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Guduguntla BA, Vasbinder A, Anderson E, Azam TU, Blakely P, Webster NJ, Gonzalez R, Atonucci T, Heidebrink JL, Giordani B, Zahodne L, Hampstead BM, Ajrouch KJ, Hayek SS. Biomarkers of chronic inflammation and cognitive decline: A prospective observational study. Alzheimers Dement (Amst) 2024; 16:e12568. [PMID: 38532827 PMCID: PMC10964918 DOI: 10.1002/dad2.12568] [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] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 02/09/2024] [Accepted: 02/14/2024] [Indexed: 03/28/2024]
Abstract
We sought to determine whether the biomarkers of chronic inflammation predict cognitive decline in a prospective observational study. We measured baseline serum soluble urokinase plasminogen activator receptor (suPAR) and high sensitivity C-reactive protein (hs-CRP) levels in 282 participants of the University of Michigan Memory and Aging Project. Cognitive function was measured using the Montreal Cognitive Assessment (MoCA) and the Clinical Dementia Rating (CDR) scale for up to five time points. SuPAR and hs-CRP levels were not significantly higher in participants with mild cognitive impairment (n = 97) or dementia (n = 59), compared to those with normal cognitive function (n = 126). Overall, 14% of participants experienced significant cognitive decline over the study period. The change in MoCA or CDR scores over time did not differ significantly according to baseline suPAR or hs-CRP levels. Chronic systemic inflammation, as measured by serum suPAR or hs-CRP levels, is unlikely to contribute significantly to cognitive decline.
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Affiliation(s)
| | - Alexi Vasbinder
- Division of CardiologyDepartment of Internal MedicineUniversity of MichiganAnn ArborMichiganUSA
| | - Elizabeth Anderson
- Division of CardiologyDepartment of Internal MedicineUniversity of MichiganAnn ArborMichiganUSA
| | - Tariq U. Azam
- Division of CardiologyDepartment of Internal MedicineUniversity of MichiganAnn ArborMichiganUSA
| | - Pennelope Blakely
- Division of CardiologyDepartment of Internal MedicineUniversity of MichiganAnn ArborMichiganUSA
| | - Noah J. Webster
- Institute for Social ResearchUniversity of MichiganAnn ArborMichiganUSA
| | - Richard Gonzalez
- Department of PsychologyUniversity of MichiganAnn ArborMichiganUSA
| | - Toni Atonucci
- Department of PsychologyUniversity of MichiganAnn ArborMichiganUSA
| | | | - Bruno Giordani
- Department of PsychologyUniversity of MichiganAnn ArborMichiganUSA
- Department of NeurologyUniversity of MichiganAnn ArborMichiganUSA
- Department of PsychiatryUniversity of MichiganAnn ArborMichiganUSA
| | - Laura Zahodne
- Department of PsychologyUniversity of MichiganAnn ArborMichiganUSA
| | - Benjamin M. Hampstead
- Department of PsychiatryUniversity of MichiganAnn ArborMichiganUSA
- Mental Health Service Line, Veterans Affairs Ann Arbor Healthcare SystemAnn ArborMichiganUSA
| | - Kristine J. Ajrouch
- Institute for Social ResearchUniversity of MichiganAnn ArborMichiganUSA
- Eastern Michigan UniversityYpsilantiMichiganUSA
| | - Salim S. Hayek
- Division of CardiologyDepartment of Internal MedicineUniversity of MichiganAnn ArborMichiganUSA
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Vasbinder A, Padalia K, Pizzo I, Machado K, Catalan T, Presswalla F, Anderson E, Ismail A, Hutten C, Huang Y, Blakely P, Azam TU, Berlin H, Feroze R, Launius C, Meloche C, Michaud E, O'Hayer P, Pan M, Shadid HR, Rasmussen LJH, Roberts DA, Zhao L, Banerjee M, Murthy V, Loosen SH, Chalkias A, Tacke F, Reiser J, Giamarellos-Bourboulis EJ, Eugen-Olsen J, Pop-Busui R, Hayek SS. SuPAR, biomarkers of inflammation, and severe outcomes in patients hospitalized for COVID-19: The International Study of Inflammation in COVID-19. J Med Virol 2024; 96:e29389. [PMID: 38235904 PMCID: PMC10829525 DOI: 10.1002/jmv.29389] [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: 11/02/2023] [Revised: 12/13/2023] [Accepted: 12/28/2023] [Indexed: 01/19/2024]
Abstract
Severe coronavirus disease 2019 (COVID-19) is a hyperinflammatory syndrome. The biomarkers of inflammation best suited to triage patients with COVID-19 are unknown. We conducted a prospective multicenter observational study of adult patients hospitalized specifically for COVID-19 from February 1, 2020 to October 19, 2022. Biomarkers measured included soluble urokinase plasminogen activator receptor (suPAR), C-reactive protein, interleukin-6, procalcitonin, ferritin, and D-dimer. In-hospital outcomes examined include death and the need for mechanical ventilation. Patients admitted in the United States (US, n = 1962) were used to compute area under the curves (AUCs) and identify biomarker cutoffs. The combined European cohorts (n = 1137) were used to validate the biomarker cutoffs. In the US cohort, 356 patients met the composite outcome of death (n = 197) or need for mechanical ventilation (n = 290). SuPAR was the most important predictor of the composite outcome and had the highest AUC (0.712) followed by CRP (0.642), ferritin (0.619), IL-6 (0.614), D-dimer (0.606), and lastly procalcitonin (0.596). Inclusion of other biomarkers did not improve discrimination. A suPAR cutoff of 4.0 ng/mL demonstrated a sensitivity of 95.4% (95% CI: 92.4%-98.0%) and negative predictive value (NPV) of 92.5% (95% CI: 87.5%-96.9%) for the composite outcome. Patients with suPAR < 4.0 ng/mL comprised 10.6% of the cohort and had a 0.8% probability of the composite outcome. Applying this cutoff to the validation cohort yielded a sensitivity of 93.8% (90.4%-96.7%) and NPV of 95.5% (93.1%-97.8%) for the composite outcome. Among commonly measured biomarkers, suPAR offered stronger discriminatory ability and may be useful in triaging low-risk patients with COVID-19.
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Affiliation(s)
- Alexi Vasbinder
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Kishan Padalia
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Ian Pizzo
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Kristen Machado
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Tonimarie Catalan
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Feriel Presswalla
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Elizabeth Anderson
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Anis Ismail
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Christina Hutten
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Yiyuan Huang
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | - Pennelope Blakely
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Tariq U Azam
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Hanna Berlin
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Rafey Feroze
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Christopher Launius
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Chelsea Meloche
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Erinleigh Michaud
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Patrick O'Hayer
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Michael Pan
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Husam R Shadid
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Donald A Roberts
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan, USA
| | - Lili Zhao
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | - Mousumi Banerjee
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | - Venkatesh Murthy
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Sven H Loosen
- Clinic for Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Athanasios Chalkias
- Institute for Translational Medicine and Therapeutics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Outcomes Research Consortium, Cleveland, Ohio, USA
| | - Frank Tacke
- Department of Hepatology and Gastroenterology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Jochen Reiser
- Department of Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | | | - Jesper Eugen-Olsen
- Department of Clinical Research, Copenhagen University Hospital Amager and Hvidovre, Hvidovre, Denmark
| | - Rodica Pop-Busui
- Division of Endocrinology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Salim S Hayek
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
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Vasbinder A, Chen Y, Procureur A, Gradone A, Azam TU, Perry D, Shadid H, Anderson E, Catalan T, Blakely P, Nelapudi N, Fardous M, Bretagne MC, Adie SK, Pogue KT, Leja M, Yentz S, Schneider B, Fecher LA, Lao CD, Salem JE, Hayek SS. Biomarker Trends, Incidence, and Outcomes of Immune Checkpoint Inhibitor-Induced Myocarditis. JACC CardioOncol 2022; 4:689-700. [PMID: 36636441 PMCID: PMC9830199 DOI: 10.1016/j.jaccao.2022.11.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 11/02/2022] [Accepted: 11/04/2022] [Indexed: 12/24/2022] Open
Abstract
Background Myocarditis is a dreaded and unpredictable complication of immune checkpoint inhibitors (ICI). We sought to determine whether routinely measured biomarkers could be helpful in monitoring for ICI myocarditis. Objectives The authors examined biomarker trends of patients on ICI and their association with the incidence of ICI myocarditis and outcomes. Methods We conducted an observational cohort study of adults who received at least one dose of ICI at Michigan Medicine between June 2014 and December 2021 and underwent systematic serial testing for aspartate aminotransferase (AST) and alanine aminotransferase (ALT), creatine phosphokinase (CPK), and lactate dehydrogenase during ICI therapy. Results Among 2,606 patients (mean age 64 ± 13 years; 60.7% men), 27 (1.0%) were diagnosed with ICI myocarditis. At diagnosis, patients with myocarditis had an elevated high-sensitivity troponin T (100%), ALT (88.9%), AST (85.2%), CPK (88.9%), and lactate dehydrogenase (92.6%). Findings were confirmed in an independent cohort of 30 patients with biopsy-confirmed ICI myocarditis. A total of 95% of patients with ICI myocarditis had elevations in at least 3 biomarkers compared with 5% of patients without myocarditis. Among the noncardiac biomarkers, only CPK was associated (per 100% increase) with the development of myocarditis (HR: 1.83; 95% CI: 1.59-2.10) and all-cause mortality (HR: 1.10; 95% CI: 1.01-1.20) in multivariable analysis. Elevations in CPK had a sensitivity of 99% and specificity of 23% for identifying myocarditis. Conclusions ICI myocarditis is associated with changes in AST, ALT, and CPK. An increase in noncardiac biomarkers during ICI treatment, notably CPK, should prompt further evaluation for ICI myocarditis.
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Affiliation(s)
- Alexi Vasbinder
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - YeeAnn Chen
- Department of Clinical Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Adrien Procureur
- Department of Pharmacology and Clinical Investigation Centre, Pitié-Salpêtrière Hospital, Sorbonne Universite, Paris, France
| | - Allison Gradone
- Rogel Cancer Center, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Tariq U. Azam
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Daniel Perry
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Husam Shadid
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Elizabeth Anderson
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Tonimarie Catalan
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Pennelope Blakely
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Namratha Nelapudi
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Mohamad Fardous
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Marie C. Bretagne
- Department of Pharmacology and Clinical Investigation Centre, Pitié-Salpêtrière Hospital, Sorbonne Universite, Paris, France
| | - Sarah K. Adie
- Department of Clinical Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Kristen T. Pogue
- Department of Clinical Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
| | - Monika Leja
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Sarah Yentz
- Rogel Cancer Center, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Bryan Schneider
- Rogel Cancer Center, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Leslie A. Fecher
- Rogel Cancer Center, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Christopher D. Lao
- Rogel Cancer Center, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Joe-Elie Salem
- Department of Pharmacology and Clinical Investigation Centre, Pitié-Salpêtrière Hospital, Sorbonne Universite, Paris, France
| | - Salim S. Hayek
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA,Address for correspondence: Dr Salim Hayek, Department of Medicine, Division of Cardiology, University of Michigan Frankel Cardiovascular Center, 1500 East Medical Center Drive, CVC #2709, Ann Arbor, Michigan 48109, USA. @salimhayek
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Vasbinder A, Meloche C, Azam TU, Anderson E, Catalan T, Shadid H, Berlin H, Pan M, O’Hayer P, Padalia K, Blakely P, Khaleel I, Michaud E, Huang Y, Zhao L, Pop-Busui R, Gupta S, Eagle K, Leaf DE, Hayek SS. Relationship Between Preexisting Cardiovascular Disease and Death and Cardiovascular Outcomes in Critically Ill Patients With COVID-19. Circ Cardiovasc Qual Outcomes 2022; 15:e008942. [PMID: 36193749 PMCID: PMC9575399 DOI: 10.1161/circoutcomes.122.008942] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Preexisting cardiovascular disease (CVD) is perceived as a risk factor for poor outcomes in patients with COVID-19. We sought to determine whether CVD is associated with in-hospital death and cardiovascular events in critically ill patients with COVID-19. METHODS This study used data from a multicenter cohort of adults with laboratory-confirmed COVID-19 admitted to intensive care units at 68 centers across the United States from March 1 to July 1, 2020. The primary exposure was CVD, defined as preexisting coronary artery disease, congestive heart failure, or atrial fibrillation/flutter. Myocardial injury on intensive care unit admission defined as a troponin I or T level above the 99th percentile upper reference limit of normal was a secondary exposure. The primary outcome was 28-day in-hospital mortality. Secondary outcomes included cardiovascular events (cardiac arrest, new-onset arrhythmias, new-onset heart failure, myocarditis, pericarditis, or stroke) within 14 days. RESULTS Among 5133 patients (3231 male [62.9%]; mean age 61 years [SD, 15]), 1174 (22.9%) had preexisting CVD. A total of 1178 (34.6%) died, and 920 (17.9%) had a cardiovascular event. After adjusting for age, sex, race, body mass index, history of smoking, and comorbidities, preexisting CVD was associated with a 1.15 (95% CI, 0.98-1.34) higher odds of death. No independent association was observed between preexisting CVD and cardiovascular events. Myocardial injury on intensive care unit admission was associated with higher odds of death (adjusted odds ratio, 1.93 [95% CI, 1.61-2.31]) and cardiovascular events (adjusted odds ratio, 1.82 [95% CI, 1.47-2.24]), regardless of the presence of CVD. CONCLUSIONS CVD risk factors, rather than CVD itself, were the major contributors to outcomes in critically ill patients with COVID-19. The occurrence of myocardial injury, regardless of CVD, and its association with outcomes suggests it is likely due to multiorgan injury related to acute inflammation rather than exacerbation of preexisting CVD. REGISTRATION NCT04343898; https://clinicaltrials.gov/ct2/show/NCT04343898.
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Affiliation(s)
- Alexi Vasbinder
- Division of Cardiology, Department of Medicine (A.V., E.A., T.C., M.P., P.O., K.P., P.B., I.K., E.M., K.E., S.S.H.), University of Michigan, Ann Arbor
| | - Chelsea Meloche
- Department of Medicine (C.M., T.U.A., H.S., H.B.), University of Michigan, Ann Arbor
| | - Tariq U. Azam
- Department of Medicine (C.M., T.U.A., H.S., H.B.), University of Michigan, Ann Arbor
| | - Elizabeth Anderson
- Division of Cardiology, Department of Medicine (A.V., E.A., T.C., M.P., P.O., K.P., P.B., I.K., E.M., K.E., S.S.H.), University of Michigan, Ann Arbor
| | - Tonimarie Catalan
- Division of Cardiology, Department of Medicine (A.V., E.A., T.C., M.P., P.O., K.P., P.B., I.K., E.M., K.E., S.S.H.), University of Michigan, Ann Arbor
| | - Husam Shadid
- Department of Medicine (C.M., T.U.A., H.S., H.B.), University of Michigan, Ann Arbor
| | - Hanna Berlin
- Department of Medicine (C.M., T.U.A., H.S., H.B.), University of Michigan, Ann Arbor
| | - Michael Pan
- Division of Cardiology, Department of Medicine (A.V., E.A., T.C., M.P., P.O., K.P., P.B., I.K., E.M., K.E., S.S.H.), University of Michigan, Ann Arbor
| | - Patrick O’Hayer
- Division of Cardiology, Department of Medicine (A.V., E.A., T.C., M.P., P.O., K.P., P.B., I.K., E.M., K.E., S.S.H.), University of Michigan, Ann Arbor
| | - Kishan Padalia
- Division of Cardiology, Department of Medicine (A.V., E.A., T.C., M.P., P.O., K.P., P.B., I.K., E.M., K.E., S.S.H.), University of Michigan, Ann Arbor
| | - Pennelope Blakely
- Division of Cardiology, Department of Medicine (A.V., E.A., T.C., M.P., P.O., K.P., P.B., I.K., E.M., K.E., S.S.H.), University of Michigan, Ann Arbor
| | - Ibrahim Khaleel
- Division of Cardiology, Department of Medicine (A.V., E.A., T.C., M.P., P.O., K.P., P.B., I.K., E.M., K.E., S.S.H.), University of Michigan, Ann Arbor
| | - Erinleigh Michaud
- Division of Cardiology, Department of Medicine (A.V., E.A., T.C., M.P., P.O., K.P., P.B., I.K., E.M., K.E., S.S.H.), University of Michigan, Ann Arbor
| | - Yiyuan Huang
- Biostatistics Department, School of Public Health (Y.H., L.Z.), University of Michigan, Ann Arbor
| | - Lili Zhao
- Biostatistics Department, School of Public Health (Y.H., L.Z.), University of Michigan, Ann Arbor
| | - Rodica Pop-Busui
- Division of Metabolism, Endocrinology and Diabetes, Department of Medicine (R.P.-B.), University of Michigan, Ann Arbor
| | - Shruti Gupta
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, MA (S.G., D.E.L.)
| | - Kim Eagle
- Division of Cardiology, Department of Medicine (A.V., E.A., T.C., M.P., P.O., K.P., P.B., I.K., E.M., K.E., S.S.H.), University of Michigan, Ann Arbor
| | - David E. Leaf
- Division of Renal Medicine, Brigham and Women’s Hospital, Boston, MA (S.G., D.E.L.)
| | - Salim S. Hayek
- Division of Cardiology, Department of Medicine (A.V., E.A., T.C., M.P., P.O., K.P., P.B., I.K., E.M., K.E., S.S.H.), University of Michigan, Ann Arbor
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5
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Luo S, Vasbinder A, Du‐Fay‐de‐Lavallaz JM, Gomez JMD, Suboc T, Anderson E, Tekumulla A, Shadid H, Berlin H, Pan M, Azam TU, Khaleel I, Padalia K, Meloche C, O'Hayer P, Catalan T, Blakely P, Launius C, Amadi K, Pop‐Busui R, Loosen SH, Chalkias A, Tacke F, Giamarellos‐Bourboulis EJ, Altintas I, Eugen‐Olsen J, Williams KA, Volgman AS, Reiser J, Hayek SS. Soluble Urokinase Plasminogen Activator Receptor and Venous Thromboembolism in COVID-19. J Am Heart Assoc 2022; 11:e025198. [PMID: 35924778 PMCID: PMC9683642 DOI: 10.1161/jaha.122.025198] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 06/21/2022] [Indexed: 11/16/2022]
Abstract
Background Venous thromboembolism (VTE) contributes significantly to COVID-19 morbidity and mortality. The urokinase receptor system is involved in the regulation of coagulation. Levels of soluble urokinase plasminogen activator receptor (suPAR) reflect hyperinflammation and are strongly predictive of outcomes in COVID-19. Whether suPAR levels identify patients with COVID-19 at risk for VTE is unclear. Methods and Results We leveraged a multinational observational study of patients hospitalized for COVID-19 with suPAR and D-dimer levels measured on admission. In 1960 patients (mean age, 58 years; 57% men; 20% Black race), we assessed the association between suPAR and incident VTE (defined as pulmonary embolism or deep vein thrombosis) using logistic regression and Fine-Gray modeling, accounting for the competing risk of death. VTE occurred in 163 (8%) patients and was associated with higher suPAR and D-dimer levels. There was a positive association between suPAR and D-dimer (β=7.34; P=0.002). Adjusted for clinical covariables, including D-dimer, the odds of VTE were 168% higher comparing the third with first suPAR tertiles (adjusted odds ratio, 2.68 [95% CI, 1.51-4.75]; P<0.001). Findings were consistent when stratified by D-dimer levels and in survival analysis accounting for death as a competing risk. On the basis of predicted probabilities from random forest, a decision tree found the combined D-dimer <1 mg/L and suPAR <11 ng/mL cutoffs, identifying 41% of patients with only 3.6% VTE probability. Conclusions Higher suPAR was associated with incident VTE independently of D-dimer in patients hospitalized for COVID-19. Combining suPAR and D-dimer identified patients at low VTE risk. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT04818866.
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Affiliation(s)
- Shengyuan Luo
- Department of MedicineRush University Medical CenterChicagoIL
| | - Alexi Vasbinder
- Division of Cardiology, Department of Internal MedicineUniversity of MichiganAnn ArborMI
| | | | | | - Tisha Suboc
- Department of MedicineRush University Medical CenterChicagoIL
| | - Elizabeth Anderson
- Division of Cardiology, Department of Internal MedicineUniversity of MichiganAnn ArborMI
| | - Annika Tekumulla
- Division of Cardiology, Department of Internal MedicineUniversity of MichiganAnn ArborMI
| | - Husam Shadid
- Department of Internal MedicineUniversity of MichiganAnn ArborMI
| | - Hanna Berlin
- Department of Internal MedicineUniversity of MichiganAnn ArborMI
| | - Michael Pan
- Department of Internal MedicineUniversity of MichiganAnn ArborMI
| | - Tariq U. Azam
- Division of Cardiology, Department of Internal MedicineUniversity of MichiganAnn ArborMI
| | - Ibrahim Khaleel
- Department of Internal MedicineUniversity of MichiganAnn ArborMI
| | - Kishan Padalia
- Department of Internal MedicineUniversity of MichiganAnn ArborMI
| | - Chelsea Meloche
- Department of Internal MedicineUniversity of MichiganAnn ArborMI
| | - Patrick O'Hayer
- Department of Internal MedicineUniversity of MichiganAnn ArborMI
| | - Tonimarie Catalan
- Division of Cardiology, Department of Internal MedicineUniversity of MichiganAnn ArborMI
| | - Pennelope Blakely
- Division of Cardiology, Department of Internal MedicineUniversity of MichiganAnn ArborMI
| | - Christopher Launius
- Division of Cardiology, Department of Internal MedicineUniversity of MichiganAnn ArborMI
| | - Kingsley‐Michael Amadi
- Division of Cardiology, Department of Internal MedicineUniversity of MichiganAnn ArborMI
| | - Rodica Pop‐Busui
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal MedicineUniversity of MichiganAnn ArborMI
| | - Sven H. Loosen
- Clinic for Gastroenterology, Hepatology and Infectious Diseases, Medical FacultyUniversity Hospital DüsseldorfDüsseldorfGermany
| | - Athanasios Chalkias
- Department of Anesthesiology, Faculty of MedicineUniversity of ThessalyLarisaGreece
- Outcomes Research ConsortiumClevelandOH
| | - Frank Tacke
- Department of Hepatology and Gastroenterology, Campus Charité Mitte and Campus Virchow‐KlinikumCharité University Medicine BerlinBerlinGermany
| | | | - Izzet Altintas
- Department of Clinical ResearchCopenhagen University Hospital HvidovreHvidovreDenmark
| | - Jesper Eugen‐Olsen
- Department of Clinical ResearchCopenhagen University Hospital HvidovreHvidovreDenmark
| | - Kim A. Williams
- Department of Internal MedicineUniversity of Louisville School of MedicineLouisvilleKY
| | | | - Jochen Reiser
- Department of MedicineRush University Medical CenterChicagoIL
| | - Salim S. Hayek
- Division of Cardiology, Department of Internal MedicineUniversity of MichiganAnn ArborMI
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6
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Porter C, Azam TU, Mohananey D, Kumar R, Chu J, Lenihan D, Dent S, Ganatra S, Beasley GS, Okwuosa T. Permissive Cardiotoxicity. JACC CardioOncol 2022; 4:302-312. [PMID: 36213359 PMCID: PMC9537074 DOI: 10.1016/j.jaccao.2022.07.005] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/22/2022] [Accepted: 07/27/2022] [Indexed: 11/29/2022] Open
Abstract
The field of cardio-oncology was born from the necessity for recognition and management of cardiovascular diseases among patients with cancer. This need for this specialty continues to grow as patients with cancer live longer as a result of lifesaving targeted and immunologic cancer therapies beyond the usual chemotherapy and/or radiation therapy. Often, potentially cardiotoxic anticancer treatment is necessary in patients with baseline cardiovascular disease. Moreover, patients may need to continue therapy in the setting of incident cancer therapy–associated cardiotoxicity. Herein, we present and discuss the concept of permissive cardiotoxicity as a novel term that represents an essential concept in the field of cardio-oncology and among practicing cardio-oncology specialists. It emphasizes a proactive rather than reactive approach to continuation of lifesaving cancer therapies in order to achieve the best oncologic outcome while mitigating associated and potentially off-target cardiotoxicities. Permissive cardiotoxicity is a terminology that represents a vital concept in cardio-oncology It emphasizes continued cancer therapy if appropriate, while mitigating cardiotoxicities. Its application is guided by understanding the cancer treatment, alternatives, and prognosis.
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Affiliation(s)
- Charles Porter
- Department of Cardiovascular Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
- Address for correspondence: Dr Charles Porter, University of Kansas Medical Center, 4000 Cambridge, MS 1023, Kansas City, Kansas 66160, USA. @charlesporter99
| | - Tariq U. Azam
- Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Divyanshu Mohananey
- Division of Cardiology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Rohit Kumar
- Division of Medical Oncology, Department of Medicine, University of Louisville, Louisville, Kentucky, USA
| | - Jian Chu
- Department of Medicine, Rush University, Chicago, Illinois, USA
| | - Daniel Lenihan
- International Cardio-Oncology Society, Tampa, Florida, USA
| | - Susan Dent
- Duke Cancer Institute, Duke University, Durham, North Carolina, USA
| | - Sarju Ganatra
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Lahey Hospital and Medical Center, Beth Israel Lahey Health, Burlington, Massachusetts, USA
| | - Gary S. Beasley
- Division of Cardiology, Department of Pediatrics, University of Iowa Stead Family Children’s Hospital, Iowa City, Iowa, USA
| | - Tochukwu Okwuosa
- Division of Cardiology, Department of Internal Medicine, Rush University, Chicago, Illinois, USA
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Brenner SK, Azam TU, Parrillo JE, Hollenberg SM, Anderson E, O'Hayer P, Berlin H, Blakley P, Bitar A, Hayek SS. Right Ventricular Dysfunction in Critically Ill Patients With COVID-19. Am J Cardiol 2022; 168:176-178. [PMID: 35090698 PMCID: PMC8787645 DOI: 10.1016/j.amjcard.2022.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 01/09/2022] [Accepted: 01/10/2022] [Indexed: 11/27/2022]
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8
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Azam TU, Berlin H, Anderson E, Pan M, Shadid HR, Padalia K, O'Hayer P, Meloche C, Feroze R, Michaud E, Launius C, Blakely P, Bitar A, Willer C, Pop-Busui R, Carethers JM, Hayek SS. Differences in Inflammation, Treatment, and Outcomes Between Black and Non-Black Patients Hospitalized for COVID-19: A Prospective Cohort Study. Am J Med 2022; 135:360-368. [PMID: 34793753 PMCID: PMC8592847 DOI: 10.1016/j.amjmed.2021.10.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 09/20/2021] [Accepted: 10/13/2021] [Indexed: 12/16/2022]
Abstract
PURPOSE Racial disparities in coronavirus disease 2019 (COVID-19) outcomes have been described. We sought to determine whether differences in inflammatory markers, use of COVID-19 therapies, enrollment in clinical trials, and in-hospital outcomes contribute to racial disparities between Black and non-Black patients hospitalized for COVID-19. METHODS We leveraged a prospective cohort study that enrolled 1325 consecutive patients hospitalized for COVID-19, of whom 341 (25.7%) were Black. We measured biomarkers of inflammation and collected data on the use COVID-19-directed therapies, enrollment in COVID-19 clinical trials, mortality, need for renal replacement therapy, and need for mechanical ventilation. RESULTS Compared to non-Black patients, Black patients had a higher prevalence of COVID-19 risk factors including obesity, hypertension, and diabetes mellitus and were more likely to require renal replacement therapy (15.8% vs 7.1%, P < .001) and mechanical ventilation (37.2% vs 26.6%, P < .001) during their hospitalization. Mortality was similar between both groups (15.5% for Blacks vs 14.0% for non-Blacks, P = .49). Black patients were less likely to receive corticosteroids (44.9% vs 63.8%, P< .001) or remdesivir (23.8% vs 57.8%, P < .001) and were less likely to be enrolled in COVID-19 clinical trials (15.3% vs 28.2%, P < .001). In adjusted analyses, Black race was associated with lower levels of C-reactive protein and soluble urokinase receptor and higher odds of death, mechanical ventilation, and renal replacement therapy. Differences in outcomes were not significant after adjusting for use of remdesivir and corticosteroids. CONCLUSIONS Racial differences in outcomes of patients with COVID-19 may be related to differences in inflammatory response and differential use of therapies.
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Affiliation(s)
- Tariq U Azam
- Department of Internal Medicine, Division of Cardiology, University of Michigan, Ann Arbor
| | - Hanna Berlin
- University of Michigan Medical School, Ann Arbor
| | - Elizabeth Anderson
- Department of Internal Medicine, Division of Cardiology, University of Michigan, Ann Arbor
| | - Michael Pan
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Husam R Shadid
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Kishan Padalia
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Patrick O'Hayer
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Chelsea Meloche
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Rafey Feroze
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | | | - Christopher Launius
- Department of Internal Medicine, Division of Cardiology, University of Michigan, Ann Arbor
| | - Penelope Blakely
- Department of Internal Medicine, Division of Cardiology, University of Michigan, Ann Arbor
| | - Abbas Bitar
- Department of Internal Medicine, Division of Cardiology, University of Michigan, Ann Arbor
| | - Cristen Willer
- Department of Internal Medicine, Division of Cardiology, University of Michigan, Ann Arbor
| | - Rodica Pop-Busui
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor MI, USA
| | - John M Carethers
- Division of Gastroenterology & Hepatology, Department of Internal Medicine and Department of Human Genetics, University of Michigan, Ann Arbor
| | - Salim S Hayek
- Department of Internal Medicine, Division of Cardiology, University of Michigan, Ann Arbor.
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9
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Vasbinder A, Anderson E, Shadid H, Berlin H, Pan M, Azam TU, Khaleel I, Padalia K, Meloche C, O'Hayer P, Michaud E, Catalan T, Feroze R, Blakely P, Launius C, Huang Y, Zhao L, Ang L, Mikhael M, Mizokami-Stout K, Pennathur S, Kretzler M, Loosen SH, Chalkias A, Tacke F, Giamarellos-Bourboulis EJ, Reiser J, Eugen-Olsen J, Feldman EL, Pop-Busui R, Hayek SS. Inflammation, Hyperglycemia, and Adverse Outcomes in Individuals With Diabetes Mellitus Hospitalized for COVID-19. Diabetes Care 2022; 45:692-700. [PMID: 35045184 PMCID: PMC8918261 DOI: 10.2337/dc21-2102] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 12/19/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Diabetes mellitus (DM) is a major risk factor for severe coronavirus disease 2019 (COVID-19) for reasons that are unclear. RESEARCH DESIGN AND METHODS We leveraged the International Study of Inflammation in COVID-19 (ISIC), a multicenter observational study of 2,044 patients hospitalized with COVID-19, to characterize the impact of DM on in-hospital outcomes and assess the contribution of inflammation and hyperglycemia to the risk attributed to DM. We measured biomarkers of inflammation collected at hospital admission and collected glucose levels and insulin data throughout hospitalization. The primary outcome was the composite of in-hospital death, need for mechanical ventilation, and need for renal replacement therapy. RESULTS Among participants (mean age 60 years, 58.2% males), those with DM (n = 686, 33.5%) had a significantly higher cumulative incidence of the primary outcome (37.8% vs. 28.6%) and higher levels of inflammatory biomarkers than those without DM. Among biomarkers, DM was only associated with higher soluble urokinase plasminogen activator receptor (suPAR) levels in multivariable analysis. Adjusting for suPAR levels abrogated the association between DM and the primary outcome (adjusted odds ratio 1.23 [95% CI 0.78, 1.37]). In mediation analysis, we estimated the proportion of the effect of DM on the primary outcome mediated by suPAR at 84.2%. Hyperglycemia and higher insulin doses were independent predictors of the primary outcome, with effect sizes unaffected by adjusting for suPAR levels. CONCLUSIONS Our findings suggest that the association between DM and outcomes in COVID-19 is largely mediated by hyperinflammation as assessed by suPAR levels, while the impact of hyperglycemia is independent of inflammation.
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Affiliation(s)
- Alexi Vasbinder
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Elizabeth Anderson
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Husam Shadid
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Hanna Berlin
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Michael Pan
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Tariq U Azam
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Ibrahim Khaleel
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Kishan Padalia
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Chelsea Meloche
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Patrick O'Hayer
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Erinleigh Michaud
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Tonimarie Catalan
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Rafey Feroze
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Pennelope Blakely
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Christopher Launius
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Yiyuan Huang
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Lili Zhao
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Lynn Ang
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Monica Mikhael
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Kara Mizokami-Stout
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Subramaniam Pennathur
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Matthias Kretzler
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Sven H Loosen
- Medical Faculty, Clinic for Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Athanasios Chalkias
- Faculty of Medicine, Department of Anesthesiology, University of Thessaly, Larisa, Greece.,Outcomes Research Consortium, Cleveland, OH
| | - Frank Tacke
- Department of Hepatology and Gastroenterology, Campus Charité Mitte and Campus Virchow-Klinikum, Charité Universitätsmedizin Berlin, Berlin, Germany
| | | | - Jochen Reiser
- Department of Medicine, Rush University Medical Center, Chicago, IL
| | - Jesper Eugen-Olsen
- Department of Clinical Research, Copenhagen University Hospital Amager and Hvidovre, Hvidovre, Denmark
| | - Eva L Feldman
- Department of Neurology, University of Michigan, Ann Arbor, MI
| | - Rodica Pop-Busui
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Salim S Hayek
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
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10
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Pan M, Vasbinder A, Anderson E, Catalan T, Shadid HR, Berlin H, Padalia K, O'Hayer P, Meloche C, Azam TU, Khaleel I, Michaud E, Blakely P, Bitar A, Huang Y, Zhao L, Pop-Busui R, Loosen SH, Chalkias A, Tacke F, Giamarellos-Bourboulis EJ, Reiser J, Eugen-Olsen J, Hayek SS. Angiotensin-Converting Enzyme Inhibitors, Angiotensin II Receptor Blockers, and Outcomes in Patients Hospitalized for COVID-19. J Am Heart Assoc 2021; 10:e023535. [PMID: 34889102 PMCID: PMC9075226 DOI: 10.1161/jaha.121.023535] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Background Use of angiotensin‐converting enzyme inhibitors and angiotensin receptor blockers (ACEi/ARB) is thought to affect COVID‐19 through modulating levels of angiotensin‐converting enzyme 2, the cell entry receptor for SARS‐CoV2. We sought to assess the association between ACEi/ARB, biomarkers of inflammation, and outcomes in patients hospitalized for COVID‐19. Methods and Results We leveraged the ISIC (International Study of Inflammation in COVID‐19), identified patients admitted for symptomatic COVID‐19 between February 1, 2020 and June 1, 2021 for COVID‐19, and examined the association between in‐hospital ACEi/ARB use and all‐cause death, need for ventilation, and need for dialysis. We estimated the causal effect of ACEi/ARB on the composite outcomes using marginal structural models accounting for serial blood pressure and serum creatinine measures. Of 2044 patients in ISIC, 1686 patients met inclusion criteria, of whom 398 (23.6%) patients who were previously on ACEi/ARB received at least 1 dose during their hospitalization for COVID‐19. There were 215 deaths, 407 patients requiring mechanical ventilation, and 124 patients who required dialysis during their hospitalization. Prior ACEi/ARB use was associated with lower levels of soluble urokinase plasminogen activator receptor and C‐reactive protein. In multivariable analysis, in‐hospital ACEi/ARB use was associated with a lower risk of the composite outcome of in‐hospital death, mechanical ventilation, or dialysis (adjusted hazard ratio 0.49, 95% CI [0.36–0.65]). Conclusions In patients hospitalized for COVID‐19, ACEi/ARB use was associated with lower levels of inflammation and lower risk of in‐hospital outcomes. Clinical trials will define the role of ACEi/ARB in the treatment of COVID‐19. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT04818866.
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Affiliation(s)
- Michael Pan
- Department of Internal Medicine University of Michigan Ann Arbor MI
| | - Alexi Vasbinder
- Department of Internal Medicine University of Michigan Ann Arbor MI.,Division of Cardiology Department of Internal Medicine University of Michigan Ann Arbor MI
| | - Elizabeth Anderson
- Division of Cardiology Department of Internal Medicine University of Michigan Ann Arbor MI
| | - Toniemarie Catalan
- Division of Cardiology Department of Internal Medicine University of Michigan Ann Arbor MI
| | - Husam R Shadid
- Department of Internal Medicine University of Michigan Ann Arbor MI
| | - Hanna Berlin
- Department of Internal Medicine University of Michigan Ann Arbor MI
| | - Kishan Padalia
- Department of Internal Medicine University of Michigan Ann Arbor MI
| | - Patrick O'Hayer
- Department of Internal Medicine University of Michigan Ann Arbor MI
| | - Chelsea Meloche
- Department of Internal Medicine University of Michigan Ann Arbor MI
| | - Tariq U Azam
- Division of Cardiology Department of Internal Medicine University of Michigan Ann Arbor MI
| | - Ibrahim Khaleel
- Department of Internal Medicine University of Michigan Ann Arbor MI
| | | | - Pennelope Blakely
- Division of Cardiology Department of Internal Medicine University of Michigan Ann Arbor MI
| | - Abbas Bitar
- Division of Cardiology Department of Internal Medicine University of Michigan Ann Arbor MI
| | - Yiyuan Huang
- Department of Biostatistics School of Public Health University of Michigan Ann Arbor MI
| | - Lili Zhao
- Department of Biostatistics School of Public Health University of Michigan Ann Arbor MI
| | - Rodica Pop-Busui
- Division of Metabolism, Endocrinology and Diabetes Department of Internal Medicine University of Michigan Ann Arbor MI
| | - Sven H Loosen
- Clinic for Gastroenterology, Hepatology and Infectious Diseases Medical Faculty University Hospital Düsseldorf Düsseldorf Germany
| | - Athanasios Chalkias
- Department of Anesthesiology School of Health Sciences Faculty of Medicine University of Thessaly Larisa Greece.,Outcomes Research Consortium Cleveland OH
| | - Frank Tacke
- Department of Hepatology & Gastroenterology Campus Charité Mitte/Campus Virchow-KlinikumCharité University Medicine Berlin Berlin Germany
| | | | - Jochen Reiser
- Department of Medicine Rush University Medical Center Chicago IL
| | - Jesper Eugen-Olsen
- Department of Clinical Research Copenhagen University Hospital Amager and Hvidovre Hvidovre Denmark
| | - Salim S Hayek
- Division of Cardiology Department of Internal Medicine University of Michigan Ann Arbor MI
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11
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Meloche C, Azam TU, Anderson E, Shadid H, Berlin H, Pan M, Feroze R, O’Hayer P, Bitar A, Padalia K, Michaud E, Launius C, Blakely P, Gupta S, Leaf DE, Hayek S. CARDIOVASCULAR DISEASE AND OUTCOMES IN CRITICALLY ILL PATIENTS WITH COVID-19: A STOP-COVID ANCILLARY. J Am Coll Cardiol 2021. [PMCID: PMC8091444 DOI: 10.1016/s0735-1097(21)04482-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
PURPOSE OF REVIEW Black patients with heart failure in the United States are underrepresented in clinical trials relative to their overrepresentation in the heart failure population and in adverse heart failure outcomes. We aim to evaluate historical trends in this space and highlight recent developments. RECENT FINDINGS Multiple landmark heart failure trials published since 2019 have underrepresented Black patients, though several discussed this lack of representation as limitations. A review of large heart failure clinical trials from 2001 to 2016 found persistent underrepresentation of Black patients without significant change over time. Trials enrolling from North America exclusively had more proportional representation, enrolling an average of 31.6% Black participants. SUMMARY There is a shrinking proportion of Black patients in pivotal heart failure trials despite a higher prevalence of disease and associated adverse outcomes. There is increasing awareness of these disparities within the heart failure community, potentially leading to improved representation in future studies.
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Affiliation(s)
- Tariq U Azam
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
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13
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Hayek SS, Brenner SK, Azam TU, Shadid HR, Anderson E, Berlin H, Pan M, Meloche C, Feroz R, O'Hayer P, Kaakati R, Bitar A, Padalia K, Perry D, Blakely P, Gupta S, Shaefi S, Srivastava A, Charytan DM, Bansal A, Mallappallil M, Melamed ML, Shehata AM, Sunderram J, Mathews KS, Sutherland AK, Nallamothu BK, Leaf DE. In-hospital cardiac arrest in critically ill patients with covid-19: multicenter cohort study. BMJ 2020; 371:m3513. [PMID: 32998872 PMCID: PMC7525342 DOI: 10.1136/bmj.m3513] [Citation(s) in RCA: 86] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES To estimate the incidence, risk factors, and outcomes associated with in-hospital cardiac arrest and cardiopulmonary resuscitation in critically ill adults with coronavirus disease 2019 (covid-19). DESIGN Multicenter cohort study. SETTING Intensive care units at 68 geographically diverse hospitals across the United States. PARTICIPANTS Critically ill adults (age ≥18 years) with laboratory confirmed covid-19. MAIN OUTCOME MEASURES In-hospital cardiac arrest within 14 days of admission to an intensive care unit and in-hospital mortality. RESULTS Among 5019 critically ill patients with covid-19, 14.0% (701/5019) had in-hospital cardiac arrest, 57.1% (400/701) of whom received cardiopulmonary resuscitation. Patients who had in-hospital cardiac arrest were older (mean age 63 (standard deviation 14) v 60 (15) years), had more comorbidities, and were more likely to be admitted to a hospital with a smaller number of intensive care unit beds compared with those who did not have in-hospital cardiac arrest. Patients who received cardiopulmonary resuscitation were younger than those who did not (mean age 61 (standard deviation 14) v 67 (14) years). The most common rhythms at the time of cardiopulmonary resuscitation were pulseless electrical activity (49.8%, 199/400) and asystole (23.8%, 95/400). 48 of the 400 patients (12.0%) who received cardiopulmonary resuscitation survived to hospital discharge, and only 7.0% (28/400) survived to hospital discharge with normal or mildly impaired neurological status. Survival to hospital discharge differed by age, with 21.2% (11/52) of patients younger than 45 years surviving compared with 2.9% (1/34) of those aged 80 or older. CONCLUSIONS Cardiac arrest is common in critically ill patients with covid-19 and is associated with poor survival, particularly among older patients.
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Affiliation(s)
- Salim S Hayek
- Division of Cardiology, Department of Medicine, University of Michigan, Frankel Cardiovascular Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Samantha K Brenner
- Department of Internal Medicine, Hackensack Meridian School of Medicine at Seton Hall, Nutley, NJ, USA
- Department of Internal Medicine, Heart and Vascular Hospital, Hackensack Meridian Health Hackensack University Medical Center, Hackensack, NJ, USA
| | - Tariq U Azam
- Division of Cardiology, Department of Medicine, University of Michigan, Frankel Cardiovascular Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Husam R Shadid
- Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Elizabeth Anderson
- Division of Cardiology, Department of Medicine, University of Michigan, Frankel Cardiovascular Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Hanna Berlin
- Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Michael Pan
- Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Chelsea Meloche
- Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Rafey Feroz
- Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Patrick O'Hayer
- Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Rayan Kaakati
- Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Abbas Bitar
- Division of Cardiology, Department of Medicine, University of Michigan, Frankel Cardiovascular Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Kishan Padalia
- Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Daniel Perry
- Division of Cardiology, Department of Medicine, University of Michigan, Frankel Cardiovascular Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Pennelope Blakely
- Division of Cardiology, Department of Medicine, University of Michigan, Frankel Cardiovascular Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Shruti Gupta
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Shahzad Shaefi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Anand Srivastava
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - David M Charytan
- Division of Nephrology, New York University Grossman School of Medicine, New York, NY, USA
| | - Anip Bansal
- Division of Renal Diseases and Hypertension, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Mary Mallappallil
- Division of Nephrology, Department of Internal Medicine, NYC Health + Hospitals Kings County Hospital Center, Brooklyn, NY, USA
| | - Michal L Melamed
- Division of Nephrology, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, USA
| | | | - Jag Sunderram
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Kusum S Mathews
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Anne K Sutherland
- Division of Pulmonary and Critical Care Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Brahmajee K Nallamothu
- Division of Cardiology, Department of Medicine, University of Michigan, Frankel Cardiovascular Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - David E Leaf
- Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA, USA
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Azam TU, Shadid HR, Blakely P, O'Hayer P, Berlin H, Pan M, Zhao P, Zhao L, Pennathur S, Pop-Busui R, Altintas I, Tingleff J, Stauning MA, Andersen O, Adami ME, Solomonidi N, Tsilika M, Tober-Lau P, Arnaoutoglou E, Keitel V, Tacke F, Chalkias A, Loosen SH, Giamarellos-Bourboulis EJ, Eugen-Olsen J, Reiser J, Hayek SS. Soluble Urokinase Receptor (SuPAR) in COVID-19-Related AKI. J Am Soc Nephrol 2020; 31:2725-2735. [PMID: 32963090 DOI: 10.1681/asn.2020060829] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [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: 06/15/2020] [Accepted: 08/17/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AKI commonly occurs in patients with coronavirus disease 2019 (COVID-19). Its pathogenesis is poorly understood. The urokinase receptor system is a key regulator of the intersection between inflammation, immunity, and coagulation, and soluble urokinase plasminogen activator receptor (suPAR) has been identified as an immunologic risk factor for AKI. Whether suPAR is associated with COVID-19-related AKI is unknown. METHODS In a multinational observational study of adult patients hospitalized for COVID-19, we measured suPAR levels in plasma samples from 352 adult patients that had been collected within 48 hours of admission. We examined the association between suPAR levels and incident in-hospital AKI. RESULTS Of the 352 patients (57.4% were male, 13.9% were black, and mean age was 61 years), 91 (25.9%) developed AKI during their hospitalization, of whom 25 (27.4%) required dialysis. The median suPAR level was 5.61 ng/ml. AKI incidence rose with increasing suPAR tertiles, from a 6.0% incidence in patients with suPAR <4.60 ng/ml (first tertile) to a 45.8% incidence of AKI in patients with suPAR levels >6.86 ng/ml (third tertile). None of the patients with suPAR <4.60 ng/ml required dialysis during their hospitalization. In multivariable analysis, the highest suPAR tertile was associated with a 9.15-fold increase in the odds of AKI (95% confidence interval [95% CI], 3.64 to 22.93) and a 22.86-fold increase in the odds of requiring dialysis (95% CI, 2.77 to 188.75). The association was independent of inflammatory markers and persisted across subgroups. CONCLUSIONS Admission suPAR levels in patients hospitalized for COVID-19 are predictive of in-hospital AKI and the need for dialysis. SuPAR may be a key component of the pathophysiology of AKI in COVID-19.
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Affiliation(s)
- Tariq U Azam
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Husam R Shadid
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Pennelope Blakely
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Patrick O'Hayer
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Hanna Berlin
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Michael Pan
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Peiyao Zhao
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Lili Zhao
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Subramaniam Pennathur
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Rodica Pop-Busui
- Division of Endocrinology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Izzet Altintas
- Emergency Department, Copenhagen University Hospital Amager and Hvidovre, Hvidovre, Denmark
| | - Jens Tingleff
- Department of Clinical Research, Copenhagen University Hospital Amager and Hvidovre, Hvidovre, Denmark
| | - Marius A Stauning
- Emergency Department, Copenhagen University Hospital Amager and Hvidovre, Hvidovre, Denmark
| | - Ove Andersen
- Department of Clinical Research, Copenhagen University Hospital Amager and Hvidovre, Hvidovre, Denmark
| | - Maria-Evangelia Adami
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Nicky Solomonidi
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria Tsilika
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Pinkus Tober-Lau
- Department of Infectious Diseases and Respiratory Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Eleni Arnaoutoglou
- Department of Anesthesiology, School of Health Sciences, Faculty of Medicine, University of Thessaly, Thessaly, Greece
| | - Verena Keitel
- Clinic for Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Frank Tacke
- Department of Hepatology and Gastroenterology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Athanasios Chalkias
- Department of Anesthesiology, School of Health Sciences, Faculty of Medicine, University of Thessaly, Thessaly, Greece
| | - Sven H Loosen
- Clinic for Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty, University Hospital Düsseldorf, Düsseldorf, Germany
| | | | - Jesper Eugen-Olsen
- Department of Clinical Research, Copenhagen University Hospital Amager and Hvidovre, Hvidovre, Denmark
| | - Jochen Reiser
- Department of Medicine, Rush University Medical Center, Chicago, Illinois
| | - Salim S Hayek
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
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15
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Orme JJ, Jazieh KA, Xie T, Harrington S, Liu X, Ball M, Madden B, Charlesworth MC, Azam TU, Lucien F, Wootla B, Li Y, Villasboas JC, Mansfield AS, Dronca RS, Dong H. ADAM10 and ADAM17 cleave PD-L1 to mediate PD-(L)1 inhibitor resistance. Oncoimmunology 2020; 9:1744980. [PMID: 32363112 PMCID: PMC7185206 DOI: 10.1080/2162402x.2020.1744980] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 02/19/2020] [Accepted: 02/20/2020] [Indexed: 12/30/2022] Open
Abstract
ADAM10 and ADAM17 expression and soluble PD-L1 (sPD-L1) predict poor prognosis in many malignancies, including in patients treated with PD-(L)1 inhibitors. The mechanism of soluble PD-L1 production and its effects are unknown. Here we uncover a novel mechanism of ADAM10- and ADAM17-mediated resistance to PD-(L)1 inhibitors. ADAM10 and ADAM17 cleave PD-L1 from the surface of malignant cells and extracellular vesicles. This cleavage produces an active sPD-L1 fragment that induces apoptosis in CD8 + T cells and compromises the killing of tumor cells by CD8 + T cells. Reduced tumor site PD-L1 protein-to-mRNA ratios predict poor outcomes and are correlated with elevated ADAM10 and ADAM17 expression in multiple cancers. These results may explain the discordance between PD-L1 immunohistochemistry and PD-(L)1 inhibitor response. Thus, including ADAM10 and ADAM17 tissue staining may improve therapy selection. Furthermore, treatment with an ADAM10/ADAM17 inhibitor may abrogate PD-(L)1 inhibitor resistance and improve clinical responses to PD-(L)1 immunotherapy.
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Affiliation(s)
- Jacob J Orme
- Division of Medical Oncology, Mayo Clinic, Rochester, MN, USA
| | - Khalid A Jazieh
- Department of Urology, Mayo Clinic, Rochester, MN, USA.,Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Tiancheng Xie
- Department of Urology, Mayo Clinic, Rochester, MN, USA
| | | | - Xin Liu
- Department of Urology, Mayo Clinic, Rochester, MN, USA
| | - Matthew Ball
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | | | | | - Tariq U Azam
- Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Fabrice Lucien
- Department of Urology, Mayo Clinic, Rochester, MN, USA.,Department of Immunology, Mayo Clinic, Rochester, MN, USA
| | - Bharath Wootla
- Center for Clinical and Translational Science, Mayo Clinic, Rochester, MN, USA
| | - Yanli Li
- Department of Urology, Mayo Clinic, Rochester, MN, USA.,Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | | | | | - Roxana S Dronca
- Division of Hematology/Oncology, Department of Internal Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Haidong Dong
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA.,Department of Immunology, Mayo Clinic, Rochester, MN, USA
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16
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Affiliation(s)
- Tariq U Azam
- Department of Medicine, Mayo Clinic, Rochester, Minnesota
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17
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Orme JJ, Jazieh K, Harrington S, Ball M, Azam TU, Liu X(C, Xie T, Mansfield A, Dronca RS, Dong H. Abstract A210: Tumor-associated ADAM10 and ADAM17 produce soluble PD-L1 (sPD-L1, sB7-H1) and affect downstream tumor immunity – A resistance mechanism to PD-1 checkpoint blockade in melanoma. Cancer Immunol Res 2019. [DOI: 10.1158/2326-6074.cricimteatiaacr18-a210] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Tumor surface PD-L1 (B7-H1) signals through T-cell surface receptor PD-1 to suppress antitumor immunity. PD-1 inhibitors like pembrolizumab block this pathway to prevent tumor escape from immunosurveillance. These PD-1 checkpoint inhibitors achieve objective response in 20-30% of patients with melanoma (1-3). As the majority of these patients are resistant to this treatment, there is a critical need to combat PD-1 checkpoint inhibitor resistance in melanoma. What is the mechanism of PD-1 checkpoint inhibitor resistance in melanoma? Our group has reported that soluble PD-L1 (sPD-L1, sB7-H1) is elevated in the serum of patients with PD-1 inhibitor-resistant melanoma and non-small cell lung cancer (NSCLC) (4). We have also shown that soluble PD-L1 is produced by cleavage from other tumor types and leads to apoptosis in CD8+ T-cells (5). The aim of this study is to confirm the source of sPD-L1 in human melanoma and its relation to outcomes. Methods: B7H1-expressing transgenic melanoma cells (Mel-B7H1) were treated with an array of protease inhibitors over 24 hours. Cells were then pelleted and supernatants were analyzed by ELISA for sPD-L1 (sB7-H1) production. Tumor serum samples were also analyzed by ELISA for sPD-L1 production.Tumor pathology slides from patients with melanoma (serum donors from the above study) were stained by immunohistochemistry with antibodies against proteases ADAM10 or ADAM17. Slides were visualized by microscopy for the presence of these antigens. Activated human CD8+ T-cells were cultured with recombinant human B7-H1 (PD-L1) protein, sPD-L1-rich, or sPD-L1-depleted supernatants from a tumor cell line in the presence of placebo or PD-1 checkpoint inhibitor antibodies. Cell survival was measured at 48 hours by flow cytometry.Results: ADAM10 inhibitor GI254023X, ADAM17 inhibitor TAPI-0, and broad metalloprotease inhibitor TAPI-2 inhibited Mel-B7H1 production of sB7H1 (p<0.001, 0.095, and 0.001 respectively). Specific inhibitors of other metalloproteases did not significantly alter sB7H1 production. PD-L1 transcription levels were not significantly altered. Tumor pathology slides from patients with high serum sPD-L1 exhibited high ADAM10 and/or ADAM17 staining. Conversely, tumors from patients with low-sPD-L1levels tended to exhibit low ADAM10 and/or ADAM17 staining. Recombinant PD-L1 and PD-L1-rich supernatants induced cell death of CD8+ T-cells, whereas PBS control solution and PD-L1-depleted supernatants did not. Supraphysiologic doses of pembrolizumab decreased cell death in PD-L1-rich supernatant-treated CD8+ T-cells. Conclusions: Matrix metalloprotease inhibitors ADAM10 and ADAM17 mediate sPD-L1 production from melanoma cells. In samples from patients with melanoma, immunohistochemical staining of these proteases in tumor tissue correlates with serum sPD-L1 levels. As we have shown previously, sPD-L1 induces apoptosis of activated CD8+ T-cells, which may explain PD-1 inhibitor resistance in most patients with melanoma.We posit that sPD-L1 outcompetes PD-1 inhibitors to suppress tumor immunosurveillance. Our results suggest that the combination of ADAM10/17 inhibitor and PD-1 checkpoint inhibitor may overcome this mechanism of PD-1 resistance in melanoma and other cancers. Future studies will determine (A) how a combined ADAM10/17 inhibitor and PD-1 inhibitor may function in clinical use, (B) how tumor-derived sPD-L1 signals downstream to cause apoptosis in T-cells, and (C) whether surface ADAM10/17 predict surface PD-L1 staining in melanoma. References: 1. Ribas et al., Lancet Oncol 2015;16(8):908–18. 2. Hamid et al., Ann Oncol 2016;27:6. 3. Weber et al., Lancet Oncol 2015:16(4):375–84. 4. Dronca et al., J Clin Oncol 2017:35(15):11534. 5. Orme et al., AACR Adv Malig Lymphoma 2018.
Citation Format: Jacob J. Orme, Khalid Jazieh, Susan Harrington, Matthew Ball, Tariq U. Azam, Xin (Cindy) Liu, Tiancheng Xie, Aaron Mansfield, Roxana S. Dronca, Haidong Dong. Tumor-associated ADAM10 and ADAM17 produce soluble PD-L1 (sPD-L1, sB7-H1) and affect downstream tumor immunity – A resistance mechanism to PD-1 checkpoint blockade in melanoma [abstract]. In: Proceedings of the Fourth CRI-CIMT-EATI-AACR International Cancer Immunotherapy Conference: Translating Science into Survival; Sept 30-Oct 3, 2018; New York, NY. Philadelphia (PA): AACR; Cancer Immunol Res 2019;7(2 Suppl):Abstract nr A210.
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Affiliation(s)
- Jacob J. Orme
- Mayo Clinic, Rochester, MN; Cleveland Clinic, Cleveland, OH
| | - Khalid Jazieh
- Mayo Clinic, Rochester, MN; Cleveland Clinic, Cleveland, OH
| | | | - Matthew Ball
- Mayo Clinic, Rochester, MN; Cleveland Clinic, Cleveland, OH
| | - Tariq U. Azam
- Mayo Clinic, Rochester, MN; Cleveland Clinic, Cleveland, OH
| | | | - Tiancheng Xie
- Mayo Clinic, Rochester, MN; Cleveland Clinic, Cleveland, OH
| | | | | | - Haidong Dong
- Mayo Clinic, Rochester, MN; Cleveland Clinic, Cleveland, OH
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18
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Duma N, Kothadia SM, Azam TU, Yadav S, Paludo J, Vera Aguilera J, Gonzalez Velez M, Halfdanarson TR, Molina JR, Hubbard JM, Go RS, Mansfield AS, Adjei AA. Characterization of Comorbidities Limiting the Recruitment of Patients in Early Phase Clinical Trials. Oncologist 2018; 24:96-102. [PMID: 30413668 DOI: 10.1634/theoncologist.2017-0687] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 09/05/2018] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Early phase clinical trials evaluate the safety and efficacy of new treatments. The exclusion/inclusion criteria in these trials are usually rigorous and may exclude many patients seen in clinical practice. Our objective was to study the comorbidities limiting the participation of patients with breast, colorectal, or lung cancer in clinical trials. MATERIALS AND METHODS We queried ClinicalTrials.gov on December 31, 2016. We reviewed the eligibility criteria of 1,103 trials. Logistic regression analyses were completed, and exclusion was studied as a binary variable. RESULTS Out of 1,103 trials, 70 trials (6%) excluded patients >75 years of age, and 45% made no reference to age. Eighty-six percent of trials placed restrictions on patients with history of prior malignancies. Regarding central nervous system (CNS) metastasis, 416 trials (38%) excluded all patients with CNS metastasis, and 373 (34%) only allowed asymptomatic CNS metastasis. Regarding chronic viral infections, 347 trials (31%) excluded all patients with human immunodeficiency virus, and 228 trials (21%) excluded all patients with hepatitis B or C infection. On univariate analysis, chemotherapy trials were more likely to exclude patients with CNS metastasis and history of other malignancies than targeted therapy trials. Multivariate analysis demonstrated that industry-sponsored trials had higher odds of excluding patients with compromised liver function. CONCLUSION Many clinical trials excluded large segments of the population of patients with cancer. Frequent exclusion criteria included patients with CNS metastasis, history of prior malignancies, and chronic viral infections. The criteria for participation in some clinical trials may be overly restrictive and limit enrollment. IMPLICATIONS FOR PRACTICE The results of this study revealed that most early phase clinic trials contain strict exclusion criteria, potentially excluding the patients who may be more likely to represent the population treated in clinical settings, leaving patients susceptible to unintended harm from inappropriate generalization of trial results. Careful liberalization of the inclusion/exclusion criteria in clinical trials will allow investigators to understand the benefits and drawbacks of the experimental drug for a broader population, and possibly improve recruitment of patients with cancer into clinical trials.
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Affiliation(s)
- Narjust Duma
- Division of Medical Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Sejal M Kothadia
- Department of Internal Medicine, Rutgers University-New Jersey Medical School, Newark, New Jersey, USA
| | - Tariq U Azam
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Siddhartha Yadav
- Division of Medical Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jonas Paludo
- Division of Medical Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Miguel Gonzalez Velez
- Department of Internal Medicine, Rutgers University-New Jersey Medical School, Newark, New Jersey, USA
| | | | - Julian R Molina
- Division of Medical Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Joleen M Hubbard
- Division of Medical Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ronald S Go
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Aaron S Mansfield
- Division of Medical Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Alex A Adjei
- Division of Medical Oncology, Mayo Clinic, Rochester, Minnesota, USA
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