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Manchikalapati R, Schening J, Farias AJ, Sacco KA. CLINICAL UTILITY OF INTERLEUKIN-1 INHIBITORS IN PEDIATRIC SEPSIS. Shock 2024; 61:340-345. [PMID: 37695659 DOI: 10.1097/shk.0000000000002223] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Abstract
ABSTRACT The pathophysiology of pediatric sepsis is characterized by increased innate immune activation earlier in life. Interleukin-1 is a proinflammatory cytokine implicated in the pathophysiology of sepsis, and ferritin is a stable surrogate biomarker for elevated IL-1 levels. Data in adult sepsis have shown that use of anakinra, an anti-IL-1 receptor antagonist, led to improved clinical outcomes in patients with features of macrophage activation and hyperferritinemia. However, data in pediatric sepsis are lacking. Our narrative review sought to highlight the current understanding of using IL-1 inhibitors in pediatric sepsis. We identified five studies including one case report and four retrospective case series that described clinical outcomes in relation to use of anakinra for secondary hemophagocytic lymphohistiocytosis (HLH). A few patients in this pooled heterogenous cohort of 72 patients had concomitant infection meeting the criteria for sepsis. All studies measured ferritin levels and reported a decrease in ferritin after initiating anakinra. Twelve patients died after treatment initiation. There was no clear comparison in clinical outcomes between infected and noninfected patients. The pathophysiology of pediatric sepsis suggests that there is a need for blinded clinical trials using targeted immunomodulation such as IL-1 inhibitors in pediatric sepsis cohort with an immunophenotype suggesting increased innate immune activation.
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Affiliation(s)
| | - Jonathon Schening
- Division of Pulmonology, Section of Allergy-Immunology, Phoenix Children's Hospital, Phoenix, Arizona
| | - Andrew J Farias
- Division of Critical Care, Phoenix Children's Hospital, Phoenix, Arizona
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2
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Napodano C, Carnazzo V, Basile V, Pocino K, Stefanile A, Gallucci S, Natali P, Basile U, Marino M. NLRP3 Inflammasome Involvement in Heart, Liver, and Lung Diseases-A Lesson from Cytokine Storm Syndrome. Int J Mol Sci 2023; 24:16556. [PMID: 38068879 PMCID: PMC10706560 DOI: 10.3390/ijms242316556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 11/16/2023] [Accepted: 11/17/2023] [Indexed: 12/18/2023] Open
Abstract
Inflammation and inflammasomes have been proposed as important regulators of the host-microorganism interaction, playing a key role in morbidity and mortality due to the coronavirus disease 2019 (COVID-19) in subjects with chronic conditions and compromised immune system. The inflammasome consists of a multiprotein complex that finely regulates the activation of caspase-1 and the production and secretion of potent pro-inflammatory cytokines such as IL-1β and IL-18. The pyrin containing NOD (nucleotide-binding oligomerization domain) like receptor (NLRP) is a family of intracellular receptors, sensing patterns associated to pathogens or danger signals and NLRP3 inflammasome is the most deeply analyzed for its involvement in the innate and adaptive immune system as well as its contribution to several autoinflammatory and autoimmune diseases. It is highly expressed in leukocytes and up-regulated in sentinel cells upon inflammatory stimuli. NLRP3 expression has also been reported in B and T lymphocytes, in epithelial cells of oral and genital mucosa, in specific parenchymal cells as cardiomyocytes, and keratinocytes, and chondrocytes. It is well known that a dysregulated activation of the inflammasome is involved in the pathogenesis of different disorders that share the common red line of inflammation in their pathogenetic fingerprint. Here, we review the potential roles of the NLRP3 inflammasome in cardiovascular events, liver damage, pulmonary diseases, and in that wide range of systemic inflammatory syndromes named as a cytokine storm.
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Affiliation(s)
- Cecilia Napodano
- Department of Laboratory of Medicine and Pathology, S. Agostino Estense Hospital, 41126 Modena, Italy;
| | - Valeria Carnazzo
- Department of Clinical Pathology, Santa Maria Goretti Hospital, AUSL Latina, 04100 Latina, Italy; (V.C.); (U.B.)
| | - Valerio Basile
- Clinical Pathology Unit and Cancer Biobank, Department of Research and Advanced Technologies, IRCCS Regina Elena National Cancer Institute, 00144 Rome, Italy;
| | - Krizia Pocino
- Unità Operativa Complessa di Patologia Clinica, Ospedale Generale di Zona San Pietro Fatebenefratelli, 00189 Rome, Italy; (K.P.); (A.S.)
| | - Annunziata Stefanile
- Unità Operativa Complessa di Patologia Clinica, Ospedale Generale di Zona San Pietro Fatebenefratelli, 00189 Rome, Italy; (K.P.); (A.S.)
| | - Stefania Gallucci
- Laboratory of Dendritic Cell Biology, Division of Innate Immunity, Department of Medicine, UMass Chan Medical School, Worcester, MA 01655, USA;
| | - Patrizia Natali
- Diagnostic Hematology and Clinical Genomics, Department of Laboratory Medicine and Pathology, AUSL/AOU Modena, 41124 Modena, Italy;
| | - Umberto Basile
- Department of Clinical Pathology, Santa Maria Goretti Hospital, AUSL Latina, 04100 Latina, Italy; (V.C.); (U.B.)
| | - Mariapaola Marino
- Dipartimento di Medicina e Chirurgia Traslazionale, Sezione di Patologia Generale, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
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3
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Abstract
Septic shock can be caused by a variety of mechanisms including direct effects of bacterial toxins such as endotoxin. Annually, approximately 5-7 million patients worldwide develop sepsis with very high endotoxin activity in the blood and more than half die. The term endotoxic septic shock has been used for these patients but it is important to emphasize that endotoxin may be a factor in all forms of septic shock including non-bacterial etiologies like COVID-19 since translocation of bacterial products is a common feature of septic shock. A pattern of organ failure including hepatic dysfunction, acute kidney injury and various forms of endothelial dysfunction ranging from disseminated intravascular coagulation to thrombotic microangiopathy characterize endotoxic septic shock. However, while characteristic, the clinical phenotype is not unique to patients with high endotoxin, and the diagnosis relies on the measurement of endotoxin activity in addition to clinical assessment. Therapies for endotoxic septic shock are limited with immune modulating therapies under investigation and extracorporeal blood purification still controversial in many parts of the world.
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Affiliation(s)
- John A Kellum
- Department of Critical Care Medicine, Center for Critical Care Nephrology, University of Pittsburgh, 600 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA, 15261, USA.
- Spectral Medical Inc, Toronto, ON, Canada.
| | - Claudio Ronco
- International Renal Research Institute of Vicenza, IRRIV Foundation, Department of Nephrology, Dialysis and Transplantation, St. Bortolo Hospital, aULSS8 Berica, Via Rodolfi, 37, 36100, Vicenza, Italy
- Department of Medicine (DIMED), University of Padua, Via Giustiniani, 2, 35128, Padua, Italy
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4
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Fan Z, Kernan KF, Qin Y, Canna S, Berg RA, Wessel D, Pollack MM, Meert K, Hall M, Newth C, Lin JC, Doctor A, Shanley T, Cornell T, Harrison RE, Zuppa AF, Sward K, Dean JM, Park HJ, Carcillo JA. Hyperferritinemic sepsis, macrophage activation syndrome, and mortality in a pediatric research network: a causal inference analysis. Crit Care 2023; 27:347. [PMID: 37674218 PMCID: PMC10481565 DOI: 10.1186/s13054-023-04628-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 08/27/2023] [Indexed: 09/08/2023] Open
Abstract
BACKGROUND One of five global deaths are attributable to sepsis. Hyperferritinemic sepsis (> 500 ng/mL) is associated with increased mortality in single-center studies. Our pediatric research network's objective was to obtain rationale for designing anti-inflammatory clinical trials targeting hyperferritinemic sepsis. METHODS We assessed differences in 32 cytokines, immune depression (low whole blood ex vivo TNF response to endotoxin) and thrombotic microangiopathy (low ADAMTS13 activity) biomarkers, seven viral DNAemias, and macrophage activation syndrome (MAS) defined by combined hepatobiliary dysfunction and disseminated intravascular coagulation, and mortality in 117 children with hyperferritinemic sepsis (ferritin level > 500 ng/mL) compared to 280 children with sepsis without hyperferritinemia. Causal inference analysis of these 41 variables, MAS, and mortality was performed. RESULTS Mortality was increased in children with hyperferritinemic sepsis (27/117, 23% vs 16/280, 5.7%; Odds Ratio = 4.85, 95% CI [2.55-9.60]; z = 4.728; P-value < 0.0001). Hyperferritinemic sepsis had higher C-reactive protein, sCD163, IL-22, IL-18, IL-18 binding protein, MIG/CXCL9, IL-1β, IL-6, IL-8, IL-10, IL-17a, IFN-γ, IP10/CXCL10, MCP-1/CCL2, MIP-1α, MIP-1β, TNF, MCP-3, IL-2RA (sCD25), IL-16, M-CSF, and SCF levels; lower ADAMTS13 activity, sFasL, whole blood ex vivo TNF response to endotoxin, and TRAIL levels; more Adenovirus, BK virus, and multiple virus DNAemias; and more MAS (P-value < 0.05). Among these variables, only MCP-1/CCL2 (the monocyte chemoattractant protein), MAS, and ferritin levels were directly causally associated with mortality. MCP-1/CCL2 and hyperferritinemia showed direct causal association with depressed ex vivo whole blood TNF response to endotoxin. MCP-1/CCL2 was a mediator of MAS. MCP-1/CCL2 and MAS were mediators of hyperferritinemia. CONCLUSIONS These findings establish hyperferritinemic sepsis as a high-risk condition characterized by increased cytokinemia, viral DNAemia, thrombotic microangiopathy, immune depression, macrophage activation syndrome, and death. The causal analysis provides rationale for designing anti-inflammatory trials that reduce macrophage activation to improve survival and enhance infection clearance in pediatric hyperferritinemic sepsis.
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Affiliation(s)
- Zhenziang Fan
- Department of Computer Sciences, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kate F Kernan
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, Faculty Pavilion, Children's Hospital of Pittsburgh, Center for Critical Care Nephrology and Clinical Research Investigation and Systems Modeling of Acute Illness Center, University of Pittsburgh, Suite 2000, 4400 Penn Avenue, Pittsburgh, PA, 15421, USA
| | - Yidi Qin
- Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Scott Canna
- Department of Pediatrics, Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Robert A Berg
- Department of Anesthesiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - David Wessel
- Division of Critical Care Medicine, Department of Pediatrics, Children's National Hospital, Washington, DC, USA
| | - Murray M Pollack
- Division of Critical Care Medicine, Department of Pediatrics, Children's National Hospital, Washington, DC, USA
| | - Kathleen Meert
- Division of Critical Care Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI, USA
- Central Michigan University, Mt Pleasant, MI, USA
| | - Mark Hall
- Division of Critical Care Medicine, Department of Pediatrics, The Research Institute at Nationwide Children's Hospital Immune Surveillance Laboratory, and Nationwide Children's Hospital, Columbus, OH, USA
| | - Christopher Newth
- Division of Pediatric Critical Care Medicine, Department of Anesthesiology and Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - John C Lin
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children's Hospital, St. Louis, MO, USA
| | - Allan Doctor
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children's Hospital, St. Louis, MO, USA
| | - Tom Shanley
- Division of Critical Care Medicine, Department of Pediatrics, C. S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Tim Cornell
- Division of Critical Care Medicine, Department of Pediatrics, C. S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Rick E Harrison
- Division of Critical Care Medicine, Department of Pediatrics, Mattel Children's Hospital at University of California Los Angeles, Los Angeles, CA, USA
| | - Athena F Zuppa
- Department of Anesthesiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Katherine Sward
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - H J Park
- Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Joseph A Carcillo
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, Faculty Pavilion, Children's Hospital of Pittsburgh, Center for Critical Care Nephrology and Clinical Research Investigation and Systems Modeling of Acute Illness Center, University of Pittsburgh, Suite 2000, 4400 Penn Avenue, Pittsburgh, PA, 15421, USA.
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5
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Kellum JA, Foster D, Walker PM. Endotoxemic Shock: A Molecular Phenotype in Sepsis. Nephron Clin Pract 2023; 147:17-20. [PMID: 35790144 DOI: 10.1159/000525548] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 05/25/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Marked heterogeneity exists among patients with sepsis, both in terms of distribution of organ dysfunction and its severity. Such heterogeneity could be explained by the presence of multiple subtypes of sepsis that may have important implications for treatment. METHODS Narrative review of published literature involving endotoxin from 1970 to 2022. RESULTS In humans, endotoxemia is most consistently associated with a specific pattern of organ failure including shock, endothelial dysfunction, acute kidney injury, and hepatic dysfunction. This pattern is consistent with complement activation and uncontrolled inflammation, two features of endotoxemia. Unbiased discovery using artificial intelligence also identifies a subtype of sepsis which features these same organ failures. CONCLUSION Endotoxin appears to represent an important molecular phenotype of sepsis with unique clinical features and high mortality.
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Affiliation(s)
- John A Kellum
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Spectral Medical, Toronto, Ontario, Canada
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6
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Horvat CM, Fabio A, Nagin DS, Banks RK, Qin Y, Park HJ, Kernan KF, Canna SW, Berg RA, Wessel D, Pollack MM, Meert K, Hall M, Newth C, Lin JC, Doctor A, Shanley T, Cornell T, Harrison RE, Zuppa AF, Reeder RW, Sward K, Holubkov R, Notterman DA, Dean JM, Carcillo JA. Mortality Risk in Pediatric Sepsis Based on C-reactive Protein and Ferritin Levels. Pediatr Crit Care Med 2022; 23:968-979. [PMID: 36178701 PMCID: PMC9722561 DOI: 10.1097/pcc.0000000000003074] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVES Interest in using bedside C-reactive protein (CRP) and ferritin levels to identify patients with hyperinflammatory sepsis who might benefit from anti-inflammatory therapies has piqued with the COVID-19 pandemic experience. Our first objective was to identify patterns in CRP and ferritin trajectory among critically ill pediatric sepsis patients. We then examined the association between these different groups of patients in their inflammatory cytokine responses, systemic inflammation, and mortality risks. DATA SOURCES A prospective, observational cohort study. STUDY SELECTION Children with sepsis and organ failure in nine pediatric intensive care units in the United States. DATA EXTRACTION Two hundred and fifty-five children were enrolled. Five distinct clinical multi-trajectory groups were identified. Plasma CRP (mg/dL), ferritin (ng/mL), and 31 cytokine levels were measured at two timepoints during sepsis (median Day 2 and Day 5). Group-based multi-trajectory models (GBMTM) identified groups of children with distinct patterns of CRP and ferritin. DATA SYNTHESIS Group 1 had normal CRP and ferritin levels ( n = 8; 0% mortality); Group 2 had high CRP levels that became normal, with normal ferritin levels throughout ( n = 80; 5% mortality); Group 3 had high ferritin levels alone ( n = 16; 6% mortality); Group 4 had very high CRP levels, and high ferritin levels ( n = 121; 11% mortality); and Group 5 had very high CRP and very high ferritin levels ( n = 30; 40% mortality). Cytokine responses differed across the five groups, with ferritin levels correlated with macrophage inflammatory protein 1α levels and CRP levels reflective of many cytokines. CONCLUSIONS Bedside CRP and ferritin levels can be used together to distinguish groups of children with sepsis who have different systemic inflammation cytokine responses and mortality risks. These data suggest future potential value in personalized clinical trials with specific targets for anti-inflammatory therapies.
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Affiliation(s)
- Christopher M. Horvat
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Anthony Fabio
- Department of Statistics, Carnegie Mellon University, Pittsburgh, PA
| | - Daniel S. Nagin
- Department of Statistics, Carnegie Mellon University, Pittsburgh, PA
| | | | - Yidi Qin
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Hyun-Jung Park
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Kate F. Kernan
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Scott W. Canna
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA
| | - Robert A. Berg
- Department of Anesthesiology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - David Wessel
- Division of Critical Care Medicine, Department of Pediatrics, Children’s National Hospital, Washington, DC
| | - Murray M. Pollack
- Division of Critical Care Medicine, Department of Pediatrics, Children’s National Hospital, Washington, DC
| | - Kathleen Meert
- Division of Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Michigan, Detroit, MI., Central Michigan University, Mt Pleasant MI
| | - Mark Hall
- Division of Critical Care Medicine, Department of Pediatrics, The Research Institute at Nationwide Children’s Hospital Immune Surveillance Laboratory, and Nationwide Children’s Hospital, Columbus, OH
| | - Christopher Newth
- Division of Pediatric Critical Care Medicine, Department of Anesthesiology and Pediatrics, Children’s Hospital Los Angeles, Los Angeles, CA
| | - John C. Lin
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children’s Hospital, St. Louis, MO
| | - Allan Doctor
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children’s Hospital, St. Louis, MO
| | - Tom Shanley
- Division of Critical Care Medicine, Department of Pediatrics, C. S. Mott Children’s Hospital, Ann Arbor, MI
| | - Tim Cornell
- Division of Critical Care Medicine, Department of Pediatrics, C. S. Mott Children’s Hospital, Ann Arbor, MI
| | - Rick E. Harrison
- Division of Critical Care Medicine, Department of Pediatrics, Mattel Children’s Hospital at University of California Los Angeles, Los Angeles, CA
| | - Athena F. Zuppa
- Department of Anesthesiology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | | | | | | | | | | | - Joseph A. Carcillo
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
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Miatello J, Lukaszewicz AC, Carter MJ, Faivre V, Hua S, Martinet KZ, Bourgeois C, Quintana-Murci L, Payen D, Boniotto M, Tissières P. CIITA promoter polymorphism impairs monocytes HLA-DR expression in patients with septic shock. iScience 2022; 25:105291. [PMID: 36304101 PMCID: PMC9593818 DOI: 10.1016/j.isci.2022.105291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 09/05/2022] [Accepted: 10/03/2022] [Indexed: 11/28/2022] Open
Abstract
Low monocyte (m)HLA-DR expression is associated with mortality in sepsis. G-286A∗rs3087456 polymorphism in promoter III of HLA class II transactivator (CIITA), the master regulator of HLA, has been associated with autoimmune diseases but its role in sepsis has never been demonstrated. In 203 patients in septic shock, GG genotype was associated with 28-day mortality and mHLA-DR remained low whereas it increased in patients with AA or AG genotype. In ex vivo cells, mHLA-DR failed to augment in GG in comparison with AG or AA genotype on exposure to IFN-γ. Promoter III transcript levels were similar in control monocytes regardless of genotype and exposure to IFN-γ. Promoter III activity was decreased in GG genotype in monocyte cell line but restored after stimulation with IFN-γ. Hereby, we demonstrated that G-286A∗rs3087456 significantly impact mHLA-DR expression in patients with septic shock in part through CIITA promoter III activity, that can be rescued using IFN-γ.
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Affiliation(s)
- Jordi Miatello
- Institute of Integrative Biology of the Cell, CNRS, CEA, Paris-Saclay University, Gif-sur-Yvette, France,Paediatric Intensive Care and Neonatal Medicine, AP-HP, Paris-Saclay University, Bicêtre Hospital, Le Kremlin-Bicêtre, France,FHU Sepsis, AP-HP, Paris-Saclay University, INSERM, Le Kremlin-Bicêtre, France
| | - Anne-Claire Lukaszewicz
- EA 7426 PI3 (Pathophysiology of Injury-induced Immunosuppression), Hospices Civils de Lyon/ Lyon University/bioMérieux, E. Herriot Hospital, Lyon, France,Anesthesia and Critical Care Medicine Department, Hospices Civils de Lyon, Edouard Herriot Hospital, Lyon, France
| | - Michael J. Carter
- Paediatric Intensive Care and Neonatal Medicine, AP-HP, Paris-Saclay University, Bicêtre Hospital, Le Kremlin-Bicêtre, France,Department of Women and Children’s Health, School of Life Course Sciences, King’s College London, London, UK,Paediatric Intensive Care, Evelina London Children’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Valérie Faivre
- Saint-Louis Lariboisière Hospital, AP-HP, Denis Diderot University, Paris, France,INSERM UMR1141 Neurodiderot, Université Paris Cité, France
| | - Stéphane Hua
- CEA, INRAE, Medicines and Healthcare Technologies Department, SIMoS, Université Paris-Saclay, Gif-sur-Yvette, France
| | - Kim Z. Martinet
- Université Paris-Saclay, Inserm, CEA, Center for Immunology of Viral, Auto-Immune, Hematological and Bacterial Diseases (IMVA-HB/IDMIT), Fontenay-aux-Roses, France
| | - Christine Bourgeois
- Université Paris-Saclay, Inserm, CEA, Center for Immunology of Viral, Auto-Immune, Hematological and Bacterial Diseases (IMVA-HB/IDMIT), Fontenay-aux-Roses, France
| | - Lluis Quintana-Murci
- Institut Pasteur, Université Paris Cité, CNRS UMR2000, Human Evolutionary Genetics Unit, Paris, France,Chair Human Genomics and Evolution, Collège de France, Paris, France
| | - Didier Payen
- Denis Diderot University, Paris, Sorbonne, Cité Paris, France
| | - Michele Boniotto
- University Paris Est Créteil, INSERM, IMRB, Translational Neuropsychiatry, 94010 Créteil, France
| | - Pierre Tissières
- Institute of Integrative Biology of the Cell, CNRS, CEA, Paris-Saclay University, Gif-sur-Yvette, France,Paediatric Intensive Care and Neonatal Medicine, AP-HP, Paris-Saclay University, Bicêtre Hospital, Le Kremlin-Bicêtre, France,FHU Sepsis, AP-HP, Paris-Saclay University, INSERM, Le Kremlin-Bicêtre, France,Corresponding author
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8
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Kellum JA, Formeck CL, Kernan KF, Gómez H, Carcillo JA. Subtypes and Mimics of Sepsis. Crit Care Clin 2022; 38:195-211. [DOI: 10.1016/j.ccc.2021.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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9
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Anderko RR, Gómez H, Canna SW, Shakoory B, Angus DC, Yealy DM, Huang DT, Kellum JA, Carcillo JA, Angus DC, Barnato AE, Eaton TL, Gimbel E, Huang DT, Keener C, Kellum JA, Landis K, Pike F, Stapleton DK, Weissfeld LA, Willochell M, Wofford KA, Yealy DM, Kulstad E, Watts H, Venkat A, Hou PC, Massaro A, Parmar S, Limkakeng AT, Brewer K, Delbridge TR, Mainhart A, Chawla LS, Miner JR, Allen TL, Grissom CK, Swadron S, Conrad SA, Carlson R, LoVecchio F, Bajwa EK, Filbin MR, Parry BA, Ellender TJ, Sama AE, Fine J, Nafeei S, Terndrup T, Wojnar M, Pearl RG, Wilber ST, Sinert R, Orban DJ, Wilson JW, Ufberg JW, Albertson T, Panacek EA, Parekh S, Gunn SR, Rittenberger JS, Wadas RJ, yEdwards AR, Kelly M, Wang HE, Holmes TM, McCurdy MT, Weinert C, Harris ES, Self WH, Phillips CA, Migues RM. Sepsis with liver dysfunction and coagulopathy predicts an inflammatory pattern of macrophage activation. Intensive Care Med Exp 2022; 10:6. [PMID: 35190900 PMCID: PMC8861227 DOI: 10.1186/s40635-022-00433-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 02/07/2022] [Indexed: 12/30/2022] Open
Abstract
Background Interleukin-1 receptor antagonists can reduce mortality in septic shock patients with hepatobiliary dysfunction and disseminated intravascular coagulation (HBD + DIC), an organ failure pattern with inflammatory features consistent with macrophage activation. Identification of clinical phenotypes in sepsis may allow for improved care. We aim to describe the occurrence of HBD + DIC in a contemporary cohort of patients with sepsis and determine the association of this phenotype with known macrophage activation syndrome (MAS) biomarkers and mortality. We performed a retrospective nested case–control study in adult septic shock patients with concurrent HBD + DIC and an equal number of age-matched controls, with comparative analyses of all-cause mortality and circulating biomarkers between the groups. Multiple logistic regression explored the effect of HBD + DIC on mortality and the discriminatory power of the measured biomarkers for HBD + DIC and mortality. Results Six percent of septic shock patients (n = 82/1341) had HBD + DIC, which was an independent risk factor for 90-day mortality (OR = 3.1, 95% CI 1.4–7.5, p = 0.008). Relative to sepsis controls, the HBD + DIC cohort had increased levels of 21 of the 26 biomarkers related to macrophage activation (p < 0.05). This panel was predictive of both HBD + DIC (sensitivity = 82%, specificity = 84%) and mortality (sensitivity = 92%, specificity = 90%). Conclusion The HBD + DIC phenotype identified patients with high mortality and a molecular signature resembling that of MAS. These observations suggest trials of MAS-directed therapies are warranted. Supplementary Information The online version contains supplementary material available at 10.1186/s40635-022-00433-y.
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10
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Kernan KF, Ghaloul-Gonzalez L, Vockley J, Lamb J, Hollingshead D, Chandran U, Sethi R, Park HJ, Berg RA, Wessel D, Pollack MM, Meert KL, Hall MW, Newth CJL, Lin JC, Doctor A, Shanley T, Cornell T, Harrison RE, Zuppa AF, Banks R, Reeder RW, Holubkov R, Notterman DA, Dean JM, Carcillo JA. Prevalence of Pathogenic and Potentially Pathogenic Inborn Error of Immunity Associated Variants in Children with Severe Sepsis. J Clin Immunol 2022; 42:350-364. [PMID: 34973142 PMCID: PMC8720168 DOI: 10.1007/s10875-021-01183-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 11/15/2021] [Indexed: 12/29/2022]
Abstract
Purpose Our understanding of inborn errors of immunity is increasing; however, their contribution to pediatric sepsis is unknown. Methods We used whole-exome sequencing (WES) to characterize variants in genes related to monogenic immunologic disorders in 330 children admitted to intensive care for severe sepsis. We defined candidate variants as rare variants classified as pathogenic or potentially pathogenic in QIAGEN’s Human Gene Mutation Database or novel null variants in a disease-consistent inheritance pattern. We investigated variant correlation with infection and inflammatory phenotype. Results More than one in two children overall and three of four African American children had immunodeficiency-associated variants. Children with variants had increased odds of isolating a blood or urinary pathogen (blood: OR 2.82, 95% CI: 1.12–7.10, p = 0.023, urine: OR: 8.23, 95% CI: 1.06–64.11, p = 0.016) and demonstrating increased inflammation with hyperferritinemia (ferritin \documentclass[12pt]{minimal}
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\begin{document}$$\ge 500$$\end{document}≥500 ng/mL, OR: 2.16, 95% CI: 1.28–3.66, p = 0.004), lymphopenia (lymphocyte count < 1000/µL, OR: 1.66, 95% CI: 1.06 – 2.60, p = 0.027), thrombocytopenia (platelet count < 150,000/µL, OR: 1.76, 95% CI: 1.12–2.76, p = 0.013), and CRP greater than 10 mg/dl (OR: 1.71, 95% CI: 1.10–2.68, p = 0.017). They also had increased odds of requiring extracorporeal membrane oxygenation (ECMO, OR: 4.19, 95% CI: 1.21–14.5, p = 0.019). Conclusion Herein, we describe the genetic findings in this severe pediatric sepsis cohort and their microbiologic and immunologic significance, providing evidence for the phenotypic effect of these variants and rationale for screening children with life-threatening infections for potential inborn errors of immunity. Supplementary Information The online version contains supplementary material available at 10.1007/s10875-021-01183-4.
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Affiliation(s)
- Kate F Kernan
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, Center for Critical Care Nephrology and Clinical Research Investigation and Systems Modeling of Acute Illness Center, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Lina Ghaloul-Gonzalez
- Division of Genetic and Genomic Medicine, Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jerry Vockley
- Division of Genetic and Genomic Medicine, Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Janette Lamb
- Genomics Core Laboratory, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Uma Chandran
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Rahil Sethi
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Hyun-Jung Park
- Department of Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - David Wessel
- Division of Critical Care Medicine, Department of Pediatrics, Children's National Hospital, Washington, DC, USA
| | - Murray M Pollack
- Division of Critical Care Medicine, Department of Pediatrics, Children's National Hospital, Washington, DC, USA
| | - Kathleen L Meert
- Division of Critical Care Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI, USA
- Central Michigan University, Mt. Pleasant, MI, USA
| | - Mark W Hall
- Division of Critical Care Medicine, Department of Pediatrics, The Research Institute at Nationwide Children's Hospital Immune Surveillance Laboratory, and Nationwide Children's Hospital, Columbus, OH, USA
| | - Christopher J L Newth
- Division of Pediatric Critical Care Medicine, Department of Anesthesiology and Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - John C Lin
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children's Hospital, St. Louis, MO, USA
| | - Allan Doctor
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children's Hospital, St. Louis, MO, USA
- Division of Pediatric Critical Care Medicine, The Center for Blood Oxygen Transport and Hemostasis, University of Maryland School of Medicine, MD, Baltimore, USA
| | - Tom Shanley
- Division of Critical Care Medicine, Department of Pediatrics, C. S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Tim Cornell
- Division of Critical Care Medicine, Department of Pediatrics, C. S. Mott Children's Hospital, Ann Arbor, MI, USA
- Department of Pediatrics, Lucile Packard Children's Hospital Stanford, Stanford University, CA, Palo Alto, USA
| | - Rick E Harrison
- Division of Critical Care Medicine, Department of Pediatrics, Mattel Children's Hospital at University of California Los Angeles, Los Angeles, CA, USA
| | - Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Russel Banks
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Richard Holubkov
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Daniel A Notterman
- Department of Molecular Biology, Princeton University, Princeton, NJ, USA
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Joseph A Carcillo
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, Center for Critical Care Nephrology and Clinical Research Investigation and Systems Modeling of Acute Illness Center, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
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11
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Garam N, Cserhalmi M, Prohászka Z, Szilágyi Á, Veszeli N, Szabó E, Uzonyi B, Iliás A, Aigner C, Schmidt A, Gaggl M, Sunder-Plassmann G, Bajcsi D, Brunner J, Dumfarth A, Cejka D, Flaschberger S, Flögelova H, Haris Á, Hartmann Á, Heilos A, Mueller T, Rusai K, Arbeiter K, Hofer J, Jakab D, Sinkó M, Szigeti E, Bereczki C, Janko V, Kelen K, Reusz GS, Szabó AJ, Klenk N, Kóbor K, Kojc N, Knechtelsdorfer M, Laganovic M, Lungu AC, Meglic A, Rus R, Kersnik Levart T, Macioniene E, Miglinas M, Pawłowska A, Stompór T, Podracka L, Rudnicki M, Mayer G, Rysava R, Reiterova J, Saraga M, Seeman T, Zieg J, Sládková E, Stajic N, Szabó T, Capitanescu A, Stancu S, Tisljar M, Galesic K, Tislér A, Vainumäe I, Windpessl M, Zaoral T, Zlatanova G, Józsi M, Csuka D. FHR-5 Serum Levels and CFHR5 Genetic Variations in Patients With Immune Complex-Mediated Membranoproliferative Glomerulonephritis and C3-Glomerulopathy. Front Immunol 2021; 12:720183. [PMID: 34566977 PMCID: PMC8461307 DOI: 10.3389/fimmu.2021.720183] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 08/11/2021] [Indexed: 12/12/2022] Open
Abstract
Background Factor H-related protein 5 (FHR-5) is a member of the complement Factor H protein family. Due to the homology to Factor H, the main complement regulator of the alternative pathway, it may also be implicated in the pathomechanism of kidney diseases where Factor H and alternative pathway dysregulation play a role. Here, we report the first observational study on CFHR5 variations along with serum FHR-5 levels in immune complex-mediated membranoproliferative glomerulonephritis (IC-MPGN) and C3 glomerulopathy (C3G) patients together with the clinical, genetic, complement, and follow-up data. Methods A total of 120 patients with a histologically proven diagnosis of IC-MPGN/C3G were enrolled in the study. FHR-5 serum levels were measured in ELISA, the CFHR5 gene was analyzed by Sanger sequencing, and selected variants were studied as recombinant proteins in ELISA and surface plasmon resonance (SPR). Results Eight exonic CFHR5 variations in 14 patients (12.6%) were observed. Serum FHR-5 levels were lower in patients compared to controls. Low serum FHR-5 concentration at presentation associated with better renal survival during the follow-up period; furthermore, it showed clear association with signs of complement overactivation and clinically meaningful clusters. Conclusions Our observations raise the possibility that the FHR-5 protein plays a fine-tuning role in the pathogenesis of IC-MPGN/C3G.
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Affiliation(s)
- Nóra Garam
- Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary
| | - Marcell Cserhalmi
- MTA-ELTE Complement Research Group, Eötvös Loránd Research Network (ELKH), Department of Immunology, ELTE Eötvös Loránd University, Budapest, Hungary
| | - Zoltán Prohászka
- Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary.,Research Group for Immunology and Haematology, Semmelweis University-Eötvös Loránd Research Network (Office for Supported Research Groups), Budapest, Hungary
| | - Ágnes Szilágyi
- Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary
| | - Nóra Veszeli
- Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary.,Research Group for Immunology and Haematology, Semmelweis University-Eötvös Loránd Research Network (Office for Supported Research Groups), Budapest, Hungary
| | - Edina Szabó
- Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary
| | - Barbara Uzonyi
- Department of Immunology, ELTE Eötvös Loránd University, Budapest, Hungary
| | - Attila Iliás
- Department of Immunology, ELTE Eötvös Loránd University, Budapest, Hungary
| | - Christof Aigner
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Alice Schmidt
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Martina Gaggl
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Gere Sunder-Plassmann
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Dóra Bajcsi
- 1st Department of Internal Medicine, University of Szeged, Szeged, Hungary
| | - Jürgen Brunner
- Department of Pediatrics, Medical University of Innsbruck, Innsbruck, Austria
| | - Alexandra Dumfarth
- Department of Medicine III: Nephrology, Transplant Medicine and Rheumatology, Geriatric Department, Ordensklinikum Linz-Elisabethinen, Linz, Austria
| | - Daniel Cejka
- Department of Medicine III: Nephrology, Transplant Medicine and Rheumatology, Geriatric Department, Ordensklinikum Linz-Elisabethinen, Linz, Austria
| | | | - Hana Flögelova
- Division of Nephrology, Department of Pediatrics, Faculty of Medicine, Palacky University and Faculty Hospital in Olomouc, Olomouc, Czechia
| | - Ágnes Haris
- Department of Nephrology, Péterfy Hospital, Budapest, Hungary
| | - Ágnes Hartmann
- Department of Pediatrics, University of Pécs, Pécs, Hungary
| | - Andreas Heilos
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Nephrology and Gastroenterology, Medical University of Vienna, Vienna, Austria
| | - Thomas Mueller
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Nephrology and Gastroenterology, Medical University of Vienna, Vienna, Austria
| | - Krisztina Rusai
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Nephrology and Gastroenterology, Medical University of Vienna, Vienna, Austria
| | - Klaus Arbeiter
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Nephrology and Gastroenterology, Medical University of Vienna, Vienna, Austria
| | - Johannes Hofer
- Department of Pediatrics, Medical University of Innsbruck, Innsbruck, Austria.,Institute of Neurology of Senses and Language, Hospital of St John of God, Linz, Austria.,Research Institute for Developmental Medicine, Johannes Kepler University Linz, Linz, Austria
| | - Dániel Jakab
- Department of Pediatrics, University of Szeged, Szeged, Hungary
| | - Mária Sinkó
- Department of Pediatrics, University of Szeged, Szeged, Hungary
| | - Erika Szigeti
- Department of Pediatrics, University of Szeged, Szeged, Hungary
| | - Csaba Bereczki
- Department of Pediatrics, University of Szeged, Szeged, Hungary
| | | | - Kata Kelen
- 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - György S Reusz
- 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Attila J Szabó
- 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Nóra Klenk
- Fresenius Medical Care (FMC) Center of Dialysis, Miskolc, Hungary
| | - Krisztina Kóbor
- Fresenius Medical Care (FMC) Center of Dialysis, Miskolc, Hungary
| | - Nika Kojc
- Institute of Pathology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | | | - Mario Laganovic
- Department of Nephrology, Arterial Hypertension, Dialysis and Transplantation, University Hospital Center Zagreb, School of Medicine, University of Zagreb, Zagreb, Croatia
| | | | - Anamarija Meglic
- Department of Pediatric Nephrology, Division of Pediatrics, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Rina Rus
- Department of Pediatric Nephrology, Division of Pediatrics, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Tanja Kersnik Levart
- Department of Pediatric Nephrology, Division of Pediatrics, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Ernesta Macioniene
- Nephrology Center, Santaros Klinikos, Medical Faculty, Vilnius University, Vilnius, Lithuania
| | - Marius Miglinas
- Nephrology Center, Santaros Klinikos, Medical Faculty, Vilnius University, Vilnius, Lithuania
| | - Anna Pawłowska
- Department of Nephrology, Hypertension and Internal Medicine, School of Medicine, Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland
| | - Tomasz Stompór
- Department of Nephrology, Hypertension and Internal Medicine, School of Medicine, Collegium Medicum, University of Warmia and Mazury, Olsztyn, Poland
| | - Ludmila Podracka
- Department of Pediatrics, Comenius University, Bratislava, Slovakia
| | - Michael Rudnicki
- Department of Internal Medicine IV-Nephrology and Hypertension, Medical University Innsbruck, Innsbruck, Austria
| | - Gert Mayer
- Department of Internal Medicine IV-Nephrology and Hypertension, Medical University Innsbruck, Innsbruck, Austria
| | - Romana Rysava
- Nephrology Clinic, 1st Faculty of Medicine, Charles University, Prague, Czechia
| | - Jana Reiterova
- Nephrology Clinic, 1st Faculty of Medicine, Charles University, Prague, Czechia
| | - Marijan Saraga
- Department of Pediatrics, University Hospital Split, Split, Croatia.,School of Medicine, University of Split, Split, Croatia
| | - Tomáš Seeman
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University Prague, University Hospital Motol, Pragu, Czechia
| | - Jakub Zieg
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University Prague, University Hospital Motol, Pragu, Czechia
| | - Eva Sládková
- Department of Pediatrics, Faculty of Medicine in Pilsen, Charles University in Prague, Pilsen, Czechia
| | - Natasa Stajic
- Institute of Mother and Childhealth Care of Serbia "Dr Vukan Čupić", Belgrade, Serbia
| | - Tamás Szabó
- Department of Pediatrics, Faculty of Medicine, Debrecen University, Debrecen, Hungary
| | | | - Simona Stancu
- Carol Davila Nephrology Hospital, Bucharest, Romania
| | - Miroslav Tisljar
- Department of Nephrology, University Hospital Dubrava Zagreb, Zagreb, Croatia
| | - Kresimir Galesic
- Department of Nephrology, University Hospital Dubrava Zagreb, Zagreb, Croatia
| | - András Tislér
- Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
| | - Inga Vainumäe
- Department of Pathology, Tartu University Hospital, Tartu, Estonia
| | - Martin Windpessl
- Internal Medicine IV, Section of Nephrology, Klinikum Wels-Grieskirchen, Wels, Austria
| | - Tomas Zaoral
- Department of Pediatrics, University Hospital and Faculty of Medicine, Ostrava, Czechia
| | - Galia Zlatanova
- University Children's Hospital, Medical University, Sofia, Bulgaria
| | - Mihály Józsi
- MTA-ELTE Complement Research Group, Eötvös Loránd Research Network (ELKH), Department of Immunology, ELTE Eötvös Loránd University, Budapest, Hungary.,Department of Immunology, ELTE Eötvös Loránd University, Budapest, Hungary
| | - Dorottya Csuka
- Department of Internal Medicine and Haematology, Semmelweis University, Budapest, Hungary.,Research Group for Immunology and Haematology, Semmelweis University-Eötvös Loránd Research Network (Office for Supported Research Groups), Budapest, Hungary
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12
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Bline KE, Hall MW. Immune Function in Critically Ill Septic Children. Pathogens 2021; 10:1239. [PMID: 34684188 PMCID: PMC8539782 DOI: 10.3390/pathogens10101239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 09/13/2021] [Accepted: 09/22/2021] [Indexed: 11/19/2022] Open
Abstract
The inflammatory response in pediatric sepsis is highly dynamic and includes both pro- and anti-inflammatory elements that involve the innate and adaptive immune systems. While the pro-inflammatory response is responsible for the initial clinical signs and symptoms of sepsis, a concurrent compensatory anti-inflammatory response often results in an occult, but highly clinically relevant, form of acquired immunodeficiency. When severe, this is termed "immunoparalysis" and is associated with increased risks for nosocomial infection, prolonged organ dysfunction, and death. This review focuses on the pathophysiology and clinical implications of both over- and under-active immune function in septic children. Host-, disease-, and treatment-specific risk factors for immunoparalysis are reviewed along with immune phenotype-specific approaches for immunomodulation in pediatric sepsis which are currently the subject of clinical trials.
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Affiliation(s)
- Katherine Elizabeth Bline
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children’s Hospital, Columbus, OH 43205, USA;
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13
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Neri P, Pichi F. SARS-CoV-2 and the Eye: The Pandora's Box of Ocular Immunology. J Ocul Pharmacol Ther 2021; 37:502-509. [PMID: 34515538 DOI: 10.1089/jop.2021.0058] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The Pandora's box myth addresses the evilness in the world that undisputedly nowadays is identified in severe acute respiratory syndrome (SARS)-Coronavirus 2 (CoV-2), formerly known as Covid-19, which belongs to coronaviridae family, identified in Wuhan, Hubei district of the Republic of China in December 2019. Since then, SARS-CoV-2 has affected ∼180 million people and made almost 4 million victims, with a mortality rate of 6.1%, which is 6 times higher than influenza virus. However, coronaviruses are well known in the ophthalmology field because they were used in the so-called experimental coronavirus retinopathy model. That model certainly brings intriguing concepts for understanding coronavirus pathophysiology, which may have important implications on treatment strategies. Certainly, the recent availability of vaccines gives hope on the control of virus spreading; however, vaccines might create immune reactions involving the eye structure. In this study, we reviewed the literature and elaborated the available data to speculate on possible new interpretation of both pathophysiology and treatment of SARS-CoV-2.
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Affiliation(s)
- Piergiorgio Neri
- Uveitis Service of The Eye Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates.,Cleveland Lerner College of Medicine, Case Western University, Cleveland, Ohio, USA.,Khalifa University Medical School, Abu Dhabi, United Arab Emirates
| | - Francesco Pichi
- Uveitis Service of The Eye Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates.,Cleveland Lerner College of Medicine, Case Western University, Cleveland, Ohio, USA
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14
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Borie R, Savale L, Dossier A, Ghosn J, Taillé C, Visseaux B, Jebreen K, Diallo A, Tesmoingt C, Morer L, Goletto T, Faucher N, Hajouji L, Neukirch C, Phillips M, Stelianides S, Bouadma L, Brosseau S, Ottaviani S, Pluvy J, Le Pluart D, Debray MP, Raynaud-Simon A, Descamps D, Khalil A, Timsit JF, Lescure FX, Descamps V, Papo T, Humbert M, Crestani B, Dieude P, Vicaut E, Zalcman G. Glucocorticoids with low-dose anti-IL1 anakinra rescue in severe non-ICU COVID-19 infection: A cohort study. PLoS One 2020; 15:e0243961. [PMID: 33326457 PMCID: PMC7743937 DOI: 10.1371/journal.pone.0243961] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 12/02/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The optimal treatment for patients with severe coronavirus-19 disease (COVID-19) and hyper-inflammation remains debated. MATERIAL AND METHODS A cohort study was designed to evaluate whether a therapeutic algorithm using steroids with or without interleukin-1 antagonist (anakinra) could prevent death/invasive ventilation. Patients with a ≥5-day evolution since symptoms onset, with hyper-inflammation (CRP≥50mg/L), requiring 3-5 L/min oxygen, received methylprednisolone alone. Patients needing ≥6 L/min received methylprednisolone + subcutaneous anakinra daily either frontline or in case clinical deterioration upon corticosteroids alone. Death rate and death or intensive care unit (ICU) invasive ventilation rate at Day 15, with Odds Ratio (OR) and 95% CIs, were determined according to logistic regression and propensity scores. A Bayesian analysis estimated the treatment effects. RESULTS Of 108 consecutive patients, 70 patients received glucocorticoids alone. The control group comprised 63 patients receiving standard of care. In the corticosteroid±stanakinra group (n = 108), death rate was 20.4%, versus 30.2% in the controls, indicating a 30% relative decrease in death risk and a number of 10 patients to treat to avoid a death (p = 0.15). Using propensity scores a per-protocol analysis showed an OR for COVID-19-related death of 0.9 (95%CI [0.80-1.01], p = 0.067). On Bayesian analysis, the posterior probability of any mortality benefit with corticosteroids+/-anakinra was 87.5%, with a 7.8% probability of treatment-related harm. Pre-existing diabetes exacerbation occurred in 29 of 108 patients (26.9%). CONCLUSION In COVID-19 non-ICU inpatients at the cytokine release phase, corticosteroids with or without anakinra were associated with a 30% decrease of death risk on Day 15.
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Affiliation(s)
- Raphael Borie
- Pulmonology and Thoracic Oncology Department, University Hospital Bichat-Claude Bernard, AP-HP, Université de Paris, Paris, France
| | - Laurent Savale
- Pulmonology Department, Kremlin-Bicêtre University Hospital, AP-HP, Paris-Saclay University, Kremlin-Bicêtre, France
| | - Antoine Dossier
- Internal Medicine Department, University Hospital Bichat-Claude Bernard, AP-HP, Université de Paris, Paris, France
| | - Jade Ghosn
- Infectious Disease Department, University Hospital Bichat-Claude Bernard, AP-HP, Université de Paris, Paris, France
| | - Camille Taillé
- Pulmonology and Thoracic Oncology Department, University Hospital Bichat-Claude Bernard, AP-HP, Université de Paris, Paris, France
| | - Benoit Visseaux
- Virology Department, University Hospital Bichat-Claude Bernard, AP-HP, Université de Paris, Paris, France
| | - Kamel Jebreen
- Biostatistics and Clinical Research Department, University Hospital Lariboisière, AP-HP, Université de Paris, Paris, France
| | - Abourahmane Diallo
- Biostatistics and Clinical Research Department, University Hospital Lariboisière, AP-HP, Université de Paris, Paris, France
| | - Chloe Tesmoingt
- Pharmacy Department, University Hospital Bichat-Claude Bernard, AP-HP, Université de Paris, Paris, France
| | - Lise Morer
- Pulmonology and Thoracic Oncology Department, University Hospital Bichat-Claude Bernard, AP-HP, Université de Paris, Paris, France
| | - Tiphaine Goletto
- Pulmonology and Thoracic Oncology Department, University Hospital Bichat-Claude Bernard, AP-HP, Université de Paris, Paris, France
| | - Nathalie Faucher
- Geriatrics Department, University Hospital Bichat-Claude Bernard, AP-HP, Université de Paris, Paris, France
| | - Linda Hajouji
- Pulmonology and Thoracic Oncology Department, University Hospital Bichat-Claude Bernard, AP-HP, Université de Paris, Paris, France
| | - Catherine Neukirch
- Pulmonology and Thoracic Oncology Department, University Hospital Bichat-Claude Bernard, AP-HP, Université de Paris, Paris, France
| | - Mathilde Phillips
- Pulmonology and Thoracic Oncology Department, University Hospital Bichat-Claude Bernard, AP-HP, Université de Paris, Paris, France
| | - Sandrine Stelianides
- Pulmonology and Thoracic Oncology Department, University Hospital Bichat-Claude Bernard, AP-HP, Université de Paris, Paris, France
| | - Lila Bouadma
- Medical and infectious Diseases ICU, Intensive Care Department, University Hospital Bichat-Claude Bernard, AP-HP, Université de Paris, Paris, France
| | - Solenn Brosseau
- Pulmonology and Thoracic Oncology Department, University Hospital Bichat-Claude Bernard, AP-HP, Université de Paris, Paris, France
| | - Sébastien Ottaviani
- Rheumatology Department, University Hospital Bichat-Claude Bernard, AP-HP, Université de Paris, Paris, France
| | - Johan Pluvy
- Pulmonology and Thoracic Oncology Department, University Hospital Bichat-Claude Bernard, AP-HP, Université de Paris, Paris, France
| | - Diane Le Pluart
- Infectious Disease Department, University Hospital Bichat-Claude Bernard, AP-HP, Université de Paris, Paris, France
| | - Marie-Pierre Debray
- Radiology Department, University Hospital Bichat-Claude Bernard, AP-HP, Université de Paris, Paris, France
| | - Agathe Raynaud-Simon
- Pharmacy Department, University Hospital Bichat-Claude Bernard, AP-HP, Université de Paris, Paris, France
| | - Diane Descamps
- Virology Department, University Hospital Bichat-Claude Bernard, AP-HP, Université de Paris, Paris, France
| | - Antoine Khalil
- Radiology Department, University Hospital Bichat-Claude Bernard, AP-HP, Université de Paris, Paris, France
| | - Jean Francois Timsit
- Medical and infectious Diseases ICU, Intensive Care Department, University Hospital Bichat-Claude Bernard, AP-HP, Université de Paris, Paris, France
| | - Francois-Xavier Lescure
- Infectious Disease Department, University Hospital Bichat-Claude Bernard, AP-HP, Université de Paris, Paris, France
| | - Vincent Descamps
- Dermatology Department, University Hospital Bichat-Claude Bernard, AP-HP, Université de Paris, Paris, France
| | - Thomas Papo
- Internal Medicine Department, University Hospital Bichat-Claude Bernard, AP-HP, Université de Paris, Paris, France
| | - Marc Humbert
- Pulmonology Department, Kremlin-Bicêtre University Hospital, AP-HP, Paris-Saclay University, Kremlin-Bicêtre, France
| | - Bruno Crestani
- Pulmonology and Thoracic Oncology Department, University Hospital Bichat-Claude Bernard, AP-HP, Université de Paris, Paris, France
| | - Philippe Dieude
- Rheumatology Department, University Hospital Bichat-Claude Bernard, AP-HP, Université de Paris, Paris, France
| | - Eric Vicaut
- Biostatistics and Clinical Research Department, University Hospital Lariboisière, AP-HP, Université de Paris, Paris, France
| | - Gérard Zalcman
- Pulmonology and Thoracic Oncology Department, University Hospital Bichat-Claude Bernard, AP-HP, Université de Paris, Paris, France
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15
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Sirpilla O, Bauss J, Gupta R, Underwood A, Qutob D, Freeland T, Bupp C, Carcillo J, Hartog N, Rajasekaran S, Prokop JW. SARS-CoV-2-Encoded Proteome and Human Genetics: From Interaction-Based to Ribosomal Biology Impact on Disease and Risk Processes. J Proteome Res 2020; 19:4275-4290. [PMID: 32686937 PMCID: PMC7418564 DOI: 10.1021/acs.jproteome.0c00421] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Indexed: 12/12/2022]
Abstract
SARS-CoV-2 (COVID-19) has infected millions of people worldwide, with lethality in hundreds of thousands. The rapid publication of information, both regarding the clinical course and the viral biology, has yielded incredible knowledge of the virus. In this review, we address the insights gained for the SARS-CoV-2 proteome, which we have integrated into the Viral Integrated Structural Evolution Dynamic Database, a publicly available resource. Integrating evolutionary, structural, and interaction data with human proteins, we present how the SARS-CoV-2 proteome interacts with human disorders and risk factors ranging from cytokine storm, hyperferritinemic septic, coagulopathic, cardiac, immune, and rare disease-based genetics. The most noteworthy human genetic potential of SARS-CoV-2 is that of the nucleocapsid protein, where it is known to contribute to the inhibition of the biological process known as nonsense-mediated decay. This inhibition has the potential to not only regulate about 10% of all biological transcripts through altered ribosomal biology but also associate with viral-induced genetics, where suppressed human variants are activated to drive dominant, negative outcomes within cells. As we understand more of the dynamic and complex biological pathways that the proteome of SARS-CoV-2 utilizes for entry into cells, for replication, and for release from human cells, we can understand more risk factors for severe/lethal outcomes in patients and novel pharmaceutical interventions that may mitigate future pandemics.
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Affiliation(s)
- Olivia Sirpilla
- Department of Pediatrics and Human
Development, College of Human Medicine, Michigan State
University, Grand Rapids, Michigan 49503,
United States
- Department of Pharmacology and
Toxicology, Michigan State University, East
Lansing, Michigan 48824, United States
- Walsh
University, North Canton, Ohio 44720,
United States
| | - Jacob Bauss
- Department of Pediatrics and Human
Development, College of Human Medicine, Michigan State
University, Grand Rapids, Michigan 49503,
United States
| | - Ruchir Gupta
- Department of Pediatrics and Human
Development, College of Human Medicine, Michigan State
University, Grand Rapids, Michigan 49503,
United States
- Department of Pharmacology and
Toxicology, Michigan State University, East
Lansing, Michigan 48824, United States
| | - Adam Underwood
- Walsh
University, North Canton, Ohio 44720,
United States
| | - Dinah Qutob
- Walsh
University, North Canton, Ohio 44720,
United States
| | - Tom Freeland
- Walsh
University, North Canton, Ohio 44720,
United States
| | - Caleb Bupp
- Department of Pediatrics and Human
Development, College of Human Medicine, Michigan State
University, Grand Rapids, Michigan 49503,
United States
- Spectrum Health Medical
Genetics, Grand Rapids, Michigan 49503,
United States
| | - Joseph Carcillo
- Department of Critical Care Medicine
and Pediatrics, Children’s Hospital of Pittsburgh,
University of Pittsburgh School of
Medicine, Pittsburgh, Pennsylvania 15421,
United States
| | - Nicholas Hartog
- Allergy & Immunology,
Spectrum Health, Grand Rapids, Michigan 49503,
United States
| | - Surender Rajasekaran
- Department of Pediatrics and Human
Development, College of Human Medicine, Michigan State
University, Grand Rapids, Michigan 49503,
United States
- Pediatric Intensive Care
Unit, Helen DeVos Children’s Hospital,
Grand Rapids, Michigan 49503, United States
- Office of Research,
Spectrum Health, Grand Rapids, Michigan 49503,
United States
| | - Jeremy W. Prokop
- Department of Pediatrics and Human
Development, College of Human Medicine, Michigan State
University, Grand Rapids, Michigan 49503,
United States
- Department of Pharmacology and
Toxicology, Michigan State University, East
Lansing, Michigan 48824, United States
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16
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Hajifathalian K, Sharaiha RZ, Kumar S, Krisko T, Skaf D, Ang B, Redd WD, Zhou JC, Hathorn KE, McCarty TR, Bazarbashi AN, Njie C, Wong D, Shen L, Sholle E, Cohen DE, Brown RS, Chan WW, Fortune BE. Development and external validation of a prediction risk model for short-term mortality among hospitalized U.S. COVID-19 patients: A proposal for the COVID-AID risk tool. PLoS One 2020; 15:e0239536. [PMID: 32997700 PMCID: PMC7526907 DOI: 10.1371/journal.pone.0239536] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 09/09/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The 2019 novel coronavirus disease (COVID-19) has created unprecedented medical challenges. There remains a need for validated risk prediction models to assess short-term mortality risk among hospitalized patients with COVID-19. The objective of this study was to develop and validate a 7-day and 14-day mortality risk prediction model for patients hospitalized with COVID-19. METHODS We performed a multicenter retrospective cohort study with a separate multicenter cohort for external validation using two hospitals in New York, NY, and 9 hospitals in Massachusetts, respectively. A total of 664 patients in NY and 265 patients with COVID-19 in Massachusetts, hospitalized from March to April 2020. RESULTS We developed a risk model consisting of patient age, hypoxia severity, mean arterial pressure and presence of kidney dysfunction at hospital presentation. Multivariable regression model was based on risk factors selected from univariable and Chi-squared automatic interaction detection analyses. Validation was by receiver operating characteristic curve (discrimination) and Hosmer-Lemeshow goodness of fit (GOF) test (calibration). In internal cross-validation, prediction of 7-day mortality had an AUC of 0.86 (95%CI 0.74-0.98; GOF p = 0.744); while 14-day had an AUC of 0.83 (95%CI 0.69-0.97; GOF p = 0.588). External validation was achieved using 265 patients from an outside cohort and confirmed 7- and 14-day mortality prediction performance with an AUC of 0.85 (95%CI 0.78-0.92; GOF p = 0.340) and 0.83 (95%CI 0.76-0.89; GOF p = 0.471) respectively, along with excellent calibration. Retrospective data collection, short follow-up time, and development in COVID-19 epicenter may limit model generalizability. CONCLUSIONS The COVID-AID risk tool is a well-calibrated model that demonstrates accuracy in the prediction of both 7-day and 14-day mortality risk among patients hospitalized with COVID-19. This prediction score could assist with resource utilization, patient and caregiver education, and provide a risk stratification instrument for future research trials.
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Affiliation(s)
- Kaveh Hajifathalian
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY, United States of America
| | - Reem Z. Sharaiha
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY, United States of America
| | - Sonal Kumar
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY, United States of America
| | - Tibor Krisko
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY, United States of America
| | - Daniel Skaf
- Joan & Sanford I. Weill Medical College, Weill Cornell Medicine, New York, NY, United States of America
| | - Bryan Ang
- Joan & Sanford I. Weill Medical College, Weill Cornell Medicine, New York, NY, United States of America
| | - Walker D. Redd
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
| | - Joyce C. Zhou
- Harvard Medical School, Boston, MA, United States of America
| | - Kelly E. Hathorn
- Harvard Medical School, Boston, MA, United States of America
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Boston, MA, United States of America
| | - Thomas R. McCarty
- Harvard Medical School, Boston, MA, United States of America
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Boston, MA, United States of America
| | - Ahmad Najdat Bazarbashi
- Harvard Medical School, Boston, MA, United States of America
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Boston, MA, United States of America
| | - Cheikh Njie
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
| | - Danny Wong
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
| | - Lin Shen
- Harvard Medical School, Boston, MA, United States of America
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Boston, MA, United States of America
| | - Evan Sholle
- Department of Research Informatics, Information Technologies Services, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY, United States of America
| | - David E. Cohen
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY, United States of America
| | - Robert S. Brown
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY, United States of America
| | - Walter W. Chan
- Harvard Medical School, Boston, MA, United States of America
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Boston, MA, United States of America
| | - Brett E. Fortune
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, NY, United States of America
- * E-mail:
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17
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Neri P, Lamperti M, Pichi F. SARS-COV-2 and eye immunity: the lesson was learned but we are not done yet. Brainstorming on possible pathophysiology inspired by ocular models. Int Ophthalmol 2020; 40:1879-1883. [PMID: 32621017 PMCID: PMC7332849 DOI: 10.1007/s10792-020-01495-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Piergiorgio Neri
- The Uveitis Service of the Eye Institute, Cleveland Clinic Abu Dhabi, Al Mariyah Island, PO Box 112412, Abu Dhabi, UAE. .,Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA.
| | - Massimo Lamperti
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA.,The Anesthesiology Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| | - Francesco Pichi
- The Uveitis Service of the Eye Institute, Cleveland Clinic Abu Dhabi, Al Mariyah Island, PO Box 112412, Abu Dhabi, UAE.,Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA
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18
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Wampler Muskardin TL. Intravenous Anakinra for Macrophage Activation Syndrome May Hold Lessons for Treatment of Cytokine Storm in the Setting of Coronavirus Disease 2019. ACR Open Rheumatol 2020; 2:283-285. [PMID: 32267072 PMCID: PMC7231517 DOI: 10.1002/acr2.11140] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 03/31/2020] [Indexed: 01/24/2023] Open
Abstract
Macrophage activation syndrome (MAS) and hemophagocytic lymphohistiocytosis (HLH) are increasingly recognized as being on a continuum of cytokine storm syndromes, with different initiating pathways culminating in cytotoxic dysfunction and uncontrolled activation and proliferation of T lymphocytes and macrophages. The activated immune cells produce large amounts of proinflammatory cytokines, including interleukin 1β (IL)‐1β. Management depends on the recognized diagnosis. In the setting of a cytokine storm syndrome and infection, collaborative involvement of specialists, including infectious disease and rheumatology is ideal. Anakinra, a recombinant IL‐1 receptor antagonist, has been used subcutaneously and intravenously in pediatric patients and is considered a first‐line treatment for MAS and secondary HLH (sHLH) among many pediatric rheumatologists. Previous reports of anakinra used in adults for treatment of MAS or sHLH are limited to subcutaneous administration. In this issue, Moneagudo et al. present a series of adult patients with sHLH treated with intravenous anakinra, including patients in whom subcutaneous anakinra was insufficient. As the authors suggest, there is a potential therapeutic use for anakinra in sHLH or the cytokine storm syndrome triggered by COVID19. Trial design will be key, with the patient subpopulation, timing of intervention, and doses tested important.
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19
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20
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The genetics of macrophage activation syndrome. Genes Immun 2020; 21:169-181. [PMID: 32291394 DOI: 10.1038/s41435-020-0098-4] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 03/13/2020] [Accepted: 03/27/2020] [Indexed: 12/12/2022]
Abstract
Macrophage activation syndrome (MAS), or secondary hemophagocytic lymphohistiocytosis (HLH), is a cytokine storm syndrome associated with multi-organ system dysfunction and high mortality rates. Laboratory and clinical features resemble primary HLH, which arises in infancy (1 in 50,000 live births) from homozygous mutations in various genes critical to the perforin-mediated cytolytic pathway employed by NK cells and cytotoxic CD8 T lymphocytes. MAS/secondary HLH is about ten times more common and typically presents beyond infancy extending into adulthood. The genetics of MAS are far less defined than for familial HLH. However, the distinction between familial HLH and MAS/secondary HLH is blurred by the finding of heterozygous perforin-pathway mutations in MAS patients, which may function as hypomorphic or partial dominant-negative alleles and contribute to disease pathogenesis. In addition, mutations in a variety of other pathogenic pathways have been noted in patients with MAS/secondary HLH. Many of these genetically disrupted pathways result in a similar cytokine storm syndrome, and can be broadly categorized as impaired viral control (e.g., SH2P1A), dysregulated inflammasome activity (e.g., NLRC4), other immune defects (e.g., IKBKG), and dysregulated metabolism (e.g., LIPA). Collectively these genetic lesions likely combine with states of chronic inflammation, as seen in various rheumatic diseases (e.g., still disease), with or without identified infections, to result in MAS pathology as explained by the threshold model of disease. This emerging paradigm may ultimately support genetic risk stratification for high-risk chronic and even acute inflammatory disorders. Moving forward, continued whole-exome and -genome sequencing will likely identify novel MAS gene associations, as well as noncoding mutations altering levels of gene expression.
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21
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Crayne C, Cron RQ. Pediatric macrophage activation syndrome, recognizing the tip of the Iceberg. Eur J Rheumatol 2020; 7:S13-S20. [PMID: 31804174 PMCID: PMC7004271 DOI: 10.5152/eurjrheum.2019.19150] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 09/26/2019] [Indexed: 12/14/2022] Open
Abstract
Macrophage activation syndrome (MAS) is the name given to secondary hemophagocytic lymphohistiocytosis (sHLH) associated with rheumatic diseases. Previously, MAS has been best studied in children with systemic juvenile idiopathic arthritis (sJIA), who are at high risk of developing MAS. MAS/sHLH is a cytokine storm that results in multi-organ system failure and is frequently fatal. Early diagnosis and treatment is critical for improving survival. Various diagnostic tools have been developed for identifying MAS in the setting of sJIA, as well as for all forms of MAS/sHLH. These are largely based on clinical (e.g., fever) and laboratory features (e.g., cytopenias). None are perfectly sensitive and specific, however, increasing awareness of this condition is also paramount in making the diagnosis. Rare familial forms of HLH can also be diagnosed based on homozygous mutation in genes largely involved in perforin-mediated cytolytic function of lymphocytes (natural killer cells and CD8 T cells). Intriguingly, heterozygous defects in these same genes are frequently identified in patients with sHLH and MAS. Decreased cytolytic function results in prolonged interaction of the lytic lymphocytes and their target antigen presenting cells, thus resulting in the pro-inflammatory cytokine storm believed responsible for the multi-organ failure. Novel cytokine-targeted therapies are currently being explored for a less toxic yet effective alternative to chemotherapeutic approaches to treating children with sHLH/MAS. As increased recognition and diagnosis of MAS is on the rise, an earlier and cytokine-targeted approach to therapy will likely save many lives of children with this disorder.
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Affiliation(s)
- Courtney Crayne
- Department of Pediatrics, University of Alabama, Birmingham, Alabama, USA
| | - Randy Q Cron
- Department of Pediatrics, University of Alabama, Birmingham, Alabama, USA
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22
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Manrique-Caballero CL, Peerapornratana S, Formeck C, Del Rio-Pertuz G, Gomez Danies H, Kellum JA. Typical and Atypical Hemolytic Uremic Syndrome in the Critically Ill. Crit Care Clin 2020; 36:333-356. [PMID: 32172817 DOI: 10.1016/j.ccc.2019.11.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Hemolytic uremic syndrome is characterized by microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury. Disseminated intravascular coagulation, thrombotic thrombocytopenic purpura, and hemolytic uremic syndrome have a similar clinical presentation. Diagnostic needs to be prompt to decrease mortality, because identifying the different disorders can help to tailor specific, effective therapies. However, diagnosis is challenging and morbidity and mortality remain high, especially in the critically ill population. Development of clinical prediction scores and rapid diagnostic tests for hemolytic uremic syndrome based on mechanistic knowledge are needed to facilitate early diagnosis and assign timely specific treatments to patients with hemolytic uremic syndrome variants.
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Affiliation(s)
- Carlos L Manrique-Caballero
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3347 Forbes Avenue Suite 220, Pittsburgh, PA 15213, USA; The CRISMA (Clinical Research, Investigation and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, Scaife Hall, Suite 600, Pittsburgh, PA 15213, USA
| | - Sadudee Peerapornratana
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3347 Forbes Avenue Suite 220, Pittsburgh, PA 15213, USA; The CRISMA (Clinical Research, Investigation and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, Scaife Hall, Suite 600, Pittsburgh, PA 15213, USA; Excellence Center for Critical Care Nephrology, Division of Nephrology, Department of Medicine, Chulalongkorn University, 1873 Rama 4 Road, Pathumwan, Bangkok 10330, Thailand; Department of Laboratory Medicine, Chulalongkorn University, 1873 Rama 4 Road, Pathumwan, Bangkok 10330, Thailand
| | - Cassandra Formeck
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3347 Forbes Avenue Suite 220, Pittsburgh, PA 15213, USA; The CRISMA (Clinical Research, Investigation and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, Scaife Hall, Suite 600, Pittsburgh, PA 15213, USA; Department of Nephrology, Children's Hospital of Pittsburgh of UPMC, 4401 Penn Avenue, Floor 3, Pittsburgh, PA 15224, USA
| | - Gaspar Del Rio-Pertuz
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3347 Forbes Avenue Suite 220, Pittsburgh, PA 15213, USA; The CRISMA (Clinical Research, Investigation and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, Scaife Hall, Suite 600, Pittsburgh, PA 15213, USA
| | - Hernando Gomez Danies
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3347 Forbes Avenue Suite 220, Pittsburgh, PA 15213, USA; The CRISMA (Clinical Research, Investigation and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, Scaife Hall, Suite 600, Pittsburgh, PA 15213, USA
| | - John A Kellum
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3347 Forbes Avenue Suite 220, Pittsburgh, PA 15213, USA; The CRISMA (Clinical Research, Investigation and Systems Modeling of Acute Illness) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 3550 Terrace Street, Scaife Hall, Suite 600, Pittsburgh, PA 15213, USA.
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Affiliation(s)
- Stefano Skurzak
- Division of Anesthesia and Resuscitation 2, Città della Salute e della Scienza, Turin, Italy -
| | - Elena Sieni
- Department of Pediatric Oncologic Hematology, A. Meyer University Hospital, Florence, Italy
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A Multicenter Network Assessment of Three Inflammation Phenotypes in Pediatric Sepsis-Induced Multiple Organ Failure. Pediatr Crit Care Med 2019; 20:1137-1146. [PMID: 31568246 PMCID: PMC8121153 DOI: 10.1097/pcc.0000000000002105] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Ongoing adult sepsis clinical trials are assessing therapies that target three inflammation phenotypes including 1) immunoparalysis associated, 2) thrombotic microangiopathy driven thrombocytopenia associated, and 3) sequential liver failure associated multiple organ failure. These three phenotypes have not been assessed in the pediatric multicenter setting. We tested the hypothesis that these phenotypes are associated with increased macrophage activation syndrome and mortality in pediatric sepsis. DESIGN Prospective severe sepsis cohort study comparing children with multiple organ failure and any of these phenotypes to children with multiple organ failure without these phenotypes and children with single organ failure. SETTING Nine PICUs in the Eunice Kennedy Shriver National Institutes of Child Health and Human Development Collaborative Pediatric Critical Care Research Network. PATIENTS Children with severe sepsis and indwelling arterial or central venous catheters. INTERVENTIONS Clinical data collection and twice weekly blood sampling until PICU day 28 or discharge. MEASUREMENTS AND MAIN RESULTS Of 401 severe sepsis cases enrolled, 112 (28%) developed single organ failure (0% macrophage activation syndrome 0/112; < 1% mortality 1/112), whereas 289 (72%) developed multiple organ failure (9% macrophage activation syndrome 24/289; 15% mortality 43/289). Overall mortality was higher in children with multiple organ and the phenotypes (24/101 vs 20/300; relative risk, 3.56; 95% CI, 2.06-6.17). Compared to the 188 multiple organ failure patients without these inflammation phenotypes, the 101 multiple organ failure patients with these phenotypes had both increased macrophage activation syndrome (19% vs 3%; relative risk, 7.07; 95% CI, 2.72-18.38) and mortality (24% vs 10%; relative risk, 2.35; 95% CI, 1.35-4.08). CONCLUSIONS These three inflammation phenotypes were associated with increased macrophage activation syndrome and mortality in pediatric sepsis-induced multiple organ failure. This study provides an impetus and essential baseline data for planning multicenter clinical trials targeting these inflammation phenotypes in children.
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26
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Understanding Disseminated Intravascular Coagulation and Hepatobiliary Dysfunction Multiple Organ Failure in Hyperferritinemic Critical Illness. Pediatr Crit Care Med 2018; 19:1006-1009. [PMID: 30281573 PMCID: PMC6173201 DOI: 10.1097/pcc.0000000000001712] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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