Selenium in Sepsis
A new magic bullet?
Daren K. Heyland, MD, FRCPC, MSc
Professor of Medicine,
Queen’s University, Kingston, Ontario
 Updated January 2009
 Summarizes 207 trials studying >20,000 patients
 34 topics
17 recommendations
www.criticalcarenutrition.com
Background
Selenium
• Essential trace element for all mammalian species
• Involved in a number of physiological processes
• Incorporated into 25 different selenoproteins with
activity related to
–
–
–
–
T cell immunity
Modulate inflammation
Prevent lipid peroxidation
Thyroid metabolism
• Deficiencies lead to submaximal expression of GSHPx and other selenoproteins compromising cell
function
Background
Selenium
• Current dietary recommendations is between 55-75
ug/day (based on optimize G-Px)
• Found in various foods such as meats, nuts, breads,
etc but is largely a function of soil composition.
• Some geographic areas are Selenium –poor (china,
parts of US and Europe)
In Critical Illness, Low Levels of Se
related to Severity of Illness
Manzanares ICM 2009;35:882
In Critical Illness, Low Levels of Se
related to Severity of Illness
Healthy
Controls
ICU
Patients
ICU
+SIRS
ICU
+MODS
Manzanares ICM 2009;35:882
…and Correlate with GPx
activity
Manzanares ICM 2009;35:882
Rationale for Antioxidants
Infection
Inflammation
Ischemia
OFR
CONSUMPTION
OFR
PRODUCTION
Depletion of
Antioxidant Enzymes
OFR Scavengers
Vitamins/Cofactors
OFR production > OFR consumption = OXIDATIVE
STRESS
Impaired
- organ function
- immune function
- mtiochondrial function
Complications and Death
Rationale for Antioxidants
•
Endogenous antioxidant defense mechanisms
• Enzymes (superoxide dismutase, catalase,
glutathione perioxidase, glutathione reductase
including their cofactors Zn and Selenium)
• Sulfhydryl group donors (glutathione)
• Vitamins E, C, and B-carotene
Low endogenous levels
Lipid peroxidation and inflammation
Organ failure
Mortality
Oxidative Stress Connected to
Organ Failure
60
50
40
With Organ
Failure
Without Organ
Failure
30
20
10
0
% increase in TBARS
Motoyama Crit Care Med 2003;31:1048
Rationale for Antioxidants
• Non-survivors associated with :
– Higher APACHE III scores
– Higher degree of oxidative stress
•
•
•
LPP
SH
TAC
– Higher levels of inflammation (NOx)
– Higher levels of leukocyte activation
(myeloperoxidase, PMN elastase)
Alonso de Vega CCM 2002; 30: 1782
Rationale for Antioxidants
• 21 patients with septic shock
• Exposed plasma from patients to naïve
human umbilical vein endothelial cells and
quantified degree of oxidative stress by a
fluorescent probe (2,7,dichorodihydrofluorescien diacetate)
Huet CCM 2007; 35: 821
Rationale for Antioxidants
Huet CCM 2007; 35: 821
Rationale for Antioxidants
• preserved ATP
•Recovery of mt DNA
•Regeneration of mito
proteins
Genetic down
regulation
Tissue
hypoxia
cytokine
effect
Prolonged
inflammation
NO
Endocrine
effects
Survivors
↓ mitochondrial
activity
•↓mt DNA
•↓ ATP, ADP,
NADPH
•↓ Resp chain
activity
•Ultra structural
changes
Metabolic
Shutdown
Death
mtDna/nDNA Ratio by Day 28 Survival
mtDna/nDNA Ratio
2.0
P=0.04
Alive Individuals
Expired Individuals
Alive Reg line
Expired Reg Line
1.5
1.0
0.5
0.0
0
5
10
15
20
25
Day
Heyland JPEN 2007;31:109
Mitochondrial Dysfunction is a TimeDependent Phenonmenon
Hypoxia Accelerates Nitric Oxide Inhibition of Complex 1 Activity
21% O2
1% O2
Nitration of Complex 1 in Macrophages
activated with LPS and IFN
Frost Am J Physio Regul Interg Comp Physio 2005;288:394
Mitochondrial Damage
Cell
mitochondria
Respiratory
chain
ROS
nDNA
mtDNA
RNS
nucleus
LPS exposure leads to GSH depletion and
oxidation of mtDNA within 6-24 hours
Potentially Irreversible by 48 hours
Levy Shock 2004;21:110 Suliman CV research 2004;279
Effect of Antioxidants on Mitochondrial Function
Heyland JPEN 2007;31:109
Smallest Randomized Trial
of Selenium in Sepsis
 Single center RCT
 double-blinded
 ITT analysis
 40 patients with severe sepsis
 Mean APACHE II 18
 Primary endpoint: need for RRT
 standard nutrition plus 474 ug x 3 days,
316 ug x 3 days; 31.6 ug thereafter vs
31.6 ug/day in control
Mishra Clinical Nutrition 2007;26:41-50
Smallest Randomized Trial
of Selenium in Sepsis
Effect on SOFA scores
• Increased selenium levels
• Increased GSH-Px activity
• No difference in
• RRT (5 vs 7 patients)
• mortality (44% vs 50%)
• Other clinical outcomes
*p=<0.006
*
*
•
Mishra Clinical Nutrition 2007;26:41-50
Randomized, Prospective Trial of Antioxidant
Supplementation in Critically Ill Surgical Patients
 Surgical ICU patients,
mostly trauma
 770 randomized; 595
analysed
 alpha-tocopherol 1,000 IU
(20 mL) q8h per naso- or
orogastric tube and 1,000
mg ascorbic acid IV q8h or
placebo

Tendency to less
pulmonary morbidity and
shorter duration of vent
days
Nathens Ann Surg 2002;236:814
Influence of early antioxidant supplements on clinical
evolution and organ function in critically ill cardiac surgery,
major trauma and subarachnoid hemorrhage patients.
250
 RCT
 200 patients
 IV supplements for 5 days
after admission (Se 270
mcg, Zn 30 mg, Vit C 1.1 g,
Vit B1 100 mg) with a
double loading dose on
days 1 and 2 (AOX group),
or placebo.
 No affect on clinical
outcomes
200
150
Cardiac
Trauma
SAH
100
50
0
0
1
2
3
4
5
CRP levels daily in the Control groups
Significant reduction with AOX in Cardiac and
Trauma but not SAH
Berger Crit Care 2008
Largest Randomized Trial
of Antioxidants
 Multicenter RCT in
Germany
 double-blinded
 non-ITT analysis
 249 patients with
severe sepsis
 standard nutrition plus
1000 ug bolus
followed by 1000
ug/day or placebo x14
days
p=0.11
100
90
80
70
60
50
40
30
20
10
0
Selenium
Placebo
28 day Mortality
Greater treatment effect observed in those
patients with:
•supra normal levels vs normal levels of selenium
•Higher APACHE III
•More than 3 organ failures Crit Care Med 2007;135:1
Supplementation with Antioxidants in
the Critically Ill: A meta-analysis
o 16 RCTs
o Single nutrients (selenium) and combination
strategies (selenium, copper, zinc, Vit A, C, & E,
and NAC)
o Administered various routes (IV/parenteral,
enteral and oral)
o Patients:
o
o
o
o
o
Critically ill surgical, trauma, head injured
SIRS, Pancreatitis, Pancreatic necrosis
Burns
Medical
Sepsis, Septic Shock
Heyland Int Care Med 2005:31;327;updated on
www.criticalcarenutrition.com
Effect of Combined Antioxidant
Strategies in the Critically Ill
Effect on Mortality
Updated Jan 2009, see www.criticalcarenutrition.com
Effect of Selenium-based Strategies
in the Critically Ill
Effect on Mortality
Updated Jan 2009, see www.criticalcarenutrition.com
Biological Plausibility!
Mitochondrial dysfunction
Antioxidants
Inflammation/oxidative stress
Antioxidants
Organ dysfunction
Antioxidants
Most Recent Trial of Selenium
Supplementation in Sepsis
• Anti-inflammatory, anti-apoptotic effects of high dose Se
• Pilot RCT, double-blind, placebo controlled
• 60 patients with severe septic shock
4000 mcg followed by
1000mcg/day x 10 days
Placebo
No difference in pressor withdrawl, LOS, mortality
New organ failure: 32 vs 14%, p=0.09
Forceville Crit Care 2007:11:R73
Toxicity dependent on dose and
type of selenium
REducing Deaths from
OXidative Stress:
The REDOXS study
t ic
a l C ar e
i als G
ro
i
d
a
Tr
a n Cri
A multicenter randomized trial of
glutamine and antioxidant supplementation
in critical illness
up C an
The Research Protocol
The Question(s)
In enterally fed, critically ill patients with a
clinical evidence of acute multi organ
dysfunction
– What is the effect of glutamine
supplementation compared to placebo
– What is the effect of antioxidant
supplementation compared to placebo
…on 28 day mortality?
REducing Deaths from OXidative Stress:
The REDOXS study
Factorial 2x2 design
1200 ICU patients
Evidence of
organ failure
R
glutamine
R
Concealed
Stratified by
 site
 Shock
placebo
antioxidants
placebo
antioxidants
R
placebo
Combined Entered and Parental Nutrients
Group
Enteral Supplement
(Glutamine AOX)
Parenteral Supplement
(Glutamine AOX)
A
Glutamine + AOX
+
Glutamine + Selenium
B
Placebo + AOX
+
Placebo + Selenium
C
Glutamine + Placebo
+
Glutamine + Placebo
D
Placebo + Placebo
+
Placebo + Placebo
Optimal Dose?
• High vs Low dose:
– observations of meta-analysis
• Providing experimental
nutrients in addition to
standard enteral diets
Optimizing the Dose of
Glutamine Dipeptides
and Antioxidants
in Critically ill Patients:
A phase 1 dose finding study of glutamine
and antioxidant supplementation in critical
illness
JPEN 2007;31:109
The Research Protocol
The Question
In critically ill patients with a clinical
evidence of hypoperfusion...
• What is the maximal tolerable dose
(MTD) of glutamine dipeptides and
antioxidants as judged by its effect on
multiorgan dysfunction?
The Research Protocol
The Design
•
•
•
•
Single Center
Open-label
Dose-ranging study
Prospective controls
Patients
• Critically Ill patients in shock
The Research Protocol
Intervention
Group
N
Dose of Dipeptides (glutamine)
Parenterally*
(gm/kg/day)
Enterally^
(gm/day)
AOX
1
30
0
0
0
2
7
.5 (.35)
0
0
3
7
.5 (.35)
21 (15)
½ can
4
7
.5 (.35)
42 (30)
full can (300 mcg
EN Selenium)
5
7
.5 (.35)
42 (30)
full can + 500ug
IV Selenium
The Research Protocol
Outcomes
•Primary: ∆SOFA
• Secondary (groups 2-5);
• Plasma levels of Se, Zn , and vitamins
• TBARS
• Glutathione
• Mitochondrial function (ratio)
Baseline Characteristics
Control
N = 30
Group 2
N =7
Group 3
N= 7
Group 4
N= 7
Group 5
N=7
All
N=58
Age (Mean)
64.2
65.5
65.2
65.6
71.8
65.6
Female (%)
11 (37%)
2(29%)
1(14%)
2(29%)
3(43%)
19(33%)
APACHE II score (Mean)
23.2
25.1
22.1
21.9
20.6
22.8
6 (86%)
1(14%)
3 (43%)
4 (57%)
3 (43%)
4 (57%)
1(14%)
5(71%)
1(14%)
13(46%)
14(50%)
1(4%)
Etiology of shock
Cardiogenic (%)
Septic (%)
Hypovolemic (%)
ICU days (Median)
6.4
14.3
7.9
13.1
9.7
8.0
28 day mortality (%)
9(30%)
3(43%)
2(29%)
3(43%)
1(14%)
18(31%)
Effect on SOFA
20
18
16
14
12
10
8
6
4
2
0
P=<0.0001
Total SOFA Score for Group 4
Individuals
Expired Individuals
Reg Line
Total Sofa Score
Total Sofa Score
Total SOFA Score for Control Group
20
18
16
14
12
10
8
6
4
2
0
P= 0.0467
Expired Individuals
Reg Line
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28
Day
Day
Total SOFA Score for Group 5
P=0.0897
Individuals
Expired Individuals
Reg Line
Total Sofa Score
Total Sofa Score
Total SOFA Score for Group 2
20
18
16
14
12
10
8
6
4
2
0
20
18
16
14
12
10
8
6
4
2
0
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28
P= 0.0005
Day
Total SOFA Regression Lines
Individuals
Expired Individuals
Reg Line
Total SOFA Score
Total Sofa score
Total SOFA Score for Group 3
P= <0.0001
Individuals
Expired Individuals
Reg Line
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28
Day
20
18
16
14
12
10
8
6
4
2
0
Individuals
P=0.1941
20
18
16
14
12
10
8
6
4
2
0
0
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28
2
4
6
8
Day
Day
4 vs 5: p=0.17
10
Control
Group 2
Group 3
Group 4
Group 5
12
14
Effect on TBARS
TBARS Group 2
P=0.82
Individuals
Expired Individuals
Average Slope
0.150
0.125
0.100
0.075
0.050
0.025
0.000
0
5
10
15
20
25
Day
TBARS Group 5
P=0.03
0.175
TBARS
(nmol/mg protein)
TBARS
(nmol/mg protein)
0.175
Individuals
Expired Individuals
0.150
0.125
Average Slope
0.100
0.075
0.050
0.025
TBARS Group 3
0.150
P=0.90
0
0.125
10
15
20
25
Day
Average Slope
0.100
0.075
0.050
TBARS Average Slopes
0.025
0.175
0.000
0.150
0
5
10
15
20
25
Day
TBARS Group 4
0.175
TBARS
(nmol/mg protein)
5
Individuals
Expired Individuals
0.150
Individuals
Expired Individuals
Average Slope
P=0.11
0.125
0.100
TBARS
(nmol/mg protein)
TBARS
(nmol/mg protein)
0.000
0.175
P=0.25
Group
Group
Group
Group
0.125
0.100
0.075
0.050
0.025
0.000
0
0.075
2
4
6
8
Day
0.050
0.025
0.000
0
5
10
15
Day
20
25
10
12
14
2
3
4
5
Effect on Glutathione
GSH Group 2
1600
P=0.03
Individuals
Expired Individuals
Average Slope
GSH (  Mol/L)
1400
1200
1000
800
600
GSH Group 5
400
1600
200
5
10
15
20
25
Day
GSH Group 3
1600
1400
GSH (  Mol/L)
Individuals
Expired Individuals
Average Slope
P=0.14
1200
GSH (  Mol/L)
0
Individuals
Expired Individuals
Average Slope
P=0.61
1400
0
1200
1000
800
600
400
200
0
1000
0
5
10
800
15
20
25
Day
600
400
200
0
0
5
10
15
20
GSH Average Slopes
25
Day
P=0.40
GSH (  Mol/L)
1400
Group 2
Group 3
Group 4
Group 5
1400
Individuals
Expired Individuals
Average Slope
1200
1000
800
600
GSH (  Mol/L)
1600
P=0.61
1600
GSH Group 4
1200
1000
800
600
400
200
400
0
200
0
0
2
4
6
8
Day
0
5
10
15
Day
20
25
10
12
14
Effect on MITO RATIO
mtDna/nDNA Ratio Group 2
P=0.99
Individuals
Expired Individuals
1.5
Average Slope
1.0
0.5
0.0
0
5
10
15
20
25
Day
mtDna/nDNA Ratio Group 3
P=<0.0001
mtDna/nDNA Ratio
2.0
Individuals
Expired Individuals
Average Slope
1.5
1.0
0.5
0.0
0
Individuals
Expired Individuals
Average Slope
1.5
5
10
15
20
25
Day
1.0
0.5
mtDna/nDNA Average Slopes
P=0.001
2.0
0
5
10
15
20
25
Day
mtDna/nDNA Ratio Group 4
P=0.90
2.0
Individuals
Expired Individuals
Average Slope
1.5
mtDna/nDNA Ratio
0.0
mtDna/nDNA Ratio
mtDna/nDNA Ratio Group 5
P=0.03
2.0
mtDna/nDNA Ratio
mtDna/nDNA Ratio
2.0
Group 2
Group 3
Group 4
Group 5
1.5
1.0
0.5
0.0
1.0
0
2
4
6
8
Day
0.5
0.0
0
5
10
15
Day
20
25
10
12
14
Inferences
Glutamine/day
Antioxidants
per day
Parenterally
Enterally
0.35 gms/kg
30 gms
500 mcg
Selenium
Vit C 1500 mg
Vit E 500 mg
B carotene 10 mg
Zinc 20 mg
Se 300 ug
• High dose appears safe
• High dose associated with
–
–
–
–
no worsening of SOFA Scores
greater resolution of oxidative stress
greater preservation of glutathione
Improved mitochondrial function
Heyland JPEN Mar 2007
REDOXS: A new paradigm!
• Nutrients dissociated from nutrition
• Focus on single nutrient administration
• Rigorous, large scale, multicenter trial of
nutrition related intervention powered to look
at mortality
• sick homogenous population
• Preceded by:
– standardization of nutrition support thru the
development and implementation of CPGs
– a dosing optimizing study
• Funded by CIHR
www.criticalcarenutrition.com
Conclusions
• “Insufficient data to put forward a
recommendation for Selenium alone”
• “Based on 3 level 1 and 13 level 2 studies,
the use of supplemental combined
vitamins and trace elements should be
considered in critically ill patients.”
Optimal Dose: 500-1000 (800) mcg/day
Canadian CPGs
www.criticalcarenutrition.com