Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

Inflammation d’origine non-pathogénique durant la gestation, implication dans les complications de la grossesse et impact sur le développement cérébral

INTRODUCTION : Le retard de croissance intra-utérin (RCIU), la prééclampsie (PE) et l’accouchement prématuré (AP) sont d’importantes pathologies de la grossesse fortement associées à un mauvais fonctionnement du placenta, organe central au développement du fœtus. Environ 5-12% de toutes les grossesses sont pathologiques et ces dernières sont associées avec un risque accru de désordres neurodéveloppementaux chez l’enfant. L'inflammation est un point central à toutes les complications de la grossesse et le lien causal entre l’inflammation et ces pathologies a été démontré à l’aide de plusieurs modèles animaux d’inflammation prénatale, menant à des dommages cérébraux chez les nouveau-nés. Cependant, la majorité des modèles utilisent des stimuli infectieux, bien que des pathogènes soient rarement détectés en clinique. Malgré l'absence d'infection détectable, des évidences d'inflammation, telles que des niveaux élevés de cytokines pro-inflammatoires et d’alarmines, sont présentes. Les alarmines sont des médiateurs endogènes et une autre cause d'inflammation de plus en plus associée aux pathologies de la grossesse. L’acide urique est une des alarmines les plus étudiées comme médiateur endogène d’inflammation, mais son effet sur la grossesse est peu connu. Ainsi, mon hypothèse était que l’exposition prénatale particulièrement à l’acide urique serait associée aux complications de la grossesse, serait une cause de dommage placentaire et subséquemment altèrerait le neurodéveloppement fœtal, menant à des dommages cérébraux à long terme chez l’enfant. Mon OBJECTIF général était de comprendre le lien entre inflammation prénatale non-pathogénique, les complications de la grossesse et les effets sur le placenta et le cerveau en développement. Spécifiquement, j’ai déterminé la présence d’inflammation dans les complications majeures de la grossesse puis je me suis concentré sur la PE et l’implication de l’activation immunitaire dans cette pathologie. En parallèle, j’ai établi le lien entre l’inflammation non-pathogénique, les dommages placentaires et le RCIU. Finalement, j’ai évalué le neurodéveloppement après l’exposition in-utero à une inflammation non-pathogénique et j’ai investigué le potentiel d’un nouveau traitement dans mon modèle préclinique. MÉTHODOLOGIES ET RÉSULTATS: J’ai analysé le profil inflammatoire de 200 femmes avec ou sans complications de la grossesse (Ctrl, PE, AP, RCIU) et j’ai démontré que chaque complication présente un profil inflammatoire circulant distinct, particulièrement présent chez les femmes avec PE. De plus, j’ai analysé plus en profondeur les femmes avec PE et observé une augmentation d’acide urique dans la circulation maternelle, en lien avec un profil immunitaire qui était altéré et des changements structuraux au niveau du placenta. Pour déterminer les effets directs de l'acide urique, nous avons utilisé des cultures de trophoblastes primaires, cellule principale du placenta, et des explants placentaires humains. Nous avons démontré que l’acide urique induisait un profil pro-inflammatoire augmentant particulièrement la sécrétion d’IL-1β et d’IL-6 et induisait aussi l'apoptose des trophoblastes. En parallèle, j’ai développé un nouveau modèle préclinique de rates gestantes qui ont été injectées par voie intrapéritonéale avec l’acide urique du temps de gestation 18 (G18) à G21. L’injection d'acide urique in vivo à la fin de la gestation chez le rat a entrainé l’augmentation de cytokines (IL-1β, TNF-α et IL-6) et l’infiltration de cellules immunitaires dans le placenta ainsi qu’un RCIU chez le fœtus qui persistait dans la période postnatale. De plus, les bébés exposés in-utero à l’acide urique avaient une altération neurodéveloppementale caractérisée par l’activation microgliale et astrogliale en plus d’une diminution des capacités motrices. Ces effets de l’acide urique étaient dépendants de l'IL-1β et bloqués par l’antagoniste spécifique du récepteur de l’IL-1 (IL-1Ra). CONCLUSIONS: L’inflammation est associée à toutes les complications de la grossesse, mais les profils diffèrent selon la pathologie étudiée. La PE est associée à des changements immunitaires importants. L'acide urique à l'interface materno-fœtale induit inflammation et altère les fonctions placentaires de façon IL-1-dépendante. Finalement, l’exposition à l’acide urique en fin de gestation chez le rat induit l’inflammation placentaire, le RCIU et altère le développement cérébral des bébés. Un traitement prénatal anti-inflammatoire permet de minimiser l’inflammation et ses effets négatifs sur le cerveau.INTRODUCTION: Intra-uterine growth restriction (IUGR), preeclampsia (PE) and preterm birth (PTB) are important pathologies of pregnancy strongly associated with poor placental function, a central organ for fetal development. About 5-12% of all pregnancies are pathological and this increases the risk of neurodevelopmental disorders. Inflammation is central to all pregnancy complications and the causal link has been demonstrated with several animal models of prenatal inflammation leading to brain damage in newborns. However, these models use infectious stimuli although pathogens are rarely detected clinically. Despite the absence of detectable infection, evidence of inflammation, such as elevated levels of pro-inflammatory cytokines and alarmins, is observed. Alarmins are endogenous mediators, another cause of inflammation increasingly associated with pathological pregnancies. Uric acid is one of the most studied alarmins, however its effect on pregnancy is mostly unknown. Thus, my hypothesis was that prenatal exposure particularly to uric acid is associated with pregnancy complications and is a cause of placental damage which subsequently impairs fetal neurodevelopment, leading to long-term brain damage in the child. My general OBJECTIVE was to understand the link between non-pathogenic prenatal inflammation, pregnancy complications and its effect on the placenta and the developing brain. Specifically, I detected the presence of inflammation in major pregnancy complications and subsequently focused on PE and its immune activation. In parallel, I established the causal link between non-infectious inflammation, placental damage and IUGR. Finally, I evaluated brain development following in utero inflammation and investigated a therapeutic target in my preclinical model. METHODS AND RESULTS: I analyzed the inflammatory profile of 200 women with or without pregnancy complications (Ctrl, IUGR, PE, PTB) and demonstrated that each complication has a distinct circulating inflammatory profile, particularly in women with PE. In addition, I further analyzed women with PE and observed a uric acid increase in the maternal circulation, related to an altered immune profile and structural changes in the placenta. To determine the direct effects of uric acid, we used cultures of primary trophoblasts, the main cell of the placenta, and human placental explants. We have shown that uric acid induces a pro-inflammatory profile, particularly increasing the secretion of IL-1β and IL-6 and induces apoptosis of trophoblasts. In parallel, I developed a new preclinical model of pregnant rats that were injected intraperitoneally with uric acid from gestation time 18 (G18) to G21. The injection of uric acid at the end of gestation in the rat caused increase cytokines (IL-1β, TNF-α and IL-6), the infiltration of immune cells in the placenta as well as an IUGR in the fetus that persisted into the postnatal period. Additionally, babies exposed to uric acid in utero have neurodevelopmental impairment characterized by microglial and astroglial activation in addition to decreased motor function. These effects of uric acid was dependent on IL-1β and was blocked by the IL-1 receptor antagonist (IL-1Ra). CONCLUSIONS: Inflammation is associated with all pregnancy complications, however, with different profiles depending on the pathology studied. PE is associated with significant immune changes. Uric acid at the maternal-fetal interface induced inflammation and altered placental functions in an IL-1-dependent manner. Ultimately, exposure to uric acid in late rat pregnancy induced placental inflammation, IUGR, and impaired brain development. Prenatal anti-inflammatory treatment helped minimize inflammation and these negative effects on the brain

Antenatal suppression of il-1 protects against inflammation-induced fetal injury and improves neonatal and developmental outcomes in mice

Preterm birth (PTB) is commonly accompanied by in utero fetal inflammation, and existing tocolytic drugs do not target fetal inflammatory injury. Of the candidate proinflammatory mediators, IL-1 appears central and is sufficient to trigger fetal loss. Therefore, we elucidated the effects of antenatal IL-1 exposure on postnatal development and investigated two IL-1 receptor antagonists, the competitive inhibitor anakinra (Kineret) and a potent noncompetitive inhibitor 101.10, for efficacy in blocking IL-1 actions. Antenatal exposure to IL-1β induced Tnfa, Il6, Ccl2, Pghs2, and Mpges1 expression in placenta and fetal membranes, and it elevated amniotic fluid IL-1β, IL-6, IL-8, and PGF2α, resulting in PTB and marked neonatal mortality. Surviving neonates had increased Il1b, Il6, Il8, Il10, Pghs2, Tnfa, and Crp expression in WBCs, elevated plasma levels of IL-1β, IL-6, and IL-8, increased IL-1β, IL-6, and IL-8 in fetal lung, intestine, and brain, and morphological abnormalities: e.g., disrupted lung alveolarization, atrophy of intestinal villus and colon-resident lymphoid follicle, and degeneration and atrophy of brain microvasculature with visual evoked potential anomalies. Late gestation treatment with 101.10 abolished these adverse outcomes, whereas Kineret exerted only modest effects and no benefit for gestation length, neonatal mortality, or placental inflammation. In a LPS-induced model of infection-associated PTB, 101.10 prevented PTB, neonatal mortality, and fetal brain inflammation. There was no substantive deviation in postnatal growth trajectory or adult body morphometry after antenatal 101.10 treatment. The results implicate IL-1 as an important driver of neonatal morbidity in PTB and identify 101.10 as a safe and effective candidate therapeutic.Mathieu Nadeau-Vallée, Peck-Yin Chin, Lydia Belarbi, Marie-Ève Brien, Sheetal Pundir, Martin H. Berryer, Alexandra Beaudry-Richard, Ankush Madaan, David J. Sharkey, Alexis Lupien-Meilleur, Xin Hou, Christiane Quiniou, Alexandre Beaulac, Ines Boufaied, Amarilys Boudreault, Adriana Carbonaro, Ngoc-Duc Doan, Jean-Sebastien Joyal, William D. Lubell, David M. Olson, Sarah A. Robertson, Sylvie Girard and Sylvain Chemto