1
|
Abbasciano RG, Tomassini S, Roman MA, Rizzello A, Pathak S, Ramzi J, Lucarelli C, Layton G, Butt A, Lai F, Kumar T, Wozniak MJ, Murphy GJ. Effects of interventions targeting the systemic inflammatory response to cardiac surgery on clinical outcomes in adults. Cochrane Database Syst Rev 2023; 10:CD013584. [PMID: 37873947 PMCID: PMC10594589 DOI: 10.1002/14651858.cd013584.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
BACKGROUND Organ injury is a common and severe complication of cardiac surgery that contributes to the majority of deaths. There are no effective treatment or prevention strategies. It has been suggested that innate immune system activation may have a causal role in organ injury. A wide range of organ protection interventions targeting the innate immune response have been evaluated in randomised controlled trials (RCTs) in adult cardiac surgery patients, with inconsistent results in terms of effectiveness. OBJECTIVES The aim of the review was to summarise the results of RCTs of organ protection interventions targeting the innate immune response in adult cardiac surgery. The review considered whether the interventions had a treatment effect on inflammation, important clinical outcomes, or both. SEARCH METHODS CENTRAL, MEDLINE, Embase, conference proceedings and two trial registers were searched on October 2022 together with reference checking to identify additional studies. SELECTION CRITERIA RCTs comparing organ protection interventions targeting the innate immune response versus placebo or no treatment in adult patients undergoing cardiac surgery where the treatment effect on innate immune activation and on clinical outcomes of interest were reported. DATA COLLECTION AND ANALYSIS Searches, study selection, quality assessment, and data extractions were performed independently by pairs of authors. The primary inflammation outcomes were peak IL-6 and IL-8 concentrations in blood post-surgery. The primary clinical outcome was in-hospital or 30-day mortality. Treatment effects were expressed as risk ratios (RR) and standardised mean difference (SMD) with 95% confidence intervals (CI). Meta-analyses were performed using random effects models, and heterogeneity was assessed using I2. MAIN RESULTS A total of 40,255 participants from 328 RCTs were included in the synthesis. The effects of treatments on IL-6 (SMD -0.77, 95% CI -0.97 to -0.58, I2 = 92%) and IL-8 (SMD -0.92, 95% CI -1.20 to -0.65, I2 = 91%) were unclear due to heterogeneity. Heterogeneity for inflammation outcomes persisted across multiple sensitivity and moderator analyses. The pooled treatment effect for in-hospital or 30-day mortality was RR 0.78, 95% CI 0.68 to 0.91, I2 = 0%, suggesting a significant clinical benefit. There was little or no treatment effect on mortality when analyses were restricted to studies at low risk of bias. Post hoc analyses failed to demonstrate consistent treatment effects on inflammation and clinical outcomes. Levels of certainty for pooled treatment effects on the primary outcomes were very low. AUTHORS' CONCLUSIONS A systematic review of RCTs of organ protection interventions targeting innate immune system activation did not resolve uncertainty as to the effectiveness of these treatments, or the role of innate immunity in organ injury following cardiac surgery.
Collapse
Affiliation(s)
| | | | - Marius A Roman
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Angelica Rizzello
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Suraj Pathak
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Joussi Ramzi
- Leicester Medical School, University of Leicester, Leicester, UK
| | - Carla Lucarelli
- Department of Cardiac Surgery, University of Verona, Verona, Italy
| | - Georgia Layton
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Ayesha Butt
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Florence Lai
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Tracy Kumar
- Leicester Clinical Trials Unit, University of Leicester, Leicester, UK
| | - Marcin J Wozniak
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Gavin J Murphy
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| |
Collapse
|
2
|
Kashiwagi S, Mihara T, Yokoi A, Yokoyama C, Nakajima D, Goto T. Effect of remote ischemic preconditioning on lung function after surgery under general anesthesia: a systematic review and meta-analysis. Sci Rep 2023; 13:17720. [PMID: 37853024 PMCID: PMC10584824 DOI: 10.1038/s41598-023-44833-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 10/12/2023] [Indexed: 10/20/2023] Open
Abstract
Remote ischemic preconditioning (RIPC) protects organs from ischemia-reperfusion injury. Recent trials showed that RIPC improved gas exchange in patients undergoing lung or cardiac surgery. We performed a systematic search to identify randomized controlled trials involving RIPC in surgery under general anesthesia. The primary outcome was the PaO2/FIO2 (P/F) ratio at 24 h after surgery. Secondary outcomes were A-a DO2, the respiratory index, duration of postoperative mechanical ventilation (MV), incidence of acute respiratory distress syndrome (ARDS), and serum cytokine levels. The analyses included 71 trials comprising 7854 patients. Patients with RIPC showed higher P/F ratio than controls (mean difference [MD] 36.6, 95% confidence interval (CI) 12.8 to 60.4, I2 = 69%). The cause of heterogeneity was not identified by the subgroup analysis. Similarly, A-a DO2 (MD 15.2, 95% CI - 29.7 to - 0.6, I2 = 87%) and respiratory index (MD - 0.17, 95% CI - 0.34 to - 0.01, I2 = 94%) were lower in the RIPC group. Additionally, the RIPC group was weaned from MV earlier (MD - 0.9 h, 95% CI - 1.4 to - 0.4, I2 = 78%). Furthermore, the incidence of ARDS was lower in the RIPC group (relative risk 0.73, 95% CI 0.60 to 0.89, I2 = 0%). Serum TNFα was lower in the RIPC group (SMD - 0.6, 95%CI - 1.0 to - 0.3 I2 = 87%). No significant difference was observed in interleukin-6, 8 and 10. Our meta-analysis suggested that RIPC improved oxygenation after surgery under general anesthesia.Clinical trial number: This study protocol was registered in the University Hospital Medical Information Network (registration number: UMIN000030918), https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000035305.
Collapse
Affiliation(s)
- Shizuka Kashiwagi
- Department of Anesthesiology, Yokohama City University Graduate School of Medicine, Yokohama, Japan.
- Department of Anesthesiology, Yokohama City University Hospital, 3-9 Fukuura, Kanazawa-Ku, Yokohama City, Kanagawa-Ken, 236-0004, Japan.
| | - Takahiro Mihara
- Department of Health Data Science, Yokohama City University Graduate School of Data Science, Yokohama, Japan
| | - Ayako Yokoi
- Department of Anesthesiology and Intensive Care Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Chisaki Yokoyama
- Department of Anesthesia, Chiba Children's Hospital, Chiba, Japan
| | - Daisuke Nakajima
- Department of Anesthesiology, Yokohama City University Medical Center, Yokohama City, Japan
| | - Takahisa Goto
- Department of Anesthesiology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| |
Collapse
|
3
|
Guo W, Zhao W, Li D, Jia H, Ren C, Li S, Zhao J, Yu B, Dong J, Guo R, Zhu K, Cao Y, Wang Y, Wang Y, Li Z, Wang Z, Wang D, Hou C, Hausenloy DJ, Chu X, Ji X. Chronic Remote Ischemic Conditioning on Mild Hypertension in the Absence of Antihypertensive Medication: A Multicenter, Randomized, Double-Blind, Proof-of-Concept Clinical Trial. Hypertension 2023; 80:1274-1282. [PMID: 37035920 DOI: 10.1161/hypertensionaha.122.20934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 03/12/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND Exploratory studies have shown that remote ischemic conditioning (RIC) has the potential to lower blood pressure (BP). We investigated whether chronic RIC reduces BP for hypertension. METHODS This is a multicenter, randomized, double-blind, parallel-controlled trial. Patients with an office BP of 130/80 to 160/100 mm Hg and a 24-hour average BP ≥125/75 mm Hg not on antihypertensive medications were recruited. After a 1-week compliance screening phase, they were randomly assigned in a 1:1 ratio to receive RIC or sham RIC twice daily for 4 weeks. The primary efficacy outcome was the change in 24-hour average systolic BP from baseline to 4 weeks. Safety events were assessed over the study period. RESULTS Ninety-five participants were randomly allocated to the RIC (n=49) and sham RIC (n=46) groups. In the intention-to-treat analysis, the reduction in 24-hour average systolic BP was greater in the RIC group than the sham RIC group (-4.6±9.5 versus -0.9±6.8 mm Hg; baseline-adjusted between-group mean difference: -3.6 mm Hg [95% CI, -6.9 to -0.3 mm Hg]; adjusted P=0.035). The per-protocol analysis showed that 24-hour average systolic BP reduced -5.9±8.6 mm Hg in the RIC group and -0.7±6.7 mm Hg in the sham RIC group (baseline-adjusted between-group mean difference: -5.2 mm Hg [95% CI, -8.5 to -1.9 mm Hg]; adjusted P=0.002). No major adverse events were reported in both groups. CONCLUSIONS RIC is safe in patients with mild hypertension and may lower BP in the absence of antihypertensive medications. However, the effects of RIC on clinical outcomes in these patients require further investigation. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT04915313.
Collapse
Affiliation(s)
- Wenting Guo
- Department of Neurology (W.G., W.Z.), Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Wenbo Zhao
- Department of Neurology (W.G., W.Z.), Xuanwu Hospital, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine (W.Z., C.R., Yan Wang), Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Dong Li
- Peking University Care Health Management Center, Beijing, China (D.L., Ying Wang, Z.L.)
| | - Haiying Jia
- Health Management Center, The 306 Hospital of People's Liberation Army, Beijing, China (H.J., Z.W., D.W.)
| | - Changhong Ren
- Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine (W.Z., C.R., Yan Wang), Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Sijie Li
- Department of Emergency (S.L.), Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jing Zhao
- Health Management Center (J.Z., B.Y., J.D., R.G., K.Z., Y.C., X.C.), Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Bingxin Yu
- Health Management Center (J.Z., B.Y., J.D., R.G., K.Z., Y.C., X.C.), Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jian Dong
- Health Management Center (J.Z., B.Y., J.D., R.G., K.Z., Y.C., X.C.), Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Rongfen Guo
- Health Management Center (J.Z., B.Y., J.D., R.G., K.Z., Y.C., X.C.), Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Kun Zhu
- Health Management Center (J.Z., B.Y., J.D., R.G., K.Z., Y.C., X.C.), Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yu Cao
- Health Management Center (J.Z., B.Y., J.D., R.G., K.Z., Y.C., X.C.), Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yan Wang
- Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine (W.Z., C.R., Yan Wang), Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Ying Wang
- Peking University Care Health Management Center, Beijing, China (D.L., Ying Wang, Z.L.)
| | - Zunshan Li
- Peking University Care Health Management Center, Beijing, China (D.L., Ying Wang, Z.L.)
| | - Zhen Wang
- Health Management Center, The 306 Hospital of People's Liberation Army, Beijing, China (H.J., Z.W., D.W.)
| | - Dan Wang
- Health Management Center, The 306 Hospital of People's Liberation Army, Beijing, China (H.J., Z.W., D.W.)
| | - Chengbei Hou
- Center for Evidence-Based Medicine (C.H.), Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Derek J Hausenloy
- Cardiovascular and Metabolic Disorders Program, Duke-National University of Singapore Medical School (D.J.H.)
- National Heart Research Institute Singapore, National Heart Centre (D.J.H.)
- Yong Loo Lin School of Medicine, National University Singapore (D.J.H.)
| | - Xi Chu
- Health Management Center (J.Z., B.Y., J.D., R.G., K.Z., Y.C., X.C.), Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xunming Ji
- Department of Neurosurgery (X.J.), Xuanwu Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
4
|
Vlastos D, Zeinah M, Ninkovic-Hall G, Vlachos S, Salem A, Asonitis A, Chavan H, Kalampalikis L, Al Shammari A, Alvarez Gallesio JM, Pons A, Andreadou I, Ikonomidis I. The effects of ischaemic conditioning on lung ischaemia-reperfusion injury. Respir Res 2022; 23:351. [PMID: 36527070 PMCID: PMC9756694 DOI: 10.1186/s12931-022-02288-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 12/09/2022] [Indexed: 12/23/2022] Open
Abstract
Ischaemia-reperfusion injury (IRI) encompasses the deleterious effects on cellular function and survival that result from the restoration of organ perfusion. Despite their unique tolerance to ischaemia and hypoxia, afforded by their dual (pulmonary and bronchial) circulation as well as direct oxygen diffusion from the airways, lungs are particularly susceptible to IRI (LIRI). LIRI may be observed in a variety of clinical settings, including lung transplantation, lung resections, cardiopulmonary bypass during cardiac surgery, aortic cross-clamping for abdominal aortic aneurysm repair, as well as tourniquet application for orthopaedic operations. It is a diagnosis of exclusion, manifesting clinically as acute lung injury (ALI) or acute respiratory distress syndrome (ARDS). Ischaemic conditioning (IC) signifies the original paradigm of treating IRI. It entails the application of short, non-lethal ischemia and reperfusion manoeuvres to an organ, tissue, or arterial territory, which activates mechanisms that reduce IRI. Interestingly, there is accumulating experimental and preliminary clinical evidence that IC may ameliorate LIRI in various pathophysiological contexts. Considering the detrimental effects of LIRI, ranging from ALI following lung resections to primary graft dysfunction (PGD) after lung transplantation, the association of these entities with adverse outcomes, as well as the paucity of protective or therapeutic interventions, IC holds promise as a safe and effective strategy to protect the lung. This article aims to provide a narrative review of the existing experimental and clinical evidence regarding the effects of IC on LIRI and prompt further investigation to refine its clinical application.
Collapse
Affiliation(s)
- Dimitrios Vlastos
- grid.415914.c0000 0004 0399 9999Department of Vascular Surgery, Countess of Chester Hospital, Chester, UK ,grid.411449.d0000 0004 0622 4662Second Department of Cardiology, Attikon University Hospital, Athens, Greece ,Present Address: Liverpool, UK
| | - Mohamed Zeinah
- grid.415992.20000 0004 0398 7066Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK ,grid.7269.a0000 0004 0621 1570Ain Shams University, Cairo, Egypt
| | - George Ninkovic-Hall
- grid.415970.e0000 0004 0417 2395Department of Vascular Surgery, Royal Liverpool University Hospital, Liverpool, UK
| | - Stefanos Vlachos
- grid.411449.d0000 0004 0622 4662Second Department of Cardiology, Attikon University Hospital, Athens, Greece
| | - Agni Salem
- grid.415992.20000 0004 0398 7066Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Athanasios Asonitis
- grid.413157.50000 0004 0590 2070Department of Cardiothoracic Surgery, NHS Golden Jubilee National Hospital, Glascow, UK
| | - Hemangi Chavan
- grid.421662.50000 0000 9216 5443Department of Thoracic Surgery, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Lazaros Kalampalikis
- grid.414012.20000 0004 0622 6596Department of Minimally Invasive Cardiac Surgery, Metropolitan General Hospital, Athens, Greece
| | - Abdullah Al Shammari
- grid.421662.50000 0000 9216 5443Department of Thoracic Surgery, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - José María Alvarez Gallesio
- grid.421662.50000 0000 9216 5443Department of Thoracic Surgery, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Aina Pons
- grid.421662.50000 0000 9216 5443Department of Thoracic Surgery, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Ioanna Andreadou
- grid.5216.00000 0001 2155 0800School of Pharmacy, National and Kapodistrian University of Athens, Athens, Greece
| | - Ignatios Ikonomidis
- grid.411449.d0000 0004 0622 4662Second Department of Cardiology, Attikon University Hospital, Athens, Greece
| |
Collapse
|
5
|
Guo W, Ren C, Zhang B, Zhao W, Gao Y, Yu W, Ji X. Chronic Limb Remote Ischemic Conditioning may have an Antihypertensive Effect in Patients with Hypertension. Aging Dis 2021; 12:2069-2079. [PMID: 34881086 PMCID: PMC8612623 DOI: 10.14336/ad.2021.0604] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 06/06/2021] [Indexed: 12/14/2022] Open
Abstract
Hypertension is the leading preventable risk factor for all-cause morbidity and mortality worldwide. Despite antihypertensive medications have been available for decades, a big challenge we are facing is to increase the blood pressure (BP) control rate among the population. Therefore, it is necessary to search for new antihypertensive means to reduce the burden of disease caused by hypertension. Limb remote ischemic conditioning (LRIC) can trigger endogenous protective effects through transient and repeated ischemia on the limb to protect specific organs and tissues including the brain, heart, and kidney. The mechanisms of LRIC involve the regulation of the autonomic nervous system, releasing humoral factors, improvement of vascular endothelial function, and modulation of immune/inflammatory responses. These underlying mechanisms of LRIC may restrain the pathogenesis of hypertension through multiple pathways theoretically, leading to a potential decline in BP. Several existing studies have explored the impact of LRIC on BP, however, controversial findings were reported. To explore the potential antihypertensive effect of LRIC and the underlying mechanisms, we systematically reviewed the relevant articles to provide an insight into the novel therapy of hypertension.
Collapse
Affiliation(s)
- Wenting Guo
- 1Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Changhong Ren
- 2Beijing Key Laboratory of Hypoxia Conditioning Translational Medicine, Xuanwu Hospital, Capital Medical, Beijing, China.,3Beijing Municipal Geriatric Medical Research Center, Beijing, China
| | - Bowei Zhang
- 1Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Wenbo Zhao
- 1Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,2Beijing Key Laboratory of Hypoxia Conditioning Translational Medicine, Xuanwu Hospital, Capital Medical, Beijing, China
| | - Yu Gao
- 5Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Wantong Yu
- 1Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xunming Ji
- 1Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,2Beijing Key Laboratory of Hypoxia Conditioning Translational Medicine, Xuanwu Hospital, Capital Medical, Beijing, China.,4Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
6
|
Cho YJ, Kim WH. Perioperative Cardioprotection by Remote Ischemic Conditioning. Int J Mol Sci 2019; 20:ijms20194839. [PMID: 31569468 PMCID: PMC6801656 DOI: 10.3390/ijms20194839] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 09/11/2019] [Accepted: 09/27/2019] [Indexed: 12/24/2022] Open
Abstract
Remote ischemic conditioning has been investigated for cardioprotection to attenuate myocardial ischemia/reperfusion injury. In this review, we provide a comprehensive overview of the current knowledge of the signal transduction pathways of remote ischemic conditioning according to three stages: Remote stimulus from source organ; protective signal transfer through neuronal and humoral factors; and target organ response, including myocardial response and coronary vascular response. The neuronal and humoral factors interact on three levels, including stimulus, systemic, and target levels. Subsequently, we reviewed the clinical studies evaluating the cardioprotective effect of remote ischemic conditioning. While clinical studies of percutaneous coronary intervention showed relatively consistent protective effects, the majority of multicenter studies of cardiac surgery reported neutral results although there have been several promising initial trials. Failure to translate the protective effects of remote ischemic conditioning into cardiac surgery may be due to the multifactorial etiology of myocardial injury, potential confounding factors of patient age, comorbidities including diabetes, concomitant medications, and the coadministered cardioprotective general anesthetic agents. Given the complexity of signal transfer pathways and confounding factors, further studies should evaluate the multitarget strategies with optimal measures of composite outcomes.
Collapse
Affiliation(s)
- Youn Joung Cho
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea.
| | - Won Ho Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea.
| |
Collapse
|