Renal replacement therapy in the critical patient: treatment variation over time.

OBJECTIVES: To analyze the evolution of patients subjected to renal replacement therapy (RRT), and to determine risk factors associated with mortality and the recovery of renal function. DESIGN: A prospective, observational study of critically ill patients. SETTING: Clinical-surgical Intensive Care Unit (ICU) of Sabadell Hospital (Spain). PATIENTS: Inclusion of all patients treated in our Unit due to acute renal failure (ARF) requiring RRT. PRIMARY VARIABLES OF INTEREST: We recorded epidemiological data, severity using the APACHE II score, days of the technique, ICU mortality, and renal function recovery. The study period was divided into 2 parts: part 1 (2000-2004) and part 2 (2005-2009). The 2 periods were compared using the Student t-test for continuous variables and the chi-squared test for categorical variables. Multiple regression analysis was performed to determine the risk factors for mortality and recovery of renal function. RESULTS: A total of 304 patients were treated. Sepsis was the main etiology of ARF (61%), involving principally respiratory and abdominal foci. In the second period the convective technique and community-acquired ARF were far more prevalent than in the first period. There were fewer days of therapy in the second period (19.7 versus 12.3 days; P=.015). Total ICU mortality was 52.3%, with a decrease in the last period (61.9% to 45.5%: P=.003). The risk factors associated to mortality were creatinine upon admission (odds ratio [OR] 0.77; 95% confidence interval [95%CI] 0.61-0.97) and treatment with IHD alone (OR 0.37, 95%CI 0.16-0.87). Survivors had normal renal function at ICU discharge in 56.7% of the cases in the second period, vs in 72.9% in the first period, with more patients subjected to IHD in the second period (10.4% versus 26.8%). The factors related to the recovery of renal function were creatinine upon admission (OR 1.98, 95%CI 1.12-3.48), acute renal failure (OR 0.11, 95%CI 0.04-0.34) and treatment with continuous techniques (OR 0.18, 95%CI 0.03-0.85). CONCLUSIONS: Mortality among critically ill patients subjected to RRT has improved in recent years.

Awake prone positioning in nonintubated spontaneous breathing ICU patients with acute hypoxemic respiratory failure (PRONELIFE)-protocol for a randomized clinical trial.

BACKGROUND: It is uncertain whether awake prone positioning can prevent intubation for invasive ventilation in spontaneous breathing critically ill patients with acute hypoxemic respiratory failure. Awake prone positioning could benefit these patients for various reasons, including a reduction in direct harm to lung tissue, and prevention of tracheal intubation-related complications. DESIGN AND METHODS: The PRONELIFE study is an investigator-initiated, international, multicenter, randomized clinical trial in patients who may need invasive ventilation because of acute hypoxemic respiratory failure. Consecutive patients admitted to participating ICUs are randomly assigned to standard care with awake prone positioning, versus standard care without awake prone positioning. The primary endpoint is a composite of tracheal intubation and all-cause mortality in the first 14 days after enrolment. Secondary endpoints include time to tracheal intubation and effects of awake prone positioning on oxygenation parameters, dyspnea sensation, and complications. Other endpoints are the number of days free from ventilation and alive at 28 days, total duration of use of noninvasive respiratory support, total duration of invasive ventilation, length of stay in ICU and hospital, and mortality in ICU and hospital, and at 28, 60, and 90 days. We will also collect data regarding the tolerance of prone positioning. DISCUSSION: The PRONELIFE study is among the first randomized clinical trials investigating the effect of awake prone positioning on intubation rate in ICU patients with acute hypoxemic failure from any cause. The PRONELIFE study is sufficiently sized to determine the effect of awake prone positioning on intubation for invasive ventilation-patients are eligible in case of acute hypoxemic respiratory failure without restrictions regarding etiology. The PRONELIFE study is a pragmatic trial in which blinding is impossible-however, as around 35 ICUs worldwide will participate in this study, its findings will be highly generalizable. The findings of the PRONELIFE study have the potential to change clinical management of patients who may need invasive ventilation because of acute hypoxemic respiratory failure. TRIAL REGISTRATION: ISRCTN ISRCTN11536318 . Registered on 17 September 2021. The PRONELIFE study is registered at clinicaltrials.gov with reference number NCT04142736 (October, 2019).

Annual variations of the plasmatic levels of glucose and amino acid and daily changes under different natural conditions of temperature and photoperiod in Gilthead Sea bream (Sparus aurata, L.).

Daily and annual changes in the plasmatic glucose and amino acid concentration have been determined in Sparus aurata L. Fish (average weight 330 g) were kept in cages under natural conditions of temperature and photoperiod and fed with a commercial diet. The months studied were chosen to establish whether there is any influence on the plasmatic glucose and amino acid concentration due to the change in temperature and photoperiod (equal photoperiod and different temperature, March and October; different photoperiod and equal temperature, May and November; and different photoperiod and temperature, June and January). To study the daily profile of glucose and amino acids concentrations, blood was extracted from six fish every 3 h during 24 h. Annual changes were determined as the average of the samples obtained during 1 day. Results show an annual rhythm with acrophase in June with a positive correlation with photoperiod for glucose and amino acids and with temperature only for amino acids. Daily profiles are rhythmical with a period of 24 h except in November with a period of 8 h for amino acids.

Clinical risk factors for early mortality in patients with community-acquired septic shock. The importance of adequate source control.

OBJECTIVE: To evaluate the incidence and risk factors for early mortality (EM) in the ICU in patients with community-acquired septic shock (CASS). DESIGN: A retrospective cohort study of patients with CASS admitted to the ICU (2003-2016). SETTING: ICU at a University Hospital in Spain. PATIENTS: All consecutive patients admitted to the ICU with CASS. INTERVENTIONS: None. MAIN VARIABLES OF INTEREST: CASS was defined according to the Sepsis-3 definitions. EM were defined as occurring within of 72h following ICU admission. A multinomial logistic regression analysis was performed to identify the risk factors associated with early deaths. RESULTS: During the study period, 625 patients met the Sepsis-3 criteria and admitted with CASS. 14.4% of all patients died within the first 72h. Of 161 patients who died in the ICU, 90 (55.9%) died within the first 72h. The percentage of early and late mortality did not vary significantly during the study period. The need and adequacy of source control were significantly lower in patients with EM. In the multivariate analysis, ARDS, non-respiratory infections, bacteremia and severity at admission were variables independently associated with EM. The only factor that decreased EM was adequate source control in patients with infections amenable to source control. CONCLUSIONS: The incidence of EM has remained stable over time, which means that more than half of the patients who die from CASS do so within the first 72h. Infections where adequate source control can be performed have lower EM.

Clinical risk factors for early mortality in patients with community-acquired septic shock. The importance of adequate source control.

OBJECTIVE: To evaluate the incidence and risk factors for early mortality (EM) in the ICU in patients with community-acquired septic shock (CASS). DESIGN: A retrospective cohort study of patients with CASS admitted to the ICU (2003-2016). SETTING: ICU at a University Hospital in Spain. PATIENTS: All consecutive patients admitted to the ICU with CASS. INTERVENTIONS: None. MAIN VARIABLES OF INTEREST: CASS was defined according to the Sepsis-3 definitions. EM were defined as occurring within of 72h following ICU admission. A multinomial logistic regression analysis was performed to identify the risk factors associated with early deaths. RESULTS: During the study period, 625 patients met the Sepsis-3 criteria and admitted with CASS. 14.4% of all patients died within the first 72h. Of 161 patients who died in the ICU, 90 (55.9%) died within the first 72h. The percentage of early and late mortality did not vary significantly during the study period. The need and adequacy of source control were significantly lower in patients with EM. In the multivariate analysis, ARDS, non-respiratory infections, bacteremia and severity at admission were variables independently associated with EM. The only factor that decreased EM was adequate source control in patients with infections amenable to source control. CONCLUSIONS: The incidence of EM has remained stable over time, which means that more than half of the patients who die from CASS do so within the first 72h. Infections where adequate source control can be performed have lower EM.

[Recommendations of the Working Groups from the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) for the management of adult critically ill patients in the coronavirus disease (COVID-19)]. / Recomendaciones de «hacer¼ y «no hacer¼ en el tratamiento de los pacientes críticos ante la pandemia por coronavirus causante de COVID-19 de los Grupos de Trabajo de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC).

On March 11, 2020, the Director-General of the World Health Organization (WHO) declared the disease caused by SARS-CoV-2 (COVID-19) as a pandemic. The spread and evolution of the pandemic is overwhelming the healthcare systems of dozens of countries and has led to a myriad of opinion papers, contingency plans, case series and emerging trials. Covering all this literature is complex. Briefly and synthetically, in line with the previous recommendations of the Working Groups, the Spanish Society of Intensive, Critical Medicine and Coronary Units (SEMICYUC) has prepared this series of basic recommendations for patient care in the context of the pandemic.

Do sedation and analgesia contribute to long-term cognitive dysfunction in critical care survivors?

Deep sedation during stay in the Intensive Care Unit (ICU) may have deleterious effects upon the clinical and cognitive outcomes of critically ill patients undergoing mechanical ventilation. Over the last decade a vast body of literature has been generated regarding different sedation strategies, with the aim of reducing the levels of sedation in critically ill patients. There has also been a growing interest in acute brain dysfunction, or delirium, in the ICU. However, the effect of sedation during ICU stay upon long-term cognitive deficits in ICU survivors remains unclear. Strategies for reducing sedation levels in the ICU do not seem to be associated with worse cognitive and psychological status among ICU survivors. Sedation strategy and management efforts therefore should seek to secure the best possible state in the mechanically ventilated patient and lower the prevalence of delirium, in order to prevent long-term cognitive alterations.

Translational inhibition by eIF-2-phospholipid complex in mammalian cell-free systems.

The polypeptide chain initiation factor 2 (eIF-2) binds phospholipid (PL) and becomes a potent inhibitor of translation in hemin-supplemented reticulocyte lysates [De Haro et al. (1986) Proc. Natl. Acad. Sci. USA 83, 6711-6715]. This binding is independent of calcium ions and seems to be specific for phosphatidylinositol or phosphatidylserine; phosphatidic and arachidonic acids are inactive. Like alpha-subunit-phosphorylated eIF-2, eIF-2.PL traps GEF in a non-dissociable eIF-2.PL.GEF complex whereby GEF is no longer able to recycle. Initiation is inhibited when no free GEF is available. Translational inhibition by eIF-2.PL is rescued by equimolar amounts of eIF-2.GEF. On the basis of this stoichiometry, we have estimated that reticulocyte lysates contain about 60 pmol of GEF/ml (60 nM). eIF-2.PL also inhibits translation in cell-free mouse liver extracts and this inhibition is prevented by reticulocyte eIF-2.GEF suggesting that GEF also functions in liver. However, the eIF-2.PL complex does not affect translation in such non-mammalian eukaryotic systems as wheat germ and Drosophila embryos.

Heat-stable translational inhibitor from rabbit reticulocyte lysates.

We have purified to apparent homogeneity a heat-stable (HS) factor from the postribosomal supernatant of rabbit reticulocyte lysates [(1988) FEBS Lett. 236, 479-483]. HS inhibits translation in hemin-supplemented lysates and induces phosphorylation of the alpha-subunit of the eukaryotic initiation factor 2 as does hemin deficiency. The translational inhibition produced by addition of HS to hemin-containing reticulocyte lysates and the accompanying phosphorylation of the eIF-2 alpha subunit can be prevented or reversed by NADPH generators including glucose 6-phosphate, NADPH itself, and also by dithiols, e.g., dithiothreitol, but not by fructose 1,6-bisphosphate or by monothiols, e.g., 2-mercaptoethanol. When added to crude preparations of the proinhibitor form (proHCI) of the heme-controlled translational inhibitor (HCI), HS produces a pronounced increase of the HCI to proHCI ratio. It appeared possible that HS might be oxidized glutathione (GSSG) but this is not the case, for HS is not a substrate for highly purified glutathione reductase from rabbit erythrocytes. The spectral analysis of highly purified HS is consistent with the idea that HS could be a nucleotide derivative.

Purification of a novel heat-stable translational inhibitor from rabbit reticulocyte lysates.

We have purified to apparent homogeneity a novel heat-stable (HS) factor from postribosomal supernatants of rabbit reticulocyte lysates by heating for 10 min at 80 degrees C, fractionation on Sephadex, anion-exchange chromatography on QMA Accell, and gel filtration HPLC. The apparent molecular mass of HS is 500-1000 Da on the basis of its behaviour on gel filtration. Like a factor from bovine heart [(1982) Proc. Natl. Acad. Sci. USA 79, 3134-3137], the reticulocyte HS inhibits translation in hemin-supplemented lysates with biphasic kinetics similar to hemin deficiency and promotes phosphorylation of the alpha-subunit of the eukaryotic initiation factor eIF-2. It is active at nanomolar concentrations. Reticulocyte HS appears to be neither a peptide nor an oligonucleotide since HS activity was insensitive to proteolytic or nucleolytic digestion.

Electrochemical platinum coatings for improving performance of implantable microelectrode arrays.

The formation and properties of electrochemical platinum films grown on platinum contacts contained in implantable flexible microelectrodes were investigated. The resulting platinum deposits were obtained by applying cyclic voltammetry to baths containing concentrations around 70 mM of chloroplatinic acid. A pre-activation step was necessary before the platinum-electroplating step in order to achieve good adhesive properties. The benefits of this process were ascribed to higher corrosion resistance, lower impedance and improved adhesion to the sputtered platinum. These improvements can make the application of this electrochemical technique highly useful for increasing the lifetime of implantable microelectrode arrays, such as cuff structures (IEEE Trans. Biomed. Eng. 40 (1993) 640). These medical devices, obtained by semiconductor technology could be used for selective stimulation of nerve fascicles, although, poor long-term performance has been achieved with them. The dissolution rate for platinum thin-film microelectrodes under fixed corrosion test conditions was 38.8 ng/C. Lower rates were observed for electroplated microelectrodes, obtaining a dissolution rate of 7.8 ng/C under analogous experimental ageing conditions. The corrosion behaviour of the electroplated platinum during stimulation experimental conditions was estimated by electrochemical impedance spectroscopy.

Casein kinase II is implicated in the regulation of heme-controlled translational inhibitor of reticulocyte lysates.

The hemin-controlled inhibitor, or HCI, is a cyclic nucleotide-independent protein kinase which specifically phosphorylates the alpha subunit of eukaryotic initiation factor 2 (eIF-2) leading to potential limitations in functional eIF-2 and decreases in protein synthesis initiation. We have recently demonstrated that hemin regulates eIF-2 alpha kinase activity by promoting formation of the inactive heterodimer between HCI and the 90-kDa heat shock protein (hsp90). The formation of the inactive form of HCI by hemin is prevented by treatment with sulfhydryl reagents such as N-ethylmaleimide or when hsp90 is previously phosphorylated (Méndez, R., Moreno, A., and de Haro, C. (1992) J. Biol. Chem. 267, 11500-11507). In this report, using isoelectric focusing and Western blot analyses with antibodies against a synthetic HCI peptide, we have demonstrated that HCI was also phosphorylated when a heme-reversible HCI preparation was preincubated with ATP. Furthermore, our results indicate that casein kinase II (CK II) is the enzyme involved in the regulation of HCI. Thus, the synthetic peptide RRREEETEEE, which is a specific substrate for CK II, acts as a competitive inhibitor of HCI and hsp90 phosphorylation and, at the same time, inhibits the activation of HCI, whereas a synthetic peptide which corresponds to residues 45-59 of the alpha subunit of eIF-2, including the Ser51 phosphorylated by HCI, only inhibits competitively the phosphorylation of eIF-2 alpha. In addition, treatments which modify hsp90 disabling the formation of the inactive dimer with HCI make unnecessary the presence of CK II for activation of HCI. The data strongly suggest that hemin promotes formation of an inactive HCI.hsp90 dimer preventing phosphorylation by CK II. Interestingly, the addition of the CK II peptide substrate also prevents the activation of HCI in a heme-deficient reticulocyte lysate. We hypothesize, therefore, that under physiological conditions, CK II activity appears to be necessary for activation of HCI.

Mode of action of the hemin-controlled inhibitor of protein synthesis: studies with factors from rabbit reticulocytes.

Previously [de Haro, C., Datta, A & Ochoa, S. (1978) Proc. Natl. Acad. Sci. USA 75, 243--247] it was shown with initiation factors from Artemia salina embryos that the activity of the initiator methionyl-tRNA binding factor eIF-2 is stimulated by another factor (ESP, for eIF-2 stimulating protein) present, like eIF-2, in ribosomal salt washes. Incubation of eIF-2 with translational inhibitor from rabit reticulocytes, in the presence of ATP, abolished the ESP effect. At physiological concentrations eIF-2 was virtually inactive without ESP. These observations indicated that the translational inhibitor acts by converting eIF-2 to a form that is not stimulated by ESP. The same observations have now been made with eIF-2 and ESP from rabbit reticulocytes but, in this case, the dependence of eIF-2 activity on ESP is much more pronounced than with the A. salina factors. eIF-2 from reticulocytes interacts with ESP from A. salina and conversely.

Further studies on the mode of action of the heme-controlled translational inhibitor.

We have isolated [de Haro, C. & Ochoa, S. (1978) Proc. Natl. Acad. Sci. USA 75, 2713-2716] a protein factor (eIF-2 stimulating protein, ESP) that is essential for formation of ternary and 40S initiation complexes by the eukaryotic polypeptide chain initiation factor 2 (eIF-2) at the low concentrations of eIF-2 present in reticulocyte lysates. The fact that stimulation of complex formation by ESP is virtually abolished when the small (38,000 daltons) subunit of eIF-2 is phosphorylated by ATP in the presence of eIF-2 kinase (heme-controlled inhibitor, HCI) is consistent with the notion that HCI inhibits translation in lysates by blocking the interaction of eIF-2 with ESP. Our present work, with highly purified eIF-2 and ESP, has additionally established that, unlike phosphorylation of the small subunit, phosphorylation of the middle (52,000 daltons) subunit of eIF-2, which does not lead to translational inhibition in lysates, does not affect eIF-2-ESP interaction. This provides further support for our model of translational inhibition by HCI.

Further studies on the mode of action of the heme-controlled translational inhibitor: stimulating protein acts at level of binary complex formation.

Previous work has shown that (i) at physiological concentrations of eukaryotic initiation factor 2 (eIF-2), formation of the ternary complex eIF-2-GTP-Met-tRNAi, which precedes the assembly of a 40S initiation complex, requires the presence of eIF-2 stimulating protein (ESP) and (ii) the interaction of eIF-2 with ESP is blocked by the translational inhibitor which, in reticulocyte lysates, is activated in the absence of hemin. Present evidence indicates that formation of the ternary complex is preceded by formation of the binary complex eIF-2-GTP and that ESP acts at the level of binary complex formation.

Characterization of cell-free protein-synthesis systems from undeveloped and developing Artemia embryos.

We have developed and characterized translationally active cell-free systems from Artemia embryos at different developmental times. The optimized lysates from 16 h-developed embryos incorporated radiolabelled amino acids into polypeptides for up to 120 min. The polypeptides synthesized ranged in Mr from 150,000 to 10,000, suggesting that the endogenous mRNA was capable of directing the synthesis of complete polypeptides. Similar results were obtained by using lysates from early developmental stages; even the cell-free system prepared from 1 h-developed embryos was partially active in protein synthesis. Furthermore, all these lysates were capable of re-initiation, as demonstrated by inhibition of initiation with the inhibitors edeine and 7-methylguanosine 5'-triphosphate. Because we found no endogenous protein-synthetic activity in the corresponding lysates from undeveloped embryos, we have used cell-free translation systems from 0 h- and 16 h-developed Artemia embryos to analyse the mechanisms limiting protein synthesis at very early developmental stages. Undeveloped-embryo lysates supplemented with nuclease-treated reticulocyte lysate were capable of translating endogenous mRNAs to give products with a wide spectrum of Mr values, but lysates of 16 h-developed embryos supplemented in this way were not further stimulated. The nuclease-treated lysate appeared to be unnecessary 5 h after resumption of development. These results suggested that a component(s) limiting translation in the undeveloped-embryo lysate was provided by the nuclease-treated reticulocyte lysate, and that this component(s) no longer limited protein synthesis after development. In view of these results, partially fractionated reticulocyte lysates were tested for restoration of protein-synthetic activity in the undeveloped embryo lysate. A high-salt ribosomal wash devoid of ribosomal subunits, which is considered a crude polypeptide-initiation-factor preparation, also restored translation activity in the undeveloped embryo lysate and made it capable of directing the synthesis of both endogenous mRNAs and exogenous (globin) mRNA.

Protein phosphorylation and translational control in reticulocytes: activation of the heme-controlled translational inhibitor by calcium ions and phospholipid.

The synthesis of globin, the major protein synthesized by reticulocytes, requires the presence of heme, the prosthetic group of hemoglobin. The absence of heme leads to the activation of a nucleotide-independent protein kinase that phosphorylates the alpha subunit of the chain initiation factor eIF-2. This modification interferes with the catalytic function of eIF-2 in protein synthesis initiation. Recent progress in our understanding of the molecular mechanism of this inhibition is briefly reviewed. The same phosphorylation is catalyzed by a different enzyme (DAI) which, while constitutive in reticulocytes, is induced by interferon in other cells. This enzyme is activated by low concentrations of double-stranded RNA in conjunction with ATP. The mechanisms of activation of these enzymes are still poorly understood. HCI is believed to form an inactive complex with heme and become active when the heme is removed by hemoglobin formation. The proinhibitor form of HCI (proHCI) is unstable in vitro and, even in the presence of heme, is irreversibly inactivated by SH-binding reagents, alkaline pH, slightly elevated temperatures, or high hydrostatic pressure. In hemin-supplemented reticulocyte lysates proHCI can also be reversibly activated by oxidized glutathione (GSSG) or NADPH depletion as well as by polyunsaturated fatty acids and by Ca2+-phospholipid. The mechanism of activation of HCI by GSSG has not been clarified although it appears to involve oxidation of proHCI SH groups to disulfides. Like activation by GSSG, the activation of HCI by polyunsaturated fatty acids and by Ca2+-phospholipid also appears to be largely due to oxidation of some of the enzyme's SH groups. There thus appear to be two fully independent mechanisms of HCI activation in reticulocyte lysates, one involving heme deficiency, the other involving oxidation of proHCI SH groups. The latter, but not the former, can be prevented or reversed by NADPH generators or dithiols. ProHCI appears to be maintained in the reduced, inactive state by a system involving NADPH, thioredoxin, and thioredoxin reductase.