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Ivachtchenko AV, Khvat AV, Shkil DO. Development and Prospects of Furin Inhibitors for Therapeutic Applications. Int J Mol Sci 2024; 25:9199. [PMID: 39273149 PMCID: PMC11394684 DOI: 10.3390/ijms25179199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2024] [Revised: 08/17/2024] [Accepted: 08/22/2024] [Indexed: 09/15/2024] Open
Abstract
Furin, a serine protease enzyme located in the Golgi apparatus of animal cells, plays a crucial role in cleaving precursor proteins into their mature, active forms. It is ubiquitously expressed across various tissues, including the brain, lungs, gastrointestinal tract, liver, pancreas, and reproductive organs. Since its discovery in 1990, furin has been recognized as a significant therapeutic target, leading to the active development of furin inhibitors for potential use in antiviral, antibacterial, anticancer, and other therapeutic applications. This review provides a comprehensive overview of the progress in the development and characterization of furin inhibitors, encompassing peptides, linear and macrocyclic peptidomimetics, and non-peptide compounds, highlighting their potential in the treatment of both infectious and non-infectious diseases.
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Nazir F, Munir I, Yesiloz G. A Microfluidics-Assisted Double-Barreled Nanobioconjugate Synthesis Introducing Aprotinin as a New Moonlight Nanocarrier Protein: Tested toward Physiologically Relevant 3D-Spheroid Models. ACS APPLIED MATERIALS & INTERFACES 2024; 16:18311-18326. [PMID: 38564228 DOI: 10.1021/acsami.3c16548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Proteins are promising substances for introducing new drug carriers with efficient blood circulation due to low possibilities of clearance by macrophages. However, such natural biopolymers have highly sophisticated molecular structures, preventing them from being assembled into nanoplatforms with manipulable payload release profiles. Here, we report a novel anticancer nanodrug carrier moonlighting protein, Aprotinin, to be used as a newly identified carrier for cytotoxic drugs. The Aprotinin-Doxorubicin (Apr-Dox) nanobioconjugate was prepared via a single-step microfluidics coflow mixing technique, a feasible and simple way to synthesize a carrier-based drug design with a double-barreled approach that can release and actuate two therapeutic agents simultaneously, i.e., Apr-Dox in 1:11 ratio (the antimetastatic carrier drug aprotinin and the chemotherapeutic drug DOX). With a significant stimuli-sensitive (i.e., pH) drug release ability, this nanobioconjugate achieves superior bioperformances, including high cellular uptake, efficient tumor penetration, and accumulation into the acidic tumor microenvironment, besides inhibiting further tumor growth by halting the urokinase plasminogen activator (uPA) involved in metastasis and tumor progression. Distinctly, in healthy human umbilical vein endothelial (HUVEC) cells, drastically lower cellular uptake of nanobioconjugates has been observed and validated compared to the anticancer agent Dox. Our findings demonstrate an enhanced cellular internalization of nanobioconjugates toward breast cancer, prostate cancer, and lung cancer both in vitro and in physiologically relevant biological 3D-spheroid models. Consequently, the designed nanobioconjugate shows a high potential for targeted drug delivery via a natural and biocompatible moonlighting protein, thus opening a new avenue for proving aprotinin in cancer therapy as both an antimetastatic and a drug-carrying agent.
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Affiliation(s)
- Faiqa Nazir
- National Nanotechnology Research Center (UNAM)- Bilkent University, 06800 Cankaya-Ankara, Türkiye
- Institute of Material Science and Nanotechnology, Bilkent University, 06800 Cankaya-Ankara, Türkiye
| | - Iqra Munir
- National Nanotechnology Research Center (UNAM)- Bilkent University, 06800 Cankaya-Ankara, Türkiye
| | - Gurkan Yesiloz
- National Nanotechnology Research Center (UNAM)- Bilkent University, 06800 Cankaya-Ankara, Türkiye
- Institute of Material Science and Nanotechnology, Bilkent University, 06800 Cankaya-Ankara, Türkiye
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Ivachtchenko AV, Ivashchenko AA, Shkil DO, Ivashchenko IA. Aprotinin-Drug against Respiratory Diseases. Int J Mol Sci 2023; 24:11173. [PMID: 37446350 DOI: 10.3390/ijms241311173] [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: 05/28/2023] [Revised: 06/28/2023] [Accepted: 07/03/2023] [Indexed: 07/15/2023] Open
Abstract
Aprotinin (APR) was discovered in 1930. APR is an effective pan-protease inhibitor, a typical "magic shotgun". Until 2007, APR was widely used as an antithrombotic and anti-inflammatory drug in cardiac and noncardiac surgeries for reduction of bleeding and thus limiting the need for blood transfusion. The ability of APR to inhibit proteolytic activation of some viruses leads to its use as an antiviral drug for the prevention and treatment of acute respiratory virus infections. However, due to incompetent interpretation of several clinical trials followed by incredible controversy in the literature, the usage of APR was nearly stopped for a decade worldwide. In 2015-2020, after re-analysis of these clinical trials' data the restrictions in APR usage were lifted worldwide. This review discusses antiviral mechanisms of APR action and summarizes current knowledge and prospective regarding the use of APR treatment for diseases caused by RNA-containing viruses, including influenza and SARS-CoV-2 viruses, or as a part of combination antiviral treatment.
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Affiliation(s)
- Alexandre V Ivachtchenko
- ChemDiv Inc., San Diego, CA 92130, USA
- ASAVI LLC, 1835 East Hallandale Blvd #442, Hallandale Beach, FL 33009, USA
| | | | - Dmitrii O Shkil
- ASAVI LLC, 1835 East Hallandale Blvd #442, Hallandale Beach, FL 33009, USA
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Dekker NAM, van Leeuwen ALI, van Meurs M, Moser J, Pankras JE, van der Wel NN, Niessen HW, Vervloet MG, Vonk ABA, Hordijk PL, Boer C, van den Brom CE. Preservation of renal endothelial integrity and reduction of renal edema by aprotinin does not preserve renal perfusion and function following experimental cardiopulmonary bypass. Intensive Care Med Exp 2021; 9:30. [PMID: 34169407 PMCID: PMC8225734 DOI: 10.1186/s40635-021-00393-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 05/04/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Acute kidney injury is a severe complication following cardiopulmonary bypass (CPB) and is associated with capillary leakage and microcirculatory perfusion disturbances. CPB-induced thrombin release results in capillary hyperpermeability via activation of protease-activated receptor 1 (PAR1). We investigated whether aprotinin, which is thought to prevent thrombin from activating PAR1, preserves renal endothelial structure, reduces renal edema and preserves renal perfusion and reduces renal injury following CPB. METHODS Rats were subjected to CPB after treatment with 33.000 KIU/kg aprotinin (n = 15) or PBS (n = 15) as control. A secondary dose of 33.000 KIU/kg aprotinin was given 60 min after initiation of CPB. Cremaster and renal microcirculatory perfusion were assessed using intravital microscopy and contrast echography before CPB and 10 and 60 min after weaning from CPB. Renal edema was determined by wet/dry weight ratio and renal endothelial structure by electron microscopy. Renal PAR1 gene and protein expression and markers of renal injury were determined. RESULTS CPB reduced cremaster microcirculatory perfusion by 2.5-fold (15 (10-16) to 6 (2-10) perfused microvessels, p < 0.0001) and renal perfusion by 1.6-fold (202 (67-599) to 129 (31-292) au/sec, p = 0.03) in control animals. Both did not restore 60 min post-CPB. This was paralleled by increased plasma creatinine (p < 0.01), neutrophil gelatinase-associated lipocalin (NGAL; p = 0.003) and kidney injury molecule-1 (KIM-1; p < 0.01). Aprotinin treatment preserved cremaster microcirculatory perfusion following CPB (12 (7-15) vs. 6 (2-10) perfused microvessels, p = 0.002), but not renal perfusion (96 (35-313) vs. 129 (31-292) au/s, p > 0.9) compared to untreated rats. Aprotinin treatment reduced endothelial gap formation (0.5 ± 0.5 vs. 3.1 ± 1.4 gaps, p < 0.0001), kidney wet/dry weight ratio (4.6 ± 0.2 vs. 4.4 ± 0.2, p = 0.046), and fluid requirements (3.9 ± 3.3 vs. 7.5 ± 3.0 ml, p = 0.006) compared to untreated rats. In addition, aprotinin treatment reduced tubulointerstitial neutrophil influx by 1.7-fold compared to untreated rats (30.7 ± 22.1 vs. 53.2 ± 17.2 neutrophil influx/section, p = 0.009). No differences were observed in renal PAR1 expression and plasma creatinine, NGAL or KIM-1 between groups. CONCLUSIONS Aprotinin did not improve renal perfusion nor reduce renal injury during the first hour following experimental CPB despite preservation of renal endothelial integrity and reduction of renal edema.
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Affiliation(s)
- Nicole A M Dekker
- Department of Anesthesiology, Experimental Laboratory for Vital Signs, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands. .,Department of Cardiothoracic Surgery, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands. .,Department of Physiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands.
| | - Anoek L I van Leeuwen
- Department of Anesthesiology, Experimental Laboratory for Vital Signs, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands.,Department of Cardiothoracic Surgery, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands.,Department of Physiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Matijs van Meurs
- Department of Pathology and Medical Biology, University Medical Center Groningen, Groningen, The Netherlands.,Department of Critical Care Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | - Jill Moser
- Department of Pathology and Medical Biology, University Medical Center Groningen, Groningen, The Netherlands.,Department of Critical Care Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | - Jeannette E Pankras
- Department of Medical Biology, Electron Microscopy Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Nicole N van der Wel
- Department of Medical Biology, Electron Microscopy Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Hans W Niessen
- Department of Pathology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Marc G Vervloet
- Department of Nephrology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Alexander B A Vonk
- Department of Cardiothoracic Surgery, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Peter L Hordijk
- Department of Physiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Christa Boer
- Department of Anesthesiology, Experimental Laboratory for Vital Signs, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Charissa E van den Brom
- Department of Anesthesiology, Experimental Laboratory for Vital Signs, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands.,Department of Physiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands.,Department of Intensive Care Medicine, Laboratory for Experimental Intensive Care and Anesthesiology (LEICA), Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Hiramoto K, Yamate Y, Matsuda K, Sugiyama D, Iizuka Y. Tranexamic Acid Improves Memory and Learning Abilities in Aging Mice. J Exp Pharmacol 2020; 12:653-663. [PMID: 33376415 PMCID: PMC7755347 DOI: 10.2147/jep.s284532] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 11/26/2020] [Indexed: 12/21/2022] Open
Abstract
Purpose Although the onset mechanism of Alzheimer’s disease, which co-occurs with aging, has been extensively studied, no effective methods that improve the decline in memory and learning abilities following aging have been developed. Tranexamic acid provided promising results for ameliorating photo-aging and extending the natural lifespan. However, it is unknown whether it affects the decline in memory and learning abilities due to aging. In this study, we examined the effect of tranexamic acid on memory and learning abilities of naturally aging mice. Methods ICR mice were orally administered with tranexamic acid (12 mg/kg/day) three times weekly for 2 years, and their memory and learning abilities were compared between the tranexamic acid-treated and non-treated groups. Results The decline in memory and learning abilities due to aging was ameliorated by tranexamic acid administration. The expression of plasmin and amyloid-β decreased following the treatment with tranexamic acid. Furthermore, the number of M1-type brain macrophages diminished and that of M2 macrophages increased. In addition, administration of tranexamic acid decreased the concentrations of interleukin (IL)-1β and tumor necrosis factor-α, while it increased the levels of IL-10 and transforming growth factor-α in the brain. Conclusion These results indicated that tranexamic acid suppressed the secretion of the inflammatory cytokines aging M1-type macrophages, thereby improving age-related memory and learning abilities.
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Affiliation(s)
- Keiichi Hiramoto
- Department of Pharmaceutical Sciences, Suzuka University of Medical Science, Suzuka, Mie 513-8670, Japan
| | - Yurika Yamate
- Department of Pharmaceutical Sciences, Suzuka University of Medical Science, Suzuka, Mie 513-8670, Japan
| | - Kazunari Matsuda
- R&D Department, Daiichi Sankyo Healthcare Co., LTD, Shinagawa-ku, Tokyo 103-8234, Japan
| | - Daijiro Sugiyama
- R&D Department, Daiichi Sankyo Healthcare Co., LTD, Shinagawa-ku, Tokyo 103-8234, Japan
| | - Yasutaka Iizuka
- R&D Department, Daiichi Sankyo Healthcare Co., LTD, Shinagawa-ku, Tokyo 103-8234, Japan
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Hiramoto K, Yamate Y, Takishita Y, Sato EF. The Role of gp91phox and the Effect of Tranexamic Acid Administration on Hair Color in Mice. Int J Mol Sci 2019; 20:ijms20112665. [PMID: 31151207 PMCID: PMC6600564 DOI: 10.3390/ijms20112665] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 05/27/2019] [Accepted: 05/29/2019] [Indexed: 01/05/2023] Open
Abstract
We observed that on long-term breeding, gp91phox-knockout (gp91phox−/−) mice developed white hair. Here, we investigate the origin of this hitherto unexplained phenomenon. Moreover, we investigated the effect of tranexamic acid administration on the hair color in gp91phox−/− mice. We administered tranexamic acid (about 12 mg/kg/day) orally to 9-week-old C57BL/6j (control) and gp91phox−/− mice, thrice a week for 12 months. Compared to control mice, gp91phox−/− mice showed more white hair. However, the concentrations of reactive oxygen species and the levels of interleukin (IL)-1β and transforming growth factor (TGF)-β in the skin were lower than those in the control group. Furthermore, increase in white hair was observed in the control mice upon administration of the IL-1β antagonist. On the other hand, administration of tranexamic acid led to brown colored hair on gp91phox−/− mice. Although tranexamic acid treatment did not alter the expression levels of melanocortin receptor 1 and agouti signaling protein on hair follicles, it increased the expression of mahogunin ring finger protein 1 (MGRN1) and collagen XVII. These results suggested that retention of black hair requires the gp91phox/ROS/IL-1β/TGF-β pathway and that elevated levels of MGRN1 and collagen XVII lead to brown hair in gp91phox−/− mice.
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Affiliation(s)
- Keiichi Hiramoto
- Department of Pharmaceutical Sciences, Suzuka University of Medical Science, 3500-3 Minamitamagakicho, Suzuka Mie 513-8670, Japan.
| | - Yurika Yamate
- Department of Pharmaceutical Sciences, Suzuka University of Medical Science, 3500-3 Minamitamagakicho, Suzuka Mie 513-8670, Japan.
| | - Yutaka Takishita
- Department of Pharmaceutical Sciences, Suzuka University of Medical Science, 3500-3 Minamitamagakicho, Suzuka Mie 513-8670, Japan.
| | - Eisuke F Sato
- Department of Pharmaceutical Sciences, Suzuka University of Medical Science, 3500-3 Minamitamagakicho, Suzuka Mie 513-8670, Japan.
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Murkin JM. Adverse Central Nervous System Outcomes After Cardiopulmonary Bypass: A Beneficial Effect of Aprotinin? Semin Cardiothorac Vasc Anesth 2016. [DOI: 10.1053/seva.2001.28175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This review considers the evidence for potential central nervous system benefits associated with use of anti- protease therapy for patients undergoing procedures involving cardiopulmonary bypass. Unfortunately, few randomized, controlled clinical trials have assessed the lysine analogue class of antifibrinolytics (ie, ∈-amino caproic acid, tranexamic acid) compared with the num ber investigating the efficacy of the enzyme-inactivator class of antifibrinolytic typified by the nonspecific serine protease inhibitors aprotinin and nafamostat.
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Al-Horani RA, Desai UR. Recent advances on plasmin inhibitors for the treatment of fibrinolysis-related disorders. Med Res Rev 2014; 34:1168-1216. [PMID: 24659483 PMCID: PMC8788159 DOI: 10.1002/med.21315] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
Growing evidence suggests that plasmin is involved in a number of physiological processes in addition to its key role in fibrin cleavage. Plasmin inhibition is critical in preventing adverse consequences arising from plasmin overactivity, e.g., blood loss that may follow cardiac surgery. Aprotinin was widely used as an antifibrinolytic drug before its discontinuation in 2008. Tranexamic acid and ε-aminocaproic acid, two small molecule plasmin inhibitors, are currently used in the clinic. Several molecules have been designed utilizing covalent, but reversible, chemistry relying on reactive cyclohexanones, nitrile warheads, and reactive aldehyde peptidomimetics. Other major classes of plasmin inhibitors include the cyclic peptidomimetics and polypeptides of the Kunitz and Kazal-type. Allosteric inhibitors of plasmin have also been designed including small molecule lysine analogs that bind to plasmin's kringle domain(s) and sulfated glycosaminoglycan mimetics that bind to plasmin's catalytic domain. Plasmin inhibitors have also been explored for resolving other disease states including cell metastasis, cell proliferation, angiogenesis, and embryo implantation. This review highlights functional and structural aspects of plasmin inhibitors with the goal of advancing their design.
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Affiliation(s)
- Rami A Al-Horani
- Department of Medicinal Chemistry and Institute for Structural Biology and Drug Discovery, Virginia Commonwealth University, Richmond, Virginia
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Baltatzis M, Pavlidis TE, Ouroumidis O, Koliakos G, Nikolaidou C, Venizelos I, Michopoulou A, Sakantamis A. Aprotinin reduces oxidative stress induced by pneumoperitoneum in rats. J Surg Res 2014; 189:238-48. [PMID: 24674839 DOI: 10.1016/j.jss.2014.02.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Revised: 02/17/2014] [Accepted: 02/20/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Ischemia-reperfusion injury induced by pneumoperitoneum is a well-studied entity, which increases oxidative stress during laparoscopic operations. The reported anti-inflammatory action of aprotinin was measured in a pneumoperitoneum model in rats for the first time in this study. MATERIALS AND METHODS A total of 60 male Albino Wistar rats were used in our protocol. Prolonged pneumoperitoneum (4 h) was applied, causing splanchnic ischemia and a period of reperfusion with a duration of 60 or 180 min followed. Several cytokines and markers of oxidative stress were measured in liver, small intestine, and lungs to compare the aprotinin group with the control group. Tissue inflammation was also evaluated and compared between groups using a five-scaled histopathologic score. RESULTS In aprotinin group values of biochemical markers (tumor necrosis factor α, interleukin 6, endothelin 1, C reactive protein, pro-oxidant-antioxidant balance, and carbonyl proteins) were lower in all tissues studied. Statistical significance was greater in liver and lungs (P < 0.05). Histopathologic examination revealed significant difference between control and aprotinin groups in all tissues examined. Aprotinin groups showed mild to moderate lesions, while in control groups severe to very severe inflammation was present. Aprotinin subgroup with prolonged reperfusion period (180 min) showed milder lesions in all tissues than the rest of the groups. CONCLUSIONS Aprotinin reduced inflammatory response and oxidative stress induced by pneumoperitoneum in liver, small intestine, and lungs.
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Affiliation(s)
- Minas Baltatzis
- Second Propedeutical Department of Surgery, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece.
| | - Theodoros E Pavlidis
- Second Propedeutical Department of Surgery, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Odysseas Ouroumidis
- Second Propedeutical Department of Surgery, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Georgios Koliakos
- Department of Biochemistry, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Ioannis Venizelos
- Department of Pathology, Hippocration Hospital, Thessaloniki, Greece
| | - Anna Michopoulou
- Department of Biochemistry, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Athanasios Sakantamis
- Second Propedeutical Department of Surgery, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Abstract
Aprotinin is a naturally occurring serine protease inhibitor that is being used with increasing frequency in cardiac surgery and beyond to reduce blood loss and the need for perioperative blood transfusion. Through inhibition of serine proteases such as plasmin, aprotinin significantly reduces fibrinolysis, thereby aiding hemostasis during surgical procedures. In addition, aprotinin interacts with other factors in the coagulation and fibrinolytic cascade, creating a hemostatic balance, without increasing the risk of thrombosis. These proven benefits are supplemented by the anti-inflammatory properties of aprotinin, which may help curb some of the deleterious effects of cardiopulmonary bypass. This article will review the discovery of aprotinin, its mechanism of action, dosing and adverse effects, and highlight the major recent trials demonstrating its efficacy.
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Affiliation(s)
- Neel R Sodha
- Division of Cardiothoracic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, LMOB 9B, Boston, MA 02215, USA.
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11
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Hall R. Identification of Inflammatory Mediators and Their Modulation by Strategies for the Management of the Systemic Inflammatory Response During Cardiac Surgery. J Cardiothorac Vasc Anesth 2013; 27:983-1033. [DOI: 10.1053/j.jvca.2012.09.013] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2012] [Indexed: 12/21/2022]
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Arakeri G, Rai KK, Shivakumar HR, Jayade B. A randomized clinical trial to compare the efficacy of submucosal aprotinin injection and intravenous dexamethasone in reducing pain and swelling after third molar surgery: a prospective study. J Maxillofac Oral Surg 2013; 12:73-9. [PMID: 24431817 PMCID: PMC3589511 DOI: 10.1007/s12663-012-0364-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2011] [Accepted: 03/01/2012] [Indexed: 10/28/2022] Open
Abstract
OBJECTIVE The purpose of this study was to compare two different groups of drugs, aprotinin and dexamethasone for its efficacy in reducing post operative swelling and pain after third molar surgery. METHODS Fifty consecutive patients requiring surgical removal of single mandibular third molar (class II position B) under local anesthesia were randomly divided into two groups, each group consisting of 25 patients. One group was administered 8 mg dexamethasone through intravenous route pre-operatively. The other group received 1 ml of Aprotinin through submucosal route in operating area after the onset of local anesthesia. Swelling was assessed by measuring facial contours at baseline and at 1st, 3rd and 7th post-operative days. Pain was measured on the 1st, 3rd and 7th post-operative days using visual analog scale. Based on statistical analysis (paired t test and Wilcoxon's signed ranking test), the results showed statistically significant difference in post operative swelling and pain on 3rd postoperative day in dexamethasone group as compared to aprotinin group. RESULTS The results of present study showed a similar reduction in the severity of pain and swelling at the aprotinin and dexamethasone sites on 1st and 7th postoperative day. It was also noticed that the aprotinin promoted a greater reduction of swelling and pain on 3rd postoperative day. CONCLUSION It appeared that, benefits of aprotinin against the risks of dexamethasone and its efficacy in controlling pain and swelling after third molar surgery makes aprotinin to be a valuable alternative to dexamethasone.
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Affiliation(s)
- Gururaj Arakeri
- />PB’s Indian Academy of Craniofacial Research (PBIACR), Gangashri Nilaya, Basaveshwara Nagar, Shahapur, Yadgir, 585223 Karnataka India
- />Department of Oral and Maxillofacial Surgery, Navodaya Dental College and Hospital, Raichur, Karnataka India
| | - Kirthi Kumar Rai
- />Department of Oral Maxillofacial Surgery, Bapuji Dental College and Hospital, Davangere, Karnataka India
| | - H. R. Shivakumar
- />Department of Oral Maxillofacial Surgery, Bapuji Dental College and Hospital, Davangere, Karnataka India
| | - Bhushan Jayade
- />Department of Oral Maxillofacial Surgery, Bapuji Dental College and Hospital, Davangere, Karnataka India
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Swedberg JE, Harris JM. Natural and engineered plasmin inhibitors: applications and design strategies. Chembiochem 2012; 13:336-48. [PMID: 22238174 DOI: 10.1002/cbic.201100673] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2011] [Indexed: 12/17/2022]
Abstract
The serine protease plasmin is ubiquitously expressed throughout the human body in the form of the zymogen plasminogen. Conversion to active plasmin occurs through enzymatic cleavage by plasminogen activators. The plasminogen activator/plasmin system has a well-established function in the removal of intravascular fibrin deposition through fibrinolysis and the inhibition of plasmin activity; this has found widespread clinical use in reducing perioperative bleeding. Increasing evidence also suggests diverse, although currently less defined, roles for plasmin in a number of physiological and pathological processes relating to extracellular matrix degradation, cell migration and tissue remodelling. In particular, dysregulation of plasmin has been linked to cancer invasion/metastasis and various chronic inflammatory conditions; this has prompted efforts to develop inhibitors of this protease. Although a number of plasmin inhibitors exist, they commonly suffer from poor potency and/or specificity of inhibition that either results in reduced efficacy or prevents clinical use. Consequently, there is a need for further development of high-affinity plasmin inhibitors that maintain selectivity over other serine proteases. This review summarises clearly defined and potential applications for plasmin inhibition. The properties of naturally occurring and engineered plasmin inhibitors are discussed in the context of current knowledge regarding plasmin structure, specificity and function. This includes design strategies to obtain the potency and specificity of inhibition in addition to controlled temporal and spatial distribution tailored for the intended use.
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Affiliation(s)
- Joakim E Swedberg
- Institute for Molecular Bioscience, The University of Queensland, Brisbane QLD 4072 (Australia)
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Reichel CA, Lerchenberger M, Uhl B, Rehberg M, Berberich N, Zahler S, Wymann MP, Krombach F. Plasmin inhibitors prevent leukocyte accumulation and remodeling events in the postischemic microvasculature. PLoS One 2011; 6:e17229. [PMID: 21364954 PMCID: PMC3043096 DOI: 10.1371/journal.pone.0017229] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2010] [Accepted: 01/26/2011] [Indexed: 12/31/2022] Open
Abstract
Clinical trials revealed beneficial effects of the broad-spectrum serine protease inhibitor aprotinin on the prevention of ischemia-reperfusion (I/R) injury. The underlying mechanisms remained largely unclear. Using in vivo microscopy on the cremaster muscle of male C57BL/6 mice, aprotinin as well as inhibitors of the serine protease plasmin including tranexamic acid and ε-aminocaproic acid were found to significantly diminish I/R-elicited intravascular firm adherence and (subsequent) transmigration of neutrophils. Remodeling of collagen IV within the postischemic perivenular basement membrane was almost completely abrogated in animals treated with plasmin inhibitors or aprotinin. In separate experiments, incubation with plasmin did not directly activate neutrophils. Extravascular, but not intravascular administration of plasmin caused a dose-dependent increase in numbers of firmly adherent and transmigrated neutrophils. Blockade of mast cell activation as well as inhibition of leukotriene synthesis or antagonism of the platelet-activating-factor receptor significantly reduced plasmin-dependent neutrophil responses. In conclusion, our data suggest that extravasated plasmin(ogen) mediates neutrophil recruitment in vivo via activation of perivascular mast cells and secondary generation of lipid mediators. Aprotinin as well as the plasmin inhibitors tranexamic acid and ε-aminocaproic acid interfere with this inflammatory cascade and effectively prevent postischemic neutrophil responses as well as remodeling events within the vessel wall.
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Affiliation(s)
- Christoph A Reichel
- Walter Brendel Centre of Experimental Medicine, Ludwig-Maximilians-Universität München, Munich, Germany.
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15
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Arakeri G, Brennan PA. Povidone-iodine: an anti-oedematous agent? Int J Oral Maxillofac Surg 2010; 40:173-6. [PMID: 20970963 DOI: 10.1016/j.ijom.2010.09.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2009] [Revised: 05/18/2010] [Accepted: 09/13/2010] [Indexed: 10/18/2022]
Abstract
Polyvinylpyrrolidone-iodine (PVP-I) is a well-known antiseptic, widely used in various preparations and concentrations in all surgical fields. It is also used as an irrigant for open wounds and in some centres for irrigating sockets after tooth extraction. One of the authors (GA) incidentally discovered an anti-oedematous effect of PVP-I after using it in low concentration as an irrigant/coolant during the surgical removal of lower third molars. A prospective randomized clinical trial was subsequently performed on 50 patients (25 control, 25 treatment group) undergoing removal of impacted lower third molars. In the treatment group a 0.5% PVP-I solution at a concentration of 0.5mg/ml (we call it as "Arakeri's iodine solution") resulted in a significant reduction in postoperative swelling compared with the control group (P<0.01). This effect of PVP-I was suspected due to its inhibitory effect on leukotriene B4 and leukocyte extravasation (chemotaxis). Further evaluation of the effects of PVP-I as an irrigant in oral and maxillofacial surgery is needed.
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Affiliation(s)
- Gururaj Arakeri
- Peter Brennan's Indian Academy of Craniofacial Research, Shahapur, Karnataka, India.
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16
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Avlonitis VS, Wigfield CH, Kirby JA, Dark JH. Treatment of the brain-dead lung donor with aprotinin and nitric oxide. J Heart Lung Transplant 2010; 29:1177-84. [PMID: 20615728 DOI: 10.1016/j.healun.2010.05.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2010] [Revised: 05/11/2010] [Accepted: 05/26/2010] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND It has been previously shown that donor treatment with aprotinin or inhaled nitric oxide reduces reperfusion injury after lung transplantation in animals. These studies used living donors with normal lungs. However, the main source of lungs for transplantation is brain-dead donors. Brain death causes systemic inflammatory response and lung injury, rendering the organ susceptible to reperfusion injury after transplantation. We hypothesized that treatment with aprotinin or inhaled nitric oxide after brain death would improve the donor inflammatory response and reduce lung reperfusion injury after transplantation. METHODS Brain death was induced in 24 rats by intracranial balloon inflation. Subsequently, the animals received intravenous aprotinin (n = 8), inhaled nitric oxide (n = 7), or no treatment (n = 9) for 5 hours. The lungs were retrieved and reperfused for 2 hours using recipient rats. RESULTS After brain death, oxygenation deteriorated earlier and significantly more in rats that received treatment, especially with nitric oxide. Treatment did not reduce the donor systemic inflammatory response as assessed by serum levels of proinflammatory cytokines. Oxygenation, airway pressure, pulmonary vascular resistance, lung water index and bronchoalveolar lavage cytokine levels were similar after reperfusion of grafts from all three groups of donors. CONCLUSIONS Donor treatment with aprotinin or inhaled nitric oxide does not improve lungs that have been injured by brain death.
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Affiliation(s)
- Vassilios S Avlonitis
- Applied Immunology and Transplant Research Group, Institute of Cellular Medicine, Medical School, Newcastle University, Newcastle upon Tyne, United Kingdom.
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17
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Homi HM, Sheng H, Arepally GM, Mackensen GB, Grocott HP. Aprotinin Improves Functional Outcome but Not Cerebral Infarct Size in an Experimental Model of Stroke During Cardiopulmonary Bypass. Anesth Analg 2010; 111:38-45. [DOI: 10.1213/ane.0b013e3181e0549f] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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18
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Iwata Y, Nicole O, Okamura T, Zurakowski D, Jonas RA. Aprotinin confers neuroprotection by reducing apoptotic cell death. Asian Cardiovasc Thorac Ann 2010; 18:170-3. [PMID: 20304853 DOI: 10.1177/0218492310362120] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aprotinin has been used in pediatric cardiac surgery for its antiinflammatory and hemostatic benefits. We have reported that aprotinin has a direct cellular neuroprotective effect through reduction of excitotoxicity. The purpose of this study was to investigate whether aprotinin is neuroprotective against apoptotic cell death. Near-pure neuronal cultures containing <5% astrocytes were obtained from fetal mice. Serum deprivation was initiated at 7 days by transferring the cultures, which are dependent on serum for survival, into growth medium lacking serum for 24 h. Neuronal cell death was assessed by phase-contrast cell counting after staining with 0.4% trypan blue dye. Aprotinin at a clinically relevant concentration of 100 KIU.mL(-1) significantly reduced apoptotic neuronal cell death from 84.4% to 51.8%. This result suggests that aprotinin has the potential to reduce brain injury resulting from apoptotic cell death induced by an ischemic insult. Additional studies are needed to evaluate the potential of aprotinin to reduce neurological injury in patients at high risk of cerebral injury, including those undergoing circulatory arrest.
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Affiliation(s)
- Yusuke Iwata
- Children's National Medical Center, 111 Michigan Avenue NW, Washington, DC 20010, USA
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19
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Ishibashi N, Iwata Y, Zurakowski D, Lidov HGW, Jonas RA. Aprotinin protects the cerebral microcirculation during cardiopulmonary bypass. Perfusion 2009; 24:99-105. [PMID: 19654152 DOI: 10.1177/0267659109106701] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND OBJECTIVE We have previously reported that administration of aprotinin at a single dose protects the cerebral microcirculation. The current study was designed to identify the optimal dose for protecting the cerebral microcirculation with assessment of neurological and behavioral recovery as well as renal function after circulatory arrest and ultra-low-flow bypass. METHODS Twenty-four piglets were randomly assigned to three bypass groups at risk for postoperative cerebral and renal dysfunction. Cerebral microcirculation was assessed by intravital microscopy. Rhodamine-stained leukocytes were observed for adhesion and rolling. Animals were randomized to one of four aprotinin doses. Neurological deficit score, histological score, creatinine and blood urea nitrogen were analyzed, both independently for this study as well as in combination with 50 animals who were studied with the same protocol and near-infrared spectroscopy. RESULTS There was a dose-dependent relationship, resulting in fewer activated rolling leukocytes with a higher aprotinin dose. Aprotinin dose was an independent predictor of more rapid recovery of neurological and behavioral outcome. We present a linear regression model where aprotinin dose predicts neurological score. Aprotinin had no impact on renal function. CONCLUSIONS Aprotinin reduces cerebral leukocyte activation and accelerates neurologic recovery in a dose-dependent fashion. Aprotinin has no measurable impact on standard indices of renal function in young piglets. The current lack of availability of aprotinin is a serious disadvantage for pediatric patients undergoing cardiopulmonary bypass.
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Affiliation(s)
- N Ishibashi
- Department of Cardiac Surgery, Children's National Medical Center, Washington, DC 20010-2970, USA
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20
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Anderson DR, Taylor SL, Fetterer DP, Holmes WW. Evaluation of protease inhibitors and an antioxidant for treatment of sulfur mustard-induced toxic lung injury. Toxicology 2009; 263:41-6. [DOI: 10.1016/j.tox.2008.08.025] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2008] [Revised: 07/25/2008] [Accepted: 08/19/2008] [Indexed: 10/21/2022]
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Abstract
From the first description of the “systemic inflammatory response” in the early 1990s, it has been recognized that this is a multifaceted response of the body to the combined insult of cardiothoracic surgery with bypass, involving causation by “activation of complement, coagulation, fibrinolytic, and kallikrein cascades, activation of neutrophils with degranulation and protease enzyme release, oxygen radical production, and the synthesis of various cytokines from mononuclear cells.” Yet the intervening 15 years have seen a narrowing of research into individual systems and interventions naively targeted at single pathways without achieving clinically meaningful benefits. The time has come to redefine the systemic inflammatory response so that research can be more productively focused on objectively measuring and interdicting this multisystem disorder. A key concept of this new understanding is that translation into a hard adverse event occurs when the systemic imbalance is combined with a localized trigger. Triggers might be inadvertently provided by transient episodes of ischemia/malperfusion to vulnerable organs or handling trauma to major vessels. Future research should be directed at suppressing systemic activation with combinations of drugs and improved circuit coating, whereas changes in clinical practice and continuous monitoring of perfusion parameters can help eliminate localized triggering events.
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Affiliation(s)
- R. Clive Landis
- Edmund Cohen Laboratory for Vascular Research, Chronic Disease Research Centre, University of the West Indies, Bridgetown, Barbados, West Indies
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22
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Türüt H, Ciralik H, Kilinc M, Ozbag D, Imrek SS. Effects of early administration of dexamethasone, N-acetylcysteine and aprotinin on inflammatory and oxidant-antioxidant status after lung contusion in rats. Injury 2009; 40:521-7. [PMID: 18707685 DOI: 10.1016/j.injury.2008.05.001] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2008] [Accepted: 05/02/2008] [Indexed: 02/02/2023]
Abstract
INTRODUCTION This experimental setting was undertaken to elucidate and confirm the role of inflammatory and oxidant-antioxidant mechanisms on blunt injury induced moderate pulmonary contusion (PC). We intended to determine the effects of dexamethasone (DXM), N-acetylcysteine (NAC) and aprotinin (APR) in terms of their ability to diminish the consequences of acute lung injury due to PC. METHODS Rats were allocated to five subgroups. Except for the control, all subgroups had a moderate pulmonary contusion. Following 45 min of observation, animals in groups I and II received intraperitoneal saline, group III 10 mg/kg DXM, group IV 500 mg/kg NAC and group V 30,000 kIU/ml APR. After the procedure, 6 h after contusion, blood gas analysis, lung tissue nitric oxide (NO) and malondialdehyde (MDA) levels, superoxide dismutase (SOD) and catalase (CAT) activity, bronchoalveolar lavage (BAL) fluid and histopathological examination were performed. RESULTS All PaO(2) values decreased significantly in contused rats as compared with the control group (p<0.05). DXM, NAC and APR resulted in a slight increase in PaO(2) values compared with group II (p<0.05). Lung tissue levels of MDA and NO were higher in the contusion group than in the control (p<0.05). DXM, NAC and APR all decreased the levels of MDA and NO (p<0.05), however the decrease in NO was not found to be significant with APR (p>0.05). SOD and CAT activities increased significantly after contusion compared to control group (p<0.05). There was no significant difference even though SOD levels were elevated in groups III, IV and V compared with contused animals (p>0.05). Neutrophils in BAL fluid significantly increased in contused animals (p<0.05). Only DXM significantly decreased neutrophil population in BAL fluid (p<0.05). Scores for alveolar haemorrhage/oedema were higher in all contusion-performed rats than those in the control (p<0.05). Compared with the other drugs, only APR significantly improved the haemorrhage/oedema scores compared to sham animals (p=0.024). CONCLUSIONS Our findings demonstrate that moderate bilateral PC induced by blunt chest trauma leads to an early inflammatory process which is clearly associated with activation of the oxidant-antioxidant cascade. On this basis, early supportive treatment with DXM, NAC and APR may yield favourable results on pulmonary pathophysiological parameters which are adversely affected due to PC.
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Affiliation(s)
- Hasan Türüt
- Department of Thoracic Surgery, Kahramanmaras Sutcu Imam University Medical School, Kahramanmaras, Turkey.
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23
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Lee DH, Choi HC, Lee KY, Kang YJ. Aprotinin Inhibits Vascular Smooth Muscle Cell Inflammation and Proliferation via Induction of HO-1. THE KOREAN JOURNAL OF PHYSIOLOGY & PHARMACOLOGY : OFFICIAL JOURNAL OF THE KOREAN PHYSIOLOGICAL SOCIETY AND THE KOREAN SOCIETY OF PHARMACOLOGY 2009; 13:123-9. [PMID: 19885007 DOI: 10.4196/kjpp.2009.13.2.123] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aprotinin is used clinically in cardiopulmonary bypass surgery to reduce transfusion requirements and the inflammatory response. The mechanism of action for the anti-inflammatory effects of aprotinin is still unclear. We examined our hypothesis whether inhibitory effects of aprotinin on cytokine-induced inducible nitric oxide synthase (iNOS) expression (IL-1beta plus TNF-alpha), reactive oxygen species (ROS) generation, and vascular smooth muscle cell (VSMC) proliferation were due to HO-1 induction in rat VSMCs. Aprotinin induced HO-1 protein expression in a dose-dependent manner, which was potentiated during inflammatory condition. Aprotinin reduced cytokine mixture (CM)-induced iNOS expression in a dose dependent manner. Furthermore, aprotinin reduced CM-induced ROS generation, cell proliferation, and phosphorylation of JNK but not of P38 and ERK1/2 kinases. Aprotinin effects were reversed by pre-treatment with the HO-1 inhibitor, tin protoporphyrin IX (SnPPIX). HO-1 is therefore closely involved in inflammatory-stimulated VSMC proliferation through the regulation of ROS generation and JNK phosphorylation. Our results suggest a new molecular basis for aprotinin anti-inflammatory properties.
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Affiliation(s)
- Dong Hyup Lee
- Department of Thoracic and Cardiovascular Surgery, College of Medicine, Yeungnam University, Daegu 705-717, Korea
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24
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A comparison of the local effectiveness of mitomycin C, aprotinin, and Adcon-L in experimental peridural fibrosis. ACTA ACUST UNITED AC 2008; 70:608-13; discussion 613. [DOI: 10.1016/j.surneu.2007.07.071] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2007] [Accepted: 07/18/2007] [Indexed: 11/19/2022]
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25
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Carter JM, Buerke U, Rössner E, Russ M, Schubert S, Schmidt H, Ebelt H, Pruefer D, Schlitt A, Werdan K, Buerke M. Anti-inflammatory actions of aprotinin provide dose-dependent cardioprotection from reperfusion injury. Br J Pharmacol 2008; 155:93-102. [PMID: 18536753 PMCID: PMC2527842 DOI: 10.1038/bjp.2008.223] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2007] [Revised: 11/29/2007] [Accepted: 04/17/2008] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND AND PURPOSE Myocardial injury following ischaemia and reperfusion has been attributed to activation and transmigration of polymorphonuclear leukocytes (PMNs) with release of mediators including oxygen-derived radicals and proteases causing damage. EXPERIMENTAL APPROACH We studied the serine protease inhibitor aprotinin in an in vivo rabbit model of 1 h of myocardial ischaemia followed by 3 h of reperfusion (MI+R). Aprotinin (10,000 Ukg(-1)) or its vehicle were injected 5 min prior to the start of reperfusion. KEY RESULTS Myocardial injury was significantly reduced with aprotinin treatment as indicated by a reduced necrotic area (11+/-2.7% necrosis as percentage of area at risk after aprotinin; 24+/-3.1% after vehicle; P<0.05) and plasma creatine kinase activity (12.2+/-1.5 and 17.3+/-2.3 IU g(-1) protein in aprotinin and vehicle groups, respectively, P<0.05). PMN infiltration (assessed by myeloperoxidase activity) was significantly decreased in aprotinin-treated animals compared to vehicle (P<0.01). Histological analysis also revealed a substantial increase in PMN infiltration following MI+R and this was significantly reduced by aprotinin therapy (44+/-15 vs 102+/-2 PMN mm2 in aprotinin vs vehicle-treated animals, P<0.05). In parallel in vitro experiments, aprotinin inhibited neutrophil-endothelium interaction by reducing PMN adhesion on isolated, activated aortic endothelium. Finally, immunohistochemical analysis illustrated aprotinin significantly reduced myocardial apoptosis following MI+R. CONCLUSIONS AND IMPLICATIONS Inhibition of serine proteases by aprotinin inhibits an inflammatory cascade initiated by MI+R. The cardioprotective effect appears to be at least partly due to reduced PMN adhesion and infiltration with subsequently reduced myocardial necrosis and apoptosis.
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Affiliation(s)
- J M Carter
- Department of Medicine III, Martin-Luther-University Halle, Germany
| | - U Buerke
- Department of Medicine III, Martin-Luther-University Halle, Germany
| | - E Rössner
- Department of Medicine III, Martin-Luther-University Halle, Germany
| | - M Russ
- Department of Medicine III, Martin-Luther-University Halle, Germany
| | - S Schubert
- Department of Medicine III, Martin-Luther-University Halle, Germany
| | - H Schmidt
- Department of Medicine III, Martin-Luther-University Halle, Germany
| | - H Ebelt
- Department of Medicine III, Martin-Luther-University Halle, Germany
| | - D Pruefer
- Department of Cardiothoracic and Vascular Surgery, Johannes-Gutenberg University Mainz Mainz, Germany
| | - A Schlitt
- Department of Medicine III, Martin-Luther-University Halle, Germany
| | - K Werdan
- Department of Medicine III, Martin-Luther-University Halle, Germany
| | - M Buerke
- Department of Medicine III, Martin-Luther-University Halle, Germany
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26
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Evans BJ, Haskard DO, Finch JR, Hambleton IR, Landis RC, Taylor KM. The inflammatory effect of cardiopulmonary bypass on leukocyte extravasation in vivo. J Thorac Cardiovasc Surg 2008; 135:999-1006. [PMID: 18455576 DOI: 10.1016/j.jtcvs.2007.08.071] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2007] [Revised: 08/22/2007] [Accepted: 08/30/2007] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Extravascular trafficking of leukocytes into organs is thought to play a major role in the pathophysiologic mechanisms of the inflammatory response to cardiopulmonary bypass, yet leukocyte extravasation is difficult to study clinically. Here we have tested the hypothesis that leukocyte emigration into skin blisters can provide a way to monitor the inflammatory effect of cardiopulmonary bypass that allows testing of anti-inflammatory interventions (exemplified by aprotinin). METHODS Patients undergoing primary elective coronary artery bypass grafting (n = 14) were randomized into 2 equal groups to receive saline infusion during cardiopulmonary bypass (control group) or high-dose aprotinin. Experimental skin blisters (in duplicate) were induced on the forearm by means of topical application of the vesicant cantharidin, and blister fluid was sampled at 5 hours postoperatively. Inflammatory leukocyte subsets in blister fluid were analyzed by means of flow cytometry by using expression of CD11b and CD62L as a phenotypic marker of activation. RESULTS In the control group of patients, cardiopulmonary bypass surgery triggered a 381% increase in leukocyte extravasation into the skin compared with reference blisters carried out before surgical intervention, with neutrophil (P = .014), monocyte (P = .014), and eosinophil (P = .009) levels all statistically significantly increased. In the aprotinin group there was no statistically significant increase during cardiopulmonary bypass surgery in any inflammatory leukocyte subset. The activation phenotype of extravascular leukocytes was not significantly altered between surgical groups. CONCLUSIONS This study introduces the cantharidin blister technique as a powerful new research tool for analyzing the inflammatory effect of cardiopulmonary bypass in vivo. It has provided detailed molecular insight into the extravascular leukocyte population during cardiopulmonary bypass. Although aprotinin blocked cardiopulmonary bypass-dependent extravasation of leukocytes, there was no change in their CD11b/CD62L activation status. The cantharidin skin test thus represents a novel research tool for evaluating future anti-inflammatory interventions in cardiothoracic surgery.
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Affiliation(s)
- B J Evans
- British Heart Foundation, Cardiothoracic Surgery Unit, Imperial College Faculty of Medicine, Hammersmith Hospital, London, United Kingdom
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27
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Apostolakis E, Panagopoulos N, Koletsis EN, Crockett J, Stamou-Kouki H, Sourgiadaki E, Filos K, Dougenis D. Influence of ultra-low dose Aprotinin on thoracic surgical operations: a prospective randomized trial. J Cardiothorac Surg 2008; 3:14. [PMID: 18361800 PMCID: PMC2287179 DOI: 10.1186/1749-8090-3-14] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2007] [Accepted: 03/24/2008] [Indexed: 11/30/2022] Open
Abstract
Background The blood saving effect of aprotinin has been well documented in cardiac surgery. In thoracic surgery, very few recent studies, using rather high doses of aprotinin, have shown a similar result. In a randomized prospective trial, we have tested the influence of aprotinin using an ultra-low dose drug regime. Methods Fifty-nine patients, mean age 58 ± 13.25 years (mean ± SD) undergoing general thoracic procedures were randomized into placebo (Group A) and treatment group (Group B). The group B (n = 29) received 500.000 IU of aprotinin after induction to anesthesia and a repeat dose immediately after chest closure. A detailed protocol with several laboratory parameters was recorded. Patients were transfused when perioperative Ht was less than 26%. Results The two groups were similar in terms of age, gender, diagnosis, pathology, co-morbidity and operations performed. The mean drainage of the first and second postoperative day in group B was significantly reduced (412.6 ± 199.2 vs. 764.3 ± 213.9 ml, p < 0.000, and 248.3 ± 178.5 vs. 455.0 ± 274.6, p < 0.001). Similarly, the need for fresh frozen plasma transfusion was lower in group B, p < 0.035. Both the operation time and the hospital stay were also less for group B but without reaching statistical significance (84.6 ± 35.2 vs 101.2 ± 52.45 min. and 5.8 ± 1.6 vs 7.2 ± 3.6 days respectively, p < 0.064). The overall transfusion rate did not differ significantly. No side effects of aprotinin were noted. Conclusion The perioperative ultra-low dose aprotinin administration was associated with a reduction of total blood losses and blood product requirements. We therefore consider the use of aprotinin safe and effective in major thoracic surgery.
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Affiliation(s)
- Efstratios Apostolakis
- Department of Cardiothoracic Surgery, Patras University School of Medicine, Patras, Greece.
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Iwata Y, Nicole O, Okamura T, Zurakowski D, Jonas RA. Aprotinin confers neuroprotection by reducing excitotoxic cell death. J Thorac Cardiovasc Surg 2008; 135:573-8; discussion 578. [DOI: 10.1016/j.jtcvs.2007.08.076] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2007] [Revised: 07/30/2007] [Accepted: 08/07/2007] [Indexed: 10/22/2022]
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McEvoy MD, Reeves ST, Reves JG, Spinale FG. Aprotinin in Cardiac Surgery: A Review of Conventional and Novel Mechanisms of Action. Anesth Analg 2007; 105:949-62. [PMID: 17898372 DOI: 10.1213/01.ane.0000281936.04102.9f] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Induction of the coagulation and inflammatory cascades can cause multiorgan dysfunction after cardiopulmonary bypass (CPB). In light of these observations, strategies that can stabilize the coagulation process as well as attenuate the inflammatory response during and after cardiac surgery are important. Aprotinin has effects on hemostasis. In addition, aprotinin may exert multiple biologically relevant effects in the context of cardiac surgery and CPB. For example, it decreases neutrophil and macrophage activation and chemotaxis, attenuates release and activation of proinflammatory cytokines, and reduces oxidative stress. Despite these perceived benefits, the routine use of aprotinin in cardiac surgery with CPB has been called into question. In this review, we examined this controversial drug by discussing the classical and novel pathways in which aprotinin may be operative in the context of cardiac surgery.
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Affiliation(s)
- Matthew D McEvoy
- Department of Anesthesiology and Perioperative Medicine, Medical University of South Carolina, Charleston, South Carolina, USA.
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Jaggers J, Lawson JH. Coagulopathy and inflammation in neonatal heart surgery: mechanisms and strategies. Ann Thorac Surg 2007; 81:S2360-6. [PMID: 16731104 DOI: 10.1016/j.athoracsur.2006.02.072] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2005] [Revised: 02/09/2006] [Accepted: 02/13/2006] [Indexed: 10/24/2022]
Affiliation(s)
- James Jaggers
- Department of Pediatric Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina 27710, USA.
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Buerke M, Pruefer D, Sankat D, Carter JM, Buerke U, Russ M, Schlitt A, Friedrich I, Börgermann J, Vahl CF, Werdan K. Effects of Aprotinin on Gene Expression and Protein Synthesis After Ischemia and Reperfusion in Rats. Circulation 2007; 116:I121-6. [PMID: 17846291 DOI: 10.1161/circulationaha.106.680249] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Reperfusion injury of ischemic myocardium has been attributed to neutrophil infiltration, inflammatory activation and cardiac necrosis/apoptosis. Serine protease inhibition with aprotinin is cardioprotective, but the mechanism is unknown.
Methods and Results—
We studied aprotinin in a rat model of myocardial ischemia for 20 minutes and reperfusion for 20 minutes, 8 hours or 24 hours. Aprotinin (20 000 IU/kg) given 5 minutes before reperfusion significantly reduced leukocyte accumulation (
P
<0.01), myocardial injury (determined by CK depletion,
P
<0.01) and myocyte apoptosis (
P
<0.05) compared with vehicle treated rats. Differential gene expression analysis showed myocardial ischemia plus reperfusion increased expression of proinflammatory genes like P-selectin, E-selectin, intercellular adhesion molecule, tumor necrosis factor-α, tumor necrosis factor-α receptor, interleukin-6, monocyte chemoattractant protein-1, p53, and Fas (CD59). Aprotinin before reperfusion suppressed expression of these inflammatory genes. Finally, differential protein expression analysis demonstrated increased intercellular adhesion molecule-1, tumor necrosis factor-α, and p53 after myocardial ischemia plus reperfusion, and this effect was diminished by aprotinin.
Conclusions—
We demonstrated myocardial ischemia plus reperfusion induced leukocyte accumulation, inflammation, gene expression, protein expression and finally tissue injury and showed aprotinin limiting reperfusion injury through each of these stages, even after 24 hours of reperfusion. This effect seems partly attributable to suppression of proinflammatory genes and leukocyte accumulation. This work casts further light on the complex signaling of ischemia and reperfusion.
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Affiliation(s)
- Michael Buerke
- Department of Internal Medicine III, Martin Luther University Halle-Wittenberg, Ernst-Grube-Str. 40, 06120 Halle/Saale, Germany.
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Young RE, Voisin MB, Wang S, Dangerfield J, Nourshargh S. Role of neutrophil elastase in LTB4-induced neutrophil transmigration in vivo assessed with a specific inhibitor and neutrophil elastase deficient mice. Br J Pharmacol 2007; 151:628-37. [PMID: 17471175 PMCID: PMC2013993 DOI: 10.1038/sj.bjp.0707267] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND AND PURPOSE The serine protease neutrophil elastase (NE) appears to regulate inflammatory responses at multiple levels but its role in leukocyte transmigration in vivo remains unclear. The present study aimed to address this issue by using both an NE inhibitor (ONO-5046) and NE deficient (NE(-/-)) mice. EXPERIMENTAL APPROACH A number of inflammatory mediators (LTB(4), KC and PAF) were investigated in vitro for their ability to stimulate the release and the surface expression of NE by neutrophils. In addition, the role of NE in leukocyte migration elicited by topical LTB(4) was investigated in vivo in mouse cremasteric venules as observed by intravital microscopy. KEY RESULTS Amongst the mediators tested in vitro, LTB(4) was found to be a highly potent and efficacious inducer of NE cell surface expression on murine neutrophils. Furthermore, in wild-type mice (WT), LTB(4)-induced leukocyte transmigration was reduced by intravenous ONO-5046 (66% inhibition), an effect that appeared to occur at the level of the perivascular basement membrane. Interestingly, LTB(4)-induced responses were normal in NE(-/-) mice and, while ONO-5046 had no inhibitory effect in these animals, the broad-spectrum serine protease inhibitor aprotinin suppressed leukocyte transmigration in both WT and NE(-/-) mice. CONCLUSIONS AND IMPLICATIONS The findings demonstrate the potent ability of LTB(4) to induce cell-surface expression of NE and provide evidence for the involvement of NE in LTB(4)-induced neutrophil transmigration in vivo. The results also suggest the existence of compensatory mechanisms in NE(-/-) mice, highlighting the added value of investigating pharmacological blockers in parallel with genetic deletion.
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Affiliation(s)
- R E Young
- Cardiovascular Medicine Unit, National Heart & Lung Institute, Faculty of Medicine, Imperial College London, Hammersmith Hospital Du Cane Road, London, UK
| | - M-B Voisin
- Cardiovascular Medicine Unit, National Heart & Lung Institute, Faculty of Medicine, Imperial College London, Hammersmith Hospital Du Cane Road, London, UK
| | - S Wang
- Cardiovascular Medicine Unit, National Heart & Lung Institute, Faculty of Medicine, Imperial College London, Hammersmith Hospital Du Cane Road, London, UK
| | - J Dangerfield
- Cardiovascular Medicine Unit, National Heart & Lung Institute, Faculty of Medicine, Imperial College London, Hammersmith Hospital Du Cane Road, London, UK
| | - S Nourshargh
- Cardiovascular Medicine Unit, National Heart & Lung Institute, Faculty of Medicine, Imperial College London, Hammersmith Hospital Du Cane Road, London, UK
- Author for correspondence:
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Landis RC. Protease activated receptors: clinical relevance to hemostasis and inflammation. Hematol Oncol Clin North Am 2007; 21:103-13. [PMID: 17258121 DOI: 10.1016/j.hoc.2006.11.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The protease-activated receptors (PARs) are a unique family of vascular receptors that confer on cells an ability to sense, and respond to, local changes in the proteolytic environment. They are activated by serine proteases of the blood coagulation cascade, notably thrombin, and are linked to thrombotic and inflammatory effector pathways. In surgery with cardiopulmonary bypass (CPB), thrombin is generated in large quantities in the extracorporeal circuit and can exert systemic effects by way of platelet and endothelial PAR1. Aprotinin (Trasylol), a serine protease inhibitor used in cardiac surgery, preserves platelet function, and attenuates the inflammatory response by protecting the PAR 1 receptor on platelets and endothelium.
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Affiliation(s)
- R Clive Landis
- Edmund Cohen Laboratory for Vascular Research, University of the West Indies, Chronic Disease Research Centre, Jemmotts Lane, Barbados, West Indies.
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Bittner HB, Binner C, Dahlberg P, Mohr FW. Reducing Ischemia–Reperfusion Injury in Clinical Lung Transplantation. Transplant Proc 2007; 39:489-92. [PMID: 17362765 DOI: 10.1016/j.transproceed.2006.12.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Acute graft dysfunction secondary to ischemia-reperfusion injury (IRI) continues to be the most common cause of early mortality after lung transplantation. The perioperative management with aprotinin could decrease the incidence of severe IRI. METHODS A retrospective analysis was conducted of the data from 180 patients who underwent either single lung (56%) or bilateral sequential lung transplantation for similar end-stage lung disease between 1997 and 2005. The most recent 68 patients were managed perioperatively with the high-dose aprotinin infusion regimen (aprotinin group). The ISHLT grade III injury score was used for the diagnosis of severe IRI, which is based on a Pao(2)-FIo(2) ratio of less than 200 mmHg. RESULTS Grade III injury was observed in 18% of the patients who were not managed with aprotinin (control group, 152 grafts, 64% single transplants, 68% male, 54 +/- 8 years of age). Early ECMO support was required in 25% of these patients. The associated mortality rate was 40%. Despite significantly longer cold ischemic times (290 +/- 14 minutes vs 231 +/- 14 minutes), older donors (42 +/- 12 years of age), and more frequently observed severely elevated systolic PAP of greater than 60 mmHg (60% vs 48%) as well as more frequently required extracorporeal circulatory support (24%* vs 12%) in the aprotinin group, the incidence of severe IRI (8%) and associated mortality (9%) was markedly reduced. CONCLUSIONS The use of aprotinin in LTX surgery, which had strong beneficial effects on patient outcomes, significantly decreased the incidence of severe posttransplant IRI.
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Affiliation(s)
- H B Bittner
- Division of Thoracic and Cardiovascular Surgery, Heart Center Leipzig of the University of Leipzig, Leipzig, Germany.
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Abstract
Hemostatic abnormalities occur following injury associated with both cardiac and noncardiac surgery. These changes are part of inflammatory pathways with signaling mechanisms that link these diverse pathways. The inflammatory response to surgery is exacerbated by allogeneic blood transfusion by enhancing intrinsic inflammatory activity and directly increasing plasma levels of inflammatory mediators. Surgical patients can be preventively treated with pharmacologic agents to modulate inflammatory responses. Multiple studies have reported preventive pharmacologic therapies to reduce bleeding and the need for allogeneic transfusions in surgery. Strategies for cardiac surgical patients during cardiopulmonary bypass include administration of either lysine analogs, such as epsilon aminocaproic acid and tranexamic acid, or the serine protease inhibitor aprotinin.
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Affiliation(s)
- Jerrold H Levy
- Department of Anesthesiology, Emory University School of Medicine, 1364 Clifton Road N.E., Atlanta, GA 30322, USA.
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36
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Abstract
Cardiac surgery is associated with a systemic inflammatory response and systemic coagulopathy, which can result in significant organ dysfunction and bleeding. Aprotinin, a serine protease inhibitor, can limit systemic inflammation, and has been associated with myocardial, pulmonary and cerebral protection in addition to its proven haemostatic efficacy. Data are currently conflicting regarding the haemostatic efficacy of aprotinin relative to alternative agents including tranexamic acid. Recent studies have demonstrated aprotinin usage is associated with increased rates of thrombotic and renal complications, but these findings are at odds with the majority of studies relating to aprotinin safety to date. The lack of adequately powered, randomised studies evaluating aprotinin and alternative agents limits drawing conclusions about the complete use or disuse of aprotinin presently and requires individualised patient selection based on bleeding risk and co-morbidities for its usage.
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Affiliation(s)
- Neel R Sodha
- Division of Cardiothoracic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts 02215, USA
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Karaca P, Konuralp C, Enc Y, Süzer A, Sokullu O, Ayoglu U, Cicek S. Cardioprotective effect of aprotinin on myocardial ischemia/reperfusion injury during cardiopulmonary bypass. Circ J 2006; 70:1432-6. [PMID: 17062966 DOI: 10.1253/circj.70.1432] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Aprotinin is a serine protease inhibitor used extensively in cardiac operations to reduce postoperative bleeding. It also has cardioprotective effects in ischemia/reperfusion injury. In this study, the effects of aprotinin on the release of cardiac markers were evaluated in patients who had good ventricular function and were undergoing coronary artery bypass grafting with cardiopulmonary bypass (CPB). METHODS AND RESULTS Eighty male patients with an ejection fraction >or=40%, were randomized into either an aprotinin (Group-I; n=40) or control (Group-II; n=40) group. Patients in the aprotinin group received the full Hammersmith doses of aprotinin (2 x 10(6) KIU pre-CPB, 2 x 10(6) KIU at pump prime, 500,000 KIU/h during CPB), whereas the patients in the control group received only saline solutions. Cardiac troponin-I (cTnI) levels were measured before surgery, immediately after surgery, and at postoperative 6(th), 12(th), 24(th) h and 5(th) day. Creatine kinase (CK)-MB measurements were performed at the same time except for the postoperative 5(th) day. Cardiac index (CI), mixed venous oxygen saturation and lactate dehydrogenase (LDH) measurements were also performed. CONCLUSION Although all patients were in reasonable condition, less myocardial enzyme leakage occurred on the aprotinin group, suggesting that aprotinin has a protective effect on the myocardium beyond that achieved with blood cardioplegia and systemic hypothermia. Because of aprotinin's effects on multiple targets of metabolism, its protective value might increase in more complicated cases.
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Affiliation(s)
- Pelin Karaca
- Department of Anesthesia and Reanimation, Siyami Ersek Thoracic and Cardiovascular Surgery Center, Istanbul, Turkey
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Day JRS, Landis RC, Taylor KM. Aprotinin and the protease-activated receptor 1 thrombin receptor: antithrombosis, inflammation, and stroke reduction. Semin Cardiothorac Vasc Anesth 2006; 10:132-42. [PMID: 16959740 DOI: 10.1177/1089253206288997] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Cardiopulmonary bypass, although remaining an indispensable asset in cardiac surgery, especially in more complex and repeat operations, is associated with significant thrombin generation in the bypass circuit, leading to the activation of platelets, the coagulation system, an inflammatory response, and perioperative stroke. Recent clinical studies and meta-analyses of clinical trials in coronary artery bypass grafting surgery have confirmed that aprotinin not only reduces transfusion requirements in cardiac surgery but also confers significant protection against platelet dysfunction, activation of the systemic inflammatory response, and perioperative stroke when administered at the full (or "Hammersmith") dose. This article reviews research from several independent groups to propose a novel mechanism through which the antithrombotic, anti-inflammatory, and neuroprotective mechanism might be mediated, via protection of the high-affinity thrombin receptor protease-activated receptor 1 (PAR1).
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Affiliation(s)
- J R S Day
- British Heart Foundation Cardiac Surgery Unit, Imperial College, London, UK.
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Anttila V, Hagino I, Iwata Y, Mettler BA, Lidov HGW, Zurakowski D, Jonas RA. Aprotinin improves cerebral protection: Evidence from a survival porcine model. J Thorac Cardiovasc Surg 2006; 132:948-53. [PMID: 17000309 DOI: 10.1016/j.jtcvs.2006.06.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2005] [Revised: 01/26/2006] [Accepted: 06/13/2006] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Aprotinin is a serine protease inhibitor used during cardiac surgery to reduce blood loss and preserve platelet function. It has also been shown to reduce leukocyte activation during and after cardiopulmonary bypass. The goal of the study was to test the hypothesis that aprotinin could reduce cerebral injury after low-flow cardiopulmonary bypass and deep hypothermic circulatory arrest. METHODS Sixteen piglets (mean weight, 13.6 +/- 1.3 kg) were randomly assigned to receive aprotinin or placebo (8 animals per group) before a 120-minute period of deep hypothermic circulatory arrest (15 degrees C) or 25 mL x kg(-1) x min(-1) low-flow cardiopulmonary bypass (25 degrees C or 34 degrees C). Piglets had a cranial window placed over the parietal cerebral cortex for direct examination of the microcirculation by means of intravital microscopy. Rhodamine-stained leukocytes were observed in postcapillary venules, with analysis for adhesion and rolling. Plasma was labeled with fluorescein isothiocyanate-dextran for assessment of functional capillary density. Neurologic and histologic scores were used as the primary outcome measures. RESULTS During rewarming, the mean number of both rolling and adherent leukocytes was significantly lower after aprotinin administration (P < .05). At 5 and 15 minutes of rewarming, functional capillary density recovered faster with aprotinin treatment (P < .05). Functional outcome (neurologic deficit score) on postoperative day 1 was significantly improved in aprotinin-treated piglets (P < .05). CONCLUSIONS Aprotinin reduces inflammation and improves neurologic outcome after a prolonged period of deep hypothermic circulatory arrest or low-flow cardiopulmonary bypass.
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Affiliation(s)
- Vesa Anttila
- Department of Cardiovascular Surgery, Children's Hospital Boston, Harvard Medical School, Boston, Mass, USA
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Abstract
Renal dysfunction following cardiopulmonary bypass (CPB) is well recognized. The extent of perioperative renal impairment ranges from subclinical injury to established renal failure requiring dialysis. Its incidence varies considerably, depending on the definition and criteria used in the different studies. Acute renal failure (ARF) affects 1-5% of patients and remains a major cause of morbidity and mortality. Co-morbidities, including diabetes mellitus, impaired left ventricular function and advanced age, are recognized predisposing factors. The pathophysiology is multifactorial and is thought related to the systemic inflammatory response and renal hypoperfusion secondary to extracorporeal circulation. Non-pulsatile flow during CPB is thought to be an important aetiological factor, resulting in renal vasoconstriction and ischaemic renal injury. A theoretical reduction in the incidence and severity of postoperative renal impairment has been proposed by advocating the use of pulsatile flow during CPB, or eliminating CPB, especially in high-risk patients. The current evidence, however, is conflicting. Several large observational studies, including a large proportion of high-risk patients, have demonstrated a significant reduction in the frequency of renal failure in patients undergoing off-pump surgery. As older, sicker patients increasingly constitute the cardiac surgical population, the incidence of postoperative renal injury is likely to increase. Further studies addressing various renoprotective strategies in higher-risk patients are awaited.
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Affiliation(s)
- Yasir Abu-Omar
- Department of Cardiothoracic Surgery, Hammersmith Hospital, London, UK
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Shann KG, Likosky DS, Murkin JM, Baker RA, Baribeau YR, DeFoe GR, Dickinson TA, Gardner TJ, Grocott HP, O'Connor GT, Rosinski DJ, Sellke FW, Willcox TW. An evidence-based review of the practice of cardiopulmonary bypass in adults: A focus on neurologic injury, glycemic control, hemodilution, and the inflammatory response. J Thorac Cardiovasc Surg 2006; 132:283-90. [PMID: 16872951 DOI: 10.1016/j.jtcvs.2006.03.027] [Citation(s) in RCA: 136] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2005] [Revised: 01/10/2006] [Accepted: 03/13/2006] [Indexed: 01/04/2023]
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Leijdekkers VJ, Vahl AC, Mackaay AJC, Huijgens PC, Rauwerda JA. Aprotinin does not diminish blood loss in elective operations for infrarenal abdominal aneurysms: a randomized double-blind controlled trial. Ann Vasc Surg 2006; 20:322-9. [PMID: 16779513 DOI: 10.1007/s10016-006-9043-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2005] [Revised: 06/27/2005] [Accepted: 02/27/2006] [Indexed: 11/29/2022]
Abstract
Surgery for abdominal aneurysm is associated with substantial blood loss. In cardiac surgery, aprotinin, a fibrinolysis inhibitor, has shown to reduce blood loss significantly. Our aim was to assess the effect of aprotinin, when administered during elective surgery of infrarenal abdominal aneurysm, on coagulation, blood loss, and morbidity. A double-blind randomized trial was performed on 35 consecutive patients. They were randomized to either an aprotinin or a placebo group. The aprotinin group received 2,000,000 kallikrein inhibiting units (KIU) of aprotinin (500,000 KIU in 50 mL NaCl 0.9%) as a starting dose, followed by 500,000 KIU per hour during the operation. The placebo group received equal amounts of only NaCl 0.9%. During the operation and 24 hr thereafter, blood samples were taken to assess coagulation factors. Blood loss was measured in suction devices and swabs. All patients were followed until their discharge from the hospital. Statistical analysis was performed by independent t-test or Mann-Whitney U-test and chi-squared test. There was no significant difference in the amount of blood loss or the amount of blood products administered between the two groups. Morbidity and mortality were also comparable. In both groups, consumption of clotting factors could be detected, indicating activation of the coagulation cascade. However, in the aprotinin group, the alpha2-antiplasmin level was raised during surgery, indicating inhibition of fibrinolysis. Administration of aprotinin during elective operations for infrarenal aortic aneurysm induces inhibition of fibrinolysis. However, it does not significantly reduce blood loss or the need for blood products.
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Lazar HL, Bao Y, Tanzillo L, O'Gara P, Reardon D, Price D, Crowley R, Cabral HJ. Aprotinin decreases ischemic damage during coronary revascularization. J Card Surg 2006; 20:519-23. [PMID: 16309402 DOI: 10.1111/j.1540-8191.2005.00136.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND AIM This study sought to determine whether the favorable anti-inflammatory effects of aprotinin might limit ischemic damage during the revascularization of ischemic myocardium. METHODS Twenty pigs underwent 90 minutes of coronary occlusion followed by 45 minutes of blood cardioplegic arrest and 180 minutes of reperfusion. Ten animals received a loading dose of aprotinin (40,000 kallikrein inhibiting units/kg) during the start of coronary occlusion followed by an infusion of 20,000 kallikrein inhibiting units/kg/hour. Ten other animals received no aprotinin. Summary statistics are expressed as the mean +/- standard error. RESULTS The aprotinin-treated animals required less cardioversions for ventricular arrhythmias (1.0 +/- 0.7 vs. 3.6 +/- 0.6; p < 0.001), accumulated less lung water (1.0 +/- 0.2% change vs. 6.2 +/- 0.9% change; p = 0.038), had more complete coronary relaxation to bradykinin (34.1 +/- 5.9% change vs. 9.2 +/- 3.5% change; p = 0.01), and had reduced infarct size (area necrosis/area risk = 20 +/- 1.1% vs. 39 +/- 1.2%; p = 0.003). CONCLUSIONS Aprotinin limits ischemic injury during acute coronary revascularization by decreasing ventricular arrhythmias and lung edema, preserving endothelial function, and minimizing myocardial necrosis.
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Affiliation(s)
- Harold L Lazar
- Department of Cardiothoracic Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts 02118, USA.
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Hess PJ. Systemic inflammatory response to coronary artery bypass graft surgery. Am J Health Syst Pharm 2006; 62:S6-9. [PMID: 16227195 DOI: 10.2146/ajhp050302] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Several aspects of the systemic inflammatory response to coronary artery bypass graft surgery are described. SUMMARY The inflammatory response is a fundamental biological protective mechanism that gathers together the body's cellular and chemical defense mechanisms at the local site of tissue injury. The systemic inflammatory response syndrome refers to a systemic, whole body, non-localized response. This response, which occurs to some degree in most patients undergoing coronary artery bypass graft surgery, has the potential to affect all tissues and vital organs. When blood interacts with the cardiopulmonary bypass machine, several cellular and humoral pathways are activated including the complement system, the coagulation system, and the fibrinolytic system. These, in turn, activate inflammatory response cells, such as leukocytes and platelets. Together these molecular pathways and activated cells mediate the frequently observed clinical sequelae such as edema, tissue and organ damage, and hyperfibrinolysis. In order for a molecule drug to attenuate effectively this response, it would need to have a broad enough spectrum of activity to inhibit multiple pathways and to limit their cross-amplification. Aprotinin, a nonspecific serine protease, is an important attenuator of this response as it inhibits several important serine proteases, including kallikrein, plasmin, thrombin, and elastase, which are involved in fibrinolysis and cell transmigration and degranulation into soft tissues. CONCLUSION Treatment with aprotinin during coronary artery bypass graft surgery should be considered as a way to attenuate bleeding and systemic inflammatory responses.
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Affiliation(s)
- Philip J Hess
- University of Florida and Shands Hospital, 1600 SW Archer Road, Gainesville, FL 32610-0286, USA.
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Day JRS, Taylor KM, Lidington EA, Mason JC, Haskard DO, Randi AM, Landis RC. Aprotinin inhibits proinflammatory activation of endothelial cells by thrombin through the protease-activated receptor 1. J Thorac Cardiovasc Surg 2006; 131:21-7. [PMID: 16399290 DOI: 10.1016/j.jtcvs.2005.08.050] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2005] [Revised: 07/26/2005] [Accepted: 08/31/2005] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Thrombin is generated in significant quantities during cardiopulmonary bypass and mediates adverse events, such as platelet aggregation and proinflammatory responses, through activation of the high-affinity thrombin receptor protease-activated receptor 1, which is expressed on platelets and endothelium. Thus antagonism of protease-activated receptor 1 might have broad therapeutic significance. Aprotinin, used clinically to reduce transfusion requirements and the inflammatory response to bypass, has been shown to inhibit protease-activated receptor 1 on platelets in vitro and in vivo. Here we have examined whether aprotinin inhibits endothelial protease-activated receptor 1 activation and resulting proinflammatory responses induced by thrombin. METHODS Protease-activated receptor 1 expression and function were examined in cultured human umbilical vein endothelial cells after treatment with alpha-thrombin at 0.02 to 0.15 U/mL in the presence or absence of aprotinin (200-1600 kallikrein inhibitory units/mL). Protease-activated receptor 1 activation was assessed by using an antibody, SPAN-12, which detects only the unactivated receptor, and thrombin-mediated calcium fluxes. Other thrombin-dependent inflammatory pathways investigated were phosphorylation of the p42/44 mitogen-activated protein kinase, upregulation of the early growth response 1 transcription factor, and production of the proinflammatory cytokine interleukin 6. RESULTS Pretreatment of cultured endothelial cells with aprotinin significantly spared protease-activated receptor 1 receptor cleavage (P < .0001) and abrogated calcium fluxes caused by thrombin. Aprotinin inhibited intracellular signaling through p42/44 mitogen-activated protein kinase (P < .05) and early growth response 1 transcription factor (P < .05), as well as interleukin 6 secretion caused by thrombin (P < .005). CONCLUSIONS This study demonstrates that endothelial cell activation by thrombin and downstream inflammatory responses can be inhibited by aprotinin in vitro through blockade of protease-activated receptor 1. Our results provide a new molecular basis to help explain the anti-inflammatory properties of aprotinin reported clinically.
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Affiliation(s)
- Jonathan R S Day
- Eric Bywaters Centre, Imperial College London, Faculty of Medicine, Hammersmith Hospital, London, United Kingdom
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Khan TA, Bianchi C, Araujo E, Voisine P, Xu SH, Feng J, Li J, Sellke FW. Aprotinin preserves cellular junctions and reduces myocardial edema after regional ischemia and cardioplegic arrest. Circulation 2006; 112:I196-201. [PMID: 16159815 DOI: 10.1161/circulationaha.104.526053] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Cardiac surgery with cardiopulmonary bypass (CPB) and cardioplegic arrest has been associated with myocardial edema attributable to vascular permeability, which is regulated in part by thrombin-induced alterations in cellular junctions. Aprotinin has been demonstrated to prevent activation of the thrombin protease-activated receptor, and we hypothesized that aprotinin preserves myocardial cellular junctions and prevents myocardial edema in a porcine model of regional ischemia and cardioplegic arrest. METHODS AND RESULTS Fourteen pigs were subjected to 30 minutes of regional ischemia, followed by 60 minutes of CPB, with 45 minutes of crystalloid cardioplegia, then 90 minutes of post-CPB reperfusion. The treatment group (n=7) was administered aprotinin (40,000 kallikrein inhibitor units [KIU]/kg loading dose, 40,000 KIU/kg pump prime, and 10,000 KIU/kg per hour continuous infusion). Control animals (n=7) received normal saline. Myocardial vascular endothelial (VE)-cadherin, beta-catenin and gamma-catenin, and associated mitogen-activated protein kinase (MAPK) pathways were assessed by immunoblot and immunoprecipitation. Histologic analysis of the cellular junctions was done by immunofluorescence. Myocardial tissue water content was measured. VE-cadherin, beta-catenin, and gamma-catenin levels were significantly greater in the aprotinin group (all P<0.05). Immunfluorescence confirmed that aprotinin prevented loss of coronary endothelial adherens junction continuity. Aprotinin reduced tyrosine phosphorylation in myocardial tissue sections. Phospho-p38 activity was approximately 30% lower in the aprotinin group (P=0.007). The aprotinin group demonstrated decreased myocardial tissue water content (81.2+/-0.5% versus 83.5+/-0.3%; P=0.01) and reduced intravenous fluid requirements (2.9+/-0.2 L versus 4.0+/-0.4 L; P=0.03). CONCLUSIONS Aprotinin preserves adherens junctions after regional ischemia and cardioplegic arrest through a mechanism potentially involving the p38 MAPK pathway, resulting in preservation of the VE barrier and reduced myocardial tissue edema.
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Affiliation(s)
- Tanveer A Khan
- Division of Cardiothoracic Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Levy JH. Overview of clinical efficacy and safety of pharmacologic strategies for blood conservation. Am J Health Syst Pharm 2005; 62:S15-9. [PMID: 16227191 DOI: 10.2146/ajhp050303] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The pharmacologic management of hemostasis in patients undergoing surgery with cardiopulmonary bypass is discussed. SUMMARY Nearly 45 studies involving 7,000 patients have reported efficacy of aprotinin in blood conservation. Both in primary coronary artery bypass graft (CABG) surgeries and in repeat surgeries, aprotinin treatment significantly reduces the incidence of blood transfusions and the number of units of blood transfused. These effects have been observed for red blood cell, platelet, and other blood products. The safety of aprotinin treatment has been extensively evaluated in randomized clinical trials, in postmarketing databases, and in systematic reviews of the literature. Overall, data do not indicate that aprotinin treatment increases mortality, myocardial infarction, or renal failure. These findings are supported by the results of a recent meta-analysis of 35 studies in patients undergoing CABG surgery. In addition, the meta-analysis suggests that aprotinin treatment was associated with a reduced incidence of stroke and a trend toward a reduced incidence of atrial fibrillation. Although lysine analogs, desmopressin, and recombinant factor VIIa are sometimes used to reduce bleeding, only aprotinin is indicated for use during CABG surgery. CONCLUSION The future of cardiac surgery will be marked by an increasingly complex, high-risk group of patients and a greater need for multiple pharmacologic options for reducing bleeding. Pharmacologic approaches that attenuate the activation of the hemostatic system and inflammation need to be employed to decrease coagulopathies and the need for allogeneic blood administration.
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Affiliation(s)
- Jerrold H Levy
- Emory University School of Medicine, 1364 Clifton Road NE, Atlanta, GA 30322, USA.
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Kohl BA, McGarvey ML. Anesthesia and Neurocerebral Monitoring for Aortic Dissection. Semin Thorac Cardiovasc Surg 2005; 17:236-46. [PMID: 16253828 DOI: 10.1053/j.semtcvs.2005.06.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2005] [Indexed: 11/11/2022]
Abstract
Patients presenting to the operating room for repair of aortic dissection are challenging in all aspects of their care. Without exception, they require a multidisciplinary team approach. This article will review some of the specific challenges faced by anesthesiologists and neurologists when confronted with such a diagnosis. Specifically, we will discuss the myriad anesthetic issues that present in the preoperative stage and continue into the postoperative period. Neurologic complications during dissection repair result in increased morbidity and mortality. A variety of neurophysiologic monitoring techniques exist that may reduce this risk and will be discussed in detail. Finally, we will present some "controversies in care," emphasizing that our respective fields continue to grow, learn, and improve what information we have on the morbidity and mortality of aortic dissection.
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Affiliation(s)
- Benjamin A Kohl
- Department of Anesthesia and Critical Care, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania 19104, USA
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Kher A, Meldrum KK, Hile KL, Wang M, Tsai BM, Turrentine MW, Brown JW, Meldrum DR. Aprotinin improves kidney function and decreases tubular cell apoptosis and proapoptotic signaling after renal ischemia-reperfusion. J Thorac Cardiovasc Surg 2005; 130:662-9. [PMID: 16153910 DOI: 10.1016/j.jtcvs.2005.02.035] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2004] [Revised: 02/08/2005] [Accepted: 02/15/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The purpose of the study was to determine the effects of aprotinin on (1) renal function, (2) apoptosis and apoptotic signaling, and (3) the inflammatory response of the kidney after ischemia-reperfusion injury. METHODS Male rats underwent a sham procedure or left renal ischemia for 1 hour. Rats were divided into three groups and received no reperfusion, reperfusion for 1 hour, or reperfusion for 24 hours. The animals undergoing ischemia received saline solution alone or aprotinin (60,000 kIU/kg). At the end of the experiment, a sample for serum creatinine was taken and the left kidney was harvested. The kidney was analyzed for expression of tumor necrosis factor alpha, interleukin 1beta, and interleukin 6 (enzyme-linked immunosorbent assay and reverse transcriptase-polymerase chain reaction) and activation of p38 mitogen-activated protein kinase, caspase 3, and caspase 8 (Western blot). The kidney was assessed for apoptosis with enzyme-linked immunosorbent assay and by terminal deoxynucleotidyl transferase biotin-deoxyuridine triphosphate nick-end labeling staining of tissue slides. RESULTS Aprotinin significantly decreased the rise in serum creatinine and apoptosis caused by ischemia-reperfusion. Aprotinin significantly reduced interleukin 1 and 6 messenger RNA production and showed a trend toward reducing tumor necrosis factor messenger RNA production after ischemia. Aprotinin also significantly reduced caspase 8 activation and showed a trend toward decreasing p38 mitogen-activated protein kinase activation after 1 hour of reperfusion. CONCLUSION These results suggest that aprotinin provides protection from renal ischemia-reperfusion injury. They also suggest that aprotinin may do so by affecting apoptotic signaling and inflammatory cytokine production. Aprotinin is a potential therapeutic measure in clinical situations where renal ischemia-reperfusion injury can be anticipated, provided adequate heparinization is possible.
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Affiliation(s)
- Ajay Kher
- Department of Surgery, Indiana University Medical Center, Indianapolis, Ind, USA
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Nader ND, Davidson BA, Tait AR, Holm BA, Knight PR. Serine Antiproteinase Administration Preserves Innate Superoxide Dismutase Levels After Acid Aspiration and Hyperoxia but Does Not Decrease Lung Injury. Anesth Analg 2005; 101:213-9, table of contents. [PMID: 15976234 DOI: 10.1213/01.ane.0000152188.65226.fe] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Acute lung injury after acid aspiration and increased ambient oxygen result in significant oxidative damage to the lungs. Lung antioxidant levels are also reduced. Because levels of serine proteinases in the airspaces are also dramatically increased, we hypothesized that these enzymes play a role in degrading lung antioxidants. Rats were treated with a serine proteinase inhibitor, aprotinin, before pulmonary aspiration of acid in the presence of increased ambient oxygen (hyperoxia). Lung Cu/Zn and Mn superoxide dismutase (SOD) activity (by colorimetric assay) and Cu/Zn SOD immune reactive protein (enzyme-linked immunosorbent assay) were assayed. The effects of antiproteinase treatment on acute lung injury were also assessed. Total SOD, Cu/Zn SOD, and Cu/Zn SOD antigenic protein levels were decreased in animals after acid aspiration and hyperoxia. However, Mn SOD activity was unchanged. The decrease in Cu/Zn SOD was attenuated in animals, where serine proteinase activity was inhibited. However, antiproteinase treatment did not decrease acute pulmonary injury, as assessed by leakage of radiolabeled albumin into the lung (permeability index), arterial blood gases, and markers of acute inflammation (pulmonary myeloperoxidase activity, a surrogate neutrophilic marker, and inflammatory cytokine profiles). We conclude that production of serine proteinases play a major role in degrading Cu/Zn SOD, thereby decreasing pulmonary antioxidant capacity. However, the role this plays in the pathogenesis of the acute lung injury is not clear.
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Affiliation(s)
- Nader D Nader
- Department of Anesthesiology, State University of New York at Buffalo, Buffalo, NY 14215, USA.
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