Impact of Treatment with Antioxidants as an Adjuvant to Standard Therapy in Patients with Septic Shock: Analysis of the Correlation between Cytokine Storm and Oxidative Stress and Therapeutic Effects

Abstract

Cellular homeostasis is lost or becomes dysfunctional during septic shock due to the activation of the inflammatory response and the deregulation of oxidative stress. Antioxidant therapy administered alongside standard treatment could restore this lost homeostasis. We included 131 patients with septic shock who were treated with standard treatment and vitamin C (Vit C), vitamin E (Vit E), N-acetylcysteine (NAC), or melatonin (MT), in a randomized trial. Organ damage quantified by Sequential Organ Failure Assessment (SOFA) score, and we determined levels of Interleukins (IL) IL1β, Tumor necrosis factor alpha (TNFα), IL-6, monocyte chemoattractant protein-1 (MCP-1), Transforming growth factor B (TGFβ), IL-4, IL-10, IL-12, and Interferon-γ (IFNγ). The SOFA score decreased in patients treated with Vit C, NAC, and MT. Patients treated with MT had statistically significantly reduced of IL-6, IL-8, MCP-1, and IL-10 levels. Lipid peroxidation, Nitrates and nitrites (NO₃^- and NO₂^-), glutathione reductase, and superoxide dismutase decreased after treatment with Vit C, Vit E, NAC, and MT. The levels of thiols recovered with the use of Vit E, and all patients treated with antioxidants maintained their selenium levels, in contrast with controls (p = 0.04). The findings regarding oxidative stress markers and cytokines after treatment with antioxidants allow us to consider to future the combined use of antioxidants in a randomized clinical trial with a larger sample to demonstrate the reproducibility of these beneficial effects.

Keywords: antioxidants; cytokines; melatonin; septic shock.

Figure 1

(A) Values of oxidative stress markers before and after antioxidant therapy. Groups: Vit C (n = 25), Vit E (n = 27), NAC (n = 24), MT (n = 26), and control (n = 29). Vit C: vitamin C; LPO: lipoperoxidation (nmol MDA/mL); TAC: total antioxidant capacity (TroloxnM/mL); Thiol (µM/mL); Nitrates and Nitrites (HNO₃^−/NO₂⁻ nmol/mL of serum). Carbonylation (ngcarbonyl/mL); (B) Enzymatic pathway before and after antioxidant therapy. Peroxidases, (U/L) SOD: superoxide dismutase (U/mgL); (C) Enzymatic pathway before and after antioxidant therapy. GPX: glutathione peroxidase (µmol of NADPH/min/mL); GSH: glutathione (µM/mL of serum); GST: (µM/mg/protein); GR: glutathione reductase (U/min/mL Thioredoxin (µM/mg/protein).

Figure 1

(A) Values of oxidative stress markers before and after antioxidant therapy. Groups: Vit C (n = 25), Vit E (n = 27), NAC (n = 24), MT (n = 26), and control (n = 29). Vit C: vitamin C; LPO: lipoperoxidation (nmol MDA/mL); TAC: total antioxidant capacity (TroloxnM/mL); Thiol (µM/mL); Nitrates and Nitrites (HNO₃^−/NO₂⁻ nmol/mL of serum). Carbonylation (ngcarbonyl/mL); (B) Enzymatic pathway before and after antioxidant therapy. Peroxidases, (U/L) SOD: superoxide dismutase (U/mgL); (C) Enzymatic pathway before and after antioxidant therapy. GPX: glutathione peroxidase (µmol of NADPH/min/mL); GSH: glutathione (µM/mL of serum); GST: (µM/mg/protein); GR: glutathione reductase (U/min/mL Thioredoxin (µM/mg/protein).

Figure 1

(A) Values of oxidative stress markers before and after antioxidant therapy. Groups: Vit C (n = 25), Vit E (n = 27), NAC (n = 24), MT (n = 26), and control (n = 29). Vit C: vitamin C; LPO: lipoperoxidation (nmol MDA/mL); TAC: total antioxidant capacity (TroloxnM/mL); Thiol (µM/mL); Nitrates and Nitrites (HNO₃^−/NO₂⁻ nmol/mL of serum). Carbonylation (ngcarbonyl/mL); (B) Enzymatic pathway before and after antioxidant therapy. Peroxidases, (U/L) SOD: superoxide dismutase (U/mgL); (C) Enzymatic pathway before and after antioxidant therapy. GPX: glutathione peroxidase (µmol of NADPH/min/mL); GSH: glutathione (µM/mL of serum); GST: (µM/mg/protein); GR: glutathione reductase (U/min/mL Thioredoxin (µM/mg/protein).

Figure 2

Proinflammatory interleukins show decreases with a significant delta when evaluating the pretreatment and posttreatment levels. With Vit C, there is a decrease in IL-6 (p = 0.006); with Vit E there is an increase in IL-2, IL-12, and IFNγ (p = 0.01, p = 0.01, and p = 0.03, respectively); with MT, there is an increase in MCP-1 and a decrease in IL-6, IL-8, and IL-4 (p = 0.001, p = 0.001, p = 0.01, and p = 0.04, respectively); and with NAC, there is a decrease in TNFα (p= 0.04) and an increase in IL-12 (p = 0.04). Individuals without antioxidant therapy had decreased levels of IL-6 (p = 0.002), IL-8 (p = 0.001), and MCP-1 (p = 0.002).

Figure 3

Intrinsic and extrinsic pathway for induction of apoptosis. Intrinsic and extrinsic pathway for induction of apoptosis. (1) The extrinsic pathway of apoptosis can be activated by TNF-dependent Apo2L/TRAIL receptors. (2) In some extional cases, Apo2L/TRAIL can be intrinsically pathway activated by Bid. (3) The intrinsic pathway can be activated by DNA or microtubule damage, involving the interaction of some proteins such as BAX and BAK. (4) Apoptosis can also be promoted by activation of p53. Abbreviations: Apaf-1 = apoptotic protease-activating factor 1, Apo2L/Trail = Recombinant human apoptosis ligand 2/inducing tumor necrosis factor-related apoptosis ligand 2, FADD = the fas-associated death domain protein, GR = glutathione reductase, GSH = glutathione, GSSG = oxidized glutathione, H₂O₂ = hydrogen peroxide, IAP = apoptosis inhibitor, NF-KB = kappa nuclear factor, O₂⁻ = superoxide anion, TNF = tumor necrosis factor.