The effects of kallidinogenase on choroidal blood flow in a hypertensive rabbit model

Human urinary kallidinogenase in treating acute ischemic stroke patients: analyses of pooled data from a randomized double-blind placebo-controlled phase IIb and phase III clinical trial

Objectives: Intravenous thrombolysis and thrombectomy are recommended for patients whose stroke onsets are within first 6 h, and very few options are available for patients whose stroke onset is more than 6 h, which includes most ischemic stroke patients. Human urinary kallidinogenase (HUK) showed potential clinical benefits in acute ischemic stroke patients. This study aims to investigate the safety and clinical benefits of HUK in ischemic stroke patients.Patients and methods: Patients were recruited for a multicenter double-blind, placebo-controlled phase II b and phase III trial. Neurophysiological outcomes were assessed by the European Stroke Scale (ESS) and the functional outcomes were assessed by the activity of daily living scale (ADL). Safety was monitored by recording adverse events.Results: The improvements in ESS scores and ADL scores in the HUK group were significantly greater than that in patients receiving placebo. Furthermore, HUK treatment was also associated with a lower rate of disable, according to ADL. HUK-related adverse events occurred at a low rate, in 1.73% of HUK-treated patients.Conclusion: HUK is safe and provides potential clinical benefits as a treatment for acute ischemic stroke. Further large post-marketing observational studies are needed.

Effects of kallidinogenase on retinal edema and size of non-perfused areas in mice with retinal vein occlusion

Kallidinogenase has been used to treat retinal vein occlusion (RVO) in patients, although there are no evidences on the effects of kallidinogenase on the retinal edema and the non-perfused areas in eyes with a RVO. We have established a murine RVO model with retinal edema and non-perfused areas. The purpose of this study was to evaluate the effects of kallidinogenase on the retinal edema and size of the non-perfused areas in the mouse RVO model. We evaluated the thickness of the retinal layers and size of the non-perfused areas, and the blood flow by laser speckle flowgraphy in RVO model. The effects of an intravenous injection of kallidinogenase on the retinal edema and size of the non-perfused areas were determined. In addition, the expressions of phosphorylated protein kinase B (Akt) and endothelial nitric oxide synthase (eNOS) were measured by Western blotting. Our results showed that kallidinogenase reduced the degree of retinal edema and size of the non-perfused areas by an increase in the blood flow in RVO model. Kallidinogenase also increased the levels of phosphorylated Akt and eNOS. These findings indicate that kallidinogenase acted through Akt/eNOS-dependent phosphorylation. Thus, kallidinogenase should be considered as a possible therapeutic agent for RVO patients.

Retinal detachment in hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome: Color vision abnormality as the first and predominant manifestation

Serous retinal detachment is sometimes caused by hypertensive disorders in pregnancy and its associated conditions, in which the predominant eye symptoms are blurred vision, distorted vision, and reduced visual acuity. To our best knowledge, this is the first report of a puerperal woman with hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome in whom color vision abnormality was the first and predominant manifestation of serous retinal detachment. At 32 weeks of gestation, the 34-year-old Japanese woman underwent cesarean section due to HELLP syndrome. She complained of color vision abnormality on day 1 post-partum and ophthalmological examination revealed serous retinal detachment of both eyes. The visual acuity was preserved. With supportive therapy, her color vision abnormality gradually ameliorated and retinal detachment completely resolved on day 34 post-partum without any sequelae. Obstetricians should be aware that color vision abnormality can be the first and predominant symptom of HELLP-related serous retinal detachment.

The effect of vascular pedicle preservation on blood flow and clinical outcome following ulnar nerve transposition

PURPOSE

To evaluate the efficacy of a technique to preserve the extrinsic vascular supply to the ulnar nerve after transposition and its effect on blood flow and clinical outcome.

METHODS

We included 36 patients with cubital tunnel syndrome. The patients were randomly selected to undergo vascular pedicles-sparing surgery for anterior ulnar nerve transposition (VP group) or nerve transposition and artery ligation (non-VP group). Blood flow to the ulnar nerve was estimated intraoperatively at 3 locations in the cubital tunnel before and after transposition using a laser Doppler flowmeter. Clinical results at 3, 6, and 12 months after surgery were also compared between the 2 groups.

RESULTS

The blood flow before ulnar nerve transposition was not significantly different between the groups. Blood flow at all 3 locations after the ulnar nerve transposition was significantly higher in the VP group than in the non-VP group. Blood flow in the non-VP group reduced to values between 28% and 52% from the pre-transposition baseline values. After surgery, no significant differences were observed in the clinical results between the groups, except for the Disabilities of the Arm, Shoulder and Hand scores at 12 months after surgery, which was greater in the non-VP group.

CONCLUSIONS

The procedure of preserving the extrinsic vascular pedicles can prevent compromise of blood flow to the ulnar nerve immediately after nerve transposition. However, this procedure had no correlation to improved recovery of ulnar nerve function after surgery.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Trigeminal interpolaris/caudalis transition neurons mediate reflex lacrimation evoked by bright light in the rat

Abnormal sensitivity to bright light can cause discomfort or pain and evoke protective reflexes such as lacrimation. Although the trigeminal nerve is probably involved, the mechanism linking luminance to somatic sensory nerve activity remains uncertain. This study determined the effect of bright light on second-order ocular neurons at the ventral trigeminal interpolaris/caudalis transition (Vi/Vc) region, a major termination zone for trigeminal sensory fibers that innervate the eye. Most Vi/Vc neurons (80.9%) identified by responses to mechanical stimulation of the ocular surface also encoded bright light intensity. Light-evoked neural activity displayed a long latency to activation (> 10 s) and required transmission through the trigeminal root ganglion. Light-evoked neural activity was inhibited by intravitreal injection of phenylephrine or l-N(G) -nitro-arginine methyl ester (L-NAME), suggesting a mechanism coupled to vascular events within the eye. Laser Doppler flowmetry revealed rapid light-evoked increases in ocular blood flow that occurred prior to the increase in Vi/Vc neural activity. Synaptic blockade of the Vi/Vc region by cobalt chloride prevented light-evoked increases in tear volume, whereas blockade at the more caudal spinomedullary junction (Vc/C1) had no effect. In summary, Vi/Vc neurons encoded bright light intensity and were inhibited by drugs that alter blood flow to the eye. These results support the hypothesis that light-responsive neurons at the Vi/Vc transition region are critical for ocular-specific functions such as reflex lacrimation, whereas neurons at the caudal Vc/C1 junction region probably serve other aspects of ocular nociception.

Tissue kallikrein inhibits retinal neovascularization via the cleavage of vascular endothelial growth factor-165

OBJECTIVE

Tissue kallikrein, a widely used vasodilator for the treatment of hypertension and peripheral circulatory disorder, acts by releasing kinin, a potent vasodilator peptide. To identify the role of tissue kallikrein in retinal neovascularization, we investigated the antiangiogenic effect by using an in vitro and in vivo angiogenesis model.

METHODS AND RESULTS

Tissue kallikrein in vitreous fluid was markedly elevated in proliferative diabetic retinopathy patients compared with that in control patients with macular hole and epiretinal membrane. Tissue kallikrein inhibited vascular endothelial growth factor-165 (VEGF165)-induced tube formation, proliferation, and migration in vitro angiogenesis model via suppression of the VEGF165-induced phosphorylation of VEGF receptor-2. Furthermore, tissue kallikrein cleavage of VEGF165 was on the C-terminal side, which was analyzed by Western blotting and mass spectrometry. When administered subcutaneously, tissue kallikrein reduced the pathological vascular changes in retinal neovascularization induced in neonatal mice by returning the retina to normoxia after exposure to hyperoxia.

CONCLUSIONS

These findings indicate that tissue kallikrein is partly involved in pathogenesis of proliferative diabetic retinopathy and may be a promising therapeutic agent that could cleave VEGF165 itself when administered by a peripheral route.

Effects of Kallidinogenase on Ischemic Changes Induced by Repeated Intravitreal Injections of Endothelin-1 in Rabbit Retina

PURPOSE

Repeated intravitreal injections of endothelin-1 (ET-1) lead to alterations in the visually evoked potentials (VEPs) and loss of retinal ganglion cells (RGCs) in rabbits. The purpose of this study was to determine whether kallidinogenase can offset the alterations induced by ET-1.

METHODS

ET-1 (2.5 x 10(-7) M, 20 microL) was injected into the vitreous of the right eye of rabbits (ET-1-treated eyes, n = 30) twice a week for 4 weeks. The vehicle for ET-1 was injected into the left eye on the same schedule (vehicle treated eyes, n = 30). During this 4 weeks period, kallidinogenase (1.0 unit/kg/day, kallidinogenase-treated group) or saline (saline-injected control group) was continuously delivered intravenously by an implanted osmotic pump. VEPs were recorded before, and 2 weeks and 4 weeks after, the first ET-1 injection, and all rabbits were sacrificed at 4 weeks. The number of RGC cells was counted in hematoxylin- and eosin-stained retinal sections. In the analyses, the ET-1 induced alterations were normalized to the values in the vehicle treated control eyes, i.e., kallidinogenase (K) + ET-1/K+ vehicle or saline (S) +ET-1/S + vehicle. Retinal sections were also examined by immunohistochemistry with antibodies to single-stranded DNA (ssDNA) or to glial fibrillary acidic protein (GFAP). The effect of kallidinogenase on the ONH blood flow was determined by a hydrogen gas clearance flowmeter.

RESULTS

The significant prolongation of the relative VEP implicit times (ITs) 4 weeks after the ET-1 injection (P < 0.01, paired t test; post-ET-1 vs. pre-ET-1) was significantly decreased by kallidinogenase (P < 0.001, t test, K + ET-1/K+ vehicle vs. S +ET-1/S + vehicle). The relative number of RGCs was decreased in the saline-injected group, and this decrease was also decreased by kallidinogenase (P < 0.05, t test, K + ET-1/K+ vehicle vs. S +ET-1/S + vehicle). ssDNA staining showed fewer apoptotic cells in the retina of kallidinogenase-treated rabbits. Intravitreal injection of ET-1 also decreased the blood flow in the optic nerve head and increased the GFAP immunostaining and axonal degeneration. These changes were also counteracted by kallidinogenase.

CONCLUSION

These results indicate that kallidinogenase can counter the effects of ET-1 and should be considered for the treatment of ischemic retinal and optic nerve disorders related to abnormal ET-1 production.

Kallidinogenase normalizes retinal vasopermeability in streptozotocin-induced diabetic rats: potential roles of vascular endothelial growth factor and nitric oxide

We studied the suppressant effect of kallidinogenase on retinal vascular permeability and vascular endothelial growth factor (VEGF) in diabetic rats. Diabetes was induced by intravenously injecting streptozotocin (60 mg/kg body weight) dissolved in citrate buffer. Kallidinogenase (7 microg/kg/day) was injected intravenously once daily for 21 days. The retinal vascular permeability was estimated from the amount of fluorescent dye leaking into the retina after administration of fluorescein isothiocyanate-conjugated dextran. VEGF in intraocular fluids was quantified by an enzyme-linked immunosorbent assay. The amounts of nitrite and nitrate in the retina were quantified by a fluorescence method using 2,3-diaminonaphthalene. Retinal vascular permeability in the diabetic control group was about 5.5 times higher than in the normal control group (P<0.001). Kallidinogenase suppressed the increased retinal vascular permeability. In the diabetic control group, the VEGF level was three times that of the normal control group (diabetic control group, 160+/-12 pg/ml; normal control group, 54+/-9 pg/ml; P<0.001). The VEGF concentration in the kallidinogenase-treated group was 120+/-12 pg/ml (P<0.05). In the diabetic control group, the amounts of nitrite and nitrate in the retina were lower by about 2.6-fold, compared with the normal control group (P<0.05). Kallidinogenase almost normalized the decreases in nitrite and nitrate in the retina. The current study showed beneficial effects of kallidinogenase on increased retinal vascular permeability and VEGF in diabetic rats, suggesting that kallidinogenase may be effective for simple retinopathy in patients with diabetes.

Arterial hypertension and brain damage--evidence from animal models (review)

Hypertension is an important risk factor for cerebrovascular disease including stroke and has also a role in the development of vascular cognitive impairment (VCI) and vascular dementia (VaD). Research on pathophysiology and treatment of hypertensive brain damage may benefit from the availability of animal models. This paper has reviewed the main animal models of hypertension in which brain damage is documented. Spontaneously hypertensive rats (SHR) represent the animal model more largely used. In these rats cerebrovascular changes, brain atrophy, loss of nerve cells in cerebrocortical areas, and glial reaction were documented. Several changes observed in SHR are similar to those found by in vivo imaging studies in essential hypertensives. It is documented that brain gets benefit from lowering abnormally elevated blood pressure and that reduction of hypertension protects brain from stroke and probably reduces the incidence of VaD. The influence of anti-hypertensive treatment on brain structure and function in animal models of hypertension is reviewed. Among classes of drugs investigated, dihydropyridine-type Ca2+ antagonists were those with a most documented protective effect on hypertensive brain damage. Limits and perspectives in the use of animal models for assessing brain damage caused by hypertension and protection from it are discussed.

Effects of kallidinogenase on ocular tissue circulation in rabbits

The purpose of this study is to evaluate the effects of kallidinogenase, a tissue kallikrein, on tissue circulation in the optic nerve head (ONH), choroid and retina. Kallidinogenase (1.0 IU/kg) or saline was injected intravenously into urethane-anesthetized rabbits, and the normalized blur value (NB), a quantitative index of in vivo tissue blood velocity, was measured in the ONH, choroid and retina before and for 90 minutes after injection, using the laser speckle method. The difference in NB values in the kallidinogenase group was significantly higher compared with that in the control group in the choroid (p < 0.05) and retina (p < 0.05, ANOVA of repeated measurements). In the ONH, however, there was no significant difference between the kallidinogenase group and the control group except transient increment 10 min after drug administration (p < 0.01, unpaired t-test). On the other hand, systemic condition parameters and intraocular pressure showed no intergroup difference significantly except for a transient decrease in blood pressure and increase in pulse rate in the kallidinogenase groups. Kallidinogenase increased blood velocity, and probably blood flow, in the choroid and retina of rabbits.

Complementary and alternative medicine for glaucoma

Given the recent interest in complementary and alternative medicine (CAM), some patients may seek such treatments to supplement their traditional glaucoma management. The prevalence of CAM use for glaucoma is approximately 5%. We reviewed the literature to determine the potential benefit of various alternative treatments. Aside from a temporary osmotic effect from high dose intravenous ascorbic acid, there is no evidence that megavitamin supplementation has a beneficial effect on glaucoma. During exercise, autoregulation in healthy eyes seems to maintain a consistent blood flow rate to the optic nerve despite fluctuations in intraocular pressure (IOP). In a glaucomatous eye, the very modest IOP-lowering that follows exercise may be offset by the initial elevation in IOP that occurs when one first initiates exercise. At this time, there is no evidence to encourage or discourage the use of special diets, acupuncture, relaxation techniques, or therapeutic touch specifically for the treatment of glaucoma. Very little research has been done on the majority of herbal remedies with regard to their treatment of glaucoma. Marijuana can cause a profound lowering of IOP, but the high nonresponse rate, short half life, and significant toxicity are strong indicators that it is not an appropriate therapeutic agent. Ginkgo biloba and some other Chinese herbal remedies do not affect IOP, but may improve blood flow to the optic nerve and, as such, may have a beneficial effect on glaucoma. These agents have recognized toxicities. Although there are some well-designed studies of alternative treatments, many of the recommendations for using alternative treatments are currently unsupported by the data provided.