CXCL10 Could Drive Longer Duration of Mechanical Ventilation During COVID-19 ARDS
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Blot et al. Critical Care (2020) 24:632 https://doi.org/10.1186/s13054-020-03328-0 RESEARCH Open Access CXCL10 could drive longer duration of mechanical ventilation during COVID-19 ARDS Mathieu Blot1,2*, Marine Jacquier2,9, Ludwig-Serge Aho Glele10, Guillaume Beltramo3, Maxime Nguyen2,4, Philippe Bonniaud3, Sebastien Prin9, Pascal Andreu9, Belaid Bouhemad2,4, Jean-Baptiste Bour5, Christine Binquet6, Lionel Piroth1,6, Jean-Paul Pais de Barros2,7, David Masson2,8, Jean-Pierre Quenot2,6,9, Pierre-Emmanuel Charles2,9 and Pneumochondrie study group Abstract Background: COVID-19-related ARDS has unique features when compared with ARDS from other origins, suggesting a distinctive inflammatory pathogenesis. Data regarding the host response within the lung are sparse. The objective is to compare alveolar and systemic inflammation response patterns, mitochondrial alarmin release, and outcomes according to ARDS etiology (i.e., COVID-19 vs. non-COVID-19). Methods: Bronchoalveolar lavage fluid and plasma were obtained from 7 control, 7 non-COVID-19 ARDS, and 14 COVID-19 ARDS patients. Clinical data, plasma, and epithelial lining fluid (ELF) concentrations of 45 inflammatory mediators and cell-free mitochondrial DNA were measured and compared. Results: COVID-19 ARDS patients required mechanical ventilation (MV) for significantly longer, even after adjustment for potential confounders. There was a trend toward higher concentrations of plasma CCL5, CXCL2, CXCL10, CD40 ligand, IL- 10, and GM-CSF, and ELF concentrations of CXCL1, CXCL10, granzyme B, TRAIL, and EGF in the COVID-19 ARDS group compared with the non-COVID-19 ARDS group. Plasma and ELF CXCL10 concentrations were independently associated with the number of ventilator-free days, without correlation between ELF CXCL-10 and viral load. Mitochondrial DNA plasma and ELF concentrations were elevated in all ARDS patients, with no differences between the two groups. ELF concentrations of mitochondrial DNA were correlated with alveolar cell counts, as well as IL-8 and IL-1β concentrations. Conclusion: CXCL10 could be one key mediator involved in the dysregulated immune response. It should be evaluated as a candidate biomarker that may predict the duration of MV in COVID-19 ARDS patients. Targeting the CXCL10-CXCR3 axis could also be considered as a new therapeutic approach. Trial registration: ClinicalTrials.gov, NCT03955887 Keywords: Acute respiratory distress syndrome, COVID-19, SARS-CoV-2, Mechanical ventilation, Immune response, Bronchoalveolar lavage, CXCL10, Mitochondrial DNA, Biomarker * Correspondence: [email protected] 1Infectious Diseases Department, Dijon Bourgogne University Hospital, Dijon, France 2INSERM, LNC UMR 1231, FCS Bourgogne-Franche Comté, LipSTIC LabEx, F-21000 Dijon, France Full list of author information is available at the end of the article © The Author(s). 2020, corrected publication 2021. 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The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Blot et al. Critical Care (2020) 24:632 Page 2 of 15 Background the department of pneumology at the University Hospital of Since December 2019, the world is experiencing an out- Dijon (France). Patients were eligible if a BAL was considered break of coronavirus disease 2019 (COVID-19) caused necessary by the attending physician and if they had (1) pneu- by severe acute respiratory syndrome coronavirus 2 monia (≥ 2 acute signs including cough, purulent sputum, (SARS-CoV-2). Clinical, radiological, and biological dif- dyspnea, chest pain, temperature < 35 °C or ≥ 38.5 °C, and ferences have been found between COVID-19-related novel radiological pulmonary infiltrate); (2) ARDS (according acute respiratory distress syndrome (ARDS) and ARDS to the Berlin Definition) [12]; (3) requiring mechanical venti- from another origin. Indeed, the sudden clinical deteri- lation (MV); and (4) BAL was performed within 72 h of the oration observed 1 week after symptom onset, together start of MV. COVID-19 ARDS patients were eligible if they with deep hypoxemia contrasting with “normal” (> 40 tested positive for SARS-CoV-2 by reverse transcriptase poly- mL/cmH2O) lung compliance, and the higher incidence merase chain reaction (RT-PCR) for at least one respiratory of thromboembolic events suggest that SARS-CoV-2 is sample. The control population consisted of outpatients with- driven by a unique pathogenesis resulting in an atypical out fever during the last 15 days, not under mechanical venti- form of ARDS [1, 2]. Notably, mechanical ventilation ap- lation, and undergoing a BAL for a condition not related to pears to be required for twice as long in COVID-19 than acute infection (evaluation of a pulmonary nodule, chronic in non-COVID-19 ARDS patients [3, 4]. interstitial syndrome, or unexplained chronic pulmonary It has been established that the virus invades type 2 alveo- sign). Seven control patients and 7 bacterial ARDS patients lar cells and ciliated epithelial cells that express ACE2 [5]. were prospectively included between June 11, 2019, and Janu- Subsequently, as they die, infected cells release virus parti- ary 20, 2020 (5 weeks before the pandemic COVID-19 started cles and intracellular components including molecules in Burgundy, France). Fourteen COVID-19 ARDS patients likely to act as alarmins (i.e., danger signals), as reflected by were included between March 30 and April 09, 2020. Oral rising lactate dehydrogenase (LDH) levels in the plasma [6]. consent was obtained from the patients or their legal repre- The ensuing recruitment and activation of immune cells sentatives. Approval was obtained from the ethics committee lead to lung damage [7]. For now, several studies have (Comité de Protection des Personnes Sud-Est III; 2018-035 B), established that the hyperinflammatory response (namely and an amendment was obtained to include supplementary the cytokine storm) induced by SARS-CoV-2 is associated patients with COVID-19-related ARDS. with disease severity and could contribute to the develop- ment of ARDS [8, 9]. In addition, since most patients need to undergo mechanical ventilation in this context, Variables of interest, clinical outcomes, and data ventilator-induced lung injury (VILI) could exacerbate tis- collection sue damage as well as local and systemic inflammation, Demographic data, comorbidities, clinical and bio- thus acting as a “second hit.” Our team has previously logical parameters, and severity scores (Sequential shown that mitochondrial alarmins (i.e., mitochondrial Organ Failure Assessment (SOFA) [13]andthenew DNA) are released by human epithelial cells submitted to simplified acute physiology score (SAPS II) [14]) were cyclic stretch, and these alarmins are also recovered from calculated on the first day of ARDS. Septic shock was bronchoalveolar lavage (BAL) fluid obtained from either defined as persistent hypotension requiring vasopres- ventilated rabbits or ARDS patients. By promoting chemo- sors and a serum lactate level > 2 mmol/L despite ad- taxis and activation of polymorphonuclear neutrophils equate volume resuscitation. Clinical outcomes were (PMNs), mitochondrial alarmins are thought to represent recorded up to 30 days after the start of ARDS: 30-day proximal endogenous mediators of VILI and ARDS when mortality; number of hospital-, ICU-, and ventilator- they are released by injured alveolar cells [10, 11]. free days; and hospital-acquired complications (ventila- The aim of our study was to compare cytokine response tory-acquired pneumonia (VAP), thrombo-embolic dis- patterns, in both alveolar and systemic compartments, be- ease). The “ventilator-free days” outcome was defined tween COVID-19-related ARDS and non-COVID-19-re- as the number of days alive from day 1 of ARDS to day lated ARDS (i.e., ARDS complicating pneumonia from 30 during which the patient was breathing without MV. another origin). In addition, we sought to establish the ex- Dedicated clinical research assistants collected all data tent to which the immune signature could be associated using a standardized electronic case report form. Auto- with clinical evolution according to ARDS etiology. matic checks were generated for missing or incoherent data. All abnormal data were controlled by a physician- Methods scientist. Study design and patient selection The concentration of inflammatory cytokines and This is an ancillary study of the ongoing prospective PNEU- mitochondrial alarmins (cell-free mitochondrial DNA MOCHONDRIE study (ClinicalTrials.gov NCT03955887) concentrations) was measured within both the systemic which started in June 2019