Hemostatic Role of a Folkloric Medicinal Plant Extract in a Rat Partial Nephrectomy Model: Controlled Experimental Trial

Ankaferd hemostat: from molecules to medicine

Ankaferd hemostat (ABS; Ankaferd Blood Stopper®, İstanbul, Turkey) is a hemostatic agent having an impact on red blood cell–fibrinogen interactions. The hemostatic effect of ABS depends upon the quick promotion of a protein network, particularly fibrinogen gamma, in relation to the erythrocyte aggregation. The entire physiological process involves ABS-induced formation of the protein network by vital erythrocyte aggregation. Vital erythrocyte aggregation occurs with the spectrine, ankyrin, and actin proteins on the membrane of the red blood cells. ABS notably affects cell metabolism and cell cycle mechanisms. Meanwhile, ABS has antiproliferative effects on cancer cells. The aim of this review is to assess molecular basis of ABS as a hemostatic drug. The literature search on ABS was performed in PubMed, Web of Science (SCI expanded), and Scopus with particular focus on the studies of molecular basis of ABS, in vivo research, case series, and controlled randomized clinical studies. Current perspective for the utilization of ABS is to provide hemostasis with accelerating wound healing. Future controlled trials are needed to elucidate the pleiotropic clinical effects of ABS such as antineoplastic, antiinflammatory, antiinfective, antifungal, and antioxidative effects.

Analysing the blood-stemming effect of Ankaferd Blood Stopper in medulla spinalis surgery

Background/aim

The aim of this study was to investigate the possible toxicity of the Ankaferd Blood Stopper (ABS) on the neural system.

Materials and methods

Thirty Sprague Dawley rats were randomized into ABS (n: 15) and control (n: 15) groups. Following the anaesthetic induction, total laminectomy was performed to the lower thoracic, and upper lumbar areas in both groups and medulla spinalis was exposed. Two myelotomies were performed on the medulla spinalis. One millilitre ABS was applied to the incision site in the ABS group, and one millilitre 0.9% saline solution was applied in the control group. Rats were observed for 15 days regarding general behaviour, neurological signs, mobility, and signs of infection. Sixteen days later, all rats were decapitated under anaesthesia. Medulla spinalis was removed en bloc from all rats and was stained with Heamatoxylin & Eosin and luxol fast blue.

Results

There was no significant difference between the ABS group and the control group regarding oedema, gliosis, the intensity of inflammatory cells, the presence of neuronal degeneration, neuron counts, and myelin degeneration.

Conclusion

No clinical or histopathological evidence for the neurotoxic effect of the ABS was observed in the present study. Our findings might precipitate the use of ABS on human subjects regarding medulla spinalis surgery.

Pharmacobiological management of hemostasis within clinical backgrounds via Ankaferd hemostat (Ankaferd blood stopper)

Ankaferd hemostat (Ankaferd blood stopper [ABS], Istanbul, Turkey) is a hemostatic agent affecting red blood cell-fibrinogen interactions. ABS has been traditionally used in Anatolia as a hemostatic agent for centuries. ABS contains a standardized combination of the plants namely Glycyrrhiza glabra, Thymus vulgaris, Alpinia officinarum, Vitis vinifera, and Urtica dioica. The hemostatic effect of ABS depends upon the quick promotion of a protein network, particularly fibrinogen gamma, in relation to the erythrocyte aggregation. The aim of this review is to indicate pharmacobiological basis and clinical backgrounds of ABS. Current perspective for using ABS is to provide hemostasis and accelerating wound healing particularly in cases which are difficult to manage. Future controlled trials are needed to elucidate the actions of ABS with in hemostasis, antithrombotic, anti-inflammatory, anti-infective, antifungal, and anti-oxidative effects.

Ultrastructural analyses of the novel chimeric hemostatic agent generated via nanotechnology, ABS nanohemostat, at the renal tissue level

Ankaferd Blood Stopper (ABS), a hemostatic agent of plant origin, has been registered for the prevention of clinical hemorrhages. Currently there is no data regarding the ultrastructural analysis of ABS at the tissue level. The aim of this study is to assess renal tissue effects via scanning electron microscopy (SEM) analyses for the ABS and ABS nanohemostat (formed by the combination of self-assembling peptide amphiphile molecules and ABS). SEM experiments were performed with FEI Nova NanoSEM 230, using the ETD detector at low vacuum mode with 30 keV beam energy. SEM analyses revealed that significant erythroid aggregation are present inside the capillary bed of the renal tissue. However, neither the signs of necrosis nor any other sign of tissue damage are evident in the surrounding renal tissue supplied by the microcapillary vasculature. Our study is important for several reasons. Firstly, in our study we used ABS nanohemostat which was recently developed. This study adds valuable information to the literature regarding ABS nanohemostat. Secondly, this study is the first ultrastructural analysis of ABS that was performed at the tissue level. Thirdly, we disclosed that ABS nanohemostat could induce vital erythroid aggregation at the renal tissue level as detected by SEM. Lastly, we detected that ABS nanohemostat causes no harm to the tissues including necrosis and any other detrimental effects.

Hemostatic Efficacy and Histopathological Effects of Ankaferd Blood Stopper in an Experimental Rat Model of Cyclophosphamide-induced Hemorrhagic Cystitis

OBJECTIVE

To evaluate the hemostatic efficacy and histopathological effects of Ankaferd Blood Stopper (ABS) in an experimental rat model of cyclophosphamide-induced (CYP) hemorrhagic cystitis (HC).

MATERIALS AND METHODS

Forty male Sprague-Dawley rats were included in the study. Firstly, 10 rats were divided equally into 2 groups where the first group was administered only an intraperitoneal (i.p.) injection of normal saline to constitute the negative control group (CON). The remaining 5 rats were administered only a single i.p. injection of CYP (without any further treatment) for induction of HC to constitute the positive control group (HC). Subsequently, the remaining 30 rats, which also received i.p. CYP for induction of HC, were divided into 3 groups to which intravesical saline (SAL group), epinephrine (EPN group), and ABS (ANK group) were administered for 3 consecutive days. Ten days after the third instillation, cystectomy was performed for histopathological examination. Specimens were evaluated for presence of congestion, edema, necrosis, ulceration, and regenerated epithelium, and scores were given for each parameter according to the severity.

RESULTS

No statistically significant difference was observed for congestion, edema, necrosis, and ulceration between HC-SAL, and also between CON-ANK groups (all P values >.05). There was a significant difference for total scores between EPN and ANK groups (P = .009). There was statistically significant difference for regenerating epithelium between CON-EPN, CON-ANK, HC-ANK, and SAL-ANK groups.

CONCLUSION

Intravesical administration of ABS is at least as efficacious as EPN in terms of congestion, edema, necrosis, and ulceration. Moreover, ABS can be considered as a better option in inducing regenerating epithelium than EPN.

Application of long-acting VLHL PAI-1 during sutureless partial nephrectomy in mice reduces bleeding

PAI-1 prevents lysis of blood clot by inhibiting the urokinase and tPA induced conversion of plasminogen to plasmin. VLHL PAI-1 protein mutant was created to extend half-life over 700 hours. The objective of this paper was to test VLHL PAI-1 effects on bleeding during partial nephrectomy in mice. All animals had a left partial nephrectomy after intravenous infusion of saline or tPA. The animals were divided into four groups. Group 1 was infused with saline and kidney was exposed to saline too; Group 2 was infused with saline and kidney was exposed to PAI-1. Group 3 was infused with tPA and kidney was exposed to saline, while Group 4 was infused with tPA and kidney was exposed to PAI-1. Preweighed gauze containing PAI-1 or saline was then applied to the kidney for 30 minutes. The gauze was afterward weighed and blood loss was measured by subtracting the preweight of gauze from the final weight. We have observed a statistically significant (P ≤ 0.05) reduction of bleeding in PAI-1-treated group in comparison to saline and tPA-treated groups. Based on these results we propose that VLHL PAI-1 can be used therapeutically in limiting the flow of blood from renal wounds.

Generation of Chimeric "ABS Nanohemostat" Complex and Comparing Its Histomorphological In Vivo Effects to the Traditional Ankaferd Hemostat in Controlled Experimental Partial Nephrectomy Model

Purpose. Using the classical Ankaferd Blood Stopper (ABS) solution to create active hemostasis during partial nephrectomy (PN) may not be so effective due to insufficient contact surface between the ABS hemostatic liquid agent and the bleeding area. In order to broaden the contact surface, we generated a chimeric hemostatic agent, ABS nanohemostat, via combining a self-assembling peptide amphiphile molecule with the traditional Ankaferd hemostat. Materials and Methods. In order to generate ABS nanohemostat, a positively charged Peptide Amphiphile (PA) molecule was synthesized by using solid phase peptide synthesis. For animal experiments, 24 Wistar rats were divided into the following 4 groups: Group 1: control; Group 2: conventional PN with only 0.5 ml Ankaferd hemostat; Group 3: conventional PN with ABS + peptide gel; Group 4: conventional PN with only 0.5 ml peptide solution. Results. Mean warm ischemia times (WITs) were 232.8  ±  56.3, 65.6 ± 11.4, 75.5 ± 17.2, and 58.1 ± 17.6 seconds in Group 1 to Group 4, respectively. Fibrosis was not different among the groups, while inflammation was detected to be significantly different in G3 and G4. Conclusions. ABS nanohemostat has comparable hemostatic efficacy to the traditional Ankaferd hemostat in the partial nephrectomy experimental model. Elucidation of the cellular and tissue effects of this chimeric compound may establish a catalytic spark and open new avenues for novel experimental and clinical studies in the battlefield of hemostasis.

The Dual Diverse Dynamic Reversible Effects of Ankaferd Blood Stopper on EPCR and PAI-1 Inside Vascular Endothelial Cells With and Without LPS Challenge

Objective: Ankaferd blood stopper (ABS) is comprised of a mixture of the plants Thymus vulgaris, Glycyrrhiza glabra, Vitis vinifera, Alpinia officinarum, and Urtica dioica. ABS is used as a topical hemostatic agent due to its antihemorrhagic effect, yet its hemostatic mechanism of action remains to be investigated. ABS does not affect the levels of coagulation factors II, V, VII, VIII, IX, X, XI and XII. The aim of this study was to investigate the effects of ABS on endothelium and immune response. As such, we evaluated changes in endothelial cell protein C receptor (EPCR) and plasminogen activator inhibitor type-1 (PAI-1) expression inside human umbilical vein endothelial cells (HUVECs) in the presence and absence of lipopolysaccharides (LPSs).

Material and Methods: We exposed HUVECs to 10 μL and 100 μL of ABS for 5 min, 25 min, 50 min, 6 h, and 24 h. Additionally, 10 μg mL–1 of LPS was administered for 1 h to observe the effects of LPS challenge on HUVECs, and then the cells were treated with ABS for 5 min, 25 min, 50 min, and 6 h to observe the effects of ABS on HUVECs. Total RNA was isolated from HUVECs and then the level of expression of EPCR and PAI-1 mRNA was measured.

Results: Cells were microscopically observed to arise from the surface and adhere to each other following the administration of ABS to HUVECs. Additionally, after 24 h the cells had normal growth and physiology, which suggests that the adhesive cellular effects of ABS might be reversible. ABS had a negative effect on EPCR and PAI-1 expression; the effect in response to 100 µL was greater than that to 10 µL. EPCR and PAI-1 expression increased over time in response to LPS and 10 µL of ABS. EPCR and PAI-1 expression was very low during the first hour of exposure to LPS and 100 µL of ABS, but after 6 h increased to levels similar to those observed in response to LPS and 10 µL of ABS.

Conclusion: It was observed that ABS had dual diverse dynamic reversible effects on EPCR and PAI-1 expression in HUVECs, which were dependent on dose and concentration. ABS might play a role in numerous cellular mechanisms, in addition to having hemostatic effects.

Conflict of interest:None declared.

Local tissue reaction after the application of topical hemostatic agents in a rat partial nephrectomy model

Various hemostatics are used for renal surgical procedures. We investigated the hemostatic efficacy of cellulose derivatives on the model of partial nephrectomy in rats focusing on the local reaction of renal parenchyma. A total of 50 Wistar rats were divided into five groups of 10 animals each. Partial nephrectomy of the caudal pole without hilar vascular control was performed. Oxidized cellulose (OC), sodium salt of oxycellulose (OCN), carboxymethyl cellulose (CMC), dialdehyde cellulose (DAC), and gelatin-based hemostatic (C) were applied to the bleeding wounds. The time to hemostasis was monitored. Half of the animals were euthanized after 3 days, the second half 30 days from the experiment start date. The left kidney was excised and subjected to histopathological examination. The biochemical data was subjected to statistical analysis. The time to hemostasis in all groups was significantly less than in the C group (in OC p = 0.0057, OCN p = 0.0039, CMC and DAC p = 0.0001). In the C group, massive hemorrhages and necrosis did occur. In the OC and OCN groups, there were regenerative changes, a receding inflammatory reaction and hemorrhage. DAC caused an immune reaction and massive interstitial hemorrhages with biochemical signs of liver damage. Parenchyma in CMC revealed a reduction of necrosis and interstitial hemorrhages with regenerative processes. The most effective hemostatics were CMC and OC, achieving the best results both in the time to hemostasis, and for histopathological evaluation.

Pleiotropic cellular, hemostatic, and biological actions of Ankaferd hemostat

Sustaining hemostasis in clinical hemorrhages is a challenging task and requires extensive effort to stabilize medically hard-to-treat traumatic injuries. Several hemostatic agents are preferred to control external and internal bleedings, yet commercially available products are not sufficiently effective or fast-acting to achieve hemostasis in extreme cases. Ankaferd Blood Stopper (ABS) is a herbal extract traditionally used as a hemostatic agent. Recent studies have shown that ABS could be utilized successfully as a hemostatic agent for the management of clinical hemorrhages when conventional methods were ineffective. This review serves as a basis to provide recent findings on several applications of ABS, specifically preclinical, biological, and clinical studies both in vitro and in vivo. Another section focuses on the ultrastructural morphology and protein network formation of ABS in an effort to understand the hemostatic mechanisms of this unique agent at tissue level.

Postoperative adhesions after application of topical hemostatic agents: outcomes in a rat partial nephrectomy model

OBJECTIVE

To compare 3 kinds of topical hemostatic agents in terms of adhesive strength, control of hemorrhage, and postoperative intra-abdominal adhesions in an experimental partial nephrectomy (PN) model.

METHODS

A total of 27 Wistar rats were divided into 5 groups. PN was performed in 6 rats (control group) with the conventional technique, in which the lower pole of the kidney was excised and sutured after hilar control. In 5 rats, oxidized cellulose was placed over the excised part of the kidney following conventional technique. In 6 rats, the hemostatic plant extract was used without hilar control. In 5 rats, the hemostatic agent chitosan was used without hilar control. As a sham group, 5 rats underwent a laparotomy and handling of the renal pedicle without the removal of renal pole. On the tenth day after the operation, the degree of adhesions to the operated kidney were evaluated. Histopathological evaluation was also performed by a blinded pathologist.

RESULTS

Mean warm ischemia times for control and oxidized cellulose groups were 4.85 ± 0.75 and 4.28 ± 1.28 minutes, respectively (P = .662). Wound healing was excellent in all groups except in 1 rat in the chitosan group. Chitosan was associated with significantly higher intestinal and peritoneal adhesion scores, although histopathologically comparable scores were revealed.

CONCLUSION

In our rat model, chitosan and the hemostatic plant extract were as effective as conventional suturing in achieving hemostasis even without hilar control. Warm ischemia was eliminated and PN time was significantly decreased. The use of oxidized cellulose was not associated with higher scores of adhesion, suppuration, or hematoma.

Haemostatic effect of Ankaferd Blood Stopper(®) seen during adenoidectomy

In Turkey, Ankaferd Blood Stopper(®) (ABS) has been approved for the management of external haemorrhages and bleedings occurring during dental surgeries (Goker et al., 2008). Ankaferd comprises a standardized mixture of plants, including Thymus vulgaris, Glycyrrhiza glabra, Vitis vinifera, Alpinia officinarum, and Urtica diodica. This study aimed to evaluate the efficacy of AB S tam ponade in the control of intra-operative bleeding occurring during ad enoidectomy performed in children under the age of 12. Sixty children were randomized to receive 1 to 5 minute-tamponade with either ABS or topical gauze sponges soaked in saline solution (SS) during their ad enoidectomy.. Time-to-haemostasis and the number of packs required were recorded. A visual analog scale was used by the operating surgeon to record subjective data, including the rate of bleeding following the first adenoid pack removal (0= none, 3=brisk). Compared to the children in the SS group (n=30), time-to-haemostasis seen in ABS patients (n=30) was significantly shorter (mean ± standard deviation, 1.93 ± 1.39 min vs 3.20 ± 1.50 min; p<0.0001); they required a lower number of packs (mean, 1.93 vs. 3.20), and appeared to bleed less (53.3% vs 6.7%; p=0.0001). ABS aids in the control of intra-operative bleeding and reduces the number of packs required to achieve haemostasis, so that it can be recommended for tamponades per formed during paediatric adenoidectomies.

Effect of Ankaferd Blood Stopper on air leakage in the lung and prevention of bleeding: an experimental study

BACKGROUND

Air leakage and hemorrhage are important causes of morbidity and mortality in operations and traumas of the lung. Ankaferd Blood Stopper is a herbal product used for stopping hemorrhage. In our study, we investigated the efficacy of Ankaferd Blood Stopper in the prevention of air leakage in the lung and bleeding.

METHODS

A total of twenty-one Wistar-Albino rats weighing 240 ± 20 grams were used in our study. An equal amount of injury was created in all groups by performing left thoracotomies. No interventions were made on tissue injury in the first group, and suturing was performed in the second group, and Ankaferd was applied in the third group. Air leakage and duration of bleeding were recorded in all groups.

RESULTS

A statistically significant difference was found between the three groups in terms of air leakage time (p = 0,0001) and bleeding time (p = 0,0001). While a significant effect of Ankaferd was detected in terms of air leakage compared to standard surgery (p = 0,017), no difference was found in terms of bleeding time.

CONCLUSIONS

Ankaferd Blood Stopper ceases the air leakage in the lung parenchyma significantly and effectively. No significant difference is seen compared to the standard surgery group, although it ceases bleeding significantly.

Ultrastructural and morphological analyses of the in vitro and in vivo hemostatic effects of Ankaferd Blood Stopper

Ultrastructural and morphological analyses of a novel hemostatic agent, Ankaferd Blood Stopper (ABS), in comparison to its in vitro and in vivo hemostatic effects were investigated. High-resolution scanning electron microscopy (SEM) images accompanied with morphological analysis after topical application of ABS revealed a very rapid (<1 second) protein network formation within concurrent vital erythroid aggregation covering the classical coagulation cascade. Histopathological examination revealed similar in vivo ABS-induced hemostatic network at the porcine hepatic tissue injury model. Instantaneous control of bleeding was achieved in human surgery-induced dental tissue injury associated with primary and secondary hemostatic abnormalities. Ankaferd Blood Stopper could hold a great premise for clinical management of surgery bleedings as well as immediate cessation of bleeding on external injuries based on upcoming clinical trials.