tropeano A, Pausini E, Pausini C, Guarniero T, Hong W, Giampieri E, Corazza I, Federico L, de Biase D, Zippi M, Zancanaro M. COVID-19, what could sepsis, severe acute pancreatitis, gender differences, and aging teach us? Cytokine 2021; 148:155628. [PMID: 34411989 PMCID: PMC8343368 DOI: 10.1016/j.cyto.2021.155628] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 06/02/2021] [Accepted: 06/29/2021] [Indexed: 02/07/2023]
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes a potentially life-threatening disease, defined as Coronavirus Disease 19 (COVID-19). The most common signs and symptoms of this pathological condition include cough, fever, shortness of breath, and sudden onset of anosmia, ageusia, or dysgeusia. The course of COVID-19 is mild or moderate in more than 80% of cases, but it is severe or critical in about 14% and 5% of infected subjects respectively, with a significant risk of mortality. SARS-CoV-2 related infection is characterized by some pathogenetic events, resembling those detectable in other pathological conditions, such as sepsis and severe acute pancreatitis. All these syndromes are characterized by some similar features, including the coexistence of an exuberant inflammatory- as well as an anti-inflammatory-response with immune depression. Based on current knowledge concerning the onset and the development of acute pancreatitis and sepsis, we have considered these syndromes as a very interesting paradigm for improving our understanding of pathogenetic events detectable in patients with COVID-19. The aim of our review is: 1)to examine the pathogenetic mechanisms acting during the emergence of inflammatory and anti-inflammatory processes in human pathology; 2)to examine inflammatory and anti-inflammatory events in sepsis, acute pancreatitis, and SARS-CoV-2 infection and clinical manifestations detectable in patients suffering from these syndromes also according to the age and gender of these individuals; as well as to analyze the possible common and different features among these pathological conditions; 3)to obtain insights into our knowledge concerning COVID-19 pathogenesis. This approach may improve the management of patients suffering from this disease and it may suggest more effective diagnostic approaches and schedules of therapy, depending on the different phases and/or on the severity of SARS-CoV-2 infection.
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Affiliation(s)
- Claudio G Gallo
- Emilian Physiolaser Therapy Center, Castel S. Pietro Terme, Bologna, Italy.
| | - Sirio Fiorino
- Internal Medicine Unit, Budrio Hospital Azienda USL, Bologna, Italy
| | | | - Donato Antonacci
- Medical Science Department, "Casa Sollievo della Sofferenza" Hospital, San Giovanni Rotondo (FG), Italy
| | | | | | | | | | - Wandong Hong
- Department of Gastroenterology and Hepatology, First Affiliated Hospital of Wenzhou Medical University, Wenzhou City, Zhejiang, The People's Republic of China
| | - Enrico Giampieri
- Experimental, Diagnostic and Specialty Medicine Department, University of Bologna, Bologna, Italy
| | - Ivan Corazza
- Experimental, Diagnostic and Specialty Medicine Department, University of Bologna, Bologna, Italy
| | - Lari Federico
- Internal Medicine Unit, Budrio Hospital Azienda USL, Bologna, Italy
| | - Dario de Biase
- Department of Pharmacy and Biotechnology, University of Bologna, Bologna, Italy
| | - Maddalena Zippi
- Unit of Gastroenterology and Digestive Endoscopy, Sandro Pertini Hospital, Rome, Italy
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21
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Coquerel D, Lamoureux J, Chagnon F, Trân K, Sage M, Fortin-Pellerin E, Delile E, Sainsily X, Fournier J, Dumont AA, Auger-Messier M, Sarret P, Marsault E, Praud JP, Fülöp T, Lesur O. Apelin-13 in septic shock: effective in supporting hemodynamics in sheep but compromised by enzymatic breakdown in patients. Sci Rep 2021; 11:22770. [PMID: 34815457 PMCID: PMC8611018 DOI: 10.1038/s41598-021-02087-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 11/09/2021] [Indexed: 11/23/2022] Open
Abstract
Sepsis is a prevalent life-threatening condition related to a systemic infection, and with unresolved issues including refractory septic shock and organ failures. Endogenously released catecholamines are often inefficient to maintain blood pressure, and low reactivity to exogenous catecholamines with risk of sympathetic overstimulation is well documented in septic shock. In this context, apelinergics are efficient and safe inotrope and vasoregulator in rodents. However, their utility in a larger animal model as well as the limitations with regards to the enzymatic breakdown during sepsis, need to be investigated. The therapeutic potential and degradation of apelinergics in sepsis were tested experimentally and in a cohort of patients. (1) 36 sheep with or without fecal peritonitis-induced septic shock (a large animal experimental design aimed to mimic the human septic shock paradigm) were evaluated for hemodynamic and renal responsiveness to incremental doses of two dominant apelinergics: apelin-13 (APLN-13) or Elabela (ELA), and (2) 52 subjects (33 patients with sepsis/septic shock and 19 healthy volunteers) were investigated for early levels of endogenous apelinergics in the blood, the related enzymatic degradation profile, and data regarding sepsis outcome. APLN-13 was the only one apelinergic which efficiently improved hemodynamics in both healthy and septic sheep. Endogenous apelinergic levels early rose, and specific enzymatic breakdown activities potentially threatened endogenous apelin system reactivity and negatively impacted the outcome in human sepsis. Short-term exogenous APLN-13 infusion is helpful in stabilizing cardiorenal functions in ovine septic shock; however, this ability might be impaired by specific enzymatic systems triggered during the early time course of human sepsis. Strategies to improve resistance of APLN-13 to degradation and/or to overcome sepsis-induced enzymatic breakdown environment should guide future works.
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Affiliation(s)
- David Coquerel
- Centre de Recherche Clinique du CHUS, Faculté de Médecine Et Des Sciences de La Santé, Université de Sherbrooke, Sherbrooke, QC, Canada.,Unité Des Soins Intensifs Médicaux Et Service de Pneumologie, Faculté de Médecine Et Des Sciences de La Santé, Université de Sherbrooke, 3001 12th Avenue Nord, Sherbrooke, QC, J1H 5N4, Canada
| | - Julie Lamoureux
- Centre de Recherche Clinique du CHUS, Faculté de Médecine Et Des Sciences de La Santé, Université de Sherbrooke, Sherbrooke, QC, Canada.,Centre de Recherche Sur Le Vieillissement, Faculté de Médecine Et Des Sciences de La Santé, Université de Sherbrooke, Sherbrooke, QC, Canada.,Unité Des Soins Intensifs Médicaux Et Service de Pneumologie, Faculté de Médecine Et Des Sciences de La Santé, Université de Sherbrooke, 3001 12th Avenue Nord, Sherbrooke, QC, J1H 5N4, Canada
| | - Frédéric Chagnon
- Centre de Recherche Clinique du CHUS, Faculté de Médecine Et Des Sciences de La Santé, Université de Sherbrooke, Sherbrooke, QC, Canada.,Unité Des Soins Intensifs Médicaux Et Service de Pneumologie, Faculté de Médecine Et Des Sciences de La Santé, Université de Sherbrooke, 3001 12th Avenue Nord, Sherbrooke, QC, J1H 5N4, Canada
| | - Kien Trân
- Centre de Recherche Clinique du CHUS, Faculté de Médecine Et Des Sciences de La Santé, Université de Sherbrooke, Sherbrooke, QC, Canada.,Département de Pharmacologie-Physiologie, Faculté de Médecine Et Des Sciences de La Santé, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Michael Sage
- Départements de Pédiatrie Et de Pharmacologie/Physiologie, Faculté de Médecine Et Des Sciences de La Santé, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Etienne Fortin-Pellerin
- Centre de Recherche Clinique du CHUS, Faculté de Médecine Et Des Sciences de La Santé, Université de Sherbrooke, Sherbrooke, QC, Canada.,Départements de Pédiatrie Et de Pharmacologie/Physiologie, Faculté de Médecine Et Des Sciences de La Santé, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Eugénie Delile
- Centre de Recherche Clinique du CHUS, Faculté de Médecine Et Des Sciences de La Santé, Université de Sherbrooke, Sherbrooke, QC, Canada.,Unité Des Soins Intensifs Médicaux Et Service de Pneumologie, Faculté de Médecine Et Des Sciences de La Santé, Université de Sherbrooke, 3001 12th Avenue Nord, Sherbrooke, QC, J1H 5N4, Canada
| | - Xavier Sainsily
- Centre de Recherche Clinique du CHUS, Faculté de Médecine Et Des Sciences de La Santé, Université de Sherbrooke, Sherbrooke, QC, Canada.,Département de Médecine, Service de Cardiologie, Faculté de Médecine Et Des Sciences de La Santé, Université de Sherbrooke, Sherbrooke, QC, Canada.,Département de Pharmacologie-Physiologie, Faculté de Médecine Et Des Sciences de La Santé, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Justin Fournier
- Centre de Recherche Clinique du CHUS, Faculté de Médecine Et Des Sciences de La Santé, Université de Sherbrooke, Sherbrooke, QC, Canada.,Département de Médecine, Service de Cardiologie, Faculté de Médecine Et Des Sciences de La Santé, Université de Sherbrooke, Sherbrooke, QC, Canada.,Département de Pharmacologie-Physiologie, Faculté de Médecine Et Des Sciences de La Santé, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Audrey-Ann Dumont
- Département de Médecine, Service de Cardiologie, Faculté de Médecine Et Des Sciences de La Santé, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Mannix Auger-Messier
- Centre de Recherche Clinique du CHUS, Faculté de Médecine Et Des Sciences de La Santé, Université de Sherbrooke, Sherbrooke, QC, Canada.,Département de Médecine, Service de Cardiologie, Faculté de Médecine Et Des Sciences de La Santé, Université de Sherbrooke, Sherbrooke, QC, Canada.,Institut de Pharmacologie de Sherbrooke (IPS), Faculté de Médecine Et Des Sciences de La Santé, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Philippe Sarret
- Centre de Recherche Clinique du CHUS, Faculté de Médecine Et Des Sciences de La Santé, Université de Sherbrooke, Sherbrooke, QC, Canada.,Département de Pharmacologie-Physiologie, Faculté de Médecine Et Des Sciences de La Santé, Université de Sherbrooke, Sherbrooke, QC, Canada.,Institut de Pharmacologie de Sherbrooke (IPS), Faculté de Médecine Et Des Sciences de La Santé, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Eric Marsault
- Centre de Recherche Clinique du CHUS, Faculté de Médecine Et Des Sciences de La Santé, Université de Sherbrooke, Sherbrooke, QC, Canada.,Département de Pharmacologie-Physiologie, Faculté de Médecine Et Des Sciences de La Santé, Université de Sherbrooke, Sherbrooke, QC, Canada.,Institut de Pharmacologie de Sherbrooke (IPS), Faculté de Médecine Et Des Sciences de La Santé, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Jean-Paul Praud
- Centre de Recherche Clinique du CHUS, Faculté de Médecine Et Des Sciences de La Santé, Université de Sherbrooke, Sherbrooke, QC, Canada.,Départements de Pédiatrie Et de Pharmacologie/Physiologie, Faculté de Médecine Et Des Sciences de La Santé, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Tamàs Fülöp
- Centre de Recherche Sur Le Vieillissement, Faculté de Médecine Et Des Sciences de La Santé, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Olivier Lesur
- Centre de Recherche Clinique du CHUS, Faculté de Médecine Et Des Sciences de La Santé, Université de Sherbrooke, Sherbrooke, QC, Canada. .,Unité Des Soins Intensifs Médicaux Et Service de Pneumologie, Faculté de Médecine Et Des Sciences de La Santé, Université de Sherbrooke, 3001 12th Avenue Nord, Sherbrooke, QC, J1H 5N4, Canada.
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22
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Han Y, Kang L, Liu X, Zhuang Y, Chen X, Li X. Establishment and validation of a logistic regression model for prediction of septic shock severity in children. Hereditas 2021; 158:45. [PMID: 34772470 PMCID: PMC8588704 DOI: 10.1186/s41065-021-00206-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 10/14/2021] [Indexed: 11/10/2022] Open
Abstract
Background Septic shock is the most severe complication of sepsis, and is a major cause of childhood mortality, constituting a heavy public health burden. Methods We analyzed the gene expression profiles of septic shock and control samples from the Gene Expression Omnibus (GEO). Four differentially expressed genes (DEGs) from survivor and control groups, non-survivor and control groups, and survivor and non-survivor groups were selected. We used data about these genes to establish a logistic regression model for predicting the survival of septic shock patients. Results Leave-one-out cross validation and receiver operating characteristic (ROC) analysis indicated that this model had good accuracy. Differential expression and Gene Set Enrichment Analysis (GSEA) between septic shock patients stratified by prediction score indicated that the systemic lupus erythematosus pathway was activated, while the limonene and pinene degradation pathways were inactivated in the high score group. Conclusions Our study provides a novel approach for the prediction of the severity of pathology in septic shock patients, which are significant for personalized treatment as well as prognostic assessment. Supplementary Information The online version contains supplementary material available at 10.1186/s41065-021-00206-9.
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Affiliation(s)
- Yujie Han
- Department of Neonatal, Qilu Children's Hospital of Shandong University, No. 23976, Huaiyin District, Jinan City, 250022, Shandong, People's Republic of China
| | - Lili Kang
- Department of Neonatal, Qilu Children's Hospital of Shandong University, No. 23976, Huaiyin District, Jinan City, 250022, Shandong, People's Republic of China
| | - Xianghong Liu
- Department of Neonatal, Qilu Children's Hospital of Shandong University, No. 23976, Huaiyin District, Jinan City, 250022, Shandong, People's Republic of China
| | - Yuanhua Zhuang
- Department of Neonatal, Qilu Children's Hospital of Shandong University, No. 23976, Huaiyin District, Jinan City, 250022, Shandong, People's Republic of China
| | - Xiao Chen
- Department of Neonatal, Qilu Children's Hospital of Shandong University, No. 23976, Huaiyin District, Jinan City, 250022, Shandong, People's Republic of China
| | - Xiaoying Li
- Department of Neonatal, Qilu Children's Hospital of Shandong University, No. 23976, Huaiyin District, Jinan City, 250022, Shandong, People's Republic of China.
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Dysregulation of the renin-angiotensin system in septic shock: Mechanistic insights and application of angiotensin II in clinical management. Pharmacol Res 2021; 174:105916. [PMID: 34597810 DOI: 10.1016/j.phrs.2021.105916] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 09/18/2021] [Accepted: 09/26/2021] [Indexed: 12/12/2022]
Abstract
Synergistic physiologic mechanisms involving the renin-angiotensin system (RAS), the sympathetic nervous system, and the arginine-vasopressin system play an integral role in blood pressure homeostasis. A subset of patients with sepsis experience septic shock with attendant circulatory, cellular, and metabolic abnormalities. Septic shock is associated with increased mortality because of an inadequacy to maintain mean arterial blood pressure (MAP) despite volume resuscitation and the use of vasopressors. Vasodilatory shock raises the dose of vasopressors required to maintain a MAP of > 65 mm Hg. The diminished response to endogenous angiotensin II in sepsis-induced vasoplegia may be related to the aberrant RAS activation that stimulates a proinflammatory beneficial antibacterial response, increasing the secretion of proinflammatory cytokines that downregulate AT-1 receptors expression. Moreover, excessive systemic upregulation of nitric oxide synthase, stimulation of prostaglandin synthesis, and activation of ATP-sensitive potassium channels followed by reduced vascular entry of calcium ions are putative mechanisms in the reduced responsiveness to vasopressors. However, intravenous angiotensin II in catecholamine-resistant septic shock patients showed substantial evidence of raising the MAP to target hemodynamic levels, thus allowing time to treat underlying conditions. Nevertheless, evidence of catecholamine-sparing effect by adding angiotensin II, aimed at increasing the therapeutic index of vasopressor therapy, does not show an attenuation of end-organ damage. The use of angiotensin II in septic shock has not been evaluated in patients who are not catecholamine resistant. This, in conjunction with an evolving definition of catecholamine resistance, provides an opportunity for further evaluation of exogenous angiotensin II in septic shock.
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24
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Xu H, An X, Tian J, Fu M, Wang Q, Li C, He X, Niu L. Angiotensin-(1-7) protects against sepsis-associated left ventricular dysfunction induced by lipopolysaccharide. Peptides 2021; 144:170612. [PMID: 34298021 DOI: 10.1016/j.peptides.2021.170612] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 07/11/2021] [Accepted: 07/16/2021] [Indexed: 12/12/2022]
Abstract
Sepsis-induced myocardial dysfunction is a major cause of death. The present study explored whether angiotensin (Ang)-(1-7), an important biologically active peptide of the renin-angiotensin system, could improve cardiac dysfunction and attenuate inflammation and apoptosis. Experiments were carried out in mice and in neonatal rat cardiomyocytes (NRCMs) treated with lipopolysaccharide (LPS) or Ang-(1-7). Angiotensin converting enzyme 2 (ACE2), Ang-(1-7) and Mas receptor (MasR) expressions were reduced in the mouse left ventricular and NRCM treated with LPS. Ang-(1-7) increased the ejection fraction and fractional shortening of left ventricular, which were reduced upon LPS injection in mice. Ang-(1-7) pre-treatment reversed LPS-induced decreases of α-myosin heavy chain (MHC) and β-MHC, and increases of S100 calcium binding protein A8 (S100A8) and S100A9 in the mouse left ventricular. The LPS-induced increases of tumor necrosis factor (TNF)-α and interleukin (IL)-1β in the mouse left ventricular and NRCMs were inhibited by Ang-(1-7) administration. Ang-(1-7) treatment reversed the increases of cleaved-caspase 3, cleaved-caspase 8 and Bax, and the decrease of Bcl2 induced by LPS in the mouse left ventricular and NRCMs. The increases of MAPKs pathway induced by LPS in NRCMs were inhibited by Ang-(1-7). These results indicate that Ang-(1-7) protects against sepsis-associated left ventricular dysfunction induced by LPS, and increases cardiac contractility via attenuating inflammation and apoptosis.
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Affiliation(s)
- Hui Xu
- Department of Cardiology, Xuzhou Children's Hospital of Xuzhou Medical University, Xuzhou, China
| | - Xinjiang An
- Department of Cardiology, Xuzhou Children's Hospital of Xuzhou Medical University, Xuzhou, China
| | - Jing Tian
- Department of Cardiology, Xuzhou Children's Hospital of Xuzhou Medical University, Xuzhou, China
| | - Mingyu Fu
- Department of Cardiology, Xuzhou Children's Hospital of Xuzhou Medical University, Xuzhou, China
| | - Qingwen Wang
- Department of Cardiology, Xuzhou Children's Hospital of Xuzhou Medical University, Xuzhou, China
| | - Chunli Li
- Department of Cardiology, Xuzhou Children's Hospital of Xuzhou Medical University, Xuzhou, China
| | - Xiuhua He
- Department of Cardiology, Xuzhou Children's Hospital of Xuzhou Medical University, Xuzhou, China
| | - Ling Niu
- Department of Cardiology, Xuzhou Children's Hospital of Xuzhou Medical University, Xuzhou, China.
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25
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Küllmar M, Saadat-Gilani K, Weiss R, Massoth C, Lagan A, Cortés MN, Gerss J, Chawla LS, Fliser D, Meersch M, Zarbock A. Kinetic Changes of Plasma Renin Concentrations Predict Acute Kidney Injury in Cardiac Surgery Patients. Am J Respir Crit Care Med 2021; 203:1119-1126. [PMID: 33320784 DOI: 10.1164/rccm.202005-2050oc] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Rationale: The renin-angiotensin-aldosterone system is a major pathway in regulating blood pressure, glomerular filtration, and fluid homeostasis. During inflammatory diseases, generation of angiotensin II might be disturbed, leading to increased renin concentrations. Cardiac surgery and the use of cardiopulmonary bypass both induce inflammatory response and cardiovascular instability, which can contribute to acute kidney injury (AKI).Objectives: To investigate whether renin concentrations are associated with hypotension and AKI.Methods: This is a single-center, prospective, observational study among patients undergoing cardiac surgery.Measurements and Main Results: The primary endpoint was the occurrence of AKI within 72 hours after cardiac surgery. A total of 197 patients were available for the primary analysis. The median renin serum concentration was 40.2 μU/ml (quartile 1 [Q1]-Q3, 9.3-144.4) at baseline and 51.3 μU/ml (Q1-Q3, 19.1-167.0) 4 hours after cardiac surgery, whereas the difference between postoperation and preoperation concentrations (Δ-renin) was 3.7 μU/ml (Q1-Q3, -22.7 to 50.9). Patients with an elevated Δ-renin developed an AKI significantly more often (43% vs. 12.2%; P < 0.001). High Δ-renin after cardiac surgery was associated with a significantly lower mean arterial pressure, longer time on vasopressors, and longer length of ICU and hospital stay. The area under the curve (AUC) of Δ-renin for the prediction of AKI (AUC, 0.817; 95% confidence interval, 0.747-0.887) was significantly greater compared with the AUC of the postoperative renin concentrations (AUC, 0.702; 95% CI, 0.610-0.793; P = 0.007).Conclusions: Elevated renin concentrations were associated with cardiovascular instability and increased AKI after cardiac surgery. Elevated renin concentrations could be used to identify high-risk patients for cardiovascular instability and AKI who would benefit from timely intervention that could improve their outcomes.
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Affiliation(s)
- Mira Küllmar
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Muenster, Muenster, Germany
| | - Khaschayar Saadat-Gilani
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Muenster, Muenster, Germany
| | - Raphael Weiss
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Muenster, Muenster, Germany
| | - Christina Massoth
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Muenster, Muenster, Germany
| | - Anas Lagan
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Muenster, Muenster, Germany
| | - Manuel Núñez Cortés
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Muenster, Muenster, Germany
| | - Joachim Gerss
- Institute of Biostatistics and Clinical Research, University of Münster, Münster, Germany
| | | | - Danilo Fliser
- Department of Internal Medicine 4, Nephrology and Hypertension, Saarland University Hospital, Homburg/Saar, Germany
| | - Melanie Meersch
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Muenster, Muenster, Germany
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Muenster, Muenster, Germany
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26
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Laghlam D, Jozwiak M, Nguyen LS. Renin-Angiotensin-Aldosterone System and Immunomodulation: A State-of-the-Art Review. Cells 2021; 10:cells10071767. [PMID: 34359936 PMCID: PMC8303450 DOI: 10.3390/cells10071767] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 06/30/2021] [Accepted: 07/09/2021] [Indexed: 12/11/2022] Open
Abstract
The renin–angiotensin system (RAS) has long been described in the field of cardiovascular physiology as the main player in blood pressure homeostasis. However, other effects have since been described, and include proliferation, fibrosis, and inflammation. To illustrate the immunomodulatory properties of the RAS, we chose three distinct fields in which RAS may play a critical role and be the subject of specific treatments. In oncology, RAS hyperactivation has been associated with tumor migration, survival, cell proliferation, and angiogenesis; preliminary data showed promise of the benefit of RAS blockers in patients treated for certain types of cancer. In intensive care medicine, vasoplegic shock has been associated with severe macro- and microcirculatory imbalance. A relative insufficiency in angiotensin II (AngII) was associated to lethal outcomes and synthetic AngII has been suggested as a specific treatment in these cases. Finally, in solid organ transplantation, both AngI and AngII have been associated with increased rejection events, with a regional specificity in the RAS activity. These elements emphasize the complexity of the direct and indirect interactions of RAS with immunomodulatory pathways and warrant further research in the field.
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27
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Intravenous calcitriol administration regulates the renin-angiotensin system and attenuates acute lung injury in obese mice complicated with polymicrobial sepsis. Biomed Pharmacother 2021; 141:111856. [PMID: 34217099 DOI: 10.1016/j.biopha.2021.111856] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 06/13/2021] [Accepted: 06/24/2021] [Indexed: 01/26/2023] Open
Abstract
Calcitriol, an active form of vitamin D, has immunomodulatory and anti-inflammatory properties. Vitamin D levels have inverse correlation with sepsis outcomes and obesity may aggravate the severity of the diseases. This study administered calcitriol to investigate its impact on sepsis-induced acute lung injury (ALI) in obese mice. Mice were fed a high-fat diet to induce obesity and were randomly assigned to control or sepsis groups, which were intravenously administered either saline (SS) or calcitriol (SD). Sepsis was induced by cecal ligation and puncture (CLP). Saline or calcitriol was injected 1 h after CLP via tail vein. Mice were sacrificed at either 12 or 24 h post-CLP and survival rates were observed. The results demonstrated that sepsis caused upregulation of inflammatory mediators and downregulation of renin-angiotensin system (RAS)-associated gene expressions in the lungs of obese mice. Cluster of differentiation 68 (CD68) expression and myeloperoxidase (MPO) activities also increased. Calcitriol treatment lowered expressions of blood and lung inflammatory mediators at 12 and/or 24 h after CLP. The RAS-proinflammatory-associated angiotensin type 1 receptor (AT1R) was lower while anti-inflammatory Mas receptor and AT2R expressions were higher at 12 h after CLP than those in the SS group. In addition, the SD group exhibited lower CD68 expression and MPO activity. Lower lung injury scores and higher survival rates were also noted in the SD group. The findings suggest that calcitriol treatment after sepsis induction upregulated RAS-associated anti-inflammatory pathway and decreased immune cell infiltration, which may have alleviated the severity of ALI of obese mice.
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28
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Lee HW, Suh JK, Jang E, Lee SM. Effect of angiotensin converting enzyme inhibitor and angiotensin II receptor blocker on the patients with sepsis. Korean J Intern Med 2021; 36:371-381. [PMID: 32264653 PMCID: PMC7969078 DOI: 10.3904/kjim.2019.262] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 11/25/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND/AIMS Inhibitors of the renin-angiotensin system, angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs), reportedly have anti-inflammatory effects. This study assessed the association of prior use of ACE inhibitors and ARBs with sepsis-related clinical outcomes. METHODS A population-based observational study was conducted using the Health Insurance Review and Assessment Service claims data. Among the adult patients hospitalized with new onset of sepsis in 2012, patients who took ARBs or ACE inhibitors at least 30 days prior to hospitalization were analyzed. Generalized linear models and logistic regression were used to examine the relation between the prior use of medication and clinical outcomes, such as in-hospital mortality, mechanical ventilation, and length of stay. RESULTS Of a total of 27,628 patients who were hospitalized for sepsis, the ACE inhibitor, ARB, and non-user groups included 1,214 (4.4%), 3,951 (14.4%), and 22,463 (82.1%) patients, respectively. As the patients in the ACE inhibitor and ARB groups had several comorbid conditions, higher rates of intensive care unit admission, hemodialysis, and mechanical ventilation were observed. However, after covariate adjustment, the use of ACE inhibitor (odds ratio [OR], 0.752; 95% confidence interval [CI], 0.661 to 0.855) or ARB (OR, 0.575; 95% CI, 0.532 to 0.621) was significantly associated with a lower rate of in-hospital mortality. CONCLUSION Pre-hospitalization use of ACE inhibitors or ARBs for sepsis was an independent factor for a lower rate of in-hospital mortality.
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Affiliation(s)
- Hyun Woo Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jae Kyung Suh
- National Evidence-Based Healthcare Collaborating Agency, Seoul, Korea
| | - Eunjin Jang
- Department of Information Statistics, Andong National University, Andong, Korea
| | - Sang-Min Lee
- National Evidence-Based Healthcare Collaborating Agency, Seoul, Korea
- Correspondence to Sang-Min Lee, Ph.D. Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea Tel: +82-2-2072-0833 Fax: +82-2-764-2199 E-mail:
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29
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Mannan S, Tordik PA, Martinho FC, Chivian N, Hirschberg CS. Dental Abscess to Septic Shock: A Case Report and Literature Review. J Endod 2021; 47:663-670. [PMID: 33422573 DOI: 10.1016/j.joen.2020.12.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 12/29/2020] [Indexed: 12/21/2022]
Abstract
Sepsis is a leading cause of death in the United States, with a mortality rate in excess of 215,000 deaths per year. It may lead to septic shock, a complex pathophysiological process with microbial and host response events that progress to multisystem derangement. There is poor documentation of the relationship between dental infection and septic shock, with only a few case reports of septic shock secondary to dentoalveolar abscess. Presented is a case of sepsis/septic shock in a 23-year-old man with signs and symptoms of pulpal necrosis, acute apical abscess, and canine space infection that rapidly progressed to an altered mental state, hyperthermia, tachycardia, hypotension, acute respiratory failure, diarrhea, renal insufficiency, lactic acidosis, leukocytosis, and hyperglycemia. Once septic shock develops, the mortality rate is nearly 50%. Early antimicrobial intervention is associated with surviving severe sepsis, making it critical for dentists to understand local factors leading to the crisis and the signs and symptoms of the sepsis-septic shock continuum.
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Affiliation(s)
- Saurabh Mannan
- Endodontics Division, Department of Advanced Oral Sciences and Therapeutics, University of Maryland School of Dentistry, Baltimore, Maryland
| | - Patricia A Tordik
- Endodontics Division, Department of Advanced Oral Sciences and Therapeutics, University of Maryland School of Dentistry, Baltimore, Maryland.
| | - Frederico C Martinho
- Endodontics Division, Department of Advanced Oral Sciences and Therapeutics, University of Maryland School of Dentistry, Baltimore, Maryland
| | - Noah Chivian
- Department of Endodontics, Rutgers School of Dental Medicine, Newark, New Jersey
| | - Craig S Hirschberg
- Department of Endodontics, Rutgers School of Dental Medicine, Newark, New Jersey
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30
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Bellomo R, Forni LG, Busse LW, McCurdy MT, Ham KR, Boldt DW, Hästbacka J, Khanna AK, Albertson TE, Tumlin J, Storey K, Handisides D, Tidmarsh GF, Chawla LS, Ostermann M. Renin and Survival in Patients Given Angiotensin II for Catecholamine-Resistant Vasodilatory Shock. A Clinical Trial. Am J Respir Crit Care Med 2020; 202:1253-1261. [PMID: 32609011 PMCID: PMC7605187 DOI: 10.1164/rccm.201911-2172oc] [Citation(s) in RCA: 107] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Rationale: Exogenous angiotensin II increases mean arterial pressure in patients with catecholamine-resistant vasodilatory shock (CRVS). We hypothesized that renin concentrations may identify patients most likely to benefit from such therapy. Objectives: To test the kinetic changes in renin concentrations and their prognostic value in patients with CRVS. Methods: We analyzed serum samples from patients enrolled in the ATHOS-3 (Angiotensin II for the Treatment of High-Output Shock) trial for renin, angiotensin I, and angiotensin II concentrations before the start of administration of angiotensin II or placebo and after 3 hours. Measurements and Main Results: Baseline serum renin concentration (normal range, 2.13–58.78 pg/ml) was above the upper limits of normal in 194 of 255 (76%) study patients with a median renin concentration of 172.7 pg/ml (interquartile range [IQR], 60.7 to 440.6 pg/ml), approximately threefold higher than the upper limit of normal. Renin concentrations correlated positively with angiotensin I/II ratios (r = 0.39; P < 0.001). At 3 hours after initiation of angiotensin II therapy, there was a 54.3% reduction (IQR, 37.9% to 66.5% reduction) in renin concentration compared with a 14.1% reduction (IQR, 37.6% reduction to 5.1% increase) with placebo (P < 0.0001). In patients with renin concentrations above the study population median, angiotensin II significantly reduced 28-day mortality to 28 of 55 (50.9%) patients compared with 51 of 73 patients (69.9%) treated with placebo (unstratified hazard ratio, 0.56; 95% confidence interval, 0.35 to 0.88; P = 0.012) (P = 0.048 for the interaction). Conclusions: The serum renin concentration is markedly elevated in CRVS and may identify patients for whom treatment with angiotensin II has a beneficial effect on clinical outcomes. Clinical trial registered with www.clinicaltrials.gov (NCT 02338843).
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Affiliation(s)
- Rinaldo Bellomo
- Centre for Integrated Critical Care, Department of Medicine & Radiology, The University of Melbourne, Melbourne, Victoria, Australia.,Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Lui G Forni
- Intensive Care Unit, Royal Surrey Hospital Foundation Trust, Guildford, United Kingdom.,Department of Clinical & Experimental Medicine, School of Biosciences & Medicine, University of Surrey, Guildford, United Kingdom
| | - Laurence W Busse
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, and
| | - Michael T McCurdy
- Division of Pulmonary & Critical Care Medicine, School of Medicine, University of Maryland, Baltimore, Maryland
| | - Kealy R Ham
- Department of Critical Care, Regions Hospital, University of Minnesota, St. Paul, Minnesota
| | - David W Boldt
- Division of Critical Care, Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles, Los Angeles, California
| | - Johanna Hästbacka
- Division of Intensive Care Medicine, Department of Perioperative, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, School of Medicine, Wake Forest University, Winston-Salem, North Carolina.,Outcomes Research Consortium, Cleveland, Ohio
| | - Timothy E Albertson
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, School of Medicine, University of California-Davis, Northern California Health System, Mather, California
| | - James Tumlin
- Renal Division, Department of Medicine, Emory University Medical Center, Emory University, Atlanta, Georgia
| | | | | | - George F Tidmarsh
- La Jolla Pharmaceutical Company, San Diego, California.,Stanford University, Palo Alto, California
| | - Lakhmir S Chawla
- La Jolla Pharmaceutical Company, San Diego, California.,Department of Medicine, Veterans Affairs Medical Center, San Diego, California; and
| | - Marlies Ostermann
- Department of Critical Care, Guy's & St. Thomas' Hospital, King's College London, London, United Kingdom
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Shomali N, Mahmoodpoor A, Abbas Abad AN, Marofi F, Akbari M, Xu H, Sandoghchian Shotorbani S. The Relationship between Extracellular/intracellular microRNAs and TLRs May Be Used as a Diagnostic and Therapeutic Approach in Sepsis. Immunol Invest 2020; 51:154-169. [PMID: 33054447 DOI: 10.1080/08820139.2020.1817067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
One of the leading causes of death in the intensive care unit (ICU) is sepsis. Different studies have been performed on different markers to determine the cause of sepsis. microRNAs (miRNAs) are non-coding RNAs that can be released both inside and outside the cell and regulate the target gene expression by binding to the 3' untranslated region (3'UTR) of the target genes. TLRs play an important role in innate immunity that can be modulated by biological markers such as microRNAs. In this study, we summarized the recent progress on the role of extracellular and intracellular microRNAs in sepsis. It has also been focused on the association of TLRs with extracellular and intracellular micro RNAs in the regulation of sepsis. In conclusion, this study has provided new insight into the role of microRNAs as a regulator of the TLRs which may lead to the aberrant inflammatory response in sepsis. Therefore, it suggests that both intracellular and extracellular microRNAs may play a therapeutic role in the treatment of sepsis via regulating TLRs. However, yet sepsis and septic shock are medical emergencies and further studies are needed to specify the exact role of microRNAs and TLRs in sepsis.
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Affiliation(s)
- Navid Shomali
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran.,Immunology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.,Department of Immunology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ata Mahmoodpoor
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran.,Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Faroogh Marofi
- Department of Hematology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Morteza Akbari
- Immunology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Huaxi Xu
- Department of Immunology, Jiangsu University, Zhenjiang, China
| | - Siamak Sandoghchian Shotorbani
- Immunology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.,Department of Immunology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran.,Department of Immunology, Jiangsu University, Zhenjiang, China
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Russell JA, Gordon AC, Williams MD, Boyd JH, Walley KR, Kissoon N. Vasopressor Therapy in the Intensive Care Unit. Semin Respir Crit Care Med 2020; 42:59-77. [PMID: 32820475 DOI: 10.1055/s-0040-1710320] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
After fluid administration for vasodilatory shock, vasopressors are commonly infused. Causes of vasodilatory shock include septic shock, post-cardiovascular surgery, post-acute myocardial infarction, postsurgery, other causes of an intense systemic inflammatory response, and drug -associated anaphylaxis. Therapeutic vasopressors are hormones that activate receptors-adrenergic: α1, α2, β1, β2; angiotensin II: AG1, AG2; vasopressin: AVPR1a, AVPR1B, AVPR2; dopamine: DA1, DA2. Vasopressor choice and dose vary widely because of patient and physician practice heterogeneity. Vasopressor adverse effects are excessive vasoconstriction causing organ ischemia/infarction, hyperglycemia, hyperlactatemia, tachycardia, and tachyarrhythmias. To date, no randomized controlled trial (RCT) of vasopressors has shown a decreased 28-day mortality rate. There is a need for evidence regarding alternative vasopressors as first-line vasopressors. We emphasize that vasopressors should be administered simultaneously with fluid replacement to prevent and decrease duration of hypotension in shock with vasodilation. Norepinephrine is the first-choice vasopressor in septic and vasodilatory shock. Interventions that decrease norepinephrine dose (vasopressin, angiotensin II) have not decreased 28-day mortality significantly. In patients not responsive to norepinephrine, vasopressin or epinephrine may be added. Angiotensin II may be useful for rapid resuscitation of profoundly hypotensive patients. Inotropic agent(s) (e.g., dobutamine) may be needed if vasopressors decrease ventricular contractility. Dopamine has fallen to almost no-use recommendation because of adverse effects; angiotensin II is available clinically; there are potent vasopressors with scant literature (e.g., methylene blue); and the novel V1a agonist selepressin missed on its pivotal RCT primary outcome. In pediatric septic shock, vasopressors, epinephrine, and norepinephrine are recommended equally because there is no clear evidence that supports the use of one vasoactive agent. Dopamine is recommended when epinephrine or norepinephrine is not available. New strategies include perhaps patients will be started on several vasopressors with complementary mechanisms of action, patients may be selected for particular vasopressors according to predictive biomarkers, and novel vasopressors may emerge with fewer adverse effects.
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Affiliation(s)
- James A Russell
- Department of Medicine, Centre for Heart Lung Innovation, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada.,Division of Critical Care Medicine, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Anthony C Gordon
- Department of Surgery and Cancer, Division of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London, United Kingdom.,Department of Surgery and Cancer, Intensive Care Unit, Imperial College Healthcare NHS Trust, St Mary's Hospital, London, United Kingdom
| | - Mark D Williams
- Department of Medicine, Indiana University Health Methodist Hospital, Indiana University School of Medicine, Indianapolis, Indiana
| | - John H Boyd
- Department of Medicine, Centre for Heart Lung Innovation, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada.,Division of Critical Care Medicine, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Keith R Walley
- Department of Medicine, Centre for Heart Lung Innovation, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada.,Division of Critical Care Medicine, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Niranjan Kissoon
- Department of Pediatrics, British Columbia Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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Lumlertgul N, Ostermann M. Roles of angiotensin II as vasopressor in vasodilatory shock. Future Cardiol 2020; 16:569-583. [PMID: 32462921 DOI: 10.2217/fca-2020-0019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Shock is an acute condition of circulatory failure resulting in life-threatening organ dysfunction, high morbidity and high mortality. Current management includes fluid and catecholamine therapy to maintain adequate mean arterial pressure and organ perfusion. Norepinephrine is recommended as first-line vasopressor, but other agents are available. Angiotensin II is an alternative potent vasoconstrictor without chronotropic or inotropic properties. Several studies, including a large randomized controlled trial have demonstrated its ability to increase blood pressure with catecholamine-sparing effects. Angiotensin II was consequently approved by the US FDA in 2017 and the EU in 2019 as an add-on vasopressor in vasodilatory shock. This review aims to discuss its basic pharmacology, clinical efficacy, safety and future perspectives.
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Affiliation(s)
- Nuttha Lumlertgul
- Department of Critical Care, Guy's & St. Thomas' Hospital, London SE1 7EH, UK.,Division of Nephrology, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Bangkok 10330, Thailand.,Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok 10330, Thailand.,Critical Care Nephrology Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
| | - Marlies Ostermann
- Department of Critical Care, Guy's & St. Thomas' Hospital, London SE1 7EH, UK
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34
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Heavner MS, McCurdy MT, Mazzeffi MA, Galvagno SM, Tanaka KA, Chow JH. Angiotensin II and Vasopressin for Vasodilatory Shock: A Critical Appraisal of Catecholamine-Sparing Strategies. J Intensive Care Med 2020; 36:635-645. [DOI: 10.1177/0885066620911601] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Vasodilatory shock is a serious medical condition that increases the morbidity and mortality of perioperative and critically ill patients. Norepinephrine is an established first-line therapy for this condition, but at high doses, it may lead to diminishing returns. Oftentimes, secondary noncatecholamine agents are required in those whose hypotension persists. Angiotensin II and vasopressin are both noncatecholamine agents available for the treatment of hypotension in vasodilatory shock. They have distinct modes of action and unique pharmacologic properties when compared to norepinephrine. Angiotensin II and vasopressin have shown promise in certain subsets of the population, such as those with acute kidney injury, high Acute Physiology and Chronic Health Evaluation II scores, or those receiving cardiac surgery. Any benefit from these drugs must be weighed against the risks, as overall mortality has not been shown to decrease mortality in the general population. The aims of this narrative review are to provide insight into the historical use of noncatecholamine vasopressors and to compare and contrast their unique modes of action, physiologic rationale for administration, efficacy, and safety profiles.
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Affiliation(s)
| | - Michael T. McCurdy
- University of Maryland School of Medicine, Department of Medicine, Baltimore, MD, USA
| | - Michael A. Mazzeffi
- University of Maryland School of Medicine, Department of Anesthesiology, Baltimore, MD, USA
| | - Samuel M. Galvagno
- University of Maryland School of Medicine, Department of Anesthesiology, Baltimore, MD, USA
| | - Kenichi A. Tanaka
- University of Maryland School of Medicine, Department of Anesthesiology, Baltimore, MD, USA
| | - Jonathan H. Chow
- University of Maryland School of Medicine, Department of Anesthesiology, Baltimore, MD, USA
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35
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Bellomo R, Wunderink RG, Szerlip H, English SW, Busse LW, Deane AM, Khanna AK, McCurdy MT, Ostermann M, Young PJ, Handisides DR, Chawla LS, Tidmarsh GF, Albertson TE. Angiotensin I and angiotensin II concentrations and their ratio in catecholamine-resistant vasodilatory shock. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:43. [PMID: 32028998 PMCID: PMC7006163 DOI: 10.1186/s13054-020-2733-x] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 01/10/2020] [Indexed: 12/12/2022]
Abstract
Background In patients with vasodilatory shock, plasma concentrations of angiotensin I (ANG I) and II (ANG II) and their ratio may reflect differences in the response to severe vasodilation, provide novel insights into its biology, and predict clinical outcomes. The objective of these protocol prespecified and subsequent post hoc analyses was to assess the epidemiology and outcome associations of plasma ANG I and ANG II levels and their ratio in patients with catecholamine-resistant vasodilatory shock (CRVS) enrolled in the Angiotensin II for the Treatment of High-Output Shock (ATHOS-3) study. Methods We measured ANG I and ANG II levels at baseline, calculated their ratio, and compared these results to values from healthy volunteers (controls). We dichotomized patients according to the median ANG I/II ratio (1.63) and compared demographics, clinical characteristics, and clinical outcomes. We constructed a Cox proportional hazards model to test the independent association of ANG I, ANG II, and their ratio with clinical outcomes. Results Median baseline ANG I level (253 pg/mL [interquartile range (IQR) 72.30–676.00 pg/mL] vs 42 pg/mL [IQR 30.46–87.34 pg/mL] in controls; P < 0.0001) and median ANG I/II ratio (1.63 [IQR 0.98–5.25] vs 0.4 [IQR 0.28–0.64] in controls; P < 0.0001) were elevated, whereas median ANG II levels were similar (84 pg/mL [IQR 23.85–299.50 pg/mL] vs 97 pg/mL [IQR 35.27–181.01 pg/mL] in controls; P = 0.9895). At baseline, patients with a ratio above the median (≥1.63) had higher ANG I levels (P < 0.0001), lower ANG II levels (P < 0.0001), higher albumin concentrations (P = 0.007), and greater incidence of recent (within 1 week) exposure to angiotensin-converting enzyme inhibitors (P < 0.00001), and they received a higher norepinephrine-equivalent dose (P = 0.003). In the placebo group, a baseline ANG I/II ratio <1.63 was associated with improved survival (hazard ratio 0.56; 95% confidence interval 0.36–0.88; P = 0.01) on unadjusted analyses. Conclusions Patients with CRVS have elevated ANG I levels and ANG I/II ratios compared with healthy controls. In such patients, a high ANG I/II ratio is associated with greater norepinephrine requirements and is an independent predictor of mortality, thus providing a biological rationale for interventions aimed at its correction. Trial registration ClinicalTrials.gov identifier NCT02338843. Registered 14 January 2015.
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Affiliation(s)
- Rinaldo Bellomo
- Centre for Integrated Critical Care, Department of Medicine & Radiology, The University of Melbourne, Melbourne, Australia. .,Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
| | - Richard G Wunderink
- Department of Medicine, Pulmonary and Critical Care Division, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Harold Szerlip
- Department of Medicine, Division of Nephrology, Baylor University Medical Center, Dallas, TX, USA
| | - Shane W English
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Department of Medicine (Critical Care), University of Ottawa, Ottawa, Ontario, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Laurence W Busse
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University, Atlanta, GA, USA
| | - Adam M Deane
- Department of Medicine and Radiology, Royal Melbourne Hospital, The University of Melbourne, Melbourne Medical School, Parkville, Australia
| | - Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA.,Outcomes Research Consortium, Cleveland, OH, USA
| | - Michael T McCurdy
- Division of Pulmonary & Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's & St Thomas' Hospital, London, UK
| | - Paul J Young
- Medical Research Institute of New Zealand, Wellington, New Zealand.,Intensive Care Unit, Wellington Hospital, Wellington, New Zealand
| | | | | | | | - Timothy E Albertson
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, School of Medicine, University of California, Davis, Sacramento, CA, USA.,Department of Veterans Affairs, Northern California Health System, Mather, CA, USA
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36
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Outcomes in Patients with Vasodilatory Shock and Renal Replacement Therapy Treated with Intravenous Angiotensin II. Crit Care Med 2019; 46:949-957. [PMID: 29509568 PMCID: PMC5959265 DOI: 10.1097/ccm.0000000000003092] [Citation(s) in RCA: 176] [Impact Index Per Article: 35.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Supplemental Digital Content is available in the text. Objective: Acute kidney injury requiring renal replacement therapy in severe vasodilatory shock is associated with an unfavorable prognosis. Angiotensin II treatment may help these patients by potentially restoring renal function without decreasing intrarenal oxygenation. We analyzed the impact of angiotensin II on the outcomes of acute kidney injury requiring renal replacement therapy. Design: Post hoc analysis of the Angiotensin II for the Treatment of High-Output Shock 3 trial. Setting: ICUs. Patients: Patients with acute kidney injury treated with renal replacement therapy at initiation of angiotensin II or placebo (n = 45 and n = 60, respectively). Interventions: IV angiotensin II or placebo. Measurements and Main Results: Primary end point: survival through day 28; secondary outcomes included renal recovery through day 7 and increase in mean arterial pressure from baseline of ≥ 10 mm Hg or increase to ≥ 75 mm Hg at hour 3. Survival rates through day 28 were 53% (95% CI, 38%–67%) and 30% (95% CI, 19%–41%) in patients treated with angiotensin II and placebo (p = 0.012), respectively. By day 7, 38% (95% CI, 25%–54%) of angiotensin II patients discontinued RRT versus 15% (95% CI, 8%–27%) placebo (p = 0.007). Mean arterial pressure response was achieved in 53% (95% CI, 38%–68%) and 22% (95% CI, 12%–34%) of patients treated with angiotensin II and placebo (p = 0.001), respectively. Conclusions: In patients with acute kidney injury requiring renal replacement therapy at study drug initiation, 28-day survival and mean arterial pressure response were higher, and rate of renal replacement therapy liberation was greater in the angiotensin II group versus the placebo group. These findings suggest that patients with vasodilatory shock and acute kidney injury requiring renal replacement therapy may preferentially benefit from angiotensin II.
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37
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Wong A, Alkazemi A, Eche IM, Petri CR, Sarge T, Cocchi MN. A Retrospective Review of Angiotensin II Use in Adult Patients With Refractory Distributive Shock. J Intensive Care Med 2019; 35:1490-1496. [PMID: 31480886 DOI: 10.1177/0885066619872720] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE Catecholamines are first-line vasopressors for hemodynamic support in distributive shock but are associated with adverse effects, which may be mitigated with noncatecholamine vasopressors. Angiotensin II (ATII) is a noncatecholamine vasopressor recently approved for the management of distributive shock, but limited data support its clinical utility. The purpose of this study was to describe our institution's usage of ATII including patient outcomes (eg, response to therapy, safety profile). MATERIALS AND METHODS Patients who received ATII at our institution were included. Patient demographics, degree of concordance with institutional ATII use guidelines, safety profile of ATII, and response to therapy (1 and 3 hours after ATII initiation) were collected. RESULTS A total of 16 patients received ATII for distributive shock. The median Sequential Organ Failure Assessment score at the time of ATII initiation was 16.5 (interquartile range: 15.8-20.0). Fourteen (87.5%) patients met institutional guidelines for ATII use; 10 (62.5%) and 8 (50.0%) patients met our definition for response at 1 and 3 hours, respectively. No patients developed thrombotic or infectious complications after receiving ATII. CONCLUSIONS In this cohort, ATII appears to be well tolerated in patients with a high predicted mortality. Future studies evaluating the clinical efficacy of ATII are needed to determine its role in the management of distributive shock.
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Affiliation(s)
- Adrian Wong
- Department of Pharmacy Practice, 1825MCPHS University, Boston, MA, USA.,Department of Pharmacy, 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Afrah Alkazemi
- Department of Pharmacy, 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - I Mary Eche
- Department of Pharmacy, 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Camille R Petri
- Division of Pulmonary, Critical Care and Sleep Medicine, 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Todd Sarge
- Department of Anesthesia, Critical Care and Pain Medicine, 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Michael N Cocchi
- Department of Anesthesia, Critical Care and Pain Medicine, 1859Beth Israel Deaconess Medical Center, Boston, MA, USA.,Department of Emergency Medicine, 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
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Carpenter JE, Murray BP, Saghafi R, Thomas B, Lee S, Kleiman R, Punja M, Silver E, Busse LW. Successful Treatment of Antihypertensive Overdose Using Intravenous Angiotensin II. J Emerg Med 2019; 57:339-344. [PMID: 31279637 DOI: 10.1016/j.jemermed.2019.05.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 04/25/2019] [Accepted: 05/06/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Despite multiple treatment options, antihypertensive overdose remains a cause of significant morbidity and mortality. Intravenous angiotensin II (AG II) is approved for use in vasodilatory shock. We describe 2 cases of refractory shock from antihypertensive overdose that were successfully treated using AG II. CASE REPORTS A 24-year-old female presented after an overdose of multiple antihypertensive medications, including an angiotensin converting enzyme inhibitor (ACEI). She developed hypotension that was refractory to norepinephrine, epinephrine, and vasopressin, with a mean arterial pressure (MAP) of 57 mm Hg 9 h after emergency department arrival. Fifteen minutes after starting AG II at 10 ng/kg/min, her heart rate and MAP rose by 7 beats/min and 12 mm Hg, respectively. Her hemodynamic parameters continued to improve thereafter. She developed acute kidney injury, which resolved prior to discharge. The second patient, a 65-year-old male, presented after an overdose of multiple antihypertensive medications, including an ACEI. Despite norepinephrine, epinephrine, and hyperinsulinemia-euglycemia, he remained bradycardic and hypotensive, with a heart rate of 47 beats/min and MAP of 59 mm Hg. Thirty minutes after starting AG II at 10 ng/kg/min, his heart rate was 61 beats/min and MAP was 66 mm Hg. He recovered without apparent sequelae. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Antihypertensive overdose can lead to shock refractory to catecholamine and vasopressin therapy. Our experience suggests that AG II is efficacious in antihypertensive overdose and may be particularly efficacious in instances of ACEI overdose. However, further study is required to confirm the appropriate indication(s).
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Affiliation(s)
| | | | - Ramin Saghafi
- WellStar Pulmonary Medicine, Atlanta, Georgia; WellStar Health System, Atlanta, Georgia
| | - Bo Thomas
- WellStar Health System, Atlanta, Georgia
| | - Sean Lee
- WellStar Pulmonary Medicine, Atlanta, Georgia; WellStar Health System, Atlanta, Georgia
| | | | | | | | - Laurence W Busse
- Department of Critical Care, Emory Johns Creek Hospital, Atlanta, Georgia; Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, Emory University, Atlanta, Georgia
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39
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Abstract
PURPOSE OF REVIEW There are limited vasoactive options to utilize for patients presenting with vasodilatory shock. This review discusses vasoactive agents in vasodilatory, specifically, septic shock and focuses on angiotensin II as a novel, noncatecholamine agent and describes its efficacy, safety, and role in the armamentarium of vasoactive agents utilized in this patient population. RECENT FINDINGS The Angiotensin II for the Treatment of High-Output Shock 3 study evaluated angiotensin II use in patients with high-output, vasodilatory shock and demonstrated reduced background catecholamine doses and improved ability to achieve blood pressure goals associated with the use of angiotensin II. A subsequent analysis showed that patients with a higher severity of illness and relative deficiency of intrinsic angiotensin II and who received angiotensin II had improved mortality rates. In addition, a systematic review showed infrequent adverse reactions with angiotensin II demonstrating its safety for use in patients with vasodilatory shock. SUMMARY With the approval and release of angiotensin II, a new vasoactive agent is now available to utilize in these patients. Overall, the treatment for vasodilatory shock should not be a one-size fits all approach and should be individualized to each patient. A multimodal approach, integrating angiotensin II as a noncatecholamine option should be considered for patients presenting with this disease state.
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40
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Abstract
Classic and nonclassic renin-angiotensin systems (RAS) are 2 sides of an ubiquitous endocrine/paracrine cascade regulating blood pressure and homeostasis. Angiotensin II and angiotensin-converting enzyme (ACE) levels are associated with severity of disease in the critically ill, and are central to the physiology and the pathogenesis of circulatory shock. Angiotensin (1-7) and ACE2 act as an endogenous counterregulatory arm to the angiotensin II/ACE axis. The tissue-based RAS has paracrine effects dissociated from those of the circulating RAS. Exogenous angiotensin II or ACE2 may improve the outcome of septic shock and acute respiratory distress syndrome, respectively.
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Affiliation(s)
- Laurent Bitker
- Department of Intensive Care, ICU Research Office, Austin Hospital, 145 Studley Road, Heidelberg, Victoria 3084, Australia.
| | - Louise M Burrell
- Department of Medicine, University of Melbourne, Austin Health, Austin Hospital, 145 Studley Road, Heidelberg, Victoria 3084, Australia
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41
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42
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Abstract
The Angiotensin II for the Treatment of Vasodilatory Shock (ATHOS-3) trial demonstrated the vasopressor effects and catecholamine-sparing properties of angiotensin II. As a result, the Food and Drug Administration has approved angiotensin II for the treatment of vasodilatory shock. This review details the goals of treatment of vasodilatory shock in addition to the history, current use, and recent research regarding the use of angiotensin II. An illustrative case of the use of angiotensin II is also incorporated for understanding the clinical utility of the drug.
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Affiliation(s)
- Brett J Wakefield
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA; Department of Anesthesiology, Division of Critical Care Medicine, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8054, St Louis, MO 63110, USA
| | - Laurence W Busse
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Emory University School of Medicine, Emory St. Joseph's Hospital, 5665 Peachtree Dunwoody Road, Atlanta, GA 30342, USA
| | - Ashish K Khanna
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA; Center for Critical Care, Department of Outcomes Research, Cleveland Clinic, 9500 Euclid Avenue - G58, Cleveland, OH 44195, USA; Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
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Ostermann M, Boldt DW, Harper MD, Lim GW, Gunnerson K. Angiotensin in ECMO patients with refractory shock. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:288. [PMID: 30382926 PMCID: PMC6211436 DOI: 10.1186/s13054-018-2225-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Accepted: 10/10/2018] [Indexed: 11/24/2022]
Affiliation(s)
- Marlies Ostermann
- Department of Critical Care, King's College London, Guy's & St Thomas' Foundation Hospital, London, SE1 7EH, UK.
| | - David W Boldt
- Department of Anesthesiology and Critical Care Medicine, UCLA Healthcare System, West Los Angeles, USA
| | - Michael D Harper
- Integris Baptist Medical Center, Nazih Zuhdi Transplant Institute, Oklahoma City, USA
| | - George W Lim
- Department of Anesthesiology and Critical Care Medicine, UCLA Healthcare System, West Los Angeles, USA
| | - Kyle Gunnerson
- Departments of Emergency Medicine, Anesthesiology and Internal Medicine, Michigan Center for Integrative Research in Critical Care, University of Michigan, Ann Arbor, MI, USA
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Chawla LS, Chen S, Bellomo R, Tidmarsh GF. Angiotensin converting enzyme defects in shock: implications for future therapy. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:274. [PMID: 30368243 PMCID: PMC6204272 DOI: 10.1186/s13054-018-2202-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 09/24/2018] [Indexed: 01/20/2023]
Affiliation(s)
- Lakhmir S Chawla
- Veterans Affairs Medical Center, San Diego, CA, USA. .,La Jolla Pharmaceutical Company, 4550 Towne Centre Court, San Diego, CA, 92121, USA.
| | - Steve Chen
- La Jolla Pharmaceutical Company, 4550 Towne Centre Court, San Diego, CA, 92121, USA
| | - Rinaldo Bellomo
- School of Medicine, The University of Melbourne, Parkville, Melbourne, VIC, Australia
| | - George F Tidmarsh
- La Jolla Pharmaceutical Company, 4550 Towne Centre Court, San Diego, CA, 92121, USA.,Stanford School of Medicine, Stanford, CA, USA
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Abstract
Angiotensin II (Ang II), part of the renin-angiotensin-aldosterone system (RAS), is a potent vasoconstrictor and has been recently approved for use by the US Food and Drug Administration in high-output shock. Though not a new drug, the recently published Angiotensin II for the Treatment of High Output Shock (ATHOS-3) trial, as well as a number of retrospective analyses have sparked renewed interest in the use of Ang II, which may have a role in treating refractory shock. We describe refractory shock, the unique mechanism of action of Ang II, RAS dysregulation in shock, and the evidence supporting the use of Ang II to restore blood pressure. Evidence suggests that Ang II may preferentially be of benefit in acute kidney injury and acute respiratory distress syndrome, where the RAS is known to be disrupted. Additionally, there may be a role for Ang II in cardiogenic shock, angiotensin converting enzyme inhibitor overdose, cardiac arrest, liver failure, and in settings of extracorporeal circulation.
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Affiliation(s)
- Rachel L Bussard
- Critical Care Pharmacy Specialist, Department of Pharmacy, Emory St Joseph's Hospital, Atlanta, GA, USA
| | - Laurence W Busse
- Department of Critical Care, Emory St Joseph's Hospital, Atlanta, GA, USA,
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, Emory University, Atlanta, GA, USA,
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Li P, Chen XR, Xu F, Liu C, Li C, Liu H, Wang H, Sun W, Sheng YH, Kong XQ. Alamandine attenuates sepsis-associated cardiac dysfunction via inhibiting MAPKs signaling pathways. Life Sci 2018; 206:106-116. [PMID: 29679702 DOI: 10.1016/j.lfs.2018.04.010] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 03/28/2018] [Accepted: 04/10/2018] [Indexed: 12/22/2022]
Abstract
Sepsis-induced myocardial dysfunction represents a major cause of death. Alamandine is an important biologically active peptide. The present study evaluated whether alamandine improves cardiac dysfunction, inflammation, and apoptosis, and affects the signaling pathways involved in these events. Experiments were carried out in mice treated with lipopolysaccharide (LPS) or alamandine, and in neonatal rat cardiomyocytes. Alamandine increased the ejection fraction and fractional shortening, both of which were decreased upon LPS infusion in mice. LPS and alamandine reduced blood pressure, and increased the expression of inducible nitric oxide synthase (iNOS) and endothelial NOS (eNOS) in the heart in mice. The LPS-induced decrease in α-myosin heavy chain (MHC) and β-MHC, and increase in S100 calcium binding protein A8 (S100A8) and S100A9, were reversed by alamandine pre-treatment. Alamandine pre-treatment prevented LPS-induced myocardial inflammation, apoptosis and autophagy. LPS increased p-ERK, p-JNK, and p-p38 levels, which were inhibited by alamandine. Dibutyryl cyclic AMP (db-cAMP) increased p-ERK, p-JNK, and p-p38 levels, and reversed the inhibitory effects of alamandine on the LPS-induced increase in p-ERK, p-JNK, and p-p38. Moreover, db-cAMP reduced the expression of α-MHC and β-MHC in cardiomyocytes, and reversed the almandine-induced attenuation of the LPS-induced decrease in α-MHC and β-MHC. These results indicate that alamandine attenuates LPS-induced cardiac dysfunction, resulting in increased cardiac contractility, and reduced inflammation, autophagy, and apoptosis. Furthermore, alamandine attenuates sepsis induced by LPS via inhibiting the mitogen-activated protein kinases (MAPKs) signaling pathways.
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Affiliation(s)
- Peng Li
- Department of Cardiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xi-Ru Chen
- Department of Cardiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Fei Xu
- Department of Cardiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Chi Liu
- Department of Cardiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Chang Li
- Department of Cardiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hui Liu
- Department of Cardiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China; Department of Ultrasound, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Hui Wang
- Department of Cardiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Wei Sun
- Department of Cardiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yan-Hui Sheng
- Department of Cardiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China.
| | - Xiang-Qing Kong
- Department of Cardiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China.
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Dong L, Li H, Zhang S, Su L. Identification of genes related to consecutive trauma-induced sepsis via gene expression profiling analysis. Medicine (Baltimore) 2018; 97:e0362. [PMID: 29642183 PMCID: PMC5908625 DOI: 10.1097/md.0000000000010362] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
We aimed to identify crucial genes relevant to the development of consecutive trauma-induced sepsis.A microarray dataset was used to identify genes differentially expressed between peripheral blood samples from consecutive traumatized patients complicated with sepsis and not complicated with sepsis. The dataset GSE12624 was obtained from Gene Expression Omnibus, containing 34 peripheral blood samples from consecutive traumatized patients complicated by sepsis and 36 consecutive traumatized controls. The differentially expressed genes (DEGs) were identified using Linear Models for Microarray Data package. Then, gene ontology (GO) enrichment analysis for DEGs was performed by Onto-Express. Subsequently, the protein-protein interaction (PPI) network was constructed and pathway enrichment analysis was performed by Search Tool for the Retrieval of Interacting Genes (STRING). Furthermore, protein complexes in the PPI network were predicted by ClusterONE and validated through GO and Kyoto Encyclopedia of Genes and Genomes pathway enrichment analyses, and protein domain analysis.Totally, 446 upregulated and 447 downregulated DEGs were identified. Some DEGs were related to acyl-CoA binding (eg, ACBD6), chromosome, and centromeric region (eg, CENPN). In the PPI network, some DEGs were enriched in renin-angiotensin system (RAS, eg, AGTR1 and AGTR2). Three predicted protein complexes were validated in the PPI network. Some genes composing protein complex A were associated with cell proliferation (eg, CDC20, CCNB1, MCM4, RPA2, and PRIM2), and several genes composing protein complex F were implicated in regulation of actin cytoskeleton (eg, PFN2, ARPC2, and WASL).The results suggest that those DEGs may be crucial in the etiology of consecutive trauma-induced sepsis, and they are expected to be therapeutic targets.
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Affiliation(s)
| | | | - Shunli Zhang
- Department of Pediatrics, Jining NO.1 People's Hospital, Jining City, Shandong Province, China
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Hall A, Busse LW, Ostermann M. Angiotensin in Critical Care. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:69. [PMID: 29558991 PMCID: PMC5861652 DOI: 10.1186/s13054-018-1995-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2018. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2018 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901 .
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Affiliation(s)
- Anna Hall
- Department of Critical Care, Guy's & St Thomas' NHS Foundation Hospital, London, UK
| | - Laurence W Busse
- Department of Medicine, Emory Saint Joseph's Hospital, Emory University School of Medicine, Atlanta, GA, USA
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's & St Thomas' NHS Foundation Hospital, London, UK.
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Khan A, Benthin C, Zeno B, Albertson TE, Boyd J, Christie JD, Hall R, Poirier G, Ronco JJ, Tidswell M, Hardes K, Powley WM, Wright TJ, Siederer SK, Fairman DA, Lipson DA, Bayliffe AI, Lazaar AL. A pilot clinical trial of recombinant human angiotensin-converting enzyme 2 in acute respiratory distress syndrome. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:234. [PMID: 28877748 PMCID: PMC5588692 DOI: 10.1186/s13054-017-1823-x] [Citation(s) in RCA: 453] [Impact Index Per Article: 64.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 08/22/2017] [Indexed: 12/15/2022]
Abstract
Background Renin-angiotensin system (RAS) signaling and angiotensin-converting enzyme 2 (ACE2) have been implicated in the pathogenesis of acute respiratory distress syndrome (ARDS). We postulated that repleting ACE2 using GSK2586881, a recombinant form of human angiotensin-converting enzyme 2 (rhACE2), could attenuate acute lung injury. Methods We conducted a two-part phase II trial comprising an open-label intrapatient dose escalation and a randomized, double-blind, placebo-controlled phase in ten intensive care units in North America. Patients were between the ages of 18 and 80 years, had an American-European Consensus Criteria consensus diagnosis of ARDS, and had been mechanically ventilated for less than 72 h. In part A, open-label GSK2586881 was administered at doses from 0.1 mg/kg to 0.8 mg/kg to assess safety, pharmacokinetics, and pharmacodynamics. Following review of data from part A, a randomized, double-blind, placebo-controlled investigation of twice-daily doses of GSK2586881 (0.4 mg/kg) for 3 days was conducted (part B). Biomarkers, physiological assessments, and clinical endpoints were collected over the dosing period and during follow-up. Results Dose escalation in part A was well-tolerated without clinically significant hemodynamic changes. Part B was terminated after 39 of the planned 60 patients following a planned futility analysis. Angiotensin II levels decreased rapidly following infusion of GSK2586881, whereas angiotensin-(1–7) and angiotensin-(1–5) levels increased and remained elevated for 48 h. Surfactant protein D concentrations were increased, whereas there was a trend for a decrease in interleukin-6 concentrations in rhACE2-treated subjects compared with placebo. No significant differences were noted in ratio of partial pressure of arterial oxygen to fraction of inspired oxygen, oxygenation index, or Sequential Organ Failure Assessment score. Conclusions GSK2586881 was well-tolerated in patients with ARDS, and the rapid modulation of RAS peptides suggests target engagement, although the study was not powered to detect changes in acute physiology or clinical outcomes. Trial registration ClinicalTrials.gov, NCT01597635. Registered on 26 January 2012. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1823-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Akram Khan
- Div. of Pulmonary & Critical Care Medicine, Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Cody Benthin
- Div. of Pulmonary & Critical Care Medicine, Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Brian Zeno
- Riverside Methodist Hospital, Columbus, OH, USA
| | | | - John Boyd
- St. Paul's Hospital, Vancouver, BC, Canada
| | - Jason D Christie
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Richard Hall
- Nova Scotia Health Authority and Dalhousie University, Halifax, NS, Canada
| | - Germain Poirier
- Charles LeMoyne Hospital, Sherbrooke University, Greenfield Park, QC, Canada
| | - Juan J Ronco
- Critical Care Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Mark Tidswell
- Division of Pulmonary and Critical Care, Department of Medicine, Baystate Medical Center, Springfield, MA, USA
| | | | | | | | | | | | - David A Lipson
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, USA.,GlaxoSmithKline R&D, King of Prussia, PA, USA
| | | | - Aili L Lazaar
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, USA. .,GlaxoSmithKline R&D, King of Prussia, PA, USA.
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