Metabolic stress, mitochondria and organ failure during ... · organ failure during critical...
Transcript of Metabolic stress, mitochondria and organ failure during ... · organ failure during critical...
Metabolic stress, mitochondria and organ failure during critical illness:underlying mechanisms revealing
therapeutic potential
Jan Gunst, MD, PhD
33rd Annual SIZ meeting
Vilvoorde, June 14, 2013
Metabolic interventions can affect outcome
Tight glycemic control with intensive insulin therapy
Early parenteral nutrition
Van den Berghe et al. NEJM 2001Van den Berghe et al. NEJM 2006 Vlasselaers et al. Lancet 2009Casaer et al. NEJM 2011
Study aims
Mechanisms of organ protection by preventing hyperglycemia with insulin
Detailed impact of early vs late PN on the kidney
Data published:
Kidney Int 2009;76(5):512-20
Part 1: Glycemic control vs insulin & renal damage
Normoinsulinemia/Normoglycemia NI/NGHyperinsulinemia/Normoglycemia HI/NG Normoinsulinemia/Hyperglycemia NI/HGHyperinsulinemia/Hyperglycemia HI/HG
InsulinemiaGlycemia
3 5 70Basel.
200
50
1 2 3 4 5 6 7Basel.
350
100500
450500550
150200250300
400
mg/d
l
Days Days
300
250
150
100
0
mU
/l
Ellger et al., Diabetes 2006
4-arm study:blood glucose and insulinemia regulated independently
Glucose vs insulin & kidney function
: p≤0.1, p≤0.05 versus control§, #
mg/d
l
0.0
0.5
1.0
1.5
2.0
2.5
3.0
#
§
Bars indicate mean s.e.m.
: p≤0.1, p≤0.05 between sick groups
Plasma creatinine
n 4 8 8 89
Glyc. NG NG HG HG
Ins. NI NI HIHI
Control Sick
Glucose vs insulin & kidney function
: p≤0.1, p≤0.05 versus control§, #
mg/d
l
0.0
0.5
1.0
1.5
2.0
2.5
3.0
#
§
Bars indicate mean s.e.m.
: p≤0.1, p≤0.05 between sick groups
Plasma creatinine
n 4 8 8 89
Glyc. NG NG HG HG
Ins. NI NI HIHI
Control Sick
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
0 5 10 15 20 25 30 35
Cre
atinin
e (
mg/d
l)Glucose (mmol/g cortex)
R=0.546P=0.0005
Mechanisms of organ protection
Mitochondrial functionTissue perfusion & DO2
r=-0.211p=0.24
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
-1 -.8 -.6 -.4 -.2 0 .2 .4 .6 .8 1
Cre
atinin
e (
mg/d
l)
log O2 delivery to cortex
U/g
cort
ex
Complex I
0
5
10
15
20
25
30
35
40
#
# #
n 4 8 8 89
Complex V
0
25
50
75
100
125
150
175
200
225
##
##
n 4 8 8 89
: p≤0.05 versus control# : p≤0.1, p≤0.05 between sick groups Bars indicate mean s.e.m.
Complex V (U/g cortex)
r=-0.609P<0.0001
0 50 100 150 200 250
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
Cre
atinin
e (
mg/d
l)
Complex I (U/g cortex)
r=-0.640P<0.0001
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
0 5 10 15 20 25 30 35 40
#
0.0
1.0
2.0
3.0
4.0
5.0
ml O
2/1
0g p
er
min
Cortical O2 delivery
n 8 8 8 89
HI/HGNI/HGHI/NGControl NI/NG
Conclusion Part 1Glycemic control versus Insulin & renal damage
Normoglycemia
Hyperinsulinemia
Renal protection
Protection againstmitochondrial damage
Glucose
Glucose-6-P
Glyceraldehyde-3-P + DHAP
Glycerate-1,3-biP
Pyruvate
L-lactateAcetyl-CoA
Krebs cycle-Respiratory chainFatty acids/TGKetone bodies
MethylglyoxalAGEs
Free adducts
D-Lactate
Glycogen
Glyoxalase IGlyoxalase II
Glyoxal
3-deoxyglucosone
Mechanisms of glucose toxicity
GAPDH
Mitochondrial dysfunction(Multiple) organ failure
Direct insult
Insufficient mitochondrial repair
Part 2: Role of intact mitochondrial repair in critical illness
Data published: J Clin Endocrinol Metab 2011;96(4):E633-645J Clin Endocrinol Metab 2012;97(1):E59-64Crit Care Med 2013; 41(1):182-94
Mitochondrial repair: autophagy
LC3-IIp62
ububub
SSub
p62ub
ubub
Sub
p62ub
ubub
Sub
Isolationmembrane
Autophagosome Autophagolysosome
Lysosome
LC3-I
LC3-I
p62
Ubiquitinated substrate
LC3-II
Boxes indicate median/IQR, whiskers interdecile range
: p≤0.05 versus control
Control (elective rectal surgery)
Conventional insulin therapy
Autophagosome
0
50
100
150
200
250
300
350
400
5 5n
Numberautophagic vacuoles
Human liver
LC3-I
p62
Ubiquitinated substrate
LC3-II
Boxes indicate median/IQR, whiskers interdecile range
: p≤0.05 versus control
Control
Conventional insulin therapy
?
?
?
60
0
10
20
30
40
50
LC3-II/LC3-I ratio
18 18n
0
10
20
30
40
50
60
p62
Rela
tive p
rote
in level
18 18n0.20
0.25
0.30
0.35
Ubiquitin staining
12 18n
Inte
nsi
ty
Autophagosome
Human liver
Mitochondrial repair in vivo?
Human post mortem biopsies: relation with outcome?
Rabbit model of prolonged critical illness: survivors vs. non-survivors
Autophagy ~ Outcome
p62
Liver Kidney
LC3-II/LC3-I ratio
Sick-Non Survivor
Sick-Survivor
Healthy
0
1
2
3
4
0
1
2
3
4
5
6
7
8
9
0.0
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6
0.0
0.2
0.4
0.6
0.8
1.0
1.2
1.4
3
4
5
6
7
8
9
10
11
12
ALT
last
day
(sqrt
-tra
nsf
orm
ed)
0.4 0.6 0.8 1.0 1.2 1.4 1.6 1.8 2.0 2.2
p62 liver (sqrt-transformed)
r=0.647p<0.0001
n 8 26 13 n 8 26 13
Boxes indicate median/IQR, whiskers interdecile range. Organs could not be sampled in 5/18 non-surviving animals.
, () : p≤0.05, 0.05<p≤0.1 vs control : p≤0.05, 0.05<p≤0.1 survivor vs non-survivor
, () : p≤0.05, 0.05<p≤0.1 vs control : p≤0.05, 0.05<p≤0.1 between sick groups
Boxes indicate median/IQR, whiskers interdecile range. Pearson correlation calculated after square root transformation of p62 and markers of organ damage
LIVER KIDNEY
3 days 7 days 3 days 7 days
0
1
2
3
4
5
6
0
1
2
3
4
5
6
7
0
1
2
3
4
0
1
2
3
4
()
p62 protein
Normo-glycemia
Hyper-glycemia
Control
Mitochondrial protection by preventing hyperglycemia (in part) explained by maintaining autophagy more efficient?
ALT last day (U/l)AST last day (U/l) Creatinine last day (mg/dl)
Complex V activ.(U/g liver)
Complex I activ.(U/g kidney)
Complex V activ.(U/g kidney)
Complex I activ.(U/g liver)
LIVER KIDNEY
3 days 7 days 3 days 7 days
0
1
2
3
4
5
6
0
1
2
3
4
5
6
7
0
1
2
3
4
0
1
2
3
4
0
1
2
3
4
5
6
7
0.6 0.8 1.0 1.2 1.4 1.6 1.8 2.04
6
8
10
12
14
16
0.6 0.8 1.0 1.2 1.4 1.6 1.8 2.0
0.6
0.8
1.0
1.2
1.4
1.6
1.8
2.0
0.8 1.0 1.2 1.4 1.6 1.8
0
2
4
6
8
0.0 0.5 1.0 1.5 2.00
10
20
30
40
50
60
70
0.0 0.5 1.0 1.5 2.0
2
3
4
5
6
7
8
9
0.5 1.0 1.5 2.0 2.5
n 7 8 8n 8 8 8 n 5 5 5n 5 5 5
()
()
2
3
4
5
6
7
8
9
0.5 1.0 1.5 2.0 2.5
p62 protein
, () : p≤0.05, 0.05<p≤0.1 vs control : p≤0.05, 0.05<p≤0.1 between sick groups
Boxes indicate median/IQR, whiskers interdecile range. Pearson correlation calculated after square root transformation of p62 and markers of organ damage
Correlation p62 protein (X-axis) with:
r=0.808p=0.0002
r=0.606p=0.01
r=0.562p=0.02
r=-0.692p=0.004
r=-0.671p=0.006
r=-0.611p=0.004
r=-0.605p=0.005
Mitochondrialdamage
Organdamage
Normo-glycemia
Hyper-glycemia
Control
Activation of autophagy
Sick-Rapamycin
Sick-Saline
Healthy
Boxes indicate median/IQR, whiskers interdecile range
0.4
0.8
1.2
1.6
2.0
2.4
p62 kidney
n 4 6 60.5
0.6
0.7
0.8
0.9
1.0
1.1
1.2
Plasma creatinine
n 4 6 6
Complex V activity kidney
20
40
60
80
100
120
140
160
()
n 4 6 6
, () : p≤0.05, 0.05<p≤0.1 vs healthy : p≤0.05, 0.05<p≤0.1 between sick groups
Insufficient autophagy
Mitochondrial dysfunctionOrgan damage
Adverse outcome
Hyperglycemia (Parenteral) feeding1
Conclusion Part 2: Role of intact mitochondrial repair in critical illness
1Derde et al. Endocrinology 2012
Casaer et al. N Engl J Med 2011
Part 3: Detailed impact of early vs late PN on AKI
Data published:
J Am Soc Nephrol 2013; 24(6):995-1005
Incidence of AKI
Early PN
n (%)
Late PN
n (%)p
AKI (any) 568 (24.9) 565 (24.6) 0.8
AKI Stage 1 219 (9.6) 197 (8.6) 0.2
AKI Stage 2 99 (4.3) 107 (4.7) 0.6
AKI Stage 3 250 (11.0) 261 (11.4) 0.7
AKI stage 1 and 2 were defined as peak creatinine 1.5-2x, respectively 1.5-2x baselinevalue. AKI stage 3 was defined as preak creatiinine 2x baseline value OR Creatinine >4mg/dl (and 0.5 mg/dl rise) OR new renal replacement therapy
Recovery from AKI
Early PN Late PN p
AKI stage 1
Days with AKI in ICU1 1 (1-2) 2 (1-3) 0.4
AKI stage 2
Days with AKI in ICU1 5 (3-9) 4 (2-6) 0.04
AKI stage 3
Days with AKI in ICU1 12 (7-21) 11 (6-21) 0.2
1 Data show median (interquartile range) for ICU survivors only
Recovery from AKI
Early PN Late PN p
AKI stage 1
Days with AKI in ICU1 1 (1-2) 2 (1-3) 0.4
Alive and AKI-free at hospital discharge, n (%) 168 (76.7) 148 (75.1) 0.7
AKI stage 2
Days with AKI in ICU1 5 (3-9) 4 (2-6) 0.04
Alive and AKI-free at hospital discharge, n (%) 63 (63.6) 68 (63.6) 0.9
AKI stage 3
Days with AKI in ICU1 12 (7-21) 11 (6-21) 0.2
Alive and AKI-free at hospital discharge, n (%) 86 (34.4) 98 (37.5) 0.5
1 Data show median (interquartile range) for ICU survivors only
2312Early PN
0.0
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6
Plasma creatinine
d1 d3 d5 d7 d9 d11 d13
1Excluded: dialyzed patients (n=428) and patients with missing samples on more than 2 consecutive days (n=584)
Bar graphs indicate mean and 95% CI
Late PN
Early PN
0.001<p≤0.01; # p≤0.001 between sick groups
Plasma urea
0
20
40
60
80
100
No. in ICU
1438 975 736 601 517 4322328 1399 913 655 524 436 365Late PN
#
## # ##
d1 d3 d5 d7 d9 d11 d13
Urea/creatinine ratio
Creatinine clearance1
0
20
40
60
80
100
120
#
##
######
0
20
40
60
80
100
d1 d3 d5 d7 d9 d11 d13
d1 d3 d5 d7 d9 d11 d13
Nitrogen loss and balance over time in ICU
Nitrogen loss (g) Nitrogen balance (g)
d1 d3 d5 d7 d9 d11 d13 d1 d3 d5 d7 d9 d11 d13
Excluded: dialyzed patients (n=428) and patients with missing samples on more than 2 consecutive days (n=584)Bar graphs indicate mean and 95% CI
No. in ICU
1801 1003 622 436 336 276 220
1827 989 598 402 298 234 191
Early
LatePN
1801 1003 622 436 336 276 220
1827 989 598 402 298 234 191
Early
LatePN
0.001<p≤0.01; # p≤0.001 between sick groups
#
#
#####
#
# ## # #
# # #
0.0
2.5
5.0
7.5
10.0
12.5
15.0
17.5
20.0
22.5
-16
-14
-12
-10
-8
-6
-4
-2
0
Late PN
Early PN
63% of extra nitrogen administration net wasted!
Conclusion Part 3Early versus late PN & AKI
Early PN:
No major impact on incidence and recovery of AKIprolonged stage 2 AKI?
Inefficient to reverse the negative nitrogen balanceIncreased ureagenesis
prolonged duration of renal replacement therapy? (as supported by multiple regression-data not shown)
Summary
Future perspectives
Open perspectives for therapies that
activate autophagy in critical illness,
to stimulate damage removal,
especially in combination with therapies that are able to
effectively suppress excessive catabolism of healthy, lean tissue
Acknowledgements
Department and Laboratory of Intensive Care Medicine
Greet Van den Berghe
Ilse Vanhorebeek Miet Schetz
Eric-Jan Ververs Annelies Aertgeerts Inge Derese
Sarah Derde Andy Wauters Pieter Wouters
Michaël Casaer Greet Hermans Fabian Güiza
Björn Ellger Yves Debaveye Magaly Boussemaere
all colleagues from the Laboratory of Intensive Care Medicine, KU Leuven
clinical staff and research nurses Intensive Care Medicine, University Hosp. Leuven
External collaborators
Wim Martinet (Univ. Antwerp) Jasperina Dubois (Jessa Hosp. Hasselt)
Christophe Magnes (Univ. Graz) Kathleen Claes (KU Leuven)
Evelyne Lerut (KU Leuven)