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Zhou FQ. Advantages of pyruvate-based fluids in preclinical shock resuscitation-A narrative review. Front Physiol 2022; 13:1027440. [PMID: 36505043 PMCID: PMC9732738 DOI: 10.3389/fphys.2022.1027440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 11/02/2022] [Indexed: 11/22/2022] Open
Abstract
This review focuses on the innate beneficial effects of sodium pyruvate-based fluids, including pyruvate in intravenous solutions, oral rehydration solutions, and peritoneal dialysis solutions, on shock resuscitation with various animal models relative to current commercial fluids over the last two decades. Due to its superior pharmacological properties, pyruvate effectively sustains cytosolic glycolytic pathways and mitochondrial oxidative phosphorylation by restoration of redox potentials and reactivation of pyruvate dehydrogenase in hypoxia, even anoxia, and diabetes, reversing the Warburg effect and diabetic glucometabolic aberration. Pyruvate has been demonstrated to protect against multiorgan dysfunction and metabolic disturbance in numerous preclinical studies with various pathogenic injuries. The unique features of pyruvate potential clinical benefits encompass to efficiently correct lethal lactic acidosis via metabolically rapid consumption of intracellular [H+] and robustly protect multiorgan metabolism and function, particularly visceral organs in addition to the heart and brain, significantly prolonging survival in various animal models. Pyruvate protection of red blood cell function and preservation of the partial pressure of arterial oxygen should be highly concerned in further studies. Pyruvate is much advantageous over existing anions such as acetate, bicarbonate, chloride, and lactate in commercial fluids. Pyruvate-based fluids act as a therapeutic agent without causing iatrogenic resuscitation injury in addition to being a volume expander, indicating a potential novel generation of resuscitation fluids, including crystalloids and colloids. Pyruvate-based fluids have an enormous potential appeal for clinicians who face the ongoing fluid debate to readily select as the first resuscitation fluid. Clinical trials with pyruvate-based fluids in shock resuscitation are urgently warranted.
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Affiliation(s)
- Fang-Qiang Zhou
- Independent Researcher, Las Vegas, NV, United States,Fresenius Medical Care, Chicago, IL, United States,*Correspondence: Fang-Qiang Zhou,
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2
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Zhou FQ. Pyruvate as a Potential Beneficial Anion in Resuscitation Fluids. Front Med (Lausanne) 2022; 9:905978. [PMID: 35991638 PMCID: PMC9382911 DOI: 10.3389/fmed.2022.905978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 06/15/2022] [Indexed: 12/02/2022] Open
Abstract
There have been ongoing debates about resuscitation fluids because each of the current fluids has its own disadvantages. The debates essentially reflect an embarrassing clinical status quo that all fluids are not quite ideal in most clinical settings. Therefore, a novel fluid that overcomes the limitations of most fluids is necessary for most patients, particularly diabetic and older patients. Pyruvate is a natural potent antioxidant/nitrosative and anti-inflammatory agent. Exogenous pyruvate as an alkalizer can increase cellular hypoxia and anoxia tolerance with the preservation of classic glycolytic pathways and the reactivation of pyruvate dehydrogenase activity to promote oxidative metabolism and reverse the Warburg effect, robustly preventing and treating hypoxic lactic acidosis, which is one of the fatal complications in critically ill patients. In animal studies and clinical reports, pyruvate has been shown to play a protective role in multi-organ functions, especially the heart, brain, kidney, and intestine, demonstrating a great potential to improve patient survival. Pyruvate-enriched fluids including crystalloids and colloids and oral rehydration solution (ORS) may be ideal due to the unique beneficial properties of pyruvate relative to anions in contemporary existing fluids, such as acetate, bicarbonate, chloride, citrate, lactate, and even malate. Preclinical studies have demonstrated that pyruvate-enriched saline is superior to 0.9% sodium chloride. Moreover, pyruvate-enriched Ringer’s solution is advantageous over lactated Ringer’s solution. Furthermore, pyruvate as a carrier in colloids, such as hydroxyethyl starch 130/0.4, is more beneficial than its commercial counterparts. Similarly, pyruvate-enriched ORS is more favorable than WHO-ORS in organ protection and shock resuscitation. It is critical that pay attention first to improving abnormal saline with pyruvate for ICU patients. Many clinical trials with a high dose of intravenous or oral pyruvate were conducted over the past half century, and results indicated its effectiveness and safety in humans. The long-term instability of pyruvate aqueous solutions and para-pyruvate cytotoxicity is not a barrier to the pharmaceutical manufacturing of pyruvate-enriched fluids for ICU patients. Clinical trials with sodium pyruvate-enriched solutions are urgently warranted.
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Mallet RT, Olivencia-Yurvati AH, Bünger R. Pyruvate-enriched resuscitation for shock. Exp Biol Med (Maywood) 2019; 243:663-664. [PMID: 29763385 DOI: 10.1177/1535370218773717] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
This commentary addresses the recent retraction of an article which reported favorable outcomes in septic patients treated with intravenous pyruvate. The retracted report was cited in the authors' recent minireview on the cellular mechanisms and clinical application of pyruvate to improve cardiac performance. Because the retracted article reports pyruvate-enhanced resuscitation of critically ill patients, the authors wish to inform the readership, especially critical care providers, that this particular clinical application of pyruvate is not now supported by robust evidence. After discussing the retraction's implications for the clinical application of pyruvate-enriched resuscitation for sepsis, this commentary summarizes the extensive preclinical evidence of the efficacy and mechanisms of pyruvate resuscitation in animal models of hemorrhagic and septic shock, which argues for renewed clinical investigation of pyruvate-enriched resuscitation. Impact statement This commentary addresses the recent retraction of a clinical report of significant benefits of intravenous pyruvate resuscitation in septic patients, including sharply lowered mortality and decreased circulating pro-inflammatory cytokines, which was cited in the authors' minireview in Experimental Biology and Medicine. The potential implications of the retraction, and the extensive preclinical evidence supporting the use of pyruvate-enriched resuscitation for shock states, are summarized and discussed.
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Affiliation(s)
- Robert T Mallet
- 1 Department of Physiology and Anatomy, University of North Texas Health Science Center, Fort Worth, TX 76107-2699, USA
| | - Albert H Olivencia-Yurvati
- 1 Department of Physiology and Anatomy, University of North Texas Health Science Center, Fort Worth, TX 76107-2699, USA
- 2 Department of Medical Education, University of North Texas Health Science Center, Fort Worth, TX 76107-2699, USA
| | - Rolf Bünger
- 3 Emeritus Member of the American Physiological Society, McLean, VA 22101, USA
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Effenberger-Neidnicht K, Brauckmann S, Jägers J, Patyk V, Waack IN, Kirsch M. Protective Effects of Sodium Pyruvate during Systemic Inflammation Limited to the Correction of Metabolic Acidosis. Inflammation 2018; 42:598-605. [PMID: 30357579 DOI: 10.1007/s10753-018-0917-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Protective effects by exogenous sodium pyruvate already have been described in various experimental models of injury, among others during intestinal ischemia-reperfusion injury, hemorrhagic shock, and shock secondary to systemic inflammation (endotoxemic shock). Low doses of sodium pyruvate reduced signs of inflammation, enhanced systemic blood pressure, and ameliorated metabolic acidosis when administered in a prophylactic manner during endotoxemic shock. In the present study, we investigated whether low-dosed infusions of sodium pyruvate exhibited beneficial effects when applied therapeutically after the induction of systemic inflammation. Lipopolysaccharide was infused at a rate of 0.5 mg/kg × h over a period of 360 min to induce systemic inflammation in male Wistar rats. Sodium pyruvate (single dose 50 mg/kg × 15 min) was administered intravenously 180 and 270 min after starting of the lipopolysaccharide infusion. Systemic/vital parameters (e.g., systemic blood pressure and breathing rate) and blood/plasma parameters (e.g., acid-base parameters; electrolytes; glucose and lactate concentration; hemolysis; aminotransferase activities; and parameters of coagulation) were determined in regular intervals. Lipopolysaccharide infusion led to metabolic acidosis, hypoglycemia, electrolyte as well as hemostatic disturbances, and hemolysis. Except for the acid-base status (amelioration of metabolic acidosis) and the plasma chloride concentration (reduction of hyperchloremia), the additional infusion of sodium pyruvate failed in significantly improving lipopolysaccharide-dependent alterations (e.g. vital, blood and plasma parameters). Protective effects of a delayed administration of the metabolizable anion pyruvate during systemic inflammation, hence, are limited to its function as alkalizer to counteract metabolic acidosis.
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Affiliation(s)
| | - Stephan Brauckmann
- Clinic for Anesthesiology and Intensive Care, University Hospital Essen, Hufelandstraße 55, 45122, Essen, Germany
| | - Johannes Jägers
- Institute of Physiology, University Hospital Essen, Hufelandstraße 55, 45122, Essen, Germany
| | - Vivien Patyk
- Institute of Physiological Chemistry, University Hospital Essen, Hufelandstraße 55, 45122, Essen, Germany
| | - Indra Naemi Waack
- Institute of Physiological Chemistry, University Hospital Essen, Hufelandstraße 55, 45122, Essen, Germany
| | - Michael Kirsch
- Institute of Physiological Chemistry, University Hospital Essen, Hufelandstraße 55, 45122, Essen, Germany
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Wang Y, Huang Y, Yang J, Zhou FQ, Zhao L, Zhou H. Pyruvate is a prospective alkalizer to correct hypoxic lactic acidosis. Mil Med Res 2018; 5:13. [PMID: 29695298 PMCID: PMC5918562 DOI: 10.1186/s40779-018-0160-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 04/05/2018] [Indexed: 12/12/2022] Open
Abstract
Type A lactic acidosis resulted from hypoxic mitochondrial dysfunction is an independent predictor of mortality for critically ill patients. However, current therapeutic agents are still in shortage and can even be harmful. This paper reviewed data regarding lactic acidosis treatment and recommended that pyruvate might be a potential alkalizer to correct type A lactic acidosis in future clinical practice. Pyruvate is a key energy metabolic substrate and a pyruvate dehydrogenase (PDH) activator with several unique beneficial biological properties, including anti-oxidant and anti-inflammatory effects and the ability to activate the hypoxia-inducible factor-1 (HIF-1α) - erythropoietin (EPO) signal pathway. Pyruvate preserves glucose metabolism and cellular energetics better than bicarbonate, lactate, acetate and malate in the efficient correction of hypoxic lactic acidosis and shows few side effects. Therefore, application of pyruvate may be promising and safe as a novel therapeutic strategy in hypoxic lactic acidosis correction accompanied with multi-organ protection in critical care patients.
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Affiliation(s)
- Ying Wang
- Institute of Transfusion Medicine, Academy of Military Medical Sciences, Beijing, 100850, China
| | - Ya Huang
- Institute of Transfusion Medicine, Academy of Military Medical Sciences, Beijing, 100850, China.,Department of Transfusion, Hainan Branch of PLA General Hospital, Sanya, 572013, Hainan, China
| | - Jing Yang
- Institute of Transfusion Medicine, Academy of Military Medical Sciences, Beijing, 100850, China
| | - Fang-Qiang Zhou
- Fresenius Dialysis Centers at Chicago, Rolling Meadows Facility, Chicago, IL, 60008, USA.,Shanghai Sandai Pharmaceutical R&D Co, Shanghai, 201203, China
| | - Lian Zhao
- Institute of Transfusion Medicine, Academy of Military Medical Sciences, Beijing, 100850, China.
| | - Hong Zhou
- Institute of Transfusion Medicine, Academy of Military Medical Sciences, Beijing, 100850, China.
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Kusza K, Mielniczuk M, Krokowicz L, Cywiński JB, Siemionow M. Ringer's lactate solution enhances the inflammatory response during fluid resuscitation of experimentally induced haemorrhagic shock in rats. Arch Med Sci 2018; 14:655-670. [PMID: 29765455 PMCID: PMC5949920 DOI: 10.5114/aoms.2017.69771] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 07/25/2017] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Hemorrhagic shock leads to systemic oxygen deficit (hypoxaemia) that results in systemic inflammatory response syndrome (SIRS), a recognised cause of late mortality in this case. The aim of this study was to analyse the impact of fluid resuscitation, using two Ringer solutions, on the microcirculation changes that take place during experimentally induced haemorrhagic shock. MATERIAL AND METHODS A model of the rat cremaster muscle was used to assess microcirculation in vivo. The experimental groups (n = 10 each) included: control (CTRL); shock (HSG); Ringer's acetate (RAG); and Ringer's lactate (RLG). Microhaemodynamic parameters were measured during the experiment. RESULTS A statistically significantly higher level of leukocytes, both those attached to the endothelium and those located in the extravascular space (p < 0.05), was reported in the lactate Ringer (LR) group compared with the AR group. There were significant differences in the activity of A3 arterioles compared with A1 and A2 arterioles. Ringer's lactate solution seemed to the inflammation response during fluid resuscitation from haemorrhagic shock. A3 arterioles are likely to play a role as a pre-capillary sphincter in the skeletal muscle. CONCLUSIONS The present study revealed that fluid resuscitation with Ringer's lactate solution exacerbates inflammation in the skeletal muscle. It is worth noting that Ringer's acetate solution reduces local inflammation and could therefore be recommended as the "first line" crystalloid of the fluid resuscitation during haemorrhagic shock.
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Affiliation(s)
- Krzysztof Kusza
- Chair and Department of Anaesthesiology and Intensive Therapy, Poznan University of Medical Sciences, Poznan, Poland
| | - Mariusz Mielniczuk
- Department of Anaesthesiology and Intensive Therapy, Doctor Antoni Jurasz University Hospital, Bydgoszcz, Poland
| | - Lukasz Krokowicz
- Department of General, Gastroenterological and Endocrine Surgery, Poznan University of Medical Science, Poznan, Poland
| | - Jacek B. Cywiński
- Department of General, Gastroenterological and Endocrine Surgery, Poznan University of Medical Science, Poznan, Poland
| | - Maria Siemionow
- Department of General, Gastroenterological and Endocrine Surgery, Poznan University of Medical Science, Poznan, Poland
- Department of Orthopaedics, University of Illinois, Chicago, IL, USA
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7
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Elamin M, Ruskin DN, Masino SA, Sacchetti P. Ketone-Based Metabolic Therapy: Is Increased NAD + a Primary Mechanism? Front Mol Neurosci 2017; 10:377. [PMID: 29184484 PMCID: PMC5694488 DOI: 10.3389/fnmol.2017.00377] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 10/30/2017] [Indexed: 12/20/2022] Open
Abstract
The ketogenic diet’s (KD) anticonvulsant effects have been well-documented for nearly a century, including in randomized controlled trials. Some patients become seizure-free and some remain so after diet cessation. Many recent studies have explored its expanded therapeutic potential in diverse neurological disorders, yet no mechanism(s) of action have been established. The diet’s high fat, low carbohydrate composition reduces glucose utilization and promotes the production of ketone bodies. Ketone bodies are a more efficient energy source than glucose and improve mitochondrial function and biogenesis. Cellular energy production depends on the metabolic coenzyme nicotinamide adenine dinucleotide (NAD), a marker for mitochondrial and cellular health. Furthermore, NAD activates downstream signaling pathways (such as the sirtuin enzymes) associated with major benefits such as longevity and reduced inflammation; thus, increasing NAD is a coveted therapeutic endpoint. Based on differential NAD+ utilization during glucose- vs. ketone body-based acetyl-CoA generation for entry into the tricarboxylic cycle, we propose that a KD will increase the NAD+/NADH ratio. When rats were fed ad libitum KD, significant increases in hippocampal NAD+/NADH ratio and blood ketone bodies were detected already at 2 days and remained elevated at 3 weeks, indicating an early and persistent metabolic shift. Based on diverse published literature and these initial data we suggest that increased NAD during ketolytic metabolism may be a primary mechanism behind the beneficial effects of this metabolic therapy in a variety of brain disorders and in promoting health and longevity.
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Affiliation(s)
- Marwa Elamin
- Neuroscience Program, Department of Biology, University of Hartford, West Hartford, CT, United States
| | - David N Ruskin
- Neuroscience Program and Psychology Department, Trinity College, Hartford, CT, United States
| | - Susan A Masino
- Neuroscience Program and Psychology Department, Trinity College, Hartford, CT, United States
| | - Paola Sacchetti
- Neuroscience Program, Department of Biology, University of Hartford, West Hartford, CT, United States
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9
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Witowski NE, Lusczek ER, Determan CE, Lexcen DR, Mulier KE, Wolf A, Ostrowski BG, Beilman GJ. Metabolomic analysis of survival in carbohydrate pre-fed pigs subjected to shock and polytrauma. MOLECULAR BIOSYSTEMS 2016; 12:1638-52. [PMID: 26989839 PMCID: PMC5577932 DOI: 10.1039/c5mb00637f] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Hemorrhagic shock, a result of extensive blood loss, is a dominant factor in battlefield morbidity and mortality. Early rodent studies in hemorrhagic shock reported carbohydrate feeding prior to the induction of hemorrhagic shock decreased mortality. When repeated in our laboratory with a porcine model, carbohydrate pre-feed resulted in a 60% increase in death rate following hemorrhagic shock with trauma when compared to fasted animals (15/32 or 47% vs. 9/32 or 28%). In an attempt to explain the unexpected death rate for pre-fed animals, we further investigated the metabolic profiles of pre-fed non-survivors (n = 15) across 4 compartments (liver, muscle, serum, and urine) at specific time intervals (pre-shock, shock, and resuscitation) and compared them to pre-fed survivors (n = 17). As hypothesized, pre-fed pigs that died as a result of hemorrhage and trauma showed differences in their metabolic and physiologic profiles at all time intervals and in all compartments when compared to pre-fed survivors. Our data suggest that, although all animals were subjected to the same shock and trauma protocol, non-survivors exhibited altered carbohydrate processing as early as the pre-shock sampling point. This was evident in (for example) the higher levels of ATP and markers of greater anabolic activity in the muscle at the pre-shock time point. Based on the metabolic findings, we propose two mechanisms that connect pre-fed status to a higher death rate: (1) animals that die are more susceptible to opening of the mitochondrial permeability transition pore, a major factor in ischemia/reperfusion injury; and (2) loss of fasting-associated survival mechanisms in pre-fed animals.
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Affiliation(s)
- Nancy E Witowski
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA.
| | | | | | - Daniel R Lexcen
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA.
| | - Kristine E Mulier
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA.
| | - Andrea Wolf
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA.
| | | | - Greg J Beilman
- Department of Surgery, University of Minnesota, Minneapolis, MN, USA.
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10
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Liu R, Wang SM, Liu XQ, Guo SJ, Wang HB, Hu S, Zhou FQ, Sheng ZY. Pyruvate alleviates lipid peroxidation and multiple-organ dysfunction in rats with hemorrhagic shock. Am J Emerg Med 2015; 34:525-30. [PMID: 26794285 DOI: 10.1016/j.ajem.2015.12.040] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 12/15/2015] [Accepted: 12/18/2015] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE Pyruvate can reduce lipid peroxidation, which plays a critical role in organ injury, in various models. However, it is not fully understood if this inhibition occurs in resuscitation of hemorrhagic shock (HS). This study examines effects of pyruvate Ringer solution (PR) in this respect in rats. METHODS Rats, subjected to 45% blood loss, were randomly allocated to the 3 groups (n = 18): HS with no fluid resuscitation (group NR), HS resuscitated with lactated Ringer solution (LR) (group LR), and HS resuscitated with PR (group PR). Mean arterial pressure, plasma levels of thiobarbituric acid reactive substances (TBARS), and superoxide dismutase were measured at various time points until 360 minutes after hemorrhage. Visceral organs were harvested at the end for evaluations of the TBARS, antioxidant enzyme, and tissue water content. Other 54 rats with identical procedures without sampling were documented for 24-hour survival rates (n = 18) after fluid resuscitation. RESULTS Pyruvate Ringer solution significantly increased mean arterial pressure and decreased blood TBARS levels after lethal HS. It also reduced TBARS concentrations and glutathione peroxidase activities but significantly enhanced glutathione reductase activities in most organs and greatly improved the ratios of reduced glutathione over oxidized glutathione in various organs in group PR, compared to group LR. Furthermore, PR significantly improved various organ function and water contents relative to LR. Group PR showed a more than 2-fold higher 24-hour survival rate of group LR. CONCLUSIONS Pyruvate Ringer solution alleviated organ edema and injury and prompted survival partially through inhibition of lipid peroxidation in various organs in severe HS rats.
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Affiliation(s)
- Rui Liu
- Department of Burn Surgery, Heilongjiang Provincial Hospital, Harbin 150036, China
| | - Shu-Ming Wang
- Department of Emergency Medicine, First Affiliated Hospital, Heilongjiang University of Chinese Medicine, Harbin 150040, China
| | - Xian-Qi Liu
- Laboratory for Shock and Multiple Organ Dysfunction, Key Research Laboratory of Tissue Repair and Regeneration of PLA, and Beijing Key Research Laboratory of Skin Injury and Repair Regeneration, the First Hospital Affiliated to the Chinese PLA General Hospital, Beijing 100048, China
| | - Si-Jia Guo
- Department of Human Resource, the First Hospital of Harbin, Harbin 150010, China
| | - Hai-Bin Wang
- Laboratory for Shock and Multiple Organ Dysfunction, Key Research Laboratory of Tissue Repair and Regeneration of PLA, and Beijing Key Research Laboratory of Skin Injury and Repair Regeneration, the First Hospital Affiliated to the Chinese PLA General Hospital, Beijing 100048, China
| | - Sen Hu
- Laboratory for Shock and Multiple Organ Dysfunction, Key Research Laboratory of Tissue Repair and Regeneration of PLA, and Beijing Key Research Laboratory of Skin Injury and Repair Regeneration, the First Hospital Affiliated to the Chinese PLA General Hospital, Beijing 100048, China.
| | - Fang-Qiang Zhou
- Shanghai Sandai Pharmarceutical R & D Co, Pudong, Shanghai 201203, China.
| | - Zhi-Yong Sheng
- Laboratory for Shock and Multiple Organ Dysfunction, Key Research Laboratory of Tissue Repair and Regeneration of PLA, and Beijing Key Research Laboratory of Skin Injury and Repair Regeneration, the First Hospital Affiliated to the Chinese PLA General Hospital, Beijing 100048, China
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11
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Bogren LK, Murphy CJ, Johnston EL, Sinha N, Serkova NJ, Drew KL. 1H-NMR metabolomic biomarkers of poor outcome after hemorrhagic shock are absent in hibernators. PLoS One 2014; 9:e107493. [PMID: 25211248 PMCID: PMC4161479 DOI: 10.1371/journal.pone.0107493] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Accepted: 08/12/2014] [Indexed: 11/20/2022] Open
Abstract
Background Hemorrhagic shock (HS) following trauma is a leading cause of death among persons under the age of 40. During HS the body undergoes systemic warm ischemia followed by reperfusion during medical intervention. Ischemia/reperfusion (I/R) results in a disruption of cellular metabolic processes that ultimately lead to tissue and organ dysfunction or failure. Resistance to I/R injury is a characteristic of hibernating mammals. The present study sought to identify circulating metabolites in the rat as biomarkers for metabolic alterations associated with poor outcome after HS. Arctic ground squirrels (AGS), a hibernating species that resists I/R injury independent of decreased body temperature (warm I/R), was used as a negative control. Methodology/principal findings Male Sprague-Dawley rats and AGS were subject to HS by withdrawing blood to a mean arterial pressure (MAP) of 35 mmHg and maintaining the low MAP for 20 min before reperfusing with Ringers. The animals’ temperature was maintained at 37±0.5°C for the duration of the experiment. Plasma samples were taken immediately before hemorrhage and three hours after reperfusion. Hydrophilic and lipid metabolites from plasma were then analyzed via 1H–NMR from unprocessed plasma and lipid extracts, respectively. Rats, susceptible to I/R injury, had a qualitative shift in their hydrophilic metabolic fingerprint including differential activation of glucose and anaerobic metabolism and had alterations in several metabolites during I/R indicative of metabolic adjustments and organ damage. In contrast, I/R injury resistant AGS, regardless of season or body temperature, maintained a stable metabolic homeostasis revealed by a qualitative 1H–NMR metabolic profile with few changes in quantified metabolites during HS-induced global I/R. Conclusions/significance An increase in circulating metabolites indicative of anaerobic metabolism and activation of glycolytic pathways is associated with poor prognosis after HS in rats. These same biomarkers are absent in AGS after HS with warm I/R.
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Affiliation(s)
- Lori K. Bogren
- Department of Chemistry and Biochemistry, University of Alaska Fairbanks, Fairbanks, AK, United States of America
- Institute of Arctic Biology, University of Alaska Fairbanks, Fairbanks, AK, United States of America
- * E-mail:
| | - Carl J. Murphy
- Department of Chemistry and Biochemistry, University of Alaska Fairbanks, Fairbanks, AK, United States of America
| | - Erin L. Johnston
- Department of Chemistry and Biochemistry, University of Alaska Fairbanks, Fairbanks, AK, United States of America
| | - Neeraj Sinha
- Centre of Biomedical Research, SGPGIMS Campus, Lucknow, Uttar Pradesh, India
| | - Natalie J. Serkova
- Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, CO, United States of America
- University of Colorado Cancer Center, University of Colorado Anschutz Medical Campus, Aurora, CO, United States of America
| | - Kelly L. Drew
- Department of Chemistry and Biochemistry, University of Alaska Fairbanks, Fairbanks, AK, United States of America
- Institute of Arctic Biology, University of Alaska Fairbanks, Fairbanks, AK, United States of America
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12
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Abstract
PURPOSE OF REVIEW This review explores the contemporary definition of the term 'balanced crystalloid' and outlines optimal design features and their underlying rationale. RECENT FINDINGS Crystalloid interstitial expansion is unavoidable, but also occurs with colloids when there is endothelial glycocalyx dysfunction. Reduced chloride exposure may lessen kidney dysfunction and injury with a possible mortality benefit. Exact balance from an acid-base perspective is achieved with a crystalloid strong ion difference of 24 mEq/l. This can be done simply by replacing 24 mEq/l of chloride in 0.9% sodium chloride with bicarbonate or organic anion bicarbonate substitutes. Potassium, calcium and magnesium additives are probably unnecessary. Large volumes of mildly hypotonic crystalloids such as lactated Ringer's solution reduce extracellular tonicity in volunteers and increase intracranial pressure in nonbrain-injured experimental animals. A total cation concentration of 154 mmol/l with accompanying anions provides isotonicity. Of the commercial crystalloids, Ringer's acetate solution is close to balanced from both acid-base and tonicity perspectives, and there is little current evidence of acetate toxicity in the context of volume loading, in contrast to renal replacement. SUMMARY The case for balanced crystalloids is growing but unproven. A large randomized controlled trial of balanced crystalloids versus 0.9% sodium chloride is the next step.
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13
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Newman JC, Verdin E. Ketone bodies as signaling metabolites. Trends Endocrinol Metab 2014; 25:42-52. [PMID: 24140022 PMCID: PMC4176946 DOI: 10.1016/j.tem.2013.09.002] [Citation(s) in RCA: 623] [Impact Index Per Article: 62.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Revised: 09/14/2013] [Accepted: 09/17/2013] [Indexed: 12/13/2022]
Abstract
Traditionally, the ketone body β-hydroxybutyrate (βOHB) has been looked upon as a carrier of energy from liver to peripheral tissues during fasting or exercise. However, βOHB also signals via extracellular receptors and acts as an endogenous inhibitor of histone deacetylases (HDACs). These recent findings support a model in which βOHB functions to link the environment, in this case the diet, and gene expression via chromatin modifications. We review the regulation and functions of ketone bodies, the relationship between ketone bodies and calorie restriction, and the implications of HDAC inhibition by the ketone body βOHB in the modulation of metabolism and in diseases of aging.
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Affiliation(s)
- John C Newman
- Gladstone Institutes and University of California San Francisco, 1650 Owens Street, San Francisco, CA 94158, USA
| | - Eric Verdin
- Gladstone Institutes and University of California San Francisco, 1650 Owens Street, San Francisco, CA 94158, USA.
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14
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Hu S, Bai XD, Liu XQ, Wang HB, Zhong YX, Fang T, Zhou FQ. Pyruvate Ringer's Solution Corrects Lactic Acidosis and Prolongs Survival during Hemorrhagic Shock in Rats. J Emerg Med 2013; 45:885-93. [DOI: 10.1016/j.jemermed.2013.04.062] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Revised: 12/12/2012] [Accepted: 04/30/2013] [Indexed: 10/26/2022]
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15
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Adverse effects of resuscitation with lactated ringer compared with ringer solution after severe hemorrhagic shock in rats. Shock 2012; 38:137-45. [PMID: 22683725 DOI: 10.1097/shk.0b013e31825b4ed9] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Lactated Ringer (LR) is a widely used resuscitation fluid that is known to mediate beneficial effects on acid-base balance when compared with normal saline. We here compared LR with the more physiological Ringer solution (RS) regarding acid-base status, hemodynamics, survival, and organ injury following fluid resuscitation subsequent to severe hemorrhagic shock. Anesthetized rats were hemorrhaged to a mean arterial blood pressure of 25 to 30 mmHg within 30 min. After 60 min, they were resuscitated with either RS or LR (three times the shed blood volume) or with RS or LR plus blood (shed blood plus twice its volume) within 30 min. Subsequently, the animals were observed for further 150 min. When the rats were resuscitated with pure LR or RS, all animals of the shock/LR group, but only three of eight shock/RS group rats were dead 100 min later (median survival, 50 ± 13.1 vs. 120 ± 14.1 min; P < 0.05). Coadministration of the shed blood with RS or LR increased the survival rates to 100%. In these blood-resuscitated groups, organ injury, especially of the kidney, was diminished by the use of RS compared with LR. Time-matched acid-base parameters were not different in all shock groups until death of the animals or euthanasia at the end of experimental time. We conclude that, in severe hemorrhagic shock, resuscitation with RS leads to an improved outcome compared with resuscitation with LR, regardless whether blood is coadministered or not.
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Szot P. Common factors among Alzheimer's disease, Parkinson's disease, and epilepsy: possible role of the noradrenergic nervous system. Epilepsia 2012; 53 Suppl 1:61-6. [PMID: 22612810 DOI: 10.1111/j.1528-1167.2012.03476.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The neurodegenerative disorders Alzheimer's disease (AD) and Parkinson's disease (PD) share in common the neuropathologic loss of locus coeruleus (LC) noradrenergic neurons. In addition, these two neurodegenerative disorders share two symptoms that define these disorders: cognitive impairment and depression. The hippocampus is a region that is known to play a role in cognition and depression, and the hippocampus receives sole noradrenergic innervation from LC neurons. However, it is unclear how the loss of LC noradrenergic neurons contributes to these common symptoms in these two disorders. Epilepsy is not considered a neurodegenerative disorder, but the hippocampus is severely affected in temporal lobe epilepsy. Of interest, cognitive impairment and depression are also common comorbid disorders in temporal lobe epilepsy. This article describes common symptoms among these three neurologic disorders and a possible role of the noradrenergic nervous system.
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Affiliation(s)
- Patricia Szot
- Northwest Network for Mental Illness Research, Education, and Clinical Center, Veterans Administration Puget Sound Health Care System, 1660 S Columbian Way,Seattle, WA 98108, U.S.A
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Klemcke HG, Joe B, Rose R, Ryan KL. Life or death? A physiogenomic approach to understand individual variation in responses to hemorrhagic shock. Curr Genomics 2011; 12:428-42. [PMID: 22379396 PMCID: PMC3178911 DOI: 10.2174/138920211797248574] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2011] [Revised: 06/29/2011] [Accepted: 07/06/2011] [Indexed: 11/22/2022] Open
Abstract
Severe hemorrhage due to trauma is a major cause of death throughout the world. It has often been observed that some victims are able to withstand hemorrhage better than others. For decades investigators have attempted to identify physiological mechanisms that distinguish survivors from nonsurvivors for the purpose of providing more informed therapies. As an alternative approach to address this issue, we have initiated a research program to identify genes and genetic mechanisms that contribute to this phenotype of survival time after controlled hemorrhage. From physiogenomic studies using inbred rat strains, we have demonstrated that this phenotype is a heritable quantitative trait, and is therefore a complex trait regulated by multiple genes. Our work continues to identify quantitative trait loci as well as potential epigenetic mechanisms that might influence survival time after severe hemorrhage. Our ultimate goal is to improve survival to traumatic hemorrhage and attendant shock via regulation of genetic mechanisms and to provide knowledge that will lead to genetically-informed personalized treatments.
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Affiliation(s)
- Harold G Klemcke
- U.S. Army Institute of Surgical Research, Fort Sam Houston, TX 78234, USA
| | - Bina Joe
- Physiological Genomics Laboratory, Department of Physiology and Pharmacology, University of Toledo College of Medicine, Toledo, OH 43614, USA
| | - Rajiv Rose
- U.S. Army Institute of Surgical Research, Fort Sam Houston, TX 78234, USA
| | - Kathy L Ryan
- U.S. Army Institute of Surgical Research, Fort Sam Houston, TX 78234, USA
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Small-volume d-β-hydroxybutyrate solution infusion increases survivability of lethal hemorrhagic shock in rats. Shock 2011; 34:565-72. [PMID: 20386494 DOI: 10.1097/shk.0b013e3181e15063] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
A small-volume therapeutic approach based on the biochemistry of hibernating mammals was evaluated to test the hypothesis that passive hypothermia and systemic administration of d-β-hydroxybutyrate (d-BHB) plus melatonin will increase survival of animals subjected to hemorrhagic shock ([HS] 60% blood loss). Anesthetized Sprague-Dawley male rats (320 ± 23 g) underwent controlled loss of 60% blood volume. Rats were instrumented to measure mean arterial pressure, body temperature (Tb), and heart rate. A passive decrease in rat Tb in response to HS significantly increased survival over animals maintained at 37°C (n = 5-6). Infusion of 4 M d-BHB, at a volume of only 5.5% of the total blood removed, significantly prolonged survival to a mean of 3 h compared with 90 min using equal osmolar 4 M NaCl (n = 6). In experiments where the shed blood was returned after 1 h of 60% blood loss, 4% fluid replacement with 4 M d-BHB plus 43 mM melatonin significantly prolonged survival up to 10 days after blood return compared with 4 M NaCl plus 43 mM melatonin and other control solutions (n = 10). We conclude that a slow decrease in animal Tb resulting from 60% blood loss, combined with infusion of 4 M d-BHB plus 43 mM melatonin, was beneficial for long-term survival after return of shed blood. This HS therapy is designed as a portable low-volume solution for further evaluation in a large-animal model and is ultimately intended for use in HS patients by first responders.
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First report on safety and efficacy of hetastarch solution for initial fluid resuscitation at a level 1 trauma center. J Am Coll Surg 2010; 210:870-80, 880-2. [PMID: 20421069 DOI: 10.1016/j.jamcollsurg.2010.01.010] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2009] [Accepted: 01/05/2010] [Indexed: 01/26/2023]
Abstract
BACKGROUND For logistics, the US Army recommends Hextend (Hospira; 6% hetastarch in buffered electrolyte, HET) for battlefield resuscitation. To support this practice, there are laboratory data, but none in humans. To test the hypothesis that HET is safe and effective in trauma, we reviewed our first 6 months of use at a civilian level 1 trauma center. STUDY DESIGN From June 2008 to December 2008, trauma patients received standard of care (SOC) +/- 500 to 1,000 mL of HET within 2 hours of admission at surgeon discretion. Each case was reviewed, with waiver of consent. RESULTS There were 1,714 admissions; 805 received HET and 909 did not. With HET versus SOC, overall mortality was 5.2% versus 8.9% (p = 0.0035) by univariate analysis. Results were similar after penetrating injury only (p = 0.0016) and in those with severe injury, defined by Glasgow Coma Scale <9 (p = 0.0013) or Injury Severity Score >26 (p = 0.0142). After HET, more patients required ICU admission (40.9% vs. 34.5%; p = 0.0334) and transfusions of blood (34.4% vs. 20.2%; p = 0.0014) or plasma (20.7% vs. 12.2%; p = 0.0251), but there were no treatment-related differences in prothrombin time or partial thromboplastin time. The 24-hour urine outputs and requirements for blood, plasma, and other fluids were similar. However, increased early deaths with SOC implicate possible selection bias. If that factor was controlled for with multivariate analysis, the same trends were present, but the apparent treatment effects of HET were no longer statistically significant. CONCLUSIONS In the first trial to date in hemodynamically unstable trauma patients, and the largest trial to date in any population of surgical patients, initial resuscitation with HET was associated with reduced mortality and no obvious coagulopathy. A randomized blinded trial is necessary before these results can be accepted with confidence.
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Abstract
Exsanguinating hemorrhage is a common clinical feature of multisystem trauma that results in death or severe disability. Cardiovascular collapse resulting from hemorrhage is unresponsive to conventional methods of cardiopulmonary resuscitation. Even when bleeding is controlled rapidly, adequate circulation cannot be restored in time to avoid neurologic consequences that appear after only 5 mins of cerebral ischemia and hypoperfusion. Reperfusion adds further insult to injury. A novel solution to this problem would be to institute a therapy that makes cells and organs more resistant to ischemic injury, thereby extending the time they can tolerate such an insult. Hypothermia can attenuate some effects of ischemia and reperfusion. Accumulating preclinical data demonstrate that hypothermia can be induced safely and rapidly to achieve emergency preservation for resuscitation during lethal hemorrhage. Hypothermia may be an effective therapeutic approach for otherwise lethal traumatic hemorrhage, and a clinical trial to determine its utility is warranted.
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Valeri CR, Ragno G, Veech RL. Effects of the Resuscitation Fluid and the Hemoglobin Based Oxygen Carrier (HBOC) Excipient on the Toxicity of the HBOC: Ringer'sD,L-Lactate, Ringer'sL-Lactate, and Ringer's Ketone Solutions. ACTA ACUST UNITED AC 2009; 34:601-6. [PMID: 17090432 DOI: 10.1080/10731190600974087] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Hemoglobin based oxygen carriers (HBOC) are resuspended in "excipients" consisting of Ringer's D,L-lactate containing antioxidants to prevent methemoglobin formation during storage. Investigators have reported cardiac arrhythmias following infusion of Ringer's D,L-lactate solution. Studies have shown that D-lactate stimulates human granulocytes to generate oxygen free radicals and L-lactate inhibits glycolysis. Patients receiving HBOC in Ringer's D,L-lactate excipient are also resuscitated or hemodiluted with Ringer's lactate solution. Oxygen-free radicals generated by Ringer's D,L-lactate and HBOC may oxidize nitric oxide in endothelial cells, causing the vasoconstrictor effects reported following HBOC infusion, and activate NF-kappab and the apoptotic cascade. The combination of Ringer's D,L-lactate and HBOC in Ringer's D,L-lactate excipient may be responsible for the severe adverse events observed in clinical studies of HBOC.Veech has recommended replacing the 27 mM of lactate in Ringer's with 27 mM D-betahydroxybutyrate (BHB). BHB reduces the generation of oxygen free radicals by mitochondria and human granulocytes.
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Affiliation(s)
- C Robert Valeri
- Naval Blood Research Laboratory, 195 Bournehurst Drive, Plymouth, MA 02360, USA.
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Cheng B, Yang X, An L, Gao B, Liu X, Liu S. Ketogenic diet protects dopaminergic neurons against 6-OHDA neurotoxicity via up-regulating glutathione in a rat model of Parkinson's disease. Brain Res 2009; 1286:25-31. [PMID: 19559687 DOI: 10.1016/j.brainres.2009.06.060] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2009] [Revised: 06/09/2009] [Accepted: 06/17/2009] [Indexed: 11/30/2022]
Abstract
The high-fat ketogenic diet (KD) leads to an increase of blood ketone bodies (KB) level and has been used to treat refractory childhood seizures for over 80 years. Recent reports show that KD, KB and their components (d-beta-hydroxybutyrate, acetoacetate and acetone) have neuroprotective for acute and chronic neurological disorders. In our present work, we examined whether KD protected dopaminergic neurons of substantia nigra (SN) against 6-hydroxydopamine (6-OHDA) neurotoxicity in a rat model of Parkinson's disease (PD) using Nissl staining and tyrosine hydroxylase (TH) immunohistochemistry. At the same time we measured dopamine (DA) and its metabolites dihydroxyphenylacetic acid (DOPAC) and homovanillic acid (HVA) in the striatum. To elucidate the mechanism, we also measured the level of glutathione (GSH) of striatum. Our data showed that Nissl and TH-positive neurons increased in rats fed with KD compared to rats with normal diet (ND) after intrastriatal 6-OHDA injection, so did DA and its metabolite DOPAC. While HVA had not changed significantly. The change of GSH was significantly similar to DA. We concluded that KD had neuroprotective against 6-OHDA neurotoxicity and in this period GSH played an important role.
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Abstract
Abstract This is a review paper that provides an overview of current information on programmed cell death in haemorrhagic shock, including the identification of different molecular receptor signals. A PubMed search for all dates was undertaken using the search terms apoptosis, trauma and haemorrhagic shock. Original research, sentinel and review papers from peer-reviewed journals were included for identification of key concepts. Haemorrhagic shock remains a primary cause of death in civilian and military trauma. Apoptosis is accelerated following haemorrhagic shock. Many methods are used to detect and quantify apoptosis. Fluid resuscitation regimens vary in their effect on the extent of apoptosis. Investigators are examining the effects of haemorrhagic shock and fluid resuscitation on apoptotic signalling pathways. Molecular information is becoming available and being applied to the care of patients experiencing haemorrhagic shock, making it essential for nurses and other health care providers to consider the mechanisms and consequences of apoptosis.
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Affiliation(s)
- William J Mach
- School of Nursing, University of Kansas, Kansas City, Kansas, USA
| | - Amanda R Knight
- School of Nursing, University of Kansas, Kansas City, Kansas, USA
| | - James A Orr
- Department of Molecular Biosciences, University of Kansas, Lawrence, Kansas, USA
| | - Janet D Pierce
- School of Nursing, University of Kansas, Kansas City, Kansas, USA
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Severe adverse events associated with hemoglobin based oxygen carriers: Role of resuscitative fluids and liquid preserved RBC. Transfus Apher Sci 2008; 39:205-11. [DOI: 10.1016/j.transci.2008.09.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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The influence of the type of resuscitation fluid on gut injury and distant organ injury in a rat model of trauma/hemorrhagic shock. ACTA ACUST UNITED AC 2008; 65:409-14; discussion 414-5. [PMID: 18695480 DOI: 10.1097/ta.0b013e3181719708] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Recognition that resuscitation with Ringers lactate (RL) potentiates trauma-hemorrhagic shock (T/HS)-induced organ injury and systemic inflammation has led to a search for improved initial fluid resuscitation regimens. However, one relatively neglected component in the search for new and novel resuscitation strategies is a determination of what fluid resuscitation therapy (i.e., control group) the new experimental regimen of interest should be tested against. Thus, we tested the effects of three commonly used resuscitation strategies on trauma-shock-induced gut and lung injury, as well as neutrophil activation and red blood cell (RBC) function. METHODS Male Sprague Dawley rats were subjected to a laparotomy (trauma) and 90 minutes of sham shock (trauma-sham shock [T/SS]) or a laparotomy plus hemorrhagic shock (T/HS), followed by a reperfusion period of 3 hours. The T/HS groups were resuscitated either with their shed blood (SB), or half the SB and 1.5 times the SB volume as RL (SB/RL), or 3 times the SB volume as RL (3RL). The T/SS groups received either no resuscitation or RL at 1.5 times the SB volume of the T/HS rats. Gut injury was quantified by measuring intestinal permeability to flourescein dextran (FD-4), as well as by histologic analysis of the terminal ileum. Lung injury was assessed histologically and by the magnitude of neutrophil sequestration as reflected in myeloperoxidase levels. Neutrophil activation was measured by quantitating the level of CD11b expression using flow cytometry. RBC injury was analyzed by measuring the RBC deformability. RESULTS As compared with the T/SS groups, all three T/HS resuscitation regimens were associated with morphologic evidence of gut and lung injury, increased gut permeability, pulmonary leukosequestration, systemic neutrophil activation, and decreased RBC deformability (p < 0.05). However, the effect of the resuscitation regimens varied based on the tissues and cells tested. Morphologically, gut and lung injury as well as pulmonary neutrophil sequestration was worse in the 3RL T/HS group than the other two T/HS groups. As compared with the other two T/HS resuscitation regimens, resuscitation with the SB/RL combination was associated with less of an increase in gut permeability, systemic neutrophil activation, and RBC rigidification (p < 0.05). CONCLUSIONS The type of resuscitation regimen used influenced the extent of organ injury and cellular activation or dysfunction observed after T/HS with different resuscitation regimens showing varying effects depending on the cell or organ tested. Thus, when testing novel fluid resuscitation regimen, attention must be paid to the control resuscitation regimen used.
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Innate Immune Response After Resuscitation With Hemoglobin-Based Oxygen Carrier and Recombinant Factor VIIA in Uncontrolled Hemorrhagic Shock in a Swine Model. ACTA ACUST UNITED AC 2008; 64:1498-510. [DOI: 10.1097/ta.0b013e3181454a05] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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do Nascimento P, Vaid SU, Hoskins SL, Espana JM, Kinsky MP, Kramer GC. Hypertonic 15% sodium pyruvate offers no initial resuscitation advantage compared with 8% hypertonic NACl in sheep with multiple hemorrhages. Shock 2007; 27:565-71. [PMID: 17438463 DOI: 10.1097/01.shk.0000245015.96419.73] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Initial fluid resuscitation of hemorrhagic shock might be enhanced by the infusion of monocarboxylate-energy substrates. We evaluated hemodynamics, metabolism, and fluid dynamics for initial resuscitation of hemorrhage using small volume 15% sodium pyruvate solution (HPY) compared with osmotically matched 8% hypertonic saline (HS). Instrumented conscious sheep were hemorrhaged 25 mL/kg at time zero through 15 min (T0-T15) and 5 mL/kg for 5 min at T50 to T55 and T70 to T75. Fluid resuscitation from T30 to T180 was performed by a computer-controlled closed-loop system, which titrated infusion rate to a mean arterial pressure of 90 mmHg. Initial infusion was 4 mL/kg of either HPY or HS, followed by the administration of lactated Ringer. Both HPY and HS restored cardiac index similarly. The lactate/pyruvate ratio was used to assess metabolic debt and was significantly higher (T180), whereas oxygen delivery was significantly lower (T120) with HPY versus HS. Total fluid administered was similar, with 43.7 +/- 6.2 mL/kg for HPY and 39.4 +/- 6.8 mL/kg for HS. Plasma volume was similarly increased and approached baseline values for both groups. Initial resuscitation with small volume HPY offered no hemodynamic or metabolic advantage compared with small volume HS when the fluids were infused to an end point pressure.
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Affiliation(s)
- Paulo do Nascimento
- Resuscitation Research Laboratory, Department of Anesthesiology, University of Texas Medical Branch, Galveston, Texas 77555-0801, USA
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Alam HB, Shults C, Ahuja N, Ayuste EC, Chen H, Koustova E, Sailhamer EA, Li Y, Liu B, de Moya M, Velmahos GC. Impact of resuscitation strategies on the acetylation status of cardiac histones in a swine model of hemorrhage. Resuscitation 2007; 76:299-310. [PMID: 17822827 DOI: 10.1016/j.resuscitation.2007.07.030] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2007] [Revised: 07/16/2007] [Accepted: 07/23/2007] [Indexed: 01/19/2023]
Abstract
BACKGROUND Chromatin remodeling through histone acetylation is a key control mechanism in gene transcription. We have shown previously that fluid resuscitation in rodents is coupled with highly structured post-translational modifications of cardiac histones. The current experiment was performed to validate this concept in a clinically relevant large animal model of hemorrhage and resuscitation, and to correlate the changes in histone acetylation with altered expression of immediate-early response genes. STUDY DESIGN Yorkshire swine (n=49, 7/group, weight=40-58kg) were subjected to combined uncontrolled and controlled hemorrhage (40% of estimated blood volume) and randomly assigned to the following resuscitation groups: (1) 0.9% saline (NS), (2) racemic lactated Ringer's (dl-LR), (3) l-isomer lactated Ringer's (l-LR), (4) Ketone Ringer's (KR), (5) 6% hetastarch in saline (Hespan). KR contained an equimolar substitution of lactate with beta-hydroxybutyrate. No hemorrhage (NH) and no resuscitation (NR) groups were included as controls. Cardiac protein was used in Western blotting to analyze total protein acetylation and histone acetylation specifically. Lysine residue-specific acetylation of histone subunits H3 and H4 was further evaluated. In addition, Chromatin Immunoprecipitation (ChIP) technique was used to separate the DNA bound to acetylated histones (H3 and H4 subunits), followed by measurement of genes that are altered by hemorrhage/resuscitation, including immediate-early response genes (c-fos and c-myc), and heat shock protein (HSP) 70. RESULTS The type of fluid used for resuscitation influenced the patterns of cardiac histone acetylation. Resuscitation with dl-LR and KR induced hyperacetylation on H3K9. KR resuscitation was also associated with increased acetylation on H3K14 and H4K5, and hypoacetylation on H3K18. The expression of genes was also fluid specific, with the largest number of changes following KR resuscitation (increased c-fos and c-myc, HSP 70 linked with H3; and increased c-myc linked with H4). Among the histone subunits studied, altered H3 acetylations were associated with the majority of changes in immediate-early gene expression. CONCLUSIONS Acetylation status of cardiac histones, affected by hemorrhage, is further modulated by resuscitation producing a fluid-specific code that is preserved in different species. Resuscitation with KR causes histone acetylation at the largest number of lysine sites (predominately H3 subunit), and has the most pronounced impact on the transcriptional regulation of selected (immediate-early response) genes.
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Affiliation(s)
- Hasan B Alam
- Trauma Research and Readiness Institute for Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, United States.
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Lin T, Chen H, Koustova E, Sailhamer EA, Li Y, Shults C, Liu B, Rhee P, Kirkpatrick J, Alam HB. Histone deacetylase as therapeutic target in a rodent model of hemorrhagic shock: effect of different resuscitation strategies on lung and liver. Surgery 2007; 141:784-94. [PMID: 17560255 DOI: 10.1016/j.surg.2007.01.014] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2006] [Revised: 01/10/2007] [Accepted: 01/12/2007] [Indexed: 11/22/2022]
Abstract
BACKGROUND DNA transcription is regulated in part by acetylation of nuclear histones, controlled by 2 groups of enzymes: histone deacetylases (HDAC) and histone acetyl transferases (HAT). We have shown previously that hemorrhage and resuscitation are associated with HDAC/HAT imbalance, which influences the acetylation status of cardiac histones. The goals of this study were to determine whether: (1) resuscitation after hemorrhage affects histone acetylation in a fluid- and organ-specific fashion; and (2) administration of HDAC inhibitors influences histone acetylation and subsequent gene expression. METHODS In the first experiment, rats (n = 6/group) were subjected to volume-controlled hemorrhage and resuscitated with: (1) racemic lactated Ringer's (DL-LR); (2) L-lactated Ringer's (L-LR); (3) 7.5% hypertonic saline (HTS); (4) ketone Ringer's (KR); or (5) pyruvate Ringer's (PR). Control groups included: (6) no hemorrhage (Sham); and (7) hemorrhage with no resuscitation (NR). In the second experiment (n = 5/group), 3 HDAC inhibitors, valproic acid (VPA), trichostatin A (TSA), and suberoylanilide hydroxamic acid (SAHA), were added to normal saline and used as fluid for resuscitation. At the end of resuscitation, lung and liver tissues were subjected to subcellular protein fractionation and Western blotting to analyze histone acetylation. In addition, cDNA microarrays and RT-PCR were used to measure expression of selected genes. RESULTS Hemorrhage did not change the level of histone acetylation in lungs, whereas resuscitation predominantly hyperacetylated histones. An analysis of histone acetylation on 10 lysine sites showed that L-LR, HTS, and KR resuscitation caused the largest number of changes (7, 6, and 6 respectively). SAHA hyperacetylated 7 sites in liver and affected expression of 57 genes (44 up, 13 down). CONCLUSIONS Resuscitation with various fluids, as well as infusion of pharmacologic HDAC inhibitors affects histone acetylation in a fluid- and organ-specific fashion, even when administered post-insult for a limited period of time. Uniquely affected genes are associated with metabolism, cellular growth, proliferation, differentiation, transformation, and cellular signaling.
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Affiliation(s)
- Tom Lin
- Department of Surgery, Washington Hospital Center, Washington, DC, USA
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Chen H, Koustova E, Shults C, Sailhamer EA, Alam HB. Differential effect of resuscitation on Toll-like receptors in a model of hemorrhagic shock without a septic challenge. Resuscitation 2007; 74:526-37. [PMID: 17386967 DOI: 10.1016/j.resuscitation.2007.01.031] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2006] [Revised: 01/08/2007] [Accepted: 01/17/2007] [Indexed: 11/19/2022]
Abstract
UNLABELLED It has been shown that the inflammatory response and cellular damage after hemorrhagic shock are influenced by resuscitation strategies. Toll-like receptors (TLRs) play an important role in signal transduction in inflammatory conditions. However, alterations in TLR expression following hemorrhagic shock and resuscitation have not been well documented. This study was conducted to measure the impact of different resuscitation strategies on TLR expression and downstream signaling in key organs. METHODS Sprague Dawley rats (n=38) were subjected to a severe volume-controlled hemorrhage protocol. After 75 min of shock, they were resuscitated over 45 min as follows: (1) lactated Ringer's (LR, 81 ml/kg), (2) ketone Ringer's (KR, 81 ml/kg), (3) 7.5% hypertonic saline (HTS, 9.7 ml/kg), (4) 6% hetastarch (HEX, 27 ml/kg), (5) pyruvate Ringer's (PR, 81 ml/kg). Sham hemorrhage (NH) and no resuscitation (NR) groups served as controls. The KR and PR solutions were identical to LR except for equimolar substitution of racemic lactate with beta hydroxybutyrate and sodium pyruvate, respectively. At the end of resuscitation, the expression of TLRs (types 1-10), and cytokines (IL-10, IL-1beta and TNF-alpha) were measured in the lung and spleen using RT-PCR. Levels of phosphorylated and total IkB-alpha and NF-kappaB were detected by Western blotting. The systemic and lung protein levels of TNF-alpha were measured using ELISA and immunohistochemistry. RESULTS Expression of TLRs in the lung was affected more than in the spleen by hemorrhagic shock and resuscitation. In the lung, hemorrhage increased TLR-2, -3 and -6 (but not TLR-4) mRNA expression, with an up-regulation of the ratio of phosphor-NF-kappaBp65 and total NF-kappaBp65, NF-kappaBp65 activation, and enhanced systemic and tissue TNF-alpha protein levels. Post-resuscitation, TLR mRNA profile and subsequent downstream proteins in the lung and spleen were affected by the choice of resuscitation strategy. CONCLUSIONS Hemorrhagic shock activates TLR signaling in lung, but not the spleen, probably through an up-regulation of TLR gene expression, and activation of NF-kappaB pathway. Resuscitation modulates this response in a fluid- and tissue-specific fashion.
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Affiliation(s)
- Huazhen Chen
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
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Abstract
Hemorrhagic shock is the leading cause of death in civilian and military trauma. Effective hemorrhage control and optimal resuscitation are the main goals in the management of severely injured patients. This article addresses the changing trends in fluid resuscitation in regards to who, when, and how. Much of these changing trends are caused by the recognition that the current method of resuscitation with crystalloid fluids may not be optimal and may even have detrimental consequences. This article summarizes a number of studies that have evaluated the cellular toxicities of commonly used resuscitation fluids, to highlight the need for the development of new fluids.
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Affiliation(s)
- Hasan B Alam
- Department of Surgery, Massachusetts General Hospital, 55 Fruit Street, WHT 1, Boston, MA 02114, USA
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Abstract
Shock resulting from life-threatening blood loss (hemorrhage) remains a common complication of traumatic injury. Intensive experimental efforts are needed if we are to understand the pathological effect(s) of hemorrhagic shock, alone or in association with traumatic tissue injury, and to reverse this deleterious process in trauma patients. Here, we overview selected studies that are representative of the different hemorrhagic shock models, considering their advantages and disadvantages from a scientific and clinical perspective. Fixed-pressure versus fixed-volume versus uncontrolled hemorrhage models, with or without tissue injury, will be discussed, as well as small versus large animal models. Most of these models are nonlethal in nature, and allow the researcher to understand the changes that contribute to increased susceptibility to subsequent infection or the development of multiple organ failure. We also consider some of the confounders in these models, including anesthesia, the nature of resuscitation, and the use of anticoagulants. The selection of model must take into consideration not only the need for experimental control but must also adequately reflect the clinical pathobiology of shock if we are to develop better pharmacological interventions.
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Affiliation(s)
- J L Lomas-Niera
- Division of Surgical Research/Department of Surgery, Rhode Island Hospital and Brown University School of Medicine, Providence, RI 02903, USA
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Abstract
Hemorrhagic shock is the leading cause of death in civilian and military trauma. Effective hemorrhage control and better resuscitation strategies have the potential of saving lives. However, if not performed properly, resuscitation can actually exacerbate cellular injury caused by hemorrhagic shock, and the type of fluid used for resuscitation plays an important role in this injury pattern. It is logical to prevent this cellular injury through wiser resuscitation strategies than attempting immunomodulation after the damage has already occurred. It is important to recognize that unlike numerous other variables, resuscitation is completely under our control. We decide who, when and how should get resuscitated. This paper summarizes data from a number of studies to illustrate the differential effects of commonly used resuscitation fluids on cellular injury, and how these relate to clinical practice. In addition, some novel resuscitation strategies are described that may become clinically available in the near future.
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Affiliation(s)
- H B Alam
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston, MA 02114, USA.
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Lin T, Alam HB, Chen H, Britten-Webb J, Rhee P, Kirkpatrick J, Koustova E. Cardiac histones are substrates of histone deacetylase activity in hemorrhagic shock and resuscitation. Surgery 2006; 139:365-76. [PMID: 16546502 DOI: 10.1016/j.surg.2005.08.022] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2005] [Revised: 08/11/2005] [Accepted: 08/18/2005] [Indexed: 01/12/2023]
Abstract
BACKGROUND DNA transcription is regulated, in part, by acetylation of nuclear histones that are controlled by 2 groups of enzymes: histone deacetylases (HDAC) and histone acetyl transferases (HAT). Whether an imbalance in HDAC/HAT system plays a role in hemorrhage/resuscitation is unknown. The goals of this study were to determine whether hemorrhage results in deacetylation of cardiac histones and whether this can be corrected through the application of different resuscitation strategies or specific HDAC inhibitors. METHODS In the first experiment, rats (n = 6 per group) were subjected to volume-controlled hemorrhage and resuscitated with racemic lactated Ringer's solution, L-lactated Ringer's solution, 7.5% hypertonic saline solution, ketone Ringer's solution, and pyruvate Ringer's solution. Control groups included no hemorrhage (sham) and hemorrhage with no resuscitation. In the second experiment (n = 5 per group), 3 HDAC inhibitors (valproic acid, trichostatin A, and suberoylanilide hydroxamic acid) were added to saline solution resuscitation. Heart tissue was collected at the end of resuscitation. Isolated subcellular protein fractions were used in Western blotting to analyze the patterns of total protein acetylation and histone acetylation specifically. HDAC and HAT activity was measured in tissue extracts. RESULTS Hemorrhage led to partial histone deacetylation. Resuscitation resulted in protein hyperacetylation in nuclear fractions only. A detailed analysis of histones (on 10 acetylation sites) revealed that ketone Ringer's solution hyperacetylated histones H2B, H3, and H4. The addition of suberoylanilide hydroxamic acid hyperacetylated histones more effectively than other resuscitation strategies, presumably by direct inhibition of HDAC activity. CONCLUSION Hemorrhage/resuscitation is associated with HDAC/HAT activity misbalance, and the acetylation status of cardiac histones is influenced by the choice of resuscitation strategy. Shock-induced changes can be reversed through the infusion of pharmacologic HDAC inhibitor, even when it is administered after the insult for a limited period of time.
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Affiliation(s)
- Tom Lin
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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Ayuste EC, Chen H, Koustova E, Rhee P, Ahuja N, Chen Z, Valeri CR, Spaniolas K, Mehrani T, Alam HB. Hepatic and Pulmonary Apoptosis After Hemorrhagic Shock in Swine Can Be Reduced Through Modifications of Conventional Ringer???s Solution. ACTA ACUST UNITED AC 2006; 60:52-63. [PMID: 16456436 DOI: 10.1097/01.ta.0000200156.05397.0b] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Cytotoxic properties of racemic (D-,L-isomers) lactated Ringer's solution detected in vitro and in small animal experiments, have not been confirmed in large animal models. Our hypothesis was that in a clinically relevant large animal model of hemorrhage, resuscitation with racemic lactated Ringer's solution would induce cellular apoptosis, which can be attenuated by elimination of d-lactate. METHODS Yorkshire swine (n = 49, weight 40-58 kg) were subjected to uncontrolled (iliac arterial and venous injuries) and controlled hemorrhage, totaling 40% of estimated blood volume. They were randomized (n = 7/group) to control groups, which consisted of (1) no hemorrhage (NH), (2) no resuscitation (NR), or resuscitation groups, which consisted of (3) 0.9% saline (NS), (4) racemic lactated Ringer's (DL-LR), (5) L-isomer lactated Ringer's (L-LR), (6) Ketone Ringer's (KR), (7) 6% hetastarch in 0.9% saline (Hespan). KR was identical to LR except for equimolar substitution of lactate with beta-hydroxybutyrate. Resuscitation was performed in three phases, simulating (1) prehospital, (2) operative, (3) postoperative/recovery periods. Arterial blood gasses, circulating cytokines (TNF-alpha, IL-1, -6, -10), and markers of organ injury were serially measured. Metabolic activity of brain, and liver, was measured with microdialysis. Four hours postinjury, organs were harvested for Western blotting, ELISA, TUNEL assay, and immunohistochemistry. RESULTS All resuscitation strategies restored blood pressure, but clearance of lactic acidosis was impeded following DL-LR resuscitation. Metabolic activity decreased during shock and improved with resuscitation, without any significant inter-group differences. Levels of cytokines in circulation were similar, but tissue levels of TNF in liver and lung increased six- and threefolds (p < 0.05) in NR group. In liver, all resuscitation strategies significantly decreased TNF levels compared with the NR group, but in the lung resuscitation with lactated Ringer (DL and L isomers) failed to decrease tissue TNF levels. DL-LR resuscitation also increased apoptosis (p < 0.05) in liver and lung, which was not seen after resuscitation with other solutions. CONCLUSIONS In this large animal model of hemorrhagic shock, resuscitation with conventional (racemic) LR solution increased apoptotic cell death in liver and lung. This effect can be prevented by simple elimination of D-lactate from the Ringer's solution.
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Affiliation(s)
- Eduardo C Ayuste
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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Smith SL, Heal DJ, Martin KF. KTX 0101: a potential metabolic approach to cytoprotection in major surgery and neurological disorders. CNS DRUG REVIEWS 2005; 11:113-40. [PMID: 16007235 PMCID: PMC6741747 DOI: 10.1111/j.1527-3458.2005.tb00265.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
KTX 0101 is the sodium salt of the physiological ketone, D-beta-hydroxybutyrate (betaOHB). This neuroprotectant, which has recently successfully completed clinical Phase IA evaluation, is being developed as an intravenous infusion fluid to prevent the cognitive deficits caused by ischemic foci in the brain during cardiopulmonary bypass (CPB) surgery. KTX 0101 maintains cellular viability under conditions of physiological stress by acting as a "superfuel" for efficient ATP production in the brain and peripheral tissues. Unlike glucose, this ketone does not require phosphorylation before entering the TCA cycle, thereby sparing vital ATP stores. Although no reliable models of CPB-induced ischemia exist, KTX 0101 is powerfully cytoprotectant under the more severe ischemic conditions of global and focal cerebral ischemia, cardiac ischemia and lung hemorrhage. Neuroprotection has been demonstrated by reductions in infarct volume, edema, markers of apoptosis and functional impairment. One significant difference between KTX 0101 and other potential neuroprotectants in development is that betaOHB is a component of human metabolic physiology which exploits the body's own neuroprotective mechanisms. KTX 0101 also protects hippocampal organotypic cultures against early and delayed cell death in an in vitro model of status epilepticus, indicating that acute KTX 0101 intervention in this condition could help prevent the development of epileptiform foci, a key mechanism in the etiology of intractable epilepsy. In models of chronic neurodegenerative disorders, KTX 0101 protects neurons against damage caused by dopaminergic neurotoxins and by the fragment of beta-amyloid, Abeta(1-42), implying possible therapeutic applications for ketogenic strategies in treating Parkinson's and Alzheimer's diseases. Major obstacles to the use of KTX 0101 for long term therapy in chronic disorders, e.g., Parkinson's and Alzheimer's diseases, are the sodium loading problem and the need to administer it in relatively large amounts because of its rapid mitochondrial metabolism. These issues are being addressed by designing and synthesizing orally bioavailable multimers of betaOHB with improved pharmacokinetics.
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Affiliation(s)
- Sharon L Smith
- RenaSci Consultancy Ltd, BioCity, Nottingham, NG1 1GF, UK.
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Jaskille A, Koustova E, Rhee P, Britten-Webb J, Chen H, Valeri CR, Kirkpatrick JR, Alam HB. Hepatic apoptosis after hemorrhagic shock in rats can be reduced through modifications of conventional Ringer's solution. J Am Coll Surg 2005; 202:25-35. [PMID: 16377494 DOI: 10.1016/j.jamcollsurg.2005.08.027] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2005] [Revised: 08/23/2005] [Accepted: 08/31/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND Resuscitation with racemic lactated Ringer's solution induces cellular apoptosis. This study was conducted to determine if the elimination of D-lactate isomer would attenuate apoptosis in the liver, and to investigate the possible mechanisms. STUDY DESIGN Sprague Dawley rats (n=30, 5 per group) were subjected to modified volume-controlled hemorrhage and randomized to the following groups: no hemorrhage (sham); no resuscitation (NR); resuscitation with racemic lactated Ringer's (DL-LR); L-isomer LR (L-LR); ketone (beta-hydroxybuturate) Ringer's (KR); or pyruvate Ringer's (PR). Animals were sacrificed 2 hours later and expressions of proapoptotic proteins (BAD), antiapoptotic (bcl-2) proteins, and poly-ADP ribose polymerase (PARP) cleavage in liver were analyzed by Western blotting. Contribution of the phosphatidylinositol 3-kinase/serine/threonine kinase (PI3k/Akt) pathway was assessed by measuring total and phosphorylated PI3K, Akt, BAD, and endothelial nitric oxide synthase (eNOS) proteins. The terminal deoxynucleotidyl transferase mediated dUTP nick end labeling (TUNEL) assay was used to detect the apoptotic cells. Liver ATP levels were measured using a luciferase reaction assay. RESULTS Hemorrhage significantly decreased the hepatic ATP level and resuscitation improved it, but it returned to normal only in the L-isomer lactated Ringer's and ketone Ringer's groups. Expression of proapoptotic proteins was significantly lower in the pyruvate Ringer's and ketone Ringer's groups; L-isomer lactated Ringer's and pyruvate Ringer's resuscitation significantly increased bcl-2 expression. Poly-ADP ribose polymerase fragmentation and total number of apoptotic cells were significantly increased in the racemic lactated Ringer's group. There was no significant induction of Akt activity or changes in phosphorylated BAD, Akt, or eNOS levels. CONCLUSIONS Resuscitation with racemic lactated Ringer's induces hepatic apoptosis, which is decreased if the D-isomer of lactate is eliminated. Apoptosis is reduced even more when lactate is substituted with beta-hydroxybutyrate or pyruvate. The beneficial effects are not through improvements in the energy status or activation of the PI3K/Akt pathway.
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Affiliation(s)
- Amin Jaskille
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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Lin T, Koustova E, Chen H, Rhee PM, Kirkpatrick J, Alam HB. Energy Substrate-Supplemented Resuscitation Affects Brain Monocarboxylate Transporter Levels and Gliosis in a Rat Model of Hemorrhagic Shock. ACTA ACUST UNITED AC 2005; 59:1191-202; discussion 1202. [PMID: 16385299 DOI: 10.1097/01.ta.0000188646.86995.9d] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Monocarboxylate (MC)-supplemented resuscitation has been shown to attenuate cellular injury after hemorrhagic shock. However, little is known about its effect on the central nervous system. The brain can use MCs such as lactate, pyruvate, and beta-hydroxybutyrate as energy substrates. The transit of MCs into the central nervous system is facilitated by the monocarboxylate transporters (MCTs), and their blockage can exacerbate neuronal damage. We examined the expression of MCT1 and markers specific for activation of astroglia and microglia in the brains of rats subjected to hemorrhagic shock and resuscitation. The hypothesis was that resuscitation with MC-based fluids would be accompanied by MCT1 up-regulation and glial response. METHODS Rats (n = 30) were subjected to volume-controlled hemorrhage. Test groups included: sham, no resuscitation, resuscitation with normal saline, resuscitation with racemic lactated Ringer's solution, resuscitation with pyruvate Ringer's solution, and resuscitation with beta-hydroxybutyrate-containing ketone Ringer's solution. Plasma levels of MC were measured serially. The brains were investigated using GFAP, CD11b, CD43, MCT1, and GLUT1 immunohistochemistry. RESULTS Rats resuscitated with MC-containing fluids had increased levels of MCT1 in brain endothelial cells and neuropil compared with sham rats. Enhanced staining was localized to the choroid plexus, astrocytic end feet, and white matter structures. None of the resuscitation treatment induced astrocytic hyperplasia, and pyruvate Ringer's solution and ketone Ringer's solution resuscitation led to hypertrophy of astrocytes. CONCLUSION In hemorrhagic shock, resuscitation with MC-based fluids increased brain MCT1 level and led to activation of astrocytes. Enhanced MC trafficking could be an essential route for energy supply to neurons under adverse circulatory conditions.
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Affiliation(s)
- Tom Lin
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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40
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Abstract
Hemorrhagic shock is the leading cause of death in civilian and combat trauma. Effective hemorrhage control and better resuscitation strategies have the potential of saving lives. The Trauma Readiness and Research Institute for Surgery (TRRI-Surg) was established to address the core mission of the Uniformed Services University, "Learning to Care for Those in Harm's Way," by conducting research to improve the outcome of combat casualties. This article highlights the salient achievements of this research effort in the areas of hemorrhage control, resuscitation, design and testing of devices, and some novel concepts such as the use of profound hypothermia. The impact of these basic science research findings on changes in military medical care and outcome of injured soldiers is also described.
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Affiliation(s)
- Hasan B Alam
- Trauma Research and Readiness Institute for Surgery, Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland 20814-4799, USA.
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Masuda R, Monahan JW, Kashiwaya Y. D-beta-hydroxybutyrate is neuroprotective against hypoxia in serum-free hippocampal primary cultures. J Neurosci Res 2005; 80:501-9. [PMID: 15825191 DOI: 10.1002/jnr.20464] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Hypoxia decreased survival of cultured rat primary hippocampal neurons in a time dependent manner. Addition of 4 mM Na D-beta-hydroxybutyrate (bHB), a ketone body, protected the cells for 2 hr and maintained the increase in survival compared to that of controls for up to 6 hr. Trypan blue exclusion indicated that acute cell death was reduced markedly after 2-hr exposure to hypoxia in the bHB-treated group. The presence of bHB also decreased the number of neurons exhibiting condensed nuclei visualized by propidium iodide, indicative of apoptosis. The mitochondrial transmembrane potential (Em/c) was maintained for up to 2 hr exposure to hypoxia in the bHB-treated group, whereas the potential in the control group was decreased. Furthermore, cytochrome C release, caspase-3 activation, and poly (ADP-ribose) polymerase (PARP) cleavage were decreased in the bHB-treated group for the first 2 hr of exposure. These findings indicate that ketone bodies may be a candidate for widening the therapeutic window before thrombolytic therapy and at the same time decreasing apoptotic damage in the ischemic penumbra.
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Affiliation(s)
- R Masuda
- Laboratory of Metabolic Control/National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, DHHS, Bethesda, Maryland 20892, USA
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Zhou FQ. Pyruvate in the correction of intracellular acidosis: a metabolic basis as a novel superior buffer. Am J Nephrol 2005; 25:55-63. [PMID: 15731550 DOI: 10.1159/000084141] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2004] [Accepted: 01/06/2005] [Indexed: 01/18/2023]
Abstract
The review focuses on biochemical metabolisms of conventional buffers and emphasizes advantages of sodium pyruvate (Pyr) in the correction of intracellular acidosis. Exogenous lactate (Lac) as an alternative of natural buffer, bicarbonate, consumes intracellular protons on an equimolar basis, regenerating bicarbonate anions in plasma while the completion of gluconeogenesis and/or oxidation occurs via tricarboxylic-acid cycle in mitochondria mainly in liver and kidney, or heart. The general assumption that Lac is 'metabolized to bicarbonate' in liver to serve as a buffer has been questioned. Pyr as a novel buffer would be superior to conventional ones in the correction of metabolic acidosis. Several likely biochemical mechanisms of Pyr action are discussed. Experimental evidence, in vivo, strongly suggested that Pyr would be particularly efficient in the correction of severe acidemia: type A lactic acidosis, hypercapnia with cardiac arrest, and diabetic and alcoholic ketoacidosis in animal experiments and clinic settings. Because of its multi-cytoprotection, Pyrs not only correct acidosis, but also benefit theunderlying dysfunction of vital organs. In addition, Pyr is also a potential buffer component of dialysis solutions. However, the instability of Pyr in aqueous solutions restricts its clinical applications as a therapeutic agent. Attempts to create a stable Pyr preparation are needed.
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Shires GT, Browder LK, Steljes TPV, Williams SJ, Browder TD, Barber AE. The effect of shock resuscitation fluids on apoptosis. Am J Surg 2005; 189:85-91. [PMID: 15701499 DOI: 10.1016/j.amjsurg.2004.06.040] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2004] [Revised: 06/23/2004] [Accepted: 06/23/2004] [Indexed: 11/19/2022]
Abstract
BACKGROUND Recent data suggest that the type of resuscitation fluid used to treat hemorrhagic shock contributes to cellular dysfunction METHODS Rats were hemorrhaged, exposed to a hypovolemic shock period for 75 minutes, and then resuscitated for 1 hour. Treatment animals were assigned randomly to lactate Ringer's solution, normal saline solution, bicarbonate Ringer's solution, hypertonic saline solution, rat plasma solution, ketone Ringer's solution, or nonresuscitation. After resuscitation, lung and liver samples were collected and evaluated for apoptosis by using ligation-mediated polymerase chain reaction. RESULTS Nonresuscitated shock rats had significantly higher levels of apoptosis in lung and liver. Rats treated with normal saline solution, bicarbonate Ringer's solution, ketone Ringer's solution, and hypertonic saline solution had significantly lower levels of apoptosis in lung compared with nonresuscitated animals. Rats treated with bicarbonate Ringer's solution and ketone Ringer's solution had significantly lower levels of apoptosis in liver tissue when compared with nonresuscitated animals. CONCLUSIONS Cellular damage results from hemorrhagic shock. The use of resuscitation fluids decreases apoptosis during shock.
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Affiliation(s)
- G Tom Shires
- Trauma Institute of UNSOM, University of Nevada School of Medicine, 2040 W. Charleston Blvd., Ste. 501, Las Vegas, NV 89102, USA.
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Kiang JG, Lu X, Tabaku LS, Bentley TB, Atkins JL, Tsokos GC. Resuscitation with lactated Ringer solution limits the expression of molecular events associated with lung injury after hemorrhage. J Appl Physiol (1985) 2004; 98:550-6. [PMID: 15489261 DOI: 10.1152/japplphysiol.00858.2004] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The aim of this study was to determine whether hemorrhage altered the caspase-3 activity and the ATP levels in rat lung and ileum tissues and determine whether resuscitation with lactated Ringer solution (LR) or whole blood (WB) reversed these changes. Male Sprague-Dawley rats were briefly anesthetized with isoflurane, and their mean arterial blood pressure was reduced from 110 to 40 mmHg by bleeding. The bled rat was then resuscitated with LR or autologous WB to bring mean arterial blood pressure back to 80 mmHg. Lung and ileum tissues were removed at the end of hemorrhage or at the end of the resuscitation period for specified bioassays. Hemorrhage increased cellular caspase-3 activity in the lung and the ileum. After the hemorrhaged rats received LR or WB, caspase-3 activity returned to the basal level in the lung and ileum, respectively. Likewise, hemorrhage decreased cellular ATP levels in lung and ileum. After LR or WB resuscitation, the cellular ATP level returned to the basal level only in the lung resuscitated with LR. The increased caspase-3 activity was associated with the increased expression of caspase-3 mRNA, which also returned to normal levels after either resuscitation. Similarly, hemorrhage increased the expression of inducible nitric oxide synthase and Kruppel-like factor 6 and decreased expression of Kruppel-like factor 4. Subsequent LR resuscitation normalized the expression of these genes in the lung tissue. Our results demonstrate that resuscitation with LR can reverse the expression of genes and their products that are thought to contribute to hemorrhage-induced lung injury.
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Affiliation(s)
- Juliann G Kiang
- Division of Military Casualty Research, Walter Reed Army Institute of Research, 503 Robert Grant Ave., Rm. 1N07, Silver Spring, MD 20910-7500, USA.
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Neigh GN, Bowers SL, Pyter LM, Gatien ML, Nelson RJ. Pyruvate prevents restraint-induced immunosuppression via alterations in glucocorticoid responses. Endocrinology 2004; 145:4309-19. [PMID: 15178646 DOI: 10.1210/en.2003-1748] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Stress-evoked immunosuppression may reflect increased demands on cellular energy signaled via elevated glucocorticoid concentrations. We hypothesized that treatment with pyruvate, an alternative energy source, would ameliorate restraint-induced elevation of glucocorticoids and that this reduction in glucocorticoid exposure will prevent stress-induced immunosuppression. We provided exogenous pyruvate to mice exposed to repeated restraint and then assessed splenocyte counts and splenocyte proliferation in response to the mitogen, concanavalin A as well as IgM production in response to keyhole limpet hemocyanin. Immune function was suppressed in mice undergoing repeated restraint but not in mice exposed to repeated restraint followed by pyruvate treatment. All mice exposed to restraint, regardless of pyruvate supplementation, displayed equivalent occurrences of repeated elevations in corticosterone concentrations; however, the cumulative exposure to corticosterone after one episode of restraint was reduced in those mice treated with pyruvate after restraint. Finally, we tested the immunoprotective ability of pyruvate supplementation in the presence of chronically elevated corticosterone. Mice implanted with restraint-like concentrations of corticosterone after adrenalectomy decreased splenocyte counts, compared with either unmanipulated mice or mice that were implanted with a cholesterol pellet after adrenalectomy, regardless of pyruvate supplementation. These data suggest that pyruvate does not possess immunoprotective properties in the presence of chronically elevated corticosterone. Pyruvate supplementation preserves immune function during exposure to repeated restraint stressors; altered dynamics of corticosterone concentrations after pyruvate administration may mediate this immunoprotection. Pyruvate prevents restraint-induced immunosuppression via alterations in the glucocorticoid response to restraint.
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Affiliation(s)
- Gretchen N Neigh
- Townshend Hall, 1885 Neil Avenue Mall, Columbus, Ohio 43210, USA
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Jaskille A, Alam HB, Rhee P, Hanes W, Kirkpatrick JR, Koustova E. D-Lactate Increases Pulmonary Apoptosis by Restricting Phosphorylation of Bad and eNOS in a Rat Model of Hemorrhagic Shock. ACTA ACUST UNITED AC 2004; 57:262-69; discussion 269-70. [PMID: 15345971 DOI: 10.1097/01.ta.0000133841.95455.73] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
UNLABELLED Resuscitation with racemic lactated Ringer's solution (containing equal amounts of D and L isomers of lactate) has been shown to induce pulmonary apoptosis. Substitution of DL-isomer lactate with ketone bodies (beta-hydroxybutyrate, BHB), sodium pyruvate, or L-isomer of lactate decrease this injury without changing the energy status of the tissues or the expression of apoptotic genes. These modified solutions however alter the function of apoptotic proteins through an unknown mechanism. We postulated that DL-LR induces apoptosis by restricting the phosphorylation of key apoptotic proteins. METHODS Male Sprague Dawley rats (n = 30, 5/group) were subjected to a three stage, volume-controlled hemorrhage and randomized to the following groups. 1) No hemorrhage (Sham); 2) Hemorrhage and no resuscitation (NR); 3) Resuscitation with 3x shed blood volume of racemic LR (DL-LR); 4) Resuscitation with 3x shed blood volume of LR containing only the L-isomer of lactate (L-LR); 5) Resuscitation with 3s shed blood volume of pyruvate Ringer's (PR); 6) Resuscitation with 3s shed blood volume of ketone Ringer's (KR). The modified Ringer's solutions were identical to racemic LR except for equimolar substitution of DL-lactate for L-lactate, pyruvate and BHB respectively. Lung tissue was obtained 2 hours later and subjected to Western Blotting. The levels of Akt, Bad, and eNOS (total and phosphorylated) proteins were measured. Finally, the expression of gene coding for protein 14-3-3 was measured using RT-PCR. RESULTS Resuscitation with DL-LR caused a significant (p < 0.05) increase in the total Bad and a decrease in phosphorylated Bad protein expression in the lung. It also caused an increase in the phosphorylated Akt levels and a decrease in gene coding for protein 14-3-3. These changes were consistent with signaling imbalances that favor apoptosis. Modified LR solutions, on the other hand, did not cause these alterations. Phosphorylation pattern of eNOS supported the involvement of PI3K/Akt pathway in this process. CONCLUSION Racemic lactate plays a role in the induction of pulmonary apoptosis by restricting phosphorylation of Bad and eNOS proteins.
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Affiliation(s)
- Amín Jaskille
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland 20814, USA
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