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Diamond JM, Anderson MR, Cantu E, Clausen ES, Shashaty MGS, Kalman L, Oyster M, Crespo MM, Bermudez CA, Benvenuto L, Palmer SM, Snyder LD, Hartwig MG, Wille K, Hage C, McDyer JF, Merlo CA, Shah PD, Orens JB, Dhillon GS, Lama VN, Patel MG, Singer JP, Hachem RR, Michelson AP, Hsu J, Russell Localio A, Christie JD. Development and validation of primary graft dysfunction predictive algorithm for lung transplant candidates. J Heart Lung Transplant 2024; 43:633-641. [PMID: 38065239 PMCID: PMC10947904 DOI: 10.1016/j.healun.2023.11.019] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 11/05/2023] [Accepted: 11/30/2023] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND Primary graft dysfunction (PGD) is the leading cause of early morbidity and mortality after lung transplantation. Accurate prediction of PGD risk could inform donor approaches and perioperative care planning. We sought to develop a clinically useful, generalizable PGD prediction model to aid in transplant decision-making. METHODS We derived a predictive model in a prospective cohort study of subjects from 2012 to 2018, followed by a single-center external validation. We used regularized (lasso) logistic regression to evaluate the predictive ability of clinically available PGD predictors and developed a user interface for clinical application. Using decision curve analysis, we quantified the net benefit of the model across a range of PGD risk thresholds and assessed model calibration and discrimination. RESULTS The PGD predictive model included distance from donor hospital to recipient transplant center, recipient age, predicted total lung capacity, lung allocation score (LAS), body mass index, pulmonary artery mean pressure, sex, and indication for transplant; donor age, sex, mechanism of death, and donor smoking status; and interaction terms for LAS and donor distance. The interface allows for real-time assessment of PGD risk for any donor/recipient combination. The model offers decision-making net benefit in the PGD risk range of 10% to 75% in the derivation centers and 2% to 10% in the validation cohort, a range incorporating the incidence in that cohort. CONCLUSION We developed a clinically useful PGD predictive algorithm across a range of PGD risk thresholds to support transplant decision-making, posttransplant care, and enrich samples for PGD treatment trials.
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Affiliation(s)
- Joshua M Diamond
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Michaela R Anderson
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Edward Cantu
- Division of Cardiovascular Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Emily S Clausen
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael G S Shashaty
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Laurel Kalman
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michelle Oyster
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Maria M Crespo
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christian A Bermudez
- Division of Cardiovascular Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Luke Benvenuto
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University School of Medicine, New York, New York
| | - Scott M Palmer
- Division of Pulmonary and Critical Care Medicine, Duke University Medical Center, Durham, North Carolina
| | - Laurie D Snyder
- Division of Pulmonary and Critical Care Medicine, Duke University Medical Center, Durham, North Carolina
| | - Matthew G Hartwig
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Keith Wille
- Division of Pulmonary and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Chadi Hage
- Division of Pulmonary, Allergy, and Critical Care, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - John F McDyer
- Division of Pulmonary, Allergy, and Critical Care, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Christian A Merlo
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University Medical Center, Baltimore, Maryland
| | - Pali D Shah
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University Medical Center, Baltimore, Maryland
| | - Jonathan B Orens
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University Medical Center, Baltimore, Maryland
| | - Ghundeep S Dhillon
- Division of Pulmonary and Critical Care Medicine, Stanford University Medical Center, Palo Alto, California
| | - Vibha N Lama
- Division of Pulmonary and Critical Care Medicine, University of Michigan Medical Center, Ann Arbor, Michigan
| | - Mrunal G Patel
- Division of Pulmonary and Critical Care Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jonathan P Singer
- Division of Pulmonary and Critical Care Allergy and Sleep Medicine, University of California, San Francisco, San Francisco, California
| | - Ramsey R Hachem
- Division of Pulmonary and Critical Care Medicine, Washington University, St. Louis, Missouri
| | - Andrew P Michelson
- Division of Pulmonary and Critical Care Medicine, Washington University, St. Louis, Missouri
| | - Jesse Hsu
- Division of Biostatistics, Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - A Russell Localio
- Division of Biostatistics, Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason D Christie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Anderson MR, Shashaty MGS. Metabolic Syndrome and Acute Respiratory Distress Syndrome Outcomes: A Most Ingenious Paradox or a Devil in the Details? Crit Care Med 2024; 52:502-505. [PMID: 38381011 DOI: 10.1097/ccm.0000000000006168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Affiliation(s)
- Michaela R Anderson
- Both authors: Pulmonary, Allergy, and Critical Care Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Diamond JM, Cantu E, Calfee CS, Anderson MR, Clausen ES, Shashaty MGS, Courtwright AM, Kalman L, Oyster M, Crespo MM, Bermudez CA, Benvenuto L, Palmer SM, Snyder LD, Hartwig MG, Todd JL, Wille K, Hage C, McDyer JF, Merlo CA, Shah PD, Orens JB, Dhillon GS, Weinacker AB, Lama VN, Patel MG, Singer JP, Hsu J, Localio AR, Christie JD. The Impact of Donor Smoking on Primary Graft Dysfunction and Mortality after Lung Transplantation. Am J Respir Crit Care Med 2024; 209:91-100. [PMID: 37734031 PMCID: PMC10870879 DOI: 10.1164/rccm.202303-0358oc] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 09/21/2023] [Indexed: 09/23/2023] Open
Abstract
Rationale: Primary graft dysfunction (PGD) is the leading cause of early morbidity and mortality after lung transplantation. Prior studies implicated proxy-defined donor smoking as a risk factor for PGD and mortality. Objectives: We aimed to more accurately assess the impact of donor smoke exposure on PGD and mortality using quantitative smoke exposure biomarkers. Methods: We performed a multicenter prospective cohort study of lung transplant recipients enrolled in the Lung Transplant Outcomes Group cohort between 2012 and 2018. PGD was defined as grade 3 at 48 or 72 hours after lung reperfusion. Donor smoking was defined using accepted thresholds of urinary biomarkers of nicotine exposure (cotinine) and tobacco-specific nitrosamine (4-[methylnitrosamino]-1-[3-pyridyl]-1-butanol [NNAL]) in addition to clinical history. The donor smoking-PGD association was assessed using logistic regression, and survival analysis was performed using inverse probability of exposure weighting according to smoking category. Measurements and Main Results: Active donor smoking prevalence varied by definition, with 34-43% based on urinary cotinine, 28% by urinary NNAL, and 37% by clinical documentation. The standardized risk of PGD associated with active donor smoking was higher across all definitions, with an absolute risk increase of 11.5% (95% confidence interval [CI], 3.8% to 19.2%) by urinary cotinine, 5.7% (95% CI, -3.4% to 14.9%) by urinary NNAL, and 6.5% (95% CI, -2.8% to 15.8%) defined clinically. Donor smoking was not associated with differential post-lung transplant survival using any definition. Conclusions: Donor smoking associates with a modest increase in PGD risk but not with increased recipient mortality. Use of lungs from smokers is likely safe and may increase lung donor availability. Clinical trial registered with www.clinicaltrials.gov (NCT00552357).
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Affiliation(s)
- Joshua M. Diamond
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
| | | | - Carolyn S. Calfee
- Department of Medicine and Anesthesia, University of California, San Francisco, San Francisco, California
| | - Michaela R. Anderson
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
| | - Emily S. Clausen
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
| | | | | | - Laurel Kalman
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
| | - Michelle Oyster
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
| | - Maria M. Crespo
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
| | | | - Luke Benvenuto
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University School of Medicine, New York, New York
| | | | | | - Matthew G. Hartwig
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jamie L. Todd
- Division of Pulmonary and Critical Care Medicine and
| | - Keith Wille
- Division of Pulmonary and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Chadi Hage
- Division of Pulmonary, Allergy, and Critical Care, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - John F. McDyer
- Division of Pulmonary, Allergy, and Critical Care, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Christian A. Merlo
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University Medical Center, Baltimore, Maryland
| | - Pali D. Shah
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University Medical Center, Baltimore, Maryland
| | - Jonathan B. Orens
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University Medical Center, Baltimore, Maryland
| | - Gundeep S. Dhillon
- Division of Pulmonary and Critical Care Medicine, Stanford University Medical Center, Palo Alto, California
| | - Ann B. Weinacker
- Division of Pulmonary and Critical Care Medicine, Stanford University Medical Center, Palo Alto, California
| | - Vibha N. Lama
- Division of Pulmonary and Critical Care Medicine, University of Michigan Medical Center, Ann Arbor, Michigan; and
| | - Mrunal G. Patel
- Division of Pulmonary and Critical Care Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jonathan P. Singer
- Department of Medicine and Anesthesia, University of California, San Francisco, San Francisco, California
| | - Jesse Hsu
- Division of Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - A. Russell Localio
- Division of Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason D. Christie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
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Reilly JP, Shashaty MGS, Miano TA, Giannini HM, Jones TK, Ittner CAG, Christie JD, Meyer NJ. ABO Histo-Blood Group and the von Willebrand Factor Axis in Severe COVID-19. CHEST Crit Care 2023; 1:100023. [PMID: 38130415 PMCID: PMC10735236 DOI: 10.1016/j.chstcc.2023.100023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Affiliation(s)
- John P Reilly
- Division of Pulmonary, Allergy, and Critical Care (J. P. R., M. G. S. S., H. M. G., T. K. J., C. A. G. I., J. D. C., and N. J. M.), the Center for Translational Lung Biology (J. P. R., M. G. S. S., T. K. J., C. A. G. I., J. D. C., and N. J. M.), and the Center for Clinical Epidemiology and Biostatics (M. G. S. S., T. A. M., T. K. J., and J. D. C.), Perelman School of Medicine, University of Pennsylvania
| | - Michael G S Shashaty
- Division of Pulmonary, Allergy, and Critical Care (J. P. R., M. G. S. S., H. M. G., T. K. J., C. A. G. I., J. D. C., and N. J. M.), the Center for Translational Lung Biology (J. P. R., M. G. S. S., T. K. J., C. A. G. I., J. D. C., and N. J. M.), and the Center for Clinical Epidemiology and Biostatics (M. G. S. S., T. A. M., T. K. J., and J. D. C.), Perelman School of Medicine, University of Pennsylvania
| | - Todd A Miano
- Division of Pulmonary, Allergy, and Critical Care (J. P. R., M. G. S. S., H. M. G., T. K. J., C. A. G. I., J. D. C., and N. J. M.), the Center for Translational Lung Biology (J. P. R., M. G. S. S., T. K. J., C. A. G. I., J. D. C., and N. J. M.), and the Center for Clinical Epidemiology and Biostatics (M. G. S. S., T. A. M., T. K. J., and J. D. C.), Perelman School of Medicine, University of Pennsylvania
| | - Heather M Giannini
- Division of Pulmonary, Allergy, and Critical Care (J. P. R., M. G. S. S., H. M. G., T. K. J., C. A. G. I., J. D. C., and N. J. M.), the Center for Translational Lung Biology (J. P. R., M. G. S. S., T. K. J., C. A. G. I., J. D. C., and N. J. M.), and the Center for Clinical Epidemiology and Biostatics (M. G. S. S., T. A. M., T. K. J., and J. D. C.), Perelman School of Medicine, University of Pennsylvania
| | - Tiffanie K Jones
- Division of Pulmonary, Allergy, and Critical Care (J. P. R., M. G. S. S., H. M. G., T. K. J., C. A. G. I., J. D. C., and N. J. M.), the Center for Translational Lung Biology (J. P. R., M. G. S. S., T. K. J., C. A. G. I., J. D. C., and N. J. M.), and the Center for Clinical Epidemiology and Biostatics (M. G. S. S., T. A. M., T. K. J., and J. D. C.), Perelman School of Medicine, University of Pennsylvania
| | - Caroline A G Ittner
- Division of Pulmonary, Allergy, and Critical Care (J. P. R., M. G. S. S., H. M. G., T. K. J., C. A. G. I., J. D. C., and N. J. M.), the Center for Translational Lung Biology (J. P. R., M. G. S. S., T. K. J., C. A. G. I., J. D. C., and N. J. M.), and the Center for Clinical Epidemiology and Biostatics (M. G. S. S., T. A. M., T. K. J., and J. D. C.), Perelman School of Medicine, University of Pennsylvania
| | - Jason D Christie
- Division of Pulmonary, Allergy, and Critical Care (J. P. R., M. G. S. S., H. M. G., T. K. J., C. A. G. I., J. D. C., and N. J. M.), the Center for Translational Lung Biology (J. P. R., M. G. S. S., T. K. J., C. A. G. I., J. D. C., and N. J. M.), and the Center for Clinical Epidemiology and Biostatics (M. G. S. S., T. A. M., T. K. J., and J. D. C.), Perelman School of Medicine, University of Pennsylvania
| | - Nuala J Meyer
- Division of Pulmonary, Allergy, and Critical Care (J. P. R., M. G. S. S., H. M. G., T. K. J., C. A. G. I., J. D. C., and N. J. M.), the Center for Translational Lung Biology (J. P. R., M. G. S. S., T. K. J., C. A. G. I., J. D. C., and N. J. M.), and the Center for Clinical Epidemiology and Biostatics (M. G. S. S., T. A. M., T. K. J., and J. D. C.), Perelman School of Medicine, University of Pennsylvania
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Jones TK, Reilly JP, Anderson BJ, Miano TA, Dunn TG, Turner AP, Agyekum RS, Feng R, Ittner CAG, Shashaty MGS, Meyer NJ. Acute Respiratory Distress Syndrome Mediates the Association between Early Plasma Soluble Receptor for Advanced Glycation End Products Concentrations and Mortality in Sepsis. Am J Respir Crit Care Med 2023; 208:628-630. [PMID: 37321246 DOI: 10.1164/rccm.202302-0314le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 06/15/2023] [Indexed: 06/17/2023] Open
Affiliation(s)
- Tiffanie K Jones
- Pulmonary, Allergy, and Critical Care Medicine Division, Department of Medicine
- Division of Epidemiology and
- Center for Translational Lung Biology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John P Reilly
- Pulmonary, Allergy, and Critical Care Medicine Division, Department of Medicine
- Center for Translational Lung Biology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Brian J Anderson
- Pulmonary, Allergy, and Critical Care Medicine Division, Department of Medicine
- Center for Translational Lung Biology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Thomas G Dunn
- Pulmonary, Allergy, and Critical Care Medicine Division, Department of Medicine
| | - Alexandra P Turner
- Pulmonary, Allergy, and Critical Care Medicine Division, Department of Medicine
| | - Roseline S Agyekum
- Pulmonary, Allergy, and Critical Care Medicine Division, Department of Medicine
| | - Rui Feng
- Division of Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, and
| | - Caroline A G Ittner
- Pulmonary, Allergy, and Critical Care Medicine Division, Department of Medicine
| | - Michael G S Shashaty
- Pulmonary, Allergy, and Critical Care Medicine Division, Department of Medicine
- Center for Translational Lung Biology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nuala J Meyer
- Pulmonary, Allergy, and Critical Care Medicine Division, Department of Medicine
- Center for Translational Lung Biology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Reilly JP, Zhao Z, Shashaty MGS, Koyama T, Jones TK, Anderson BJ, Ittner CA, Dunn T, Miano TA, Oniyide O, Balmes JR, Matthay MA, Calfee CS, Christie JD, Meyer NJ, Ware LB. Exposure to ambient air pollutants and acute respiratory distress syndrome risk in sepsis. Intensive Care Med 2023; 49:957-965. [PMID: 37470831 PMCID: PMC10561716 DOI: 10.1007/s00134-023-07148-y] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 06/20/2023] [Indexed: 07/21/2023]
Abstract
PURPOSE Exposures to ambient air pollutants may prime the lung enhancing risk of acute respiratory distress syndrome (ARDS) in sepsis. Our objective was to determine the association of short-, medium-, and long-term pollutant exposures and ARDS risk in critically ill sepsis patients. METHODS We analyzed a prospective cohort of 1858 critically ill patients with sepsis, and estimated short- (3 days), medium- (6 weeks), and long- (5 years) term exposures to ozone, nitrogen dioxide (NO2), sulfur dioxide (SO2), carbon monoxide (CO), particulate matter < 2.5 μm (PM2.5), and PM < 10 μm (PM10) using weighted averages of daily levels from monitors within 50 km of subjects' residences. Subjects were followed for 6 days for ARDS by the Berlin Criteria. The association between each pollutant and ARDS was determined using multivariable logistic regression adjusting for preselected confounders. In 764 subjects, we measured plasma concentrations of inflammatory proteins at presentation and tested for an association between pollutant exposure and protein concentration via linear regression. RESULTS ARDS developed in 754 (41%) subjects. Short- and long-term exposures to SO2, NO2, and PM2.5 were associated with ARDS risk (SO2: odds ratio (OR) for the comparison of the 75-25th long-term exposure percentile 1.43 (95% confidence interval (CI) 1.16, 1.77); p < 0.01; NO2: 1.36 (1.06, 1.74); p = 0.04, PM2.5: 1.21 (1.04, 1.41); p = 0.03). Long-term exposures to these three pollutants were also associated with plasma interleukin-1 receptor antagonist and soluble tumor necrosis factor receptor-1 concentrations. CONCLUSION Short and long-term exposures to ambient SO2, PM2.5, and NO2 are associated with increased ARDS risk in sepsis, representing potentially modifiable environmental risk factors for sepsis-associated ARDS.
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Affiliation(s)
- John P Reilly
- Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania, Perelman School of Medicine, 5005 Gibson Building, 3400 Spruce Street, Philadelphia, PA, 19104, USA.
- Center for Translational Lung Biology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, USA.
| | - Zhiguo Zhao
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, USA
| | - Michael G S Shashaty
- Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania, Perelman School of Medicine, 5005 Gibson Building, 3400 Spruce Street, Philadelphia, PA, 19104, USA
- Center for Translational Lung Biology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, USA
| | - Tatsuki Koyama
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, USA
| | - Tiffanie K Jones
- Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania, Perelman School of Medicine, 5005 Gibson Building, 3400 Spruce Street, Philadelphia, PA, 19104, USA
- Center for Translational Lung Biology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, USA
- Center for Clinical Epidemiology and Biostatics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, USA
| | - Brian J Anderson
- Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania, Perelman School of Medicine, 5005 Gibson Building, 3400 Spruce Street, Philadelphia, PA, 19104, USA
- Center for Translational Lung Biology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, USA
| | - Caroline A Ittner
- Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania, Perelman School of Medicine, 5005 Gibson Building, 3400 Spruce Street, Philadelphia, PA, 19104, USA
- Center for Translational Lung Biology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, USA
| | - Thomas Dunn
- Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania, Perelman School of Medicine, 5005 Gibson Building, 3400 Spruce Street, Philadelphia, PA, 19104, USA
- Center for Translational Lung Biology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, USA
| | - Todd A Miano
- Center for Clinical Epidemiology and Biostatics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, USA
| | - Oluwatosin Oniyide
- Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania, Perelman School of Medicine, 5005 Gibson Building, 3400 Spruce Street, Philadelphia, PA, 19104, USA
- Center for Translational Lung Biology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, USA
| | - John R Balmes
- Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley, USA
- Department of Medicine, University of California, San Francisco, USA
| | - Michael A Matthay
- Department of Medicine, University of California, San Francisco, USA
- Department of Anesthesia and Cardiovascular Research Institute, University of California, San Francisco, USA
| | - Carolyn S Calfee
- Department of Medicine, University of California, San Francisco, USA
- Department of Anesthesia and Cardiovascular Research Institute, University of California, San Francisco, USA
| | - Jason D Christie
- Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania, Perelman School of Medicine, 5005 Gibson Building, 3400 Spruce Street, Philadelphia, PA, 19104, USA
- Center for Translational Lung Biology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, USA
- Center for Clinical Epidemiology and Biostatics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, USA
| | - Nuala J Meyer
- Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania, Perelman School of Medicine, 5005 Gibson Building, 3400 Spruce Street, Philadelphia, PA, 19104, USA
- Center for Translational Lung Biology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, USA
| | - Lorraine B Ware
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, USA
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, USA
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Miano TA, Feng R, Griffiths S, Kalman L, Oyster M, Cantu E, Yang W, Diamond JM, Christie JD, Scheetz MH, Shashaty MGS. Development and validation of a population pharmacokinetic model to guide perioperative tacrolimus dosing after lung transplantation. medRxiv 2023:2023.06.26.23291248. [PMID: 37425807 PMCID: PMC10327259 DOI: 10.1101/2023.06.26.23291248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/11/2023]
Abstract
Background Tacrolimus therapy is standard of care for immunosuppression after lung transplantation. However, tacrolimus exposure variability during the early postoperative period may contribute to poor outcomes in this population. Few studies have examined tacrolimus pharmacokinetics (PK) during this high-risk time period. Methods We conducted a retrospective pharmacokinetic study in lung transplant recipients at the University of Pennsylvania who were enrolled in the Lung Transplant Outcomes Group (LTOG) cohort. We derived a model in 270 patients using NONMEM (version 7.5.1) and examined validity in a separate cohort of 114 patients. Covariates were examined with univariate analysis and multivariable analysis was developed using forward and backward stepwise selection. Performance of the final model in the validation cohort was examined with calculation of mean prediction error (PE). Results We developed a one-compartment base model with a fixed rate absorption constant. Significant covariates in multivariable analysis were postoperative day, hematocrit, transplant type, CYP3A5 genotype, total body weight, and time-varying postoperative day, hematocrit, and CYP inhibitor drugs. The strongest predictor of tacrolimus clearance was postoperative day, with median predicted clearance increasing more than threefold over the 14 day study period. In the validation cohort, the final model showed a mean PE of 36.4% (95%CI 30.8%-41.9%) and a median PE of 7.2% (IQR -29.3%-70.53%). Conclusion Postoperative day was the strongest predictor of tacrolimus exposure in the early post-lung transplant period. Future multicenter studies employing intensive sampling to examine a broad set of variables related to critical illness physiology are needed to understand determinants of clearance, volume of distribution and absorption in this population.
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Cosgriff CV, Miano TA, Mathew D, Huang AC, Giannini HM, Kuri-Cervantes L, Pampena MB, Ittner CAG, Weisman AR, Agyekum RS, Dunn TG, Oniyide O, Turner AP, D'Andrea K, Adamski S, Greenplate AR, Anderson BJ, Harhay MO, Jones TK, Reilly JP, Mangalmurti NS, Shashaty MGS, Betts MR, Wherry EJ, Meyer NJ. Validating a Proteomic Signature of Severe COVID-19. Crit Care Explor 2022; 4:e0800. [PMID: 36479446 PMCID: PMC9722553 DOI: 10.1097/cce.0000000000000800] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
COVID-19 is a heterogenous disease. Biomarker-based approaches may identify patients at risk for severe disease, who may be more likely to benefit from specific therapies. Our objective was to identify and validate a plasma protein signature for severe COVID-19. DESIGN Prospective observational cohort study. SETTING Two hospitals in the United States. PATIENTS One hundred sixty-seven hospitalized adults with COVID-19. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS We measured 713 plasma proteins in 167 hospitalized patients with COVID-19 using a high-throughput platform. We classified patients as nonsevere versus severe COVID-19, defined as the need for high-flow nasal cannula, mechanical ventilation, extracorporeal membrane oxygenation, or death, at study entry and in 7-day intervals thereafter. We compared proteins measured at baseline between these two groups by logistic regression adjusting for age, sex, symptom duration, and comorbidities. We used lead proteins from dysregulated pathways as inputs for elastic net logistic regression to identify a parsimonious signature of severe disease and validated this signature in an external COVID-19 dataset. We tested whether the association between corticosteroid use and mortality varied by protein signature. One hundred ninety-four proteins were associated with severe COVID-19 at the time of hospital admission. Pathway analysis identified multiple pathways associated with inflammatory response and tissue repair programs. Elastic net logistic regression yielded a 14-protein signature that discriminated 90-day mortality in an external cohort with an area under the receiver-operator characteristic curve of 0.92 (95% CI, 0.88-0.95). Classifying patients based on the predicted risk from the signature identified a heterogeneous response to treatment with corticosteroids (p = 0.006). CONCLUSIONS Inpatients with COVID-19 express heterogeneous patterns of plasma proteins. We propose a 14-protein signature of disease severity that may have value in developing precision medicine approaches for COVID-19 pneumonia.
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Affiliation(s)
- Christopher V Cosgriff
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Todd A Miano
- Department of Epidemiology, Biostatistics, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Divij Mathew
- Institute for Immunology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Department of Systems Pharmacology and Translational Therapeutics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Alexander C Huang
- Institute for Immunology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Division of Hematology/Oncology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Parker Institute for Cancer Immunotherapy, Philadelphia, PA
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Heather M Giannini
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Leticia Kuri-Cervantes
- Institute for Immunology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - M Betina Pampena
- Institute for Immunology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Caroline A G Ittner
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Center for Translational Lung Biology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Ariel R Weisman
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Center for Translational Lung Biology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Roseline S Agyekum
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Center for Translational Lung Biology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Thomas G Dunn
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Center for Translational Lung Biology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Oluwatosin Oniyide
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Center for Translational Lung Biology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Alexandra P Turner
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Center for Translational Lung Biology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Kurt D'Andrea
- Institute for Immunology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Sharon Adamski
- Immune Health Project, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Allison R Greenplate
- Institute for Immunology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Department of Systems Pharmacology and Translational Therapeutics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Immune Health Project, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Brian J Anderson
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Center for Translational Lung Biology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Michael O Harhay
- Department of Epidemiology, Biostatistics, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Tiffanie K Jones
- Department of Epidemiology, Biostatistics, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Center for Translational Lung Biology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - John P Reilly
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Center for Translational Lung Biology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Nilam S Mangalmurti
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Center for Translational Lung Biology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Institute for Immunology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Lung Biology Institute, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Michael G S Shashaty
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Center for Translational Lung Biology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Michael R Betts
- Institute for Immunology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - E John Wherry
- Institute for Immunology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Department of Systems Pharmacology and Translational Therapeutics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Parker Institute for Cancer Immunotherapy, Philadelphia, PA
| | - Nuala J Meyer
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Center for Translational Lung Biology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Institute for Immunology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Lung Biology Institute, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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Mitchell OJL, Neefe S, Ginestra JC, Schweickert WD, Falk S, Weissman GE, Covin D, Shults J, Abella BS, Shashaty MGS. Association of Time to Rapid Response Team Activation With Patient Outcomes Using a Range of Physiologic Deterioration Thresholds. Crit Care Explor 2022; 4:e0786. [PMID: 36349290 PMCID: PMC9635041 DOI: 10.1097/cce.0000000000000786] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Clinical deterioration of hospitalized patients is common and can lead to critical illness and death. Rapid response teams (RRTs) assess and treat high-risk patients with signs of clinical deterioration to prevent further worsening and subsequent adverse outcomes. Whether activation of the RRT early in the course of clinical deterioration impacts outcomes, however, remains unclear. We sought to characterize the relationship between increasing time to RRT activation after physiologic deterioration and short-term patient outcomes. DESIGN Retrospective multicenter cohort study. SETTING Three academic hospitals in Pennsylvania. PATIENTS We included the RRT activation of a hospitalization for non-ICU inpatients greater than or equal to 18 years old. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary exposure was time to RRT activation after physiologic deterioration. We selected four Cardiac Arrest Risk Triage (CART) score thresholds a priori from which to measure time to RRT activation (CART score ≥ 12, ≥ 16, ≥ 20, and ≥ 24). The primary outcome was 7-day mortality-death or discharge to hospice care within 7 days of RRT activation. For each CART threshold, we modeled the association of time to RRT activation duration with 7-day mortality using multivariable fractional polynomial regression. Increased time from clinical decompensation to RRT activation was associated with higher risk of 7-day mortality. This relationship was nonlinear, with odds of mortality increasing rapidly as time to RRT activation increased from 0 to 4 hours and then plateauing. This pattern was observed across several thresholds of physiologic derangement. CONCLUSIONS Increasing time to RRT activation was associated in a nonlinear fashion with increased 7-day mortality. This relationship appeared most marked when using a CART score greater than 20 threshold from which to measure time to RRT activation. We suggest that these empirical findings could be used to inform RRT delay definitions in further studies to determine the clinical impact of interventions focused on timely RRT activation.
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Affiliation(s)
- Oscar J L Mitchell
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Emergency Medicine, Center for Resuscitation Science, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Stacie Neefe
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jennifer C Ginestra
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA
| | - William D Schweickert
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Scott Falk
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA
| | - Gary E Weissman
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Palliative and Advanced Illness Research (PAIR) Center, University of Pennsylvania, Philadelphia, PA
- Penn Institute for Biomedical Informatics, University of Pennsylvania, Philadelphia, PA
| | - Donna Covin
- Penn Medicine Princeton Health, Plainsboro, NJ
| | - Justine Shults
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
- Children's Hospital of Philadelphia, Philadelphia, PA
| | - Benjamin S Abella
- Department of Emergency Medicine, Center for Resuscitation Science, Philadelphia, PA
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA
| | - Michael G S Shashaty
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
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10
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Miano TA, Hennessy S, Yang W, Dunn TG, Weisman AR, Oniyide O, Agyekum RS, Turner AP, Ittner CAG, Anderson BJ, Wilson FP, Townsend R, Reilly JP, Giannini HM, Cosgriff CV, Jones TK, Meyer NJ, Shashaty MGS. Association of vancomycin plus piperacillin-tazobactam with early changes in creatinine versus cystatin C in critically ill adults: a prospective cohort study. Intensive Care Med 2022; 48:1144-1155. [PMID: 35833959 PMCID: PMC9463324 DOI: 10.1007/s00134-022-06811-0] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 06/28/2022] [Indexed: 01/01/2023]
Abstract
PURPOSE Although dozens of studies have associated vancomycin + piperacillin-tazobactam with increased acute kidney injury (AKI) risk, it is unclear whether the association represents true injury or a pseudotoxicity characterized by isolated effects on creatinine secretion. We tested this hypothesis by contrasting changes in creatinine concentration after antibiotic initiation with changes in cystatin C concentration, a kidney biomarker unaffected by tubular secretion. METHODS We included patients enrolled in the Molecular Epidemiology of SepsiS in the ICU (MESSI) prospective cohort who were treated for ≥ 48 h with vancomycin + piperacillin-tazobactam or vancomycin + cefepime. Kidney function biomarkers [creatinine, cystatin C, and blood urea nitrogen (BUN)] were measured before antibiotic treatment and at day two after initiation. Creatinine-defined AKI and dialysis were examined through day-14, and mortality through day-30. Inverse probability of treatment weighting was used to adjust for confounding. Multiple imputation was used to impute missing baseline covariates. RESULTS The study included 739 patients (vancomycin + piperacillin-tazobactam n = 297, vancomycin + cefepime n = 442), of whom 192 had cystatin C measurements. Vancomycin + piperacillin-tazobactam was associated with a higher percentage increase of creatinine at day-two 8.04% (95% CI 1.21, 15.34) and higher incidence of creatinine-defined AKI: rate ratio (RR) 1.34 (95% CI 1.01, 1.78). In contrast, vancomycin + piperacillin-tazobactam was not associated with change in alternative biomarkers: cystatin C: - 5.63% (95% CI - 18.19, 8.86); BUN: - 4.51% (95% CI - 12.83, 4.59); or clinical outcomes: dialysis: RR 0.63 (95% CI 0.31, 1.29); mortality: RR 1.05 (95%CI 0.79, 1.41). CONCLUSIONS Vancomycin + piperacillin-tazobactam was associated with creatinine-defined AKI, but not changes in alternative kidney biomarkers, dialysis, or mortality, supporting the hypothesis that vancomycin + piperacillin-tazobactam effects on creatinine represent pseudotoxicity.
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Affiliation(s)
- Todd A Miano
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, 423 Guardian Drive, 809 Blockley Hall, Philadelphia, PA, 19104, USA.
- Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Sean Hennessy
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, 423 Guardian Drive, 809 Blockley Hall, Philadelphia, PA, 19104, USA
- Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Wei Yang
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, 423 Guardian Drive, 809 Blockley Hall, Philadelphia, PA, 19104, USA
- Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Thomas G Dunn
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Ariel R Weisman
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Oluwatosin Oniyide
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Roseline S Agyekum
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Alexandra P Turner
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Caroline A G Ittner
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Brian J Anderson
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - F Perry Wilson
- Section of Nephrology and Clinical and Translational Research Accelerator, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Raymond Townsend
- Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - John P Reilly
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Heather M Giannini
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Christopher V Cosgriff
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Tiffanie K Jones
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Nuala J Meyer
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Michael G S Shashaty
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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11
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Farrell CL, Miano TA, Griffiths S, Christie JD, Diamond JM, Shashaty MGS. Early post-lung transplant calcineurin inhibitor management varies widely: An international survey. Clin Transplant 2022; 36:e14510. [PMID: 34643962 PMCID: PMC9993702 DOI: 10.1111/ctr.14510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 09/29/2021] [Accepted: 10/01/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Christine L Farrell
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Todd A Miano
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Stephen Griffiths
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jason D Christie
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joshua M Diamond
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael G S Shashaty
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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12
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Pike DP, McGuffee RM, Geerling E, Albert CJ, Hoft DF, Shashaty MGS, Meyer NJ, Pinto AK, Ford DA. Plasmalogen Loss in Sepsis and SARS-CoV-2 Infection. Front Cell Dev Biol 2022; 10:912880. [PMID: 35784479 PMCID: PMC9242022 DOI: 10.3389/fcell.2022.912880] [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: 04/05/2022] [Accepted: 05/23/2022] [Indexed: 11/13/2022] Open
Abstract
Plasmalogens are plasma-borne antioxidant phospholipid species that provide protection as cellular lipid components during cellular oxidative stress. In this study we investigated plasma plasmalogen levels in human sepsis as well as in rodent models of infection. In humans, levels of multiple plasmenylethanolamine molecular species were decreased in septic patient plasma compared to control subject plasma as well as an age-aligned control subject cohort. Additionally, lysoplasmenylcholine levels were significantly decreased in septic patients compared to the control cohorts. In contrast, plasma diacyl phosphatidylethanolamine and phosphatidylcholine levels were elevated in septic patients. Lipid changes were also determined in rats subjected to cecal slurry sepsis. Plasma plasmenylcholine, plasmenylethanolamine, and lysoplasmenylcholine levels were decreased while diacyl phosphatidylethanolamine levels were increased in septic rats compared to control treated rats. Kidney levels of lysoplasmenylcholine as well as plasmenylethanolamine molecular species were decreased in septic rats. Interestingly, liver plasmenylcholine and plasmenylethanolamine levels were increased in septic rats. Since COVID-19 is associated with sepsis-like acute respiratory distress syndrome and oxidative stress, plasmalogen levels were also determined in a mouse model of COVID-19 (intranasal inoculation of K18 mice with SARS-CoV-2). 3 days following infection, lung infection was confirmed as well as cytokine expression in the lung. Multiple molecular species of lung plasmenylcholine and plasmenylethanolamine were decreased in infected mice. In contrast, the predominant lung phospholipid, dipalmitoyl phosphatidylcholine, was not decreased following SARS-CoV-2 infection. Additionally total plasmenylcholine levels were decreased in the plasma of SARS-CoV-2 infected mice. Collectively, these data demonstrate the loss of plasmalogens during both sepsis and SARS-CoV-2 infection. This study also indicates plasma plasmalogens should be considered in future studies as biomarkers of infection and as prognostic indicators for sepsis and COVID-19 outcomes.
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Affiliation(s)
- Daniel P Pike
- Edward A. Doisy Department of Biochemistry and Molecular Biology, Saint Louis University School of Medicine, St. Louis, MO, United States.,Center for Cardiovascular Research, Saint Louis University School of Medicine, St. Louis, MO, United States
| | - Reagan M McGuffee
- Edward A. Doisy Department of Biochemistry and Molecular Biology, Saint Louis University School of Medicine, St. Louis, MO, United States.,Center for Cardiovascular Research, Saint Louis University School of Medicine, St. Louis, MO, United States
| | - Elizabeth Geerling
- Department of Molecular Microbiology and Immunology, Saint Louis University School of Medicine, St. Louis, MO, United States
| | - Carolyn J Albert
- Edward A. Doisy Department of Biochemistry and Molecular Biology, Saint Louis University School of Medicine, St. Louis, MO, United States.,Center for Cardiovascular Research, Saint Louis University School of Medicine, St. Louis, MO, United States
| | - Daniel F Hoft
- Department of Molecular Microbiology and Immunology, Saint Louis University School of Medicine, St. Louis, MO, United States.,Department of Internal Medicine, Division of Infectious Diseases, Allergy and Immunology, Saint Louis University School of Medicine, St. Louis, MO, United States
| | - Michael G S Shashaty
- Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States.,Center for Translational Lung Biology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Nuala J Meyer
- Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States.,Center for Translational Lung Biology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Amelia K Pinto
- Department of Molecular Microbiology and Immunology, Saint Louis University School of Medicine, St. Louis, MO, United States
| | - David A Ford
- Edward A. Doisy Department of Biochemistry and Molecular Biology, Saint Louis University School of Medicine, St. Louis, MO, United States.,Center for Cardiovascular Research, Saint Louis University School of Medicine, St. Louis, MO, United States
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13
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Amunugama K, Jellinek MJ, Kilroy MP, Albert CJ, Rasi V, Hoft DF, Shashaty MGS, Meyer NJ, Ford DA. Identification of novel neutrophil very long chain plasmalogen molecular species and their myeloperoxidase mediated oxidation products in human sepsis. Redox Biol 2021; 48:102208. [PMID: 34902676 PMCID: PMC8671113 DOI: 10.1016/j.redox.2021.102208] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 12/07/2021] [Indexed: 11/25/2022] Open
Abstract
Plasmalogens are a class of phospholipids containing vinyl ether linked aliphatic groups at the sn-1 position. Plasmalogens are known to contain 16- and 18-carbon aliphatic groups at the sn-1 position. Here, we reveal that the human neutrophil plasmenylethanolamine pool uniquely includes molecular species with very long carbon chain (VLC) aliphatic groups, including 20-, 22- and 24-carbon vinyl ether linked aliphatic groups at the sn-1 position. We identified these novel VLC plasmalogen species by electrospray ionization mass spectrometry methods. VLC plasmalogens were only found in the neutrophil plasmenylethanolamine pool. During neutrophil activation, VLC plasmenylethanolamines undergo myeloperoxidase-dependent oxidation to produce VLC 2-chlorofatty aldehyde and its oxidation product, 2-chlorofatty acid (2-ClFA). Furthermore, plasma concentrations of VLC 2-ClFA are elevated in human sepsis. These studies demonstrate for the first time VLC plasmenylethanolamine molecular species, their myeloperoxidase-mediated chlorolipid products and the presence of these chlorolipids in human sepsis.
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Affiliation(s)
- Kaushalya Amunugama
- Edward A. Doisy Department of Biochemistry and Molecular Biology, Saint Louis University School of Medicine, St. Louis, MO, 63104, USA; Center for Cardiovascular Research, Saint Louis University School of Medicine, St. Louis, MO, 63104, USA
| | - Matthew J Jellinek
- Edward A. Doisy Department of Biochemistry and Molecular Biology, Saint Louis University School of Medicine, St. Louis, MO, 63104, USA; Center for Cardiovascular Research, Saint Louis University School of Medicine, St. Louis, MO, 63104, USA
| | - Megan P Kilroy
- Edward A. Doisy Department of Biochemistry and Molecular Biology, Saint Louis University School of Medicine, St. Louis, MO, 63104, USA; Center for Cardiovascular Research, Saint Louis University School of Medicine, St. Louis, MO, 63104, USA
| | - Carolyn J Albert
- Edward A. Doisy Department of Biochemistry and Molecular Biology, Saint Louis University School of Medicine, St. Louis, MO, 63104, USA; Center for Cardiovascular Research, Saint Louis University School of Medicine, St. Louis, MO, 63104, USA
| | - Valerio Rasi
- Department of Molecular Microbiology and Immunology, Saint Louis University School of Medicine, St. Louis, MO, 63104, USA; Department of Internal Medicine, Division of Infectious Diseases, Allergy and Immunology, Saint Louis University School of Medicine, St. Louis, MO, 63104, USA
| | - Daniel F Hoft
- Department of Molecular Microbiology and Immunology, Saint Louis University School of Medicine, St. Louis, MO, 63104, USA; Department of Internal Medicine, Division of Infectious Diseases, Allergy and Immunology, Saint Louis University School of Medicine, St. Louis, MO, 63104, USA
| | - Michael G S Shashaty
- Pulmonary, Allergy, Critical Care Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA; Center for Translational Lung Biology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104-6021, USA
| | - Nuala J Meyer
- Pulmonary, Allergy, Critical Care Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA; Center for Translational Lung Biology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104-6021, USA
| | - David A Ford
- Edward A. Doisy Department of Biochemistry and Molecular Biology, Saint Louis University School of Medicine, St. Louis, MO, 63104, USA; Center for Cardiovascular Research, Saint Louis University School of Medicine, St. Louis, MO, 63104, USA.
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14
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Abstract
The prevalence of obesity is rising worldwide. Adipose tissue exerts anatomic and physiological effects with significant implications for critical illness. Changes in respiratory mechanics cause expiratory flow limitation, atelectasis, and V̇/Q̇ mismatch with resultant hypoxemia. Altered work of breathing and obesity hypoventilation syndrome may cause hypercapnia. Challenging mask ventilation and peri-intubation hypoxemia may complicate intubation. Patients with obesity are at increased risk of ARDS and should receive lung-protective ventilation based on predicted body weight. Increased positive end expiratory pressure (PEEP), coupled with appropriate patient positioning, may overcome the alveolar decruitment and intrinsic PEEP caused by elevated baseline pleural pressure; however, evidence is insufficient regarding the impact of high PEEP strategies on outcomes. Venovenous extracorporeal membrane oxygenation may be safely performed in patients with obesity. Fluid management should account for increased prevalence of chronic heart and kidney disease, expanded blood volume, and elevated acute kidney injury risk. Medication pharmacodynamics and pharmacokinetics may be altered by hydrophobic drug distribution to adipose depots and comorbid liver or kidney disease. Obesity is associated with increased risk of VTE and infection; appropriate dosing of prophylactic anticoagulation and early removal of indwelling catheters may decrease these risks. Obesity is associated with improved critical illness survival in some studies. It is unclear whether this reflects a protective effect or limitations inherent to observational research. Obesity is associated with increased risk of intubation and death in SARS-CoV-2 infection. Ongoing molecular studies of adipose tissue may deepen our understanding of how obesity impacts critical illness pathophysiology.
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Affiliation(s)
- Michaela R Anderson
- Division of Pulmonary Disease and Critical Care Medicine, Columbia University
| | - Michael G S Shashaty
- Pulmonary, Allergy, and Critical Care Division and the Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania.
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15
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Qu HQ, Qu J, Dunn T, Snyder J, Miano TA, Connolly J, Glessner J, Anderson BJ, Reilly JP, Jones TK, Giannini HM, Agyekum RS, Weisman AR, Ittner CAG, Rodrigues LG, Kao C, Shashaty MGS, Sleiman P, Meyer NJ, Hakonarson H. Elevation of Circulating LIGHT (TNFSF14) and Interleukin-18 Levels in Sepsis-Induced Multi-Organ Injuries. medRxiv 2021. [PMID: 34075388 DOI: 10.1101/2021.05.25.21257799] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Objective The cytokines, LIGHT (TNFSF14) and Interleukin-18 (IL-18), are two important therapeutic targets due to their central roles in the function of activated T cells and inflammatory injury. LIGHT was recently shown to play a major role in COVID19 induced acute respiratory distress syndrome (ARDS), reducing mortality and hospital stay. This study aims to investigate the associations of LIGHT and IL-18 with non-COVID19 related ARDS, acute hypoxic respiratory failure (AHRF) or acute kidney injury (AKI), secondary to viral or bacterial sepsis. Research Design and Methods A cohort of 280 subjects diagnosed with sepsis, including 91 cases with sepsis triggered by viral infections, were investigated in this study and compared to healthy controls. Serum LIGHT, IL-18, and 59 other biomarkers (cytokines, chemokines and acute-phase reactants) were measured and associated with symptom severity. Results ARDS was observed in 36% of the patients, with 29% of the total patient cohort developing multi-organ failure (failure of two or more organs). We observed significantly increased LIGHT level (>2SD above mean of healthy subjects) in both bacterial sepsis patients (P=1.80E-05) and patients with sepsis from viral infections (P=1.78E-03). In bacterial sepsis, increased LIGHT level associated with ARDS, AKI and higher Apache III scores, findings also supported by correlations of LIGHT with other biomarkers of organ failures, suggesting LIGHT may be an inflammatory driver. IL-18 levels were highly variable across individuals, and consistently correlated with Apache III scores, mortality, and AKI, in both bacterial and viral sepsis. Conclusions For the first time, we demonstrate independent effects of LIGHT and IL-18 in septic organ failures. LIGHT levels are significantly elevated in non-COVID19 sepsis patients with ARDS and/or multi-organ failures suggesting that anti-LIGHT therapy may be effective therapy in a subset of patients with sepsis. Given the large variance of plasma IL-18 among septic subjects, targeting this pathway raises opportunities that require a precision application.
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16
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Vasquez CR, Gupta S, Miano TA, Roche M, Hsu J, Yang W, Holena DN, Reilly JP, Schrauben SJ, Leaf DE, Shashaty MGS. Identification of Distinct Clinical Subphenotypes in Critically Ill Patients With COVID-19. Chest 2021; 160:929-943. [PMID: 33964301 PMCID: PMC8099539 DOI: 10.1016/j.chest.2021.04.062] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 04/09/2021] [Accepted: 04/25/2021] [Indexed: 02/08/2023] Open
Abstract
Background Subphenotypes have been identified in patients with sepsis and ARDS and are associated with different outcomes and responses to therapies. Research Question Can unique subphenotypes be identified among critically ill patients with COVID-19? Study Design and Methods Using data from a multicenter cohort study that enrolled critically ill patients with COVID-19 from 67 hospitals across the United States, we randomly divided centers into discovery and replication cohorts. We used latent class analysis independently in each cohort to identify subphenotypes based on clinical and laboratory variables. We then analyzed the associations of subphenotypes with 28-day mortality. Results Latent class analysis identified four subphenotypes (SP) with consistent characteristics across the discovery (45 centers; n = 2,188) and replication (22 centers; n = 1,112) cohorts. SP1 was characterized by shock, acidemia, and multiorgan dysfunction, including acute kidney injury treated with renal replacement therapy. SP2 was characterized by high C-reactive protein, early need for mechanical ventilation, and the highest rate of ARDS. SP3 showed the highest burden of chronic diseases, whereas SP4 demonstrated limited chronic disease burden and mild physiologic abnormalities. Twenty-eight-day mortality in the discovery cohort ranged from 20.6% (SP4) to 52.9% (SP1). Mortality across subphenotypes remained different after adjustment for demographics, comorbidities, organ dysfunction and illness severity, regional and hospital factors. Compared with SP4, the relative risks were as follows: SP1, 1.67 (95% CI, 1.36-2.03); SP2, 1.39 (95% CI, 1.17-1.65); and SP3, 1.39 (95% CI, 1.15-1.67). Findings were similar in the replication cohort. Interpretation We identified four subphenotypes of COVID-19 critical illness with distinct patterns of clinical and laboratory characteristics, comorbidity burden, and mortality.
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Affiliation(s)
- Charles R Vasquez
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| | - Shruti Gupta
- Harvard Medical School, Brigham and Women's Hospital, Boston, MA; Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA
| | - Todd A Miano
- Center for Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Meaghan Roche
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jesse Hsu
- Center for Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Wei Yang
- Center for Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Daniel N Holena
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Center for Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - John P Reilly
- Pulmonary, Allergy and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sarah J Schrauben
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - David E Leaf
- Harvard Medical School, Brigham and Women's Hospital, Boston, MA; Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA
| | - Michael G S Shashaty
- Center for Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Pulmonary, Allergy and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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17
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Anesi GL, Jablonski J, Harhay MO, Atkins JH, Bajaj J, Baston C, Brennan PJ, Candeloro CL, Catalano LM, Cereda MF, Chandler JM, Christie JD, Collins T, Courtright KR, Fuchs BD, Gordon E, Greenwood JC, Gudowski S, Hanish A, Hanson CW, Heuer M, Kinniry P, Kornfield ZN, Kruse GB, Lane-Fall M, Martin ND, Mikkelsen ME, Negoianu D, Pascual JL, Patel MB, Pugliese SC, Qasim ZA, Reilly JP, Salmon J, Schweickert WD, Scott MJ, Shashaty MGS, Sicoutris CP, Wang JK, Wang W, Wani AA, Anderson BJ, Gutsche JT. Characteristics, Outcomes, and Trends of Patients With COVID-19-Related Critical Illness at a Learning Health System in the United States. Ann Intern Med 2021; 174:613-621. [PMID: 33460330 PMCID: PMC7901669 DOI: 10.7326/m20-5327] [Citation(s) in RCA: 77] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND The coronavirus disease 2019 (COVID-19) pandemic continues to surge in the United States and globally. OBJECTIVE To describe the epidemiology of COVID-19-related critical illness, including trends in outcomes and care delivery. DESIGN Single-health system, multihospital retrospective cohort study. SETTING 5 hospitals within the University of Pennsylvania Health System. PATIENTS Adults with COVID-19-related critical illness who were admitted to an intensive care unit (ICU) with acute respiratory failure or shock during the initial surge of the pandemic. MEASUREMENTS The primary exposure for outcomes and care delivery trend analyses was longitudinal time during the pandemic. The primary outcome was all-cause 28-day in-hospital mortality. Secondary outcomes were all-cause death at any time, receipt of mechanical ventilation (MV), and readmissions. RESULTS Among 468 patients with COVID-19-related critical illness, 319 (68.2%) were treated with MV and 121 (25.9%) with vasopressors. Outcomes were notable for an all-cause 28-day in-hospital mortality rate of 29.9%, a median ICU stay of 8 days (interquartile range [IQR], 3 to 17 days), a median hospital stay of 13 days (IQR, 7 to 25 days), and an all-cause 30-day readmission rate (among nonhospice survivors) of 10.8%. Mortality decreased over time, from 43.5% (95% CI, 31.3% to 53.8%) to 19.2% (CI, 11.6% to 26.7%) between the first and last 15-day periods in the core adjusted model, whereas patient acuity and other factors did not change. LIMITATIONS Single-health system study; use of, or highly dynamic trends in, other clinical interventions were not evaluated, nor were complications. CONCLUSION Among patients with COVID-19-related critical illness admitted to ICUs of a learning health system in the United States, mortality seemed to decrease over time despite stable patient characteristics. Further studies are necessary to confirm this result and to investigate causal mechanisms. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality.
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Affiliation(s)
- George L Anesi
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Juliane Jablonski
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Michael O Harhay
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Joshua H Atkins
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Jasmeet Bajaj
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Cameron Baston
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Patrick J Brennan
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Christina L Candeloro
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Lauren M Catalano
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Maurizio F Cereda
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - John M Chandler
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Jason D Christie
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Tara Collins
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Katherine R Courtright
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Barry D Fuchs
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Emily Gordon
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - John C Greenwood
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Steven Gudowski
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Asaf Hanish
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - C William Hanson
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Monica Heuer
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Paul Kinniry
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Zev Noah Kornfield
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Gregory B Kruse
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Meghan Lane-Fall
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Niels D Martin
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Mark E Mikkelsen
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Dan Negoianu
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Jose L Pascual
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Maulik B Patel
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Steven C Pugliese
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Zaffer A Qasim
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - John P Reilly
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - John Salmon
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - William D Schweickert
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Michael J Scott
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Michael G S Shashaty
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Corinna P Sicoutris
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - John K Wang
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Wei Wang
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Arshad A Wani
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Brian J Anderson
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
| | - Jacob T Gutsche
- University of Pennsylvania Health System, Philadelphia, Pennsylvania (G.L.A., J.J., M.O.H., J.H.A., J.B., C.B., P.J.B., C.L.C., L.M.C., M.F.C., J.M.C., J.D.C., T.C., K.R.C., B.D.F., E.G., J.C.G., S.G., A.H., C.W.H., M.H., P.K., Z.N.K., G.B.K., M.L., N.D.M., M.E.M., D.N., J.L.P., M.B.P., S.C.P., Z.A.Q., J.P.R., J.S., W.D.S., M.J.S., M.G.S., C.P.S., J.K.W., W.W., A.A.W., B.J.A., J.T.G.)
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Sjoding MW, Taylor D, Motyka J, Lee E, Co I, Claar D, McSparron JI, Ansari S, Kerlin MP, Reilly JP, Shashaty MGS, Anderson BJ, Jones TK, Drebin HM, Ittner CAG, Meyer NJ, Iwashyna TJ, Ward KR, Gillies CE. Deep learning to detect acute respiratory distress syndrome on chest radiographs: a retrospective study with external validation. Lancet Digit Health 2021; 3:e340-e348. [PMID: 33893070 PMCID: PMC8182690 DOI: 10.1016/s2589-7500(21)00056-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 03/06/2021] [Accepted: 03/11/2021] [Indexed: 02/06/2023]
Abstract
Background Acute respiratory distress syndrome (ARDS) is a common, but under-recognised, critical illness syndrome associated with high mortality. An important factor in its under-recognition is the variability in chest radiograph interpretation for ARDS. We sought to train a deep convolutional neural network (CNN) to detect ARDS findings on chest radiographs. Methods CNNs were pretrained on 595 506 radiographs from two centres to identify common chest findings (eg, opacity and effusion), and then trained on 8072 radiographs annotated for ARDS by multiple physicians using various transfer learning approaches. The best performing CNN was tested on chest radiographs in an internal and external cohort, including a subset reviewed by six physicians, including a chest radiologist and physicians trained in intensive care medicine. Chest radiograph data were acquired from four US hospitals. Findings In an internal test set of 1560 chest radiographs from 455 patients with acute hypoxaemic respiratory failure, a CNN could detect ARDS with an area under the receiver operator characteristics curve (AUROC) of 0·92 (95% CI 0·89–0·94). In the subgroup of 413 images reviewed by at least six physicians, its AUROC was 0·93 (95% CI 0·88–0·96), sensitivity 83·0% (95% CI 74·0–91·1), and specificity 88·3% (95% CI 83·1–92·8). Among images with zero of six ARDS annotations (n=155), the median CNN probability was 11%, with six (4%) assigned a probability above 50%. Among images with six of six ARDS annotations (n=27), the median CNN probability was 91%, with two (7%) assigned a probability below 50%. In an external cohort of 958 chest radiographs from 431 patients with sepsis, the AUROC was 0·88 (95% CI 0·85–0·91). When radiographs annotated as equivocal were excluded, the AUROC was 0·93 (0·92–0·95). Interpretation A CNN can be trained to achieve expert physician-level performance in ARDS detection on chest radiographs. Further research is needed to evaluate the use of these algorithms to support real-time identification of ARDS patients to ensure fidelity with evidence-based care or to support ongoing ARDS research. Funding National Institutes of Health, Department of Defense, and Department of Veterans Affairs.
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Affiliation(s)
- Michael W Sjoding
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA; Center for Computational Medicine and Bioinformatics, University of Michigan Medical School, Ann Arbor, MI, USA; Michigan Center for Integrative Research in Critical Care; Ann Arbor, MI, USA; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.
| | - Daniel Taylor
- Michigan Center for Integrative Research in Critical Care; Ann Arbor, MI, USA
| | - Jonathan Motyka
- Michigan Center for Integrative Research in Critical Care; Ann Arbor, MI, USA
| | - Elizabeth Lee
- Department of Radiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Ivan Co
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA; Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, USA; Michigan Center for Integrative Research in Critical Care; Ann Arbor, MI, USA
| | - Dru Claar
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Jakob I McSparron
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA; Michigan Center for Integrative Research in Critical Care; Ann Arbor, MI, USA
| | - Sardar Ansari
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, USA; Michigan Center for Integrative Research in Critical Care; Ann Arbor, MI, USA
| | - Meeta Prasad Kerlin
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - John P Reilly
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Center for Translational Lung Biology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Michael G S Shashaty
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Brian J Anderson
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Tiffanie K Jones
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Center for Translational Lung Biology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Harrison M Drebin
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Center for Translational Lung Biology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Caroline A G Ittner
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Center for Translational Lung Biology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Nuala J Meyer
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Center for Translational Lung Biology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Theodore J Iwashyna
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA; VA Center for Clinic Management Research, Ann Arbor, MI, USA; Institute for Social Research, Ann Arbor, MI, USA
| | - Kevin R Ward
- Center for Computational Medicine and Bioinformatics, University of Michigan Medical School, Ann Arbor, MI, USA; Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, USA; Michigan Center for Integrative Research in Critical Care; Ann Arbor, MI, USA
| | - Christopher E Gillies
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, USA; Michigan Center for Integrative Research in Critical Care; Ann Arbor, MI, USA; Michigan Institute for Data Science, University of Michigan, Ann Arbor, MI, USA
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Mitchell OJL, Yuriditsky E, Johnson NJ, Doran O, Buckler DG, Neefe S, Seethala RR, Motov S, Moskowitz A, Lee J, Griffin KM, Shashaty MGS, Horowitz JM, Abella BS. In-hospital cardiac arrest in patients with coronavirus 2019. Resuscitation 2021; 160:72-78. [PMID: 33515638 PMCID: PMC7839632 DOI: 10.1016/j.resuscitation.2021.01.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 12/18/2020] [Accepted: 01/08/2021] [Indexed: 12/29/2022]
Abstract
Background Coronavirus Disease 2019 (COVID-19) has caused over 1 200 000 deaths worldwide as of November 2020. However, little is known about the clinical outcomes among hospitalized patients with active COVID-19 after in-hospital cardiac arrest (IHCA). Aim We aimed to characterize outcomes from IHCA in patients with COVID-19 and to identify patient- and hospital-level variables associated with 30-day survival. Methods We conducted a multicentre retrospective cohort study across 11 academic medical centres in the U.S. Adult patients who received cardiopulmonary resuscitation and/or defibrillation for IHCA between March 1, 2020 and May 31, 2020 who had a documented positive test for Severe Acute Respiratory Syndrome Coronavirus 2 were included. The primary outcome was 30-day survival after IHCA. Results There were 260 IHCAs among COVID-19 patients during the study period. The median age was 69 years (interquartile range 60–77), 71.5% were male, 49.6% were White, 16.9% were Black, and 16.2% were Hispanic. The most common presenting rhythms were pulseless electrical activity (45.0%) and asystole (44.6%). ROSC occurred in 58 patients (22.3%), 31 (11.9%) survived to hospital discharge, and 32 (12.3%) survived to 30 days. Rates of ROSC and 30-day survival in the two hospitals with the highest volume of IHCA over the study period compared to the remaining hospitals were considerably lower (10.8% vs. 64.3% and 5.9% vs. 35.7% respectively, p < 0.001 for both). Conclusions We found rates of ROSC and 30-day survival of 22.3% and 12.3% respectively. There were large variations in centre-level outcomes, which may explain the poor survival in prior studies.
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Affiliation(s)
- Oscar J L Mitchell
- Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania, United States; Center for Resuscitation Science, University of Pennsylvania, United States.
| | | | - Nicholas J Johnson
- Department of Emergency Medicine and Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, United States
| | - Olivia Doran
- Center for Resuscitation Science, University of Pennsylvania, United States
| | - David G Buckler
- Center for Emergency Care Policy and Research, University of Pennsylvania, United States
| | - Stacie Neefe
- Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania, United States
| | - Raghu R Seethala
- Division of Emergency Critical Care Medicine, Brigham and Women's Hospital, United States
| | - Sergey Motov
- Department of Emergency Medicine, Maimonides Medical Center, United States
| | - Ari Moskowitz
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, United States
| | - Jarone Lee
- Department of Critical Care and Emergency Medicine, Massachusetts General Hospital, United States
| | - Kelly M Griffin
- Department of Pulmonary and Critical Care Medicine, Weill Cornell Medicine, New York Presbyterian Hospital, United States
| | - Michael G S Shashaty
- Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania, United States; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, United States; Department of Emergency Medicine, University of Pennsylvania, United States
| | | | - Benjamin S Abella
- Center for Resuscitation Science, University of Pennsylvania, United States; Department of Emergency Medicine, University of Pennsylvania, United States
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20
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Miano TA, Shashaty MGS, Yang W, Brown JR, Zuppa A, Hennessy S. Effect of Renin-Angiotensin System Inhibitors on the Comparative Nephrotoxicity of NSAIDs and Opioids during Hospitalization. ACTA ACUST UNITED AC 2020; 1:604-613. [PMID: 33163971 DOI: 10.34067/kid.0001432020] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background Nonsteroidal anti-inflammatory drugs (NSAIDS) are increasingly important alternatives to opioids for analgesia during hospitalization as health systems implement opioid-minimization initiatives. Increasing NSAID use may increase AKI rates, particularly in patients with predisposing risk factors. Inconclusive data in outpatient populations suggests that NSAID nephrotoxicity is magnified by renin-angiotensin system inhibitors (RAS-I). No studies have tested this in hospitalized patients. Methods Retrospective, active-comparator cohort study of patients admitted to four hospitals in Philadelphia, Pennsylvania. To minimize confounding by indication, NSAIDs were compared to oxycodone, and RAS-I were compared to amlodipine. We tested synergistic NSAID+RAS-I nephrotoxicity by comparing the difference in AKI rate between NSAID versus oxycodone in patients treated with RAS-I to the difference in AKI rate between NSAID versus oxycodone in patients treated with amlodipine. In a secondary analysis, we restricted the cohort to patients with baseline diuretic treatment. AKI rates were adjusted for 71 baseline characteristics with inverse probability of treatment-weighted Poisson regression. Results The analysis included 25,571 patients who received a median of 2.4 days of analgesia. The overall AKI rate was 23.6 per 1000 days. The rate difference (RD) for NSAID versus oxycodone in patients treated with amlodipine was 4.1 per 1000 days (95% CI, -2.8 to 11.1), and the rate difference for NSAID versus oxycodone in patients treated with RAS-I was 5.9 per 1000 days (95% CI, 1.9 to 10.1), resulting in a nonsignificant interaction estimate: 1.85 excess AKI events per 1000 days (95% CI, -6.23 to 9.92). Analysis in patients treated with diuretics produced a higher, albeit nonsignificant, interaction estimate: 9.89 excess AKI events per 1000 days (95% CI, -5.04 to 24.83). Conclusions Synergistic nephrotoxicity was not observed with short-term NSAID+RAS-I treatment in the absence of concomitant diuretics, suggesting that RAS-I treatment may not be a reason to choose opioids in lieu of NSAIDs in this population. Synergistic nephrotoxicity cannot be ruled out in patients treated with diuretics.
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Affiliation(s)
- Todd A Miano
- Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael G S Shashaty
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Wei Yang
- Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeremiah R Brown
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire.,Department of Epidemiology, Geisel School of Medicine, Hanover, New Hampshire.,Department of Biomedical Data Science, Geisel School of Medicine, Hanover, New Hampshire
| | - Athena Zuppa
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sean Hennessy
- Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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21
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Miano TA, Yang W, Shashaty MGS, Zuppa A, Brown JR, Hennessy S. The Magnitude of the Warfarin-Amiodarone Drug-Drug Interaction Varies With Renal Function: A Propensity-Matched Cohort Study. Clin Pharmacol Ther 2020; 107:1446-1456. [PMID: 32112562 DOI: 10.1002/cpt.1819] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 02/16/2020] [Indexed: 12/20/2022]
Abstract
Amiodarone inhibits warfarin metabolism and is associated with major bleeding during warfarin therapy. Managing this drug-drug interaction (DDI) is challenging because of substantial interpatient variability in DDI magnitude. Because renal dysfunction induces changes in drug metabolism and protein binding that could alter cytochrome P450 inhibition mechanisms, we hypothesized that renal dysfunction alters the impact of the warfarin-amiodarone DDI. We tested this question in a propensity-matched cohort study of hospitalized patients with atrial fibrillation. Patients were queried from an electronic health record database. Renal function was estimated with creatinine clearance (CrCl). Warfarin response was measured with the warfarin sensitivity index (WSI), a dose-normalized international normalized ratio (INR) measure, and was modeled with multilevel mixed-effects linear regression. Time to supratherapeutic INR (> 4) was modeled using Cox regression. Propensity score matching resulted in 4,518 patients administered amiodarone and 4,518 controls. Amiodarone's effect on warfarin response varied threefold across the renal function range, increasing WSI by 36% in patients with normal renal function (CrCl 115 mL/minute), but by only 11.8% in patients with severe renal dysfunction (CrCl 15 mL/minute). Similarly, amiodarone had a strong effect in patients with normal renal function (hazard ratio (HR) 1.80; 1.23, 2.64), but a negligible effect on supratherapeutic INR hazard in patients with severe renal dysfunction (HR 1.01; 0.75, 1.37). These results suggest that renal function is a novel factor that explains substantial variability in the warfarin-amiodarone DDI. This information could inform warfarin dosage adjustment and monitoring and may have implications for the selection of oral anticoagulation agents in patients treated with amiodarone.
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Affiliation(s)
- Todd A Miano
- Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Wei Yang
- Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael G S Shashaty
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Athena Zuppa
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jeremiah R Brown
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire, USA.,Department of Epidemiology, Geisel School of Medicine, Hanover, New Hampshire, USA.,Department of Biomedical Data Science, Geisel School of Medicine, Hanover, New Hampshire, USA
| | - Sean Hennessy
- Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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22
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Miano TA, Flesch JD, Feng R, Forker CM, Brown M, Oyster M, Kalman L, Rushefski M, Cantu E, Porteus M, Yang W, Localio AR, Diamond JM, Christie JD, Shashaty MGS. Early Tacrolimus Concentrations After Lung Transplant Are Predicted by Combined Clinical and Genetic Factors and Associated With Acute Kidney Injury. Clin Pharmacol Ther 2020; 107:462-470. [PMID: 31513279 PMCID: PMC6980920 DOI: 10.1002/cpt.1629] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 08/25/2019] [Indexed: 12/13/2022]
Abstract
Tacrolimus exhibits unpredictable pharmacokinetics (PKs) after lung transplant, partly explained by cytochrome P450 (CYP)-enzyme polymorphisms. However, whether exposure variability during the immediate postoperative period affects outcomes is unknown, and pharmacogenetic dosing may be limited by residual PK variability. We estimated adjusted associations between early postoperative tacrolimus concentrations and acute kidney injury (AKI) and acute cellular rejection (ACR), and identified clinical and pharmacogenetic factors that explain postoperative tacrolimus concentration variability in 484 lung transplant patients. Increasing tacrolimus concentration was associated with higher AKI risk (hazard ratio (HR) 1.54; 95% confidence interval (CI) 1.20-1.96 per 5-mg/dL); and increasing AKI severity (odds ratio 1.29; 95% CI 1.04-1.60 per 5-mg/dL), but not ACR (HR 1.02; 95% CI 0.73-1.42). A model with clinical and pharmacogenetic factors explained 42% of concentration variance compared with 19% for pharmacogenetic factors only. Early tacrolimus exposure was independently associated with AKI after lung transplantation, but not ACR. Clinical factors accounted for substantial residual tacrolimus concentration variability not explained by CYP-enzyme polymorphisms.
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Affiliation(s)
- Todd A. Miano
- Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine at the University of Pennsylvania
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania
| | - Judd D. Flesch
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine at the University of Pennsylvania
| | - Rui Feng
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania
| | - Caitlin M. Forker
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine at the University of Pennsylvania
| | - Melanie Brown
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine at the University of Pennsylvania
| | - Michelle Oyster
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine at the University of Pennsylvania
| | - Laurel Kalman
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine at the University of Pennsylvania
| | - Melanie Rushefski
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine at the University of Pennsylvania
| | - Edward Cantu
- Division of Cardiovascular Surgery, Perelman School of Medicine at the University of Pennsylvania
| | - Mary Porteus
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine at the University of Pennsylvania
| | - Wei Yang
- Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine at the University of Pennsylvania
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania
| | - A. Russel Localio
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania
| | - Joshua M. Diamond
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine at the University of Pennsylvania
| | - Jason D. Christie
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine at the University of Pennsylvania
| | - Michael G. S. Shashaty
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine at the University of Pennsylvania
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23
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Faust HE, Reilly JP, Anderson BJ, Ittner CAG, Forker CM, Zhang P, Weaver BA, Holena DN, Lanken PN, Christie JD, Meyer NJ, Mangalmurti NS, Shashaty MGS. Plasma Mitochondrial DNA Levels Are Associated With ARDS in Trauma and Sepsis Patients. Chest 2020; 157:67-76. [PMID: 31622590 PMCID: PMC6965693 DOI: 10.1016/j.chest.2019.09.028] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 08/13/2019] [Accepted: 09/19/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Critically ill patients who develop ARDS have substantial associated morbidity and mortality. Circulating mitochondrial DNA (mtDNA) released during critical illness causes endothelial dysfunction and lung injury in experimental models. This study hypothesized that elevated plasma mtDNA is associated with ARDS in critically ill patients with trauma and sepsis. METHODS Plasma mtDNA concentrations were measured at ED presentation and approximately 48 h later in separate prospective cohorts of critically ill patients with trauma and sepsis. ARDS was classified according to the Berlin definition. The association of mtDNA with ARDS was tested by using multivariable logistic regression, adjusted for covariates previously shown to contribute to ARDS risk in each population. RESULTS ARDS developed in 41 of 224 (18%) trauma patients and in 45 of 120 (38%) patients with sepsis. Forty-eight-hour mtDNA levels were significantly associated with ARDS (trauma: OR, 1.58/log copies/μL; 95% CI, 1.14-2.19 [P = .006]; sepsis: OR, 1.52/log copies/μL; 95% CI, 1.12-2.06 [P = .007]). Plasma mtDNA on presentation was not significantly associated with ARDS in either cohort. In patients with sepsis, 48-h mtDNA was more strongly associated with ARDS among those with a nonpulmonary infectious source (OR, 2.20/log copies/μL; 95% CI, 1.36-3.55 [P = .001], n = 69) than those with a pulmonary source (OR, 1.04/log copies/μL; 95% CI, 0.68-1.59 [P = .84], n = 51; P = .014 for interaction). CONCLUSIONS Plasma mtDNA levels were associated with incident ARDS in two critical illness populations. Given supportive preclinical data, our findings suggest a potential link between circulating mtDNA and lung injury and merit further investigation as a potentially targetable mediator of ARDS.
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Affiliation(s)
- Hilary E Faust
- Allergy, Pulmonary and Critical Care Division, University of Wisconsin School of Medicine and Public Health, Madison, WI.
| | - John P Reilly
- Pulmonary, Allergy and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Center for Translational Lung Biology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Brian J Anderson
- Pulmonary, Allergy and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Caroline A G Ittner
- Pulmonary, Allergy and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Caitlyn M Forker
- Pulmonary, Allergy and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Peggy Zhang
- Pulmonary, Allergy and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Benjamin A Weaver
- Pulmonary, Allergy and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Daniel N Holena
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Center for Resuscitation Science, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Paul N Lanken
- Pulmonary, Allergy and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jason D Christie
- Pulmonary, Allergy and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Center for Translational Lung Biology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Nuala J Meyer
- Pulmonary, Allergy and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Center for Translational Lung Biology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Nilam S Mangalmurti
- Pulmonary, Allergy and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Center for Translational Lung Biology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Michael G S Shashaty
- Pulmonary, Allergy and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Center for Translational Lung Biology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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24
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Jones TK, Feng R, Kerchberger VE, Reilly JP, Anderson BJ, Shashaty MGS, Wang F, Dunn TG, Riley TR, Abbott J, Ittner CAG, Christiani DC, Mikacenic C, Wurfel MM, Ware LB, Calfee CS, Matthay MA, Christie JD, Meyer NJ. Plasma sRAGE Acts as a Genetically Regulated Causal Intermediate in Sepsis-associated Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2020; 201:47-56. [PMID: 31487195 PMCID: PMC6938154 DOI: 10.1164/rccm.201810-2033oc] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Accepted: 09/05/2019] [Indexed: 12/31/2022] Open
Abstract
Rationale: Acute respiratory distress syndrome (ARDS) lacks known causal biomarkers. Plasma concentrations of sRAGE (soluble receptor for advanced glycation end products) strongly associate with ARDS risk. However, whether plasma sRAGE contributes causally to ARDS remains unknown.Objectives: Evaluate plasma sRAGE as a causal intermediate in ARDS by Mendelian randomization (MR), a statistical method to infer causality using observational data.Methods: We measured early plasma sRAGE in two critically ill populations with sepsis. The cohorts were whole-genome genotyped and phenotyped for ARDS. To select validated genetic instruments for MR, we regressed plasma sRAGE on genome-wide genotypes in both cohorts. The causal effect of plasma sRAGE on ARDS was inferred using the top variants with significant associations in both populations (P < 0.01, R2 > 0.02). We applied the inverse variance-weighted method to obtain consistent estimates of the causal effect of plasma sRAGE on ARDS risk.Measurements and Main Results: There were 393 European and 266 African ancestry patients in the first cohort and 843 European ancestry patients in the second cohort. Plasma sRAGE was strongly associated with ARDS risk in both populations (odds ratio, 1.86; 95% confidence interval [1.54-2.25]; 2.56 [2.14-3.06] per log increase). Using genetic instruments common to both populations, plasma sRAGE had a consistent causal effect on ARDS risk with a β estimate of 0.50 (95% confidence interval [0.09-0.91] per log increase).Conclusions: Plasma sRAGE is genetically regulated during sepsis, and MR analysis indicates that increased plasma sRAGE leads to increased ARDS risk, suggesting plasma sRAGE acts as a causal intermediate in sepsis-related ARDS.
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Affiliation(s)
- Tiffanie K. Jones
- Pulmonary, Allergy, and Critical Care Medicine Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Rui Feng
- Department of Biostatistics, Center for Clinical Epidemiology and Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - V. Eric Kerchberger
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - John P. Reilly
- Pulmonary, Allergy, and Critical Care Medicine Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Brian J. Anderson
- Pulmonary, Allergy, and Critical Care Medicine Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Michael G. S. Shashaty
- Pulmonary, Allergy, and Critical Care Medicine Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
- Department of Biostatistics, Center for Clinical Epidemiology and Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Fan Wang
- Department of Cardiovascular and Metabolic Sciences, Cleveland Clinic Lerner Research Institute, Cleveland, Ohio
| | - Thomas G. Dunn
- Pulmonary, Allergy, and Critical Care Medicine Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Thomas R. Riley
- Pulmonary, Allergy, and Critical Care Medicine Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Jason Abbott
- Department of Anesthesia, Cardiovascular Research Institute, and
| | - Caroline A. G. Ittner
- Pulmonary, Allergy, and Critical Care Medicine Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - David C. Christiani
- Harvard School of Public Health, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; and
| | - Carmen Mikacenic
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington
| | - Mark M. Wurfel
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington
| | - Lorraine B. Ware
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Carolyn S. Calfee
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, California
| | - Michael A. Matthay
- Department of Anesthesia, Cardiovascular Research Institute, and
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, California
| | - Jason D. Christie
- Pulmonary, Allergy, and Critical Care Medicine Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
- Department of Biostatistics, Center for Clinical Epidemiology and Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nuala J. Meyer
- Pulmonary, Allergy, and Critical Care Medicine Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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25
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Anderson BJ, Calfee CS, Liu KD, Reilly JP, Kangelaris KN, Shashaty MGS, Lazaar AL, Bayliffe AI, Gallop RJ, Miano TA, Dunn TG, Johansson E, Abbott J, Jauregui A, Deiss T, Vessel K, Belzer A, Zhuo H, Matthay MA, Meyer NJ, Christie JD. Plasma sTNFR1 and IL8 for prognostic enrichment in sepsis trials: a prospective cohort study. Crit Care 2019; 23:400. [PMID: 31818332 PMCID: PMC6902425 DOI: 10.1186/s13054-019-2684-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 11/22/2019] [Indexed: 01/07/2023]
Abstract
Background Enrichment strategies improve therapeutic targeting and trial efficiency, but enrichment factors for sepsis trials are lacking. We determined whether concentrations of soluble tumor necrosis factor receptor-1 (sTNFR1), interleukin-8 (IL8), and angiopoietin-2 (Ang2) could identify sepsis patients at higher mortality risk and serve as prognostic enrichment factors. Methods In a multicenter prospective cohort study of 400 critically ill septic patients, we derived and validated thresholds for each marker and expressed prognostic enrichment using risk differences (RD) of 30-day mortality as predictive values. We then used decision curve analysis to simulate the prognostic enrichment of each marker and compare different prognostic enrichment strategies. Measurements and main results An admission sTNFR1 concentration > 8861 pg/ml identified patients with increased mortality in both the derivation (RD 21.6%) and validation (RD 17.8%) populations. Among immunocompetent patients, an IL8 concentration > 94 pg/ml identified patients with increased mortality in both the derivation (RD 17.7%) and validation (RD 27.0%) populations. An Ang2 level > 9761 pg/ml identified patients at 21.3% and 12.3% increased risk of mortality in the derivation and validation populations, respectively. Using sTNFR1 or IL8 to select high-risk patients improved clinical trial power and efficiency compared to selecting patients with septic shock. Ang2 did not outperform septic shock as an enrichment factor. Conclusions Thresholds for sTNFR1 and IL8 consistently identified sepsis patients with higher mortality risk and may have utility for prognostic enrichment in sepsis trials.
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Affiliation(s)
- Brian J Anderson
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, 5036 Gates Building, Philadelphia, PA, 19104, USA.
| | - Carolyn S Calfee
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, USA
| | - Kathleen D Liu
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, USA
| | - John P Reilly
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, 5036 Gates Building, Philadelphia, PA, 19104, USA
| | - Kirsten N Kangelaris
- Division of Hospital Medicine, Department of Medicine, University of California San Francisco, San Francisco, USA
| | - Michael G S Shashaty
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, 5036 Gates Building, Philadelphia, PA, 19104, USA.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Aili L Lazaar
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA.,GlaxoSmithKline R&D, Brentford, UK
| | | | - Robert J Gallop
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA.,Department of Mathematics, West Chester University, West Chester, USA
| | - Todd A Miano
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Thomas G Dunn
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, 5036 Gates Building, Philadelphia, PA, 19104, USA
| | - Erik Johansson
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, 5036 Gates Building, Philadelphia, PA, 19104, USA
| | - Jason Abbott
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, USA
| | - Alejandra Jauregui
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, USA
| | - Thomas Deiss
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, USA
| | - Kathryn Vessel
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, USA
| | - Annika Belzer
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, USA
| | - Hanjing Zhuo
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, USA
| | - Michael A Matthay
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, USA
| | - Nuala J Meyer
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, 5036 Gates Building, Philadelphia, PA, 19104, USA
| | - Jason D Christie
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, 5036 Gates Building, Philadelphia, PA, 19104, USA.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
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26
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Shashaty MGS, Forker CM, Miano TA, Wu Q, Yang W, Oyster ML, Porteous MK, Cantu EE, Diamond JM, Christie JD. The association of post-lung transplant acute kidney injury with mortality is independent of primary graft dysfunction: A cohort study. Clin Transplant 2019; 33:e13678. [PMID: 31355953 DOI: 10.1111/ctr.13678] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 07/11/2019] [Accepted: 07/25/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Prior studies of post-lung transplant acute kidney injury (AKI) have not accounted for confounding effects of primary graft dysfunction (PGD). We sought to test the impact of PGD on AKI risk factors and on the association of AKI with mortality. METHODS We included patients transplanted at the University of Pennsylvania from 2005-12, defined AKI using consensus criteria during transplant hospitalization, and defined PGD as grade 3 at 48-72 hours. We used multivariable logistic regression to test the impact of PGD on AKI risk factors and Cox models to test association of AKI with one-year mortality adjusting for PGD and other confounders. RESULTS Of 299 patients, 188 (62.9%) developed AKI with 142 (75%) cases occurring by postoperative day 4. In multivariable models, PGD was strongly associated with AKI (OR 3.76, 95% CI 1.72-8.19, P = .001) but minimally changed associations of other risk factors with AKI. Both AKI (HR 3.64, 95% CI 1.68-7.88, P = .001) and PGD (HR 2.55, 95% CI 1.40-4.64, P = .002) were independently associated with one-year mortality. CONCLUSIONS Post-lung transplant AKI risk factors and association of AKI with mortality were independent of PGD. AKI may therefore be a target for improving lung transplant mortality rather than simply an epiphenomenon of PGD.
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Affiliation(s)
- Michael G S Shashaty
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Caitlin M Forker
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Todd A Miano
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Qufei Wu
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Wei Yang
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michelle L Oyster
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mary K Porteous
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Edward E Cantu
- Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joshua M Diamond
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jason D Christie
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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27
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Forker CM, Miano TA, Reilly JP, Oyster ML, Porteous MK, Cantu EE, Ware LB, Diamond JM, Christie JD, Shashaty MGS. Postreperfusion plasma endothelial activation markers are associated with acute kidney injury after lung transplantation. Am J Transplant 2019; 19:2366-2373. [PMID: 31017370 PMCID: PMC6658345 DOI: 10.1111/ajt.15402] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 03/31/2019] [Accepted: 04/03/2019] [Indexed: 01/25/2023]
Abstract
Acute kidney injury (AKI) is common after lung transplantation, but molecular markers remain poorly studied. The endothelial activation markers soluble thrombomodulin (sTM), protein C, and plasminogen activator inhibitor-1 (PAI-1) are implicated in kidney microcirculatory injury in animal models of AKI. We tested the association of 6-hour postreperfusion plasma levels of these markers with posttransplant AKI severity in patients enrolled in the Lung Transplant Outcomes Group prospective cohort study at the University of Pennsylvania during two eras: 2004-06 (n = 61) and 2013-15 (n = 67). We defined AKI stage through postoperative day 5 using Kidney Disease Improving Global Outcomes creatinine criteria. We used multivariable ordinal logistic regression to determine the association of each biomarker with AKI, adjusted for primary graft dysfunction and extracorporeal life support. AKI occurred in 57 (45%) patients across both eras: 28 (22%) stage 1, 29 (23%) stage 2-3. Higher sTM and lower protein C plasma levels were associated with AKI stage in each era and remained so in multivariable models utilizing both eras (sTM: OR 1.76 [95% CI 1.19-2.60] per standard deviation, P = .005; protein C: OR 0.54 [1.19-2.60], P = .003). We conclude that 6-hour postreperfusion plasma sTM and protein C levels are associated with early postlung transplant AKI severity.
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Affiliation(s)
- Caitlin M. Forker
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Todd A. Miano
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John P. Reilly
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michelle L. Oyster
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mary K. Porteous
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Edward E. Cantu
- Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lorraine B. Ware
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Joshua M. Diamond
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason D. Christie
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael G. S. Shashaty
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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28
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Hotz MJ, Qing D, Shashaty MGS, Zhang P, Faust H, Sondheimer N, Rivella S, Worthen GS, Mangalmurti NS. Red Blood Cells Homeostatically Bind Mitochondrial DNA through TLR9 to Maintain Quiescence and to Prevent Lung Injury. Am J Respir Crit Care Med 2019; 197:470-480. [PMID: 29053005 DOI: 10.1164/rccm.201706-1161oc] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
RATIONALE Potentially hazardous CpG-containing cell-free mitochondrial DNA (cf-mtDNA) is routinely released into the circulation and is associated with morbidity and mortality in critically ill patients. How the body avoids inappropriate innate immune activation by cf-mtDNA remains unknown. Because red blood cells (RBCs) modulate innate immune responses by scavenging chemokines, we hypothesized that RBCs may attenuate CpG-induced lung inflammation through direct scavenging of CpG-containing DNA. OBJECTIVES To determine the mechanisms of CpG-DNA binding to RBCs and the effects of RBC-mediated DNA scavenging on lung inflammation. METHODS mtDNA on murine RBCs was measured under basal conditions and after systemic inflammation. mtDNA content on human RBCs from healthy control subjects and trauma patients was measured. Toll-like receptor 9 (TLR9) expression on RBCs and TLR9-dependent binding of CpG-DNA to RBCs were determined. A murine model of RBC transfusion after CpG-DNA-induced lung injury was used to investigate the role of RBC-mediated DNA scavenging in mitigating lung injury in vivo. MEASUREMENTS AND MAIN RESULTS Under basal conditions, RBCs bind CpG-DNA. The plasma-to-RBC mtDNA ratio is low in naive mice and in healthy volunteers but increases after systemic inflammation, demonstrating that the majority of cf-mtDNA is RBC-bound under homeostatic conditions and that the unbound fraction increases during inflammation. RBCs express TLR9 and bind CpG-DNA through TLR9. Loss of TLR9-dependent RBC-mediated CpG-DNA scavenging increased lung injury in vivo. CONCLUSIONS RBCs homeostatically bind mtDNA, and RBC-mediated DNA scavenging is essential in mitigating lung injury after CpG-DNA. Our data suggest a role for RBCs in regulating lung inflammation during disease states where cf-mtDNA is elevated, such as sepsis and trauma.
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Affiliation(s)
| | | | | | - Peggy Zhang
- 1 Pulmonary, Allergy and Critical Care Division and
| | - Hilary Faust
- 1 Pulmonary, Allergy and Critical Care Division and
| | - Neal Sondheimer
- 2 Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada; and
| | | | - G Scott Worthen
- 5 Penn Center for Pulmonary Biology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,4 Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Nilam S Mangalmurti
- 1 Pulmonary, Allergy and Critical Care Division and.,5 Penn Center for Pulmonary Biology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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29
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Shashaty MGS, Reilly JP, Faust HE, Forker CM, Ittner CAG, Zhang PX, Hotz MJ, Fitzgerald D, Yang W, Anderson BJ, Holena DN, Lanken PN, Christie JD, Meyer NJ, Mangalmurti NS. Plasma receptor interacting protein kinase-3 levels are associated with acute respiratory distress syndrome in sepsis and trauma: a cohort study. Crit Care 2019; 23:235. [PMID: 31253195 PMCID: PMC6599265 DOI: 10.1186/s13054-019-2482-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 05/19/2019] [Indexed: 02/06/2023]
Abstract
Background Necroptosis, a form of programmed cell death mediated by receptor interacting serine/threonine-protein kinase-3 (RIPK3), is implicated in murine models of acute respiratory distress syndrome (ARDS). We hypothesized that plasma RIPK3 concentrations in sepsis and trauma would be associated with ARDS development and that plasma RIPK3 would reflect changes in lung tissue RIPK3 in a murine model of systemic inflammation. Methods We utilized prospective cohort studies of critically ill sepsis (n = 120) and trauma (n = 180) patients and measured plasma RIPK3 at presentation and 48 h. Patients were followed for 6 days for ARDS by the Berlin definition. We used multivariable logistic regression to determine the association of plasma RIPK3 with ARDS in each cohort, adjusting for confounders. In mice, we determined whether plasma and lung tissue RIPK3 levels rise concomitantly 4 h after injection with lipopolysaccharide and ZVAD-FMK, an apoptosis inhibitor. Results The change in plasma RIPK3 from presentation to 48 h (ΔRIPK3) was associated with ARDS in sepsis (OR 1.30, 95% CI 1.03–1.63, per ½ standard deviation) and trauma (OR 1.79, 95% CI 1.33–2.40). This association was not evident for presentation RIPK3 levels. Secondary analyses showed similar findings for the association of ΔRIPK3 with acute kidney injury and 30-day mortality. Mice injected with lipopolysaccharide and ZVAD-FMK had significantly higher plasma (p < 0.001) and lung (p = 0.005) RIPK3 than control mice. Conclusions The change in plasma RIPK3 from presentation to 48 h in both sepsis and trauma patients is independently associated with ARDS, and plasma RIPK3 may reflect RIPK3 activity in lung tissue. Electronic supplementary material The online version of this article (10.1186/s13054-019-2482-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Michael G S Shashaty
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, 5039 W Gates Building, 3600 Spruce Street, Philadelphia, PA, 19104, USA. .,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Pennsylvania, USA. .,Center for Translational Lung Biology, Perelman School of Medicine, University of Pennsylvania, Pennsylvania, USA.
| | - John P Reilly
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, 5039 W Gates Building, 3600 Spruce Street, Philadelphia, PA, 19104, USA.,Center for Translational Lung Biology, Perelman School of Medicine, University of Pennsylvania, Pennsylvania, USA
| | - Hilary E Faust
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, 5039 W Gates Building, 3600 Spruce Street, Philadelphia, PA, 19104, USA.,Center for Translational Lung Biology, Perelman School of Medicine, University of Pennsylvania, Pennsylvania, USA
| | - Caitlin M Forker
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, 5039 W Gates Building, 3600 Spruce Street, Philadelphia, PA, 19104, USA
| | - Caroline A G Ittner
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, 5039 W Gates Building, 3600 Spruce Street, Philadelphia, PA, 19104, USA
| | - Peggy X Zhang
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, 5039 W Gates Building, 3600 Spruce Street, Philadelphia, PA, 19104, USA
| | - Meghan J Hotz
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, 5039 W Gates Building, 3600 Spruce Street, Philadelphia, PA, 19104, USA
| | - David Fitzgerald
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, 5039 W Gates Building, 3600 Spruce Street, Philadelphia, PA, 19104, USA
| | - Wei Yang
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Pennsylvania, USA
| | - Brian J Anderson
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, 5039 W Gates Building, 3600 Spruce Street, Philadelphia, PA, 19104, USA.,Center for Translational Lung Biology, Perelman School of Medicine, University of Pennsylvania, Pennsylvania, USA
| | - Daniel N Holena
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, Pennsylvania, USA
| | - Paul N Lanken
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, 5039 W Gates Building, 3600 Spruce Street, Philadelphia, PA, 19104, USA
| | - Jason D Christie
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, 5039 W Gates Building, 3600 Spruce Street, Philadelphia, PA, 19104, USA.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Pennsylvania, USA.,Center for Translational Lung Biology, Perelman School of Medicine, University of Pennsylvania, Pennsylvania, USA
| | - Nuala J Meyer
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, 5039 W Gates Building, 3600 Spruce Street, Philadelphia, PA, 19104, USA.,Center for Translational Lung Biology, Perelman School of Medicine, University of Pennsylvania, Pennsylvania, USA
| | - Nilam S Mangalmurti
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, 5039 W Gates Building, 3600 Spruce Street, Philadelphia, PA, 19104, USA.,Center for Translational Lung Biology, Perelman School of Medicine, University of Pennsylvania, Pennsylvania, USA
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30
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Reilly JP, Zhao Z, Shashaty MGS, Koyama T, Christie JD, Lanken PN, Wang C, Balmes JR, Matthay MA, Calfee CS, Ware LB. Low to Moderate Air Pollutant Exposure and Acute Respiratory Distress Syndrome after Severe Trauma. Am J Respir Crit Care Med 2019; 199:62-70. [PMID: 30067389 PMCID: PMC6353017 DOI: 10.1164/rccm.201803-0435oc] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 08/01/2018] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Exposure to air pollution has molecular and physiologic effects on the lung that may increase the risk of acute respiratory distress syndrome (ARDS) after injury. OBJECTIVES To determine the association of short- and long-term air pollutant exposures and ARDS risk after severe trauma. METHODS We analyzed data from a prospective cohort of 996 critically ill patients presenting with acute trauma and an injury severity score greater than 15. Exposures to ozone, nitrogen dioxide, sulfur dioxide, carbon monoxide, and particulate matter less than 2.5 μm were assessed by weighted averages of daily levels from all monitors within 50 km of the geocoded location of a patient's residence. Patients were followed for 6 days for the development of ARDS according to Berlin Criteria. The association between each exposure and ARDS was determined via multivariable logistic regression adjusting for potential confounders. MEASUREMENTS AND MAIN RESULTS ARDS developed in 243 (24%) patients. None of the short-term exposures averaged over the 3 days before presentation was associated with ARDS, except sulfur dioxide, which demonstrated a nonlinear association. Nitrogen dioxide, sulfur dioxide, and particulate matter less than or equal to 2.5 μm in aerodynamic diameter exposure over the 6 weeks before presentation was significantly associated with ARDS (P < 0.05). All long-term exposures (3 yr) were associated with ARDS (P < 0.01) in adjusted models, despite exposure levels largely below U.S. and European Union air quality standards. CONCLUSIONS Long-term low- to moderate-level air pollutant exposure is associated with a greater risk of developing ARDS after severe trauma and represents a novel and potentially modifiable environmental risk factor for ARDS.
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Affiliation(s)
- John P. Reilly
- Division of Pulmonary, Allergy, and Critical Care
- Center for Translational Lung Biology, and
| | | | - Michael G. S. Shashaty
- Division of Pulmonary, Allergy, and Critical Care
- Center for Translational Lung Biology, and
| | | | - Jason D. Christie
- Division of Pulmonary, Allergy, and Critical Care
- Center for Translational Lung Biology, and
- Center for Clinical Epidemiology and Biostatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Associate Editor, AJRCCM
| | | | | | - John R. Balmes
- Associate Editor, AJRCCM
- Division of Environmental Health Sciences, School of Public Health, University of California, Berkeley, Berkeley, California; and
- Department of Medicine and
| | - Michael A. Matthay
- Department of Medicine and
- Department of Anesthesia and Cardiovascular Research Institute, University of California, San Francisco, San Francisco, California
| | - Carolyn S. Calfee
- Department of Medicine and
- Department of Anesthesia and Cardiovascular Research Institute, University of California, San Francisco, San Francisco, California
| | - Lorraine B. Ware
- Department of Medicine, and
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee
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31
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Reilly JP, Anderson BJ, Hudock KM, Dunn TG, Kazi A, Tommasini A, Charles D, Shashaty MGS, Mikkelsen ME, Christie JD, Meyer NJ. Neutropenic sepsis is associated with distinct clinical and biological characteristics: a cohort study of severe sepsis. Crit Care 2016; 20:222. [PMID: 27431667 PMCID: PMC4950810 DOI: 10.1186/s13054-016-1398-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 07/01/2016] [Indexed: 12/31/2022]
Abstract
Background Immunocompromised patients who develop sepsis while neutropenic are at high risk for morbidity and mortality; however, it is unknown if neutropenic sepsis is associated with distinct clinical and biological characteristics. Methods We conducted a prospective cohort study of patients admitted to the medical intensive care unit of an academic medical center with severe sepsis. Patients were followed for the development of acute respiratory distress syndrome (ARDS), acute kidney injury (AKI), and mortality. Plasma proteins, representing the host inflammatory response, anti-inflammatory response, and endothelial leak were measured in 30 % of subjects. Clinical characteristics and plasma protein concentrations of patients with neutropenia at enrollment were compared to patients without neutropenia. Results Of 797 subjects enrolled, 103 (13 %) were neutropenic at ICU admission. The neutropenic subjects were more often in shock, admitted from the hospital ward, had higher APACHE III scores, and more likely bacteremic. Neutropenia was an independent risk factor for AKI (RR 1.28; 95 % CI 1.04, 1.57; p = 0.03), but not ARDS (RR 0.90; 95 % CI 0.70, 1.17; p = 0.42) or 30-day mortality (RR 1.05; 95 % CI 0.85, 1.31; p = 0.65). Neutropenic subjects had higher plasma interleukin (IL)-6 (457 vs. 249 pg/ml; p = 0.03), IL-8 (581 vs. 94 pg/ml; p <0.001), and granulocyte colony-stimulating factor (G-CSF) (3624 vs. 99 pg/ml; p <0.001). Angiopoietin-2 and IL-1 receptor antagonist concentrations did not differ between groups. Conclusions Neutropenic sepsis is associated with a higher AKI risk and concentrations of inflammatory mediators IL-6, IL-8, and G-CSF relative to non-neutropenic patients. These differences may have implications for future therapies targeting neutropenic sepsis. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1398-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- John P Reilly
- Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania, Perelman School of Medicine, 3400 Spruce Street, Philadelphia, 19104, PA, USA.
| | - Brian J Anderson
- Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania, Perelman School of Medicine, 3400 Spruce Street, Philadelphia, 19104, PA, USA.,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Kristin M Hudock
- Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania, Perelman School of Medicine, 3400 Spruce Street, Philadelphia, 19104, PA, USA.,Division of Pulmonary, Critical Care, and Sleep Medicine, University of Cincinnati, Cincinnati, OH, USA.,Division of Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Thomas G Dunn
- Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania, Perelman School of Medicine, 3400 Spruce Street, Philadelphia, 19104, PA, USA
| | - Altaf Kazi
- Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania, Perelman School of Medicine, 3400 Spruce Street, Philadelphia, 19104, PA, USA
| | - Anna Tommasini
- Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania, Perelman School of Medicine, 3400 Spruce Street, Philadelphia, 19104, PA, USA
| | - Dudley Charles
- Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania, Perelman School of Medicine, 3400 Spruce Street, Philadelphia, 19104, PA, USA
| | - Michael G S Shashaty
- Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania, Perelman School of Medicine, 3400 Spruce Street, Philadelphia, 19104, PA, USA.,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Mark E Mikkelsen
- Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania, Perelman School of Medicine, 3400 Spruce Street, Philadelphia, 19104, PA, USA.,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Jason D Christie
- Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania, Perelman School of Medicine, 3400 Spruce Street, Philadelphia, 19104, PA, USA.,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Nuala J Meyer
- Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania, Perelman School of Medicine, 3400 Spruce Street, Philadelphia, 19104, PA, USA
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32
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Anderson BJ, Reilly JP, Shashaty MGS, Palakshappa JA, Wysoczanski A, Dunn TG, Kazi A, Tommasini A, Mikkelsen ME, Schweickert WD, Kolson DL, Christie JD, Meyer NJ. Admission plasma levels of the neuronal injury marker neuron-specific enolase are associated with mortality and delirium in sepsis. J Crit Care 2016; 36:18-23. [PMID: 27546742 DOI: 10.1016/j.jcrc.2016.06.012] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 05/13/2016] [Accepted: 06/13/2016] [Indexed: 12/30/2022]
Abstract
PURPOSE Neuron-specific enolase (NSE) concentrations are prognostic following traumatic and anoxic brain injury and may provide a method to quantify neuronal injury in other populations. We determined the association of admission plasma NSE concentrations with mortality and delirium in critically ill septic patients. METHODS We performed a retrospective analysis of 124 patients from a larger sepsis cohort. Plasma NSE was measured in the earliest blood draw at intensive care unit admission. Primary outcomes were 30-day mortality and intensive care unit delirium determined by chart review. RESULTS Sixty-one patients (49.2%) died within 30 days, and delirium developed in 34 (31.5%) of the 108 patients who survived at least 24 hours and were not persistently comatose. Each doubling of the NSE concentration was associated with a 7.3% (95% confidence interval [CI] 2.5-12.0, P= .003) increased risk of 30-day mortality and a 5.2% (95% CI 3.2-7.2, P< .001) increased risk of delirium. An NSE concentration >12.5 μg/L was independently associated with a 23.3% (95% CI 6.7-39.9, P= .006) increased risk of 30-day mortality and a 29.3% (95% CI 8.8-49.8, P= .005) increased risk of delirium. CONCLUSIONS Higher plasma NSE concentrations were associated with mortality and delirium in critically ill septic patients, suggesting that NSE may have utility as a marker of neuronal injury in sepsis.
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Affiliation(s)
- Brian J Anderson
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - John P Reilly
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - Michael G S Shashaty
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - Jessica A Palakshappa
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - Alex Wysoczanski
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - Thomas G Dunn
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - Altaf Kazi
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - Anna Tommasini
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - Mark E Mikkelsen
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - William D Schweickert
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - Dennis L Kolson
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - Jason D Christie
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - Nuala J Meyer
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
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Palakshappa JA, Anderson BJ, Reilly JP, Shashaty MGS, Ueno R, Wu Q, Ittner CAG, Tommasini A, Dunn TG, Charles D, Kazi A, Christie JD, Meyer NJ. Low Plasma Levels of Adiponectin Do Not Explain Acute Respiratory Distress Syndrome Risk: a Prospective Cohort Study of Patients with Severe Sepsis. Crit Care 2016; 20:71. [PMID: 26984771 PMCID: PMC4794929 DOI: 10.1186/s13054-016-1244-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 02/17/2016] [Indexed: 01/01/2023]
Abstract
BACKGROUND Obesity is associated with the development of acute respiratory distress syndrome (ARDS) in at-risk patients. Low plasma levels of adiponectin, a circulating hormone-like molecule, have been implicated as a possible mechanism for this association. The objective of this study was to determine the association of plasma adiponectin level at ICU admission with ARDS and 30-day mortality in patients with severe sepsis and septic shock. METHODS This is a prospective cohort study of patients admitted to the medical ICU at the Hospital of the University of Pennsylvania. Plasma adiponectin was measured at the time of ICU admission. ARDS was defined by Berlin criteria. Multivariable logistic regression was used to determine the association of plasma adiponectin with the development of ARDS and mortality at 30 days. RESULTS The study included 164 patients. The incidence of ARDS within 5 days of admission was 45%. The median initial plasma adiponectin level was 7.62 mcg/ml (IQR: 3.87, 14.90) in those without ARDS compared to 8.93 mcg/ml (IQR: 4.60, 18.85) in those developing ARDS. The adjusted odds ratio for ARDS associated with each 5 mcg increase in adiponectin was 1.12 (95% CI 1.01, 1.25), p-value 0.025). A total of 82 patients (51%) of the cohort died within 30 days of ICU admission. There was a statistically significant association between adiponectin and mortality in the unadjusted model (OR 1.11, 95% CI 1.00, 1.23, p-value 0.04) that was no longer significant after adjusting for potential confounders. CONCLUSIONS In this study, low levels of adiponectin were not associated with an increased risk of ARDS in patients with severe sepsis and septic shock. This argues against low levels of adiponectin as a mechanism explaining the association of obesity with ARDS. At present, it is unclear whether circulating adiponectin is involved in the pathogenesis of ARDS or simply represents an epiphenomenon of other unknown functions of adipose tissue or metabolic alterations in sepsis.
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Affiliation(s)
- Jessica A Palakshappa
- Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine, University of Pennsylvania, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA.
| | - Brian J Anderson
- Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine, University of Pennsylvania, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA
| | - John P Reilly
- Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine, University of Pennsylvania, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Blockley Hall, 423 Guardian Drive, Philadelphia, PA, 19104, USA
| | - Michael G S Shashaty
- Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine, University of Pennsylvania, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Blockley Hall, 423 Guardian Drive, Philadelphia, PA, 19104, USA
| | - Ryo Ueno
- Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 1130033, Japan
| | - Qufei Wu
- Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine, University of Pennsylvania, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA
| | - Caroline A G Ittner
- Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine, University of Pennsylvania, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA
| | - Anna Tommasini
- Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine, University of Pennsylvania, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA
| | - Thomas G Dunn
- Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine, University of Pennsylvania, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA
| | - Dudley Charles
- Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine, University of Pennsylvania, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA
| | - Altaf Kazi
- Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine, University of Pennsylvania, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA
| | - Jason D Christie
- Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine, University of Pennsylvania, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Blockley Hall, 423 Guardian Drive, Philadelphia, PA, 19104, USA
| | - Nuala J Meyer
- Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine, University of Pennsylvania, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA
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Lin J, Zhang X, Xue C, Zhang H, Shashaty MGS, Gosai SJ, Meyer N, Grazioli A, Hinkle C, Caughey J, Li W, Susztak K, Gregory BD, Li M, Reilly MP. The long noncoding RNA landscape in hypoxic and inflammatory renal epithelial injury. Am J Physiol Renal Physiol 2015; 309:F901-13. [PMID: 26400545 DOI: 10.1152/ajprenal.00290.2015] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 09/18/2015] [Indexed: 11/22/2022] Open
Abstract
Long noncoding RNAs (lncRNAs) are emerging as key species-specific regulators of cellular and disease processes. To identify potential lncRNAs relevant to acute and chronic renal epithelial injury, we performed unbiased whole transcriptome profiling of human proximal tubular epithelial cells (PTECs) in hypoxic and inflammatory conditions. RNA sequencing revealed that the protein-coding and noncoding transcriptomic landscape differed between hypoxia-stimulated and cytokine-stimulated human PTECs. Hypoxia- and inflammation-modulated lncRNAs were prioritized for focused followup according to their degree of induction by these stress stimuli, their expression in human kidney tissue, and whether exposure of human PTECs to plasma of critically ill sepsis patients with acute kidney injury modulated their expression. For three lncRNAs (MIR210HG, linc-ATP13A4-8, and linc-KIAA1737-2) that fulfilled our criteria, we validated their expression patterns, examined their loci for conservation and synteny, and defined their associated epigenetic marks. The lncRNA landscape characterized here provides insights into novel transcriptomic variations in the renal epithelial cell response to hypoxic and inflammatory stress.
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Affiliation(s)
- Jennie Lin
- Renal Electrolyte and Hypertension Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania;
| | - Xuan Zhang
- Cardiovascular Institute, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Chenyi Xue
- Cardiovascular Institute, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Hanrui Zhang
- Cardiovascular Institute, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Michael G S Shashaty
- Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; and
| | - Sager J Gosai
- Department of Biology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nuala Meyer
- Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; and
| | - Alison Grazioli
- Renal Electrolyte and Hypertension Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Christine Hinkle
- Cardiovascular Institute, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Jennifer Caughey
- Cardiovascular Institute, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Wenjun Li
- Cardiovascular Institute, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Katalin Susztak
- Renal Electrolyte and Hypertension Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Brian D Gregory
- Department of Biology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mingyao Li
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Muredach P Reilly
- Cardiovascular Institute, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Reilly JP, Anderson BJ, Mangalmurti NS, Nguyen TD, Holena DN, Wu Q, Nguyen ET, Reilly MP, Lanken PN, Christie JD, Meyer NJ, Shashaty MGS. The ABO Histo-Blood Group and AKI in Critically Ill Patients with Trauma or Sepsis. Clin J Am Soc Nephrol 2015; 10:1911-20. [PMID: 26342043 DOI: 10.2215/cjn.12201214] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Accepted: 07/22/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND OBJECTIVE ABO blood types are determined by antigen modifications on glycoproteins and glycolipids and associated with altered plasma levels of inflammatory and endothelial injury markers implicated in AKI pathogenesis. We sought to determine the association of ABO blood types with AKI risk in critically ill patients with trauma or sepsis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted two prospective cohort studies at an urban, academic, level I trauma center and tertiary referral center; 497 patients with trauma admitted to the surgical intensive care unit between 2005 and 2010 with an injury severity score >15 and 759 patients with severe sepsis admitted to the medical intensive care unit between 2008 and 2013 were followed for 6 days for the development of incident AKI. AKI was defined by Acute Kidney Injury Network creatinine and dialysis criteria. RESULTS Of 497 patients with trauma, 134 developed AKI (27%). In multivariable analysis, blood type A was associated with higher AKI risk relative to type O among patients of European descent (n=229; adjusted risk, 0.28 versus 0.14; risk difference, 0.14; 95% confidence interval, 0.03 to 0.24; P=0.02). Of 759 patients with sepsis, AKI developed in 326 (43%). Blood type A again conferred higher AKI risk relative to type O among patients of European descent (n=437; adjusted risk, 0.53 versus 0.40; risk difference, 0.14; 95% confidence interval, 0.04 to 0.23; P=0.01). Findings were similar when analysis was restricted to those patients who did not develop acute respiratory distress syndrome or were not transfused. We did not detect a significant association between blood type and AKI risk among individuals of African descent in either cohort. CONCLUSIONS Blood type A is independently associated with AKI risk in critically ill patients with trauma or severe sepsis of European descent, suggesting a role for ABO glycans in AKI susceptibility.
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Affiliation(s)
- John P Reilly
- Divisions of Pulmonary, Allergy, and Critical Care and
| | | | | | - Tam D Nguyen
- Divisions of Pulmonary, Allergy, and Critical Care and
| | | | - Qufei Wu
- Center for Clinical Epidemiology and Biostatistics, and
| | | | - Muredach P Reilly
- Penn Cardiovascular Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Paul N Lanken
- Divisions of Pulmonary, Allergy, and Critical Care and
| | - Jason D Christie
- Divisions of Pulmonary, Allergy, and Critical Care and Center for Clinical Epidemiology and Biostatistics, and
| | - Nuala J Meyer
- Divisions of Pulmonary, Allergy, and Critical Care and
| | - Michael G S Shashaty
- Divisions of Pulmonary, Allergy, and Critical Care and Center for Clinical Epidemiology and Biostatistics, and
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Lin J, Fernandez H, Shashaty MGS, Negoianu D, Testani JM, Berns JS, Parikh CR, Wilson FP. False-Positive Rate of AKI Using Consensus Creatinine-Based Criteria. Clin J Am Soc Nephrol 2015; 10:1723-31. [PMID: 26336912 DOI: 10.2215/cjn.02430315] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Accepted: 07/22/2015] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND OBJECTIVES Use of small changes in serum creatinine to diagnose AKI allows for earlier detection but may increase diagnostic false-positive rates because of inherent laboratory and biologic variabilities of creatinine. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We examined serum creatinine measurement characteristics in a prospective observational clinical reference cohort of 2267 adult patients with AKI by Kidney Disease Improving Global Outcomes creatinine criteria and used these data to create a simulation cohort to model AKI false-positive rates. We simulated up to seven successive blood draws on an equal population of hypothetical patients with unchanging true serum creatinine values. Error terms generated from laboratory and biologic variabilities were added to each simulated patient's true serum creatinine value to obtain the simulated measured serum creatinine for each blood draw. We determined the proportion of patients who would be erroneously diagnosed with AKI by Kidney Disease Improving Global Outcomes creatinine criteria. RESULTS Within the clinical cohort, 75.0% of patients received four serum creatinine draws within at least one 48-hour period during hospitalization. After four simulated creatinine measurements that accounted for laboratory variability calculated from assay characteristics and 4.4% of biologic variability determined from the clinical cohort and publicly available data, the overall false-positive rate for AKI diagnosis was 8.0% (interquartile range =7.9%-8.1%), whereas patients with true serum creatinine ≥1.5 mg/dl (representing 21% of the clinical cohort) had a false-positive AKI diagnosis rate of 30.5% (interquartile range =30.1%-30.9%) versus 2.0% (interquartile range =1.9%-2.1%) in patients with true serum creatinine values <1.5 mg/dl (P<0.001). CONCLUSIONS Use of small serum creatinine changes to diagnose AKI is limited by high false-positive rates caused by inherent variability of serum creatinine at higher baseline values, potentially misclassifying patients with CKD in AKI studies.
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Affiliation(s)
- Jennie Lin
- Renal Electrolyte and Hypertension Division, Department of Medicine and
| | - Hilda Fernandez
- Division of Nephrology, Department of Medicine, Columbia University Medical Center, New York, New York; and
| | - Michael G S Shashaty
- Pulmonary, Allergy, and Critical Care Division, Department of Medicine and Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Dan Negoianu
- Renal Electrolyte and Hypertension Division, Department of Medicine and
| | | | - Jeffrey S Berns
- Renal Electrolyte and Hypertension Division, Department of Medicine and
| | - Chirag R Parikh
- Nephrology and Program of Applied Translational Research, Department of Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - F Perry Wilson
- Nephrology and Program of Applied Translational Research, Department of Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut
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Qing DY, Conegliano D, Shashaty MGS, Seo J, Reilly JP, Worthen GS, Huh D, Meyer NJ, Mangalmurti NS. Red blood cells induce necroptosis of lung endothelial cells and increase susceptibility to lung inflammation. Am J Respir Crit Care Med 2015; 190:1243-54. [PMID: 25329368 DOI: 10.1164/rccm.201406-1095oc] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
RATIONALE Red blood cell (RBC) transfusions are associated with increased risk of acute respiratory distress syndrome (ARDS) in the critically ill, yet the mechanisms for enhanced susceptibility to ARDS conferred by RBC transfusions remain unknown. OBJECTIVES To determine the mechanisms of lung endothelial cell (EC) High Mobility Group Box 1 (HMGB1) release following exposure to RBCs and to determine whether RBC transfusion increases susceptibility to lung inflammation in vivo through release of the danger signal HMGB1. METHODS In vitro studies examining human lung EC viability and HMGB1 release following exposure to allogenic RBCs were conducted under static conditions and using a microengineered model of RBC perfusion. The plasma from transfused and nontransfused patients with severe sepsis was examined for markers of cellular injury. A murine model of RBC transfusion followed by LPS administration was used to determine the effects of RBC transfusion and HMGB1 release on LPS-induced lung inflammation. MEASUREMENTS AND MAIN RESULTS After incubation with RBCs, lung ECs underwent regulated necrotic cell death (necroptosis) and released the essential mediator of necroptosis, receptor-interacting serine/threonine-protein kinase 3 (RIP3), and HMGB1. RIP3 was detectable in the plasma of patients with severe sepsis, and was increased with blood transfusion and among nonsurvivors of sepsis. RBC transfusion sensitized mice to LPS-induced lung inflammation through release of the danger signal HMGB1. CONCLUSIONS RBC transfusion enhances susceptibility to lung inflammation through release of HMGB1 and induces necroptosis of lung EC. Necroptosis and subsequent danger signal release is a novel mechanism of injury following transfusion that may account for the increased risk of ARDS in critically ill transfused patients.
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Affiliation(s)
- Danielle Y Qing
- 1 Pulmonary, Allergy and Critical Care Division, Perelman School of Medicine, and
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Wong HR, Walley KR, Pettilä V, Meyer NJ, Russell JA, Karlsson S, Shashaty MGS, Lindsell CJ. Comparing the prognostic performance of ASSIST to interleukin-6 and procalcitonin in patients with severe sepsis or septic shock. Biomarkers 2015; 20:132-5. [PMID: 25578228 DOI: 10.3109/1354750x.2014.1000971] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
CONTEXT We recently derived and validated a multi-biomarker-based model (ASSIST) to stratify patients with sepsis based on initial mortality risk. OBJECTIVE The objective of this study was to compare the performance of ASSIST to interleukin-6 (IL6) and procalcitonin (PCT). METHODS The area-under-the-receiver operating characteristic curve for predicting 28-d mortality using ASSIST was compared with that of IL6 (n = 452) and PCT (n = 235). RESULTS The area under the curve for ASSIST was greater than that of IL6 and PCT. CONCLUSIONS ASSIST estimated the probability of mortality more reliably than IL6 and PCT in this cohort of patients with sepsis.
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Affiliation(s)
- Hector R Wong
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Hospital Research Foundation , Cincinnati, OH , USA
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Wong HR, Lindsell CJ, Pettilä V, Meyer NJ, Thair SA, Karlsson S, Russell JA, Fjell CD, Boyd JH, Ruokonen E, Shashaty MGS, Christie JD, Hart KW, Lahni P, Walley KR. A multibiomarker-based outcome risk stratification model for adult septic shock*. Crit Care Med 2014; 42:781-9. [PMID: 24335447 PMCID: PMC4620515 DOI: 10.1097/ccm.0000000000000106] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Clinical trials in septic shock continue to fail due, in part, to inequitable and sometimes unknown distribution of baseline mortality risk between study arms. Investigators advocate that interventional trials in septic shock require effective outcome risk stratification. We derived and tested a multibiomarker-based approach to estimate mortality risk in adults with septic shock. DESIGN Previous genome-wide expression studies identified 12 plasma proteins as candidates for biomarker-based risk stratification. The current analysis used banked plasma samples and clinical data from existing studies. Biomarkers were assayed in plasma samples obtained from 341 subjects with septic shock within 24 hours of admission to the ICU. Classification and regression tree analysis was used to generate a decision tree predicting 28-day mortality based on a combination of both biomarkers and clinical variables. The derived tree was first tested in an independent cohort of 331 subjects, then calibrated using all subjects (n = 672), and subsequently validated in another independent cohort (n = 209). SETTING Multiple ICUs in Canada, Finland, and the United States. SUBJECTS Eight hundred eighty-one adults with septic shock or severe sepsis. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS The derived decision tree included five candidate biomarkers, admission lactate concentration, age, and chronic disease burden. In the derivation cohort, sensitivity for mortality was 94% (95% CI, 87-97), specificity was 56% (50-63), positive predictive value was 50% (43-57), and negative predictive value was 95% (89-98). Performance was comparable in the test cohort. The calibrated decision tree had the following test characteristics in the validation cohort: sensitivity 85% (76-92), specificity 60% (51-69), positive predictive value 61% (52-70), and negative predictive value 85% (75-91). CONCLUSIONS We have derived, tested, calibrated, and validated a risk stratification tool and found that it reliably estimates the probability of mortality in adults with septic shock.
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Affiliation(s)
- Hector R Wong
- 1Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center and Cincinnati Children's Hospital Research Foundation, Cincinnati, OH. 2Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH. 3Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH. 4Intensive Care Units, Division of Anaesthesia and Intensive Care Medicine, Department of Surgery, Helsinki University Central Hospital, Helsinki, Finland. 5Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA. 6University of British Columbia, Vancouver, BC, Canada. 7Critical Care Research Laboratories, Centre for Heart Lung Innovation, St. Paul's Hospital, Vancouver, BC, Canada. 8Department of Intensive Care Medicine, Tampere University Hospital, Tampere, Finland. 9Department of Intensive Care Medicine, Kuopio University Hospital, Kuopio, Finland. 10Department of Epidemiology, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
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Reilly JP, Meyer NJ, Shashaty MGS, Feng R, Lanken PN, Gallop R, Kaplan S, Herlim M, Oz NL, Hiciano I, Campbell A, Holena DN, Reilly MP, Christie JD. ABO blood type A is associated with increased risk of ARDS in whites following both major trauma and severe sepsis. Chest 2014; 145:753-761. [PMID: 24385226 PMCID: PMC3971970 DOI: 10.1378/chest.13-1962] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Accepted: 11/27/2013] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND ABO glycosyltransferases catalyze antigen modifications on various glycans and glycoproteins and determine the ABO blood types. Blood type A has been associated with increased risk of vascular diseases and differential circulating levels of proteins related to inflammation and endothelial function. The objective of this study was to determine the association of ABO blood types with ARDS risk in patients with major trauma and severe sepsis. METHODS We conducted prospective cohort studies in two populations at an urban tertiary referral, level I trauma center. Critically ill patients (n 5 732) presenting after major trauma were followed for 5 days for ARDS development. Additionally, 976 medical patients with severe sepsis were followed for 5 days for ARDS. Multivariable logistic regression was used to adjust for confounders. RESULTS ARDS developed in 197 of the 732 trauma patients (27%). Blood type A was associated with increased ARDS risk among whites (37% vs 24%; adjusted OR, 1.88; 95% CI, 1.14-3.12; P 5 .014), but not blacks (adjusted OR, 0.61; 95% CI, 0.33-1.13; P=.114). ARDS developed in 222 of the 976 patients with severe sepsis (23%). Blood type A was also associated with an increased ARDS risk among whites (31% vs 21%; adjusted OR, 1.67; 95% CI, 1.08-2.59; P=.021) but, again, not among blacks (adjusted OR, 1.17; 95% CI, 0.59-2.33; P=.652). CONCLUSIONS Blood type A is associated with an increased risk of ARDS in white patients with major trauma and severe sepsis. These results suggest a role for ABO glycans and glycosyltransferases in ARDS susceptibility.
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Affiliation(s)
- John P Reilly
- Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
| | - Nuala J Meyer
- Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Michael G S Shashaty
- Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Rui Feng
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Paul N Lanken
- Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Robert Gallop
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Sandra Kaplan
- Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Maximilian Herlim
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Nathaniel L Oz
- Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Isabel Hiciano
- Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Ana Campbell
- Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Daniel N Holena
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Muredach P Reilly
- Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Penn Cardiovascular Institute, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Jason D Christie
- Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Shashaty MGS, Meyer NJ, Localio AR, Gallop R, Bellamy SL, Holena DN, Lanken PN, Kaplan S, Yarar D, Kawut SM, Feldman HI, Christie JD. African American race, obesity, and blood product transfusion are risk factors for acute kidney injury in critically ill trauma patients. J Crit Care 2012; 27:496-504. [PMID: 22591570 PMCID: PMC3472045 DOI: 10.1016/j.jcrc.2012.02.002] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2011] [Revised: 01/02/2012] [Accepted: 02/04/2012] [Indexed: 01/24/2023]
Abstract
PURPOSE Acute kidney injury (AKI) is a common source of morbidity after trauma. We sought to determine novel risk factors for AKI, by Acute Kidney Injury Network (AKIN) criteria, in critically ill trauma patients. MATERIALS AND METHODS A prospective cohort of 400 patients admitted to the intensive care unit of a level 1 trauma center was followed for the development of AKI over 5 days. RESULTS Acute kidney injury developed in 147 (36.8%) of 400 patients. In multivariable regression analysis, independent risk factors for AKI included African American race (odds ratio [OR], 1.86; 95% confidence interval [CI], 1.08-3.18; P = .024), body mass index of 30 kg/m(2) or greater (OR, 4.72 versus normal body mass index; 95% CI, 2.59-8.61; P < .001), diabetes mellitus (OR, 3.26; 95% CI, 1.30-8.20; P = .012), abdominal Abbreviated Injury Scale score of 4 or more (OR, 3.78; 95% CI, 1.79-7.96; P < .001), and unmatched packed red blood cells administered during resuscitation (OR, 1.13 per unit; 95% CI, 1.04-1.23; P = .004). Acute Kidney Injury Network stages 1, 2, and 3 were associated with hospital mortality rates of 9.8%, 13.7%, and 30.4%, respectively, compared with 3.8% for those without AKI (P < .001). CONCLUSIONS Acute kidney injury in critically ill trauma patients is associated with substantial mortality. The findings of African American race, obesity, and blood product administration as independent risk factors for AKI deserve further study to elucidate underlying mechanisms.
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Affiliation(s)
- Michael G S Shashaty
- Division of Pulmonary, Allergy, and Critical Care, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA.
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Meyer NJ, Daye ZJ, Rushefski M, Aplenc R, Lanken PN, Shashaty MGS, Christie JD, Feng R. SNP-set analysis replicates acute lung injury genetic risk factors. BMC Med Genet 2012; 13:52. [PMID: 22742663 PMCID: PMC3512475 DOI: 10.1186/1471-2350-13-52] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Accepted: 06/18/2012] [Indexed: 12/19/2022]
Abstract
BACKGROUND We used a gene - based replication strategy to test the reproducibility of prior acute lung injury (ALI) candidate gene associations. METHODS We phenotyped 474 patients from a prospective severe trauma cohort study for ALI. Genomic DNA from subjects' blood was genotyped using the IBC chip, a multiplex single nucleotide polymorphism (SNP) array. Results were filtered for 25 candidate genes selected using prespecified literature search criteria and present on the IBC platform. For each gene, we grouped SNPs according to haplotype blocks and tested the joint effect of all SNPs on susceptibility to ALI using the SNP-set kernel association test. Results were compared to single SNP analysis of the candidate SNPs. Analyses were separate for genetically determined ancestry (African or European). RESULTS We identified 4 genes in African ancestry and 2 in European ancestry trauma subjects which replicated their associations with ALI. Ours is the first replication of IL6, IL10, IRAK3, and VEGFA associations in non-European populations with ALI. Only one gene - VEGFA - demonstrated association with ALI in both ancestries, with distinct haplotype blocks in each ancestry driving the association. We also report the association between trauma-associated ALI and NFKBIA in European ancestry subjects. CONCLUSIONS Prior ALI genetic associations are reproducible and replicate in a trauma cohort. Kernel - based SNP-set analysis is a more powerful method to detect ALI association than single SNP analysis, and thus may be more useful for replication testing. Further, gene-based replication can extend candidate gene associations to diverse ethnicities.
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Affiliation(s)
- Nuala J Meyer
- Department of Medicine: Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine University of Pennsylvania, 3600 Spruce Street, 874 Maloney, Philadelphia, PA 19104, USA.
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