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Pathophysiology of Pediatric Multiple Organ Dysfunction Syndrome

Carcillo, Joseph A. MD; Podd, Bradley MD; Aneja, Rajesh MD; Weiss, Scott L. MD; Hall, Mark W. MD; Cornell, Timothy T. MD; Shanley, Thomas P. MD; Doughty, Lesley A. MD; Nguyen, Trung C. MD

doi: 10.1097/PCC.0000000000001052
MODS Supplement
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Objective: To describe the pathophysiology associated with multiple organ dysfunction syndrome in children.

Data Sources: Literature review, research data, and expert opinion.

Study Selection: Not applicable.

Data Extraction: Moderated by an experienced expert from the field, pathophysiologic processes associated with multiple organ dysfunction syndrome in children were described, discussed, and debated with a focus on identifying knowledge gaps and research priorities.

Data Synthesis: Summary of presentations and discussion supported and supplemented by relevant literature.

Conclusions: Experiment modeling suggests that persistent macrophage activation may be a pathophysiologic basis for multiple organ dysfunction syndrome. Children with multiple organ dysfunction syndrome have 1) reduced cytochrome P450 metabolism inversely proportional to inflammation; 2) increased circulating damage-associated molecular pattern molecules from injured tissues; 3) increased circulating pathogen-associated molecular pattern molecules from infection or endogenous microbiome; and 4) cytokine-driven epithelial, endothelial, mitochondrial, and immune cell dysfunction. Cytochrome P450s metabolize endogenous compounds and xenobiotics, many of which ameliorate inflammation, whereas damage-associated molecular pattern molecules and pathogen-associated molecular pattern molecules alone and together amplify the cytokine production leading to the inflammatory multiple organ dysfunction syndrome response. Genetic and environmental factors can impede inflammation resolution in children with a spectrum of multiple organ dysfunction syndrome pathobiology phenotypes. Thrombocytopenia-associated multiple organ dysfunction syndrome patients have extensive endothelial activation and thrombotic microangiopathy with associated oligogenic deficiencies in inhibitory complement and a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13. Sequential multiple organ dysfunction syndrome patients have soluble Fas ligand-Fas–mediated hepatic failure with associated oligogenic deficiencies in perforin and granzyme signaling. Immunoparalysis-associated multiple organ dysfunction syndrome patients have impaired ability to resolve infection and have associated environmental causes of lymphocyte apoptosis. These inflammation phenotypes can lead to macrophage activation syndrome. Resolution of multiple organ dysfunction syndrome requires elimination of the source of inflammation. Full recovery of organ functions is noted 6–18 weeks later when epithelial, endothelial, mitochondrial, and immune cell regeneration and reprogramming is completed.

1Department of Critical Care Medicine and Pediatrics, University of Pittsburgh, Pittsburgh, PA.

2Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA.

3Department of Pediatrics, Nationwide Children’s Hospital, Columbus, OH.

4Department of Pediatrics, University of Michigan, Ann Arbor, MI.

5Department of Pediatrics, Cincinnati Children’s Hospital, Cincinnati, OH.

6Department of Pediatrics, Texas Children’s Hospital, Houston, TX.

Supported, in part, by RO1GM108618 (to Dr. Carcillo), R01GM094203 (to Dr. Hall), K12HD047349 and K23GM110496 (to Dr. Weiss), and R01GM112806 (to Dr. Nguyen).

Dr. Carcillo’s institution received funding from National Institute of General Medical Science (NIGMS), and he received support for article research from the National Institutes of Health (NIH). Dr. Podd’s institution received funding from NIH, and he received support for article research from the NIH. Dr. Aneja’s institution received funding from NIH NIGMS (R01 funding), and he received support for article research from the NIH. Dr. Weiss’ institution received funding from NIGMS K23GM110496; he received support for article research from the NIH; and he received funding from ThermoFisher Scientific (honorarium for lectures). Dr. Hall disclosed offproduct use of immunomodulators, such as GM-CSF for the reversal of critical illness-induced immune suppression. Dr. Cornell’s institution received funding from NIH, and he received support for article research from the NIH. Dr. Shanley received funding from IPRF and from Springer, and he received support for article research from the NIH. Dr. Nguyen received support for article research from the NIH. Dr. Doughty disclosed that she does not have any potential conflicts of interest.

For information regarding this article, E-mail: carcilloja@ccm.upmc.edu

©2017The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies