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François B, Lambden S, Fivez T, Gibot S, Derive M, Grouin JM, Salcedo-Magguilli M, Lemarié J, De Schryver N, Jalkanen V, Hicheur T, Garaud JJ, Cuvier V, Ferrer R, Bestle M, Pettilä V, Mira JP, Bouisse C, Mercier E, Vermassen J, Huberlant V, Vinatier I, Anguel N, Levy M, Laterre PF. Prospective evaluation of the efficacy, safety, and optimal biomarker enrichment strategy for nangibotide, a TREM-1 inhibitor, in patients with septic shock (ASTONISH): a double-blind, randomised, controlled, phase 2b trial. Lancet Respir Med 2023; 11:894-904. [PMID: 37269870 DOI: 10.1016/s2213-2600(23)00158-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 04/19/2023] [Accepted: 04/19/2023] [Indexed: 06/05/2023]
Abstract
BACKGROUND Activation of the triggering receptor expressed on myeloid cells-1 (TREM-1) pathway is associated with septic shock outcomes. Data suggest that modulation of this pathway in patients with activated TREM-1 might improve survival. Soluble TREM-1 (sTREM-1), a potential mechanism-based biomarker, might facilitate enrichment of patient selection in clinical trials of nangibotide, a TREM-1 modulator. In this phase 2b trial, we aimed to confirm the hypothesis that TREM1 inhibition might improve outcomes in patients with septic shock. METHODS This double-blind, randomised, placebo-controlled, phase 2b trial assessed the efficacy and safety of two different doses of nangibotide compared with placebo, and aimed to identify the optimum treatment population, in patients across 42 hospitals with medical, surgical, or mixed intensive care units (ICUs) in seven countries. Non-COVID-19 patients (18-85 years) meeting the standard definition of septic shock, with documented or suspected infection (lung, abdominal, or urinary [in patients ≥65 years]), were eligible within 24 h of vasopressor initiation for the treatment of septic shock. Patients were randomly assigned in a 1:1:1 ratio to intravenous nangibotide 0·3 mg/kg per h (low-dose group), nangibotide 1·0 mg/kg per h (high-dose group), or matched placebo, using a computer-generated block randomisation scheme (block size 3). Patients and investigators were masked to treatment allocation. Patients were grouped according to sTREM-1 concentrations at baseline (established from sepsis observational studies and from phase 2a change to data) into high sTREM-1 (≥ 400 pg/mL). The primary outcome was the mean difference in total Sequential Organ Failure Assessment (SOFA) score from baseline to day 5 in the low-dose and high-dose groups compared with placebo, measured in the predefined high sTREM-1 (≥ 400 pg/mL) population and in the overall modified intention-to-treat population. Secondary endpoints included all-cause 28-day mortality, safety, pharmacokinetics, and evaluation of the relationship between TREM-1 activation and treatment response. This study is registered with EudraCT, 2018-004827-36, and Clinicaltrials.gov, NCT04055909. FINDINGS Between Nov 14, 2019, and April 11, 2022, of 402 patients screened, 355 were included in the main analysis (116 in the placebo group, 118 in the low-dose group, and 121 in the high-dose group). In the preliminary high sTREM-1 population (total 253 [71%] of 355; placebo 75 [65%] of 116; low-dose 90 [76%] of 118; high-dose 88 [73%] of 121), the mean difference in SOFA score from baseline to day 5 was 0·21 (95% CI -1·45 to 1·87, p=0·80) in the low-dose group and 1·39 (-0·28 to 3·06, p=0·104) in the high-dose group versus placebo. In the overall population, the difference in SOFA score from baseline to day 5 between the placebo group and low-dose group was 0·20 (-1·09 to 1·50; p=0·76),and between the placebo group and the high-dose group was 1·06 (-0·23 to 2·35, p=0·108). In the predefined high sTREM-1 cutoff population, 23 (31%) patients in the placebo group, 35 (39%) in the low-dose group, and 25 (28%) in the high-dose group had died by day 28. In the overall population, 29 (25%) patients in the placebo, 38 (32%) in the low-dose, and 30 (25%) in the high-dose group had died by day 28. The number of treatment-emergent adverse events (111 [96%] patients in the placebo group, 113 [96%] in the low-dose group, and 115 [95%] in the high-dose group) and serious treatment-emergent adverse events (28 [24%], 26 [22%], and 31 [26%]) was similar between all three groups. High-dose nangibotide led to a clinically relevant improvement in SOFA score (of two points or more) from baseline to day 5 over placebo in those with higher cutoff concentrations (≥532 pg/mL) of sTREM-1 at baseline. Low dose nangibotide displayed a similar pattern with lower magnitude of effect across all cutoff values. INTERPRETATION This trial did not achieve the primary outcome of improvement in SOFA score at the predefined sTREM-1 value. Future studies are needed to confirm the benefit of nangibotide at higher concentrations of TREM-1 activation. FUNDING Inotrem.
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Affiliation(s)
- Bruno François
- Medical-Surgical ICU Department and Inserm CIC1435 & UMR1092, CRICS-TRIGGERSEP Network, CHU Limoges, Limoges, France.
| | - Simon Lambden
- Victor Phillip Dahdaleh Heart and Lung Research Institute, University of Cambridge, Cambridge, UK; Inotrem, Paris, France
| | - Tom Fivez
- Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Sebastien Gibot
- Intensive Care Unit, Centre Hospitalier Regional Universitaire, Nancy, France
| | | | - Jean-Marie Grouin
- Statistics Department, Université de Rouen, Mont Saint-Aignan, France
| | | | | | | | - Ville Jalkanen
- Tampere University Hospital, Intensive Care Unit, Tampere, Finland
| | | | | | | | - Ricard Ferrer
- Intensive Care Department, Hospital Universitari Vall d'Hebron, SODIR Research Group, Vall d'Hebron Institut de Recerca, Spain; Paseig de la Vall d'Hebron, Barcelona, Spain
| | - Morten Bestle
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital-North Zealand, Denmark; Department of Clinical Medicine, University of Copenhagen, Hilleroed, Denmark
| | - Ville Pettilä
- University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jean-Paul Mira
- Groupe Hospitalier Cochin St Vincent de Paul La Roche Guyon, Paris, France
| | - Camille Bouisse
- Centre Hospitalier de Bourg-en-Bresse, Bourg-en-Bresse, France
| | | | | | | | - Isabelle Vinatier
- Centre Hospitalier Départemental de Vendée, La Roche-sur-Yon, France
| | | | - Mitchell Levy
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Warren Alpert School of Medicine at Brown University, Providence, RI, USA
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Schaubroeck H, Vandenberghe W, Boer W, Boonen E, Dewulf B, Bourgeois C, Dubois J, Dumoulin A, Fivez T, Gunst J, Hermans G, Lormans P, Meersseman P, Mesotten D, Stessel B, Vanhoof M, De Vlieger G, Hoste E. Acute kidney injury in critical COVID-19: a multicenter cohort analysis in seven large hospitals in Belgium. Crit Care 2022; 26:225. [PMID: 35879765 PMCID: PMC9310674 DOI: 10.1186/s13054-022-04086-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 07/02/2022] [Indexed: 11/11/2022] Open
Abstract
Background Acute kidney injury (AKI) has been reported as a frequent complication of critical COVID-19. We aimed to evaluate the occurrence of AKI and use of kidney replacement therapy (KRT) in critical COVID-19, to assess patient and kidney outcomes and risk factors for AKI and differences in outcome when the diagnosis of AKI is based on urine output (UO) or on serum creatinine (sCr). Methods Multicenter, retrospective cohort analysis of patients with critical COVID-19 in seven large hospitals in Belgium. AKI was defined according to KDIGO within 21 days after ICU admission. Multivariable logistic regression analysis was used to explore the risk factors for developing AKI and to assess the association between AKI and ICU mortality. Results Of 1286 patients, 85.1% had AKI, and KRT was used in 9.8%. Older age, obesity, a higher APACHE II score and use of mechanical ventilation at day 1 of ICU stay were associated with an increased risk for AKI. After multivariable adjustment, all AKI stages were associated with ICU mortality. AKI was based on sCr in 40.1% and UO in 81.5% of patients. All AKI stages based on sCr and AKI stage 3 based on UO were associated with ICU mortality. Persistent AKI was present in 88.6% and acute kidney disease (AKD) in 87.6%. Rapid reversal of AKI yielded a better prognosis compared to persistent AKI and AKD. Kidney recovery was observed in 47.4% of surviving AKI patients. Conclusions Over 80% of critically ill COVID-19 patients had AKI. This was driven by the high occurrence rate of AKI defined by UO criteria. All AKI stages were associated with mortality (NCT04997915). Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-04086-x.
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3
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Engelen MM, Van Thillo Q, Betrains A, Gyselinck I, Martens CP, Spalart V, Ockerman A, Devooght C, Wauters J, Gunst J, Wouters C, Vandenbriele C, Rex S, Liesenborghs L, Wilmer A, Meersseman P, Van den Berghe G, Dauwe D, Belmans A, Thomeer M, Fivez T, Mesotten D, Ruttens D, Heytens L, Dapper I, Tuyls S, De Tavernier B, Verhamme P, Vanassche T. Modulation of thromboinflammation in hospitalized COVID-19 patients with aprotinin, low molecular weight heparin, and anakinra: The DAWn-Antico study. Res Pract Thromb Haemost 2022; 6:e12826. [PMID: 36324831 PMCID: PMC9618401 DOI: 10.1002/rth2.12826] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 09/19/2022] [Accepted: 09/20/2022] [Indexed: 11/08/2022] Open
Abstract
Background Thromboinflammation plays a central role in severe COVID-19. The kallikrein pathway activates both inflammatory pathways and contact-mediated coagulation. We investigated if modulation of the thromboinflammatory response improves outcomes in hospitalized COVID-19 patients. Methods In this multicenter open-label randomized clinical trial (EudraCT 2020-001739-28), patients hospitalized with COVID-19 were 1:2 randomized to receive standard of care (SOC) or SOC plus study intervention. The intervention consisted of aprotinin (2,000,000 IE IV four times daily) combined with low molecular weight heparin (LMWH; SC 50 IU/kg twice daily on the ward, 75 IU/kg twice daily in intensive care). Additionally, patients with predefined hyperinflammation received the interleukin-1 receptor antagonist anakinra (100 mg IV four times daily). The primary outcome was time to a sustained 2-point improvement on the 7-point World Health Organization ordinal scale for clinical status, or discharge. Findings Between 24 June 2020 and 1 February 2021, 105 patients were randomized, and 102 patients were included in the full analysis set (intervention N = 67 vs. SOC N = 35). Twenty-five patients from the intervention group (37%) received anakinra. The intervention did not affect the primary outcome (HR 0.77 [CI 0.50-1.19], p = 0.24) or mortality (intervention n = 3 [4.6%] vs. SOC n = 2 [5.7%], HR 0.82 [CI 0.14-4.94], p = 0.83). There was one treatment-related adverse event in the intervention group (hematuria, 1.49%). There was one thrombotic event in the intervention group (1.49%) and one in the SOC group (2.86%), but no major bleeding. Conclusions In hospitalized COVID-19 patients, modulation of thromboinflammation with high-dose aprotinin and LMWH with or without anakinra did not improve outcome in patients with moderate to severe COVID-19.
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Affiliation(s)
- Matthias M. Engelen
- Department of Cardiovascular DiseasesUniversity Hospitals LeuvenLeuvenBelgium,Department of Cardiovascular Sciences, Center for Molecular and Vascular BiologyKU LeuvenLeuvenBelgium
| | | | - Albrecht Betrains
- Department of Microbiology, Immunology and Transplantation, Laboratory for Clinical Infectious and Inflammatory DisordersKU LeuvenLeuvenBelgium
| | - Iwein Gyselinck
- BREATHE Lab, Department CHROMETAKU LeuvenLeuvenBelgium,Department of Respiratory DiseasesUZ LeuvenLeuvenBelgium
| | - Caroline P. Martens
- Department of Cardiovascular Sciences, Center for Molecular and Vascular BiologyKU LeuvenLeuvenBelgium
| | - Valérie Spalart
- Department of Cardiovascular DiseasesUniversity Hospitals LeuvenLeuvenBelgium,Department of Cardiovascular Sciences, Center for Molecular and Vascular BiologyKU LeuvenLeuvenBelgium
| | - Anna Ockerman
- Department of Cardiovascular DiseasesUniversity Hospitals LeuvenLeuvenBelgium
| | - Caroline Devooght
- Department of Cardiovascular DiseasesUniversity Hospitals LeuvenLeuvenBelgium
| | - Joost Wauters
- Department of General Internal Medicine, Medical Intensive Care UnitUniversity Hospitals LeuvenLeuvenBelgium
| | - Jan Gunst
- Clinical Department and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular MedicineKU LeuvenLeuvenBelgium
| | - Carine Wouters
- Pediatric RheumatologyUniversity Hospitals LeuvenLeuvenBelgium,Laboratory of Adaptive Immunology & Immunobiology, Department of Microbiology and ImmunologyKU LeuvenLeuvenBelgium
| | - Christophe Vandenbriele
- Department of Cardiovascular DiseasesUniversity Hospitals LeuvenLeuvenBelgium,Department of Cardiovascular Sciences, Center for Molecular and Vascular BiologyKU LeuvenLeuvenBelgium
| | - Steffen Rex
- Department of Cardiovascular SciencesUniversity Hospitals LeuvenLeuvenBelgium,Department of AnesthesiologyUniversity Hospitals LeuvenLeuvenBelgium
| | - Laurens Liesenborghs
- Department of Cardiovascular Sciences, Center for Molecular and Vascular BiologyKU LeuvenLeuvenBelgium
| | - Alexander Wilmer
- Department of General Internal Medicine, Medical Intensive Care UnitUniversity Hospitals LeuvenLeuvenBelgium
| | - Philippe Meersseman
- Department of General Internal Medicine, Medical Intensive Care UnitUniversity Hospitals LeuvenLeuvenBelgium
| | - Greet Van den Berghe
- Clinical Department and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular MedicineKU LeuvenLeuvenBelgium
| | - Dieter Dauwe
- Clinical Department and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular MedicineKU LeuvenLeuvenBelgium
| | - Ann Belmans
- Interuniversity Institute for Biostatistics and statistical Bioinformatics (I‐BioStat), KU LeuvenLeuvenBelgium
| | - Michiel Thomeer
- Department of Respiratory MedicineZiekenhuis Oost‐LimburgGenkBelgium,Department of Medicine and Life SciencesHasselt UniversityDiepenbeekBelgium
| | - Tom Fivez
- Department of Medicine and Life SciencesHasselt UniversityDiepenbeekBelgium,Department of Anaesthesiology, Intensive Care, Emergency Medicine and Pain TherapyZiekenhuis Oost‐LimburgGenkBelgium
| | - Dieter Mesotten
- Department of Medicine and Life SciencesHasselt UniversityDiepenbeekBelgium,Department of Anaesthesiology, Intensive Care, Emergency Medicine and Pain TherapyZiekenhuis Oost‐LimburgGenkBelgium
| | - David Ruttens
- Department of Respiratory MedicineZiekenhuis Oost‐LimburgGenkBelgium
| | - Luc Heytens
- Department of Intensive CareGZA Hospital GroupAntwerpBelgium
| | - Ilse Dapper
- Department of Intensive CareGZA Hospital GroupAntwerpBelgium
| | | | | | - Peter Verhamme
- Department of Cardiovascular DiseasesUniversity Hospitals LeuvenLeuvenBelgium,Department of Cardiovascular Sciences, Center for Molecular and Vascular BiologyKU LeuvenLeuvenBelgium
| | - Thomas Vanassche
- Department of Cardiovascular DiseasesUniversity Hospitals LeuvenLeuvenBelgium,Department of Cardiovascular Sciences, Center for Molecular and Vascular BiologyKU LeuvenLeuvenBelgium
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de Laat B, Stragier H, de Laat-Kremers R, Ninivaggi M, Mesotten D, Thiessen S, Van Pelt K, Roest M, Penders J, Vanelderen P, Huskens D, De Jongh R, Laenen MV, Fivez T, ten Cate H, Heylen R, Heylen L, Steensels D. Population-wide persistent hemostatic changes after vaccination with ChAdOx1-S. Front Cardiovasc Med 2022; 9:966028. [PMID: 35966540 PMCID: PMC9372359 DOI: 10.3389/fcvm.2022.966028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 07/04/2022] [Indexed: 11/13/2022] Open
Abstract
Various vaccines were developed to reduce the spread of the Severe Acute Respiratory Syndrome Cov-2 (SARS-CoV-2) virus. Quickly after the start of vaccination, reports emerged that anti-SARS-CoV-2 vaccines, including ChAdOx1-S, could be associated with an increased risk of thrombosis. We investigated the hemostatic changes after ChAdOx1-S vaccination in 631 health care workers. Blood samples were collected 32 days on average after the second ChAdOx1-S vaccination, to evaluate hemostatic markers such as D-dimer, fibrinogen, α2-macroglobulin, FVIII and thrombin generation. Endothelial function was assessed by measuring Von Willebrand Factor (VWF) and active VWF. IL-6 and IL-10 were measured to study the activation of the immune system. Additionally, SARS-CoV-2 anti-nucleoside and anti-spike protein antibody titers were determined. Prothrombin and fibrinogen levels were significantly reduced after vaccination (−7.5% and −16.9%, p < 0.0001). Significantly more vaccinated subjects were outside the normal range compared to controls for prothrombin (42.1% vs. 26.4%, p = 0.026) and antithrombin (23.9% vs. 3.6%, p = 0.0010). Thrombin generation indicated a more procoagulant profile, characterized by a significantly shortened lag time (−11.3%, p < 0.0001) and time-to-peak (−13.0% and p < 0.0001) and an increased peak height (32.6%, p = 0.0015) in vaccinated subjects compared to unvaccinated controls. Increased VWF (+39.5%, p < 0.0001) and active VWF levels (+24.1 %, p < 0.0001) pointed toward endothelial activation, and IL-10 levels were significantly increased (9.29 pg/mL vs. 2.43 pg/mL, p = 0.032). The persistent increase of IL-10 indicates that the immune system remains active after ChAdOx1-S vaccination. This could trigger a pathophysiological mechanism causing an increased thrombin generation profile and vascular endothelial activation, which could subsequently result in and increased risk of thrombotic events.
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Affiliation(s)
- Bas de Laat
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, Netherlands
- Department of Data Analysis and Artificial Intelligence, Synapse Research Institute, Maastricht, Netherlands
- *Correspondence: Bas de Laat
| | - Hendrik Stragier
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Hospital Oost-Limburg, Genk, Belgium
- CARIM School for Cardiovascular Diseases, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands
| | - Romy de Laat-Kremers
- Department of Data Analysis and Artificial Intelligence, Synapse Research Institute, Maastricht, Netherlands
| | - Marisa Ninivaggi
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, Netherlands
| | - Dieter Mesotten
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Hospital Oost-Limburg, Genk, Belgium
- UHasselt, Faculty of Medicine and Life Sciences, Diepenbeek, Belgium
| | - Steven Thiessen
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Hospital Oost-Limburg, Genk, Belgium
| | - Kristien Van Pelt
- Department of Laboratory Medicine, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Mark Roest
- Department of Platelet Pathophysiology, Synapse Research Institute, Maastricht, Netherlands
| | - Joris Penders
- UHasselt, Faculty of Medicine and Life Sciences, Diepenbeek, Belgium
- Department of Laboratory Medicine, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Pascal Vanelderen
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Hospital Oost-Limburg, Genk, Belgium
- UHasselt, Faculty of Medicine and Life Sciences, Diepenbeek, Belgium
| | - Dana Huskens
- Department of Platelet Pathophysiology, Synapse Research Institute, Maastricht, Netherlands
| | - Raf De Jongh
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Hospital Oost-Limburg, Genk, Belgium
| | - Margot Vander Laenen
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Hospital Oost-Limburg, Genk, Belgium
| | - Tom Fivez
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Hospital Oost-Limburg, Genk, Belgium
| | - Hugo ten Cate
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, Netherlands
- Thrombosis Expertise Center, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, Netherlands
| | - Rene Heylen
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Hospital Oost-Limburg, Genk, Belgium
- Department of Cardiovascular Sciences, Section Anesthesiology and Algology KULeuven, Leuven, Belgium
| | - Line Heylen
- UHasselt, Faculty of Medicine and Life Sciences, Diepenbeek, Belgium
- Department of Nephrology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Deborah Steensels
- Department of Laboratory Medicine, Ziekenhuis Oost-Limburg, Genk, Belgium
- Université Libre de Bruxelles, Faculty of Medicine, Brussels, Belgium
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5
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Boer W, Fivez T, Vander Laenen M, Bruckers L, Grön HJ, Schetz M, Oudemans-van Straaten H. Citrate dose for continuous hemofiltration: effect on calcium and magnesium balance, parathormone and vitamin D status, a randomized controlled trial. BMC Nephrol 2021; 22:409. [PMID: 34895160 PMCID: PMC8665615 DOI: 10.1186/s12882-021-02598-2] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 11/03/2021] [Indexed: 11/16/2022] Open
Abstract
Background Regional citrate anticoagulation may cause a negative calcium balance, systemic hypocalcemia and parathormone (PTH) activation but randomzed studies are not available. Aim was to determine the effect of citrate dose on calcium (Ca) and magnesium (Mg) balance, PTH and Vitamin D. Methods Single center prospective randomized study. Patients, requiring continuous venovenous hemofiltration (CVVH) with citrate, randomized to low dose citrate (2.5 mmol/L) vs. high dose (4.5 mmol/L) for 24 h, targeting post-filter ionized calcium (pfiCa) of 0.325–0.4 mmol/L vs. 0.2–0.275 mmol/L, using the Prismaflex® algorithm with 100% postfilter calcium replacement. Extra physician-ordered Ca and Mg supplementation was performed aiming at systemic iCa > 1.0 mmol/L. Arterial blood, effluent and post-filter aliquots were taken for balance calculations (area under the curve), intact (i), oxidized (ox) and non-oxidized (nox) PTH, 25-hydroxy-Vitamin D (25D) and 1,25-dihydroxy-Vitamin D (1,25D). Results 35 patients were analyzed, 17 to high, 18 to low citrate. Mean 24-h Ca balance was - 9.72 mmol/d (standard error 1.70) in the high vs − 1.18 mmol/d (se 1.70)) (p = 0.002) in the low citrate group and 24-h Mg-balance was − 25.99 (se 2.10) mmol/d vs. -17.63 (se 2.10) mmol/d (p = 0.008) respectively. Physician-ordered Ca supplementation, higher in the high citrate group, resulted in a positive Ca-balance in both groups. iPTH, oxPTH or noxPTH were not different between groups. Over 24 h, median PTH decreased from 222 (25th–75th percentile 140–384) to 162 (111–265) pg/ml (p = 0.002); oxPTH from 192 (124–353) to 154 pg/ml (87–231), p = 0.002. NoxPTH did not change significantly. Mean 25 D (standard deviation), decreased from 36.5 (11.8) to 33.3 (11.2) nmol/l (p = 0.003), 1,25D rose from 40.9 pg/ml (30.7) to 43.2 (30.7) pg/ml (p = 0.046), without differences between groups. Conclusions A higher citrate dose caused a more negative CVVH Ca balance than a lower dose, due to a higher effluent Calcium loss. Physician-ordered Ca supplementation, targeting a systemic iCa > 1.0 mmol/L, higher in the high citrate group, resulted in a positive Ca-balance in both groups. iPTH and oxPTH declined, suggesting decreased oxidative stress, while noxPTH did not change. 25D decreased while 1,25-D rose. Mg balance was negative in both groups, more so in the high citrate group. Trial registration ClinicalTrials.gov: NCT02194569. Registered 18 July 2014. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-021-02598-2.
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Affiliation(s)
- Willem Boer
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine & Pain Medicine, Ziekenhuis Oost Limburg ZOL, Genk, Belgium.
| | - Tom Fivez
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine & Pain Medicine, Ziekenhuis Oost Limburg ZOL, Genk, Belgium
| | - Margot Vander Laenen
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine & Pain Medicine, Ziekenhuis Oost Limburg ZOL, Genk, Belgium
| | - Liesbeth Bruckers
- I-BioStat, Data Science Institute, Hasselt University, Hasselt, Belgium
| | | | - Miet Schetz
- Department of Laboratory and Intensive Care Medicine, Catholic University Leuven, Leuven, Belgium
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6
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Declercq J, Van Damme KFA, De Leeuw E, Maes B, Bosteels C, Tavernier SJ, De Buyser S, Colman R, Hites M, Verschelden G, Fivez T, Moerman F, Demedts IK, Dauby N, De Schryver N, Govaerts E, Vandecasteele SJ, Van Laethem J, Anguille S, van der Hilst J, Misset B, Slabbynck H, Wittebole X, Liénart F, Legrand C, Buyse M, Stevens D, Bauters F, Seys LJM, Aegerter H, Smole U, Bosteels V, Hoste L, Naesens L, Haerynck F, Vandekerckhove L, Depuydt P, van Braeckel E, Rottey S, Peene I, Van Der Straeten C, Hulstaert F, Lambrecht BN. Effect of anti-interleukin drugs in patients with COVID-19 and signs of cytokine release syndrome (COV-AID): a factorial, randomised, controlled trial. Lancet Respir Med 2021; 9:1427-1438. [PMID: 34756178 PMCID: PMC8555973 DOI: 10.1016/s2213-2600(21)00377-5] [Citation(s) in RCA: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 07/29/2021] [Accepted: 08/16/2021] [Indexed: 12/29/2022]
Abstract
Background Infections with SARS-CoV-2 continue to cause significant morbidity and mortality. Interleukin (IL)-1 and IL-6 blockade have been proposed as therapeutic strategies in COVID-19, but study outcomes have been conflicting. We sought to study whether blockade of the IL-6 or IL-1 pathway shortened the time to clinical improvement in patients with COVID-19, hypoxic respiratory failure, and signs of systemic cytokine release syndrome. Methods We did a prospective, multicentre, open-label, randomised, controlled trial, in hospitalised patients with COVID-19, hypoxia, and signs of a cytokine release syndrome across 16 hospitals in Belgium. Eligible patients had a proven diagnosis of COVID-19 with symptoms between 6 and 16 days, a ratio of the partial pressure of oxygen to the fraction of inspired oxygen (PaO2:FiO2) of less than 350 mm Hg on room air or less than 280 mm Hg on supplemental oxygen, and signs of a cytokine release syndrome in their serum (either a single ferritin measurement of more than 2000 μg/L and immediately requiring high flow oxygen or mechanical ventilation, or a ferritin concentration of more than 1000 μg/L, which had been increasing over the previous 24 h, or lymphopenia below 800/mL with two of the following criteria: an increasing ferritin concentration of more than 700 μg/L, an increasing lactate dehydrogenase concentration of more than 300 international units per L, an increasing C-reactive protein concentration of more than 70 mg/L, or an increasing D-dimers concentration of more than 1000 ng/mL). The COV-AID trial has a 2 × 2 factorial design to evaluate IL-1 blockade versus no IL-1 blockade and IL-6 blockade versus no IL-6 blockade. Patients were randomly assigned by means of permuted block randomisation with varying block size and stratification by centre. In a first randomisation, patients were assigned to receive subcutaneous anakinra once daily (100 mg) for 28 days or until discharge, or to receive no IL-1 blockade (1:2). In a second randomisation step, patients were allocated to receive a single dose of siltuximab (11 mg/kg) intravenously, or a single dose of tocilizumab (8 mg/kg) intravenously, or to receive no IL-6 blockade (1:1:1). The primary outcome was the time to clinical improvement, defined as time from randomisation to an increase of at least two points on a 6-category ordinal scale or to discharge from hospital alive. The primary and supportive efficacy endpoints were assessed in the intention-to-treat population. Safety was assessed in the safety population. This study is registered online with ClinicalTrials.gov (NCT04330638) and EudraCT (2020-001500-41) and is complete. Findings Between April 4, and Dec 6, 2020, 342 patients were randomly assigned to IL-1 blockade (n=112) or no IL-1 blockade (n=230) and simultaneously randomly assigned to IL-6 blockade (n=227; 114 for tocilizumab and 113 for siltuximab) or no IL-6 blockade (n=115). Most patients were male (265 [77%] of 342), median age was 65 years (IQR 54–73), and median Systematic Organ Failure Assessment (SOFA) score at randomisation was 3 (2–4). All 342 patients were included in the primary intention-to-treat analysis. The estimated median time to clinical improvement was 12 days (95% CI 10–16) in the IL-1 blockade group versus 12 days (10–15) in the no IL-1 blockade group (hazard ratio [HR] 0·94 [95% CI 0·73–1·21]). For the IL-6 blockade group, the estimated median time to clinical improvement was 11 days (95% CI 10–16) versus 12 days (11–16) in the no IL-6 blockade group (HR 1·00 [0·78–1·29]). 55 patients died during the study, but no evidence for differences in mortality between treatment groups was found. The incidence of serious adverse events and serious infections was similar across study groups. Interpretation Drugs targeting IL-1 or IL-6 did not shorten the time to clinical improvement in this sample of patients with COVID-19, hypoxic respiratory failure, low SOFA score, and low baseline mortality risk. Funding Belgian Health Care Knowledge Center and VIB Grand Challenges program.
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Affiliation(s)
- Jozefien Declercq
- Laboratory of Mucosal Immunology, VIB-UGhent Center for Inflammation Research, Ghent University, Ghent, Belgium; Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium; Department of Pulmonary Medicine, University Hospital Ghent, Ghent, Belgium
| | - Karel F A Van Damme
- Laboratory of Mucosal Immunology, VIB-UGhent Center for Inflammation Research, Ghent University, Ghent, Belgium; Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium; Department of Pulmonary Medicine, University Hospital Ghent, Ghent, Belgium
| | - Elisabeth De Leeuw
- Laboratory of Mucosal Immunology, VIB-UGhent Center for Inflammation Research, Ghent University, Ghent, Belgium; Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium; Department of Pulmonary Medicine, University Hospital Ghent, Ghent, Belgium
| | - Bastiaan Maes
- Laboratory of Mucosal Immunology, VIB-UGhent Center for Inflammation Research, Ghent University, Ghent, Belgium; Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium; Department of Pulmonary Medicine, University Hospital Ghent, Ghent, Belgium
| | - Cedric Bosteels
- Laboratory of Mucosal Immunology, VIB-UGhent Center for Inflammation Research, Ghent University, Ghent, Belgium; Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium; Department of Pulmonary Medicine, University Hospital Ghent, Ghent, Belgium
| | - Simon J Tavernier
- Laboratory of Mucosal Immunology, VIB-UGhent Center for Inflammation Research, Ghent University, Ghent, Belgium; Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium; Primary Immunodeficiency Research Laboratory, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Stefanie De Buyser
- Biostatistics Unit, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Roos Colman
- Biostatistics Unit, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Maya Hites
- Clinic of Infectious Diseases, Cliniques Universitaires de Bruxelles, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Gil Verschelden
- Clinic of Infectious Diseases, Cliniques Universitaires de Bruxelles, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Tom Fivez
- Intensive Care Unit, ZOL Genk General Hospital, Genk, Belgium
| | - Filip Moerman
- Department of Infectious Diseases, CHR de La Citadelle General Hospital, Liège, Belgium
| | - Ingel K Demedts
- Department of Pulmonary Medicine, AZ Delta General Hospital, Roeselare, Belgium
| | - Nicolas Dauby
- Institute for Medical Immunology, Université Libre de Bruxelles and CHU Saint-Pierre University Hospital, Brussels, Belgium
| | | | - Elke Govaerts
- Department of Pulmonary Medicine, AZ Sint-Lucas General Hospital, Ghent, Belgium
| | | | - Johan Van Laethem
- Department of Internal Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | | | - Jeroen van der Hilst
- Department of Infectious Diseases and Immune Pathology, Jessa General Hospital and Limburg Clinical Research Center, Hasselt University, Hasselt, Belgium
| | - Benoit Misset
- Department of Intensive Care Medicine, University Hospital, Liège, Belgium
| | - Hans Slabbynck
- Department of Pulmonary Medicine, ZNA General Hospital, Antwerp, Belgium
| | - Xavier Wittebole
- Intensive Care Unit, Saint Luc University Hospital, UC Louvain, Brussels, Belgium
| | - Fabienne Liénart
- Department of Internal Medicine, CHU Tivoli University Hospital, La Louvière, Belgium
| | - Catherine Legrand
- Institute of Statistics, Biostatistics and Actuarial Sciences (ISBA), Louvain Institute for Data Analysis and Modeling, Louvain-la-Neuve, Belgium
| | - Marc Buyse
- (22)IDDI, Louvain-la-Neuve, and Interuniversity Institute for Biostatistics and Statistical Bioinformatics, Hasselt, Belgium
| | - Dieter Stevens
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium; Department of Pulmonary Medicine, University Hospital Ghent, Ghent, Belgium
| | - Fre Bauters
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium; Department of Pulmonary Medicine, University Hospital Ghent, Ghent, Belgium
| | - Leen J M Seys
- Laboratory of Mucosal Immunology, VIB-UGhent Center for Inflammation Research, Ghent University, Ghent, Belgium; Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Helena Aegerter
- Laboratory of Mucosal Immunology, VIB-UGhent Center for Inflammation Research, Ghent University, Ghent, Belgium; Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Ursula Smole
- Laboratory of Mucosal Immunology, VIB-UGhent Center for Inflammation Research, Ghent University, Ghent, Belgium; Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Victor Bosteels
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium; Laboratory of ER Stress and Inflammation, VIB-UGhent Center for Inflammation Research, Ghent University, Ghent, Belgium
| | - Levi Hoste
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium; Primary Immunodeficiency Research Laboratory, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Leslie Naesens
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium; Primary Immunodeficiency Research Laboratory, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Filomeen Haerynck
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium; Primary Immunodeficiency Research Laboratory, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Linos Vandekerckhove
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium; Department of Infectious Diseases, University Hospital Ghent, Ghent, Belgium
| | - Pieter Depuydt
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium; Intensive Care Unit, University Hospital Ghent, Ghent, Belgium
| | - Eva van Braeckel
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium; Department of Pulmonary Medicine, University Hospital Ghent, Ghent, Belgium
| | - Sylvie Rottey
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium; Drug Research Unit, Ghent University, Ghent, Belgium
| | - Isabelle Peene
- Department of Rheumatology, AZ Sint-Jan Brugge-Oostende, Brugge, Belgium
| | | | | | - Bart N Lambrecht
- Laboratory of Mucosal Immunology, VIB-UGhent Center for Inflammation Research, Ghent University, Ghent, Belgium; Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium; Department of Pulmonary Medicine, University Hospital Ghent, Ghent, Belgium.
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7
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Vanassche T, Engelen MM, Van Thillo Q, Wauters J, Gunst J, Wouters C, Vandenbriele C, Rex S, Liesenborghs L, Wilmer A, Meersseman P, Van den Berghe G, Dauwe D, Verbeke G, Thomeer M, Fivez T, Mesotten D, Ruttens D, Heytens L, Dapper I, Tuyls S, De Tavernier B, Verhamme P. Correction to: A randomized, open-label, adaptive, proof-of-concept clinical trial of modulation of host thromboinflammatory response in patients with COVID-19: the DAWn-Antico study. Trials 2020; 21:1033. [PMID: 33375932 PMCID: PMC7770739 DOI: 10.1186/s13063-020-04991-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
An amendment to this paper has been published and can be accessed via the original article.
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Affiliation(s)
- T Vanassche
- Center for Molecular and Vascular Biology, KU Leuven Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium. .,Department of Cardiovascular Sciences, University Hospitals Leuven, Leuven, Belgium.
| | - M M Engelen
- Center for Molecular and Vascular Biology, KU Leuven Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, University Hospitals Leuven, Leuven, Belgium
| | | | - J Wauters
- Department of General Internal Medicine, Medical Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - J Gunst
- Clinical Department and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - C Wouters
- Pediatric Rheumatology, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Adaptive Immunology & Immunobiology, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | - C Vandenbriele
- Center for Molecular and Vascular Biology, KU Leuven Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, University Hospitals Leuven, Leuven, Belgium
| | - S Rex
- Department of Cardiovascular Sciences, University Hospitals Leuven, Leuven, Belgium.,Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - L Liesenborghs
- Center for Molecular and Vascular Biology, KU Leuven Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.,REGA Institute, KU Leuven, Leuven, Belgium
| | - A Wilmer
- Department of General Internal Medicine, Medical Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - P Meersseman
- Department of General Internal Medicine, Medical Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - G Van den Berghe
- Clinical Department and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - D Dauwe
- Clinical Department and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - G Verbeke
- Interuniversity Institute for Biostatistics and statistical Bioinformatics (I-BioStat), KU Leuven, Leuven, and Hasselt University (UHasselt), Hasselt, Belgium
| | - M Thomeer
- Department of Respiratory Medicine, Ziekenhuis Oost-Limburg, Genk, Belgium.,Department of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - T Fivez
- Department of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium.,Department of Anaesthesiology, Intensive Care, Emergency Medicine and Pain Therapy, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - D Mesotten
- Department of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium.,Department of Anaesthesiology, Intensive Care, Emergency Medicine and Pain Therapy, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - D Ruttens
- Department of Respiratory Medicine, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - L Heytens
- Department of Anesthestiology, GZA hospital group, Antwerp, Belgium
| | - I Dapper
- Emergency Medicine and Intensive Care, GZA hospital group, Antwerp, Belgium
| | - S Tuyls
- Respiratory Medicine, GZA hospital group, Antwerp, Belgium
| | - B De Tavernier
- Emergency Medicine and Intensive Care, GZA hospital group, Antwerp, Belgium
| | - P Verhamme
- Center for Molecular and Vascular Biology, KU Leuven Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, University Hospitals Leuven, Leuven, Belgium
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8
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Vanassche T, Engelen MM, Van Thillo Q, Wauters J, Gunst J, Wouters C, Vandenbriele C, Rex S, Liesenborghs L, Wilmer A, Meersseman P, Van den Berghe G, Dauwe D, Verbeke G, Thomeer M, Fivez T, Mesotten D, Ruttens D, Heytens L, Dapper I, Tuyls S, De Tavernier B, Verhamme P. A randomized, open-label, adaptive, proof-of-concept clinical trial of modulation of host thromboinflammatory response in patients with COVID-19: the DAWn-Antico study. Trials 2020; 21:1005. [PMID: 33298149 PMCID: PMC7724460 DOI: 10.1186/s13063-020-04878-y] [Citation(s) in RCA: 12] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 11/06/2020] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND The peak of the global COVID-19 pandemic has not yet been reached, and many countries face the prospect of a second wave of infections before effective vaccinations will be available. After an initial phase of viral replication, some patients develop a second illness phase in which the host thrombotic and inflammatory responses seem to drive complications. Severe COVID-19 disease is linked to high mortality, hyperinflammation, and a remarkably high incidence of thrombotic events. We hypothesize a crucial pathophysiological role for the contact pathway of coagulation and the kallikrein-bradykinin pathway. Therefore, drugs that modulate this excessive thromboinflammatory response should be investigated in severe COVID-19. METHODS In this adaptive, open-label multicenter randomized clinical trial, we compare low molecular weight heparins at 50 IU anti-Xa/kg twice daily-or 75 IU anti-Xa twice daily for intensive care (ICU) patients-in combination with aprotinin to standard thromboprophylaxis in hospitalized COVID-19 patients. In the case of hyperinflammation, the interleukin-1 receptor antagonist anakinra will be added on top of the drugs in the interventional arm. In a pilot phase, the effect of the intervention on thrombotic markers (D-dimer) will be assessed. In the full trial, the primary outcome is defined as the effect of the interventional drugs on clinical status as defined by the WHO ordinal scale for clinical improvement. DISCUSSION In this trial, we target the thromboinflammatory response at multiple levels. We intensify the dose of low molecular weight heparins to reduce thrombotic complications. Aprotinin is a potent kallikrein pathway inhibitor that reduces fibrinolysis, activation of the contact pathway of coagulation, and local inflammatory response. Additionally, aprotinin has shown in vitro inhibitory effects on SARS-CoV-2 cellular entry. Because the excessive thromboinflammatory response is one of the most adverse prognostic factors in COVID-19, we will add anakinra, a recombinant interleukin-1 receptor antagonist, to the regimen in case of severely increased inflammatory parameters. This way, we hope to modulate the systemic response to SARS-CoV-2 and avoid disease progressions with a potentially fatal outcome. TRIAL REGISTRATION The EU Clinical Trials Register 2020-001739-28 . Registered on April 10, 2020.
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Affiliation(s)
- T Vanassche
- Center for Molecular and Vascular Biology, KU Leuven Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium. .,Department of Cardiovascular Sciences, University Hospitals Leuven, Leuven, Belgium.
| | - M M Engelen
- Center for Molecular and Vascular Biology, KU Leuven Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, University Hospitals Leuven, Leuven, Belgium
| | | | - J Wauters
- Department of General Internal Medicine, Medical Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - J Gunst
- Clinical Department and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - C Wouters
- Pediatric Rheumatology, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Adaptive Immunology & Immunobiology, Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | - C Vandenbriele
- Center for Molecular and Vascular Biology, KU Leuven Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, University Hospitals Leuven, Leuven, Belgium
| | - S Rex
- Department of Cardiovascular Sciences, University Hospitals Leuven, Leuven, Belgium.,Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - L Liesenborghs
- Center for Molecular and Vascular Biology, KU Leuven Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.,REGA Institute, KU Leuven, Leuven, Belgium
| | - A Wilmer
- Department of General Internal Medicine, Medical Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - P Meersseman
- Department of General Internal Medicine, Medical Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - G Van den Berghe
- Clinical Department and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - D Dauwe
- Clinical Department and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - G Verbeke
- Interuniversity Institute for Biostatistics and statistical Bioinformatics (I-BioStat), KU Leuven, Leuven, and Hasselt University (UHasselt), Hasselt, Belgium
| | - M Thomeer
- Department of Respiratory Medicine, Ziekenhuis Oost-Limburg, Genk, Belgium.,Department of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - T Fivez
- Department of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium.,Department of Anaesthesiology, Intensive Care, Emergency Medicine and Pain Therapy, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - D Mesotten
- Department of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium.,Department of Anaesthesiology, Intensive Care, Emergency Medicine and Pain Therapy, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - D Ruttens
- Department of Respiratory Medicine, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - L Heytens
- Department of Anesthestiology, GZA hospital group, Antwerp, Belgium
| | - I Dapper
- Emergency Medicine and Intensive Care, GZA hospital group, Antwerp, Belgium
| | - S Tuyls
- Respiratory Medicine, GZA hospital group, Antwerp, Belgium
| | - B De Tavernier
- Emergency Medicine and Intensive Care, GZA hospital group, Antwerp, Belgium
| | - P Verhamme
- Center for Molecular and Vascular Biology, KU Leuven Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, University Hospitals Leuven, Leuven, Belgium
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9
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Boons J, Van Biesen S, Fivez T, de Velde MV, Al Tmimi L. Mechanisms, Prevention, and Treatment of Atrial Fibrillation After Cardiac Surgery: A Narrative Review. J Cardiothorac Vasc Anesth 2020; 35:3394-3403. [PMID: 33308918 DOI: 10.1053/j.jvca.2020.11.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 10/20/2020] [Accepted: 11/15/2020] [Indexed: 11/11/2022]
Abstract
New onset of postoperative atrial fibrillation (AF) generally is recognized as a frequent and debilitating complication after cardiac surgery, contributing to a considerable health- care cost. Extensive research has been conducted to study the underlying mechanisms and risk factors of AF in the perioperative period. Many options have been suggested to lower the incidence, and the concurrent cost in health resources. This review attempts to synthesize the large body of existing literature on AF, as well as expand and illustrate the available knowledge on its management strategies. The latter incorporates recent developments in the anesthesthetic approach as well as in the pharmacologic arsenal. In addition, the current review provides a tool for understanding the pathophysiology of AF and for reducing the occurrence after cardiac surgery. By using it, clinicians can manage patients with AF in the perioperative period of cardiac surgery and minimize the relatively high economic cost that accompanies it.
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Affiliation(s)
- Jeroen Boons
- Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium; Department of Intensive Care Medicine, Ziekenhuis Oost-Limburg, Genk, Belgium.
| | - Stefaan Van Biesen
- Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium; Department of Intensive Care Medicine, OLVG-Hospital, Amsterdam, The Netherlands
| | - Tom Fivez
- Department of Intensive Care Medicine, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Marc Van de Velde
- Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, KU Leuven, University of Leuven, Leuven, Belgium
| | - Layth Al Tmimi
- Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium
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10
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Hadzic A, Vandepitte C, Knezevic NN, Mesotten D, Kuroda MM, Van Boxstael S, Bellemans J, Van de Velde M, Fivez T, Corten K. Clinical research and trial registries: the times they are a-changin. Reg Anesth Pain Med 2020; 45:844-846. [PMID: 32784230 DOI: 10.1136/rapm-2020-101851] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 06/30/2020] [Indexed: 11/04/2022]
Affiliation(s)
- Admir Hadzic
- Anesthesiology, Ziekenhuis Oost-Limburg, Genk, Limburg, Belgium
| | | | - Nebojsa Nick Knezevic
- Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, Illinois, USA.,Anesthesiology and Surgery, University of Illinois at Chicago College of Medicine, Chicago, Illinois, USA
| | - Dieter Mesotten
- Anesthesiology, Ziekenhuis Oost-Limburg, Genk, Limburg, Belgium.,Faculty of Medicine and Life Sciences & Limburg Clinical Research Center, Hasselt University, Diepenbeek, Limburg, Belgium
| | - Maxine M Kuroda
- Anesthesiology, Ziekenhuis Oost-Limburg, Genk, Limburg, Belgium
| | | | - Johan Bellemans
- Orthopedic Surgery, Ziekenhuis Oost-Limburg, Genk, Limburg, Belgium
| | | | - Tom Fivez
- Anesthesiology, Ziekenhuis Oost-Limburg, Genk, Limburg, Belgium
| | - Kristoff Corten
- Orthopedic Surgery, Ziekenhuis Oost-Limburg, Genk, Limburg, Belgium
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11
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Criel M, Falter M, Jaeken J, Van Kerrebroeck M, Lefere I, Meylaerts L, Mesotten D, Vander Laenen M, Fivez T, Thomeer M, Ruttens D. Venous thromboembolism in SARS-CoV-2 patients: only a problem in ventilated ICU patients, or is there more to it? Eur Respir J 2020; 56:2001201. [PMID: 32398294 PMCID: PMC7236825 DOI: 10.1183/13993003.01201-2020] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 04/28/2020] [Indexed: 01/18/2023]
Abstract
Venous thromboembolism (VTE) is a well-known complication in hospitalised patients [1–5]. Risk factors include older age, obesity, immobilisation, active malignancy, systemic inflammatory response syndrome (SIRS), (major) surgery, thrombophilia and a history of thromboembolism [2, 5]. In 1884, Rudolph Virchow first described the underlying pathophysiological mechanisms, which consist of endothelial cell dysfunction/inflammation, low blood flow and blood hypercoagulability. Current guidelines recommend the use of thromboprophylaxis in acutely ill medical patients who are at high risk for VTE (Padua score ≥4, IMPROVE (International Medical Prevention Registry on Venous Thromboembolism) score ≥2) [6]. However, in medical practice, less than half of the patients at risk receive adequate thromboprophylaxis [4]. Insidious venous thromboembolism (VTE) is mainly a problem in ICU-ventilated SARS-CoV-2 patients, while patients in the general ward, treated with thromboprophylaxis (0.5 mg·kg−1), had a low incidence of insidious VTE https://bit.ly/2Yl8jft
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Affiliation(s)
- Maarten Criel
- Dept Pulmonary Medicine, Ziekenhuis Oost Limburg, Genk, Belgium
| | - Maarten Falter
- Dept Pulmonary Medicine, Ziekenhuis Oost Limburg, Genk, Belgium
| | - Jasmien Jaeken
- Dept Pulmonary Medicine, Ziekenhuis Oost Limburg, Genk, Belgium
| | | | | | | | - Dieter Mesotten
- Dept of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
- Dept of Anaesthesiology, Intensive Care, Emergency Medicine and Pain Therapy, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Margot Vander Laenen
- Dept of Anaesthesiology, Intensive Care, Emergency Medicine and Pain Therapy, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Tom Fivez
- Dept of Anaesthesiology, Intensive Care, Emergency Medicine and Pain Therapy, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Michiel Thomeer
- Dept Pulmonary Medicine, Ziekenhuis Oost Limburg, Genk, Belgium
- Dept of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - David Ruttens
- Dept Pulmonary Medicine, Ziekenhuis Oost Limburg, Genk, Belgium
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Fivez T, Kerklaan D, Mesotten D, Verbruggen S, Wouters PJ, Vanhorebeek I, Debaveye Y, Vlasselaers D, Desmet L, Casaer MP, Garcia Guerra G, Hanot J, Joffe A, Tibboel D, Joosten K, Van den Berghe G. Early versus Late Parenteral Nutrition in Critically Ill Children. N Engl J Med 2016; 374:1111-22. [PMID: 26975590 DOI: 10.1056/nejmoa1514762] [Citation(s) in RCA: 311] [Impact Index Per Article: 38.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Recent trials have questioned the benefit of early parenteral nutrition in adults. The effect of early parenteral nutrition on clinical outcomes in critically ill children is unclear. METHODS We conducted a multicenter, randomized, controlled trial involving 1440 critically ill children to investigate whether withholding parenteral nutrition for 1 week (i.e., providing late parenteral nutrition) in the pediatric intensive care unit (ICU) is clinically superior to providing early parenteral nutrition. Fluid loading was similar in the two groups. The two primary end points were new infection acquired during the ICU stay and the adjusted duration of ICU dependency, as assessed by the number of days in the ICU and as time to discharge alive from ICU. For the 723 patients receiving early parenteral nutrition, parenteral nutrition was initiated within 24 hours after ICU admission, whereas for the 717 patients receiving late parenteral nutrition, parenteral nutrition was not provided until the morning of the 8th day in the ICU. In both groups, enteral nutrition was attempted early and intravenous micronutrients were provided. RESULTS Although mortality was similar in the two groups, the percentage of patients with a new infection was 10.7% in the group receiving late parenteral nutrition, as compared with 18.5% in the group receiving early parenteral nutrition (adjusted odds ratio, 0.48; 95% confidence interval [CI], 0.35 to 0.66). The mean (±SE) duration of ICU stay was 6.5±0.4 days in the group receiving late parenteral nutrition, as compared with 9.2±0.8 days in the group receiving early parenteral nutrition; there was also a higher likelihood of an earlier live discharge from the ICU at any time in the late-parenteral-nutrition group (adjusted hazard ratio, 1.23; 95% CI, 1.11 to 1.37). Late parenteral nutrition was associated with a shorter duration of mechanical ventilatory support than was early parenteral nutrition (P=0.001), as well as a smaller proportion of patients receiving renal-replacement therapy (P=0.04) and a shorter duration of hospital stay (P=0.001). Late parenteral nutrition was also associated with lower plasma levels of γ-glutamyltransferase and alkaline phosphatase than was early parenteral nutrition (P=0.001 and P=0.04, respectively), as well as higher levels of bilirubin (P=0.004) and C-reactive protein (P=0.006). CONCLUSIONS In critically ill children, withholding parenteral nutrition for 1 week in the ICU was clinically superior to providing early parenteral nutrition. (Funded by the Flemish Agency for Innovation through Science and Technology and others; ClinicalTrials.gov number, NCT01536275.).
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Affiliation(s)
- Tom Fivez
- From the Department of Cellular and Molecular Medicine, Clinical Division and Laboratory of Intensive Care Medicine, KU Leuven University Hospital, Leuven, Belgium (T.F., D.M., P.J.W., I.V., Y.D., D.V., L.D., M.P.C., J.H., G.V.B.); the Department of Pediatrics and Pediatric Surgery, Intensive Care, Erasmus-MC Sophia Children's Hospital, Rotterdam, the Netherlands (D.K., S.V., D.T., K.J.); and the Department of Pediatrics, Intensive Care Unit, University of Alberta, Stollery Children's Hospital, Edmonton, Canada (G.G.G., J.H., A.J.)
| | - Dorian Kerklaan
- From the Department of Cellular and Molecular Medicine, Clinical Division and Laboratory of Intensive Care Medicine, KU Leuven University Hospital, Leuven, Belgium (T.F., D.M., P.J.W., I.V., Y.D., D.V., L.D., M.P.C., J.H., G.V.B.); the Department of Pediatrics and Pediatric Surgery, Intensive Care, Erasmus-MC Sophia Children's Hospital, Rotterdam, the Netherlands (D.K., S.V., D.T., K.J.); and the Department of Pediatrics, Intensive Care Unit, University of Alberta, Stollery Children's Hospital, Edmonton, Canada (G.G.G., J.H., A.J.)
| | - Dieter Mesotten
- From the Department of Cellular and Molecular Medicine, Clinical Division and Laboratory of Intensive Care Medicine, KU Leuven University Hospital, Leuven, Belgium (T.F., D.M., P.J.W., I.V., Y.D., D.V., L.D., M.P.C., J.H., G.V.B.); the Department of Pediatrics and Pediatric Surgery, Intensive Care, Erasmus-MC Sophia Children's Hospital, Rotterdam, the Netherlands (D.K., S.V., D.T., K.J.); and the Department of Pediatrics, Intensive Care Unit, University of Alberta, Stollery Children's Hospital, Edmonton, Canada (G.G.G., J.H., A.J.)
| | - Sascha Verbruggen
- From the Department of Cellular and Molecular Medicine, Clinical Division and Laboratory of Intensive Care Medicine, KU Leuven University Hospital, Leuven, Belgium (T.F., D.M., P.J.W., I.V., Y.D., D.V., L.D., M.P.C., J.H., G.V.B.); the Department of Pediatrics and Pediatric Surgery, Intensive Care, Erasmus-MC Sophia Children's Hospital, Rotterdam, the Netherlands (D.K., S.V., D.T., K.J.); and the Department of Pediatrics, Intensive Care Unit, University of Alberta, Stollery Children's Hospital, Edmonton, Canada (G.G.G., J.H., A.J.)
| | - Pieter J Wouters
- From the Department of Cellular and Molecular Medicine, Clinical Division and Laboratory of Intensive Care Medicine, KU Leuven University Hospital, Leuven, Belgium (T.F., D.M., P.J.W., I.V., Y.D., D.V., L.D., M.P.C., J.H., G.V.B.); the Department of Pediatrics and Pediatric Surgery, Intensive Care, Erasmus-MC Sophia Children's Hospital, Rotterdam, the Netherlands (D.K., S.V., D.T., K.J.); and the Department of Pediatrics, Intensive Care Unit, University of Alberta, Stollery Children's Hospital, Edmonton, Canada (G.G.G., J.H., A.J.)
| | - Ilse Vanhorebeek
- From the Department of Cellular and Molecular Medicine, Clinical Division and Laboratory of Intensive Care Medicine, KU Leuven University Hospital, Leuven, Belgium (T.F., D.M., P.J.W., I.V., Y.D., D.V., L.D., M.P.C., J.H., G.V.B.); the Department of Pediatrics and Pediatric Surgery, Intensive Care, Erasmus-MC Sophia Children's Hospital, Rotterdam, the Netherlands (D.K., S.V., D.T., K.J.); and the Department of Pediatrics, Intensive Care Unit, University of Alberta, Stollery Children's Hospital, Edmonton, Canada (G.G.G., J.H., A.J.)
| | - Yves Debaveye
- From the Department of Cellular and Molecular Medicine, Clinical Division and Laboratory of Intensive Care Medicine, KU Leuven University Hospital, Leuven, Belgium (T.F., D.M., P.J.W., I.V., Y.D., D.V., L.D., M.P.C., J.H., G.V.B.); the Department of Pediatrics and Pediatric Surgery, Intensive Care, Erasmus-MC Sophia Children's Hospital, Rotterdam, the Netherlands (D.K., S.V., D.T., K.J.); and the Department of Pediatrics, Intensive Care Unit, University of Alberta, Stollery Children's Hospital, Edmonton, Canada (G.G.G., J.H., A.J.)
| | - Dirk Vlasselaers
- From the Department of Cellular and Molecular Medicine, Clinical Division and Laboratory of Intensive Care Medicine, KU Leuven University Hospital, Leuven, Belgium (T.F., D.M., P.J.W., I.V., Y.D., D.V., L.D., M.P.C., J.H., G.V.B.); the Department of Pediatrics and Pediatric Surgery, Intensive Care, Erasmus-MC Sophia Children's Hospital, Rotterdam, the Netherlands (D.K., S.V., D.T., K.J.); and the Department of Pediatrics, Intensive Care Unit, University of Alberta, Stollery Children's Hospital, Edmonton, Canada (G.G.G., J.H., A.J.)
| | - Lars Desmet
- From the Department of Cellular and Molecular Medicine, Clinical Division and Laboratory of Intensive Care Medicine, KU Leuven University Hospital, Leuven, Belgium (T.F., D.M., P.J.W., I.V., Y.D., D.V., L.D., M.P.C., J.H., G.V.B.); the Department of Pediatrics and Pediatric Surgery, Intensive Care, Erasmus-MC Sophia Children's Hospital, Rotterdam, the Netherlands (D.K., S.V., D.T., K.J.); and the Department of Pediatrics, Intensive Care Unit, University of Alberta, Stollery Children's Hospital, Edmonton, Canada (G.G.G., J.H., A.J.)
| | - Michael P Casaer
- From the Department of Cellular and Molecular Medicine, Clinical Division and Laboratory of Intensive Care Medicine, KU Leuven University Hospital, Leuven, Belgium (T.F., D.M., P.J.W., I.V., Y.D., D.V., L.D., M.P.C., J.H., G.V.B.); the Department of Pediatrics and Pediatric Surgery, Intensive Care, Erasmus-MC Sophia Children's Hospital, Rotterdam, the Netherlands (D.K., S.V., D.T., K.J.); and the Department of Pediatrics, Intensive Care Unit, University of Alberta, Stollery Children's Hospital, Edmonton, Canada (G.G.G., J.H., A.J.)
| | - Gonzalo Garcia Guerra
- From the Department of Cellular and Molecular Medicine, Clinical Division and Laboratory of Intensive Care Medicine, KU Leuven University Hospital, Leuven, Belgium (T.F., D.M., P.J.W., I.V., Y.D., D.V., L.D., M.P.C., J.H., G.V.B.); the Department of Pediatrics and Pediatric Surgery, Intensive Care, Erasmus-MC Sophia Children's Hospital, Rotterdam, the Netherlands (D.K., S.V., D.T., K.J.); and the Department of Pediatrics, Intensive Care Unit, University of Alberta, Stollery Children's Hospital, Edmonton, Canada (G.G.G., J.H., A.J.)
| | - Jan Hanot
- From the Department of Cellular and Molecular Medicine, Clinical Division and Laboratory of Intensive Care Medicine, KU Leuven University Hospital, Leuven, Belgium (T.F., D.M., P.J.W., I.V., Y.D., D.V., L.D., M.P.C., J.H., G.V.B.); the Department of Pediatrics and Pediatric Surgery, Intensive Care, Erasmus-MC Sophia Children's Hospital, Rotterdam, the Netherlands (D.K., S.V., D.T., K.J.); and the Department of Pediatrics, Intensive Care Unit, University of Alberta, Stollery Children's Hospital, Edmonton, Canada (G.G.G., J.H., A.J.)
| | - Ari Joffe
- From the Department of Cellular and Molecular Medicine, Clinical Division and Laboratory of Intensive Care Medicine, KU Leuven University Hospital, Leuven, Belgium (T.F., D.M., P.J.W., I.V., Y.D., D.V., L.D., M.P.C., J.H., G.V.B.); the Department of Pediatrics and Pediatric Surgery, Intensive Care, Erasmus-MC Sophia Children's Hospital, Rotterdam, the Netherlands (D.K., S.V., D.T., K.J.); and the Department of Pediatrics, Intensive Care Unit, University of Alberta, Stollery Children's Hospital, Edmonton, Canada (G.G.G., J.H., A.J.)
| | - Dick Tibboel
- From the Department of Cellular and Molecular Medicine, Clinical Division and Laboratory of Intensive Care Medicine, KU Leuven University Hospital, Leuven, Belgium (T.F., D.M., P.J.W., I.V., Y.D., D.V., L.D., M.P.C., J.H., G.V.B.); the Department of Pediatrics and Pediatric Surgery, Intensive Care, Erasmus-MC Sophia Children's Hospital, Rotterdam, the Netherlands (D.K., S.V., D.T., K.J.); and the Department of Pediatrics, Intensive Care Unit, University of Alberta, Stollery Children's Hospital, Edmonton, Canada (G.G.G., J.H., A.J.)
| | - Koen Joosten
- From the Department of Cellular and Molecular Medicine, Clinical Division and Laboratory of Intensive Care Medicine, KU Leuven University Hospital, Leuven, Belgium (T.F., D.M., P.J.W., I.V., Y.D., D.V., L.D., M.P.C., J.H., G.V.B.); the Department of Pediatrics and Pediatric Surgery, Intensive Care, Erasmus-MC Sophia Children's Hospital, Rotterdam, the Netherlands (D.K., S.V., D.T., K.J.); and the Department of Pediatrics, Intensive Care Unit, University of Alberta, Stollery Children's Hospital, Edmonton, Canada (G.G.G., J.H., A.J.)
| | - Greet Van den Berghe
- From the Department of Cellular and Molecular Medicine, Clinical Division and Laboratory of Intensive Care Medicine, KU Leuven University Hospital, Leuven, Belgium (T.F., D.M., P.J.W., I.V., Y.D., D.V., L.D., M.P.C., J.H., G.V.B.); the Department of Pediatrics and Pediatric Surgery, Intensive Care, Erasmus-MC Sophia Children's Hospital, Rotterdam, the Netherlands (D.K., S.V., D.T., K.J.); and the Department of Pediatrics, Intensive Care Unit, University of Alberta, Stollery Children's Hospital, Edmonton, Canada (G.G.G., J.H., A.J.)
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Delrue HGJ, Guiza F, Vlasselaers D, Fivez T, Desmet L, Van den Berghe G, Meyfroidt G. The value of the fore-sightTM monitor in the postoperative phase after congenital cardiac surgery. a descriptive statistical interim-analysis. Intensive Care Med Exp 2015. [PMCID: PMC4798524 DOI: 10.1186/2197-425x-3-s1-a595] [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: 11/16/2022] Open
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Fivez T, Kerklaan D, Mesotten D, Verbruggen S, Joosten K, Van den Berghe G. Evidence for the use of parenteral nutrition in the pediatric intensive care unit. Clin Nutr 2015; 36:218-223. [PMID: 26646358 DOI: 10.1016/j.clnu.2015.11.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 10/30/2015] [Accepted: 11/04/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIMS During hospitalization in a pediatric intensive care unit (PICU), critically ill children are fed artificially. Administered via the preferred enteral route, caloric targets are often not reached. Hence, parenteral nutrition is given to this patient population. In this review we analyzed the available evidence from randomized controlled trials (RCTs) that supports the use of parenteral nutrition in children during critical illness. METHODS A search strategy in Ovid MEDLINE and Ovid EMBASE was created and trial registries were screened to identify the relevant RCTs. Studies were included if they were randomized controlled trials, involved pediatric patients admitted to PICU, and compared different dosing/compositions of parenteral nutrition. Descriptive studies and reviews were excluded. RESULTS Of the 584 articles identified by the search strategy, only 114 articles were retained after title screening. Further abstract and full text screening identified 6 small RCTs that compared two dosing/composition strategies of parenteral nutrition. These trials reported differences in surrogate endpoints without an effect on hard clinical endpoints. The RCTs observed improvements in these surrogate endpoints with the use of more calories or when parenteral glutamine or fish oil was added. CONCLUSIONS The few RCTs suggest that surrogate endpoints can be affected by providing parenteral nutrition to critically ill children, but the studies were not statistically powered to draw meaningful clinical conclusions. Large RCTs with clinically relevant outcome measures are urgently needed to support the current nutritional guidelines that advise the use of parenteral nutrition in the PICU.
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Affiliation(s)
- Tom Fivez
- Clinical Division and Laboratory of Intensive Care Medicine, Department Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium.
| | - Dorian Kerklaan
- Intensive Care Unit, Department of Paediatrics and Pediatric Surgery, Erasmus Medical Centre, Sophia Children's Hospital, Rotterdam, The Netherlands.
| | - Dieter Mesotten
- Clinical Division and Laboratory of Intensive Care Medicine, Department Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium.
| | - Sascha Verbruggen
- Intensive Care Unit, Department of Paediatrics and Pediatric Surgery, Erasmus Medical Centre, Sophia Children's Hospital, Rotterdam, The Netherlands.
| | - Koen Joosten
- Intensive Care Unit, Department of Paediatrics and Pediatric Surgery, Erasmus Medical Centre, Sophia Children's Hospital, Rotterdam, The Netherlands.
| | - Greet Van den Berghe
- Clinical Division and Laboratory of Intensive Care Medicine, Department Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium.
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Fivez T, Kerklaan D, Verbruggen S, Vanhorebeek I, Verstraete S, Tibboel D, Guerra GG, Wouters PJ, Joffe A, Joosten K, Mesotten D, Van den Berghe G. Impact of withholding early parenteral nutrition completing enteral nutrition in pediatric critically ill patients (PEPaNIC trial): study protocol for a randomized controlled trial. Trials 2015; 16:202. [PMID: 25927936 PMCID: PMC4422419 DOI: 10.1186/s13063-015-0728-8] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 04/22/2015] [Indexed: 11/17/2022] Open
Abstract
Background The state-of-the-art nutrition used for critically ill children is based essentially on expert opinion and extrapolations from adult studies or on studies in non-critically ill children. In critically ill adults, withholding parenteral nutrition (PN) during the first week in ICU improved outcome, as compared with early supplementation of insufficient enteral nutrition (EN) with PN. We hypothesized that withholding PN in children early during critical illness reduces the incidence of new infections and accelerates recovery. Methods/Design The Pediatric Early versus Late Parenteral Nutrition in Intensive Care Unit (PEPaNIC) study is an investigator-initiated, international, multicenter, randomized controlled trial (RCT) in three tertiary referral pediatric intensive care units (PICUs) in three countries on two continents. This study compares early versus late initiation of PN when EN fails to reach preset caloric targets in critically ill children. In the early-PN (control, standard of care) group, PN comprising glucose, lipids and amino acids is administered within the first days to reach the caloric target. In the late-PN (intervention) group, PN completing EN is only initiated beyond PICU-day 7, when EN fails. For both study groups, an early EN protocol is applied and micronutrients are administered intravenously. The primary assessor-blinded outcome measures are the incidence of new infections during PICU-stay and the duration of intensive care dependency. The sample size (n = 1,440, 720 per arm) was determined in order to detect a 5% absolute reduction in PICU infections, with at least 80% 1-tailed power (70% 2-tailed) and an alpha error rate of 5%. Based on the actual incidence of new PICU infections in the control group, the required sample size was confirmed at the time of an a priori- planned interim-analysis focusing on the incidence of new infections in the control group only. Discussion Clinical evidence in favor of early administration of PN in critically ill children is currently lacking, despite potential benefit but also known side effects. This large international RCT will help physicians to gain more insight in the clinical effects of omitting PN during the first week of critical illness in children. Trial registration ClinicalTrials.gov: NCT01536275 on 16 February 2012.
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Affiliation(s)
- Tom Fivez
- Clinical Department and Laboratory of Intensive Care Medicine, Academic Division Cellular and Molecular Medicine, KU Leuven University and Hospital, Herestraat 49, B-3000, Leuven, Belgium.
| | - Dorian Kerklaan
- Intensive Care Unit, Department of Pediatrics and Pediatric Surgery, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands.
| | - Sascha Verbruggen
- Intensive Care Unit, Department of Pediatrics and Pediatric Surgery, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands.
| | - Ilse Vanhorebeek
- Clinical Department and Laboratory of Intensive Care Medicine, Academic Division Cellular and Molecular Medicine, KU Leuven University and Hospital, Herestraat 49, B-3000, Leuven, Belgium.
| | - Sören Verstraete
- Clinical Department and Laboratory of Intensive Care Medicine, Academic Division Cellular and Molecular Medicine, KU Leuven University and Hospital, Herestraat 49, B-3000, Leuven, Belgium.
| | - Dick Tibboel
- Intensive Care Unit, Department of Pediatrics and Pediatric Surgery, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands.
| | - Gonzalo Garcia Guerra
- Department of Pediatrics, Intensive Care Unit, University Alberta, Stollery Children's Hospital, Edmonton, AB, Canada.
| | - Pieter J Wouters
- Clinical Department and Laboratory of Intensive Care Medicine, Academic Division Cellular and Molecular Medicine, KU Leuven University and Hospital, Herestraat 49, B-3000, Leuven, Belgium.
| | - Ari Joffe
- Department of Pediatrics, Intensive Care Unit, University Alberta, Stollery Children's Hospital, Edmonton, AB, Canada.
| | - Koen Joosten
- Intensive Care Unit, Department of Pediatrics and Pediatric Surgery, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands.
| | - Dieter Mesotten
- Clinical Department and Laboratory of Intensive Care Medicine, Academic Division Cellular and Molecular Medicine, KU Leuven University and Hospital, Herestraat 49, B-3000, Leuven, Belgium.
| | - Greet Van den Berghe
- Clinical Department and Laboratory of Intensive Care Medicine, Academic Division Cellular and Molecular Medicine, KU Leuven University and Hospital, Herestraat 49, B-3000, Leuven, Belgium.
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Fivez T, Hendrickx A, Van Herpe T, Vlasselaers D, Desmet L, Van den Berghe G, Mesotten D. An Analysis of Reliability and Accuracy of Muscle Thickness Ultrasonography in Critically Ill Children and Adults. JPEN J Parenter Enteral Nutr 2015; 40:944-9. [PMID: 25754437 DOI: 10.1177/0148607115575033] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Accepted: 02/05/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Muscle wasting starts already within the first week in critically patients and is strongly related to poor outcome. Nevertheless, the early detection of muscle wasting is difficult. Therefore, we investigated the reliability and accuracy of ultrasonography to evaluate skeletal muscle wasting in critically ill children and adults. METHODS This prospective observational study enrolled 30 sedated critically ill children and 14 critically ill adults. Two independent investigators made 210 ultrasonographical assessments of muscle thigh thickness. Inter- and intraobserver reliability and cutoff levels were calculated as a function of muscle thickness and the expected reduction in muscle size (predefined at 20% and 30%). RESULTS Mean ± SD muscle thickness was 1.67 ± 0.55 cm in the pediatric and 2.10 ± 0.85 cm in the adult population. The median absolute interobserver variability was 0.07 cm (interquartile range [IQR], 0.04-0.20 cm) in the pediatric population and 0.05 cm (IQR, 0.03-0.09 cm) in the adult population. However, the absolute intraobserver accuracy had a 95% confidence interval of 0.43 cm in children and 0.22 cm in adults. Only a 30% decrease (0.50 cm) in muscle thickness can be detected in critically ill children. CONCLUSION Although the interobserver variability is acceptable in the pediatric population, the intraobserver variability is too large with respect to the expected reduction in muscle thickness. In adults, ultrasonography may be a reliable tool for early detection of muscle mass wasting.
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Affiliation(s)
- Tom Fivez
- Department of Intensive Care Medicine, U Leuven-University of Leuven, University Hospitals Leuven, Leuven, Belgium
| | - Alexandra Hendrickx
- Department of Intensive Care Medicine, U Leuven-University of Leuven, University Hospitals Leuven, Leuven, Belgium
| | - Tom Van Herpe
- Department of Intensive Care Medicine, U Leuven-University of Leuven, University Hospitals Leuven, Leuven, Belgium Department of Electrical Engineering-ESAT-SCD/iMINDS Medical Information Technologies, KU Leuven-University of Leuven, Leuven, Belgium
| | - Dirk Vlasselaers
- Department of Intensive Care Medicine, U Leuven-University of Leuven, University Hospitals Leuven, Leuven, Belgium
| | - Lars Desmet
- Department of Intensive Care Medicine, U Leuven-University of Leuven, University Hospitals Leuven, Leuven, Belgium
| | - Greet Van den Berghe
- Department of Intensive Care Medicine, U Leuven-University of Leuven, University Hospitals Leuven, Leuven, Belgium
| | - Dieter Mesotten
- Department of Intensive Care Medicine, U Leuven-University of Leuven, University Hospitals Leuven, Leuven, Belgium
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Kerklaan D, Fivez T, van Rosmalen J, Mesotten D, Mehta N, Van den Berghe G, Joosten K, Verbruggen S. PP264-SUN: Survey of Nutritional Practices in 156 Paediatric Intensive Care Units in 52 Countries. Clin Nutr 2014. [DOI: 10.1016/s0261-5614(14)50305-6] [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: 10/24/2022]
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