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Maltepe E, Smith M, Boehme J, Datar SA, Hutchings RS, Vento CA, Manzoor H, Loucks A, Winger JA, Fineman JR. OMX: A NOVEL OXYGEN DELIVERY BIOTHERAPEUTIC IMPROVES OUTCOMES IN AN OVINE MODEL OF CONTROLLED HEMORRHAGIC SHOCK. Shock 2024; 62:103-110. [PMID: 38662597 DOI: 10.1097/shk.0000000000002356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
ABSTRACT Hemorrhagic shock is a major source of morbidity and mortality worldwide. While whole blood or blood product transfusion is a first-line treatment, maintaining robust supplies presents significant logistical challenges, particularly in austere environments. OMX is a novel nonhemoglobin (Hb)-based oxygen carrier derived from the H-NOX (heme-nitric oxide/oxygen binding) protein family. Because of their engineered oxygen (O 2 ) affinities, OMX proteins only deliver O 2 to severely hypoxic tissues. Additionally, unlike Hb-based oxygen carriers, OMX proteins do not scavenge nitric oxide in the vasculature. To determine the safety and efficacy of OMX in supporting tissue oxygen delivery and cardiovascular function in a large animal model of controlled hemorrhage, 2-3-week-old lambs were anesthetized, intubated, and mechanically ventilated. Hypovolemic shock was induced by acute hemorrhage to obtain a 50% reduction over 30 min. Vehicle (n = 16) or 400 mg/kg OMX (n = 13) treatment was administered over 15 min. Hemodynamics, arterial blood gases, and laboratory values were monitored throughout the 6-h study. Comparisons between groups were made using t tests, Wilcoxon rank sum test, and Fisher's exact test. Survival was assessed using Kaplan-Meier curves and the log-rank test. We found that OMX was well-tolerated and significantly improved lactate and base deficit trends, and hemodynamic indices ( P < 0.05). Median survival time was greater in the OMX-treated group (4.7 vs. 6.0 h, P < 0.003), and overall survival was significantly increased in the OMX-treated group (25% vs. 85%, P = 0.004). We conclude that OMX is well-tolerated and improves metabolic, hemodynamic, and survival outcomes in an ovine model of controlled hemorrhagic shock.
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Affiliation(s)
| | | | - Jason Boehme
- Department of Pediatrics, UCSF, San Francisco, CA
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Charbe NB, Castillo F, Tambuwala MM, Prasher P, Chellappan DK, Carreño A, Satija S, Singh SK, Gulati M, Dua K, González-Aramundiz JV, Zacconi FC. A new era in oxygen therapeutics? From perfluorocarbon systems to haemoglobin-based oxygen carriers. Blood Rev 2022; 54:100927. [PMID: 35094845 DOI: 10.1016/j.blre.2022.100927] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 12/14/2021] [Accepted: 01/12/2022] [Indexed: 02/09/2023]
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3
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Faggiano S, Ronda L, Bruno S, Abbruzzetti S, Viappiani C, Bettati S, Mozzarelli A. From hemoglobin allostery to hemoglobin-based oxygen carriers. Mol Aspects Med 2021; 84:101050. [PMID: 34776270 DOI: 10.1016/j.mam.2021.101050] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 11/05/2021] [Accepted: 11/05/2021] [Indexed: 12/18/2022]
Abstract
Hemoglobin (Hb) plays its vital role through structural and functional properties evolutionarily optimized to work within red blood cells, i.e., the tetrameric assembly, well-defined oxygen affinity, positive cooperativity, and heterotropic allosteric regulation by protons, chloride and 2,3-diphosphoglycerate. Outside red blood cells, the Hb tetramer dissociates into dimers, which exhibit high oxygen affinity and neither cooperativity nor allosteric regulation. They are prone to extravasate, thus scavenging endothelial NO and causing hypertension, and cause nephrotoxicity. In addition, they are more prone to autoxidation, generating radicals. The need to overcome the adverse effects associated with cell-free Hb has always been a major hurdle in the development of substitutes of allogeneic blood transfusions for all clinical situations where blood is unavailable or cannot be used due to, for example, religious objections. This class of therapeutics, indicated as hemoglobin-based oxygen carriers (HBOCs), is formed by genetically and/or chemically modified Hbs. Many efforts were devoted to the exploitation of the wealth of biochemical and biophysical information available on Hb structure, function, and dynamics to design safe HBOCs, overcoming the negative effects of free plasma Hb. Unfortunately, so far, no HBOC has been approved by FDA and EMA, except for compassionate use. However, the unmet clinical needs that triggered intensive investigations more than fifty years ago are still awaiting an answer. Recently, HBOCs "repositioning" has led to their successful application in organ perfusion fluids.
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Affiliation(s)
- Serena Faggiano
- Department of Food and Drug, University of Parma, Parma, Italy; Institute of Biophysics, National Research Council, Pisa, Italy
| | - Luca Ronda
- Institute of Biophysics, National Research Council, Pisa, Italy; Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Stefano Bruno
- Department of Food and Drug, University of Parma, Parma, Italy
| | - Stefania Abbruzzetti
- Department of Mathematical, Physical and Computer Sciences, University of Parma, Parma, Italy
| | - Cristiano Viappiani
- Department of Mathematical, Physical and Computer Sciences, University of Parma, Parma, Italy
| | - Stefano Bettati
- Institute of Biophysics, National Research Council, Pisa, Italy; Department of Medicine and Surgery, University of Parma, Parma, Italy; National Institute of Biostructures and Biosystems, Rome, Italy
| | - Andrea Mozzarelli
- Department of Food and Drug, University of Parma, Parma, Italy; Institute of Biophysics, National Research Council, Pisa, Italy.
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Portörő I, Mukli P, Kocsis L, Hermán P, Caccia D, Perrella M, Mozzarelli A, Ronda L, Mathe D, Eke A. Model-based evaluation of the microhemodynamic effects of PEGylated HBOC molecules in the rat brain cortex: a laser speckle imaging study. BIOMEDICAL OPTICS EXPRESS 2020; 11:4150-4175. [PMID: 32923034 PMCID: PMC7449705 DOI: 10.1364/boe.388089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 04/24/2020] [Accepted: 05/04/2020] [Indexed: 06/11/2023]
Abstract
Hemoglobin-based oxygen carriers (HBOCs) were developed with the aim of substituting transfusions in emergency events. However, they exhibit adverse events, such as nitric oxide (NO) scavenging, vasoactivity, enhanced platelet aggregation, presently hampering their clinical application. The impact of two prototypical PEGylated HBOCs, Euro-PEG-Hb and PEG-HbO2, endowed by different oxygen affinities and hydrodynamic volumes, was assessed on the cerebrocortical parenchymal microhemodynamics, and extravasation through the blood-brain-barrier (BBB) by laser speckle contrast imaging (LSCI) method and near-infrared (NIR) imaging, respectively. By evaluating voxel-wise cerebrocortical red blood cell velocity, non-invasively for its mean kernel-wise value ( v ¯ RBC ), and model-derived kernel-wise predictions for microregional tissue hematocrit, THt, and fractional change in hematocrit-corrected vascular resistance, R', as measures of potential adverse effects (enhanced platelet aggregation and vasoactivity, respectively) we found i) no significant difference between tested HBOCs in the systemic and microregional parameters, and in the relative spatial dispersion of THt, and R' as additional measures of HBOC-related adverse effects, and ii) no extravasation through BBB by Euro-PEG-Hb. We conclude that Euro-PEG-Hb does not exhibit adverse effects in the brain microcirculation that could be directly attributed to NO scavenging.
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Affiliation(s)
- István Portörő
- Institute of Translational Medicine, Semmelweis University, Hungary
- These authors contributed equally to this work
| | - Péter Mukli
- Institute of Translational Medicine, Semmelweis University, Hungary
- Department of Physiology, Semmelweis University, Hungary
- These authors contributed equally to this work
| | - László Kocsis
- Institute of Translational Medicine, Semmelweis University, Hungary
| | - Péter Hermán
- Department of Radiology and Biomedical Imaging, Yale University, New Haven, CT 06520, USA
| | - Dario Caccia
- Department of Biomedical Science and Technology, University of Milan, Italy
- Department of Food and Drug, University of Parma, Italy
| | - Michele Perrella
- Department of Biomedical Science and Technology, University of Milan, Italy
| | - Andrea Mozzarelli
- Department of Food and Drug, University of Parma, Italy
- Institute of Biophysics, National Research Council, Pisa, Italy
- Biopharmanet-TEC, University of Parma, Italy
| | - Luca Ronda
- Institute of Biophysics, National Research Council, Pisa, Italy
- Biopharmanet-TEC, University of Parma, Italy
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Domokos Mathe
- CROmed Research and Service Centers Ltd., Budapest, Hungary
| | - Andras Eke
- Institute of Translational Medicine, Semmelweis University, Hungary
- Department of Physiology, Semmelweis University, Hungary
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5
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Seno S, Wang J, Cao S, Saraswati M, Park S, Simoni J, Ma L, Soltys B, Hsia CJC, Koehler RC, Robertson CL. Resuscitation with macromolecular superoxide dismutase/catalase mimetic polynitroxylated PEGylated hemoglobin offers neuroprotection in guinea pigs after traumatic brain injury combined with hemorrhage shock. BMC Neurosci 2020; 21:22. [PMID: 32404052 PMCID: PMC7222507 DOI: 10.1186/s12868-020-00571-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 05/09/2020] [Indexed: 12/21/2022] Open
Abstract
Background Polynitroxylated PEGylated hemoglobin (PNPH, aka SanFlow) possesses superoxide dismutase/catalase mimetic activities that may directly protect the brain from oxidative stress. Stabilization of PNPH with bound carbon monoxide prevents methemoglobin formation during storage and permits it to serve as a carbon monoxide donor. We determined whether small volume transfusion of hyperoncotic PNPH is neuroprotective in a polytrauma model of traumatic brain injury (TBI) plus hemorrhagic shock. Guinea pigs were used because, like humans, they do not synthesize their own ascorbic acid, which is important in reducing methemoglobin. Results TBI was produced by controlled cortical impact and was followed by 20 mL/kg hemorrhage to a mean arterial pressure (MAP) of 40 mmHg. At 90 min, animals were resuscitated with 20 mL/kg lactated Ringer’s solution or 10 mL/kg PNPH. Resuscitation with PNPH significantly augmented the early recovery of MAP after hemorrhagic shock by 10–18 mmHg; whole blood methemoglobin was only 1% higher and carboxyhemoglobin was 2% higher. At 9 days of recovery, unbiased stereology analysis revealed that, compared to animals resuscitated with lactated Ringer’s solution, those treated with PNPH had significantly more viable neurons in the hippocampus CA1 + 2 region (59 ± 10% versus 87 ± 18% of sham and naïve mean value) and in the dentate gyrus (70 ± 21% versus 96 ± 24%; n = 12 per group). Conclusion PNPH may serve as a small-volume resuscitation fluid for polytrauma involving TBI and hemorrhagic shock. The neuroprotection afforded by PNPH seen in other species was sustained in a species without endogenous ascorbic acid synthesis, thereby supporting potential translatability for human use.
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Affiliation(s)
- Soichiro Seno
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, 600 North Wolfe Street, Blalock 1404, Baltimore, MD, USA.,Division of Traumatology, Research Institute, National Defense Medical College, Saitama, Japan
| | - Jun Wang
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, 600 North Wolfe Street, Blalock 1404, Baltimore, MD, USA
| | - Suyi Cao
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, 600 North Wolfe Street, Blalock 1404, Baltimore, MD, USA
| | - Manda Saraswati
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, 600 North Wolfe Street, Blalock 1404, Baltimore, MD, USA
| | - Sharon Park
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, 600 North Wolfe Street, Blalock 1404, Baltimore, MD, USA
| | - Jan Simoni
- AntiRadical Therapeutics, Sioux Falls, SD, USA
| | - Li Ma
- Department of Physics, Georgia Southern University, Statesboro, GA, USA
| | | | | | - Raymond C Koehler
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, 600 North Wolfe Street, Blalock 1404, Baltimore, MD, USA.
| | - Courtney L Robertson
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, 600 North Wolfe Street, Blalock 1404, Baltimore, MD, USA
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6
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Terraneo L, Bianciardi P, Malavalli A, Mkrtchyan G, Spann SN, Lohman J, Samaja M, Vandegriff KD. Hemoglobin extravasation in the brain of rats exchange-transfused with hemoglobin-based oxygen carriers. ARTIFICIAL CELLS NANOMEDICINE AND BIOTECHNOLOGY 2016; 45:710-716. [PMID: 27908199 DOI: 10.1080/21691401.2016.1263640] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Haemoglobin (Hb)-based oxygen carriers are under consideration as oxygen therapeutics. Their effect on apoptosis is critical, because the onset of pro-apoptotic pathways may lead to tissue damage. MP4OX, a polyethylene glycol-conjugated human Hb preserves the baseline level of neuron apoptosis with respect to sham. Here we develop a method for measuring Hb extravasation in brain. We exchange transfused rats by haemorrhaging 50% of their blood with simultaneous, isovolemic replacement with Hextend (negative control), MP4OX, or αα-cross-linked Hb. Animals were sacrificed 2 h after transfusion, brain tissue was harvested and processed for double-staining immunofluorescence, whereby Hb ? chain and NeuN (a neuron protein) were stained and quantitated. Whereas Hextend did not induce Hb extravasation, in both MP4OX and ??Hb brains Hb molecules were detected outside neurons. The level of extravasated Hb chains was > 3-fold higher in Hb compared to MP4OX. Western blot analysis revealed that the expression levels of protein related to redox imbalance (e.g., Nrf2, iNOS and ERK phosphorylation) were higher in ααHb than MP4OX. In conclusions, higher Hb extravasation in ααHb than MP4OX induces redox imbalance, which causes higher anti-oxidant response. Whereas Nrf2 response may be considered protective, iNOS response appears damaging.
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Affiliation(s)
- Laura Terraneo
- a Department of Health Science , University of Milan , Milan , Italy
| | - Paola Bianciardi
- a Department of Health Science , University of Milan , Milan , Italy
| | - Ashok Malavalli
- b NovoSang, Inc. , San Diego , CA , USA.,c Sangart Inc. , San Diego , CA , USA
| | | | | | | | - Michele Samaja
- a Department of Health Science , University of Milan , Milan , Italy
| | - Kim D Vandegriff
- b NovoSang, Inc. , San Diego , CA , USA.,c Sangart Inc. , San Diego , CA , USA
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7
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Li T, Yang G, Zhu Y, Tzang FC, Lau SH, Kwok SY, Wong BL, Liu L. Beneficial effects of novel cross-linked hemoglobin YQ23 on hemorrhagic shock in rats and pigs. J Surg Res 2016; 210:213-222. [PMID: 28457331 DOI: 10.1016/j.jss.2016.11.045] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 10/21/2016] [Accepted: 11/23/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND To overcome the problems of previously reported hemoglobin-based oxygen carriers, we developed a stabilized nonpolymeric cross-linked tetrameric hemoglobin solution (YQ23). The aims of this study were to investigate the oxygen carrying and releasing properties of this novel hemoglobin-based oxygen carrier and to determine whether it has beneficial effects for hemorrhagic shock. METHODS Using a hemorrhagic shock model in Sprague-Dawley rats and mini-pigs, we tested the effects of infusing 0.1, 0.3, and 0.5 g/kg YQ23 on animal survival, tissue oxygen delivery (DO2) and consumption (VO2), hemodynamics parameters, and liver, renal, and cardiac function. RESULTS YQ23 infusion increased the survival rate of rats and pigs with severe hemorrhagic shock in a dose-dependent manner. Moreover, it improved the hemodynamic parameters, cardiac output, DO2 and VO2, and the mitochondrial respiratory function of vital organs. Among the three doses of YQ23, 0.5 gHb/kg YQ23 achieved a similar beneficial effect as whole blood. CONCLUSIONS This study indicated that the novel cross-linked tetrameric hemoglobin YQ23 has good oxygen carrying and releasing properties and exhibits beneficial effects on hemorrhagic shock in rats and pigs by improving the oxygen carrying and delivery function of blood, which maintains organ function.
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Affiliation(s)
- Tao Li
- State Key Laboratory of Trauma, Burns and Combined Injury, Second Department of Research Institute of Surgery, Daping Hospital, Third Military Medical University, Chongqing, P.R. China
| | - Guangming Yang
- State Key Laboratory of Trauma, Burns and Combined Injury, Second Department of Research Institute of Surgery, Daping Hospital, Third Military Medical University, Chongqing, P.R. China
| | - Yu Zhu
- State Key Laboratory of Trauma, Burns and Combined Injury, Second Department of Research Institute of Surgery, Daping Hospital, Third Military Medical University, Chongqing, P.R. China
| | | | | | - Sui-Yi Kwok
- New B Innovation Limited, Hong Kong, P.R. China
| | - Bing L Wong
- New B Innovation Limited, Hong Kong, P.R. China
| | - Liangming Liu
- State Key Laboratory of Trauma, Burns and Combined Injury, Second Department of Research Institute of Surgery, Daping Hospital, Third Military Medical University, Chongqing, P.R. China.
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8
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Weiskopf RB, Beliaev AM, Shander A, Guinn NR, Cap AP, Ness PM, Silverman TA. Addressing the unmet need of life-threatening anemia with hemoglobin-based oxygen carriers. Transfusion 2016; 57:207-214. [PMID: 27859328 DOI: 10.1111/trf.13923] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 09/22/2016] [Accepted: 10/02/2016] [Indexed: 01/02/2023]
Affiliation(s)
| | - Andrei M Beliaev
- Green Lane Cardiothoracic Surgical Unit, Auckland City Hospital, Auckland, New Zealand
| | - Aryeh Shander
- Department of Anesthesiology, Center for Blood Conservation, Duke University Medical Center, Durham, North Carolina
| | - Nicole R Guinn
- Department of Anesthesiology, Critical Care Medicine, Pain Management and Hyperbaric Medicine, Englewood Hospital & Medical Center, Englewood, New Jersey.,Medicine & Surgery, Icahn School of Medicine Mount Sinai, New York, New York
| | - Andrew P Cap
- US Army Institute of Surgical Research, JBSA-Fort Sam Houston, Texas
| | - Paul M Ness
- Pathology, Medicine, Oncology, Johns Hopkins School of Medicine, Baltimore, Maryland
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9
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Vandegriff KD, Malavalli A, Lohman J, Young MA, Terraneo L, Virgili E, Bianciardi P, Caretti A, Samaja M. Impact of acellular hemoglobin-based oxygen carriers on brain apoptosis in rats. Transfusion 2014; 54:2045-54. [PMID: 24673504 DOI: 10.1111/trf.12643] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Revised: 12/23/2013] [Accepted: 12/26/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND Extracellular hemoglobin (Hb)-based oxygen carriers (HBOCs) are under extensive consideration as oxygen therapeutics. Their effects on cellular mechanisms related to apoptosis are of particular interest, because the onset of proapoptotic pathways may give rise to tissue damage. STUDY DESIGN AND METHODS The objective was to assess whether the properties of the Hb that replaces blood during an isovolemic hemodilution would modulate apoptotic-response mechanisms in rat brain and whether such signaling favors cytoprotection or damage. We exposed rats to exchange transfusion (ET; 50% blood volume and isovolemic replacement with Hextend [negative colloid control], MP4OX [PEGylated HBOC with high oxygen affinity], and ααHb [αα-cross-linked HBOC with low oxygen affinity; n=4-6/group]). Sham rats acted as control. Animals were euthanized at 2, 6, and 12 hours after ET; brain tissue was harvested and processed for analysis. RESULTS In MP4OX animals, the number of neurons that overexpressed the hypoxia-inducible factor (HIF)-1α was higher than in ααHb, particularly at the early time points. In addition, MP4OX was associated with greater phosphorylation of protein kinase B (Akt), a well-known cytoprotective factor. Indeed, the degree of apoptosis, measured as terminal deoxynucleotidyl transferase-positive neurons and caspase-3 cleavage, ranked in order of MP4OX < Hextend < ααHb. CONCLUSION Even though both HBOCs showed increased levels of HIF-1α compared to shams or Hextend-treated animals, differences in signaling events resulted in very different outcomes for the two HBOCs. ααHb-treated brain tissue showed significant neuronal damage, measured as apoptosis. This was in stark contrast to the protection seen with MP4OX, apparently due to recruitment of Akt and neuronal specific HIF-1α pathways.
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10
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Meng F, Tsai AG, Intaglietta M, Acharya SA. PEGylation of αα-Hb using succinimidyl propionic acid PEG 5K: Conjugation chemistry and PEG shell structure dictate respectively the oxygen affinity and resuscitation fluid like properties of PEG αα-Hbs. ARTIFICIAL CELLS NANOMEDICINE AND BIOTECHNOLOGY 2014; 43:270-81. [PMID: 24597567 DOI: 10.3109/21691401.2014.885443] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PEGylation of intramolecularly crosslinked Hb has been studied here to overcome the limitation of dissociation of Hb tetramers. New hexa and deca PEGylated low oxygen affinity PEG-ααHbs have been generated. Influence of PEG conjugation chemistry and the PEG shell structure on the functional properties as well as PEGylation induced plasma expander like properties of the protein has been delineated. The results have established that in the design of PEG-Hbs as oxygen therapeutics, the influence of conjugation chemistry and the PEG shell structure on the oxygen affinity of Hb needs to be optimized independently besides optimizing the PEG shell structure for inducing resuscitation fluid like properties.
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Affiliation(s)
- Fantao Meng
- Hematology Division, Department of Medicine, Albert Einstein College of Medicine of Yeshiva University , Bronx, NY , USA
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11
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MP4CO, a pegylated hemoglobin saturated with carbon monoxide, is a modulator of HO-1, inflammation, and vaso-occlusion in transgenic sickle mice. Blood 2013; 122:2757-64. [PMID: 23908468 DOI: 10.1182/blood-2013-02-486282] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Transgenic sickle mice expressing β(S) hemoglobin have activated vascular endothelium in multiple organs that exhibits enhanced expression of NF-ĸB and adhesion molecules and promotes microvascular stasis in sickle, but not normal, mice in response to hypoxia/reoxygenation (H/R), or heme. Induction of heme oxygenase-1 (HO-1) or administration of its products, carbon monoxide (CO) or biliverdin, inhibits microvascular stasis in sickle mice. Infusion of human hemoglobin conjugated with polyethylene glycol and saturated with CO (MP4CO) markedly induced hepatic HO-1 activity and inhibited NF-ĸB activation and H/R-induced microvascular stasis in sickle mice. These effects were mediated by CO; saline or MP4 saturated with O2 (MP4OX) had little to no effect on H/R-induced stasis, though unmodified oxyhemoglobin exacerbated stasis. The HO-1 inhibitor, tin protoporphyrin, blocked MP4CO protection, consistent with HO-1 involvement in the protection afforded by MP4CO. MP4CO also induced nuclear factor-erythroid 2 p45-related factor 2 (Nrf2), an important transcriptional regulator of HO-1 and other antioxidant genes. In a heterozygous (hemoglobin-AS) sickle mouse model, intravenous hemin induced cardiovascular collapse and mortality within 120 minutes, which was significantly reduced by MP4CO, but not MP4OX. These data demonstrate that MP4CO induces cytoprotective Nrf2 and HO-1 and decreases NF-ĸB activation, microvascular stasis, and mortality in transgenic sickle mouse models.
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12
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Abstract
The development of oxygen (O2)-carrying blood substitutes has evolved from the goal of replicating blood O2 transport properties to that of preserving microvascular and organ function, reducing the inherent or potential toxicity of the material used to carry O2, and treating pathologies initiated by anemia and hypoxia. Furthermore, the emphasis has shifted from blood replacement fluid to "O2 therapeutics" that restore tissue oxygenation to specific tissues regions. This review covers the different alternatives, potential and limitations of hemoglobin-based O2 carriers (HBOCs) and perfluorocarbon-based O2 carriers (PFCOCs), with emphasis on the physiologic conditions disturbed in the situation that they will be used. It describes how concepts learned from plasma expanders without O2-carrying capacity can be applied to maintain O2 delivery and summarizes the microvascular responses due to HBOCs and PFCOCs. This review also presents alternative applications of HBOCs and PFCOCs namely: 1) How HBOC O2 affinity can be engineered to target O2 delivery to hypoxic tissues; and 2) How the high gas solubility of PFCOCs provides new opportunities for carrying, dissolving, and delivering gases with biological activity. It is concluded that the development of current blood substitutes has amplified their applications horizon by devising therapeutic functions for O2 carriers requiring limited O2 delivery capacity restoration. Conversely, full, blood-like O2-carrying capacity reestablishment awaits the control of O2 carrier toxicity.
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Affiliation(s)
- Pedro Cabrales
- Department of Bioengineering, University of California, San Diego, La Jolla, California 92093-0412, USA.
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13
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Abstract
SIGNIFICANCE There has been a striking advancement in our understanding of red cell substitutes over the past decade. Although regulatory oversight has influenced many aspects of product development in this period, those who have approached the demonstration of efficacy of red cell substitutes have failed to understand their implication at the level of the microcirculation, where blood interacts closely with tissue. RECENT ADVANCES The understanding of the adverse effects of acellular hemoglobin (Hb)-based oxygen carriers (HBOCs) has fortunately expanded from Hb-induced renal toxicity to a more complete list of biochemical mechanism. In addition, various unexpected adverse reactions were seen in early clinical studies. The effects of the presence of acellular Hb in plasma are relatively unique because of the convergence of mechanical and biochemical natures. CRITICAL ISSUES Controlling the variables using genetic engineering and chemical modification to change specific characteristics of the Hb molecule may allow for solving the complex multivariate problems of acellular Hb vasoactivity. HBOCs may never be rendered free of negative effects; however, quantifying the nature and extent of microvascular complications establishes a platform for designing new ameliorative therapies. FUTURE DIRECTIONS It is time to leave behind the study of vasoactivity and toxicity based on bench-top measurements of biochemical changes and those based solely on systemic parameters in vivo, and move to a more holistic analysis of the mechanisms creating the problems, complemented with meaningful studies of efficacy.
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Affiliation(s)
- Pedro Cabrales
- Department of Bioengineering, University of California, San Diego, La Jolla, CA 92093, USA.
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14
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Bouglé A, Harrois A, Duranteau J. Resuscitative strategies in traumatic hemorrhagic shock. Ann Intensive Care 2013; 3:1. [PMID: 23311726 PMCID: PMC3626904 DOI: 10.1186/2110-5820-3-1] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Accepted: 12/01/2012] [Indexed: 01/06/2023] Open
Abstract
Managing trauma patients with hemorrhagic shock is complex and difficult. Despite our knowledge of the pathophysiology of hemorrhagic shock in trauma patients that we have accumulated during recent decades, the mortality rate of these patients remains high. In the acute phase of hemorrhage, the therapeutic priority is to stop the bleeding as quickly as possible. As long as this bleeding is uncontrolled, the physician must maintain oxygen delivery to limit tissue hypoxia, inflammation, and organ dysfunction. This process involves fluid resuscitation, the use of vasopressors, and blood transfusion to prevent or correct acute coagulopathy of trauma. The optimal resuscitative strategy is controversial. To move forward, we need to establish optimal therapeutic approaches with clear objectives for fluid resuscitation, blood pressure, and hemoglobin levels to guide resuscitation and limit the risk of fluid overload and transfusion.
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Affiliation(s)
- Adrien Bouglé
- Departement of Anesthesia and Intensive Care, Bicêtre Hospital, Hôpitaux universitaires Paris-Sud, Université Paris-Sud, Assistance Publique-Hôpitaux de Paris, 78, rue du Général Leclerc, 94275, Le Kremlin Bicêtre, France.
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Hemoglobin-based oxygen carriers for hemorrhagic shock. Resuscitation 2012; 83:285-92. [DOI: 10.1016/j.resuscitation.2011.09.020] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2011] [Revised: 08/28/2011] [Accepted: 09/19/2011] [Indexed: 02/04/2023]
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16
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van der Linden P, Gazdzik TS, Jahoda D, Heylen RJ, Skowronski JC, Pellar D, Kofranek I, Górecki AZ, Fagrell B, Keipert PE, Hardiman YJ, Levy H. A Double-Blind, Randomized, Multicenter Study of MP4OX for Treatment of Perioperative Hypotension in Patients Undergoing Primary Hip Arthroplasty Under Spinal Anesthesia. Anesth Analg 2011; 112:759-73. [PMID: 21317165 DOI: 10.1213/ane.0b013e31820c7b5f] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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17
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Haemoglobin-based oxygen carriers: research and reality towards an alternative to blood transfusions. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2010; 8 Suppl 3:s59-68. [PMID: 20606751 DOI: 10.2450/2010.010s] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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18
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Young MA, Lohman J, Malavalli A, Vandegriff KD, Winslow RM. Hemospan Improves Outcome in a Model of Perioperative Hemodilution and Blood Loss in the Rat: Comparison With Hydroxyethyl Starch. J Cardiothorac Vasc Anesth 2009; 23:339-47. [DOI: 10.1053/j.jvca.2008.08.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2008] [Indexed: 11/11/2022]
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19
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Hemoglobin-based Oxygen Carriers: First, Second or Third Generation? Human or Bovine? Where are we Now? Crit Care Clin 2009; 25:279-301, Table of Contents. [DOI: 10.1016/j.ccc.2009.01.003] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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20
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Vandegriff KD, Winslow RM. Hemospan: Design Principles for a New Class of Oxygen Therapeutic. Artif Organs 2009; 33:133-8. [DOI: 10.1111/j.1525-1594.2008.00697.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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21
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Vandegriff KD, Malavalli A, Mkrtchyan GM, Spann SN, Baker DA, Winslow RM. Sites of Modification of Hemospan, a Poly(ethylene glycol)-Modified Human Hemoglobin for Use As an Oxygen Therapeutic. Bioconjug Chem 2008; 19:2163-70. [DOI: 10.1021/bc8002666] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Kim D. Vandegriff
- Sangart Inc., 6175 Lusk Boulevard, San Diego, California, 92121, and Department of Bioengineering, University of California, San Diego, La Jolla, California 92093
| | - Ashok Malavalli
- Sangart Inc., 6175 Lusk Boulevard, San Diego, California, 92121, and Department of Bioengineering, University of California, San Diego, La Jolla, California 92093
| | - Gnel M. Mkrtchyan
- Sangart Inc., 6175 Lusk Boulevard, San Diego, California, 92121, and Department of Bioengineering, University of California, San Diego, La Jolla, California 92093
| | - Stephanie N. Spann
- Sangart Inc., 6175 Lusk Boulevard, San Diego, California, 92121, and Department of Bioengineering, University of California, San Diego, La Jolla, California 92093
| | - Dale A. Baker
- Sangart Inc., 6175 Lusk Boulevard, San Diego, California, 92121, and Department of Bioengineering, University of California, San Diego, La Jolla, California 92093
| | - Robert M. Winslow
- Sangart Inc., 6175 Lusk Boulevard, San Diego, California, 92121, and Department of Bioengineering, University of California, San Diego, La Jolla, California 92093
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Towards a novel haemoglobin-based oxygen carrier: Euro-PEG-Hb, physico-chemical properties, vasoactivity and renal filtration. BIOCHIMICA ET BIOPHYSICA ACTA-PROTEINS AND PROTEOMICS 2008; 1784:1402-9. [DOI: 10.1016/j.bbapap.2008.03.005] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2007] [Revised: 03/08/2008] [Accepted: 03/08/2008] [Indexed: 11/17/2022]
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23
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Liposome-Encapsulated Hemoglobin Transfusion Rescues Rats Undergoing Progressive Hemodilution From Lethal Organ Hypoxia Without Scavenging Nitric Oxide. Ann Surg 2008; 248:310-9. [DOI: 10.1097/sla.0b013e3181820c80] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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24
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Olofsson C, Nygårds EB, Ponzer S, Fagrell B, Przybelski R, Keipert PE, Winslow N, Winslow RM. A randomized, single-blind, increasing dose safety trial of an oxygen-carrying plasma expander (Hemospan) administered to orthopaedic surgery patients with spinal anaesthesia. Transfus Med 2008; 18:28-39. [PMID: 18279190 DOI: 10.1111/j.1365-3148.2007.00811.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The objective of this study was to further explore the safety of Hemospan (Sangart Inc., San Diego, CA, USA), an oxygen-carrying plasma expander. The aim of this study was to determine if Hemospan is well tolerated in orthopaedic surgery patients with spinal anaesthesia in doses up to 1 L. Hemospan was previously found to be well tolerated in normal volunteers and orthopaedic surgery patients with spinal anaesthesia in doses up to 500 mL. Five cohorts of six orthopaedic surgery patients, American Society of Anesthesiologists (ASA) I and II, were studied. In each cohort, four patients received Hemospan in doses ranging from 200 to 1000 mL, and two received Ringer's lactate immediately prior to induction of spinal anaesthesia. There were no serious adverse events (SAEs). Iohexol clearance measured before and 24 h after dosing was unaffected. There were 14 adverse events (AEs) in the 10 control patients (1.4 per patient) and 30 in the 20 patients receiving Hemospan (1.5 per patient). One patient in the group receiving 200 mL Hemospan had elevated mean arterial pressure after dosing, but there were no elevations in any of the other patients. The peak plasma Hemospan concentration in the 1000 mL group was 1.3 g dL(-1), with a dose-dependent clearance (T(1/2)) ranging from 14.1 to 23.0 h. Plasma methaemoglobin levels were independent of dose, reaching a maximum at 40 h after dosing and never exceeded 0.125 g dL(-1). Troponin T was transiently elevated in two patients receiving Hemospan without symptoms or electrocardiographic abnormalities or elevation of myocardial creatinine kinase isoenzyme. Hemospan was well tolerated in this group of patients at doses up to 1000 mL.
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Affiliation(s)
- C Olofsson
- Department of Anaesthesiology, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
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25
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The effects of decreasing low-molecular weight hemoglobin components of hemoglobin-based oxygen carriers in swine with hemorrhagic shock. ACTA ACUST UNITED AC 2008; 64:1240-57. [PMID: 18469646 DOI: 10.1097/ta.0b013e318058245e] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Some hemoglobin-based oxygen carriers (HBOCs) improve outcome in animal models of hemorrhagic shock (HS) in comparison with standard asanguinous resuscitation fluids. Nevertheless, concern about intrinsic vasoactivity, linked in part to low-molecular weight (MW) hemoglobin (Hb), has slowed HBOC development. We assessed the impact of decreasing the low-MW Hb component of bovine HBOC on vasoactivity in severe HS. METHODS Anesthetized invasively monitored swine were hemorrhaged 55% blood volume and resuscitated with bovine HBOC containing 31% (31 TD [HBOC-301]), 2% (2 TD [HBOC-201]), or 0.4% (0.4 TD) low-MW Hb. Pigs received four 10 mL/kg infusions over 60 minutes, hospital arrival was simulated at 75 minutes, organ blood flow (BF) was evaluated by microsphere injection, and monitoring was continued for 4 hours followed by complete necrotic evaluation. RESULTS There were few differences between 2 TD and 0.4 TD. Thirty-one TD pigs had higher systemic and pulmonary blood pressure (BP), systemic vascular resistance index, and pulmonary artery wedge pressure, compared with 2 TD or 0.4 TD (p < 0.01); however, pigs in all groups had at least mildly elevated BP. Transcutaneous tissue oxygenation, base excess, and mixed venous oxygen saturation were similar across groups; lactate and methemoglobin were highest with 0.4 TD (p < 0.03). There were no group differences in BF. Over time, myocardial BF increased and hepatic BF decreased in all groups (for 31 TD, p < 0.05); renal BF was unchanged in all groups. There were no group differences in heart, lung, or liver histopathology, and survival. CONCLUSIONS Although purification from 31% to 2% low-MW Hb content significantly decreased vasoactive responses, further purification to 0.4% had no additional clinically measurable effects in severe HS. If further diminution in HBOC vasoactivity is desired for use in HS, additional technical approaches may be required.
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Cell-free oxygen carriers: scientific foundations, clinical development, and new directions. BIOCHIMICA ET BIOPHYSICA ACTA-PROTEINS AND PROTEOMICS 2008; 1784:1382-6. [PMID: 18555029 DOI: 10.1016/j.bbapap.2008.04.032] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2008] [Revised: 04/16/2008] [Accepted: 04/22/2008] [Indexed: 11/23/2022]
Abstract
The most significant hurdle to the development of a safe and effective hemoglobin-based oxygen carrier ("blood substitute") is generally thought to be its propensity to cause vasoconstriction in the microcirculation and hypertension. Two theories for this effect are currently being studied: in one, scavenging NO by hemoglobin reduces vasorelaxation; in the other, cell-free hemoglobin oversupplies O2 (a known vasoconstrictor) to vascular walls by facilitated diffusion. While both mechanisms might lead to reduction of local NO concentration, the important distinction between the two is that if the NO scavenging theory is correct, it greatly diminishes the prospects to develop any solution based on free hemoglobin. However, if the O2-oversupply theory is correct, modifications to the hemoglobin molecule can be envisioned that can prevent oversupply and reduce toxicity. This review summarizes the development of Hemospan, a novel modification of human hemoglobin whose design is based on the O2-oversupply theory. Because of its low P50 and increased molecular size, the release of O2 in resistance vessels (arterioles) by Hemospan is restricted, and vasoconstriction is greatly reduced.
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27
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Svergun DI, Ekström F, Vandegriff KD, Malavalli A, Baker DA, Nilsson C, Winslow RM. Solution structure of poly(ethylene) glycol-conjugated hemoglobin revealed by small-angle X-ray scattering: implications for a new oxygen therapeutic. Biophys J 2008; 94:173-81. [PMID: 17827244 PMCID: PMC2134876 DOI: 10.1529/biophysj.107.114314] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2007] [Accepted: 08/07/2007] [Indexed: 11/18/2022] Open
Abstract
Developing protein therapeutics has posed challenges due to short circulating times and toxicities. Recent advances using poly(ethylene) glycol (PEG) conjugation have improved their performance. A PEG-conjugated hemoglobin (Hb), Hemospan, is in clinical trials as an oxygen therapeutic. Solutions of PEG-hemoglobin with two (P5K2) or six to seven strands of 5-kD PEG (P5K6) were studied by small-angle x-ray scattering. PEGylation elongates the dimensions (Hb < P5K2 < P5K6) and leaves the tertiary hemoglobin structure unchanged but compacts its quaternary structure. The major part of the PEG chains visualized by ab initio reconstruction protrudes away from hemoglobin, whereas the rest interacts with the protein. PEGylation introduces intermolecular repulsion, increasing with conjugated PEG amount. These results demonstrate how PEG surface shielding and intermolecular repulsion may prolong intravascular retention and lack of reactivity of PEG-Hb, possibly by inhibiting binding to the macrophage CD163 hemoglobin-scavenger receptor. The proposed methodology for assessment of low-resolution structures and interactions is a powerful means for rational design of PEGylated therapeutic agents.
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Affiliation(s)
- Dmitri I Svergun
- European Molecular Biology Laboratory, Hamburg Outstation, Hamburg, Germany
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28
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Young MA, Riddez L, Kjellström BT, Winslow RM. Effect of Maleimide-Polyethylene Glycol Hemoglobin (MP4) on Hemodynamics and Acid-Base Status After Uncontrolled Hemorrhage in Anesthetized Swine: Comparison With Crystalloid and Blood. ACTA ACUST UNITED AC 2007; 63:1234-44. [DOI: 10.1097/ta.0b013e31815bd7b0] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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29
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TSAI AMYG, CABRALES PEDRO, ACHARYA SEETHARAMAA, INTAGLIETTA MARCOS. Resuscitation from hemorrhagic shock: recovery of oxygen carrying capacity or perfusion? Efficacy of new plasma expanders. ACTA ACUST UNITED AC 2007. [DOI: 10.1111/j.1778-428x.2007.00086.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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30
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Acosta S, Nilsson TK, Malina J, Malina M. L-Lactate After Embolization of the Superior Mesenteric Artery. J Surg Res 2007; 143:320-8. [PMID: 17659304 DOI: 10.1016/j.jss.2007.02.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2006] [Revised: 01/16/2007] [Accepted: 02/01/2007] [Indexed: 01/15/2023]
Abstract
BACKGROUND Plasma markers for intestinal ischemia have not proven to be accurate. The value of L-lactate is unclear. Experimental models based on open surgery confound the effects of surgical trauma with that of ischemia. The aim was to create an endovascular model for acute superior mesenteric artery thromboembolism, and then to study L-lactate and lactate dehydrogenase (LD) activity in plasma and peritoneal fluid in pigs with extensive, high-grade intestinal ischemia. MATERIALS AND METHODS Nine pigs underwent full superior mesenteric artery embolization with 4 h of intended intestinal ischemia, whereas six were control animals. Sampling of central venous and arterial blood was performed throughout the experiment, ending with laparotomy to collect peritoneal fluid and segmental intestinal biopsies. A pathologist, blinded to the performed interventions, graded the ischemic lesions. RESULTS There were no differences in plasma L-lactate (P = 0.61) or LD activity levels (P = 0.69), measured at different time points from baseline to end of study, between animals with extensive, high-grade intestinal ischemia and sham. Intraperitoneal L-Lactate (P = 0.005) and LD activity (P = 0.018) levels were elevated compared with sham. There were differences in grades of ischemia in the duodenum (P = 0.003), small intestine (P < 0.001), proximal (P < 0.001), and sigmoid (P = 0.032) colon between experimental animals and sham. The grade of small bowel ischemia (n = 15) correlated to intraperitoneal fluid L-lactate (r = 0.80; P < 0.001) and LD activity levels (r = 0.72; P = 0.003). CONCLUSIONS This endovascular study in a porcine model showed that L-lactate and LD activity levels in peritoneal fluid, not in plasma, reflect intestinal ischemia. The study suggests that plasma L-lactate not is a useful early marker in patients with suspicion of intestinal ischemia.
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Affiliation(s)
- Stefan Acosta
- Department of Vascular Diseases, Malmö University Hospital, Malmö, Sweden.
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31
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VANDEGRIFF KIMD, YOUNG MARKA, KEIPERT PETERE, WINSLOW ROBERTM. The safety profile of Hemospan®: a new oxygen therapeutic designed using maleimide poly(ethylene) glycol conjugation to human hemoglobin. ACTA ACUST UNITED AC 2007. [DOI: 10.1111/j.1778-428x.2007.00083.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Young MA, Malavalli A, Winslow N, Vandegriff KD, Winslow RM. Toxicity and hemodynamic effects after single dose administration of MalPEG-hemoglobin (MP4) in rhesus monkeys. Transl Res 2007; 149:333-42. [PMID: 17543852 DOI: 10.1016/j.trsl.2006.09.007] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2006] [Revised: 09/25/2006] [Accepted: 09/27/2006] [Indexed: 01/22/2023]
Abstract
Maleimide-polyethylene glycol-modified (MalPEG) hemoglobin, 4.3 g/dL (MP4; Hemospan), is a hemoglobin-based oxygen carrier consisting of human hemoglobin (Hb) modified with maleimide polyethylene glycol. This study evaluates the potential toxicity and hemodynamic actions of a single dose of MP4 administered by exchange transfusion to rhesus monkeys. Monkeys were administered MP4 (21 mL/kg, or approximately 30% of estimated blood volume) or an equivalent volume of lactated Ringer's solution (LR). In the toxicity study, blood samples were obtained predose and 3, 7, and 13 days after dosing for clinical chemistry and hematology. Animals were euthanized for complete necropsy and histopathology on day 3 or day 13. A separate group of animals was used for evaluation of arterial pressure, core temperature, and electrocardiogram, by telemetry, for 7 days after dosing with MP4. The results demonstrate no significant toxicity, with only modest, transient elevation of aspartate aminotransferase (AST), alanine aminotransferase (ALT), and lactate dehydrogenase (LDH) on day 3. Mild anemia caused by hemodilution was observed at each time point in both groups, but to a slightly greater degree in the MP4-treated animals. Histologic observations included foamy or vacuolated macrophages in the spleen and marrow of the sternum, rib, and femur, representing the accumulation of test article or a metabolite. In the telemetry study, no changes occurred in arterial pressure, heart rate, or electrocardiogram attributable to administration of MP4 at any time for 7 days after administration. These results demonstrate that MP4 is safe and is without hemodynamic effects when administered as an exchange transfusion of 30% of estimated blood volume.
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Abstract
Oxygen-carrying plasma expanders (blood substitutes) have been sought for over a century. Development of current products is a result of evolution in the understanding of proteins in general, of hemoglobin in particular, and of how cell-free hemoglobin interacts with the control of local blood flow to ensure adequate tissue oxygenation. Hemoglobin-based products are considered in four "generations" corresponding to major improvements. First-generation products consisted of hemoglobin, freed of red cell membranes (stroma-free hemoglobin [SFH]), which was renal toxic and vasoactive. Second-generation products were polymerized with aldehyde reagents to reduce or eliminate the renal toxicity, but the products were heterogeneous and still vasoactive. Third-generation products employed more specific intramolecular crosslinking to eliminate polymerization and promote homogeneity, but they also remained vasoactive. Fourth-generation products are based on a new understanding of the way in which microvascular blood flow is controlled and the influence of O(2) delivery to vascular walls. After more than a century of research, one of these new solutions should find use as an alternative to red cells for transfusion in certain clinical settings.
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Affiliation(s)
- Robert M Winslow
- Sangart, Inc, and Department of Bioengineering, University of California, San Diego, CA 92121, USA.
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Rice J, Philbin N, McGwin G, Arnaud F, Johnson T, Flournoy WS, Pearce LB, McCarron R, Kaplan L, Handrigan M, Freilich D. BOVINE POLYMERIZED HEMOGLOBIN VERSUS HEXTEND RESUSCITATION IN A SWINE MODEL OF SEVERE CONTROLLED HEMORRHAGIC SHOCK WITH DELAY TO DEFINITIVE CARE. Shock 2006; 26:302-10. [PMID: 16912657 DOI: 10.1097/01.shk.0000226338.48033.c2] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
To compare the efficacy of low-volume resuscitation with bovine polymerized hemoglobin (HBOC-201) versus hetastarch (HEX) in an intermediate severity combat-relevant hemorrhagic shock swine model with a simulated delay to hospital care. Twenty-four anesthetized pigs were hemorrhaged 55% estimated blood volume in conjunction with a 5-min rectus abdominus crush. At 20 min, pigs were resuscitated with 10 mL/kg of HBOC-201 or HEX or nothing (NON); resuscitated pigs received additional infusions (5 mL/kg) at 30, 60, 120, or 180 min if hypotension or tachycardia persisted. Pigs were monitored for a 4-h "prehospital" period. At 4-h, hospital arrival was simulated: surgical sites were repaired, blood, or saline provided, and pigs were recovered from anesthesia. Pigs were monitored for 72 h and then killed for histological evaluation. One hundred percent (8/8) of HBOC-201-, 75% (6/8) of HEX-, and 25% (2/8) of NON-resuscitated pigs survived to 72 h (P = 0.007 overall, HBOC vs. HEX P > 0.05). Mean arterial pressure and mean pulmonary arterial pressure were highest in the HBOC-201 group (P < 0.001), and HR was lowest (P < 0.001). HBOC-201- and HEX-resuscitated pigs had comparable cardiac index and prehospital fluid requirements. HBOC-201 pigs had higher transcutaneous tissue oxygen tension, P < 0.001) and lower urine output (P < 0.001). At simulated hospital arrival, no HBOC-201 pigs required additional fluids or blood transfusion. In contrast, 100% of HEX pigs required blood transfusions (P < 0.01). In this swine model of controlled hemorrhage with low-volume resuscitation and delayed definitive care, HBOC-201 pigs had improved hemodynamics, transcutaneous tissue oxygen tension, and transfusion avoidance compared with HEX.
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Affiliation(s)
- Jennifer Rice
- Naval Medical Research Center, Silver Spring, MD 20910, USA.
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Abstract
An alternative to blood transfusion, based on oxygen-carrying solutions, has been sought for over a century. The present 'first-generation' haemoglobin-products were based on observations that crosslinking with, for example, glutaraldehyde, overcame subunit dissociation and renal toxicity. Experience with these solutions has shown that they can be vasoactive, sometimes increasing blood pressure, sometimes decreasing tissue perfusion and sometimes both. Clinical trials have been disappointing because of unexpected toxicity. The 'second-generation' products are based on a better understanding of the mechanisms of this vasoconstriction. Such products may seem counterintuitive by traditional standards, but it is hoped that they will be less toxic, more beneficial to patients, and more economical to produce.
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Tsai AG, Cabrales P, Manjula BN, Acharya SA, Winslow RM, Intaglietta M. Dissociation of local nitric oxide concentration and vasoconstriction in the presence of cell-free hemoglobin oxygen carriers. Blood 2006; 108:3603-10. [PMID: 16857991 PMCID: PMC1895434 DOI: 10.1182/blood-2006-02-005272] [Citation(s) in RCA: 101] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Cell-free hemoglobin's (CFH) high affinity for nitric oxide (NO) could limit CFH's use as an oxygen-carrying blood replacement fluid because it scavenges NO, causing vasoconstriction and hypertension. However, the extent to which perivascular NO levels change following intravascular administration of hemoglobin (Hb) with different molecular dimensions correlates with vasoconstrictive responses in the microcirculation is unknown. The study objective was to determine vasoconstrictive effects following bolus infusions of (1) alphaalpha cross-linked Hb; (2) polymerized bovine Hb; or (3) polyethylene glycol-decorated Hb (PEG-Hb), by measurements of in vivo microvessel diameter, blood flow, perivascular NO concentration, and systemic hemodynamic parameters. All CFHs caused reductions in perivascular NO levels, not correlated to microvascular responses. PEG-Hb (largest molecular volume) maintained blood flow, while the others caused vasoconstriction and reduced perfusion. All solutions increased mean arterial pressure due to vasoconstriction and blood volume expansion, except for PEG-Hb, which increased blood pressure due to blood volume expansion and maintenance of cardiac output. In conclusion, perivascular NO reduction is similar for all Hb solutions because NO binding affinities are similar; however, effects on vascular resistance are related to the type of molecular modification, molecular volume, and oxygen affinity.
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Affiliation(s)
- Amy G Tsai
- Department of Bioengineering, University of California, San Diego, La Jolla, CA 92093-0412, USA.
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Tsai AG, Cabrales P. Can the effects of vasoactivity of molecular hemoglobin-based plasma expanders be ignored? Crit Care Med 2006; 34:1566-7. [PMID: 16633264 DOI: 10.1097/01.ccm.0000216188.79290.20] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ball J. Recently published papers: what not to do and how not to do it? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2005; 9:419-21. [PMID: 16277724 PMCID: PMC1297633 DOI: 10.1186/cc3812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Controversies abound in the areas of blood transfusion, albumin, lipoproteins in sepsis and pulmonary artery catheters. We are also making too many errors, but at least there is a new nitric oxide therapy in the offing.
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