1
|
Nanchal R, Subramanian R, Alhazzani W, Dionne JC, Peppard WJ, Singbartl K, Truwit J, Al-Khafaji AH, Killian AJ, Alquraini M, Alshammari K, Alshamsi F, Belley-Cote E, Cartin-Ceba R, Hollenberg SM, Galusca DM, Huang DT, Hyzy RC, Junek M, Kandiah P, Kumar G, Morgan RL, Morris PE, Olson JC, Sieracki R, Steadman R, Taylor B, Karvellas CJ. Guidelines for the Management of Adult Acute and Acute-on-Chronic Liver Failure in the ICU: Neurology, Peri-Transplant Medicine, Infectious Disease, and Gastroenterology Considerations. Crit Care Med 2023; 51:657-676. [PMID: 37052436 DOI: 10.1097/ccm.0000000000005824] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
OBJECTIVES To develop evidence-based recommendations for clinicians caring for adults with acute liver failure (ALF) or acute on chronic liver failure (ACLF) in the ICU. DESIGN The guideline panel comprised 27 members with expertise in aspects of care of the critically ill patient with liver failure or methodology. We adhered to the Society of Critical Care Medicine standard operating procedures manual and conflict-of-interest policy. Teleconferences and electronic-based discussion among the panel, as well as within subgroups, served as an integral part of the guideline development. INTERVENTIONS In part 2 of this guideline, the panel was divided into four subgroups: neurology, peri-transplant, infectious diseases, and gastrointestinal groups. We developed and selected Population, Intervention, Comparison, and Outcomes (PICO) questions according to importance to patients and practicing clinicians. For each PICO question, we conducted a systematic review and meta-analysis where applicable. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation approach. We used the evidence to decision framework to facilitate recommendations formulation as strong or conditional. We followed strict criteria to formulate best practice statements. MEASUREMENTS AND MAIN RESULTS We report 28 recommendations (from 31 PICO questions) on the management ALF and ACLF in the ICU. Overall, five were strong recommendations, 21 were conditional recommendations, two were best-practice statements, and we were unable to issue a recommendation for five questions due to insufficient evidence. CONCLUSIONS Multidisciplinary, international experts formulated evidence-based recommendations for the management ALF and ACLF patients in the ICU, acknowledging that most recommendations were based on low quality and indirect evidence.
Collapse
Affiliation(s)
- Rahul Nanchal
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, WI
| | | | - Waleed Alhazzani
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Joanna C Dionne
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | | | | | | | | | | | | | | | | | | | | | | | - David T Huang
- University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | - Mats Junek
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Gagan Kumar
- Northeast Georgia Medical Center, Gainesville, GA
| | - Rebecca L Morgan
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Peter E Morris
- University of Kentucky College of Medicine, Lexington, KY
| | - Jody C Olson
- Kansas University Medical Center, Kansas City, KS
| | | | - Randolph Steadman
- University of California Los Angeles Medical Center, Los Angeles, CA
| | | | - Constantine J Karvellas
- Department of Critical Care Medicine and Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, AB, Canada
| |
Collapse
|
2
|
Speiser LJ, Graf EH, Seville MT, Singbartl K, Dalton ML, Harrington D, Kretschmer M, Kuljanin M, Zabel K, Sunenshine R, Ruberto I, Venkat H, Grys TE. Burkholderia pseudomallei Laboratory Exposure, Arizona, USA. Emerg Infect Dis 2023; 29:1061-1063. [PMID: 37081593 PMCID: PMC10124630 DOI: 10.3201/eid2905.221865] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/22/2023] Open
Abstract
We describe an incidental Burkholderia pseudomallei laboratory exposure in Arizona, USA. Because melioidosis cases are increasing in the United States and B. pseudomallei reservoirs have been discovered in the Gulf Coast Region, US laboratory staff could be at increased risk for B. pseudomallei exposure.
Collapse
|
3
|
Nanchal R, Subramanian R, Alhazzani W, Dionne JC, Peppard WJ, Singbartl K, Truwit J, Al-Khafaji AH, Killian AJ, Alquraini M, Alshammari K, Alshamsi F, Belley-Cote E, Cartin-Ceba R, Hollenberg SM, Galusca DM, Huang DT, Hyzy RC, Junek M, Kandiah P, Kumar G, Morgan RL, Morris PE, Olson JC, Sieracki R, Steadman R, Taylor B, Karvellas CJ. Executive Summary: Guidelines for the Management of Adult Acute and Acute-on-Chronic Liver Failure in the ICU: Neurology, Peri-Transplant Medicine, Infectious Disease, and Gastroenterology Considerations. Crit Care Med 2023; 51:653-656. [PMID: 37052435 DOI: 10.1097/ccm.0000000000005825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Affiliation(s)
- Rahul Nanchal
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, WI
| | | | - Waleed Alhazzani
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Joanna C Dionne
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | | | | | | | | | | | | | | | | | | | | | | | - David T Huang
- University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | - Mats Junek
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Gagan Kumar
- Northeast Georgia Medical Center, Gainesville, GA
| | - Rebecca L Morgan
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Peter E Morris
- University of Kentucky College of Medicine, Lexington, KY
| | - Jody C Olson
- Kansas University Medical Center, Kansas City, KS
| | | | - Randolph Steadman
- University of California Los Angeles Medical Center, Los Angeles, CA
| | | | - Constantine J Karvellas
- Department of Critical Care Medicine and Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, AB, Canada
| |
Collapse
|
4
|
Prasad A, Brehm C, Singbartl K. The impact of preservation and recovery of renal function on survival after veno-arterial extracorporeal life support: A retrospective cohort study. Artif Organs 2023; 47:554-565. [PMID: 36325712 DOI: 10.1111/aor.14449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 09/23/2022] [Accepted: 10/04/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Veno-arterial extracorporeal life support (V-A ECLS) has become a cornerstone in the management of critical cardiogenic shock, but it can also precipitate organ injury, e.g., acute kidney injury (AKI). Available studies highlight the effect of non-cardiac organ injury on patient outcomes. Only very little is known about the impact of non-cardiac organ recovery on patient survival. AKI occurs frequently during cardiogenic shock and carries a poor prognosis. We have developed descriptive models to hypothesize on the role of AKI severity versus that of recovery of renal function for patient survival. METHODS Retrospective, observational study including 175 patients who were successfully decannulated from V-A ECLS. We assessed AKI severity using the "Kidney Disease: Improving Global Outcomes" (KDIGO) criteria. We defined recovered or preserved renal function (RPRF) prior to decannulation from V-A ECLS as 0 (AKI with no improvement) or 1 (no AKI or AKI with improvement). We classified patient outcomes as alive or dead at hospital discharge. RESULTS 78% (n = 138) of all patients survived hospital discharge of which 38% (n = 67) never developed AKI. After adjusting for shock severity and non-renal organ injury, RPRF emerged as an independent predictor of survival in both the overall cohort [OR (95% CI) - 4.11 (1.72-9.79)] and the AKI-only sub-cohort [OR (95% CI) - 5.18 (1.8-14.92)]. Neither maximum KDIGO stage nor KDIGO stage at the end of V-A ECLS was independently associated with survival. CONCLUSIONS Our model identifies RPRF, but not AKI severity, as an independent predictor of hospital survival in patients undergoing V-A ECLS for cardiogenic shock. We hypothesize that recovered or preserved non-cardiac organ function during V-A ECLS is crucial for patient survival.
Collapse
Affiliation(s)
- Amit Prasad
- Heart and Vascular Institute, PennState Health, Hershey, Pennsylvania, USA
| | - Christoph Brehm
- Heart and Vascular Institute, PennState Health, Hershey, Pennsylvania, USA
| | - Kai Singbartl
- Department of Critical Care Medicine, Mayo Clinic, Phoenix, Arizona, USA
| |
Collapse
|
5
|
Smith BB, Bosch W, O'Horo JC, Girardo ME, Bolton PB, Murray AW, Hirte IL, Singbartl K, Martin DP. Surgical Site Infections During the Covid-19 Era: A Retrospective, Multicenter Analysis. Am J Infect Control 2022; 51:607-611. [PMID: 36162605 PMCID: PMC9500048 DOI: 10.1016/j.ajic.2022.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 09/15/2022] [Accepted: 09/16/2022] [Indexed: 11/28/2022]
Abstract
Background Surgical site infections (SSIs) are an undesired perioperative outcome. Recent studies have shown increases in hospital acquired infections during the coronavirus disease 2019 (COVID-19) pandemic. The objective of this study was to evaluate postoperative SSIs in the COVID-19-era compared to a historical cohort at a large, multicenter, academic institution. Methods A retrospective review of all patients who underwent National Health and Safety Network (NHSN) inpatient surgical procedures between January 1, 2018 and December 31, 2020. Patients from the COVID-19-era (March-December 2020) were compared and matched 1:1 with historical controls (2018/2019) utilizing the standardized infection ratio (SIR) to detect difference. Results/Discussion During the study period, 29,904 patients underwent NHSN procedures at our institution. When patients from the matched cohort (2018/2019) were compared to the COVID-19-era cohort (2020), a decreased risk of SSI was observed following colorectal surgery (RR = 0.94, 95% CI [0.65, 1.37], P = .76), hysterectomy (RR = 0.88, 95% CI [0.39, 1.99], P = .75), and knee prothesis surgery (RR = 0.95, 95% CI [0.52, 1.74], P = .88), though not statistically significant. An increased risk of SSI was observed following hip prosthesis surgery (RR 1.09, 95% CI [0.68, 1.75], P = .72), though not statistically significant. Conclusions The risk of SSI in patients who underwent NHSN inpatient surgical procedures in 2020 with perioperative COVID-19 precautions was not significantly different when compared to matched controls at our large, multicenter, academic institution.
Collapse
Affiliation(s)
- Bradford B Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 5777 E. Mayo Blvd; Phoenix, AZ 85054.
| | - Wendelyn Bosch
- Division of Infectious Diseases, Mayo Clinic, 4500 San Pablo Rd; Jacksonville, FL 32224
| | - John C O'Horo
- Division of Public Health, Infectious Diseases and Occupational Medicine, Mayo Clinic, 200 1(st) St. SW; Rochester, MN 55905; Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 1st St. SW; Rochester, MN 55905
| | - Marlene E Girardo
- Department of Quantitative Health Sciences, Mayo Clinic, 5777 E. Mayo Blvd; Phoenix, AZ 85054
| | - Patrick B Bolton
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 5777 E. Mayo Blvd; Phoenix, AZ 85054
| | - Andrew W Murray
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 5777 E. Mayo Blvd; Phoenix, AZ 85054
| | - Ingrid L Hirte
- Mayo Clinic Alix School of Medicine, 13400 E. Shea Blvd. Scottsdale, AZ 85259
| | - Kai Singbartl
- Division of Critical Care Medicine, Mayo Clinic, 5777 E. Mayo Blvd; Phoenix, AZ 85054
| | - David P Martin
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 1st St. SW; Rochester, MN 55905
| |
Collapse
|
6
|
Molinari L, Del Rio-Pertuz G, Smith A, Landsittel DP, Singbartl K, Palevsky PM, Chawla LS, Huang DT, Yealy DM, Angus DC, Kellum JA. Utility of Biomarkers for Sepsis-Associated Acute Kidney Injury Staging. JAMA Netw Open 2022; 5:e2212709. [PMID: 35583867 PMCID: PMC9118077 DOI: 10.1001/jamanetworkopen.2022.12709] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 03/31/2022] [Indexed: 11/14/2022] Open
Abstract
Importance The 23rd Acute Disease Quality Initiative (ADQI-23) consensus conference proposed a framework to integrate biomarkers into the staging of acute kidney injury (AKI). It is unknown whether tissue inhibitor of metalloproteinases 2 (TIMP-2) and insulinlike growth factor binding protein 7 (IGFBP7) could be used for staging. Objective To test whether higher levels of urinary [TIMP-2] × [IGFBP7] are associated with lower survival among patients with the same functional stage of AKI. Design, Setting, and Participants This cohort study was performed using data from the Protocolized Care for Early Septic Shock (ProCESS) trial, which enrolled critically ill patients with septic shock who presented at academic and community emergency departments and intensive care units in the US from March 2008 to May 2013. Patients with end-stage kidney disease, a reference serum creatinine level of 4 mg/dL or greater (to convert to μmol/L, multiply by 76.25), or missing data on serum creatinine levels or urinary levels of [TIMP-2] × [IGFBP7] were excluded. Data were analyzed from October 2020 to October 2021. Exposures The presence of AKI, assessed using Kidney Disease: Improving Global Outcomes criteria within 24 hours after enrollment and the highest AKI stage as well as urinary [TIMP-2] × [IGFBP7] level at 6 hours after enrollment. A previously reported high-specificity cutoff level for [TIMP-2] × [IGFBP7] of 2.0 (ng/mL)2/1000 was used to categorize patients (including those without functional criteria of AKI) according to the new staging system proposed by the ADQI-23 as biomarker negative (urinary [TIMP-2] × [IGFBP7] level ≤2.0 [ng/mL]2/1000) or biomarker positive ([TIMP-2] × [IGFBP7] >2.0 [ng/mL]2/1000). Main Outcomes and Measures Survival (assessed using Kaplan-Meier plots and the log-rank test) and mortality (assessed using relative risk [RR] 30 days after enrollment). Results The analysis included 999 patients with a median age of 61 years (IQR, 50-73 years); 554 (55.5%) were male. Biomarker-positive patients had lower survival and higher mortality at 30 days in the groups with AKI stage 1 (RR, 2.20; 95% CI, 1.02-4.72), stage 2 (RR, 1.53; 95% CI, 1.04-2.27), and stage 3 (RR, 1.61; 95% CI, 1.00-2.60). The associations were specific to patients with AKI. No difference in 30-day survival was found between biomarker-positive and biomarker-negative patients in the absence of functional criteria for AKI (RR, 1.16; 95% CI, 0.45-3.01). Conclusions and Relevance The findings suggest that assessment of the cell-cycle arrest biomarkers TIMP-2 and IGFBP7 may augment AKI staging for patients with functional criteria for AKI.
Collapse
Affiliation(s)
- Luca Molinari
- Center for Critical Care Nephrology, Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Translational Medicine, Università degli Studi del Piemonte Orientale, Novara, Italy
| | - Gaspar Del Rio-Pertuz
- Center for Critical Care Nephrology, Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock
| | - Ali Smith
- Center for Critical Care Nephrology, Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Douglas P. Landsittel
- Department of Biomedical Informatics, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kai Singbartl
- Center for Critical Care Nephrology, Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Critical Care Medicine, Mayo Clinic, Phoenix, Arizona
| | - Paul M. Palevsky
- Kidney Medicine (Renal) Section, Medical Service, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Lakhmir S. Chawla
- Department of Medicine, Veterans Affairs Medical Center, San Diego, California
| | - David T. Huang
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Emergency Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Donald M. Yealy
- Department of Emergency Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Derek C. Angus
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - John A. Kellum
- Center for Critical Care Nephrology, Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| |
Collapse
|
7
|
Sen A, Blakeman S, DeValeria PA, Peworski D, Lanza LA, Downey FX, Alwardt CM, Dobberpuhl JG, DeMarco M, Callisen H, Shively J, McKay K, Singbartl K, Sell-Dottin KA, D’Cunha J, Patel BM. Practical Considerations for and Outcomes of Interfacility ECMO Transfer of Patients With COVID-19 During a Pandemic: Mayo Clinic Experience. Mayo Clin Proc Innov Qual Outcomes 2021; 5:525-531. [PMID: 33686378 PMCID: PMC7927641 DOI: 10.1016/j.mayocpiqo.2021.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Interfacility transport of a critically ill patient with acute respiratory distress syndrome (ARDS) may be necessary for a higher level of care or initiation of extracorporeal membrane oxygenation (ECMO). During the COVID-19 pandemic, ECMO has been used for patients with severe ARDS with successful results. Transporting a patient after ECMO cannulation by the receiving facility brings forth logistic challenges, including availability of adequate personal protective equipment for the transport team and hospital capacity management issues. We report our designated ECMO transport team's experience of 5 patients with COVID-19-associated severe ARDS after cannulation at the referring facility. Focusing on transport-associated logistics, creation of checklists, and collaboration with emergency medical services partners is necessary for safe and good outcomes for patients while maintaining team safety.
Collapse
Affiliation(s)
- Ayan Sen
- Department of Critical Care Medicine, Mayo Clinic Arizona, Phoenix
| | | | | | | | - Louis A. Lanza
- Department of Cardiothoracic Surgery, Mayo Clinic Arizona, Phoenix
| | | | - Cory M. Alwardt
- Department of Cardiothoracic Surgery, Mayo Clinic Arizona, Phoenix
| | | | | | | | | | - Kelly McKay
- Mayo Clinic Center for Military Medicine, Mayo Clinic Arizona, Phoenix
| | - Kai Singbartl
- Department of Cardiothoracic Surgery, Mayo Clinic Arizona, Phoenix
| | | | - Jonathan D’Cunha
- Department of Cardiothoracic Surgery, Mayo Clinic Arizona, Phoenix
| | - Bhavesh M. Patel
- Department of Critical Care Medicine, Mayo Clinic Arizona, Phoenix
| |
Collapse
|
8
|
O'Horo JC, Cerhan JR, Cahn EJ, Bauer PR, Temesgen Z, Ebbert J, Abril A, Abu Saleh OM, Assi M, Berbari EF, Bierle DM, Bosch W, Burger CD, Cano Cevallos EJ, Clements CM, Carmona Porquera EM, Castillo Almeida NE, Challener DW, Chesdachai S, Comba IY, Corsini Campioli CG, Crane SJ, Dababneh AS, Enzler MJ, Fadel HJ, Ganesh R, De Moraes AG, Go JR, Gordon JE, Gurram PR, Guru PK, Halverson EL, Harrison MF, Heaton HA, Hurt R, Kasten MJ, Lee AS, Levy ER, Libertin CR, Mallea JM, Marshall WF, Matcha G, Meehan AM, Franco PM, Morice WG, O'Brien JJ, Oeckler R, Ommen S, Oravec CP, Orenstein R, Ough NJ, Palraj R, Patel BM, Pureza VS, Pickering B, Phelan DM, Razonable RR, Rizza S, Sampathkumar P, Sanghavi DK, Sen A, Siegel JL, Singbartl K, Shah AS, Shweta F, Speicher LL, Suh G, Tabaja H, Tande A, Ting HH, Tontz RC, Vaillant JJ, Vergidis P, Warsame MY, Yetmar ZA, Zomok CCD, Williams AW, Badley AD. Outcomes of COVID-19 With the Mayo Clinic Model of Care and Research. Mayo Clin Proc 2021; 96:601-618. [PMID: 33673913 PMCID: PMC7831394 DOI: 10.1016/j.mayocp.2020.12.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 12/11/2020] [Accepted: 12/15/2020] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To report the Mayo Clinic experience with coronavirus disease 2019 (COVID-19) related to patient outcomes. METHODS We conducted a retrospective chart review of patients with COVID-19 diagnosed between March 1, 2020, and July 31, 2020, at any of the Mayo Clinic sites. We abstracted pertinent comorbid conditions such as age, sex, body mass index, Charlson Comorbidity Index variables, and treatments received. Factors associated with hospitalization and mortality were assessed in univariate and multivariate models. RESULTS A total of 7891 patients with confirmed COVID-19 infection with research authorization on file received care across the Mayo Clinic sites during the study period. Of these, 7217 patients were adults 18 years or older who were analyzed further. A total of 897 (11.4%) patients required hospitalization, and 354 (4.9%) received care in the intensive care unit (ICU). All hospitalized patients were reviewed by a COVID-19 Treatment Review Panel, and 77.5% (695 of 897) of inpatients received a COVID-19-directed therapy. Overall mortality was 1.2% (94 of 7891), with 7.1% (64 of 897) mortality in hospitalized patients and 11.3% (40 of 354) in patients requiring ICU care. CONCLUSION Mayo Clinic outcomes of patients with COVID-19 infection in the ICU, hospital, and community compare favorably with those reported nationally. This likely reflects the impact of interprofessional multidisciplinary team evaluation, effective leveraging of clinical trials and available treatments, deployment of remote monitoring tools, and maintenance of adequate operating capacity to not require surge adjustments. These best practices can help guide other health care systems with the continuing response to the COVID-19 pandemic.
Collapse
Key Words
- apache iv, acute physiology and chronic health evaluation iv
- ards, acute respiratory distress syndrome
- bmi, body mass index
- cci, charlson comorbidity index
- covid-19, coronavirus disease 2019
- eap, expanded access program
- ecmo, extracorporeal membrane oxygenation
- ehr, electronic health record
- icd-10, international classification of diseases, tenth revision
- icu, intensive care unit
- los, length of stay
- nih, national institutes of health
- or, odds ratio
- sars-cov-2, severe acute respiratory syndrome coronavirus 2
- sofa, sequential organ failure assessment
Collapse
Affiliation(s)
- John Charles O'Horo
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN; Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - James R Cerhan
- Division of Health Science Research, Mayo Clinic, Rochester, MN
| | - Elliot J Cahn
- Division of Health Science Research, Mayo Clinic, Rochester, MN
| | - Philippe R Bauer
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | | | - Jon Ebbert
- Division of Community Internal Medicine, Mayo Clinic, Rochester, MN
| | - Andy Abril
- Division of Rheumatology, Mayo Clinic, Jacksonville, FL
| | | | - Mariam Assi
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN
| | - Elie F Berbari
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN
| | - Dennis M Bierle
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
| | - Wendelyn Bosch
- Division of Infectious Diseases, Mayo Clinic, Jacksonville, FL
| | - Charles D Burger
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Jacksonville, FL
| | | | | | - Eva M Carmona Porquera
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN; Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | | | | | | | - Isin Y Comba
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN
| | | | - Sarah J Crane
- Division of Community Internal Medicine, Mayo Clinic, Rochester, MN
| | - Ala S Dababneh
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN
| | - Mark J Enzler
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN
| | - Hind J Fadel
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN
| | - Ravindra Ganesh
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
| | | | - John R Go
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN
| | - Joel E Gordon
- Department of Family Medicine, Mayo Clinic Health System, Mankato, MN
| | - Pooja R Gurram
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN
| | - Pramod K Guru
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL
| | | | | | | | - Ryan Hurt
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
| | - Mary J Kasten
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN
| | - Augustine S Lee
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Jacksonville, FL
| | - Emily R Levy
- Division of Pediatric Critical Care Medicine, Mayo Clinic, Rochester, MN; Division of Pediatric Infectious Diseases, Mayo Clinic, Rochester, MN
| | | | - Jorge M Mallea
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Jacksonville, FL
| | | | - Gautam Matcha
- Department of Internal Medicine, Mayo Clinic, Jacksonville, FL
| | - Anne M Meehan
- Division of Hospital Medicine, Mayo Clinic, Rochester, MN
| | | | - William G Morice
- Department of Laboratory Medicine Pathology, Mayo Clinic, Rochester, MN
| | - Jennifer J O'Brien
- Department of Laboratory Medicine Pathology, Mayo Clinic, Jacksonville, FL
| | - Richard Oeckler
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN; Division of Infectious Diseases, Mayo Clinic, Scottsdale, AZ
| | - Steve Ommen
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | | | | | - Natalie J Ough
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN
| | - Raj Palraj
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN
| | - Bhavesh M Patel
- Department of Critical Care Medicine, Mayo Clinic, Scottsdale, AZ
| | - Vincent S Pureza
- Division of Hospital Internal Medicine, Mayo Clinic, Rochester, MN
| | - Brian Pickering
- Division of Intensive Care, Department of Anesthesia, Mayo Clinic, Rochester, MN
| | - David M Phelan
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN
| | | | - Stacey Rizza
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN
| | | | | | - Ayan Sen
- Department of Critical Care Medicine, Mayo Clinic, Scottsdale, AZ
| | | | - Kai Singbartl
- Department of Critical Care, Mayo Clinic, Rochester, MN
| | - Aditya S Shah
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN
| | - Fnu Shweta
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN
| | - Leigh L Speicher
- Division of General Internal Medicine, Mayo Clinic, Jacksonville, FL
| | - Gina Suh
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN
| | - Hussam Tabaja
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN
| | - Aaron Tande
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN
| | - Henry H Ting
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL
| | - Russell C Tontz
- Division of Occupational Medicine, Mayo Clinic Health System, Mankato, MN
| | | | | | | | | | | | - Amy W Williams
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Andrew D Badley
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN; Department of Molecular Medicine, Mayo Clinic, Rochester, MN.
| |
Collapse
|
9
|
Sadan O, Singbartl K, Kraft J, Plancher JM, Greven ACM, Kandiah P, Pimentel C, Hall CL, Papangelou A, Asbury WH, Hanfelt JJ, Samuels O. Correction to: Low-chloride- versus high-chloride-containing hypertonic solution for the treatment of subarachnoid hemorrhage-related complications: The ACETatE (A low ChloriE hyperTonic solution for brain Edema) randomized trial. J Intensive Care 2020; 8:66. [PMID: 32922802 PMCID: PMC7460738 DOI: 10.1186/s40560-020-00485-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Ofer Sadan
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University Hospital and Emory University School of Medicine, 1364 Clifton Rd. NE, Atlanta, GA 30322 USA
| | - Kai Singbartl
- Department of Critical Care Medicine, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054 USA
| | - Jacqueline Kraft
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University Hospital and Emory University School of Medicine, 1364 Clifton Rd. NE, Atlanta, GA 30322 USA
| | - Joao McONeil Plancher
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University Hospital and Emory University School of Medicine, 1364 Clifton Rd. NE, Atlanta, GA 30322 USA
| | - Alexander C M Greven
- School of Medicine, Emory University, 1364 Clifton Rd. NE, Atlanta, GA 30322 USA
| | - Prem Kandiah
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University Hospital and Emory University School of Medicine, 1364 Clifton Rd. NE, Atlanta, GA 30322 USA
| | - Cederic Pimentel
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University Hospital and Emory University School of Medicine, 1364 Clifton Rd. NE, Atlanta, GA 30322 USA
| | - C L Hall
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University Hospital and Emory University School of Medicine, 1364 Clifton Rd. NE, Atlanta, GA 30322 USA
| | - Alexander Papangelou
- Department of Anesthesiology, Emory University Hospital and Emory University School of Medicine, 1364 Clifton Rd. NE, Atlanta, GA 30322 USA
| | - William H Asbury
- Department of Pharmacy, Emory University Hospital, 1364 Clifton Rd. NE, Atlanta, GA 30322 USA
| | - John J Hanfelt
- Department of Biostatistics and Bioinformatics, Emory University, 1364 Clifton Rd. NE, Atlanta, GA 30322 USA
| | - Owen Samuels
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University Hospital and Emory University School of Medicine, 1364 Clifton Rd. NE, Atlanta, GA 30322 USA
| |
Collapse
|
10
|
Fiorentino M, Xu Z, Smith A, Singbartl K, Palevsky PM, Chawla LS, Huang DT, Yealy DM, Angus DC, Kellum JA. Serial Measurement of Cell-cycle Arrest Biomarkers [TIMP-2]•[IGFBP7] and Risk for Progression to Death, Dialysis or Severe Acute Kidney Injury in Patients with Septic Shock. Am J Respir Crit Care Med 2020; 202:1262-1270. [PMID: 32584598 DOI: 10.1164/rccm.201906-1197oc] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
RATIONALE Urinary tissue inhibitor of metalloproteinases-2 (TIMP-2) and insulin-like growth factor-binding protein 7 (IGFBP7) can predict AKI in patients with sepsis. OBJECTIVES Since most sepsis patients present with AKI, critical questions are whether biomarkers can inform on the response to treatment and whether they might be used to guide therapy. METHODS We measured [TIMP-2]•[IGFBP7] before and after a 6-hour resuscitation in 688 patients with septic shock enrolled in the ProCESS trial. Our primary endpoint was stage 3 AKI, renal replacement therapy or death within 7 days. MEASUREMENTS AND MAIN RESULTS The endpoint was reached in 113 patients (16.4%). In patients with negative [TIMP-2]•[IGFBP7] at baseline, those who became positive (>0.3 units) after resuscitation had 3-times higher risk compared to those who remained negative (21.8% vs 8.5%, p=0.01; OR 3.0, 95%CI 1.31-6.87). Conversely, compared to patients with a positive biomarker at baseline that were still positive at hour 6, risk was reduced for patients who became negative (23.8% vs 9.8%, p=0.01; OR 2.15, 95%CI 1.17-3.95). A positive [TIMP-2]•[IGFBP7] following resuscitation was associated with worse outcomes in both patients with and without AKI at that time point. Clinical response to resuscitation, as judged by APACHE II score, was weakly predictive of the endpoint (AUC 0.68, 95%CI 0.62-0.73) and improved with addition of [TIMP-2]•[IGFBP7] (0.72, 95%CI 0.66-0.77 p=0.03). Different resuscitation protocols did not alter biomarker trajectories, nor outcomes in biomarker positive or negative patients. However, biomarker trajectories were associated with outcome. CONCLUSIONS Changes in urinary [TIMP-2]•[IGFBP7] following initial fluid resuscitation identify sepsis patients with differing risk for progression of AKI. Clinical trial registration available at www.clinicaltrials.gov, ID: NCT00510835.
Collapse
Affiliation(s)
- Marco Fiorentino
- University of Pittsburgh, Center for Critical Care Nephrology; Department of Critical Care Medicine, Pittsburgh, Pennsylvania, United States.,University of Bari, Department of Emergency and Organ Transplantation, Nephrology, Dialysis and Transplantation Unit, Bari, Italy
| | - Zhongying Xu
- University of Pittsburgh Graduate School of Public Health, 51303, Pittsburgh, Pennsylvania, United States
| | - Ali Smith
- University of Pittsburgh, Center for Critical Care Nephrology; Department of Critical Care Medicine, Pittsburgh, Pennsylvania, United States
| | - Kai Singbartl
- University of Pittsburgh, Center for Critical Care Nephrology; Department of Critical Care Medicine, Pittsburgh, Pennsylvania, United States.,Mayo Clinic, Critical Care Medicine, Phoenix, Arizona, United States
| | - Paul M Palevsky
- University of Pittsburgh, 6614, Center for Critical Care Nephrology; Department of Critical Care Medicine, Pittsburgh, Pennsylvania, United States.,Pittsburgh VA Medical Center, Renal Section, Medical Service, Pittsburgh, Pennsylvania, United States.,University of Pittsburgh, Renal-Electrolyte Division, Pittsburgh, Pennsylvania, United States
| | | | - David T Huang
- University of Pittsburgh, The CRISMA (Clinical Research, Investigation and Systems Modeling of Acute Illness) Center, Critical Care Medicine, Pittsburgh, Pennsylvania, United States.,University of Pittsburgh, 6614, Emergency Medicine, Pittsburgh, Pennsylvania, United States
| | - Donald M Yealy
- University of Pittsburgh, Emergency Medicine, Pittsburgh, Pennsylvania, United States
| | - Derek C Angus
- University of Pittsburgh, The CRISMA (Clinical Research, Investigation and Systems Modeling of Acute Illness) Center, Critical Care Medicine, Pittsburgh, Pennsylvania, United States
| | - John A Kellum
- University of Pittsburgh, Center for Critical Care Nephrology; Department of Critical Care Medicine, Pittsburgh, Pennsylvania, United States;
| | | |
Collapse
|
11
|
Prasad A, Cios TJ, Staub-Juergens W, Dziedzina C, Rao S, Singbartl K. Standardization improves postoperative patient handoff experience for junior clinicians. Am J Manag Care 2020; 26:e184-e190. [PMID: 32549068 DOI: 10.37765/ajmc.2020.43494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Effective communication among health care providers is critically important for patient safety. Handoff of patient care from the operating room (OR) to the intensive care unit (ICU) is particularly prone to errors. The process is more complicated in an academic environment in which junior clinicians are being trained. Standardization of, and training in, transitions of care can be a crucial means to improve patient safety. STUDY DESIGN Pre- and postintervention surveys of health care providers. METHODS Based on a workflow analysis and qualitative needs assessments, we developed a 3-step protocol to standardize the handoff of care from the OR to the ICU for adult patients after cardiac surgery and to provide an effective learning environment. The process starts during surgery, continues when the patient leaves the OR, and concludes with the actual face-to-face transfer of care between providers, at the bedside, in the ICU. We conducted pre- and postimplementation surveys among physician trainees and nursing staff regarding their perception of the handoff process. RESULTS We surveyed 42 clinicians before and 33 after implementation of the handoff process. Prior to implementation, most clinicians expressed a need to improve the current process; this perceived need was significantly greater in health care professionals with 4 or fewer years of experience. Post implementation, clinicians saw a significant improvement in information provided, efficiency, relevance to patient care, and psychological safety, a concept in which participants feel accepted and respected in a group setting without fear of negative consequences or judgement. CONCLUSIONS Our workflow-oriented, standardized process for handoff of care from the OR to the ICU can improve perceived communication and psychological safety, especially for junior clinicians.
Collapse
Affiliation(s)
- Amit Prasad
- Department of Anesthesiology and Perioperative Medicine, Penn State Health, 500 University Dr, Hershey, PA 17033.
| | | | | | | | | | | |
Collapse
|
12
|
Sadan O, Singbartl K, Kraft J, Plancher JM, Greven ACM, Kandiah P, Pimentel C, Hall CL, Papangelou A, Asbury WH, Hanfelt JJ, Samuels O. Low-chloride- versus high-chloride-containing hypertonic solution for the treatment of subarachnoid hemorrhage-related complications: The ACETatE (A low ChloriE hyperTonic solution for brain Edema) randomized trial. J Intensive Care 2020; 8:32. [PMID: 32391156 PMCID: PMC7197130 DOI: 10.1186/s40560-020-00449-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 04/17/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Recent reports have demonstrated that among patients with subarachnoid hemorrhage (SAH) treated with hypertonic NaCl, resultant hyperchloremia has been associated with the development of acute kidney injury (AKI). We report a trial comparing the effect of two hypertonic solutions with different chloride contents on the resultant serum chloride concentrations in SAH patients, with a primary outcome aimed at limiting chloride elevation. METHODS A low ChloridE hyperTonic solution for brain Edema (ACETatE) trial is a single-center, double-blinded, double-dummy, randomized pilot trial comparing bolus infusions of 23.4% NaCl and 16.4% NaCl/Na-acetate for the treatment of cerebral edema in patients with SAH. Randomization occurred when patients developed hyperchloremia (serum Cl- ≥ 109 mmol/L) and required hyperosmolar treatment. RESULTS We enrolled 59 patients, of which 32 developed hyperchloremia and required hyperosmolar treatment. 15 patients were randomized to the 23.4% NaCl group, and 17 patients were randomized to the 16.4% NaCl/Na-acetate group. Although serum chloride levels increased similarly in both groups, the NaCl/Acetate group showed a significantly lower Cl- load at the end of the study period (978mEq vs. 2,464mEq, p < 0.01). Secondary outcome analysis revealed a reduced rate of AKI in the Na-acetate group (53.3% in the NaCl group vs. 11.8% in the Na-acetate group, p = 0.01). Both solutions had similar effects on ICP reduction, but NaCl/Acetate treatment had a more prominent effect on immediate post-infusion Na+ concentrations (increase of 2.2 ± 2.8 vs. 1.4 ± 2.6, (p < 0.01)). Proximal tubule renal biomarkers differed in concentration between the two groups. CONCLUSIONS Our pilot trial showed the feasibility and safety of replacing 23.4% NaCl infusions with 16.4% NaCl/Na-acetate infusions to treat cerebral edema in patients with SAH. The degree of hyperchloremia was similar in the two groups. 16.4% NaCl/Na-acetate infusions led to lower Cl- load and AKI rates than 23.4% NaCl infusions. Further multi-center studies are needed to corroborate these results. TRIAL REGISTRATION clinicaltrials.gov # NCT03204955, registered on 6/28/2017.
Collapse
Affiliation(s)
- Ofer Sadan
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University Hospital and Emory University School of Medicine, 1364 Clifton Rd. NE, Atlanta, GA 30322 USA
| | - Kai Singbartl
- Department of Critical Care Medicine, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054 USA
| | - Jacqueline Kraft
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University Hospital and Emory University School of Medicine, 1364 Clifton Rd. NE, Atlanta, GA 30322 USA
| | - Joao McONeil Plancher
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University Hospital and Emory University School of Medicine, 1364 Clifton Rd. NE, Atlanta, GA 30322 USA
| | | | - Prem Kandiah
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University Hospital and Emory University School of Medicine, 1364 Clifton Rd. NE, Atlanta, GA 30322 USA
| | - Cederic Pimentel
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University Hospital and Emory University School of Medicine, 1364 Clifton Rd. NE, Atlanta, GA 30322 USA
| | - C. L. Hall
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University Hospital and Emory University School of Medicine, 1364 Clifton Rd. NE, Atlanta, GA 30322 USA
| | - Alexander Papangelou
- Department of Anesthesiology, Emory University Hospital and Emory University School of Medicine, 1364 Clifton Rd. NE, Atlanta, GA 30322 USA
| | - William H. Asbury
- Department of Pharmacy, Emory University Hospital, 1364 Clifton Rd. NE, Atlanta, GA 30322 USA
| | - John J. Hanfelt
- Department of Biostatistics and Bioinformatics, Emory University, 1364 Clifton Rd. NE, Atlanta, GA 30322 USA
| | - Owen Samuels
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University Hospital and Emory University School of Medicine, 1364 Clifton Rd. NE, Atlanta, GA 30322 USA
| |
Collapse
|
13
|
Peerapornratana S, Priyanka P, Wang S, Smith A, Singbartl K, Palevsky PM, Chawla LS, Yealy DM, Angus DC, Kellum JA. Sepsis-Associated Acute Kidney Disease. Kidney Int Rep 2020; 5:839-850. [PMID: 32518866 PMCID: PMC7270721 DOI: 10.1016/j.ekir.2020.03.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 02/10/2020] [Accepted: 03/02/2020] [Indexed: 12/20/2022] Open
Abstract
Introduction About one-third of critically ill patients with acute kidney injury (AKI) develop persistently decreased kidney function, known as acute kidney disease (AKD), which may progress to chronic kidney disease (CKD). Although sepsis is the most common cause of AKI, little is known about sepsis-associated AKD. Methods Using data from a large randomized trial including 1341 patients with septic shock, we studied patients with stage 2 or 3 AKI on day 1 of hospitalization. We defined AKD as a persistently reduced glomerular filtration rate for >7 days. In addition to clinical data, we measured several urinary biomarkers (tissue inhibitor of metalloproteinases-2 and insulin-like growth factor-binding protein 7 [TIMP-2∗IGFBP7], neutrophil gelatinase-associated lipocalin [NGAL], kidney injury molecule-1 [KIM-1], liver-type fatty acid binding protein, and type 4 collagen) at 0, 6, and 24 hours, to predict AKD. Results Of 598 patients, 119 (19.9%) died within 7 days, 318 (53.2%) had early reversal of AKI within the first 7 days, whereas 161 (26.9%) developed AKD. In patients with early reversal, 45 (14.2%) had relapsed AKI after early reversal, and only about one-third of these recovered. Among patients developing AKD, only 15 (9.3%) recovered renal function prior to discharge. Male sex, African American race, and underlying CKD were more predominant in patients developing AKD. None of the biomarkers tested performed well for prediction of AKD, although NGAL modestly increased the performance of a clinical model. Conclusions AKD is common in patients with septic shock, especially among African American males and those with underlying CKD. Existing AKI biomarkers have limited utility for predicting AKD but might be useful together with clinical variables. Novel predictive biomarkers for renal recovery are needed.
Collapse
Affiliation(s)
- Sadudee Peerapornratana
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,The CRISMA (Clinical Research, Investigation and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Excellence Center for Critical Care Nephrology, Division of Nephrology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Critical Care Nephrology Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Department of Laboratory Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Priyanka Priyanka
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Shu Wang
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,University of Florida Health Cancer Center, Gainesville, Florida, USA.,Department of Biostatistics, University of Florida, Gainesville, Florida, USA
| | - Ali Smith
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Kai Singbartl
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Department of Critical Care Medicine, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Paul M Palevsky
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Renal Section, Medical Service, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Lakhmir S Chawla
- Department of Medicine, Veterans Affairs Medical Center, San Diego, California, USA
| | - Donald M Yealy
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Derek C Angus
- The CRISMA (Clinical Research, Investigation and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - John A Kellum
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,The CRISMA (Clinical Research, Investigation and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | | |
Collapse
|
14
|
Prasad A, Brehm CE, Goldenberg M, Ghodsizad A, Koerner MM, El-Banayosy A, Singbartl K. Early prediction of transition to durable mechanical circulatory support in patients undergoing peripheral veno-arterial extracorporeal membrane oxygenation for critical cardiogenic shock. Artif Organs 2019; 44:402-410. [PMID: 31660618 DOI: 10.1111/aor.13590] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 10/22/2019] [Accepted: 10/24/2019] [Indexed: 01/02/2023]
Abstract
Peripheral veno-arterial extracorporeal membrane oxygenation (pVA-ECMO) has gained increasing value in the management of patients with critical cardiogenic shock (cCS), allowing time for myocardial recovery. Failure of myocardial recovery has life-altering consequences: transition to durable mechanical circulatory support (dMCS), urgent heart transplantation, or withdrawal of support. Clinical factors controlling myocardial recovery under these circumstances remain largely unknown. Using a retrospective cohort, we developed a model for early prediction of transition to dMCS in patients undergoing pVA-ECMO for cCS. To promote myocardial recovery, our clinical management centered around left ventricular pressure unloading, that is, targeting pulmonary capillary wedge pressures (PCWP) ≤18 mm Hg. We collected demographic data, laboratory findings, inotrope use, and two-dimensional transthoracic echocardiography measurements, all limited to the first 72h of pVA-ECMO (D1-3). Out of 70 patients who were alive after pVA-ECMO, 27 patients underwent implantation of dMCS. There was no significant difference in survival to hospital discharge between patients with or without transition to dMCS. Ejection fractionD1-3 (per 10% increase, OR 0.37 [0.17-0.79]) and amount of inotropic supportD1-3 (OR 4.77 [1.6-14.18]) but neither myocardial wall tension nor PCWP emerged as significant predictors of transition to dMCS. Optimism-corrected c-index (0.90 [0.89-0.90]) revealed an excellent discriminative ability of our model. In summary, our model for early prediction of transition to dMCS in patients with cCS undergoing pVA-ECMO identifies indicators of inotropic state as relevant factors. Absence of markers for myocardial oxygen consumption or left ventricular pressure loading allows us to hypothesize sufficient cardiac unloading in our cohort with PCWP-targeted management.
Collapse
Affiliation(s)
- Amit Prasad
- Heart and Vascular Institute, Penn State Health, Hershey, PA, USA
| | | | | | - Ali Ghodsizad
- Miami Transplant Institute, University of Miami, Miami, FL, USA
| | - Michael M Koerner
- Advanced Cardiac Care and Transplant Institute, INTEGRIS Baptist Medical Center, Oklahoma City, OK, USA
| | - Aly El-Banayosy
- Advanced Cardiac Care and Transplant Institute, INTEGRIS Baptist Medical Center, Oklahoma City, OK, USA
| | - Kai Singbartl
- Critical Care Medicine, Mayo Clinic, Phoenix, AZ, USA
| |
Collapse
|
15
|
Joannidis M, Forni LG, Klein SJ, Honore PM, Kashani K, Ostermann M, Prowle J, Bagshaw SM, Cantaluppi V, Darmon M, Ding X, Fuhrmann V, Hoste E, Husain-Syed F, Lubnow M, Maggiorini M, Meersch M, Murray PT, Ricci Z, Singbartl K, Staudinger T, Welte T, Ronco C, Kellum JA. Lung-kidney interactions in critically ill patients: consensus report of the Acute Disease Quality Initiative (ADQI) 21 Workgroup. Intensive Care Med 2019; 46:654-672. [PMID: 31820034 PMCID: PMC7103017 DOI: 10.1007/s00134-019-05869-7] [Citation(s) in RCA: 135] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 11/13/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Multi-organ dysfunction in critical illness is common and frequently involves the lungs and kidneys, often requiring organ support such as invasive mechanical ventilation (IMV), renal replacement therapy (RRT) and/or extracorporeal membrane oxygenation (ECMO). METHODS A consensus conference on the spectrum of lung-kidney interactions in critical illness was held under the auspices of the Acute Disease Quality Initiative (ADQI) in Innsbruck, Austria, in June 2018. Through review and critical appraisal of the available evidence, the current state of research, and both clinical and research recommendations were described on the following topics: epidemiology, pathophysiology and strategies to mitigate pulmonary dysfunction among patients with acute kidney injury and/or kidney dysfunction among patients with acute respiratory failure/acute respiratory distress syndrome. Furthermore, emphasis was put on patients receiving organ support (RRT, IMV and/or ECMO) and its impact on lung and kidney function. CONCLUSION The ADQI 21 conference found significant knowledge gaps about organ crosstalk between lung and kidney and its relevance for critically ill patients. Lung protective ventilation, conservative fluid management and early recognition and treatment of pulmonary infections were the only clinical recommendations with higher quality of evidence. Recommendations for research were formulated, targeting lung-kidney interactions to improve care processes and outcomes in critical illness.
Collapse
Affiliation(s)
- Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
| | - Lui G Forni
- Department of Clinical and Experimental Medicine, Faculty of Health Sciences, University of Surrey, Guildford, UK.,Intensive Care Unit, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Sebastian J Klein
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.,Doctoral College Medical Law and Healthcare, Faculty of Law, University Innsbruck, Innsbruck, Austria
| | - Patrick M Honore
- Department of Intensive Care Medicine, CHU Brugmann University Hospital, Brussels, Belgium
| | - Kianoush Kashani
- Division of Nephrology and Hypertension, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's and St Thomas' Hospital, London, UK
| | - John Prowle
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, London, UK.,William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Vincenzo Cantaluppi
- Nephrology, Dialysis and Kidney Transplantation Unit, Department of Translational Medicine, University of Eastern Piedmont "A. Avogadro", Maggiore della Carità University Hospital, Novara, Italy
| | - Michael Darmon
- Medical ICU, Saint-Louis University Hospital, AP-HP, Paris, France.,Faculté de Médecine, Université Paris-Diderot, Sorbonne-Paris-Cité, Paris, France.,ECSTRA Team, Biostatistics and Clinical Epidemiology, UMR 1153 (Center of Epidemiology and Biostatistic Sorbonne Paris Cité, CRESS), INSERM, Paris, France
| | - Xiaoqiang Ding
- Department of Nephrology, Shanghai Institute of Kidney and Dialysis, Shanghai Key Laboratory of Kidney and Blood Purification, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Valentin Fuhrmann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Medicine B, University Muenster, Muenster, Germany
| | - Eric Hoste
- ICU, Ghent University Hospital, Ghent, Belgium.,Research Fund-Flanders (FWO), Brussels, Belgium
| | - Faeq Husain-Syed
- Division of Nephrology, Pulmonology and Critical Care Medicine, Department of Internal Medicine II, University Hospital Giessen and Marburg, Giessen, Germany
| | - Matthias Lubnow
- Department of Cardiology, Pulmonary and Critical Care Medicine, University Hospital Regensburg, Regensburg, Germany
| | - Marco Maggiorini
- Medical Intensive Care Unit, Institute for Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Melanie Meersch
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Patrick T Murray
- School of Medicine, University College Dublin, Dublin, Ireland.,UCD Catherine McAuley Education and Research Centre, Dublin, Ireland
| | - Zaccaria Ricci
- Department of Cardiology and Cardiac Surgery, Paediatric Cardiac Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Kai Singbartl
- Department of Critical Care Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Thomas Staudinger
- Department of Medicine I, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
| | - Tobias Welte
- Klinik für Pneumologie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Claudio Ronco
- Department of Medicine, University of Padova, Padua, Italy.,International Renal Research Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy.,Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza, Italy
| | - John A Kellum
- Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, PA, USA
| |
Collapse
|
16
|
Miller L, Singbartl K, Chroneos ZC, Ruiz-Velasco V, Lang CH, Bonavia A. Resistin directly inhibits bacterial killing in neutrophils. Intensive Care Med Exp 2019; 7:30. [PMID: 31147868 PMCID: PMC6542889 DOI: 10.1186/s40635-019-0257-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 05/17/2019] [Indexed: 12/12/2022] Open
Abstract
Background Sepsis-induced immunosuppression is a key factor contributing to the morbidity and mortality of critically ill patients, and polymorphonuclear neutrophil dysfunction is believed to be a hallmark of this immunosuppression. Circulating myeloid cells produce the cytokine resistin (RETN), which has been associated with poor outcomes in sepsis/septic shock and can directly inhibit neutrophil function. We previously demonstrated that resistin caused a dose-dependent impairment in neutrophil migration, reactive oxygen species production, and bacterial clearance in neutrophil cell lines. However, the relative antimicrobial responses of other innate immune cells to Gram-positive and Gram-negative infections in the presence of elevated levels of resistin have not been evaluated. We hypothesized that resistin directly contributes to sepsis-induced immunosuppression by selectively targeting the neutrophil component of the innate cellular immune system. Thus, the goal of the present study was to compare the effect of resistin on bacterial killing using monocultures or co-cultures of monocyte and neutrophil cell lines, as well as to extend our findings to primary immune cells. Results Our results indicate that human resistin impairs the ability of neutrophils to kill the Gram-negative bacterium Pseudomonas aeruginosa and the Gram-positive bacterium Staphylococcus aureus. In contrast, with the exception of macrophages incubated with P. aeruginosa, resistin did not affect the ability of macrophages or monocytes to kill either Gram-positive or Gram-negative organisms. Furthermore, co-incubation of neutrophils with increasing proportions of monocytes did not enhance bacterial killing. Resistin blocked bactericidal activity through partial reduction of F-actin polymerization and suppression of the oxidative burst in neutrophils. Conclusions Our studies indicate that resistin selectively impairs neutrophil bacterial killing. These findings further support the notion that resistin can mimic cell type-dependent immunosuppressive effects. This is consistent with its putative role in the pathogenesis of bacterial sepsis.
Collapse
Affiliation(s)
- Lauren Miller
- Department of Anesthesiology and Perioperative Medicine, Penn State Milton S. Hershey Medical Center, 500 University Dr, Mail Code H-187, Hershey, PA, 17033, USA
| | - Kai Singbartl
- Department of Critical Care Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Zissis C Chroneos
- Department of Pediatrics, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA.,Department of Microbiology and Immunology, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Victor Ruiz-Velasco
- Department of Anesthesiology and Perioperative Medicine, Penn State Milton S. Hershey Medical Center, 500 University Dr, Mail Code H-187, Hershey, PA, 17033, USA
| | - Charles H Lang
- Department of Cellular and Molecular Physiology, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA.,Department of Surgery, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Anthony Bonavia
- Department of Anesthesiology and Perioperative Medicine, Penn State Milton S. Hershey Medical Center, 500 University Dr, Mail Code H-187, Hershey, PA, 17033, USA.
| |
Collapse
|
17
|
Prasad A, Brehm C, Goldenberg M, Ghodsizad A, Koerner M, Banayosy AE, Singbartl K. Assessing Left Ventricular Unloading and Wall Tension to Predict the Need for Durable Mechanical Circulatory Support after Peripheral VA-ECMO. J Heart Lung Transplant 2019. [DOI: 10.1016/j.healun.2019.01.416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
|
18
|
|
19
|
Abstract
The liver and kidney are key organs of metabolic homeostasis in the body and display complex interactions. Liver diseases often have direct and immediate effects on renal physiology and function. Conversely, acute kidney injury (AKI) is a common problem in patients with both acute and chronic liver diseases. AKI in patients with acute liver failure is usually multifactorial and involves insults similar to those seen in the general AKI population. Liver cirrhosis affects and is directly affected by aberrations in systemic and renal hemodynamics, inflammatory response, renal handling of sodium and free water excretion, and additional nonvasomotor mechanisms. Subsequent problems, for example, worsening ascites, hyponatremia, and AKI, often complicate management of patients with chronic progressive liver disease and add to their morbidity and mortality. Thus, AKI must be carefully defined and diagnosed in patients with liver disease. The kidney also plays a pivotal role in balancing acid-base disturbances resulting from advanced liver disease, making AKI in the setting of end-stage liver disease very difficult to manage clinically. While renal dysfunction in these patients often resolves following orthotopic liver transplant, dialysis may be required as a bridge to transplantation to mitigate the metabolic disarray found in these critically ill patients.
Collapse
Affiliation(s)
- Anthony Bonavia
- Department of Anesthesiology and Perioperative Medicine, PennState Health, Hershey, Pennsylvania
| | - Kai Singbartl
- Department of Critical Care Medicine, Mayo Clinic, Phoenix, Arizona
| |
Collapse
|
20
|
Sadan O, Samuels O, Asbury WH, Hanfelt JJ, Singbartl K. Low-chloride versus high-chloride hypertonic solution for the treatment of subarachnoid hemorrhage-related complications (The ACETatE trial): study protocol for a pilot randomized controlled trial. Trials 2018; 19:628. [PMID: 30428930 PMCID: PMC6236880 DOI: 10.1186/s13063-018-3007-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 10/20/2018] [Indexed: 01/29/2023] Open
Abstract
Background Aneurysmal subarachnoid hemorrhage (aSAH) is a life-threatening condition that results from a ruptured cerebral vessel. Cerebral edema and vasospasm are common complications and frequently require treatment with hypertonic solutions, in particular hypertonic sodium chloride (NaCl). We have previously shown that hyperchloremia in patients with aSAH given hypertonic NaCl is associated with the development of acute kidney injury (AKI), which leads to higher morbidity and mortality. Our current trial aims to study the effect of two hypertonic solutions with different chloride content on serum chloride concentrations in patients with aSAH who are at risk for AKI. Methods A low ChloridE hyperTonic solution for brain Edema (ACETatE) is a single center, double-blinded, double-dummy pilot trial comparing bolus doses of 23.4% NaCl and 16.4% NaCl/Na-Acetate for the treatment of cerebral edema in patients with aSAH. All patients will be enrolled within 36 h following admission. Randomization will occur once patients who receive hypertonic treatment for cerebral edema develop hyperchloremia (serum Cl− concentration ≥ 109 mmol/L). Subsequent treatment will consist of either NaCl 23.4% or NaCl/Na-Acetate 16.4%. The primary outcome of this study will be the change in serum Cl− concentrations during treatment. Secondary outcomes will include incidence of AKI, mortality, changes in intracranial pressure, and extent of hypernatremia. Discussion In patients with aSAH, hyperchloremia is a known risk factor for subsequent development of AKI. The primary goal of this pilot study is to determine the effect of two hypertonic solutions with different Cl− content on serum Cl− concentrations in patients with aSAH who have already developed hyperchloremia. Data will be collected prospectively to determine the extent to which the choice of hypertonic saline solution affects subsequent serum Cl− concentrations and the occurrence of AKI. This approach will allow us to obtain preliminary data to design a large randomized trial assessing the effects of chloride-sparing hypertonic solutions on development of AKI in patients with SAH. This pilot study is the first to prospectively evaluate the relationship between hypertonic solution chloride content and its effect on serum electrolytes and renal function in aSAH patients at risk of AKI due to hyperchloremia. Trial registration Clinicaltrials.gov, NCT03204955. Registered on 28 June 2017. Electronic supplementary material The online version of this article (10.1186/s13063-018-3007-7) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Ofer Sadan
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University Hospital and Emory School of Medicine, 1364 Clifton Road NE, Atlanta, GA, 30322, USA.
| | - Owen Samuels
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University Hospital and Emory School of Medicine, 1364 Clifton Road NE, Atlanta, GA, 30322, USA
| | - William H Asbury
- Department of Pharmacy, Emory University Hospital, 1364 Clifton Road NE, Atlanta, GA, 30322, USA
| | - John J Hanfelt
- Department of Biostatistics and Bioinformatics, Emory University, 1518 Clifton Road NE, Atlanta, GA, 30322, USA
| | - Kai Singbartl
- Department of Critical Care Medicine, Mayo Clinic, Phoenix, AZ, 85054, USA.
| |
Collapse
|
21
|
Bonavia A, Groff A, Karamchandani K, Singbartl K. Clinical Utility of Extracorporeal Cytokine Hemoadsorption Therapy: A Literature Review. Blood Purif 2018; 46:337-349. [PMID: 30176653 DOI: 10.1159/000492379] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 07/21/2018] [Indexed: 12/13/2022]
Abstract
Cytokines play a critical role in coordinating and amplifying a host immune response to infection. The normal pattern of localized and systemic release of proinflammatory and anti-inflammatory cytokines varies on the basis of the disease process. A dysregulated cytokine response can lead to a hyper-inflammatory condition called a cytokine storm. This is believed to contribute to the pathophysiology of sepsis and septic shock, a condition carrying high morbidity and mortality in critically ill patients. Extracorporeal cytokine hemoadsorption is an emerging technology utilized in the treatment of dysregulated inflammatory states such as sepsis, although there is a paucity of clinical evidence supporting its outcomes benefits. We assess the peer-reviewed literature relating to cytokine hemoadsorption in the context of sepsis and suggest areas of future research incorporating this novel technology.
Collapse
Affiliation(s)
- Anthony Bonavia
- Department of Anesthesiology and Perioperative Medicine, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Andrew Groff
- Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Kunal Karamchandani
- Department of Anesthesiology and Perioperative Medicine, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Kai Singbartl
- Department of Critical Care Medicine, Mayo Clinic, Phoenix, Arizona, USA
| |
Collapse
|
22
|
Klein SJ, Husain-Syed F, Karagiannidis C, Lehner GF, Singbartl K, Joannidis M. [Interactions between lung and kidney in the critically ill]. Med Klin Intensivmed Notfmed 2018; 113:448-455. [PMID: 30094502 DOI: 10.1007/s00063-018-0472-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 07/12/2018] [Indexed: 01/09/2023]
Abstract
Interactions between lung and kidney can significantly affect the course of acute diseases, a phenomenon that was first observed in the 1950s by describing pulmonary dysfunction in uremic patients. From animal experiments there is ample evidence for remote lung injury following acute kidney injury (AKI), with an increased risk for the development of pulmonary edema and acute respiratory distress syndrome (ARDS). Coincident ARDS and AKI are associated with higher rates of intubation and mechanical ventilation, significantly prolonged weaning from mechanical ventilation and increased mortality. On the other hand, acute lung diseases and mechanical ventilation can promote the development of AKI and are associated with increased mortality when AKI is also present. These bidirectional interactions may include hemodynamic adverse effects during mechanical ventilation or volume overload as well as the release or decreased clearance and metabolism of proinflammatory mediators (e.g., interleukin-6 and tumor necrosis factor-α), which may induce and aggravate distant organ injury. The aim of this work is to examine the interactions between lung and the kidney in critically ill patients, as well as discuss potential preventive approaches.
Collapse
Affiliation(s)
- S J Klein
- Gemeinsame Einrichtung Internistische Intensiv- und Notfallmedizin, Department für Innere Medizin, Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich
| | - F Husain-Syed
- Innere Medizin und Poliklinik II, Nephrologie, Pneumologie und Internistische Intensivmedizin, Uniklinik Gießen und Marburg - Standort Gießen, Gießen, Deutschland
| | - C Karagiannidis
- Lungenklinik Köln-Merheim, ARDS und ECMO Zentrum, Abteilung Pneumologie, Intensiv- und Beatmungsmedizin, Kliniken der Stadt Köln, Universität Witten/Herdecke, Köln, Deutschland
| | - G F Lehner
- Gemeinsame Einrichtung Internistische Intensiv- und Notfallmedizin, Department für Innere Medizin, Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich
| | - K Singbartl
- Department of Critical Care Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - M Joannidis
- Gemeinsame Einrichtung Internistische Intensiv- und Notfallmedizin, Department für Innere Medizin, Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich.
| |
Collapse
|
23
|
Prasad A, Singbartl K, Soleimani B, Brehm C, Ghodsizad A. Pressure Support Breaths Triggered by Total Artificial Heart in Invasive and Non-Invasive Mechanical Ventilation. Heart Surg Forum 2018; 21:E070-E071. [PMID: 29658860 DOI: 10.1532/hsf.1637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 06/07/2017] [Accepted: 10/25/2017] [Indexed: 11/20/2022]
Abstract
Because of the risks associated with extended mechanical ventilation, it is desirable to extubate patients as early as possible. However, weaning patients from mechanical ventilation too early has risks associated with it as well. Thus, it is important to note that in the two cases presented here, pressure-supported breaths were falsely triggered by a patient's a Syncardia® total artificial heart (TAH), influencing decisions about weaning the patient from mechanical ventilation.
Collapse
Affiliation(s)
- Amit Prasad
- Heart and Vascular Institute, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Kai Singbartl
- Heart and Vascular Institute, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Behzad Soleimani
- Heart and Vascular Institute, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Christoph Brehm
- Heart and Vascular Institute, Penn State Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Ali Ghodsizad
- Miami Transplant Institute, University of Miami, Jackson Memorial Hospital, Miami, Florida, USA
| |
Collapse
|
24
|
Prasad A, Ghodsizad A, Brehm C, Kozak M, Körner M, El Banayosy A, Singbartl K. Refractory Pulmonary Edema and Upper Body Hypoxemia During Veno-Arterial Extracorporeal Membrane Oxygenation-A Case for Atrial Septostomy. Artif Organs 2018; 42:664-669. [PMID: 29344963 DOI: 10.1111/aor.13082] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 10/09/2017] [Accepted: 10/24/2017] [Indexed: 11/29/2022]
Abstract
Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) provides mechanical circulatory support for patients with advanced cardiogenic shock, facilitating myocardial recovery and limiting multi-organ failure. In patients with severely limited left ventricular ejection, peripheral VA-ECMO can further increase left ventricular and left atrial pressures (LAP). Failure to decompress the left heart under these circumstances can result in pulmonary edema and upper body hypoxemia, that is, myocardial and cerebral ischemia. Atrial septostomy can decrease LAP in these situations. However, the effects of atrial septostomy on upper body oxygenation remain unknown. After IRB approval, we identified 9 out of 242 adult VA-ECMO patients between January 2011 and June 2016 who also underwent atrial septostomy for refractory pulmonary edema/upper body hypoxemia. We analyzed LAP/pulmonary capillary wedge pressure (PCWP), right atrial pressures (RAPs), Pa O2 /Fi O2 ratios (blood samples from right radial artery), intrathoracic volume status, and resolution of pulmonary edema before and up to 48 h after septostomy. There were no procedure-related complications. Thirty-day survival was 44%. LAP/PCWP decreased by approximately 40% immediately following septostomy and remained so for at least 24 h. Pa O2 /Fi O2 ratios significantly increased from 0.49 (0.38-2.12) before to 5.35 (3.01-7.69) immediately after septostomy and continued so for 24 h, 6.6 (4.49-10.93). Radiographic measurements also indicated a significant improvement in thoracic intravascular volume status after atrial septostomy. Atrial septostomy reduces LAP and improves upper body oxygenation and intrathoracic vascular volume status in patients developing severe refractory pulmonary edema while undergoing peripheral VA-ECMO. Atrial septostomy therefore appears safe and suitable to reduce the risk of upper body ischemia under these circumstances.
Collapse
Affiliation(s)
- Amit Prasad
- Department of Anesthesiology and Perioperative Medicine, Penn State Health, Hershey, PA, USA
| | - Ali Ghodsizad
- Division of Cardiothoracic Surgery, University of Miami, Miami, FL, USA
| | - Christoph Brehm
- Heart and Vascular Institute, Penn State Health, Hershey, PA, USA
| | - Mark Kozak
- Heart and Vascular Institute, Penn State Health, Hershey, PA, USA
| | - Michael Körner
- INTEGRIS Nazih Zuhdi Transplant Institute Baptist Medical Center, Oklahoma City, OK, USA
| | - Aly El Banayosy
- INTEGRIS Nazih Zuhdi Transplant Institute Baptist Medical Center, Oklahoma City, OK, USA
| | - Kai Singbartl
- Department of Critical Care Medicine, Mayo Clinic, Phoenix, AZ, USA
| |
Collapse
|
25
|
Gibney N, Cerda J, Davenport A, Ramirez J, Singbartl K, Leblanc M, Ronco C. Volume Management by Renal Replacement Therapy in Acute Kidney Injury. Int J Artif Organs 2018; 31:145-55. [DOI: 10.1177/039139880803100207] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Management of fluid balance is one of the basic but vital tasks in the care of critically ill patients. Hypovolemia results in a decrease in cardiac output and tissue perfusion and may lead to progressive multiple organ dysfunction, including the development of acute renal injury (AKI). However, in an effort to reverse pre-renal oliguria, it is not uncommon for patients with established oliguric acute renal failure, particularly when associated with sepsis, to receive excessive fluid resuscitation, leading to fluid overload. In patients with established oliguria, renal replacement therapy may be required to treat hypervolemia. Safe prescription of fluid loss during RRT requires intimate knowledge of the patient's underlying condition, understanding of the process of ultrafiltration and close monitoring of the patient's cardiovascular response to fluid removal. To preserve tissue perfusion in patients with AKI, it is important that RRT be prescribed in a way that optimizes fluid balance by removing fluid without compromising the effective circulating fluid volume. In patients who are clinically fluid overloaded, it is equally important that the amount of fluid removed be as exact as possible. Fluid balance errors can occur as a result of inappropriate prescription, operator error or machine error. Some CRRT machines have potential for significant fluid errors if alarms can be overridden. Threshold values for fluid balance error have been developed which can be used to predict the severity of harm. It is important that RRT education programs emphasize the risk associated with fluid balance errors and with overriding machine alarms.
Collapse
Affiliation(s)
- N. Gibney
- Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton - Canada
| | - J. Cerda
- Division of Nephrology, Albany Medical College and Capital District Renal Physicians, Albany, New York - USA
| | - A. Davenport
- Centre for Nephrology, Royal Free Hospital and University College Medical School, London - UK
| | - J. Ramirez
- Surgical Intensive Care Unit, Hospital Dr. Rafel Ángel Calderón Guardia, San Jose - Costa Rica
| | - K. Singbartl
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania - USA
| | - M. Leblanc
- Division of Nephrology and Critical Care, Maisonneuve - Rosemont Hospital, Montreal - Canada
| | - C. Ronco
- Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital - International Renal Research Institute Vicenza (IRRIV), Vicenza - Italy
| |
Collapse
|
26
|
Bonavia A, Miller L, Kellum JA, Singbartl K. Hemoadsorption corrects hyperresistinemia and restores anti-bacterial neutrophil function. Intensive Care Med Exp 2017; 5:36. [PMID: 28779451 PMCID: PMC5544662 DOI: 10.1186/s40635-017-0150-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 07/24/2017] [Indexed: 12/16/2022] Open
Abstract
Background Mounting evidence suggests that sepsis-induced morbidity and mortality are due to both immune activation and immunosuppression. Resistin is an inflammatory cytokine and uremic toxin. Septic hyperresistinemia (plasma resistin >20 ng/ml) has been associated with greater disease severity and worse outcomes, and it is further exacerbated by concomitant acute kidney injury (AKI). Septic hyperresistinemia disturbs actin polymerization in neutrophils leading to impaired neutrophil migration, a crucial first-line mechanism in host defense to bacterial infection. Our experimental objective was to study the effects of hyperresistinemia on other F-actin-dependent neutrophil defense mechanisms, in particular intracellular bacterial clearance and generation of reactive oxygen species (ROS). We also sought to examine the effects of hemoadsorption on hyperresistinemia and neutrophil dysfunction. Methods Thirteen patients with septic shock and six control patients were analyzed for serum resistin levels and their effects on neutrophil migration. In vitro, following incubation with resistin-spiked serum samples, Pseudomonasaeruginosa clearance and ROS generation in neutrophils were measured. Phosphorylation of 3-phosphoinositide-dependent protein kinase-1 (PDPK1) was assessed using flow cytometry. In vitro hemoadsorption with both Amberchrome™ columns (AC) and CytoSorb® cartridges (CC) were used to test correction of hyperresistinemia. We further tested AC for their effect on cell migration and ROS generation and CC for their effect on bacterial clearance. Results Patients with septic shock had higher serum resistin levels than control ICU patients and showed a strong, negative correlation between hyperresistinemia and neutrophil transwell migration (ρ= − 0.915, p < 0.001). In vitro, neutrophils exposed to hyperresistinemia exhibited twofold lower intracellular bacterial clearance rates compared to controls. Resistin impaired intracellular signaling and ROS production in a dose-dependent manner. Hemoadsorption with AC reduced serum concentrations of resistin and restored neutrophil migration and generation of ROS to normal levels. Hemoadsorption with CC also corrected hyperresistinemia and reconstituted normal intracellular bacterial clearance. Conclusions Septic hyperresistinemia strongly correlates with inhibition of neutrophil migration in vitro. Hyperresistinemia itself reversibly impairs neutrophil intracellular bacterial clearance and ROS generation. Hemoadsorption therapy with a clinically approved device corrects hyperresistinemia and neutrophil dysfunction. It may therefore provide a therapeutic option to improve neutrophil function during septic hyperresistinemia and ultimately alleviate immunosuppression in this disease state.
Collapse
Affiliation(s)
- Anthony Bonavia
- Department of Anesthesiology and Perioperative Medicine, Penn State Health, Hershey, PA, USA
| | - Lauren Miller
- Department of Anesthesiology and Perioperative Medicine, Penn State Health, Hershey, PA, USA
| | - John A Kellum
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA.,Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kai Singbartl
- Department of Anesthesiology and Perioperative Medicine, Penn State Health, Hershey, PA, USA. .,Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, PA, USA. .,Department of Critical Care Medicine, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ, 85054, USA.
| |
Collapse
|
27
|
Abstract
Acute kidney injury (AKI) occurs frequently in patients with liver disease and increases morbidity and mortality. Hepatorenal syndrome is a common cause of AKI in patients with decompensated cirrhosis and is due to alterations in systemic and renal hemodynamics. Serum creatinine-based estimation of kidney function is a key component of the Model for End-stage Liver Disease score in liver transplant candidates. Continuous renal replacement therapy is used in critically ill patients with liver failure and AKI. Simultaneous liver-kidney transplantation (SLK) may be required in patients with liver failure and prolonged AKI. Identification of appropriate candidates for SLK remains controversial.
Collapse
Affiliation(s)
- Kevin R Regner
- Division of Nephrology, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA
| | - Kai Singbartl
- Department of Anesthesiology, Milton S. Hershey Medical Center, Penn State College of Medicine, PO Box 850, H187, Hershey, PA 17033, USA.
| |
Collapse
|
28
|
Kellum JA, Chawla LS, Keener C, Singbartl K, Palevsky PM, Pike FL, Yealy DM, Huang DT, Angus DC. The Effects of Alternative Resuscitation Strategies on Acute Kidney Injury in Patients with Septic Shock. Am J Respir Crit Care Med 2016; 193:281-7. [PMID: 26398704 DOI: 10.1164/rccm.201505-0995oc] [Citation(s) in RCA: 157] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
RATIONALE Septic shock is a common cause of acute kidney injury (AKI), and fluid resuscitation is a major part of therapy. OBJECTIVES To determine if structured resuscitation designed to alter fluid, blood, and vasopressor use affects the development or severity of AKI or outcomes. METHODS Ancillary study to the ProCESS (Protocolized Care for Early Septic Shock) trial of alternative resuscitation strategies (two protocols vs. usual care) for septic shock. MEASUREMENTS AND MAIN RESULTS We studied 1,243 patients and classified AKI using serum creatinine and urine output. We determined recovery status at hospital discharge, examined rates of renal replacement therapy and fluid overload, and measured biomarkers of kidney damage. Among patients without evidence of AKI at enrollment, 37.6% of protocolized care and 38.1% of usual care patients developed kidney injury (P = 0.90). AKI duration (P = 0.59) and rates of renal replacement therapy did not differ between study arms (6.9% for protocolized care and 4.3% for usual care; P = 0.08). Fluid overload occurred in 8.3% of protocolized care and 6.3% of usual care patients (P = 0.26). Among patients with severe AKI, complete and partial recovery was 50.7 and 13.2% for protocolized patients and 49.1 and 13.4% for usual care patients (P = 0.93). Sixty-day hospital mortality was 6.2% for patients without AKI, 16.8% for those with stage 1, and 27.7% for stages 2 to 3. CONCLUSIONS In patients with septic shock, AKI is common and associated with adverse outcomes, but it is not influenced by protocolized resuscitation compared with usual care.
Collapse
Affiliation(s)
- John A Kellum
- 1 CRISMA Center, Department of Critical Care Medicine.,2 Center for Critical Care Nephrology
| | - Lakhmir S Chawla
- 2 Center for Critical Care Nephrology.,3 Department of Medicine, Divisions of Intensive Care Medicine and Nephrology, Veterans Affairs Medical Center, Washington, DC
| | - Christopher Keener
- 1 CRISMA Center, Department of Critical Care Medicine.,4 Graduate School of Public Health
| | - Kai Singbartl
- 2 Center for Critical Care Nephrology.,5 Department of Anesthesia, Penn State Hershey Medical Center, Hershey, Pennsylvania; and
| | - Paul M Palevsky
- 2 Center for Critical Care Nephrology.,7 Renal-Electrolyte Division, Department of Medicine, and.,6 Renal Section, Medical Service, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | | | - Donald M Yealy
- 8 Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - David T Huang
- 1 CRISMA Center, Department of Critical Care Medicine
| | - Derek C Angus
- 1 CRISMA Center, Department of Critical Care Medicine
| | | |
Collapse
|
29
|
Prasad A, Singbartl K, Boone J, Soleimani B, Zeriouh M, Loebe M, Koerner M, Oei JE, Brehm CE, Ghodsizad A. Percutaneous Endoscopic Gastrostomy Tube in a Syncardia™ Total Artificial Heart. Heart Surg Forum 2016; 19:E14-5. [PMID: 26913678 DOI: 10.1532/hsf.1411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Revised: 11/16/2015] [Accepted: 12/22/2015] [Indexed: 11/20/2022]
Abstract
As a bridge to transplant, the Syncardia™ total artificial heart (TAH) is an option for patients who are not candidates for left ventricular assist devices (LVAD) due to right ventricular failure. The need for nutritional support in these patients is essential for a favorable outcome. Low body mass indexes and albumin levels have been associated with increased morbidity and mortality in cardiac surgery patients [Alverdy 2003]. It is not uncommon for postoperative patients to have difficulty in consuming enough calories after surgery, which is further complicated by a hypermetabolic demand due to surgical stress. Enteral nutrition has typically been favored for gut mucosal integrity and bacterial flora [Alverdy 2003] [Engleman 1999]. We describe the need for prolonged enteral nutritional support in a TAH patient that was accomplished with a percutaneous endoscopic gastrostomy (PEG) tube.
Collapse
Affiliation(s)
- Amit Prasad
- Pennsylvania State University College of Medicine Department of Anesthesiology and Perioperative Medicine, Hershey, Pennsylvania, USA
| | - Kai Singbartl
- Pennsylvania State University College of Medicine Department of Anesthesiology and Perioperative Medicine, Hershey, Pennsylvania, USA
| | - Jacqueline Boone
- Pennsylvania State University College of Medicine Heart and Vascular Institute, Hershey, Pennsylvania, USA
| | - Behzad Soleimani
- Pennsylvania State University College of Medicine Heart and Vascular Institute, Hershey, Pennsylvania, USA
| | - Mohamad Zeriouh
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Harefield Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
| | - M Loebe
- INTEGRIS Baptist Medical Center, Oklahoma City, Oklahoma
| | | | | | - Christoph E Brehm
- Pennsylvania State University College of Medicine Heart and Vascular Institute, Hershey, Pennsylvania, USA
| | - Ali Ghodsizad
- Pennsylvania State University College of Medicine Heart and Vascular Institute, Hershey, Pennsylvania, USA
| |
Collapse
|
30
|
Prasad A, Ghodsizad A, Pae W, Singbartl K, Boone J, Zeriouh M, Ruhparwar A, Loebe M, Khorrami GSH, Koerner MM, Brehm C. Non-Cardiac Symptoms of Moderate to Severe Hypokalemia in a Patient with a Syncardia™ Total Artificial Heart. Heart Surg Forum 2016; 19:E12-3. [PMID: 26913677 DOI: 10.1532/hsf.1427] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 01/08/2016] [Accepted: 01/26/2016] [Indexed: 11/20/2022]
Abstract
The Syncardia™ total artificial heart (TAH) is an option for patients as a bridge to transplant in those who are not candidates for left ventricular assist devices (LVAD) due to right ventricular failure. Postoperative course is highly dependent on volume status and aggressive diuresis is often necessary. One complication from aggressive diuresis is hypokalemia; however, in these patients we tolerate a lower potassium level because cardiac arrhythmias are not a concern. However, in two separate instances non-cardiac symptoms related to severe hypokalemia occurred. These symptoms included nystagmus in one patient and agitation, tremors, and having an "out-of-body" experience in the other patient. Both these patients had resolution of symptoms with potassium replacement.
Collapse
Affiliation(s)
- Amit Prasad
- Pennsylvania State University College of Medicine Department of Anesthesiology and Perioperative Medicine, Hershey, Pennsylvania, USA
| | - Ali Ghodsizad
- Pennsylvania State University College of Medicine Heart and Vascular Institute, Hershey, Pennsylvania, USA
| | - Walter Pae
- Pennsylvania State University College of Medicine Department of Anesthesiology and Perioperative Medicine, Hershey, Pennsylvania, USA
| | - Kai Singbartl
- Pennsylvania State University College of Medicine Department of Anesthesiology and Perioperative Medicine, Hershey, Pennsylvania, USA
| | - Jacqueline Boone
- Pennsylvania State University College of Medicine Heart and Vascular Institute, Hershey, Pennsylvania, USA
| | - M Zeriouh
- Pennsylvania State University College of Medicine Heart and Vascular Institute, Hershey, Pennsylvania, USA
| | - Arjang Ruhparwar
- University of Heidelberg, Department of Cardiac Surgery, Heidelberg, Germany
| | - M Loebe
- University of Heidelberg, Department of Cardiac Surgery, Heidelberg, Germany
| | | | | | - Christoph Brehm
- Pennsylvania State University College of Medicine Heart and Vascular Institute, Hershey, Pennsylvania, USA
| |
Collapse
|
31
|
Humphreys BD, Cantaluppi V, Portilla D, Singbartl K, Yang L, Rosner MH, Kellum JA, Ronco C. Targeting Endogenous Repair Pathways after AKI. J Am Soc Nephrol 2015; 27:990-8. [PMID: 26582401 DOI: 10.1681/asn.2015030286] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
AKI remains a highly prevalent disease associated with poor short- and long-term outcomes and high costs. Although significant advances in our understanding of repair after AKI have been made over the last 5 years, this knowledge has not yet been translated into new AKI therapies. A consensus conference held by the Acute Dialysis Quality Initiative was convened in April of 2014 and reviewed new evidence on successful kidney repair to identify the most promising pathways that could be translated into new treatments. In this paper, we provide a summary of current knowledge regarding successful kidney repair and offer a framework for conceptualizing the therapeutic targeting that may facilitate this process. We outline gaps in knowledge and suggest a research agenda to more efficiently bring new discoveries regarding repair after AKI to the clinic.
Collapse
Affiliation(s)
- Benjamin D Humphreys
- Renal Division, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri;
| | - Vincenzo Cantaluppi
- Nephrology, Dialysis and Kidney Transplantation Unit, Department of Medical Sciences, University of Torino, Azienda Ospedaliera Città della Salute e della Scienza 'Molinette,' Turin, Italy
| | - Didier Portilla
- Division of Nephrology, Center for Immunity, Inflammation and Regenerative Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - Kai Singbartl
- Center for Critical Care Nephrology and Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Li Yang
- Renal Division, Peking University First Hospital, Beijing, China; and
| | - Mitchell H Rosner
- Division of Nephrology, Center for Immunity, Inflammation and Regenerative Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - John A Kellum
- Center for Critical Care Nephrology and Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Claudio Ronco
- Department of Nephrology Dialysis and Transplantation, San Bortolo Hospital and the International Renal Research Institute, Vicenza, Italy
| | | |
Collapse
|
32
|
Abstract
Acute kidney injury (AKI) is associated with significant short-term morbidity and mortality, which cannot solely be explained by loss of organ function. Renal replacement therapy allows rapid correction of most acute changes associated with AKI, indicating that additional pathogenetic factors play a major role in AKI. Evidence suggests that reduced renal cytokine clearance as well as increased cytokine production by the acutely injured kidney contribute to a systemic inflammation state, which results in significant effects on other organs. AKI seems to compromise the function of the innate immune system. AKI is an acute systemic disease with serious distant organ effects.
Collapse
Affiliation(s)
- Kai Singbartl
- Department of Anesthesiology, Penn State College of Medicine, Milton S. Hershey Medical Center, P.O. Box 850, H187 Hershey, PA 17033, USA
| | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Anichstr. 35, Innsbruck A-6020, Austria.
| |
Collapse
|
33
|
Singbartl K, Singbartl G. In reply. Transfusion 2014; 54:2133-4. [DOI: 10.1111/trf.12737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Kai Singbartl
- Department of Anesthesiology; Penn State College of Medicine; Hershey PA
| | | |
Collapse
|
34
|
McCullough PA, Kellum JA, Haase M, Müller C, Damman K, Murray PT, Cruz D, House AA, Schmidt-Ott KM, Vescovo G, Bagshaw SM, Hoste EA, Briguori C, Braam B, Chawla LS, Costanzo MR, Tumlin JA, Herzog CA, Mehta RL, Rabb H, Shaw AD, Singbartl K, Ronco C. Pathophysiology of the Cardiorenal Syndromes: Executive Summary from the Eleventh Consensus Conference of the Acute Dialysis Quality Initiative (ADQI). Blood Purif 2014. [DOI: 10.1159/000361059] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
35
|
Peng ZY, Bishop JV, Wen XY, Elder MM, Zhou F, Chuasuwan A, Carter MJ, Devlin JE, Kaynar AM, Singbartl K, Pike F, Parker RS, Clermont G, Federspiel WJ, Kellum JA. Modulation of chemokine gradients by apheresis redirects leukocyte trafficking to different compartments during sepsis, studies in a rat model. Crit Care 2014; 18:R141. [PMID: 24992991 PMCID: PMC4227131 DOI: 10.1186/cc13969] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Accepted: 06/11/2014] [Indexed: 12/15/2022]
Abstract
Introduction Prior work suggests that leukocyte trafficking is determined by local chemokine gradients between the nidus of infection and the plasma. We recently demonstrated that therapeutic apheresis can alter immune mediator concentrations in the plasma, protect against organ injury, and improve survival. Here we aimed to determine whether the removal of chemokines from the plasma by apheresis in experimental peritonitis changes chemokine gradients and subsequently enhances leukocyte localization into the infected compartment, and away from healthy tissues. Methods In total, 76 male adult Sprague–Dawley rats weighing 400 g to 600 g were included in this study. Eighteen hours after inducing sepsis by cecal ligation and puncture, we randomized these rats to apheresis or sham treatment for 4 hours. Cytokines, chemokines, and leukocyte counts from blood, peritoneal cavity, and lung were measured. In a separate experiment, we labeled neutrophils from septic donor animals and injected them into either apheresis or sham-treated animals. All numeric data with normal distributions were compared with one-way analysis of variance, and numeric data not normally distributed were compared with the Mann–Whitney U test. Results Apheresis significantly removed plasma cytokines and chemokines, increased peritoneal fluid-to-blood chemokine (C-X-C motif ligand 1, ligand 2, and C-C motif ligand 2) ratios, and decreased bronchoalveolar lavage fluid-to-blood chemokine ratios, resulting in enhanced leukocyte recruitment into the peritoneal cavity and improved bacterial clearance, but decreased recruitment into the lung. Apheresis also reduced myeloperoxidase activity and histologic injury in the lung, liver, and kidney. These Labeled donor neutrophils exhibited decreased localization in the lung when infused into apheresis-treated animals. Conclusions Our results support the concept of chemokine gradient control of leukocyte trafficking and demonstrate the efficacy of apheresis to target this mechanism and reduce leukocyte infiltration into the lung.
Collapse
|
36
|
Zarbock A, Meersch M, Schmidt C, Martens S, Rossaint J, Singbartl K, Görlich D, Kellum J, Van Aken H. Urinary tissue inhibitor of metalloproteinases-2 and insulin-like growth factor-binding protein 7 as early biomarkers of acute kidney injury and renal recovery following cardiac surgery. Crit Care 2014. [PMCID: PMC4069553 DOI: 10.1186/cc13571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
|
37
|
McCullough PA, Kellum JA, Haase M, Müller C, Damman K, Murray PT, Cruz D, House AA, Schmidt-Ott KM, Vescovo G, Bagshaw SM, Hoste EA, Briguori C, Braam B, Chawla LS, Costanzo MR, Tumlin JA, Herzog CA, Mehta RL, Rabb H, Shaw AD, Singbartl K, Ronco C. Pathophysiology of the cardiorenal syndromes: executive summary from the eleventh consensus conference of the Acute Dialysis Quality Initiative (ADQI). Contrib Nephrol 2013; 182:82-98. [PMID: 23689657 DOI: 10.1159/000349966] [Citation(s) in RCA: 114] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Cardiorenal syndromes (CRS) have been recently classified into five distinct entities, each with different major pathophysiologic mechanisms. CRS type 1 most commonly occurs in the setting of acutely decompensated heart failure where approximately 25% of patients develop a rise in serum creatinine and a reduction of urine output after the first several doses of intravenous diuretics. Altered cardiac and renal hemodynamics are believed to be the most important determinants of CRS type 1. CRS type 2 is the hastened progression of chronic kidney disease (CKD) in the setting of chronic heart failure. Accelerated renal cell apoptosis and replacement fibrosis is considered to be the dominant mechanism. CRS type 3 is acutely decompensated heart failure after acute kidney injury from inflammatory, toxic, or ischemic insults. This syndrome is precipitated by salt and water overload, acute uremic myocyte dysfunction, and neurohormonal dysregulation. CRS type 4 is manifested by the acceleration of the progression of chronic heart failure in the setting of CKD. Cardiac myocyte dysfunction and fibrosis, so-called 'CKD cardiomyopathy', is believed to be the predominant pathophysiologic mechanism. Type 5 CRS is simultaneous acute cardiac and renal injury in the setting of an overwhelming systemic insult such as sepsis. In this scenario, the predominant pathophysiological disturbance is microcirculatory dysfunction as a result of acutely abnormal immune cell signaling, catecholamine cellular toxicity, and enzymatic activation which result in simultaneous organ injury often extending beyond both the heart and the kidneys. This paper will summarize these and other key findings from an international consensus conference on the spectrum of pathophysiologic mechanisms at work in the CRS.
Collapse
Affiliation(s)
- Peter A McCullough
- St. John Providence Health System, Warren, Mich., Providence Hospitals and Medical Centers, Southfield and Novi, MI 48374 , USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
38
|
Mehta RL, Rabb H, Shaw AD, Singbartl K, Ronco C, McCullough PA, Kellum JA. Cardiorenal syndrome type 5: clinical presentation, pathophysiology and management strategies from the eleventh consensus conference of the Acute Dialysis Quality Initiative (ADQI). Contrib Nephrol 2013; 182:174-94. [PMID: 23689662 DOI: 10.1159/000349970] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Cardiorenal syndrome type 5 (CRS-5) includes conditions where there is a simultaneous involvement of the heart and kidney from a systemic disorder. Given the wide spectrum of diseases that contribute to CRS-5, several pathophysiological mechanisms are invoked representing the response of the heart and kidney to the contributing disorder that is ongoing. The nature, duration and the underlying condition of the heart and kidney strongly influence the clinical course of CRS-5. In this paper we discuss the pathophysiology of CRS-5 in the setting of sepsis as a model system for CRS-5 providing a brief overview of strategies for monitoring and therapeutic intervention. We offer a framework for reference for considering other disorders leading to CRS-5 where the development of cardiac and renal dysfunction is more insidious.
Collapse
Affiliation(s)
- Ravindra L Mehta
- Department of Medicine, University of California San Diego, San Diego, CA 92103 , USA.
| | | | | | | | | | | | | |
Collapse
|
39
|
Singbartl G, Held AL, Singbartl K. Ranking the effectiveness of autologous blood conservation measures through validated modeling of independent clinical data. Transfusion 2013; 53:3060-79. [PMID: 23656520 DOI: 10.1111/trf.12233] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2012] [Revised: 01/26/2013] [Accepted: 01/29/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND Future supply with allogeneic blood transfusions faces several crucial challenges that warrant thorough (re-)evaluation of existing alternatives. Meta-analyses have indicated a significant potential for autologous blood conservation (ABC) measures to reduce the need for allogeneic blood transfusions. The quality of currently available studies, however, prohibits definite conclusions. Under these circumstances, mathematical modeling offers unique opportunities to compare various ABC measures and to test the impact of different variables on efficacy and effectiveness. STUDY DESIGN AND METHODS We performed an extensive search for clinical ABC studies, focusing on acute normovolemic hemodilution (ANH), intraoperative blood salvage (IBS), or preoperative autologous deposit (PAD). Only ABC studies providing a minimum set of clinical variables were included. Using a clinically validated mathematical model, we then calculated maximal allowable blood loss (efficacy) and increase in red blood cell (RBC) mass (effectiveness) to rank the three techniques. RESULTS We identified 21 clinical ABC studies, including 3926 patients, as suitable for our model. Our model shows that IBS with high recovery rates is the most efficacious and effective ABC measure. PAD will reveal nearly similar efficacy and effectiveness, only if sufficient time for RBC regeneration has passed and if 4 PAD units or more are available. Our model further demonstrates that ANH as well as IBS with low recovery rates are the least efficacious and effective alternatives. CONCLUSIONS IBS appears to be the most efficacious and effective ABC measure. PAD can only reduce the need for allogeneic blood transfusions under certain circumstances. ANH does not appear to play an important role in ABC.
Collapse
Affiliation(s)
- Günter Singbartl
- Krankenhaus Salzhausen, Salzhausen, Germany; Abteilung Gynaekologie, Klinik Hallerwiese, Nuremberg, Germany; Department of Anesthesiology, Penn State College of Medicine-Milton S. Hershey Medical Center, Hershey, Pennsylvania; CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | | |
Collapse
|
40
|
Rimmelé T, Kaynar AM, McLaughlin JN, Bishop JV, Fedorchak MV, Chuasuwan A, Peng Z, Singbartl K, Frederick DR, Zhu L, Carter M, Federspiel WJ, Zeevi A, Kellum JA. Leukocyte capture and modulation of cell-mediated immunity during human sepsis: an ex vivo study. Crit Care 2013; 17:R59. [PMID: 23531333 PMCID: PMC3672497 DOI: 10.1186/cc12587] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/11/2012] [Accepted: 03/18/2013] [Indexed: 01/06/2023]
|
41
|
Murugan R, Weissfeld L, Yende S, Singbartl K, Angus DC, Kellum JA. Association of statin use with risk and outcome of acute kidney injury in community-acquired pneumonia. Clin J Am Soc Nephrol 2012; 7:895-905. [PMID: 22461537 DOI: 10.2215/cjn.07100711] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Sepsis is a leading cause of AKI. Animal studies suggest that the pleiotropic effect of statins attenuates the risk for AKI and decreases mortality. This study examined whether statin use was associated with a lower risk for pneumonia-induced AKI and 1-year and cause-specific mortality in patients with AKI. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Multicenter, prospective cohort study of 1836 patients hospitalized with community-acquired pneumonia. RESULTS Baseline characteristics differed among statin users and nonusers. Of the 413 patients (22.5%) who received a statin before hospitalization, statin treatment, when adjusted for differences in age, severity of pneumonia, admission from nursing home, health insurance, and propensity for statin use, did not reduce the risk for AKI (odds ratio [OR], 1.32 [95% confidence interval (CI), 1.02-1.69]; P=0.05). Of patients with AKI (n=631), statin use was associated with a lower risk for death at 1 year (27.8% versus 38.8%; P=0.01), which was not significant when adjusted for differences in age, severity of pneumonia and AKI, use of mechanical ventilation, and propensity score (OR, 0.72 [95% CI, 0.50-1.06]; P=0.09). Among patients with AKI, cardiovascular disease accounted for one third of all deaths. CONCLUSIONS In a large cohort of patients hospitalized with pneumonia, statins did not reduce the risk for AKI. Among patients with AKI, statin use was not associated with lower risk for death at 1 year. The higher risk for AKI observed among statin users may be due to indication bias.
Collapse
Affiliation(s)
- Raghavan Murugan
- CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | | | | | | | | | | | | |
Collapse
|
42
|
Zhou F, Cove ME, Peng ZY, Bishop J, Singbartl K, Kellum JA. Normal saline resuscitation worsens lactic acidosis in experimental sepsis. Crit Care 2012. [PMCID: PMC3363671 DOI: 10.1186/cc10860] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
|
43
|
Wen X, Peng Z, Li Y, Wang H, Bishop JV, Chedwick LR, Singbartl K, Kellum JA. One dose of cyclosporine A is protective at initiation of folic acid-induced acute kidney injury in mice. Nephrol Dial Transplant 2012; 27:3100-9. [PMID: 22294776 DOI: 10.1093/ndt/gfr766] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND In most patients, acute kidney injury (AKI) represents the combined effects of ischemic, toxic and inflammatory insults. No effective pharmacologic interventions have been developed to prevent AKI or to improve outcomes to date. Cyclosporine A (CsA) is a calcineurin inhibitor that mediates T-cell receptor signaling, suppresses inflammatory cytokine expression and inhibits leukocyte migration. It is also a potent inhibitor of mitochondrial permeability, protecting cells from death. These properties make it a potentially valuable drug to prevent or treat AKI. It does, however, carry a significant risk of nephrotoxicity, especially with chronic use. By contrast, a single dose of CsA may be protective while limiting the risk of nephrotoxicity. METHODS We conducted a controlled animal experiment in male CD-1 mice. Specifically, mice were subjected to folic acid (FA)-induced AKI and then randomly assigned to sham operation or one of three dosage of CsA treatment groups. Results Intraperitoneal injection of FA consistently induced AKI. Serum interleukin (IL)-6 and urinary neutrophil gelatinase-associated lipocalin (NGAL) rose 1 day after FA injection. Compared to sham treatment, one dose (1 and 5 mg/kg body weight) of CsA significantly reduced kidney tubular cell apoptosis, serum creatinine, blood urea, serum IL-6 and urinary NGAL 2 days after FA injection. It was also shown to block the inflammatory mediator tumor necrosis factor (TNF)-like weak inducer of apoptosis (TWEAK) expression, nuclear factor kappa-B (NFκB) activation, inflammatory cell infiltration and interstitial fibrosis 14 days after treatment in a dose-dependent fashion. By contrast, a dose of 10 mg/kg body weight CsA resulted in nephrotoxicity in the setting of FA-induced AKI. CONCLUSIONS A single dose of CsA, currently used for organ transplant, significantly protects mice from FA-induced AKI, presumably through inhibition of cell death, inflammatory reaction, interstitial cell infiltration and fibrosis. The protective effects have the potential to open a completely new line of investigation in the prevention and treatment of AKI.
Collapse
Affiliation(s)
- Xiaoyan Wen
- The Clinical Research, Investigation and Systems Modeling of Acute illness Center, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | | | | | | | | | | | | | | |
Collapse
|
44
|
Abstract
Acute kidney injury (AKI) has emerged as a major public health problem that affects millions of patients worldwide and leads to decreased survival and increased progression of underlying chronic kidney disease (CKD). Recent consensus criteria for definition and classification of AKI have provided more consistent estimates of AKI epidemiology. Patients, in particular those in the ICU, are dying of AKI and not just simply with AKI. Even small changes in serum creatinine concentrations are associated with a substantial increase in the risk of death. AKI is not a single disease but rather a syndrome comprising multiple clinical conditions. Outcomes from AKI depend on the underlying disease, the severity and duration of renal impairment, and the patient's renal baseline condition. The development of AKI is the consequence of complex interactions between the actual insult and subsequent activation of inflammation and coagulation. Contrary to the conventional view, recent experimental and clinical data argue against renal ischemia-reperfusion as a sine qua non condition for the development of AKI. Loss of renal function can occur without histological signs of tubular damage or even necrosis. The detrimental effects of AKI are not limited to classical well-known symptoms such as fluid overload and electrolyte abnormalities. AKI can also lead to problems that are not readily appreciated at the bedside and can extend well beyond the ICU stay, including progression of CKD and impaired innate immunity. Experimental and small observational studies provide evidence that AKI impairs (innate) immunity and is associated with higher infection rates.
Collapse
Affiliation(s)
- Kai Singbartl
- Department of Critical Care Medicine, Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, USA
| | | |
Collapse
|
45
|
Peng ZY, Wang HZ, Carter MJ, Dileo MV, Bishop JV, Zhou FH, Wen XY, Rimmelé T, Singbartl K, Federspiel WJ, Clermont G, Kellum JA. Acute removal of common sepsis mediators does not explain the effects of extracorporeal blood purification in experimental sepsis. Kidney Int 2011; 81:363-9. [PMID: 21918497 DOI: 10.1038/ki.2011.320] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The effect of extracorporeal blood purification on clinical outcomes in sepsis is assumed to be related to modulation of plasma cytokine concentrations. To test this hypothesis directly, we treated rats that had a cecal ligation followed by puncture (a standard model of sepsis) with a modest dose of extracorporeal blood purification that did not result in acute changes in a panel of common cytokines associated with inflammation (TNF-α, IL-1β, IL-6, and IL-10). Pre- and immediate post-treatment levels of these cytokines were unchanged compared to the sham therapy of extracorporeal circulation without blood purifying sorbent. The overall survival to 7 days, however, was significantly better in animals that received extracorporeal blood purification compared to those with a sham procedure. This panel of common plasma cytokines along with alanine aminotransferase and creatinine was significantly lower 72 h following extracorporeal blood purification compared to sham-treated rats. Thus, the effects of this procedure on organ function and survival do not appear to be due solely to immediate changes in the usual measured circulating cytokines. These results may have important implications for the design and conduct of future trials in sepsis including defining alternative targets for extracorporeal blood purification and other therapies.
Collapse
Affiliation(s)
- Zhi-Yong Peng
- The CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute illness) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15261, USA
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
46
|
Abstract
Acute kidney injury (AKI) remains a major clinical challenge, especially in combination with acute lung injury (ALI). Clinical as well as experimental studies have provided evidence for clinically relevant kidney-lung interactions, ultimately leading to a drastic reduction in survival. The crosstalk between AKI and ALI is a consequence of both direct loss of normal organ function and inflammatory dysregulation resulting from each organ failure. Cellular (e.g. neutrophils) as well as soluble mediators (cytokines) contribute to the inflammatory dysregulation under these circumstances. Clinical interventions are currently limited to general, unspecific preventive or supportive measures. With respect to AKI, these strategies include adequate volume control, correction of acid-base/electrolyte abnormalities and elimination of uremic substances by renal replacement therapy. Lung protective ventilation, including low tidal volume ventilation, is a cornerstone in the management of ALI. This approach has been shown to attenuate both the direct mechanical effects of ventilation and the inflammatory response arising from ALI and mechanical ventilation, ultimately reducing the incidence of extrapulmonary organ failure. The fact that multiorgan failure is not only the sum of organ functions lost, but also includes inflammatory dysregulation together with a lack of treatment options greatly emphasizes the need for future research in this area.
Collapse
Affiliation(s)
- Kai Singbartl
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pa., USA
| |
Collapse
|
47
|
Srisawat N, Wen X, Lee M, Kong L, Elder M, Carter M, Unruh M, Finkel K, Vijayan A, Ramkumar M, Paganini E, Singbartl K, Palevsky PM, Kellum JA. Urinary biomarkers and renal recovery in critically ill patients with renal support. Clin J Am Soc Nephrol 2011; 6:1815-23. [PMID: 21757640 DOI: 10.2215/cjn.11261210] [Citation(s) in RCA: 118] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Despite significant advances in the epidemiology of acute kidney injury (AKI), prognostication remains a major clinical challenge. Unfortunately, no reliable method to predict renal recovery exists. The discovery of biomarkers to aid in clinical risk prediction for recovery after AKI would represent a significant advance over current practice. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted the Biological Markers of Recovery for the Kidney study as an ancillary to the Acute Renal Failure Trial Network study. Urine samples were collected on days 1, 7, and 14 from 76 patients who developed AKI and received renal replacement therapy (RRT) in the intensive care unit. We explored whether levels of urinary neutrophil gelatinase-associated lipocalin (uNGAL), urinary hepatocyte growth factor (uHGF), urinary cystatin C (uCystatin C), IL-18, neutrophil gelatinase-associated lipocalin/matrix metalloproteinase-9, and urine creatinine could predict subsequent renal recovery. RESULTS We defined renal recovery as alive and free of dialysis at 60 days from the start of RRT. Patients who recovered had higher uCystatin C on day 1 (7.27 versus 6.60 ng/mg·creatinine) and lower uHGF on days 7 and 14 (2.97 versus 3.48 ng/mg·creatinine; 2.24 versus 3.40 ng/mg·creatinine). For predicting recovery, decreasing uNGAL and uHGF in the first 14 days was associated with greater odds of renal recovery. The most predictive model combined relative changes in biomarkers with clinical variables and resulted in an area under the receiver-operator characteristic curve of 0.94. CONCLUSIONS We showed that a panel of urine biomarkers can augment clinical risk prediction for recovery after AKI.
Collapse
Affiliation(s)
- Nattachai Srisawat
- 604 Scaife Hall, Department of Critical Care Medicine, University of Pittsburgh, 3550 Terrace Street, Pittsburgh, PA 15261, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
48
|
Singbartl K, Murugan R, Kaynar AM, Crippen DW, Tisherman SA, Shutterly K, Stuart SA, Simmons R, Darby JM. Intensivist-led management of brain-dead donors is associated with an increase in organ recovery for transplantation. Am J Transplant 2011; 11:1517-21. [PMID: 21449934 DOI: 10.1111/j.1600-6143.2011.03485.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The disparity between the number of patients in need of organ transplantation and the number of available organs is steadily rising. We hypothesized that intensivist-led management of brain dead donors would increase the number of organs recovered for transplantation. We retrospectively analyzed data from all consented adult brain dead patients in the year before (n = 35) and after (n = 43) implementation of an intensivist-led donor management program. Donor characteristics before and after implementation were similar. After implementation of the organ donor support team, the overall number of organs recovered for transplantation increased significantly (66 out of 210 potentially available organs vs. 113 out of 258 potentially available organs, p = 0.008). This was largely due to an increase in the number of lungs (8 out of 70 potentially available lungs vs. 21 out of 86 potentially available lungs; p = 0.039) and kidneys (31 out of 70 potentially available kidneys vs. 52 out of 86 potentially available kidneys; p = 0.044) recovered for transplantation. The number of hearts and livers recovered for transplantation did not change significantly. Institution of an intensivist-led organ donor support team may be a new and viable strategy to increase the number of organs available for transplantations.
Collapse
Affiliation(s)
- K Singbartl
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
49
|
Abstract
Ex vivo circuits are commonly used to evaluate biomaterials or devices used for extracorporeal blood purification. However, various aspects of the ex vivo circuit, apart from the circuit materials, may affect inflammation and coagulation. One such aspect is temperature. The aim of this study was to evaluate the influence of different blood temperature conditions on inflammation parameters in an ex vivo circuit. Blood was collected from 20 healthy volunteers and run through three different experimental conditions for 4 h: a miniaturized ex vivo extracorporeal circuit equipped with a blood warmer set to 37°C, the same circuit without the warmer (23°C), and a tube placed in an incubator at 37°C (no circuit). We measured the granulocyte macrophage colony-stimulating factor, the tumor necrosis factor, and the interleukin (IL)-1β, IL-6, IL-8, and IL-10 concentrations at baseline, 15, 60, 120, and 240 min. Human leukocyte antigen (HLA)-DR, CD11b, CD11a, CD62L, tumor necrosis factor alpha converting enzyme, annexin V expression, and NFkB DNA binding were measured in monocytes and polymorphonuclear neutrophils (PMNs) using flow cytometry at baseline, 120 min, and 240 min. While cytokine production over time was very slight at room temperature, levels increased by more than 100-fold in the two heated conditions. Differences in the expression of some surface markers were also observed between the room temperature circuit and the two heated conditions (CD11b PMN, P < 0.0001; HLA-DR Mono, P=0.0019; and CD11a PMN, P<0.0001). Evolution of annexin V expression was also different over time between the three groups (P=0.0178 for monocytes and P=0.0011 for PMNs). A trend for a greater NFkB DNA binding was observed in the heated conditions. Thus, for ex vivo studies using extracorporeal circuits, heating blood to maintain body temperature results in significant activation of inflammatory cells while hypothermia (room temperature) seems to suppress the leukocyte response. Both strategies may lead to erroneous conclusions, possibly masking some specific effects of the device being studied. Investigators in this field must be aware of the fact that blood temperature is a crucial confounding parameter and the type of "background noise" they will face depending on the strategy adopted.
Collapse
Affiliation(s)
- Thomas Rimmelé
- The CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Laboratory, Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | | | | | | | | | | | | |
Collapse
|
50
|
Peng Z, Singbartl K, Simon P, Rimmelé T, Bishop J, Clermont G, Kellum JA. Blood purification in sepsis: a new paradigm. Contrib Nephrol 2010; 165:322-328. [PMID: 20427984 DOI: 10.1159/000313773] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Sepsis is one of the main causes of death in critically ill patients. The pathophysiology of sepsis is complex and not completely understood. The proinflammatory and anti-inflammatory response leads to cell and organ dysfunction and, in many cases, death. Thus, the goal of the intervention is to restore the homeostasis of circulating mediators rather than to inhibit selectively the proinflammatory or anti-inflammatory mediators. Blood purification has been reported to remove a wide array of inflammatory mediators. The effects are broad-spectrum and auto-regulating. Blood purification has also been demonstrated to restore immune function through improving antigen-presenting capability, adjusting leukocyte recruitment, oxidative burst and phagocytosis, and improving leukocyte responsiveness. A great deal of work has to be done in order to find and optimize the best extracorporeal blood purification therapy for sepsis. New devices specifically target the pathophysiological mechanisms involved in these conditions. High-volume hemofiltration, hemoadsorption, coupled plasma filtration adsorption, and high cutoff membrane are now being tested in septic patients. Preliminary data indicate the feasibility of these modified techniques in sepsis. Their impact on patient prognosis, however, still needs proof by large randomized clinical trials. Finally, the emerging paradigm of sepsis-induced immune suppression provides additional rationale for the development of extracorporeal blood purification therapy for sepsis.
Collapse
|