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Khan S, Bolotova O, Sahib H, Foster D, Mallipattu SK. Endotoxemia in Critically Ill Patients with COVID-19. Blood Purif 2021; 51:513-519. [PMID: 34515062 PMCID: PMC8450835 DOI: 10.1159/000518230] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 03/12/2021] [Accepted: 06/29/2021] [Indexed: 12/29/2022]
Abstract
Introduction Mechanism(s) mediating critical illness in coronavirus disease 2019 (COVID-19) remain unclear. Previous reports demonstrate the existence of endotoxemia in viral infections without superimposed gram-negative bacteremia, but the rate and severity of endotoxemia in critically ill patients with COVID-19 requires further exploration. Materials and Methods This is a single-center cross-sectional study of 92 intensive care unit patients diagnosed with COVID-19 pneumonia. Endotoxin activity (EA) was measured in patients that met the following criteria: (1) age ≥18 years and (2) multi-organ dysfunction score >9 from March 24, 2020, to June 20, 2020. Results A total of 32 patients met the inclusion/exclusion criteria for measurement of EA. The median age of the study cohort was 60 years with a majority male (21/32, 65%) with hypertension (50%). A significant proportion of the patients exhibited either elevated EA in the intermediate range (0.40–0.59 EA units) (10/32, 31%) or high range (≥0.60 EA units) (14/32, 44%) or were nonresponders (NRs, low neutrophil response) to EA (6/32, 19%), with the presence of gram-negative bacteremia only in 2/32 (6%) patients. Low EA was reported in 2/32 patients. NRs (5/6, 83%) and patients with high EA (7/14, 50%) exhibited higher acute kidney injury (AKI) as compared to patients with low/intermediate EA level (1/12, 8.3%). Discussion/Conclusion Elevated EA was observed in a large majority of critically ill patients with COVID-19 and multi-organ dysfunction despite a low incidence of concurrent gram-negative bacteremia. While we observed that elevated EA and nonresponsiveness to EA were associated with AKI in critically ill patients with COVID-19, these findings require further validation in larger longitudinal cohorts.
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Affiliation(s)
- Sobia Khan
- Department of Medicine, Stony Brook University, Stony Brook, New York, USA
| | - Olena Bolotova
- Department of Medicine, Stony Brook University, Stony Brook, New York, USA
| | - Haseena Sahib
- Department of Medicine, Stony Brook University, Stony Brook, New York, USA
| | | | - Sandeep K Mallipattu
- Department of Medicine, Stony Brook University, Stony Brook, New York, USA.,Renal Section, Northport VA Medical Center, Northport, New York, USA
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Bolotova O, Yoo J, Chaudhri I, Marcos LA, Sahib H, Koraishy FM, Skopicki H, Ahmad S, Mallipattu SK. Safety, tolerability, and outcomes of losartan use in patients hospitalized with SARS-CoV-2 infection: A feasibility study. PLoS One 2020; 15:e0244708. [PMID: 33378401 PMCID: PMC7773257 DOI: 10.1371/journal.pone.0244708] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 12/15/2020] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Retrospective studies on the use of Renin-Angiotensin-Aldosterone System blockade in patients with Coronavirus Disease 2019 (COVID-19) have been informative but conflicting, and prospective studies are required to demonstrate the safety, tolerability, and outcomes of initiating these agents in hospitalized patients with COVID-19 and hypertension. METHODS AND FINDINGS This is a single center feasibility study encompassing two cohorts: (1) prospective cohort (April 21, 2020 to May 29, 2020) and (2) retrospective cohort (March 7, 2020 to April 1, 2020) of hospitalized patients with real-time polymerase chain reaction (PCR) positive SARS-CoV-2 by nasopharyngeal swab. Key inclusion criteria include BP > 130/80 and a requirement of supplemental oxygen with FiO2 of 25% or higher to maintain SpO2 > 92%. Key exclusion criteria included hyperkalemia and acute kidney injury (AKI) at the time of enrollment. Prospective cohort consisted of de novo initiation of losartan and continuation for a minimum of 7 days and assessed for adverse events (AKI, hyperkalemia, transaminitis, hypotension) and clinical outcomes (change in SpO2/FiO2 and inflammatory markers, need for ICU admission and mechanical ventilation). Retrospective cohort consisted of continuation of losartan (prior-to-hospitalization) and assessment of similar outcomes. In the prospective cohort, a total of 250 hospitalized patients were screened and inclusion/exclusion criteria were met in 16/250 patients and in the retrospective cohort, a total of 317 hospitalized patients were screened and inclusion/exclusion criteria were met in 14/317 patients. Most common adverse event was hypotension, leading to discontinuation in 3/16 (19%) and 2/14 (14%) patients in the prospective and retrospective cohort. No patients developed AKI in the prospective cohort as compared to 1/14 (7%) patients in the retrospective cohort, requiring discontinuation of losartan. Hyperkalemia occurred in 1/16 (6%) and 0/14 patients in the prospective and retrospective cohorts, respectively. In the prospective cohort, 3/16 (19%) and 2/16 (13%) patients required ICU admission and mechanical ventilation. In comparison, 3/14 (21%) required ICU admission and mechanical ventilation in the retrospective cohort. A majority of patients in both cohorts (14/16 (88%) and 13/14 (93%) patients from the prospective and retrospective cohort) were discharged alive from the hospital. A total of 9/16 (prospective) and 5/14 (retrospective) patients completed a minimum 7 days of losartan. In these 9 patients in the prospective cohort, a significant improvement in SpO2/FiO2 ratio was observed from day 1 to 7. No significant changes in inflammatory markers (initiation, peak, and day 7) were observed in either cohort. CONCLUSION In this pilot study we demonstrate that losartan was well-tolerated among hospitalized patients with COVID-19 and hypertension. We also demonstrate the feasibility of patient recruitment and the appropriate parameters to assess the outcomes and safety of losartan initiation or continuation, which provides a framework for future randomized clinical trials.
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Affiliation(s)
- Olena Bolotova
- Department of Medicine, Stony Brook University, Stony Brook, NY, United States of America
| | - Jeanwoo Yoo
- Department of Medicine, Stony Brook University, Stony Brook, NY, United States of America
| | - Imran Chaudhri
- Department of Medicine, Stony Brook University, Stony Brook, NY, United States of America
| | - Luis A. Marcos
- Department of Medicine, Stony Brook University, Stony Brook, NY, United States of America
| | - Haseena Sahib
- Department of Medicine, Stony Brook University, Stony Brook, NY, United States of America
| | - Farrukh M. Koraishy
- Department of Medicine, Stony Brook University, Stony Brook, NY, United States of America
| | - Hal Skopicki
- Department of Medicine, Stony Brook University, Stony Brook, NY, United States of America
| | - Sahar Ahmad
- Department of Medicine, Stony Brook University, Stony Brook, NY, United States of America
| | - Sandeep K. Mallipattu
- Department of Medicine, Stony Brook University, Stony Brook, NY, United States of America
- Renal Section, Northport VA Medical Center, Northport, NY, United States of America
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Chaudhri I, Moffitt R, Taub E, Annadi RR, Hoai M, Bolotova O, Yoo J, Dhaliwal S, Sahib H, Daccueil F, Hajagos J, Saltz M, Saltz J, Mallipattu SK, Koraishy FM. Association of Proteinuria and Hematuria with Acute Kidney Injury and Mortality in Hospitalized Patients with COVID-19. Kidney Blood Press Res 2020; 45:1018-1032. [PMID: 33171466 DOI: 10.1159/000511946] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 09/24/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Acute kidney injury (AKI) is strongly associated with poor outcomes in hospitalized patients with coronavirus disease 2019 (COVID-19), but data on the association of proteinuria and hematuria are limited to non-US populations. In addition, admission and in-hospital measures for kidney abnormalities have not been studied separately. METHODS This retrospective cohort study aimed to analyze these associations in 321 patients sequentially admitted between March 7, 2020 and April 1, 2020 at Stony Brook University Medical Center, New York. We investigated the association of proteinuria, hematuria, and AKI with outcomes of inflammation, intensive care unit (ICU) admission, invasive mechanical ventilation (IMV), and in-hospital death. We used ANOVA, t test, χ2 test, and Fisher's exact test for bivariate analyses and logistic regression for multivariable analysis. RESULTS Three hundred patients met the inclusion criteria for the study cohort. Multivariable analysis demonstrated that admission proteinuria was significantly associated with risk of in-hospital AKI (OR 4.71, 95% CI 1.28-17.38), while admission hematuria was associated with ICU admission (OR 4.56, 95% CI 1.12-18.64), IMV (OR 8.79, 95% CI 2.08-37.00), and death (OR 18.03, 95% CI 2.84-114.57). During hospitalization, de novo proteinuria was significantly associated with increased risk of death (OR 8.94, 95% CI 1.19-114.4, p = 0.04). In-hospital AKI increased (OR 27.14, 95% CI 4.44-240.17) while recovery from in-hospital AKI decreased the risk of death (OR 0.001, 95% CI 0.001-0.06). CONCLUSION Proteinuria and hematuria both at the time of admission and during hospitalization are associated with adverse clinical outcomes in hospitalized patients with COVID-19.
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Affiliation(s)
- Imran Chaudhri
- Division of Nephrology and Hypertension, Department of Medicine, Stony Brook University, Stony Brook, New York, USA
| | - Richard Moffitt
- Department of Biomedical Informatics, Stony Brook University, Stony Brook, New York, USA
| | - Erin Taub
- Division of Nephrology and Hypertension, Department of Medicine, Stony Brook University, Stony Brook, New York, USA
| | - Raji R Annadi
- Department of Computer Science, Stony Brook University, Stony Brook, New York, USA
| | - Minh Hoai
- Department of Computer Science, Stony Brook University, Stony Brook, New York, USA
| | - Olena Bolotova
- Division of Nephrology and Hypertension, Department of Medicine, Stony Brook University, Stony Brook, New York, USA
| | - Jeanwoo Yoo
- Division of Nephrology and Hypertension, Department of Medicine, Stony Brook University, Stony Brook, New York, USA
| | - Simrat Dhaliwal
- Division of Nephrology and Hypertension, Department of Medicine, Stony Brook University, Stony Brook, New York, USA
| | - Haseena Sahib
- Division of Nephrology and Hypertension, Department of Medicine, Stony Brook University, Stony Brook, New York, USA
| | - Farah Daccueil
- Division of Nephrology and Hypertension, Department of Medicine, Stony Brook University, Stony Brook, New York, USA
| | - Janos Hajagos
- Department of Biomedical Informatics, Stony Brook University, Stony Brook, New York, USA
| | - Mary Saltz
- Department of Biomedical Informatics, Stony Brook University, Stony Brook, New York, USA
| | - Joel Saltz
- Department of Biomedical Informatics, Stony Brook University, Stony Brook, New York, USA
| | - Sandeep K Mallipattu
- Division of Nephrology and Hypertension, Department of Medicine, Stony Brook University, Stony Brook, New York, USA.,Renal Section, Northport VA Medical Center, Northport, New York, USA
| | - Farrukh M Koraishy
- Division of Nephrology and Hypertension, Department of Medicine, Stony Brook University, Stony Brook, New York, USA, .,Renal Section, Northport VA Medical Center, Northport, New York, USA,
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Chaudhri I, Koraishy FM, Bolotova O, Yoo J, Marcos LA, Taub E, Sahib H, Bloom M, Ahmad S, Skopicki H, Mallipattu SK. Outcomes Associated with the Use of Renin-Angiotensin-Aldosterone System Blockade in Hospitalized Patients with SARS-CoV-2 Infection. ACTA ACUST UNITED AC 2020; 1:801-809. [PMID: 33345195 DOI: 10.34067/kid.0003792020] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background Data regarding the benefits or harm associated with the continuation of Angiotensin Converting Enzyme Inhibitors (ACEIs) and Angiotensin II Receptor Blockers (ARBs), especially the impact on inflammation, in hypertensive, hospitalized patients with COVID-19 in the United States is unclear. Methods This is a single-center cohort study of sequentially hospitalized patients with COVID-19 at Stony Brook University Medical Center from March 7, 2020 to April 1, 2020, inclusive of these dates. Data collection included history of known comorbidities, medications, vital signs and laboratory values (admission and during the hospitalization). Outcomes include inflammatory burden (composite scores for multiple markers of inflammation), acute kidney injury (AKI), admission to the intensive care unit (ICU), need for invasive mechanical ventilation, and mortality. Results Of the 300 patients in the study cohort, 80 patients (26.7%) had history of ACEI or ARB use prior to admission, with 61.3% (49/80) of these patients continuing the medications during hospitalization. Multivariable analysis revealed that the history of ACEI or ARB use prior to hospitalization was not associated with worse outcomes. In addition, the continuation of these agents during hospitalization was not associated with an increase in adverse outcomes and predicted fewer ICU admissions (OR=0.25, 0.08-0.81) with a decrease in the severity of inflammatory burden (peak CRP (6.9±3.1mg/dl, p=0.03) and peak inflammation score (2.3±1.1unit reduction, p=0.04)). Conclusion Use of ACEI or ARBs prior to hospitalization was not associated with adverse outcomes in COVID-19 and the therapeutic benefits of continuing ACEI or ARB in hospitalized patients with COVID-19 was not offset by adverse outcomes.
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Affiliation(s)
- Imran Chaudhri
- Department of Medicine, Stony Brook University, Stony Brook, NY
| | | | - Olena Bolotova
- Department of Medicine, Stony Brook University, Stony Brook, NY
| | - Jeanwoo Yoo
- Department of Medicine, Stony Brook University, Stony Brook, NY
| | - Luis A Marcos
- Department of Medicine, Stony Brook University, Stony Brook, NY
| | - Erin Taub
- Department of Medicine, Stony Brook University, Stony Brook, NY
| | - Haseena Sahib
- Department of Medicine, Stony Brook University, Stony Brook, NY
| | - Michelle Bloom
- Department of Medicine, Stony Brook University, Stony Brook, NY
| | - Sahar Ahmad
- Department of Medicine, Stony Brook University, Stony Brook, NY
| | - Hal Skopicki
- Department of Medicine, Stony Brook University, Stony Brook, NY
| | - Sandeep K Mallipattu
- Department of Medicine, Stony Brook University, Stony Brook, NY.,Renal Section, Northport VA Medical Center, Northport, NY
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