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Olausson M, Antony D, Travnikova G, Johansson M, Nayakawde NB, Banerjee D, Søfteland JM, Premaratne GU. Novel Ex-Vivo Thrombolytic Reconditioning of Kidneys Retrieved 4 to 5 Hours After Circulatory Death. Transplantation 2022; 106:1577-1588. [PMID: 34974455 PMCID: PMC9311461 DOI: 10.1097/tp.0000000000004037] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 11/09/2021] [Accepted: 11/10/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Due to organ shortage, many patients do not receive donor organs. The present novel thrombolytic technique utilizes organs from donors with uncontrolled donation after circulatory deaths (uDCD), with up to 4-5 h warm ischemia, without advanced cardiopulmonary resuscitation (aCPR) or extracorporeal circulation (EC) after death. METHODS The study group of pigs (n = 21) underwent simulated circulatory death. After 2 h, an ice slush was inserted into the abdomen. Kidneys were retrieved 4.5 h after death. Lys-plasminogen, antithrombin-III (ATIII), and alteplase (tPA) were injected through the renal arteries on the back table. Subsequent ex vivo perfusion at 15 °C was continued for 3 h, followed by 3 h with red blood cells (RBCs) at 32 °C. Perfusion outcome and histology were compared between uDCD kidneys, receiving no thrombolytic treatment (n = 8), and live donor kidneys (n = 7). The study kidneys were then transplanted into pigs as autologous grafts with a single functioning autologous kidney as the only renal support. uDCD control pigs (n = 8), receiving no ex vivo perfusion, served as controls. RESULTS Vascular resistance decreased to <200 mmHg/mL/min ( P < 0.0023) and arterial flow increased to >100 mL/100 g/min ( P < 0.00019) compared to controls. In total 13/21 study pigs survived for >10 days, while all uDCD control pigs died. Histology was preserved after reconditioning, and the creatinine level after 10 days was next to normal. CONCLUSIONS Kidneys from extended uDCD, not receiving aCPR/EC, can be salvaged using thrombolytic treatment to remove fibrin thrombi while preserving histology and enabling transplantation with a clinically acceptable early function.
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Affiliation(s)
- Michael Olausson
- Department of Transplantation, Sahlgrenska Academy, University of Gothenburg University and the Sahlgrenska Transplant Institute at Sahlgrenska University Hospital, SE-41345 Göteborg, Sweden
- Laboratory for Transplantation and Regenerative Medicine, Sahlgrenska Academy at Gothenburg University and the Sahlgrenska Transplant Institute at Sahlgrenska University Hospital, SE-41345 Göteborg, Sweden
| | - Deepti Antony
- Laboratory for Transplantation and Regenerative Medicine, Sahlgrenska Academy at Gothenburg University and the Sahlgrenska Transplant Institute at Sahlgrenska University Hospital, SE-41345 Göteborg, Sweden
| | - Galina Travnikova
- Laboratory for Transplantation and Regenerative Medicine, Sahlgrenska Academy at Gothenburg University and the Sahlgrenska Transplant Institute at Sahlgrenska University Hospital, SE-41345 Göteborg, Sweden
| | - Martin Johansson
- Department of Laboratory Medicine, Sahlgrenska Academy, University of Gothenburg, SE-41345 Göteborg, Sweden
| | - Nikhil B. Nayakawde
- Laboratory for Transplantation and Regenerative Medicine, Sahlgrenska Academy at Gothenburg University and the Sahlgrenska Transplant Institute at Sahlgrenska University Hospital, SE-41345 Göteborg, Sweden
| | - Debashish Banerjee
- Laboratory for Transplantation and Regenerative Medicine, Sahlgrenska Academy at Gothenburg University and the Sahlgrenska Transplant Institute at Sahlgrenska University Hospital, SE-41345 Göteborg, Sweden
| | - John Mackay Søfteland
- Department of Transplantation, Sahlgrenska Academy, University of Gothenburg University and the Sahlgrenska Transplant Institute at Sahlgrenska University Hospital, SE-41345 Göteborg, Sweden
- Laboratory for Transplantation and Regenerative Medicine, Sahlgrenska Academy at Gothenburg University and the Sahlgrenska Transplant Institute at Sahlgrenska University Hospital, SE-41345 Göteborg, Sweden
| | - Goditha U. Premaratne
- Laboratory for Transplantation and Regenerative Medicine, Sahlgrenska Academy at Gothenburg University and the Sahlgrenska Transplant Institute at Sahlgrenska University Hospital, SE-41345 Göteborg, Sweden
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Sharp CR, Blais MC, Boyd CJ, Brainard BM, Chan DL, de Laforcade A, Goggs R, Guillaumin J, Lynch A, Mays E, McBride D, Rosati T, Rozanski EA. 2022 Update of the Consensus on the Rational Use of Antithrombotics and Thrombolytics in Veterinary Critical Care (CURATIVE) Domain 6: Defining rational use of thrombolytics. J Vet Emerg Crit Care (San Antonio) 2022; 32:446-470. [PMID: 35881647 PMCID: PMC9544803 DOI: 10.1111/vec.13227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 05/25/2022] [Accepted: 05/25/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To systematically review available evidence and establish guidelines related to the use of thrombolytics for the management of small animals with suspected or confirmed thrombosis. DESIGN PICO (Population, Intervention, Control, and Outcome) questions were formulated, and worksheets completed as part of a standardized and systematic literature evaluation. The population of interest included dogs and cats (considered separately) and arterial and venous thrombosis. The interventions assessed were the use of thrombolytics, compared to no thrombolytics, with or without anticoagulants or antiplatelet agents. Specific protocols for recombinant tissue plasminogen activator were also evaluated. Outcomes assessed included efficacy and safety. Relevant articles were categorized according to level of evidence, quality, and as to whether they supported, were neutral to, or opposed the PICO questions. Conclusions from the PICO worksheets were used to draft guidelines, which were subsequently refined via Delphi surveys undertaken by the Consensus on the Rational Use of Antithrombotics and Thrombolytics in Veterinary Critical Care (CURATIVE) working group. RESULTS Fourteen PICO questions were developed, generating 14 guidelines. The majority of the literature addressing the PICO questions in dogs is experimental studies (level of evidence 3), thus providing insufficient evidence to determine if thrombolysis improves patient-centered outcomes. In cats, literature was more limited and often neutral to the PICO questions, precluding strong evidence-based recommendations for thrombolytic use. Rather, for both species, suggestions are made regarding considerations for when thrombolytic drugs may be considered, the combination of thrombolytics with anticoagulant or antiplatelet drugs, and the choice of thrombolytic agent. CONCLUSIONS Substantial additional research is needed to address the role of thrombolytics for the treatment of arterial and venous thrombosis in dogs and cats. Clinical trials with patient-centered outcomes will be most valuable for addressing knowledge gaps in the field.
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Affiliation(s)
- Claire R Sharp
- School of Veterinary Medicine, Murdoch University, Murdoch, Western Australia, Australia
| | - Marie-Claude Blais
- Department of Clinical Sciences, University of Montreal, Saint-Hyacinthe, Quebec, Canada
| | - Corrin J Boyd
- School of Veterinary Medicine, Murdoch University, Murdoch, Western Australia, Australia
| | - Benjamin M Brainard
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, Georgia, USA
| | - Daniel L Chan
- Department of Clinical Science and Services, The Royal Veterinary College, London, UK
| | - Armelle de Laforcade
- Department of Clinical Sciences, Cummings School of Veterinary Medicine, Tufts University, North Grafton, Massachusetts, USA
| | - Robert Goggs
- Department of Clinical Sciences, Cornell University College of Veterinary Medicine, Ithaca, New York, USA
| | - Julien Guillaumin
- Department of Clinical Sciences, Colorado State University, Fort Collins, Colorado, USA
| | - Alex Lynch
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, USA
| | - Erin Mays
- Veterinary Specialty Services, St. Louis, Missouri, USA
| | | | - Tommaso Rosati
- Department for Small Animals, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
| | - Elizabeth A Rozanski
- Department of Clinical Sciences, Cummings School of Veterinary Medicine, Tufts University, North Grafton, Massachusetts, USA
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Fatah-Ardalani K, Wallén P, Petersen LC, Blombäck M. More porous fibrin gel structure obtained by interaction with Lys-plasminogen than with Glu-plasminogen. Blood Coagul Fibrinolysis 2000; 11:335-42. [PMID: 10847420 DOI: 10.1097/00001721-200006000-00004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The effect of Glu1- and Lys78-plasminogen on the assembly and structure of fibrin gels was studied in purified fibrinogen-thrombin system and in plasminogen-free plasma, using turbidity, liquid permeation and three-dimensional (3D) confocal laser microscopy methods. In the purified fibrinogen system using the turbidity method, the final optical density of the fibrin gels increased with increasing concentrations of Lys-plasminogen. The fiber mass/length ratio mu increased with increasing concentrations of both Glu1- and Lys78-plasminogen, the effect of Lys78-plasminogen being much stronger. The permeability coefficient (Ks) analyzed with the permeation method revealed that fibrin gels formed in the presence of Lys78-plasminogen were more permeable (porous) than the control gels. The effect on the gel structure was inhibited by the fibrinolytic inhibitor epsilon-aminocaproic acid. The same results were obtained in plasma milieu for both mu and Ks as in the purified system, i.e. the gels became more porous with increasing concentrations of Lys78-plasminogen. 3D microscopy pictures of the gels verified the findings.
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Affiliation(s)
- K Fatah-Ardalani
- Department of Laboratory Medicine/Coagulation Research, Karolinska Institutet, Karolinska Hospital, Stockholm, Sweden
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Sundell IB, Marzec UM, Kelly AB, Chronos NA, Petersen LC, Hanson SR, Hedner U, Harker LA. Reduction in stent and vascular graft thrombosis and enhancement of thrombolysis by recombinant Lys-plasminogen in nonhuman primates. Circulation 1997; 96:941-8. [PMID: 9264505 DOI: 10.1161/01.cir.96.3.941] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND To enhance thrombolytic responses without increasing hemorrhagic risks, the antithrombotic effects of recombinant Lys-plasminogen (r-LysPgn), a prothrombolytic plasminogen intermediate, were examined in baboon models of thrombus formation and dissolution. METHODS AND RESULTS The dose-response effects of r-LysPgn, alone or in combination with subthreshold dosing of tissue plasminogen activator (TPA), were measured with respect to the accumulation of (111)In-labeled platelets and (125)I-fibrin in thrombus forming on endovascular metallic stents or thrombogenic segments of vascular graft interposed in exteriorized long-term arteriovenous (AV) femoral shunts. Thrombolytic losses have also been determined for preformed, stable, (111)In-platelet- and (125)I-fibrin-labeled graft thrombus and corresponding propagated thrombotic tails, together with changes in blood tests of thrombosis, thrombolysis, and hemostasis. Bolus intravenous r-LysPgn in escalating doses (2, 4, or 8 mg/kg) increased circulating plasminogen levels in a dose-dependent manner, was removed by log-linear clearance with a T50 of 120 minutes, and reciprocally decreased the accumulating thrombus on metallic stents and segments of vascular graft (P<.001 in all cases for 8-mg/kg doses). r-LysPgn also impaired platelet aggregatory responses to physiological agonists in vitro but not ex vivo. Prethrombosis administration of low-dose r-LysPgn (2 mg/kg) greatly enhanced the lysis of radiolabeled nonoccluding thrombus by a subthreshold dose of TPA (0.1 mg/kg) compared with TPA-only controls (P=.03). CONCLUSIONS Elective bolus injections of r-LysPgn before stent deployment decrease the amount of thrombus formed without compromising hemostasis by facilitating endogenous TPA thrombolysis. r-LysPgn may provide effective and safe antithrombotic therapy for interventional vascular procedures.
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Affiliation(s)
- I B Sundell
- Department of Medicine, Yerkes Regional Primate Research Center, Emory University School of Medicine, Atlanta, GA 30322, USA
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Kajimoto Y, Ohta T, Kuroiwa T. Comparison of Intrathecally Administered Urokinase, Tissue-type Plasminogen Activator, and Combination of Urokinase and Lysine-Plasminogen for Clot Lysis after Experimental Subarachnoid Hemorrhage in Dogs. Neurosurgery 1997. [DOI: 10.1227/00006123-199703000-00029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Kajimoto Y, Ohta T, Kuroiwa T. Comparison of intrathecally administered urokinase, tissue-type plasminogen activator, and combination of urokinase and lysine-plasminogen for clot lysis after experimental subarachnoid hemorrhage in dogs. Neurosurgery 1997; 40:572-7. [PMID: 9055298 DOI: 10.1097/00006123-199703000-00029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE The purpose of this study was to compare the fibrinolytic effect of urokinase (UK) with that of tissue plasminogen activator (tPA) on subarachnoid clots and to investigate the effect of lysine-plasminogen (Lys-plg) on fibrinolytic therapy. METHODS We measured subarachnoid clot lysis rate chronologically for 24 hours during continuous intrathecal irrigation with tPA or UK alone in a canine subarachnoid hemorrhage model. Also, we measured the clot lysis rate for 24 hours during continuous irrigation with UK and Lys-plg or with UK after preadministration of Lys-plg in the same model. RESULTS The rate of clot lysis caused by UK and tPA dose-dependently increased up to 3,000 IU/ml and 125,000 IU/ml, respectively. With the same molar concentrations, the lytic effect of tPA was significantly higher than that of UK. The slope of the dose-response curve, however, was almost the same with both agents, and the slope of the dose-response curve of UK and tPA for a 24-hour irrigation was 25 and 23% per log 10 concentration, respectively. On the other hand, clot lysis with the combined use of UK and Lys-plg was higher than that with the single use of UK. Particularly, the preadministration of Lys-plg markedly enhanced clot lysis by UK at the early stage of irrigation. CONCLUSION Subarachnoid clot lysis can be accelerated by administration of Lys-plg before UK administration and by use of high concentrations of UK or tPA.
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Affiliation(s)
- Y Kajimoto
- Department of Neurosurgery, Osaka Medical College, Takatsuki, Japan
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Chen LY, Nichols WW, Saldeen TG, Mehta JL. Recombinant lys-plasminogen given before, but not after, recombinant tissue-type plasminogen activator markedly improves coronary thrombolysis in dogs: relationship of thrombolytic efficacy with parameters of fibrinolysis. J Cardiovasc Pharmacol 1996; 27:283-9. [PMID: 8720429 DOI: 10.1097/00005344-199602000-00016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Recombinant tissue-type plasminogen activator (rt-PA) administration rapidly restores blood flow in thrombosed coronary arteries, but coronary arteries often reocclude after initial thrombolysis. This occurs because of the short half-life of rt-PA and rapid increase in plasminogen activator inhibitor (PAI-1) and alpha2-antiplasmin levels in plasma. We hypothesized that administration of lys-plasminogen, which binds to fibrin with 10 times greater affinity and results in a loose fibrin structure (as compared with native glu-plasminogen), before rt-PA would enhance the thrombolytic efficacy of rt-PA and modulate parameters of fibrinolysis. To examine this hypothesis, dogs with electrically induced stable thrombus in the left anterior descending coronary artery (LAD) were treated with saline (group A, n = 9) or lys-plasminogen (group B, 2 mg/kg, n = 5), followed 10 min later by rt-PA (1 mg/kg in 20 min). Four other dogs with occlusive LAD thrombus were first given rt-PA, followed by lys-plasminogen (2 mg/kg) 50 min later (group C). Lys-plasminogen given before rt-PA restored flow in all dogs in 14 +/- 4 min (vs. 22 +/- 9 min in group A, p < 0.05), continuing > 2 h (vs. 41 +/- 15 min in group A, p < 0.02). Lys-plasminogen given after rt-PA did not potentiate the effect of rt-PA. Plasma t-PA antigen concentrations were highest in group B dogs at 2 h after rt-PA infusion. PAI-1 and alpha2-antiplasmin plasma levels were suppressed in all dogs receiving lys-plasminogen whether it was given before or after rt-PA. Therefore, lys-plasminogen given before rt-PA markedly potentiates the effect of rt-PA and alters the parameters of fibrinolysis. In contrast, lys-plasminogen given after rt-PA does not influence the thrombolytic effect of rt-PA, whereas it suppresses PAI-1 and alpha2-antiplasmin levels in plasma. This study also suggests that binding of plasminogen to the clot is more important than the plasma levels of PAI-1 and alpha2-antiplasmin.
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Affiliation(s)
- L Y Chen
- Department of Medicine, University of Florida College of Medicine, Gainesville 32610-0277, USA
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