The role of cardiometabolic risk factors and endothelial dysfunction in serum albumin levels and capillary leak syndrome of patients with COVID-19

Background

Growing evidence focuses on the role of hypoalbuminemia in the COVID-19 course and the role of vascular inflammation in the progression to Capillary Leak Syndrome (CLS). CLS may be mediated by a derangement of endothelial barrier following vascular endothelial dysfunction. We investigated the role of cardiometabolic risk factors in the association of hypoalbuminemia with endothelial dysfunction of hospitalized COVID-19 patients.

Methods

In this cross-sectional study, patients hospitalized for COVID-19 at the medical ward or Intensive Care Unit (ICU) were enrolled. Medical history and laboratory examinations were collected while the endothelial function was assessed by brachial artery flow-mediated dilation (FMD) between the first 24–72 hours of their admission to the hospital. According to the body mass index, history of hypertension, dyslipidemia, and diabetes mellitus, COVID-19 patients were categorized in those with Cardiometabolic Risk Factors (CRFact) or without CRFact (no-CRFact). From the study population, we excluded subjects with established cardiovascular disease.

Results

Sixty-six patients with COVID-19 (37% admitted in ICU) were recruited. From the study population, 41 were in the group of CRFact and 25 in the no-CRFact. Patients with CFRact were older (65±9 years vs. 53±14 years, p<0.001), had more impaired FMD (1.16±2.13% vs. 2.60±2.44%, p=0.01), and lower serum albumin levels (3.10±0.68 g/dL vs. 3.52±0.26 g/dL, p=0.006) compared to the no-CRFact group. Between CRFact and no-CRFact, there was no difference in CRP and IL-6 levels. Interestingly, serum albumin in patients with CRFact was significantly lower than the lower reference limit (LRL) (=3.5 g/dl) of albumin (p=0.001), while no such finding was noted in subjects with no CRFact (p=0.64). Furthermore, regression analysis revealed that, even after adjustment for age, the presence of CRFact was associated with decreased serum albumin levels by 0.31mg/dl (95% CI 0.08 to 0.63, p=0.04). In the CRFact population, there was a correlation of albumin with FMD (R=0.29, p=0.05) and an inverse correlation with CRP (rho=−0.48, p=0.02) and IL-6 (rho=−0.66, p<0.001), while in the no-CRFact group no such correlation were observed (p=NS for all).

Conclusion

COVID-19 patients with cardiometabolic risk factors present with low serum albumin levels early at the course of the disease, which may be driven by endothelial dysfunction and vascular inflammation. This data gives insights into the potential association of a dysfunctional endothelial layer and the progression to capillary leak syndrome.

Funding Acknowledgement

Type of funding sources: None.

The effects of empagliflozin on arterial stiffness, endothelial function and ventriculoarterial coupling in type 2 diabetes mellitus: 1 year follow up

Introduction

Sodium glucose cotransporters inhibitors (SGLT2i) are currently used in the treatment of patients with type 2 diabetes mellitus (T2DM) who pose high cardiovascular risk. However their effects on arterial stiffness, endothelial function and ventriculoarterial coupling have not been described.

Methods

We recruited 120 patients with T2DM. They received either the SGLT2i empagliflozin (n=60) or insulin (n=60). We measured at baseline and after 1 year of treatment: 1) Perfused Boundary Region (PBR 5–25μm) to evaluate endothelial glycocalyx integrity via Glycocheck, 2) Pulse wave Velocity (PWVc-f), 3)central systolic blood pressure (cSBP), 4) central Pulse Pressure (cPP) via Complior,5) the ratio PWV/GLS by echocardiography to assess ventriculoarterial coupling (VA coupling).

Results

The patients were matched for age, gender, smoking, hypertension and hyperlipidemia (p=NS). Hemoglobin A1c was deteriorated in both groups (8.1% vs 8.2%, p=NS). The baseline measurements of aforementioned markers did not differ between the 2 groups (p=NS). PWV was correlated with cSBP (r=0.4.p&lt;0.05) and cPP (r=0.35, p&lt;0.05) for all participants at baseline. After 1 year of treatment both groups achieved significant reduction of HbA1c. Patients treated with insulin showed an increase of PWV in contrary with empagliflogin group (11.4±0.5 to 12.6±0.4 vs 11.7±0.5 to 10.9±0.4, correspondingly, p&lt;0.05). cSBP declined considerably in empagliflozin group (135±10 to 129±10 vs 134±9 to 136±9 respectively, p&lt;0.05) and cPP remained approximately steady (47±8 to 48±8 vs 49±6 to 55±6 respectively, p&lt;0.05) compared with insulin group. PBR dropped in SGLT2i group (2.20±0.2 to 1.98±0.2, p&lt;0.05) whereas PBR fluctuated at the same level in insulin group (2.18±0.2 to 2.15±0.3, p=NS).PWV/GLS fell in both groups but the reduction was more prominent in empagliflozin group (−0.72±0.1 to −0.67±0.1 vs −0.72±0.1 to −0.60±0.1 respectively, p&lt;0.05).

Conclusion

1 year treatment with empagliflozin resulted in improved markers of arterial stiffness, ventriculoarterial coupling and endothelial function, independently of glycemic control.

Funding Acknowledgement

Type of funding source: None

Cisplatin-based chemotherapy for merkel cell carcinoma of the skin

PURPOSE

Merkel cell carcinoma (MCC), a rare tumor of the skin with aggressive behavior, is usually fatal when advanced disease is present. The role of chemotherapy (CT) in the treatment of patients with MCC is unclear.

METHODS

Over 15 years, 9 patients with locally advanced or metastatic disease were treated with carboplatin (CBDCA) (300 mg/m(2) of AUC 5 on Day 1) and etoposide (VP-16) (100 mg/m(2) on Days 1-3) every 3 weeks. As second-line CT, cisplatin (CDDP) (60-100 mg/m(2)), ifosfamide (IFO) (3-5 g/m(2)) and epirubicin (EPI) (30-50 mg/m(2)) were utilized.

RESULTS

Of the 3 patients who received adjuvant therapy, one achieved complete response after 108+ months with second-line chemotherapy and radiotherapy, despite a brief relapse; 2 patients remain disease-free after 84+ and 108+ months. Of the 6 patients with locally advanced or metastatic disease who were treated with first-line chemotherapy, one (16.6 percent) achieved a complete response and 3 (50 percent) achieved partial response, for an overall response rate of 66.6 percent. Two patients (one with complete and one with partial response) received subsequent radiotherapy, following which complete response was achieved. Of the 2 complete responders, one patient remains disease-free after 56+ months. The median overall survival from the time of initial diagnosis for the whole group was 56 months (range 15-114 months); the median overall survival from the initiation of chemotherapy was 18 months (range 6-108+). Local recurrences and soft tissue metastases responded better than visceral metastases. Patients with partial response and no response had rapid disease progression and fatality, despite second-line chemotherapy and/or radiotherapy.

CONCLUSION

MCC appears to be chemosensitive but can progress rapidly with fatal outcomes. Although the rarity of these tumors precludes randomized trials, a common treatment plan should be utilized by those treating MCC. This may allow some conclusions regarding the optimum treatment of patients with MCC to be drawn in the future.