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Kofke WA, Ren Y, Augoustides JG, Li H, Nathanson K, Siman R, Meng QC, Bu W, Yandrawatthana S, Kositratna G, Kim C, Bavaria JE. Reframing the Biological Basis of Neuroprotection Using Functional Genomics: Differentially Weighted, Time-Dependent Multifactor Pathogenesis of Human Ischemic Brain Damage. Front Neurol 2018; 9:497. [PMID: 29997569 PMCID: PMC6028620 DOI: 10.3389/fneur.2018.00497] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 06/07/2018] [Indexed: 12/18/2022] Open
Abstract
Background: Neuroprotection studies are generally unable to demonstrate efficacy in humans. Our specific hypothesis is that multiple pathophysiologic pathways, of variable importance, contribute to ischemic brain damage. As a corollary to this, we discuss the broad hypothesis that a multifaceted approach will improve the probability of efficacious neuroprotection. But to properly test this hypothesis the nature and importance of the multiple contributing pathways needs elucidation. Our aim is to demonstrate, using functional genomics, in human cardiac surgery procedures associated with cerebral ischemia, that the pathogenesis of perioperative human ischemic brain damage involves the function of multiple variably weighted proteins involving several pathways. We then use these data and literature to develop a proposal for rational design of human neuroprotection protocols. Methods: Ninety-four patients undergoing deep hypothermic circulatory arrest (DHCA) and/or aortic valve replacement surgery had brain damage biomarkers, S100β and neurofilament H (NFH), assessed at baseline, 1 and 24 h post-cardiopulmonary bypass (CPB) with analysis for association with 92 single nucleotide polymorphisms (SNPs) (selected by co-author WAK) related to important proteins involved in pathogenesis of cerebral ischemia. Results: At the nominal significance level of 0.05, changes in S100β and in NFH at 1 and 24 h post-CPB were associated with multiple SNPs involving several prospectively determined pathophysiologic pathways, but were not individually significant after multiple comparison adjustments. Variable weights for the several evaluated SNPs are apparent on regression analysis and, notably, are dissimilar related to the two biomarkers and over time post CPB. Based on our step-wise regression model, at 1 h post-CPB, SOD2, SUMO4, and GP6 are related to relative change of NFH while TNF, CAPN10, NPPB, and SERPINE1 are related to the relative change of S100B. At 24 h post-CPB, ADRA2A, SELE, and BAX are related to the relative change of NFH while SLC4A7, HSPA1B, and FGA are related to S100B. Conclusions: In support of the proposed hypothesis, association SNP data suggest function of specific disparate proteins, as reflected by genetic variation, may be more important than others with variation at different post-insult times after human brain ischemia. Such information may support rational design of post-insult time-sensitive multifaceted neuroprotective therapies.
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Affiliation(s)
- William A Kofke
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, United States
| | - Yue Ren
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA, United States
| | - John G Augoustides
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, United States
| | - Hongzhe Li
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA, United States
| | - Katherine Nathanson
- Department of Medicine, Division of Translational Medicine and Human Genetics Abramson Cancer Center Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Robert Siman
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Qing Cheng Meng
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, United States
| | - Weiming Bu
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, United States
| | - Sukanya Yandrawatthana
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, United States
| | - Guy Kositratna
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, United States
| | - Cecilia Kim
- The Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Joseph E Bavaria
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, United States
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Abstract
OBJECTIVES The 2006 revision of the Uniform Anatomical Gift Act (UAGA) attempts to enhance the availability of organs in part by granting new authority to organ procurement organizations over patients who are near death and may be candidates for donation after death while limiting patients' end of life (EOL) decisional authority through advance directives or surrogates. To examine the revised UAGA that may alter the ethics and law of EOL medical care in the United States. To analyze the revised UAGA in light of established legal and ethical standards. DATA SOURCES We evaluated the 2006 UAGA and accompanying commentary. Case law and ethics literature regarding informed consent and EOL care, state laws and regulations concerning advance directives and medical licensure, and literature concerning the fiduciary obligations of physicians were reviewed and compared with the 2006 UAGA and its 2007 amendment. DATA EXTRACTION AND SYNTHESIS We examined the legal and medical ethics literature to evaluate the 2006 UAGA and its 2007 amendment. CONCLUSIONS The 2006 UAGA reflects the important public policy goal of making more organs available for transplantation. However, it transfers authority over EOL decisions from patients or surrogates to organ procurement organizations, which is inconsistent with EOL U.S. common law and the ethical and legal standards that govern medicine. The extent of informed consent transferred to organ procurement organizations at the time of signing a donor registry card is legally and ethically uncertain under the UAGA. As states consider enacting the 2006 UAGA, further revisions should be considered to balance the public policy goals of increasing the availability of donated organs with truly informed and voluntary EOL decisions for patients. Further revision of the 2006 UAGA is necessary to respect patients' civil liberties and the professional integrity of physicians who have legally and ethically recognized fiduciary duties to their dying patients.
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Affiliation(s)
- George C Velmahos
- John F. Burke Professor of Surgery, Harvard Medical School, Chief, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
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