Adipocyte fatty acid binding protein (A-FABP) is a novel adipokine involved in the regulation of lipid and glucose metabolism and inflammation. To evaluate its potential role in the development of postoperative hyperglycemia and insulin resistance we assessed A-FABP serum concentrations and mRNA expression in skeletal and myocardial muscle, subcutaneous and epicardial adipose tissue and peripheral monocytes in 11 diabetic and 20 age- and sex-matched non-diabetic patients undergoing elective cardiac surgery. Baseline serum A-FABP did not differ between the groups (31.1+/-5.1 vs. 25.9+/-4.6 ng/ml, p=0.175). Cardiac surgery markedly increased serum A-FABP in both groups with a rapid peak at the end of surgery followed by a gradual decrease to baseline values during the next 48 h with no significant difference between the groups at any timepoint. These trends were analogous to postoperative excursions of plasma glucose, insulin and selected proinflammatory markers. Cardiac surgery increased A-FABP mRNA expression in peripheral monocytes, while no effect was observed in adipose tissue or muscle. Our data suggest that circulating A-FABP might be involved in the development of acute perioperative stress response, insulin resistance and hyperglycemia of critically ill irrespectively of the presence of diabetes mellitus.
- MeSH
- biologické markery krev MeSH
- kardiochirurgické výkony * škodlivé účinky MeSH
- lidé středního věku MeSH
- lidé MeSH
- messenger RNA biosyntéza MeSH
- monocyty metabolismus MeSH
- proteiny vázající mastné kyseliny biosyntéza MeSH
- regulace genové exprese MeSH
- senioři MeSH
- tuková tkáň metabolismus MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- Publikační typ
- časopisecké články MeSH
- práce podpořená grantem MeSH
In the critically ill patient, hyperglycemia was believed to be a response by the body to a stressful situation. Stress-induced hyperglycemia is the consequence of increased levels of cortisol, cytokines, growth hormones, catecholamines, and glucagon resulting in the stimulation of endogenous glucose production through glycogenolysis and gluconeogenesis as well as other mechanisms including central and peripheral insulin resistance. Among other things, hyperglycemia has an effect on inflammation and function of the myocardium, kidney, central nervous system, and the immune system. The protective role of intensified insulin therapy (glycemia of 4.4-6.1 mmol/l) in the critically ill patient, as suggested by the Leuven trial, resulted in the quick and widespread adoption of this approach in practice. However, later studies did not support the Leuven trial results while pointing to the possibility of developing severe hyperglycemia. The large multicenter NICE-SUGAR study in 6,022 patients showed higher 90-day mortality in the group with tight glycemic control. The results of NICE-SUGAR led to revision of the guidelines for glycemic control in the critically, recommending to control glycemia below 10 mmol/l. The aim of this overview is to summarize available data on glycemic control in the critically ill patient.
- Klíčová slova
- kriticky nemocný pacient, těsná kontrola glykémie,
- MeSH
- fyziologický stres fyziologie MeSH
- hyperglykemie diagnóza etiologie farmakoterapie patofyziologie MeSH
- inzulin terapeutické užití MeSH
- inzulinová rezistence MeSH
- krevní glukóza analýza MeSH
- kritický stav MeSH
- lidé MeSH
- péče o pacienty v kritickém stavu MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- přehledy MeSH
We studied the changes in serum fibroblast growth factor-21 (FGF-21) concentrations, its mRNA, and protein expression in skeletal muscle and adipose tissue of 15 patients undergoing cardiac surgery. Blood samples were obtained: prior to initiation of anesthesia, prior to the start of extracorporeal circulation, upon completion of the surgery, and 6, 24, 48, and 96 hours after the end of the surgery. Tissue sampling was performed at the start and end of surgery. The mean baseline serum FGF-21 concentration was 63.1 (43.03-113.95) pg/ml and it increased during surgery with peak 6 hours after its end [385.5 (274.55- 761.65) pg/ml, p<0.001], and returned to baseline value [41.4 (29.15-142.83) pg/ml] 96 hours after the end of the surgery. Serum glucose, insulin, CRP, IL-6, IL-8, MCP-1, and TNF-alpha concentrations significantly increased during the surgery. Baseline FGF-21 mRNA expression in skeletal muscle was higher than in both adipose tissue depots and it was not affected by the surgery. Epicardial fat FGF-21 mRNA increased after surgery. Muscle FGF-21 mRNA positively correlated with blood glucose levels at the end of the surgery. Our data suggest a possible role of FGF-21 in the regulation of glucose metabolism and insulin sensitivity in surgery-related stress.
- MeSH
- fibroblastové růstové faktory genetika metabolismus MeSH
- inzulinová rezistence MeSH
- koronární bypass škodlivé účinky MeSH
- lidé středního věku MeSH
- lidé MeSH
- messenger RNA metabolismus MeSH
- perikard metabolismus MeSH
- senioři MeSH
- syndrom systémové zánětlivé reakce etiologie metabolismus MeSH
- tuková tkáň metabolismus MeSH
- upregulace MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- Publikační typ
- práce podpořená grantem MeSH
Akutní selhání ledvin (ASL) je častou komplikací u kriticky nemocných pacientů. Přes rozvoj nových očišťovacích technik (RRT), lepší nutriční podporu a hemodynamické monitorování v posledních dekádách zůstává mortalita u ASL stale vysoká (60%). Existuje několik otázek v nastavení RRT. První je otázka načasování zahájení RRT a možné ovlivnění návratu ledvinných funkcí nebo přežití. Výsledky klinických studií porovnávající časné vs pozdní zahájení RRT neumožňují definitivní závěry. Srovnání přežití nebo návrat ledvinných funkcí byl primárním cílem několika studií porovnávajících CRRT s intermitentními technikami u kriticky nemocných. Přes lepší hemodynamickou stabilitu u CRRT nedetekovaly práce žádný rozdíl v přežití nebo návratu ledvinných funkcí. Jedna práce prokázala lepší přežití pacientů s ASL léčených intermitentní denní hemodialýzou versus IHD každý druhý den. Nové hybridní terapie jako je slow low-efficient daily dialysis (SLEDD) jsou slibné, protože spojují výhody kontinuálních technik a IHD. Koncept odstranění mediátorů vysokoobjemovou hemofiltrací je diskutován jako experimentální terapie u pacientů v sepsi. V této problematice přinese více dat velká multicentrická randomizovaná klinická studie. V současné době není doporučeno rutinně používat HVHF jako pomocnou terapii u pacientů v sepsi bez ASL. Výsledek terapie není, v souladu se současnými daty, ovlivněn výběrem modality RRT.
Acute renal injury (ARI) is a frequent complication in critically ill patients. Despite the development of new renal replacement techniques (RRT), better nutritional support and haemodynamic monitoring over past decades the mortality of ARI remains high (60%). There are several issues in the management of RRT. The first question is the timing of the initiation of the intervention and its impact on the outcome of ARI and renal recovery. Results of trials on early versus late initiation of renal replacement therapy do not allow the drawing of definitive conclusions. Survival or recovery of renal function has been evaluated as an outcome in several trials comparing continuous RRT (CRRT) to intermittent haemodialysis (IHD) in critically ill patients. Despite better haemodynamic stability in the CRRT groups, the studies did not detect any difference in survival or renal recovery between the groups. One study demonstrated increased survival of ARI patients treated with daily IHD versus alternate day IHD. New hybrid therapies such as slow low-efficient daily dialysis (SLEDD) show promising features due to combining the advantages of CRRT and IHD. The concept of mediator removal using high volume haemofiltration (HVHF) has been discussed as an experimental therapy in sepsis. A large multicentric randomized clinical trial shall provide more answers. At this time HVHF cannot be routinely considered as adjunctive therapy of sepsis without ARI. In conclusion, according to the current knowledge the outcome of ARI is not influenced by the modality of RRT used
