Antiviral effectiveness and survival correlation of azvudine and nirmatrelvir/ritonavir in elderly severe patients with COVID-19: a retrospective real-world study

Background

Azvudine and nirmatrelvir/ritonavir are approved to treat mild-to-moderate coronavirus disease 2019 (COVID-19) in adults with a high risk for progression to severe infection. We sought to compare the antiviral effectiveness and clinical outcomes of elderly severe patients with COVID-19 receiving these two antiviral agents.

Methods

In this observational study, we identified 249 elderly patients with severe COVID-19 infection who were admitted to the Second Medical Center of the People's Liberation Army General Hospital from December 2022 to January 2023, including 128 azvudine recipients, 66 nirmatrelvir/ritonavir recipients and 55 patients not received antiviral treatments. We compared the cycle threshold (Ct) value dynamic change of all three groups. The primary outcome was a composite outcome of disease progression, including all-cause death, intensive care unit admission, and initiation of invasive mechanical ventilation. The outcomes of all enrolled patients were followed up from the electronic medical record system. Kaplan-Meier and Cox risk proportional regression analyses were used to compare the clinical outcomes of all three groups. To more directly compare the effectiveness of the two antiviral drugs, we performed propensity-score matching between the two antiviral groups and compared antiviral efficacy and clinical outcomes in the matched population.

Findings

Among 249 patients (mean age, 91.41 years), 77 patients died during the follow-up period. When compared to patients who did not receive any antivirals, neither nirmatrelvir/ritonavir nor azvudine demonstrated a survival benefit. The Cox analysis of the all-cause death of the three groups showed that the risk of death was 0.730 (0.423-1.262) in the azvudine group 0.802 (0.435-1.480) and in the nirmatrelvir/ritonavir group compared with the non-antiviral group. After propensity score matching, we included 58 azvudine recipients and 58 nirmatrelvir/ritonavir recipients. The fitted curve of the Ct value after matching illustrated that the rate of viral decline in the early stage of nirmatrelvir/ritonavir treatment seems to surpass that of azvudine, but there was no statistical significance. Azvudine was seemly associated with a lower risk of composite outcomes (HR:1.676, 95% CI:0.805-3.488) and short-term all-cause death (HR: 1.291, 95%CI: 0.546-3.051).

Interpretation

Patients who received azvudine have a similar antiviral effectiveness and survival curve trend compared to nirmatrelvir/ritonavir. In this limited series, antiviral treatment was not associated with a significant clinical benefit. This lack of clinical benefit might be attributed to potential bias.

Funding

This study was supported by the "National Key R&D Program of China" (Funding No. 2020YFC2008900) and the National Defense Science and Technology Innovation Special Zone Project (223-CXCY-N101-07-18-01).

A novel lncRNA DFRV plays a dual function in influenza A virus infection

Long noncoding RNAs (lncRNAs) have been associated with a variety of biological activities, including immune responses. However, the function of lncRNAs in antiviral innate immune responses are not fully understood. Here, we identified a novel lncRNA, termed dual function regulating influenza virus (DFRV), elevating in a dose- and time-dependent manner during influenza A virus (IAV) infection, which was dependent on the NFκB signaling pathway. Meanwhile, DFRV was spliced into two transcripts post IAV infection, in which DFRV long suppress the viral replication while DFRV short plays the opposite role. Moreover, DFRV regulates IL-1β and TNF-α via activating several pro-inflammatory signaling cascades, including NFκB, STAT3, PI3K, AKT, ERK1/2 and p38. Besides, DFRV short can inhibit DFRV long expression in a dose-dependent manner. Collectively, our studies reveal that DFRV may act as a potential dual-regulator to preserve innate immune homeostasis in IAV infection.

Induced pluripotent stem cells-podocytes promote repair in acute kidney injury is dependent on Mafb/CCR5/Nampt axis-mediated M2 macrophage polarization

Induced pluripotent stem cells (iPSCs) have been the focus of cellular therapy studies. The use of iPSCs in regenerative medicine is limited by their tumorigenic potential. This study sought to determine whether iPSCs-derived podocytes attenuate acute kidney injury (AKI) and the molecular mechanism. Inoculation of iPSCs-podocytes significantly promoted the repair of kidney injury in AKI mice, reduced the levels of kidney injury factors Scr, BUN, and urinary NAG, and alleviated the inflammatory response. Histological analysis revealed a significant increase in the number of M2 macrophages and a significant decrease in M1 macrophages in the kidney tissues. Subsequently, the genes and signaling pathways that may be associated with kidney injury repair in mice were analyzed by RNA-seq and bioinformatics prediction. The polarization of M2 macrophages was promoted by MAF bZIP transcription factor B (Mafb)-mediated activation of C-C motif chemokine receptor 5 (Ccr5) and nicotinamide phosphoribosyltransferase (Nampt) signaling pathway. Taken together, these results show that iPSCs-podocytes depend on Mafb to activate the Nampt signaling pathway through transcriptional activation of Ccr5, thereby promoting the repair of AKI caused by ischemia-reperfusion.

Association of serum N-terminal pro-brain natriuretic peptide levels with survival and renal outcomes among elderly patients with acute kidney injury in chronic heart failure

Background

Elderly patients exhibit a higher incidence of chronic heart failure (CHF). Patients with CHF can develop acute kidney injury (AKI) during follow-up, which can result in poor prognosis. This relationship between kidney dysfunction and levels of N-terminal pro-brain natriuretic peptides (NT-proBNP), with regard to prognosis, is complicated and has rarely been analyzed in elderly patients with CHF.

Method

We conducted a retrospective cohort study involving patients with a CHF history aged ≥ 65 years, who experienced an episode of AKI. Kaplan-Meier curves and Cox or logistic proportional hazards regression models were used to evaluate the association between serum NT-proBNP concentrations and mortality or renal recovery by day 90.

Results

A total of 1,160 eligible patients with AKI were available for the study. Of this sample, 41.5% of patients died within 90 days of the onset of AKI. Patients with a decreased change in NT-proBNP accompanying the episode of AKI had a lower risk (adjusted OR = 0.56, 95% CI = 0.34-0.91) of more severe AKI (stage 2 and 3 vs. stage 1). The more severe AKI were associated with higher mortality and non-recovery of renal function in elderly patients with CHF, independent of NT-proBNP levels. Elevated levels of baseline lnNT-proBNP (adjusted HR = 1.27, 95% CI = 1.17-1.38) predicted mortality in elderly patients with CHF within 90 days of AKI onset. Patients with a decrease in NT-proBNP accompanying AKI had a lower risk of mortality (adjusted HR = 0.62, 95% CI = 0.48-0.79). However, a decrease in NT-proBNP is a risk factor (adjusted OR = 1.59, 95% CI = 1.02-2.48) for the non-recovery of renal function following AKI-especially in elderly survivors with low baseline NT-proBNP levels.

Conclusion

A decreased change in NT-proBNP maybe protective for elderly patients with CHF by improving survival outcomes and preventing severe AKI. However, an excessive decrease in NT-proBNP is a risk factor for the non-recovery of renal function following AKI. Avoiding excessive changes in NT-proBNP may be protective for survival and renal injury prognosis.

Efficacy of tolvaptan on the short and mid-term prognosis in elderly patients with acute heart failure coexisting with oliguria: A retrospective cohort study

Background

In patients with acute heart failure (AHF) coexisting with oliguria, high doses of loop diuretics are often ineffective in increasing urine output and may adversely affect the patient's prognosis, especially in elderly patients. We investigated the efficacy of adding tolvaptan (TLV) on improving the prognosis in elderly patients with AHF coexisting with oliguria.

Methods

All data for this retrospective cohort study were extracted from the electronic medical record system of the Second Medical Center of Chinese PLA General Hospital from January 2018 to December 2020. Patients diagnosed with AHF coexisting with oliguria were enrolled in this study and were divided into TLV and non-TLV groups based on the use of TLV. The primary outcome was all-cause mortality at 7 and 90-day. The secondary outcomes were the remission of AHF within 7 and 30 days or continued progression of AHF, and new-onset chronic kidney disease (CKD) after 90 days. Cox proportional hazards regression was used to assess the relationships between all-cause mortality and diuretic regimens, demographics, laboratory parameters, comorbidities, and medications.

Results

A total of 308 patients met the study criteria for the final statistical analysis, and they had a median age of 91 years (88, 95). The results showed that the addition of TLV was associated with a decreased risk of the 7 and 90-day all-cause mortality in patients with AHF with oliguria [adjusted HR, 95% CI: 0.60 (0.37, 0.98), p = 0.042; 0.56 (0.41, 0.75), p < 0.001, respectively]. Adding TLV significantly increased urine output and decreased N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels in 7 days, and alleviated the progression of AHF within 30 days. There were no statistically significant differences between the patients with or without TLV in terms of the occurrence of hypernatremia, the development of hepatic impairment within 30 days, and new-onset CKD after 90 days.

Conclusions

This study demonstrated that the addition of TLV was clinically effective in increasing urine output, and had favorable effects on alleviating AHF progression and may reduce the risk of all-cause mortality at 7 and 90-day in elderly patients with AHF with oliguria, and TLV had a good safety profile.

Trial registration

http://www.chictr.org.cn/showprojen.aspx?proj=148046, identifier: ChiCTR2200055518.

Impact of Diabetes on the Recurrence and Prognosis of Acute Kidney Injury in Older Male Patients: A 10-Year Retrospective Cohort Study

INTRODUCTION

While patients with diabetes are at higher risk of developing acute kidney injury (AKI), there are few studies on the recurrence of AKI in older adult patients. This study therefore aimed to examine the impact of diabetes on AKI recurrence and long-term outcomes in older male patients.

METHODS

This retrospective cohort study included older male patients who experienced AKI during hospitalization from July 2007 to August 2011. Medical records of all patients were followed up for 10 years. Patients with AKI were classified into groups with and without diabetes. We analyzed differences in common geriatric comorbidities, AKI recurrence frequency, and severity between the two groups, identified risk factors affecting recurrence frequency, and assessed outcomes.

RESULTS

Of all 266 patients, 128 had diabetes and 138 did not. The AKI recurrence rate was significantly higher in the group with diabetes (80.5 vs. 66.7%; P = 0.011). There was a significantly higher proportion of AKI caused by infections in patients with diabetes (43.3 vs. 33.2%, P = 0.006). The proportion of patients with an AKI recurrence frequency ≥ 3 was significantly higher in the group with diabetes (44.7 vs. 29.4%, P = 0.027). Diabetes and coronary heart disease were independent risk factors for AKI recurrence (P < 0.05), diabetes control was associated with multiple AKI recurrences (P = 0.016), and no significant difference was found between the groups regarding the 10-year prognosis (P = 0.522). However, a subgroup analysis showed that patients with multiple AKI recurrences within 2 years had the worst survival outcome (P = 0.004).

CONCLUSIONS

Older male patients with diabetes are prone to AKI recurrence after initial onset of AKI. Diabetes is an independent risk factor for AKI recurrence, and active diabetes control (HbA1c < 7%) may thus reduce the recurrence of AKI and improve the very poor outcomes of patients with multiple recurrences of AKI within 2 years.

[Early renal tubulointerstitial changes and their interventions with Shenkang Injection in diabetic rats]

OBJECTIVE

To explore whether renal tubulointerstitial lesions are early renal pathological changes and its interventions in diabetic rats.

METHODS

The type 2 diabetic rat model was induced by a high-sugar and high-fat diet with a low-dose intraperitoneal injection of streptozotocin. And Shenkang Injection (SKI) was used as an intervention drug. A total of 30 Sprague-Dawley rats were divided randomly into diabetic (DM), DM+SKI (DMSK) and normal control (NC) groups. The general status, blood biochemical parameters, microalbuminuria and urinary N-acetyl-D-glueosaminidas (NAG) were recorded. The insulin resistance of diabetic rats was detected with hyperinsulinemic-euglycemic clamp test.Renal pathological changes were evaluated with periodic acid-Schiff (PAS) staining. The expression of Toll-like receptor 4 (TLR4) in kidney tissue and renal interstitial CD68(+) cells was detected with immunohistochemistry.

RESULTS

The levels of microalbuminuria, urinary NAG, glomerular volume, renal tubular score, TLR4 expression and renal interstitial CD68(+) cells significantly increased in DM rats with body weight loss and insulin resistance (IOD value of TLR4: 6 289.86 ± 272.45 vs 207.14 ± 22.37; CD68(+) cells: 8.79 ± 0.79 vs.1.23 ± 0.52). All changes in DM rats improved after SKI intervention (P < 0.05).

CONCLUSION

Renal tubulointerstitial lesions are early renal damages in type 2 diabetic rats.SKI can attenuate diabetic tubulointerstitial damage and delay the progression of diabetic nephropathy associated with the inhibition of TLR4 expression and inflammation-mediated macrophage infiltration.

Inhibition of calcium(2+)/calmodulin-dependent protein kinase type IV ameliorates experimental nephrotic syndrome

OBJECTIVE

Evidence has demonstrated that Ca(2+)/calmodulin-dependent protein kinase type IV (CaMKIV) contributes to altered cytokine production by promoting the production of inflammatory cytokines. This study aimed to explore the protective role and underlying mechanisms of CaMKIV inhibition in experimental nephrotic syndrome.

METHODS

BALB/c mice received single intravenous injections of adriamycin (10 mg/kg) then were sacrificed at two, four and six weeks. In the second study, treatment with KN-93, a CaMKIV inhibitor, or vehicle administered via intraperitoneal injection was started five days after adriamycin injection. Functional and pathologic parameters, the presence of inflammatory infiltration and the expressions of pro-inflammatory cytokines were assessed.

RESULTS

The CaMKIV protein expression levels were upregulated in the mice with adriamycin nephropathy, which was significantly inhibited by KN-93 (p<0.01). As compared with the vehicle-treated controls, KN-93 treatment resulted in marked suppression of proteinuria and serum creatinine at week 6 (p<0.01), but not at two weeks after induction of the disease. KN-93 inhibited glomerulosclerosis and the development of tubulointerstitial lesions. The renal alpha-smooth muscle actin (α-SMA) expression was also significantly suppressed by KN-93 treatment at week 6 (p<0.01). Moreover, KN-93 inhibited the renal monocyte chemoattractant protein-1 (MCP-1) expression, paralleled by a reduction in the interstitial infiltration of macrophages and T-cells (p<0.01).

CONCLUSION

Our findings suggest that activation of CaMKIV signaling is involved in the progression of glomerular diseases with a proteinuric state. Our data therefore justify the development of small molecule CaMKIV inhibitors for the treatment of clinical nephrotic syndrome.

Schwann-like cell differentiation of rat adipose-derived stem cells by indirect co-culture with Schwann cells in vitro

OBJECTIVES

Schwann cell (SC) transplantation is a promising therapy for peripheral nerve transaction, however, clinical use of SCs is limited due to their very limited availability. Adipose-derived stem cells (ADSCs) have been identified as an alternative source of adult stem cells in recent years. The aim of this study was to evaluate the feasibility of using ADSCs as a source of stem cells for differentiation into Schwann-like cells by an indirect co-culture approach, in vitro.

MATERIALS AND METHODS

Multilineage differentiation potential of the obtained ADSCs was assayed by testing their ability to differentiate into osteoblasts and adipocytes. The ADSCs were co-cultured with SCs to be induced into Schwann-like cells through proximity, using a Millicell system. Expression of typical SC markers S-100, GFAP and P75NTR of the treated ADSCs was determined by immunocytochemical staining, western blotting and RT-PCR. Myelination capacity of the differentiated ADSCs (dADSCs) was evaluated in dADSC/dorsal root ganglia neuron (DRGN) co-cultures.

RESULTS

The treated ADSCs adopted a spindle shaped-like morphology after co-cultured with SCs for 6 days. All results of immunocytochemical staining, western blotting and RT-PCR showed that the treated cells expressed S-100, GFAP and P75NTR, indications of differentiation. dADSCs could form Schwann-like cell myelin in co-culture with DRGNs. Undifferentiated ADSCs (uADSCs) did not form myelin compared to DRGNs cultured alone, but could produce neurite extension.

CONCLUSIONS

These results demonstrate that this indirect co-culture microenvironment could induce ADSCs to differentiate into Schwann-like cells in vitro, which may be beneficial for treatment of peripheral nerve injuries in the near future.

Protective role of tretinoin and N-acetyl-L-cysteine from antiproliferative action of cigarette smoke extract on alveolar epithelial cells

To investigate the mechanisms by which tretinoin and N-acetyl-L-cysteine (NAC) reverse the growth inhibition of alveolar epithelial cells induced by cigarette smoke extract (CSE), MTT assay was used to evaluate cell viability. It was observed that both tretinoin and NAC could restore the viability of CSE-inhibited A549 cells. By incubation with fluorescent indicator H2DCFDA, it was documented that CSE-stimulated accumulation of intracellular reactive oxygen species (ROS) was obviously decreased by tretinoin or NAC. Furthermore, using semi-quantitative and real-time quantitative RT-PCR as well as western blot methods, high expression of insulin-like growth factor binding protein-2 (IGFBP-2) in A549 cells treated with CSE was found at both transcriptional and protein levels, and concomitant with the restoration of cell growth after treatment with tretinoin or NAC, down regulation of IGFBP-2 was observed. From the present study, it is concluded that both RA and NAC can antagonize CSE-induced growth arrest of alveolar epithelial cells and that down regulation of IGFBP-2 may play an important role in the process.

Combined transplantation of neural stem cells and olfactory ensheathing cells for the repair of spinal cord injuries

Spinal cord repair is a problem that has long puzzled neuroscientists. The failure of the spinal cord to regenerate and undergo reconstruction after spinal cord injury (SCI) can be attributed to secondary axonal demyelination and neuronal death followed by cyst formation and infarction as well as to the nature of the injury environment, which promotes glial scar formation. Cellular replacement and axon guidance are both necessary for SCI repair. Multipotent neural stem cells (NSCs) have the potential to differentiate into both neuronal and glial cells and are, therefore, likely candidates for cell replacement therapy following SCI. However, NSC transplantation alone is not sufficient for spinal cord repair because the majority of the NSCs engrafted into the spinal cord have been shown to differentiate with a phenotype which is restricted to glial lineages, further promoting glial scaring. Olfactory ensheathing cells (OECs) are a unique type of glial cell that occur both peripherally and centrally along the olfactory nerve. The ability of olfactory neurons to grow axons in the mature central nervous system (CNS) milieu has been attributed to the presence of OECs. It has been shown that transplanted OECs are capable of migrating into and through astrocytic scars and thereby facilitating axonal regrowth through an injury barrier. Given the complementary properties of NSCs and OECs, we predict that the co-transplantation of NSCs and OECs into an injured spinal cord would have a synergistic effect, promoting neural regeneration and functional reconstruction. The lost neurocytes would be replaced by NSCs, while the OECs would build "bridges" crossing the glial scaring that conduct axon elongation and promote myelinization simultaneously. Furthermore, the two types of cells could first be seeded into a bioactive scaffold and then the cell seeded construct could be implanted into the defect site. We believe that this type of treatment would lead to improved neural regeneration and functional reconstruction after SCI.

Protective effects of extract of Ginkgo biloba (EGb 761) on nerve cells after spinal cord injury in rats

STUDY DESIGN

An experimental animal model was used to assess spinal cord injury following lateral hemitransection at thoracic spinal cord level.

OBJECTIVE

To determine whether extract of Ginkgo biloba (EGb) could have a neuroprotective effect in spinal cord injury (SCI) in rats.

SETTING

Department of Biological Sciences and Biotechnology, Tsinghua University, China.

METHODS

A total of 72 adult rats were divided randomly into three groups: the EGb group, normal saline (NS) group, and sham operation group (sham group). After thoracic spinal cord hemitransection was performed at the level of the 9th thoracic vertebra (T9), rats in the EGb group were given 100 mg/kg EGb 761 daily, while rats in the NS group received NS. The rats in the sham group only underwent laminectomy without spinal cord hemitransection. At various time points after surgery, thoracic spinal cords were sampled and sliced for histochemistry, immunohistochemistry of inducible nitric oxide synthase (iNOS), and terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling (TUNEL) of apoptotic cells.

RESULTS

Myelin staining showed that the area of cavities was small and the demyelinated zones were limited at and around the injury site of the spinal cord in the EGb group, while the area of cavities was large and the demyelinated zones were serious in the NS group. Nissl staining showed that the ratio of bilateral ventral horn neurons (transection side/uninjured side) in the EGb group was higher than that in the NS group (P<0.05). The apoptotic index and the percentage of iNOS-positive cells were lower in the EGb group than in the NS group. Furthermore, the percentage of iNOS-positive cells positively correlated with the apoptotic index (r( 2)=0.729, P<0.01) after SCI.

CONCLUSION

This study demonstrated that EGb 761 could inhibit iNOS expression and have neuroprotective effect by preventing nerve cells from apoptosis after SCI in rats.

Development of the specific purpose Monte Carlo code CEARXRF for the design and use of in vivo X-ray fluorescence analysis systems for lead in bone

X-ray fluorescence (XRF) systems have been increasingly used for in vivo toxic trace-element analysis in the human body, such as lead in the tibia. Monte Carlo simulation can provide an efficient and flexible method for designing and using in vivo XRF systems. The Monte Carlo code CEARXRF has been developed specifically to simulate the complete pulse height spectrum of energy-dispersive XRF systems. This code is capable of tracking photons in a general geometry and modelling all of the physics of photon interactions in the energy range 1-150 keV for elements Z = 1-94, including primary and higher degree excitations of K and L XRF, the Doppler broadening of Compton-scattered photon energies, and the polarization effects in low-energy photon scatterings. The scattering background for minimum detectable concentration (MDC) analysis may be simulated more accurately by taking into account Doppler broadening in the distribution of the Compton-scattered photon energy due to electron-binding effects. The use of polarized excitation photons has been shown to be important in producing a low scattering background and good measurement sensitivity. The code has two very unique and important features: (1) complete composition and density correlated sampling that is extremely useful for studying measurement sensitivity to small changes in sample composition and density; and (2) Monte Carlo library spectra calculation for the determination of elemental amounts by the Monte Carlo-Library Least-Squares (MCLLS) method. The capability of CEARXRF to aid the design and optimization of in vivo XRF analysis has been verified by modelling hypothesized lead K and L XRF measurement systems.

Optimization of in vivo X-ray fluorescence analysis methods for bone lead by simulation with the Monte Carlo code CEARXRF

In the design of X-ray fluorescence (XRF) systems for in vivo measurements of lead in human bone, the most important considerations are the minimum detectable concentration (MDC), and accuracy and precision. Possible design optimizations can be investigated much more easily and economically by Monte Carlo simulation than by experiment. The specific purpose Monte Carlo code CEARXRF has been used in the present study for: (1) improving the MDC of a hypothesized in vivo 109Cd source-based KXRF system and a 109Cd source or X-ray tube source-based LXRF system by investigating the effects of source polarization and source-bone-detector geometry modification on reducing the scattering background, and (2) investigating the effects of sample variables, such as overlying skin thickness on the MDC and the lead XRF intensity precision. In addition, the feasibility of the Monte Carlo-Library Least-Squares (MCLLS) approach has been investigated in a preliminary fashion for 109Cd-based KXRF spectroscopy analysis.

Black box radiation gauges and analyzers: dream or reality?

This paper describes our attempts to make radiation gauges and analyzers operate in more of a 'black box' manner-being more independent of or at least more insensitive to changes in such things as sample composition and position. Our overall approach relies heavily on Monte Carlo simulation and that is discussed first in relation to radiation gauge and analyzer design and usage. Then the principles and applications of radiation gauges and analyzers including the Measurement Chi-Square and Monte Carlo Library Least-Squares, respectively, are treated. Finally, future work in this area is discussed.