[Protective effect of ulinastatin on pulmonary function after cardiopulmonary bypass]

OBJECTIVE

To investigate the effects of Ulinastatin with different doses on pulmonary protection after cardiopulmonary bypass (CPB).

METHODS

Ninety patients after CPB were brought into this study and divided into low doses Ulinastatin group (L group, n=30, 5 000 U/kg), high doses Ulinastatin group (H group, n=30, 20 000 U/kg) and control group (C group, n= 30), respectively. When the patients were transferred into ICU after CPB, Ulinastatin was given intravenously to those in L and H group, while saline was given in C group. Blood samples were harvested at the time before the treatments (T0) and 12 hours (T1), 24 hours (T2) after the treatments, for the measurements of arterial pressure of oxygen (PaO2), arterial pressure of carbon monoxide (PaCO2),difference of alveoli-arterial oxygen pressure (PO(2A), oxygenation index (Ol),and tumor necrosis factor-alpha (TNF-alpha) level. Pulmonary dynamic compliance (Cd), plat pressure (Pplat) and peak pressure (Ppeak) were determined at the time of To and wean (Tw). The durations of ventilation and intubation were recorded.

RESULTS

At T0, the levels of PaO2, PaCO2, PO2A-a, OI and TNF-alpha in each group showed no significantly difference (P> 0. 05). At T1 and T2, the patients in H group had higher levels of PO2, PO2A-a. and OI, lower level of TNF-alpha, shorter duration of ventilation and intubation than the patients in other two groups(P<0. 05). The parameters in L group were better than those in C group, but the differences were not stastically significant (P>0. 05). There was no significantly difference in the levels of Cd, Pplat, and Ppeak at T0 and Tw between any two groups (P>0. 05). The intubation and ventilation time in H group were shorter than that in L and C group (P<0. 05).

CONCLUSION

The application of Ulinastatin could achieve pulmonary protective effect after CPB, and it seems the effect could be better with high dose (20 000 U/kg) of Ulinastatin.

Transcriptome analysis of the duodenum in Wistar rats fed a trypsin inhibitor derived from squid viscera

To investigate the effects of oral administration of a trypsin inhibitor (TI), normal Wistar rats were fed a TI derived from squid (Todarodes pacificus) for 10 weeks and gene expression profiles in the duodenum, pancreas, liver, and muscle were then analyzed using DNA microarrays. Although no significant changes could be observed in growth, food intake, tissue weight, or blood tests among the tissues tested, the duodenum showed the most remarkable changes in the global gene expression profile. Significant up-regulation of mRNAs encoding gastrin, gastrokine, cholecystokinin and somatostatin in the duodenum was validated by qPCR analysis. In gene ontology (GO) analysis of the up-regulated differentially expressed genes (DEGs), GO terms related to keratinization and innate mucosal defense were enriched (p < 0.001) in the category of biological processes in addition to assumable terms such as regulation of secretion and response to nutrients, vesicle-mediated transport, and so forth. In the same analysis, calcium ion binding was listed at the deepest hierarchy in the category of molecular function. These results indicate that the duodenum responds to TI treatment by a wider range of physiological processes than previously assumed such as keratinocyte differentiation and innate mucosal defense, in which calcium plays a crucial role.

Oral trypsin-inhibitor-induced improvement of the exocrine and endocrine pancreatic functions in alloxan diabetic rats

Studies are presented dealing with the effect on the exocrine and endocrine pancreas of long-term oral trypsin inhibitor administration to alloxan diabetic rats. Three categories of rats were used: a) normal rats, b) alloxan diabetic rats, and c) alloxan diabetic rats treated with the trypsin inhibitor. 1. The concentration of amylase in both pancreas and intestinal contents were markedly decreased in alloxan diabetic rats as compared with normal rats, whereas the concentrations of lipase and trypsin(ogen) were practically unaffected by the diabetic state. 2. Trypsin inhibitor treatment of diabetic rats enhanced the concentrations of both amylase, trypsin(ogen), and lipase in pancreas and intestinal contents when compared with untreated diabetic controls. 3. Alloxan diabetic rats treated with trypsin inhibitor displayed an increased weight gain, increased pancreatic weight, and increased pancreatic protein concentration as compared with the untreated diabetic controls. 4. Alloxan diabetic rats treated for 3 or 5 weeks with the trypsin inhibitor were found to have decreased basal blood glucose levels and an increased plasma insulin: blood glucose ratio as compared to the untreated diabetic controls. 5. There was no apparent difference in the glucose elimination rate after I.V. glucose loads in diabetic rats given trypsin inhibitor and their diabetic controls. However, the insulin secretory response to the glucose stimulus was slightly improved in the trypsin inhibitor group. 6. Alloxan diabetic rats treated with trypsin inhibitor had an increased total pancreatic insulin content compared with their diabetic controls. It is concluded that long-term daily treatment with oral trypsin inhibitor in alloxan diabetic rats increased enzyme production and secretion in the exocrine pancreas, and produced an improvement of the diabetic condition of the animals. This improvement might partly be due to an increased pancreatic content and secretion of insulin.

31P-NMR studies of energy metabolites in rat pancreas treated with trypsin inhibitor

The energy metabolites and the composition of rat pancreas treated with trypsin inhibitor (T.I.) were investigated. T.I. treatment significantly induced the hypertrophy of pancreatic acinar cells and the increase in the amylase and sialic acid contents. However, when the pancreas was perfused by control solution or the solution containing acetylcholine (10(-7) M), the 31P-NMR spectra of energy metabolites in the pancreas treated with T.I. were similar to those of normal rats.

Reducing neutrophil elastase-induced lung injury

The first trial of alpha1-proteinase inhibitor therapy for the prevention of chronic lung disease of prematurity was recently completed. Receipt of four intravenous doses of the medication was associated with a trend towards a reduction in respiratory morbidity. A dose-ranging trial is in progress.

Suppression of dimethylhydrazine-induced carcinogenesis in mice by dietary addition of the Bowman-Birk protease inhibitor

In the present study the effect of feeding the soybean-derived Bowman-Birk protease inhibitor (BBI) on dimethylhydrazine (DHM)-induced gastrointestinal tract and liver carcinogenesis in mice was examined. In this investigation we found the addition of 0.5 or 0.1% semipurified BBI or 0.1% purified BBI to the diet of DMH-treated mice resulted in a statistically significant suppression of angiosarcomas and nodular hyperplasia of the liver and adenomatous tumors of the gastrointestinal tract. Autoclaved BBI or BBI which had its trypsin inhibitory domain specifically inactivated was found to be ineffective in suppressing the induction of these liver and gastrointestinal tract lesions. The results of this study also indicate that BBI, included as 0.5% of the diet or less, has the ability to suppress carcinogenesis with no observed adverse effects on the health of the mice.

[Effect of soybean trypsin inhibitor and chicken ovomucoid on the immunogenic and sensitizing properties of various dietary proteins]

Adult male guinea pigs were sensitized by intragastric administration of bovine serum albumin (BSA) and chick ovalbumin (OA) and their mixtures with soybean Kunitz trypsin inhibitor (SBTI) and chick ovomucoid (OM). Sensitization of the animals was evaluated by the anaphylactic shock reaction and also by the levels of serum specific IgG antibodies against BSA and OA as measured in the solid phase radioimmunoassay. The experiment revealed pronounced desensitizing properties of SBTI combined both with OA and BSA. OM produced no effect on the animal sensitization caused by OA and enhanced the BSA-induced sensitization. The results obtained demonstrate the necessity of differential approach to the evaluation of the action of varying trypsin inhibitors on food sensitization.

[The effect of granulocyte elastase inhibitor (urinastatin) vaginal suppository on patients with imminent premature delivery]

Cervical maturation, dilatation and uterine contraction in imminent premature delivery are closely related to chemical mediators from activated granulocytes which infiltrate into the cervix. It is known that urinastatin (urinary trypsin inhibitor, UTI) inhibits many kinds of chemical mediators from granulocytes and macrophages such as granulocyte elastase (elastase) and interleukin 1. We examined the effect of a UTI suppository on uterine contraction and the elastase level in cervical mucus in cases of imminent premature delivery. We treated 43 cases of imminent premature delivery with tocolysis index 3 or 4 with 4 kinds of therapy: Group A (N = 12): ritodorine drop infusion therapy; Group B (N = 9): daily UTI suppository (1,000U) therapy; Group C (N = 14): daily UTI suppository + ritodorine drop infusion therapy; Group D: daily UTI suppository + ritodorine drop infusion + antibiotics (oral cepharosporine) therapy. The elastase level of cervical mucus before treatment was 0.76 +/- 0.40 micrograms/ml in group A, 0.93 +/- 0.43 micrograms/ml in group B, 0.85 +/- 0.40 micrograms/ml in group C and 0.90 +/- 0.41 micrograms/ml in group D. There was no significant difference between these groups. The elastase level in cervical mucus was 0.75 +/- 0.47 micrograms/ml in group A, 0.27 +/- 0.35 micrograms/ml in group B, 0.27 +/- 0.33 micrograms/ml in group C and 0.30 +/- 0.19 micrograms/ml in group D, respectively. The elastase level was decreased significantly in groups B, C and D. The time taken to depress uterine contraction was 65 +/- 66 min in group A, 375 +/- 336 min in group B, 70 +/- 64 min in group C and 58 +/- 53 min in group D, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of hyperbaric oxygen and ulinastatin on plasma endotoxin, soluble CD14, endotoxin-neutralizing capacity and cytokines in acute necrotizing pancreatitis

BACKGROUND

We sought to study the effect of a combination therapy comprised of hyperbaric oxygen (HBO) and ulinastatin on the plasma levels of endotoxin, soluble CD14 (sCD14), endotoxin neutralizing capacity (ENC) and cytokines in acute necrotizing pancreatitis (ANP) in rats.

METHODS

We randomly allocated 90 Sprague-Dawley rats into 6 groups: group 1 (ordinary control), group 2 (sham operation), group 3 (ANP), group 4 (ANP with HBO), group 5 (ANP with ulinastatin) and group 6 (ANP with HBO and ulinastatin). We induced ANP by retrograde injection of 3.5% sodium taurocholate (2.5 mL/kg) via the pancreatic duct. Five minutes after induction, animals in groups 5 and 6 were infused with ulinastatin (20 000 U/kg) via the portal vein. Thirty minutes after induction, animals in groups 4 and 6 received HBO therapy. We collected samples 3, 6 and 10 hours after induction of ANP.

RESULTS

We found that the plasma level of endotoxin in group 3 was significantly higher than in group 4 (3, 6 h, both p < 0.001), group 5 (3 h, p < 0.001; 6 h, p = 0.014) and group 6 (both p < 0.001). The level of plasma sCD14 in group 3 was significantly higher than in group 4 (3, 6 h, both p < 0.001), group 5 (3, 6 h, both p = 0.001) and group 6 (3 h, p < 0.001; 6 h, p = 0.001). The plasma endotoxin and sCD14 levels in group 6 were significantly lower than in groups 4 and 5. The plasma ENC level in group 6 was significantly higher than in groups 3, 4 and 5 (p < 0.001). The ENC level in groups 4 and 5 were higher than in group 3, but there was no significant difference. The plasma level of tumour necrosis factor-alpha (TNF-alpha) and IL-6 in group 6 were significantly lower than in groups 3, 4 and 5 (p < 0.001). The TNF-alpha and IL-6 levels in groups 4 and 5 were lower than in group 3, but there was no significant difference.

CONCLUSION

The use of an early combination therapy of HBO and ulinastatin was more effective than either therapy alone in the treatment of ANP.

Total ginsenosides synergize with ulinastatin against septic acute lung injury and acute respiratory distress syndrome

Total ginsenosides synergize with ulinastatin (UTI) against septic acute lung injury (ALI) and acute respiratory distress syndrome (ARDS). We randomly divided 80 cases of severe sepsis-induced ALI and ARDS into a UTI group and a ginsenosides (GS)+UTI group. Continuous electrocardiac monitoring of pulse, respiratory rate, blood pressure, and heart rate; invasive hemodynamic monitoring; ventilator-assisted breathing and circulation support; and anti-infection as well as UTI treatment were given in the UTI group with GS treatment added for 7 consecutive days in the GS+UTI group. The indicators of pulmonary vascular permeability, pulmonary circulation, blood gases, and hemodynamics as well as APACHE II and ALI scores were detected on days 1, 3, and 7. The ALI score in the GS+UTI group was significantly decreased (P < 0.05) compared with that of the UTI group, and the indicators of pulmonary capillary permeability such as pulmonary vascular permeability index, extravascular lung water index, and oxygenation index, in the GS+UTI group improved significantly more than that of the UTI group. The indicators of hemodynamics and pulmonary circulation such as cardiac index, intrathoracic blood volume index, and central venous pressure improved significantly (P < 0.05), and the APACHE II score in the GS+UTI group was lower than that of the UTI group. GS can effectively collaborate with UTI against ALI and/or ARDS.

[Continuous arterial infusion of protease inhibitor with supplementary therapy for the patients with severe acute pancreatitis--clinical effect of arterial injection of ulinastatin]

We treated five patients with severe acute pancreatitis by continuous arterial infusion (CAI) of protease inhibitor, nafamostat mesilate. Arterial injection (AI) of ulinastatin was performed in four cases and AI of antibiotics (IPM/CS) was done in one case, as supplemental therapies of CAI. Abdominal pain disappeared in 7.9 hours on the average, abdominal tenderness disappeared in 5.0 days and laboratory data lately recovered. All five cases treated by these therapies were cured without hemodialysis or surgical treatment in acute phase. AI of ulinastatin through arterial infusion catheter is pharmacokinetically more effective, because it yields a relatively high concentration of the drug at the acting site when compared with that of intravenous injection. Furthermore ulinastatin inhibits different types of protease from nafamostat mesilate. Therefore the clinical effect of CAI of nafamostat mesilate is enhanced by the combined therapy with AI of ulinastatin. It is also suggested that arterial injection of ulinastatin might be effective for the control of abdominal pain and that arterial injection of antibiotics might have an advantage on prevention of infectious pancreatic necrosis.

Single-dose administration of Bowman-Birk inhibitor concentrate in patients with oral leukoplakia

The Bowman-Birk inhibitor (BBI) is a soybean-derived serine protease inhibitor and a potential cancer chemopreventive agent for humans. In this Phase I clinical trial, BBI concentrate was administered as a single oral dose to 24 subjects with oral leukoplakia. Pharmacokinetics of BBI was analyzed, and subjects were monitored clinically for toxic effects. Subjects received between 25 and 800 chymotrypsin inhibitor units (CIU) of the compound in a dose escalation trial. BBI was taken up rapidly, and a metabolic product of BBI was excreted in the urine within 24-48 h. No clinical or laboratory evidence of toxicity was observed in the study. Protease activity was also measured in buccal cells to evaluate usefulness as a biomarker. Single-dose BBI concentrate administered up to 800 CIU was well tolerated and appeared to be nontoxic. Further investigation in Phase II clinical trials is being done.

[Effect of acute aprotinin (Gordox) therapy on hemostasis in heart surgery patients, with special reference to hyperfibrinolysis]

Authors have studied the effect of Gordox-therapy on haemostasis after open heart surgery in a prospective clinical trial. Thirty seven patients (pts) undergoing cardiac surgery due to their valve disease were randomly assigned either to control-group (20 pts) or to Gordox-group (17 pts). The patients in the Gordox group were given Gordox according the following scheme: 2 M IU within 20 min. after induction of anaesthesia followed by 0.5 M IU/hour infusion until the end of the operation. One M IU also was given into the oxygenator before starting the extracorporeal circulation. The postoperative chest tube drainage was less in Gordox-group (534 +/- 260 ml vs. 987 +/- 583 ml, p less than 0.005), and donor blood and fresh frozen plasma requirement was also lower in this group (534 +/- 633 ml vs. 935 +/- 718 ml p less than 0.05; 70 +/- 153 ml vs. 211 +/- 245 ml p less than 0.05, respectively). There was no significant difference between the two groups concerning the postoperative activated partial thromboplastin time, prothrombin time, thrombin time values. The authors could document significantly higher fibrinogen concentration and significantly lower fibrinolytic activity postoperatively in the Gordox-group (p less than 0.05). Gordox therapy has advantageous effect on haemostasis after open heart surgery which can be documented both by clinical and laboratory examination.

[Clinical utility of ulinastatin, urinary protease inhibitor in acute Kawasaki disease]

Ulinastatin, a trypsin inhibitor, is useful as a first-line or a second-line treatment regimen including alternative therapy for IVIG-resistant or IVIG nonresponder Kawasaki disease (KD) patients. Mechanisms involving protections against tissue organs and endthelial cell and anti-inflammatory effects by ulinastatin, are dependent on the inhibition of PMN-derived elastase, tumor necrosis factor alpha (TNFalpha), and other proinflammatory cytokines/interleukins(IL-1, IL-6, IL-8). Ulinastatin also suppresses the activation of PMN cells, macrophages, and platelets. Although almost no statistical data related to the definitive effect in acute stage of KD, ulinastatin have shown possible effects, but not always, in a part of KD patients. The indications of clinical use include shock and pancreatitis. Off-label uses of ulinastatin have been reported in hematological, hepatic, renal, OB/Gy diseases and cardiovascular diseases including vasculitis syndromes. The efficacy of ulinastatin in aKD remained to be investigated.

[Effect of protease in the lumen of rat intestine on inflammatory reaction during hemorrhagic shock]

OBJECTIVE

To investigate the effect of intraluminal administration of ulinastatin (a protease inhibitor) in the intestine on intestinal inflammation in rats with hemorrhagic shock.

METHODS

Twenty-eight Wistar rats were randomized into control group (A), intestinal saline perfusion group (B), ulinastatin intestinal perfusion group (C), and intravenous ulinastatin injection group (D) (n=7). The mean arterial blood pressure (MAP) and survival time of the rats were recorded. The changes in human polymorphonuclear cell (PMN) CD11b expression were detected by flow cytometry. The leukocyte count was recorded at different time points after the treatment, and the pathology of the intestinal mucosa was observed comparatively.

RESULTS

Groups C and D showed significantly slower reduction of the MAP than groups A and B after hemorrhagic shock (P<0.05). The survival time of the rats was the longest in group C (P<0.05). CD11b expression increased gradually during hemorrhagic shock in all the groups, but the expression level was the lowest in group C (P<0.05). Hemorrhagic shock caused a reduction in leukocyte counts, which remained the highest in group C (P<0.05). Group C also showed the least intestinal pathology among the 4 groups.

CONCLUSION

Intestinal perfusion of ulinastatin can lower the reduction rate of MAP, attenuate plasma activation and intestinal inflammation, and prolong the survival of rats with hemorrhagic shock. These results indicate an important role of protease in intestinal inflammation during hemorrhagic shock.

[Complex treatment of pancreatic necrosis]

The experience in the treatment of 1800 patients with acute pancreatitis is described. Destructive forms were found in 36% of cases during the last five years. The main methods of treatment and the mortality rate following the methods used are analyzed. The authors believe cytostaticotherapy with the infusion of 5-phthoruracil into the celiac artery and forced diuresis with the infusion of fluids into the celiac artery to be the most perspective methods. The use of the above methods decreased the lethality in destructive forms to 8,3%. The intraaretrial infusion of 5-phthoruracil with antibiotics allowed coping processes of the pancreatic tissue autolysis and avoiding broad sequestration and severe suppurative complications of pancreatitis.

[A clinical phase III trial of ulinastatin (MR-20) for nephrotoxicity of cisplatin]

MR-20 was administered to 140 lung cancer patients who presented with nephrotoxicity due to cisplatin (CDDP) treatment at 59 institutions throughout Japan during the period from September 1992 through March 1994 to study its suppressive effect on the nephrotoxicity as well as its safety. The results are reported in this paper.

METHODS

The efficacy and usefulness of MR-20 were studied in a placebo-controlled, double-blind manner. An efficacy rate of 58.7% was achieved in the MR-20 group, and 36.8% in the placebo group: MR-20 was significantly more effective for nephrotoxicity than placebo (U-test). Serum Cr, Ccr and FENa were prevented from significant variations in the MR-20 group, compared with the control group. It was considered that MR-20 is a safe drug, and that it is useful in suppressing the nephrotoxicity of CDDP treatment.

Alpha 1-antitrypsin deficiency and the impact of nursing interventions and treatment with intravenous therapy. An overview

The primary function of alpha1-antitrypsin is to protect the alveoli in the lung from harmful destruction from proteolytic enzymes, which prevent optimal elastic recoil of the lungs and destroy the lungs. Insufficient serum levels of alpha1-antitrypsin eventually lead to early onset of emphysema in the third, fourth, or fifth decade of life. Treatment of alpha1-antitrypsin deficiency by intravenous administration of an enzyme inhibitor known as alpha1-proteinase inhibitor, a human-derived blood product, can be administered to help replace the enzymes required to maintain lung function. Early detection, nursing intervention, and clinical management slow the progression of this hereditary disease.

Evaluation of perioperative administration of methylprednisolone sodium succinate and urinary trypsin inhibitor for prevention of surgical stress

The authors could confirm that the laparoscopy-assisted cholecystectomy (LAC) elicited less postoperative biological responses compared to the ordinary cholecystectomy under laparotomy (OCL), when granulocyte elastase (GE)-alpha1-protease inhibitor complex (GEcomplex), interleukin-6, pancreatic secretory trypsin inhibitor (PSTI) and alpha1-antitrypsin (alpha1-AT) were used as biological response markers. Perioperative administrations of methylprednisolone sodium succinate (MPSL: 10 mg/kg body weigh) or MPSL with urinary trypsin inhibitor (UTI) could suppress such postoperative reactions after OCL down to the levels after LAC, especially immediately after surgery. Preoperative MPSL followed by continuous infusion of UTI for 3 days exerted the most prominent suppressive effects on these markers compared to the effect of the preoperative MPSL alone as well as the preoperative administration of MPSL followed by UTI infusion for only one hour. Bolus administration of MPSL induced no lymphocytopenia. Decreased plasma level of alpha1-AT immediately after operation is thought to be due to consumption in binding to GE as well as other lysosomal enzymes, while production of rapid turn over proteins are still not accelerated in the liver. In early postoperative phase after administration of MPSL, administration of UTI was efficacious to prevent fluctuation of biological response markers. Clinical applications of these drugs might be approved especially for those patients with poor risk.

Cytotoxic effects of cyclosporin A on the exocrine pancreas in rats

The current study was done to evaluate the subacute toxic effects of cyclosporin A (CS) on the exocrine pancreas and the protective effect of potent protease inhibitor camostate (FOY-305). CS administration (15 milligrams, twice a day) for 14 days caused a significant increase in serum amylase levels, pancreatic amylase and cathepsin B content and mild acinar cell vacuolization and interstitial edema. CS also caused the redistribution of cathepsin B activity from the lysosomal fraction to the zymogen fraction, indicating colocalization of lysosomal enzyme with pancreatic digestive enzymes. The administration of camostate (150 milligrams per kilogram, twice a day for 14 days) almost completely prevented the toxic changes induced by CS. These results indicate that CS induces exocrine pancreatic injury and that lysosomal enzymes play important roles in the pathogenesis of the injury. The results also suggest the usefulness of camostate in protecting the exocrine pancreas in patients treated with CS after organ transplantation, because it can inhibit some proteases that are closely involved in the fragility of the subcellular organelles.