Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial.

Importance: Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited. Objective: To determine whether hydrocortisone improves outcome for patients with severe COVID-19. Design, Setting, and Participants: An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020. Interventions: The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108). Main Outcomes and Measures: The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%). Results: After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively. Conclusions and Relevance: Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions. Trial Registration: ClinicalTrials.gov Identifier: NCT02735707

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

<i>NDUFA10/ND42</i> overexpression does not restore CCCP-induced Parkin translocation in the absence of <i>pink1</i>.

<p>(A) Quantification of the percentage of cells showing mitochondrially localized Parkin following 4 hours CCCP treatment of HeLa cells stably expressing YFP-Parkin transfected with (B) control siRNA, (C) <i>NDUFA10</i> siRNA, or (D) <i>PINK1</i> siRNA treatment and transfection with <i>NDUFA10</i> or fly <i>ND42</i> expression constructs. Scale bar  = 20 µm. * <i>P</i><0.05, *** <i>P</i><0.001, One-way ANOVA with Bonferroni correction compared to respective control siRNA treatment.</p

Overexpression of <i>parkin</i> can rescue behavioral phenotypes in <i>pink1</i> mutants but not complex I deficiency.

<p>Analysis of (A) climbing and (B) flight ability in <i>pink1^B9</i> mutants overexpressing <i>parkin</i>. Charts show (C) the ratio of complex I to citrate synthase (CS) activity, and (D) relative ATP levels, normalized to control. Histograms indicate mean ± s.e.m. Overexpression was driven by the ubiquitous driver <i>da-GAL4</i>. Control genotype is <i>da-GAL4</i>/+. * <i>P<</i>0.05, ** <i>P<</i>0.01, *** <i>P<</i>0.001, **** <i>P</i><0.0001, One-way ANOVA with Bonferroni correction. Comparisons are with <i>pink1^B9</i> mutants.</p

A cell based RNAi screen to identify phenocopiers and suppressors of <i>pink1</i> RNAi-induced mitochondrial hyperfusion.

<p>(A) Schematic of the RNAi screen protocol (see <a href="http://www.plosgenetics.org/article/info:doi/10.1371/journal.pgen.1004815#s4" target="_blank">Methods</a> for details). (B) Representative images of <i>Drosophila</i> S2R+ cells for mitochondrial morphology following dsRNA treatment of the indicated genes, stained with MitoTracker Red and imaged live (top row). Fluorescence images are converted to binary (B&W) and inverted to clarify the mitochondrial morphology (bottom row). Numbers represent the designated ‘morphology score’: 1, fragmented; 2, wild type; 3, fused/tubular; 4, hyperfused/clumped. (C) Comparison of morphology score of screen library amplicons in WT and <i>pink1</i> RNAi backgrounds. Solid-line box depicts those amplicons that phenocopy <i>pink1</i> RNAi (box limits: mean ± s.d. <i>pink1</i> control). Dashed-line box depicts amplicons which suppress <i>pink1</i> RNAi-induced fusion back to WT morphology (box limits: mean ± s.d. <i>DsRed</i> control). Controls for fragmentation (<i>Marf)</i> and fusion (<i>Drp1</i>) are shown. Scale bar  = 10 µm.</p

<i>ND42</i> or <i>sicily</i> overexpression can rescue <i>pink1</i> mutant phenotypes in flies.

<p>Overexpression of two <i>ND42</i> transgenes, <i>ND42</i> and <i>ND42-HA</i>, in a wild type background has no effect on climbing (A) or flight behavior (B). In <i>pink1^B9</i> mutants, climbing (C) and flight ability (D), normalized to control, is significantly rescued by overexpression <i>ND42</i> or <i>sicily</i>. Histograms indicate mean ± s.e.m. (E) Transmission electron microscopy of flight muscle shows partial rescue of mitochondrial disruption. Scale bar  = 1 µm. Overexpression was driven by the ubiquitous driver <i>da-GAL4</i>. Control genotype is <i>da-GAL4</i>/+. Number of animals tested, n>50. * <i>P</i><0.05, *** <i>P</i><0.001, **** <i>P</i><0.0001, One-way ANOVA with Bonferroni correction. Comparisons are with control (A, B) or <i>pink1^B9</i> mutants (C, D).</p

List of genes that phenocopy <i>pink1</i> dsRNA induced mitochondrial fusion.

<p>List of genes that phenocopy <i>pink1</i> dsRNA induced mitochondrial fusion.</p

Analysis of ND42 Ser-250 phospho-variant rescue of <i>pink1</i> mutant climbing defect and complex I deficiency.

<p>Transgenes from different sources, labeled ‘HB’ <a href="http://www.plosgenetics.org/article/info:doi/10.1371/journal.pgen.1004815#pgen.1004815-Zhang1" target="_blank">[29]</a> and ‘BDS’ <a href="http://www.plosgenetics.org/article/info:doi/10.1371/journal.pgen.1004815#pgen.1004815-Morais2" target="_blank">[25]</a>, expressing wild type <i>ND42</i> (WT), non-phosphorylatable (SA) or phospho-mimetic (SD) variants of Ser-250 were tested for rescue of climbing (A), flight (B) and complex I (C) deficiencies in <i>pink1^B9</i> mutants. For comparison, transgenic expression of the yeast complex I equivalent, <i>NDI1</i>, was also tested. Overexpression was driven by the ubiquitous driver <i>da-GAL4</i>. Control genotype is <i>da-GAL4</i>/+. * <i>P<</i>0.05, ** <i>P<</i>0.01, **** <i>P</i><0.0001, One-way ANOVA with Bonferroni correction. Comparisons are with <i>pink1^B9</i> mutants unless otherwise shown.</p

List of genes that suppress <i>pink1</i> dsRNA induced mitochondrial fusion.

<p>List of genes that suppress <i>pink1</i> dsRNA induced mitochondrial fusion.</p