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Sathe NA, Zelnick LR, Morrell ED, Bhatraju PK, Kerchberger VE, Hough CL, Ware LB, Fohner AE, Wurfel MM. Development and External Validation of Models to Predict Persistent Hypoxemic Respiratory Failure for Clinical Trial Enrichment. Crit Care Med 2024; 52:764-774. [PMID: 38197736 PMCID: PMC11018468 DOI: 10.1097/ccm.0000000000006181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
OBJECTIVES Improving the efficiency of clinical trials in acute hypoxemic respiratory failure (HRF) depends on enrichment strategies that minimize enrollment of patients who quickly resolve with existing care and focus on patients at high risk for persistent HRF. We aimed to develop parsimonious models predicting risk of persistent HRF using routine data from ICU admission and select research immune biomarkers. DESIGN Prospective cohorts for derivation ( n = 630) and external validation ( n = 511). SETTING Medical and surgical ICUs at two U.S. medical centers. PATIENTS Adults with acute HRF defined as new invasive mechanical ventilation (IMV) and hypoxemia on the first calendar day after ICU admission. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We evaluated discrimination, calibration, and practical utility of models predicting persistent HRF risk (defined as ongoing IMV and hypoxemia on the third calendar day after admission): 1) a clinical model with least absolute shrinkage and selection operator (LASSO) selecting Pa o2 /F io2 , vasopressors, mean arterial pressure, bicarbonate, and acute respiratory distress syndrome as predictors; 2) a model adding interleukin-6 (IL-6) to clinical predictors; and 3) a comparator model with Pa o2 /F io2 alone, representing an existing strategy for enrichment. Forty-nine percent and 69% of patients had persistent HRF in derivation and validation sets, respectively. In validation, both LASSO (area under the receiver operating characteristic curve, 0.68; 95% CI, 0.64-0.73) and LASSO + IL-6 (0.71; 95% CI, 0.66-0.76) models had better discrimination than Pa o2 /F io2 (0.64; 95% CI, 0.59-0.69). Both models underestimated risk in lower risk deciles, but exhibited better calibration at relevant risk thresholds. Evaluating practical utility, both LASSO and LASSO + IL-6 models exhibited greater net benefit in decision curve analysis, and greater sample size savings in enrichment analysis, compared with Pa o2 /F io2 . The added utility of LASSO + IL-6 model over LASSO was modest. CONCLUSIONS Parsimonious, interpretable models that predict persistent HRF may improve enrichment of trials testing HRF-targeted therapies and warrant future validation.
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Affiliation(s)
- Neha A. Sathe
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - Leila R. Zelnick
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA
| | - Eric D. Morrell
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - Pavan K. Bhatraju
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
- Sepsis Center of Research Excellence, University of Washington
| | - V. Eric Kerchberger
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Catherine L. Hough
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Lorraine B, Ware
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
- Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, TN
| | - Alison E Fohner
- Department of Epidemiology, School of Public Health, University of Washington
| | - Mark M. Wurfel
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
- Sepsis Center of Research Excellence, University of Washington
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Khader A, Zelnick LR, Sathe NA, Kestenbaum BR, Himmelfarb J, Johnson NJ, Shapiro NI, Douglas IS, Hough CL, Bhatraju PK. The Interaction of Acute Kidney Injury with Resuscitation Strategy in Sepsis: A Secondary Analysis of a Multicenter, Phase 3, Randomized Clinical Trial (CLOVERS). Am J Respir Crit Care Med 2023; 208:1335-1338. [PMID: 37870416 PMCID: PMC10765399 DOI: 10.1164/rccm.202308-1448le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 10/20/2023] [Indexed: 10/24/2023] Open
Affiliation(s)
- Ayesha Khader
- Division of Pulmonary, Critical Care and Sleep Medicine
| | - Leila R. Zelnick
- Kidney Research Institute, Division of Nephrology, Department of Medicine
| | - Neha A. Sathe
- Division of Pulmonary, Critical Care and Sleep Medicine
| | | | | | - Nicholas J. Johnson
- Division of Pulmonary, Critical Care and Sleep Medicine
- Department of Emergency Medicine, University of Washington, Seattle, Washington
| | - Nathan I. Shapiro
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Ivor S. Douglas
- Pulmonary Science and Critical Care Medicine, Denver Health Medical Center and University of Colorado, Anschutz Medical Campus, Denver, Colorado; and
| | - Catherine L. Hough
- Division of Pulmonary, Allergy, and Critical Care Medicine, Oregon Health & Science University, Portland, Oregon
| | - Pavan K. Bhatraju
- Division of Pulmonary, Critical Care and Sleep Medicine
- Kidney Research Institute, Division of Nephrology, Department of Medicine
- Sepsis Center of Research Excellence, and
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Sathe NA, Xian S, Mabrey FL, Crosslin DR, Mooney SD, Morrell ED, Lybarger K, Yetisgen M, Jarvik GP, Bhatraju PK, Wurfel MM. Evaluating construct validity of computable acute respiratory distress syndrome definitions in adults hospitalized with COVID-19: an electronic health records based approach. BMC Pulm Med 2023; 23:292. [PMID: 37559024 PMCID: PMC10413524 DOI: 10.1186/s12890-023-02560-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 07/11/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND Evolving ARDS epidemiology and management during COVID-19 have prompted calls to reexamine the construct validity of Berlin criteria, which have been rarely evaluated in real-world data. We developed a Berlin ARDS definition (EHR-Berlin) computable in electronic health records (EHR) to (1) assess its construct validity, and (2) assess how expanding its criteria affected validity. METHODS We performed a retrospective cohort study at two tertiary care hospitals with one EHR, among adults hospitalized with COVID-19 February 2020-March 2021. We assessed five candidate definitions for ARDS: the EHR-Berlin definition modeled on Berlin criteria, and four alternatives informed by recent proposals to expand criteria and include patients on high-flow oxygen (EHR-Alternative 1), relax imaging criteria (EHR-Alternatives 2-3), and extend timing windows (EHR-Alternative 4). We evaluated two aspects of construct validity for the EHR-Berlin definition: (1) criterion validity: agreement with manual ARDS classification by experts, available in 175 patients; (2) predictive validity: relationships with hospital mortality, assessed by Pearson r and by area under the receiver operating curve (AUROC). We assessed predictive validity and timing of identification of EHR-Berlin definition compared to alternative definitions. RESULTS Among 765 patients, mean (SD) age was 57 (18) years and 471 (62%) were male. The EHR-Berlin definition classified 171 (22%) patients as ARDS, which had high agreement with manual classification (kappa 0.85), and was associated with mortality (Pearson r = 0.39; AUROC 0.72, 95% CI 0.68, 0.77). In comparison, EHR-Alternative 1 classified 219 (29%) patients as ARDS, maintained similar relationships to mortality (r = 0.40; AUROC 0.74, 95% CI 0.70, 0.79, Delong test P = 0.14), and identified patients earlier in their hospitalization (median 13 vs. 15 h from admission, Wilcoxon signed-rank test P < 0.001). EHR-Alternative 3, which removed imaging criteria, had similar correlation (r = 0.41) but better discrimination for mortality (AUROC 0.76, 95% CI 0.72, 0.80; P = 0.036), and identified patients median 2 h (P < 0.001) from admission. CONCLUSIONS The EHR-Berlin definition can enable ARDS identification with high criterion validity, supporting large-scale study and surveillance. There are opportunities to expand the Berlin criteria that preserve predictive validity and facilitate earlier identification.
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Affiliation(s)
- Neha A Sathe
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, 325 9th Avenue HMC #359640, Seattle, WA, 98104-2499, USA.
| | - Su Xian
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, WA, USA
| | - F Linzee Mabrey
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, 325 9th Avenue HMC #359640, Seattle, WA, 98104-2499, USA
| | - David R Crosslin
- Division of Biomedical Informatics and Genomics, John W. Deming Department of Medicine, Tulane University School of Medicine, New Orleans, LA, USA
| | - Sean D Mooney
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, WA, USA
| | - Eric D Morrell
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, 325 9th Avenue HMC #359640, Seattle, WA, 98104-2499, USA
| | - Kevin Lybarger
- Department of Information Sciences and Technology, George Mason University, Fairfax, VA, USA
| | - Meliha Yetisgen
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, WA, USA
| | - Gail P Jarvik
- Department of Genome Sciences and Division of Medical Genetics, Department of Medicine, University of Washington Medical Center, Seattle, WA, USA
| | - Pavan K Bhatraju
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, 325 9th Avenue HMC #359640, Seattle, WA, 98104-2499, USA
| | - Mark M Wurfel
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, 325 9th Avenue HMC #359640, Seattle, WA, 98104-2499, USA
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Sathe NA, Mostaghim A, Barnes E, O'Connor NG, Sahi SK, Sakr SS, Zahlan JM, Smith CH, Fitzpatrick M, Morrell ED, Liles WC, Bhatraju PK. Biomarker Signatures of Severe Acute Kidney Injury in a Critically Ill Cohort of COVID-19 and Non-COVID-19 Acute Respiratory Illness. Crit Care Explor 2023; 5:e0945. [PMID: 37457915 PMCID: PMC10348733 DOI: 10.1097/cce.0000000000000945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023] Open
Abstract
Kidney and lung injury are closely inter-related during acute respiratory illness, but the molecular risk factors that these organ injuries share are not well defined. OBJECTIVES We identified plasma biomarkers associated with severe acute kidney injury (AKI) during acute respiratory illness, and compared them to biomarkers associated with severe acute respiratory failure (ARF). DESIGN SETTINGS AND PARTICIPANTS Prospective observational cohort study enrolling March 2020 through May 2021, at three hospitals in a large academic health system. We analyzed 301 patients admitted to an ICU with acute respiratory illness. MAIN OUTCOMES AND MEASURES Outcomes were ascertained between ICU admission and day 14, and included: 1) severe AKI, defined as doubling of serum creatinine or new dialysis and 2) severe ARF, which included new or persistent need for high-flow oxygen or mechanical ventilation. We measured biomarkers of immune response and endothelial function, pathways related to adverse kidney and lung outcomes, in plasma collected within 24 hours of ICU admission. Severe AKI occurred in 48 (16%), severe ARF occurred in 147 (49%), and 40 (13%) patients experienced both. Two-fold higher concentrations of soluble tumor necrosis factor receptor-1 (sTNFR-1) (adjusted relative risk [aRR], 1.56; 95% CI, 1.24-1.96) and soluble triggering receptor on myeloid cells-1 (sTREM-1) (aRR, 1.85; 95% CI, 1.42-2.41), biomarkers of innate immune activation, were associated with higher risk for severe AKI after adjustment for age, sex, COVID-19, and Acute Physiology and Chronic Health Evaluation-III. These biomarkers were not significantly associated with severe ARF. Soluble programmed cell death receptor-1 (sPDL-1), a checkpoint pathway molecule, as well as soluble intercellular adhesion molecule-1 (sICAM-1) and soluble vascular adhesion molecule-1 (sVCAM-1), molecules involved with endothelial-vascular leukocyte adhesion, were associated with both severe AKI and ARF. CONCLUSIONS AND RELEVANCE sTNFR-1 and sTREM-1 were linked strongly to severe AKI during respiratory illness, while sPDL-1, sICAM-1 and sVCAM-1 were associated with both severe AKI and ARF. These biomarker signatures may shed light on pathophysiology of lung-kidney interactions, and inform precision medicine strategies for identifying patients at high risk for these organ injuries.
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Affiliation(s)
- Neha A Sathe
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA
| | - Ana Mostaghim
- Department of Critical Care Medicine, National Institutes of Health Clinical Center, Bethesda, MD
| | - Elizabeth Barnes
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA
| | - Nicholas G O'Connor
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA
| | - Sharon K Sahi
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA
| | - Sana S Sakr
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA
| | - Jana M Zahlan
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA
| | - Craig H Smith
- Sepsis Center Of Research Excellence-UW (SCORE-UW), University of Washington, Seattle, WA
| | - Michael Fitzpatrick
- Sepsis Center Of Research Excellence-UW (SCORE-UW), University of Washington, Seattle, WA
| | - Eric D Morrell
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA
| | - W Conrad Liles
- Sepsis Center Of Research Excellence-UW (SCORE-UW), University of Washington, Seattle, WA
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA
| | - Pavan K Bhatraju
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA
- Sepsis Center Of Research Excellence-UW (SCORE-UW), University of Washington, Seattle, WA
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Thau MR, Liu T, Sathe NA, O’Keefe GE, Robinson BRH, Bulger E, Wade CE, Fox EE, Holcomb JB, Liles WC, Stanaway IB, Mikacenic C, Wurfel MM, Bhatraju PK, Morrell ED. Association of Trauma Molecular Endotypes With Differential Response to Transfusion Resuscitation Strategies. JAMA Surg 2023; 158:728-736. [PMID: 37099286 PMCID: PMC10134038 DOI: 10.1001/jamasurg.2023.0819] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 12/12/2022] [Indexed: 04/27/2023]
Abstract
Importance It is not clear which severely injured patients with hemorrhagic shock may benefit most from a 1:1:1 vs 1:1:2 (plasma:platelets:red blood cells) resuscitation strategy. Identification of trauma molecular endotypes may reveal subgroups of patients with differential treatment response to various resuscitation strategies. Objective To derive trauma endotypes (TEs) from molecular data and determine whether these endotypes are associated with mortality and differential treatment response to 1:1:1 vs 1:1:2 resuscitation strategies. Design, Setting, and Participants This was a secondary analysis of the Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) randomized clinical trial. The study cohort included individuals with severe injury from 12 North American trauma centers. The cohort was taken from the participants in the PROPPR trial who had complete plasma biomarker data available. Study data were analyzed on August 2, 2021, to October 25, 2022. Exposures TEs identified by K-means clustering of plasma biomarkers collected at hospital arrival. Main Outcomes and Measures An association between TEs and 30-day mortality was tested using multivariable relative risk (RR) regression adjusting for age, sex, trauma center, mechanism of injury, and injury severity score (ISS). Differential treatment response to transfusion strategy was assessed using an RR regression model for 30-day mortality by incorporating an interaction term for the product of endotype and treatment group adjusting for age, sex, trauma center, mechanism of injury, and ISS. Results A total of 478 participants (median [IQR] age, 34.5 [25-51] years; 384 male [80%]) of the 680 participants in the PROPPR trial were included in this study analysis. A 2-class model that had optimal performance in K-means clustering was found. TE-1 (n = 270) was characterized by higher plasma concentrations of inflammatory biomarkers (eg, interleukin 8 and tumor necrosis factor α) and significantly higher 30-day mortality compared with TE-2 (n = 208). There was a significant interaction between treatment arm and TE for 30-day mortality. Mortality in TE-1 was 28.6% with 1:1:2 treatment vs 32.6% with 1:1:1 treatment, whereas mortality in TE-2 was 24.5% with 1:1:2 treatment vs 7.3% with 1:1:1 treatment (P for interaction = .001). Conclusions and Relevance Results of this secondary analysis suggest that endotypes derived from plasma biomarkers in trauma patients at hospital arrival were associated with a differential response to 1:1:1 vs 1:1:2 resuscitation strategies in trauma patients with severe injury. These findings support the concept of molecular heterogeneity in critically ill trauma populations and have implications for tailoring therapy for patients at high risk for adverse outcomes.
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Affiliation(s)
- Matthew R. Thau
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
- Sepsis Center of Research Excellence—University of Washington (SCORE-UW), Seattle
| | - Ted Liu
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Neha A. Sathe
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
- Sepsis Center of Research Excellence—University of Washington (SCORE-UW), Seattle
| | - Grant E. O’Keefe
- Sepsis Center of Research Excellence—University of Washington (SCORE-UW), Seattle
- Department of Surgery, University of Washington, Seattle
| | | | - Eileen Bulger
- Department of Surgery, University of Washington, Seattle
| | - Charles E. Wade
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, University of Texas Health Science Center, Houston
| | - Erin E. Fox
- Center for Translational Injury Research, Division of Acute Care Surgery, Department of Surgery, University of Texas Health Science Center, Houston
| | | | - W. Conrad Liles
- Sepsis Center of Research Excellence—University of Washington (SCORE-UW), Seattle
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle
| | - Ian B. Stanaway
- Kidney Research Institute, University of Washington, Seattle
- Division of Nephrology, Department of Medicine, University of Washington, Seattle
| | - Carmen Mikacenic
- Sepsis Center of Research Excellence—University of Washington (SCORE-UW), Seattle
- Translational Immunology, Benaroya Research Institute, Seattle, Washington
| | - Mark M. Wurfel
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
- Sepsis Center of Research Excellence—University of Washington (SCORE-UW), Seattle
| | - Pavan K. Bhatraju
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
- Sepsis Center of Research Excellence—University of Washington (SCORE-UW), Seattle
| | - Eric D. Morrell
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
- Sepsis Center of Research Excellence—University of Washington (SCORE-UW), Seattle
- Hospital and Specialty Medicine, VA Puget Sound Health Care System, Seattle, Washington
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Sathe NA, Morrell ED, Bhatraju PK, Fessler MB, Stapleton RD, Wurfel MM, Mikacenic C. Alveolar Biomarker Profiles in Subphenotypes of the Acute Respiratory Distress Syndrome. Crit Care Med 2023; 51:e13-e18. [PMID: 36519995 PMCID: PMC9764239 DOI: 10.1097/ccm.0000000000005704] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES We sought to determine whether hyperinflammatory acute respiratory distress syndrome (ARDS) and hypoinflammatory ARDS, which have been associated with differences in plasma biomarkers and mortality risk, also display differences in bronchoalveolar lavage (BALF) biomarker profiles. We then described the relationship between hyperinflammatory ARDS and hypoinflammatory ARDS to novel subphenotypes derived using BALF biomarkers. DESIGN Secondary analysis of a randomized control trial testing omega-3 fatty acids for the treatment of ARDS. SETTING Five North American intensive care units. PATIENTS Adults (n = 88) on invasive mechanical ventilation within 48 hours of ARDS onset. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We classified 57 patients as hypoinflammatory and 31 patients as hyperinflammatory using a previously validated logistic regression model. Of 14 BALF biomarkers analyzed, interleukin-6 and granulocyte colony stimulating factor were higher among patients with hyperinflammatory ARDS compared with hypoinflammatory ARDS, though the differences were not robust to multiple hypothesis testing. We then performed a de novo latent class analysis of the 14 BALF biomarkers to identify two classes well separated by alveolar profiles. Class 2 (n = 63) displayed significantly higher interleukin-6, von Willebrand factor, soluble programmed cell death receptor-1, % neutrophils, and other biomarkers of inflammation compared with class 1 (n = 25). These BALF-derived classes had minimal overlap with the plasma-derived hyperinflammatory and hypoinflammatory classes, and the majority of both plasma-derived classes were in BALF-derived class 2 and characterized by high BALF biomarkers. Additionally, the BALF-derived classes were associated with clinical severity of pulmonary disease, with class 2 exhibiting lower Pao2 to Fio2 and distinct ventilatory parameters, unlike the plasma-derived classes, which were only related to nonpulmonary organ dysfunction. CONCLUSIONS Hyperinflammatory and hypoinflammatory ARDS subphenotypes did not display significant differences in alveolar biologic profiles. Identifying ARDS subgroups using BALF measurements is a unique approach that complements information obtained from plasma, with potential to inform enrichment strategies in trials of lung-targeted therapies.
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Affiliation(s)
- Neha A. Sathe
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA
| | - Eric D. Morrell
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA
| | - Pavan K. Bhatraju
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA
| | - Michael B. Fessler
- Immunity, Inflammation and Disease Laboratory, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, NC
| | - Renee D. Stapleton
- Division of Pulmonary Disease and Critical Care Medicine, University of Vermont, Burlington, VT
| | - Mark M. Wurfel
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA
| | - Carmen Mikacenic
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA
- Benaroya Research Institute, Virginia Mason, Seattle, WA
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Bhatraju PK, Morrell ED, Stanaway IB, Sathe NA, Srivastava A, Postelnicu R, Green R, Andrews A, Gonzalez M, Kratochvil CJ, Kumar VK, Hsiang TY, Gale M, Anesi GL, Wyles D, Broadhurst MJ, Brett-Major D, Mukherjee V, Sevransky JE, Landsittel D, Hung C, Altemeier WA, Gharib SA, Uyeki TM, Cobb JP, Liebler JM, Crosslin DR, Jarvik GP, Segal LN, Evans L, Mikacenic C, Wurfel MM. Angiopoietin-Like4 Is a Novel Marker of COVID-19 Severity. Crit Care Explor 2023; 5:e0827. [PMID: 36600780 PMCID: PMC9803343 DOI: 10.1097/cce.0000000000000827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Vascular dysfunction and capillary leak are common in critically ill COVID-19 patients, but identification of endothelial pathways involved in COVID-19 pathogenesis has been limited. Angiopoietin-like 4 (ANGPTL4) is a protein secreted in response to hypoxic and nutrient-poor conditions that has a variety of biological effects including vascular injury and capillary leak. OBJECTIVES To assess the role of ANGPTL4 in COVID-19-related outcomes. DESIGN SETTING AND PARTICIPANTS Two hundred twenty-five COVID-19 ICU patients were enrolled from April 2020 to May 2021 in a prospective, multicenter cohort study from three different medical centers, University of Washington, University of Southern California and New York University. MAIN OUTCOMES AND MEASURES Plasma ANGPTL4 was measured on days 1, 7, and 14 after ICU admission. We used previously published tissue proteomic data and lung single nucleus RNA (snRNA) sequencing data from specimens collected from COVID-19 patients to determine the tissues and cells that produce ANGPTL4. RESULTS Higher plasma ANGPTL4 concentrations were significantly associated with worse hospital mortality (adjusted odds ratio per log2 increase, 1.53; 95% CI, 1.17-2.00; p = 0.002). Higher ANGPTL4 concentrations were also associated with higher proportions of venous thromboembolism and acute respiratory distress syndrome. Longitudinal ANGPTL4 concentrations were significantly different during the first 2 weeks of hospitalization in patients who subsequently died compared with survivors (p for interaction = 8.1 × 10-5). Proteomics analysis demonstrated abundance of ANGPTL4 in lung tissue compared with other organs in COVID-19. ANGPTL4 single-nuclear RNA gene expression was significantly increased in pulmonary alveolar type 2 epithelial cells and fibroblasts in COVID-19 lung tissue compared with controls. CONCLUSIONS AND RELEVANCE ANGPTL4 is expressed in pulmonary epithelial cells and fibroblasts and is associated with clinical prognosis in critically ill COVID-19 patients.
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Affiliation(s)
- Pavan K Bhatraju
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington Medical Center, Seattle, WA
- School of Medicine, University of Washington, Sepsis Center of Research Excellence-University of Washington (SCORE-UW), Seattle, WA
- Kidney Research Institute, Division of Nephrology, Department of Medicine, University of Washington Medical Center, Seattle, WA
| | - Eric D Morrell
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington Medical Center, Seattle, WA
| | - Ian B Stanaway
- Kidney Research Institute, Division of Nephrology, Department of Medicine, University of Washington Medical Center, Seattle, WA
| | - Neha A Sathe
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington Medical Center, Seattle, WA
| | - Avantika Srivastava
- Department of Biomedical Informatics, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Radu Postelnicu
- Division of Pulmonary, Critical Care, and Sleep Medicine, NYU Grossman School of Medicine, NYU Langone Health, New York, NY
| | - Richard Green
- Departments of Medicine (Division of Medical Genetics) and Genome Sciences, University of Washington Medical Center, Seattle, WA
| | - Adair Andrews
- Society of Critical Care Medicine, Mount Prospect, IL
| | | | | | | | | | - Michael Gale
- Department of Immunology, University of Washington, Seattle, WA
| | - George L Anesi
- Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - David Wyles
- Division of Infectious Diseases, Denver Health Medical Center, Denver, CO
| | - M Jana Broadhurst
- Global Center for Health Security, University of Nebraska Medical Center, Omaha, NE
| | - David Brett-Major
- Global Center for Health Security, University of Nebraska Medical Center, Omaha, NE
| | - Vikramjit Mukherjee
- Division of Pulmonary, Critical Care, and Sleep Medicine, NYU Grossman School of Medicine, NYU Langone Health, New York, NY
| | - Jonathan E Sevransky
- Division of Pulmonary, Allergy, Critical Care and Sleep, School of Medicine, Emory University, Atlanta, GA
- Emory Critical Care Center, Emory Healthcare, Atlanta, GA
| | - Douglas Landsittel
- Department of Epidemiology and Biostatistics, School of Public Health, Indiana University, Bloomington, IN
| | - Chi Hung
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington Medical Center, Seattle, WA
| | - William A Altemeier
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington Medical Center, Seattle, WA
| | - Sina A Gharib
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington Medical Center, Seattle, WA
| | - Timothy M Uyeki
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, GA
| | - J Perren Cobb
- Departments of Surgery and Anesthesiology, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA
| | - Janice M Liebler
- Division of Pulmonary, Critical Care and Sleep Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - David R Crosslin
- Division of Biomedical Informatics and Genomics, John W. Deming Department of Medicine, Tulane University, School of Medicine, New Orleans, LA
| | - Gail P Jarvik
- Departments of Medicine (Division of Medical Genetics) and Genome Sciences, University of Washington Medical Center, Seattle, WA
| | - Leopoldo N Segal
- Division of Pulmonary, Critical Care, and Sleep Medicine, NYU Grossman School of Medicine, NYU Langone Health, New York, NY
| | - Laura Evans
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington Medical Center, Seattle, WA
| | - Carmen Mikacenic
- Translational Research, Benaroya Research Institute, Seattle, WA
| | - Mark M Wurfel
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington Medical Center, Seattle, WA
- School of Medicine, University of Washington, Sepsis Center of Research Excellence-University of Washington (SCORE-UW), Seattle, WA
- Kidney Research Institute, Division of Nephrology, Department of Medicine, University of Washington Medical Center, Seattle, WA
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8
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Wu W, Bhatraju PK, Cobb N, Sathe NA, Duan KI, Seitz KP, Thau MR, Sung CC, Hippe DS, Reddy G, Pipavath S. Radiographic Findings and Association With Clinical Severity and Outcomes in Critically Ill Patients With COVID-19. Curr Probl Diagn Radiol 2022; 51:884-891. [PMID: 35610068 PMCID: PMC9023378 DOI: 10.1067/j.cpradiol.2022.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 03/16/2022] [Accepted: 04/18/2022] [Indexed: 01/08/2023]
Abstract
PURPOSE To describe evolution and severity of radiographic findings and assess association with disease severity and outcomes in critically ill COVID-19 patients. MATERIALS AND METHODS This retrospective study included 62 COVID-19 patients admitted to the intensive care unit (ICU). Clinical data was obtained from electronic medical records. A total of 270 chest radiographs were reviewed and qualitatively scored (CXR score) using a severity scale of 0-30. Radiographic findings were correlated with clinical severity and outcome. RESULTS The CXR score increases from a median initial score of 10 at hospital presentation to the median peak CXR score of 18 within a median time of 4 days after hospitalization, and then slowly decreases to a median last CXR score of 15 in a median time of 12 days after hospitalization. The initial and peak CXR score was independently associated with invasive MV after adjusting for age, gender, body mass index, smoking, and comorbidities (Initial, odds ratio [OR]: 2.11 per 5-point increase, confidence interval [CI] 1.35-3.32, P= 0.001; Peak, OR: 2.50 per 5-point increase, CI 1.48-4.22, P= 0.001). Peak CXR scores were also independently associated with vasopressor usage (OR: 2.28 per 5-point increase, CI 1.30-3.98, P= 0.004). Peak CXR scores strongly correlated with the duration of invasive MV (Rho = 0.62, P< 0.001), while the initial CXR score (Rho = 0.26) and the peak CXR score (Rho = 0.27) correlated weakly with the sequential organ failure assessment score. No statistically significant associations were found between radiographic findings and mortality. CONCLUSIONS Evolution of radiographic features indicates rapid disease progression and correlate with requirement for invasive MV or vasopressors but not mortality, which suggests potential nonpulmonary pathways to death in COVID-19.
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Affiliation(s)
- Wei Wu
- University of Washington School of Medicine, Department of Radiology, Seattle, WA.
| | - Pavan K Bhatraju
- University of Washington School of Medicine, Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Seattle, WA
| | - Natalie Cobb
- University of Washington School of Medicine, Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Seattle, WA
| | - Neha A Sathe
- University of Washington School of Medicine, Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Seattle, WA
| | - Kevin I Duan
- University of Washington School of Medicine, Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Seattle, WA
| | - Kevin P Seitz
- University of Washington School of Medicine, Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Seattle, WA
| | - Matthew R Thau
- University of Washington School of Medicine, Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Seattle, WA
| | - Clifford C Sung
- University of Washington School of Medicine, Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Seattle, WA
| | - Daniel S Hippe
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Gautham Reddy
- University of Washington School of Medicine, Department of Radiology, Seattle, WA
| | - Sudhakar Pipavath
- University of Washington School of Medicine, Department of Radiology, Seattle, WA
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9
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Morrell ED, Bhatraju PK, Sathe NA, Lawson J, Mabrey L, Holton SE, Presnell SR, Wiedeman A, Acosta-Vega C, Mitchem MA, Liu T, Chai XY, Sahi S, Brager C, Orlov M, Sakr SS, Sader A, Lum DM, Koetje N, Garay A, Barnes E, Cromer G, Bray MK, Pipavath S, Fink SL, Evans L, Long SA, West TE, Wurfel MM, Mikacenic C. Chemokines, soluble PD-L1, and immune cell hyporesponsiveness are distinct features of SARS-CoV-2 critical illness. Am J Physiol Lung Cell Mol Physiol 2022; 323:L14-L26. [PMID: 35608267 PMCID: PMC9208434 DOI: 10.1152/ajplung.00049.2022] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Critically ill patients manifest many of the same immune features seen in coronavirus disease 2019 (COVID-19), including both "cytokine storm" and "immune suppression." However, direct comparisons of molecular and cellular profiles between contemporaneously enrolled critically ill patients with and without severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) are limited. We sought to identify immune signatures specifically enriched in critically ill patients with COVID-19 compared with patients without COVID-19. We enrolled a multisite prospective cohort of patients admitted under suspicion for COVID-19, who were then determined to be SARS-CoV-2-positive (n = 204) or -negative (n = 122). SARS-CoV-2-positive patients had higher plasma levels of CXCL10, sPD-L1, IFN-γ, CCL26, C-reactive protein (CRP), and TNF-α relative to SARS-CoV-2-negative patients adjusting for demographics and severity of illness (Bonferroni P value < 0.05). In contrast, the levels of IL-6, IL-8, IL-10, and IL-17A were not significantly different between the two groups. In SARS-CoV-2-positive patients, higher plasma levels of sPD-L1 and TNF-α were associated with fewer ventilator-free days (VFDs) and higher mortality rates (Bonferroni P value < 0.05). Lymphocyte chemoattractants such as CCL17 were associated with more severe respiratory failure in SARS-CoV-2-positive patients, but less severe respiratory failure in SARS-CoV-2-negative patients (P value for interaction < 0.01). Circulating T cells and monocytes from SARS-CoV-2-positive subjects were hyporesponsive to in vitro stimulation compared with SARS-CoV-2-negative subjects. Critically ill SARS-CoV-2-positive patients exhibit an immune signature of high interferon-induced lymphocyte chemoattractants (e.g., CXCL10 and CCL17) and immune cell hyporesponsiveness when directly compared with SARS-CoV-2-negative patients. This suggests a specific role for T-cell migration coupled with an immune-checkpoint regulatory response in COVID-19-related critical illness.
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Affiliation(s)
- Eric D Morrell
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington.,Hospital and Specialty Medicine, VA Puget Sound Health Care System, Seattle, Washington
| | - Pavan K Bhatraju
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Neha A Sathe
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Jonathan Lawson
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Linzee Mabrey
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Sarah E Holton
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Scott R Presnell
- Translational Immunology, Benaroya Research Institute, Seattle, Washington
| | - Alice Wiedeman
- Translational Immunology, Benaroya Research Institute, Seattle, Washington
| | | | - Mallorie A Mitchem
- Translational Immunology, Benaroya Research Institute, Seattle, Washington
| | - Ted Liu
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Xin-Ya Chai
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Sharon Sahi
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Carolyn Brager
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Marika Orlov
- Hospital and Specialty Medicine, VA Puget Sound Health Care System, Seattle, Washington
| | - Sana S Sakr
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Anthony Sader
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Dawn M Lum
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Neall Koetje
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Ashley Garay
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Elizabeth Barnes
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Gail Cromer
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Mary K Bray
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Sudhakar Pipavath
- Department of Radiology, University of Washington, Seattle, Washington
| | - Susan L Fink
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington
| | - Laura Evans
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - S Alice Long
- Translational Immunology, Benaroya Research Institute, Seattle, Washington
| | - T Eoin West
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Mark M Wurfel
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Carmen Mikacenic
- Translational Immunology, Benaroya Research Institute, Seattle, Washington
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Sathe NA, Bhatraju PK, Mikacenic C, Morrell ED, Mabrey FL, Liles WC, Wurfel MM. Relationships Between Age, Soluble Triggering Receptor Expressed on Myeloid Cells-1 (sTREM-1), and Mortality Among Critically Ill Adults: A Cohort Study. Shock 2022; 57:205-211. [PMID: 34812186 PMCID: PMC8969235 DOI: 10.1097/shk.0000000000001888] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Innate immune dysregulation may contribute to age-related differences in outcomes among critically ill adults. Soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) is an important innate immune marker with prognostic value in sepsis, but age-related differences have not been studied. METHODS This was a prospective cohort from a large tertiary care hospital enrolling adults from both medical and trauma-surgical intensive care units (ICUs). Plasma sTREM-1 was measured in participants within 24 h of ICU admission. We analyzed associations between age (≤50 and >50 years) and sTREM-1 using linear regression. We then examined associations between sTREM-1 and both 28-day mortality and persistent organ dysfunction (defined as need for dialysis, vasopressors, or invasive mechanical ventilation) 7 days following admission using relative risk regression. RESULTS Of 231 critically ill adults, older patients (n = 122) had higher prevalence of chronic disease and sepsis on enrollment than younger patients, but acute illness severity was similar. Age over 50 was associated with 27% higher sTREM-1 concentrations (95% CI 6%-53%), adjusted for sex and Charlson comorbidity index (CCI). Two-fold higher sTREM-1 was associated with 2.42-fold higher risk for mortality (95% CI 1.57, 3.73) and 1.86-fold higher risk for persistent organ dysfunction (95% CI 1.45, 2.39), adjusted for sex, CCI, and age. CONCLUSIONS sTREM-1 was elevated among critically ill older adults, and strongly associated with both death and persistent organ dysfunction. Immune responses associated with sTREM-1 may contribute to age-related differences in ICU outcomes, warranting further study as a potential therapeutic target in older adults.
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Affiliation(s)
- Neha A. Sathe
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - Pavan K. Bhatraju
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
- Sepsis Center of Research Excellence-University of Washington (SCORE-UW)
| | - Carmen Mikacenic
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
- Benaroya Research Institute, Seattle, WA
| | - Eric D. Morrell
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
- Sepsis Center of Research Excellence-University of Washington (SCORE-UW)
| | - F. Linzee Mabrey
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - W. Conrad Liles
- Sepsis Center of Research Excellence-University of Washington (SCORE-UW)
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA
| | - Mark M. Wurfel
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
- Sepsis Center of Research Excellence-University of Washington (SCORE-UW)
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11
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Bhatraju PK, Chai XY, Sathe NA, Ruzinski J, Siew ED, Himmelfarb J, Hoofnagle AN, Wurfel MM, Kestenbaum BR. Assessment of kidney proximal tubular secretion in critical illness. JCI Insight 2021; 6:145514. [PMID: 33886506 PMCID: PMC8262320 DOI: 10.1172/jci.insight.145514] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 04/21/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUNDSerum creatinine concentrations (SCrs) are used to determine the presence and severity of acute kidney injury (AKI). SCr is primarily eliminated by glomerular filtration; however, most mechanisms of AKI in critical illness involve kidney proximal tubules, where tubular secretion occurs. Proximal tubular secretory clearance is not currently estimated in the intensive care unit (ICU). Our objective was to estimate the kidney clearance of secretory solutes in critically ill adults.METHODSWe collected matched blood and spot urine samples from 170 ICU patients and from a comparison group of 70 adults with normal kidney function. We measured 7 endogenously produced secretory solutes using liquid chromatography-tandem mass spectrometry. We computed a composite secretion score incorporating all 7 solutes and evaluated associations with 28-day major adverse kidney events (MAKE28), defined as doubling of SCr, dialysis dependence, or death.RESULTSThe urine-to-plasma ratios of 6 of 7 secretory solutes were lower in critically ill patients compared with healthy individuals after adjustment for SCr. The composite secretion score was moderately correlated with SCr and cystatin C (r = -0.51 and r = -0.53, respectively). Each SD higher composite secretion score was associated with a 25% lower risk of MAKE28 (95% CI 9% to 38% lower) independent of severity of illness, SCr, and tubular injury markers. Higher urine-to-plasma ratios of individual secretory solutes isovalerylglycine and tiglylglycine were associated with MAKE28 after accounting for multiple testing.CONCLUSIONAmong critically ill adults, tubular secretory clearance is associated with adverse outcomes, and its measurement could improve assessment of kidney function and dosing of essential ICU medications.FUNDINGGrants from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK/NIH) K23DK116967, the University of Washington Diabetes Research Center P30DK017047, an unrestricted gift to the Kidney Research Institute from the Northwest Kidney Centers, and the Vanderbilt O'Brien Kidney Center (NIDDK 5P30 DK114809-03). The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.
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Affiliation(s)
- Pavan K Bhatraju
- Division of Pulmonary, Critical Care and Sleep Medicine and.,Kidney Research Institute, Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Xin-Ya Chai
- Division of Pulmonary, Critical Care and Sleep Medicine and
| | - Neha A Sathe
- Division of Pulmonary, Critical Care and Sleep Medicine and
| | - John Ruzinski
- Kidney Research Institute, Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Edward D Siew
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Vanderbilt Integrated Program for AKI, Nashville, Tennessee, USA.,Tennessee Valley Health Services, Nashville VA Medical Center, Nashville, Tennessee, USA
| | - Jonathan Himmelfarb
- Kidney Research Institute, Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Andrew N Hoofnagle
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | - Mark M Wurfel
- Division of Pulmonary, Critical Care and Sleep Medicine and
| | - Bryan R Kestenbaum
- Kidney Research Institute, Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington, USA
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12
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Bhatraju PK, Morrell ED, Zelnick L, Sathe NA, Chai XY, Sakr SS, Sahi SK, Sader A, Lum DM, Liu T, Koetje N, Garay A, Barnes E, Lawson J, Cromer G, Bray MK, Pipavath S, Kestenbaum BR, Liles WC, Fink SL, West TE, Evans L, Mikacenic C, Wurfel MM. Comparison of host endothelial, epithelial and inflammatory response in ICU patients with and without COVID-19: a prospective observational cohort study. Crit Care 2021; 25:148. [PMID: 33874973 PMCID: PMC8054255 DOI: 10.1186/s13054-021-03547-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 03/22/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Analyses of blood biomarkers involved in the host response to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) viral infection can reveal distinct biological pathways and inform development and testing of therapeutics for COVID-19. Our objective was to evaluate host endothelial, epithelial and inflammatory biomarkers in COVID-19. METHODS We prospectively enrolled 171 ICU patients, including 78 (46%) patients positive and 93 (54%) negative for SARS-CoV-2 infection from April to September, 2020. We compared 22 plasma biomarkers in blood collected within 24 h and 3 days after ICU admission. RESULTS In critically ill COVID-19 and non-COVID-19 patients, the most common ICU admission diagnoses were respiratory failure or pneumonia, followed by sepsis and other diagnoses. Similar proportions of patients in both groups received invasive mechanical ventilation at the time of study enrollment. COVID-19 and non-COVID-19 patients had similar rates of acute respiratory distress syndrome, severe acute kidney injury, and in-hospital mortality. While concentrations of interleukin 6 and 8 were not different between groups, markers of epithelial cell injury (soluble receptor for advanced glycation end products, sRAGE) and acute phase proteins (serum amyloid A, SAA) were significantly higher in COVID-19 compared to non-COVID-19, adjusting for demographics and APACHE III scores. In contrast, angiopoietin 2:1 (Ang-2:1 ratio) and soluble tumor necrosis factor receptor 1 (sTNFR-1), markers of endothelial dysfunction and inflammation, were significantly lower in COVID-19 (p < 0.002). Ang-2:1 ratio and SAA were associated with mortality only in non-COVID-19 patients. CONCLUSIONS These studies demonstrate that, unlike other well-studied causes of critical illness, endothelial dysfunction may not be characteristic of severe COVID-19 early after ICU admission. Pathways resulting in elaboration of acute phase proteins and inducing epithelial cell injury may be promising targets for therapeutics in COVID-19.
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Affiliation(s)
- Pavan K Bhatraju
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, 325 9th Avenue, Seattle, WA, 98104, USA.
- Sepsis Center of Research Excellence - University of Washington (SCORE-UW), Seattle, WA, USA.
- Division of Nephrology, Department of Medicine, Kidney Research Institute, University of Washington, Seattle, USA.
| | - Eric D Morrell
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, 325 9th Avenue, Seattle, WA, 98104, USA
| | - Leila Zelnick
- Division of Nephrology, Department of Medicine, Kidney Research Institute, University of Washington, Seattle, USA
| | - Neha A Sathe
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, 325 9th Avenue, Seattle, WA, 98104, USA
| | - Xin-Ya Chai
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, 325 9th Avenue, Seattle, WA, 98104, USA
| | - Sana S Sakr
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, 325 9th Avenue, Seattle, WA, 98104, USA
| | - Sharon K Sahi
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, 325 9th Avenue, Seattle, WA, 98104, USA
| | - Anthony Sader
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, 325 9th Avenue, Seattle, WA, 98104, USA
| | - Dawn M Lum
- Division of Nephrology, Department of Medicine, Kidney Research Institute, University of Washington, Seattle, USA
| | - Ted Liu
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, 325 9th Avenue, Seattle, WA, 98104, USA
| | - Neall Koetje
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, 325 9th Avenue, Seattle, WA, 98104, USA
| | - Ashley Garay
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, 325 9th Avenue, Seattle, WA, 98104, USA
| | - Elizabeth Barnes
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, 325 9th Avenue, Seattle, WA, 98104, USA
| | - Jonathan Lawson
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, 325 9th Avenue, Seattle, WA, 98104, USA
| | - Gail Cromer
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, 325 9th Avenue, Seattle, WA, 98104, USA
| | - Mary K Bray
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, 325 9th Avenue, Seattle, WA, 98104, USA
| | | | - Bryan R Kestenbaum
- Division of Nephrology, Department of Medicine, Kidney Research Institute, University of Washington, Seattle, USA
| | - W Conrad Liles
- Sepsis Center of Research Excellence - University of Washington (SCORE-UW), Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Susan L Fink
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA
| | - T Eoin West
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, 325 9th Avenue, Seattle, WA, 98104, USA
| | - Laura Evans
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, 325 9th Avenue, Seattle, WA, 98104, USA
| | - Carmen Mikacenic
- Translational Research, Benaroya Research Institute, Seattle, WA, USA
| | - Mark M Wurfel
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, 325 9th Avenue, Seattle, WA, 98104, USA
- Sepsis Center of Research Excellence - University of Washington (SCORE-UW), Seattle, WA, USA
- Division of Nephrology, Department of Medicine, Kidney Research Institute, University of Washington, Seattle, USA
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13
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Sathe NA, Nocon RS, Hughes B, Peek ME, Chin MH, Huang ES. The Costs of Participating in a Diabetes Quality Improvement Collaborative: Variation Among Five Clinics. Jt Comm J Qual Patient Saf 2016; 42:18-25. [PMID: 26685930 DOI: 10.1016/s1553-7250(16)42002-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Quality improvement collaboratives (QICs) support rapid testing and implementation of interventions through the collective experience of participating organizations to improve care quality and reduce costs. Although QICs have been societally cost-effective in improving the care of chronic diseases, they may not be adopted by outpatient clinics if their costs are high. Diabetes QICs warrant reexamination as secular trends in the quality of diabetes care, new care guidelines for diabetes, and evolving strategies for quality improvement may have altered implementation costs. METHODS The costs over the first four years-from June 2009 through May 2013-of an ongoing diabetes QIC were characterized by activities and over time. The QIC, linking six clinics on Chicago's South Side, tailored interventions to minority populations and built community partnerships. Costs were calculated from clinic surveys regarding activities, labor, and purchases. RESULTS Data were obtained from five of the six participating clinics. Cost/diabetic patient/year ranged across clinic sites from $6 (largest clinic) to $68 (smallest clinic). Clinics spent 62%-88% of their total QIC costs on labor. The cost/diabetic patient/year changed over time from Year 1 (range across clinics, $5-$51), Year 2 ($11-$84), Year 3 ($4-$57), to Year 4 ($4-$80), with costs peaking at Year 2 for all clinics except Clinic 4, where costs peaked at Year 4. DISCUSSION Cost experiences of QICs in clinics were di- verse over time and setting. High per-patient costs may stem from small clinic size, a sicker patient population, and variation in personnel type used. Cost decreases over time may represent increasing organizational learning and efficiency. Sharing resources may have achieved additional cost savings. This practical information can help administrators and policy makers predict, manage, and support costs of QICs as payers increasingly seek high-value health care.
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Affiliation(s)
- Neha A Sathe
- Pritzker School of Medicine, University of Chicago, USA
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14
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Jerome RN, Giuse NB, Gish KW, Sathe NA, Dietrich MS. Information needs of clinical teams: analysis of questions received by the Clinical Informatics Consult Service. Bull Med Libr Assoc 2001; 89:177-84. [PMID: 11337949 PMCID: PMC31725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
Abstract
OBJECTIVES To examine the types of questions received by Clinical Informatics Consult Service (CICS) librarians from clinicians on rounds and to analyze the number of clearly differentiated viewpoints provided in response. DESIGN Questions were retrieved from an internal database, the CICS Knowledge Base, and analyzed for redundancy by subject analysis. The unique questions were classified into ten categories by subject. Treatment-related questions were analyzed for the number of viewpoints represented in the librarian's response. RESULTS The CICS Knowledge Base contained 476 unique questions and 71 redundant questions. Among the unique queries, the top two categories accounted for 67%: treatment (36%) and disease description (31%). Within the treatment-related subset, 138 questions (59%) required representation of more than one viewpoint in the librarian's response. DISCUSSION Questions generated by clinicians frequently require comprehensive, critical appraisal of the medical literature, a need that can be filled by librarians trained in such techniques. This study demonstrates that many questions require representation of more than one viewpoint to answer completely. Moreover, the redundancy rate underscores the need for resources like the CICS Knowledge Base. By critically analyzing the medical literature, CICS librarians are providing a time-saving and valuable service for clinicians and charting new territory for librarians.
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Affiliation(s)
- R N Jerome
- Annette and Irwin Eskind Biomedical Library, Vanderbilt University Medical Center, Nashville, Tennessee 37232, USA
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15
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Williams MD, Gish KW, Giuse NB, Sathe NA, Carrell DL. The Patient Informatics Consult Service (PICS): an approach for a patient-centered service. Bull Med Libr Assoc 2001; 89:185-93. [PMID: 11337950 PMCID: PMC31726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
Abstract
The Patient Informatics Consult Service (PICS) at the Eskind Biomedical Library at Vanderbilt University Medical Center (VUMC) provides patients with consumer-friendly information by using an information prescription mechanism. Clinicians refer patients to the PICS by completing the prescription and noting the patient's condition and any relevant factors. In response, PICS librarians critically appraise and summarize consumer-friendly materials into a targeted information report. Copies of the report are given to both patient and clinician, thus facilitating doctor-patient communication and closing the clinician-librarian feedback loop. Moreover, the prescription form also circumvents many of the usual barriers for patients in locating information, namely, patients' unfamiliarity with medical terminology and lack of knowledge of authoritative sources. PICS librarians capture the time and expertise put into these reports by creating Web-based pathfinders on prescription topics. Pathfinders contain librarian-created disease overviews and links to authoritative resources and seek to minimize the consumer's exposure to unreliable information. Pathfinders also adhere to strict guidelines that act as a model for locating, appraising, and summarizing information for consumers. These mechanisms--the information prescription, research reports, and pathfinders--serve as steps toward the long-term goal of full integration of consumer health information into patient care at VUMC.
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Affiliation(s)
- M D Williams
- Annette and Irwin Eskind Biomedical Library, Vanderbilt University Medical Center, Nashville, Tennessee 37232-8340, USA
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Giuse NB, Kafantaris SR, Miller MD, Wilder KS, Martin SL, Sathe NA, Campbell JD. Clinical medical librarianship: the Vanderbilt experience. Bull Med Libr Assoc 1998; 86:412-6. [PMID: 9681179 PMCID: PMC226391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- N B Giuse
- Annette and Irwin Eskind Biomedical Library, Vanderbilt University Medical Center, Nashville, Tennessee 37232, USA
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