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Gulati A, Jain D, Agrawal NR, Rahate P, Choudhuri R, Das S, Dhibar DP, Prabhu M, Haveri S, Agarwal R, Lavhale MS. Resuscitative Effect of Centhaquine (Lyfaquin ®) in Hypovolemic Shock Patients: A Randomized, Multicentric, Controlled Trial. Adv Ther 2021; 38:3223-3265. [PMID: 33970455 PMCID: PMC8189997 DOI: 10.1007/s12325-021-01760-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 04/22/2021] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Centhaquine (Lyfaquin®) showed significant efficacy as a resuscitative agent in animal models of haemorrhagic shock. Its safety and tolerability were confirmed in healthy human volunteers. In this study, our primary objective was to determine the safety, and the secondary objective was to assess the efficacy of centhaquine in patients with hypovolemic shock. METHODS A prospective, multicentre, randomized phase II study was conducted in male and female patients aged 18-70 years with hypovolemic shock having systolic BP ≤ 90 mmHg. Patients were randomized in a 1:1 ratio to either the control or centhaquine group. The control group received 100 ml of normal saline infusion over 1 h, while the centhaquine group received 0.01 mg/kg of centhaquine in 100 ml normal saline infusion over 1 h. Every patient received standard of care (SOC) and was followed for 28 days. RESULTS Fifty patients were included, and 45 completed the trial: 22 in the control group and 23 in the centhaquine group. The demographics of patients in both groups were comparable. No adverse event related to centhaquine was recorded in the 28-day observation period. The baseline, Injury Scoring System score, haemoglobin, and haematocrit were similar in both groups. However, 91% of the patients in the centhaquine group needed major surgery, whereas only 68% in the control group (p = 0.0526). Twenty-eight-day all-cause mortality was 0/23 in the centhaquine group and 2/22 in the control group. The percent time in ICU and ventilator support was less in the centhaquine group than in the control group. The total amount of vasopressors needed in the first 48 h of resuscitation was lower in the centhaquine group than in the control group (3.12 ± 2.18 vs. 9.39 ± 4.28 mg). An increase in systolic and diastolic BP from baseline through 48 h was more marked in the centhaquine group than in the control group. Compared with the control group, blood lactate level was lower by 1.75 ± 1.07 mmol/l in the centhaquine group on day 3 of resuscitation. Improvements in base deficit, multiple organ dysfunction syndrome (MODS) score and adult respiratory distress syndrome (ARDS) were greater in the centhaquine group than in the control group. CONCLUSION When added to SOC, centhaquine is a well-tolerated and effective resuscitative agent. It improves the clinical outcome of patients with hypovolemic shock. TRIAL REGISTRATION ClinicalTrials.gov identifier number: NCT04056065.
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Affiliation(s)
- Anil Gulati
- Professor Emeritus, Midwestern University, Downers Grove, IL USA
| | - Dinesh Jain
- Department of Medicine, Dayanand Medical College & Hospital, Civil Lines, Tagore Nagar, Ludhiana, Punjab 141001 India
| | - Nilesh Radheshyam Agrawal
- Department of Neurology, New Era Hospital, Near Jalaram Mandir, Queta Colony, Telephone Exchange Chowk, Central Avenue Road, Nagpur, Maharashtra 440008 India
| | - Prashant Rahate
- Seven Star Hospital Jagnade Square, KDK College Road, Nagpur, Maharashtra 440009 India
| | - Rajat Choudhuri
- Department of Anaesthesiology, Institute of Post-Graduate Medical Education and Research and SSKM Hospital, 244 A.J.C. Bose Road, Kolkata, West Bengal 700020 India
| | - Soumen Das
- Department of Surgery, Institute of Post-Graduate Medical Education and Research and SSKM Hospital, 244 A.J.C. Bose Road, Kolkata, West Bengal 700020 India
| | - Deba Prasad Dhibar
- Department of Internal Medicine, Nehru Hospital, Post-Graduate Institute of Medical Education and Research (PGIMER), Sector-12, Chandigarh, 160 012 India
| | - Madhav Prabhu
- Department of Medicine, KLE’s Dr. Prabhakar Kore Hospital and Medical Research Centre, Nehru Nagar, Belgaum, Karnataka 590010 India
| | - Sameer Haveri
- Department of Orthopaedics, KLE’s Dr. Prabhakar Kore Hospital and Medical Research Centre, Nehru Nagar, Belgaum, Karnataka 590010 India
| | - Rohit Agarwal
- Department of Anaesthesiology, ORIANA Hospital, Plot No.: 6, 7, 8 Ravindrapuri Bhelpur, Varanasi, Uttar Pradesh 221005 India
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Gulati A, Choudhuri R, Gupta A, Singh S, Ali SKN, Sidhu GK, Haque PD, Rahate P, Bothra AR, Singh GP, Maheshwari S, Jeswani D, Haveri S, Agarwal A, Agrawal NR. A Multicentric, Randomized, Controlled Phase III Study of Centhaquine (Lyfaquin ®) as a Resuscitative Agent in Hypovolemic Shock Patients. Drugs 2021; 81:1079-1100. [PMID: 34061314 PMCID: PMC8167383 DOI: 10.1007/s40265-021-01547-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2021] [Indexed: 11/30/2022]
Abstract
Introduction Centhaquine (Lyfaquin®) showed significant safety and efficacy in preclinical and clinical phase I and II studies. Methods A prospective, multicentric, randomized phase III study was conducted in patients with hypovolemic shock, systolic blood pressure (SBP) ≤ 90 mmHg, and blood lactate levels ≥ 2 mmol/L. Patients were randomized in a 2:1 ratio to the centhaquine group (n = 71) or the control (saline) group (n = 34). Every patient received standard of care (SOC) and was followed for 28 days. The study drug (normal saline or centhaquine 0.01 mg/kg) was administered in 100 mL of normal saline infusion over 1 h. The primary objectives were to determine changes (mean through 48 h) in SBP, diastolic blood pressure (DBP), blood lactate levels, and base deficit. The secondary objectives included the amount of fluids, blood products, and vasopressors administered in the first 48 h, duration of hospital stay, time in intensive care units, time on ventilator support, change in acute respiratory distress syndrome (ARDS), multiple organ dysfunction syndrome (MODS), and the proportion of patients with 28-day all-cause mortality. Results The demographics of patients and baseline vitals in both groups were comparable. The cause of hypovolemic shock was trauma in 29.4 and 47.1% of control group and centhaquine group patients, respectively, and gastroenteritis in 44.1 and 29.4%, respectively. Shock index (SI) and quick sequential organ failure assessment at baseline were similar in the two groups. An equal amount of fluids and blood products were administered in both groups during the first 48 h of resuscitation. A lesser amount of vasopressors was needed in the first 48 h of resuscitation in the centhaquine group. An increase in SBP from baseline was consistently higher up to 48 h (12.9% increase in area under the curve from 0 to 48 h [AUC0–48]) in the centhaquine group than in the control group. A significant increase in pulse pressure (48.1% increase in AUC0–48) in the centhaquine group compared with the control group suggests improved stroke volume due to centhaquine. The SI was significantly lower in the centhaquine group from 1 h (p = 0.032) to 4 h (p = 0.049) of resuscitation. Resuscitation with centhaquine resulted in a significantly greater number of patients with improved blood lactate (control 46.9%; centhaquine 69.3%; p = 0.03) and the base deficit (control 43.7%; centhaquine 69.8%; p = 0.01) than in the control group. ARDS and MODS improved with centhaquine, and an 8.8% absolute reduction in 28-day all-cause mortality was observed in the centhaquine group. Conclusion Centhaquine is an efficacious resuscitative agent for treating hypovolemic shock. The efficacy of centhaquine in distributive shock is being explored. Trial Registration Clinical Trials Registry, India; ctri.icmr.org.in, CTRI/2019/01/017196; clinicaltrials.gov, NCT04045327. Supplementary Information The online version contains supplementary material available at 10.1007/s40265-021-01547-5.
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Affiliation(s)
- Anil Gulati
- Pharmazz, Inc., 50 West 75th Street, Suite 105, Willowbrook, IL, 60527, USA.
| | - Rajat Choudhuri
- Institute of Postgraduate Medical Education and Research/SSKM Hospital, Kolkata, West Bengal, India
| | - Ajay Gupta
- Chiranjeev Medical Centre, Jhansi, Uttar Pradesh, India
| | - Saurabh Singh
- Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - S K Noushad Ali
- ACSR Government Medical College and Hospital, Nellore, Andhra Pradesh, India
| | | | | | | | - Aditya R Bothra
- Rahate Surgical Hospital and ICU, Nagpur, Maharashtra, India
| | - Gyan P Singh
- King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Sanjiv Maheshwari
- Jawahar Lal Nehru Medical College and Attached Hospital, Ajmer, Rajasthan, India
| | - Deepak Jeswani
- Criticare Hospital and Research Institute, Nagpur, Maharashtra, India
| | - Sameer Haveri
- KLE's Dr. Prabhakar Kore Hospital and Medical Research Centre, Belgaum, Karnataka, India
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Kure T, Sakai H. Preparation of Artificial Red Blood Cells (Hemoglobin Vesicles) Using the Rotation-Revolution Mixer for High Encapsulation Efficiency. ACS Biomater Sci Eng 2021; 7:2835-2844. [PMID: 34029046 DOI: 10.1021/acsbiomaterials.1c00424] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Hemoglobin vesicles (Hb-V) are artificial red blood cells encapsulating highly concentrated hemoglobin (Hb) in liposomes comprising phospholipids, cholesterol, negatively charged lipids, and polyethylene glycol (PEG)-conjugated phospholipids. Safety and efficacy of Hb-V as a transfusion alternative have been extensively studied. For this study, we prepared Hb-V using the kneading method with a rotation-revolution mixer as an alternative to the conventional extrusion method. We optimized the kneading operation parameters to obtain Hb-V with a high yield. Results show that the Hb encapsulation efficiency was increased dramatically up to 74.2%, which is higher than that of the extrusion method (20%) because the kneading method enabled mixing of a highly concentrated carbonylhemoglobin (HbCO) solution (40 g/dL) and a considerably large amount of powdered lipids in only 10 min. The high viscosity of the Hb-lipid mixture paste (ca. 103-105 cP) favorably induces frictional heat by kneading and increases the paste temperature (ca. 60 °C), which facilitates lipid dispersion and liposome formation. During the kneading operation using a thermostable HbCO solution, Hb denaturation was prevented. Hb-V prepared using this method showed no marked changes in particle sizes, Hb denaturation, or Hb leakage from liposomes during two years of long-term storage-stability tests. Collectively, these results demonstrate that the kneading method using a rotation-revolution mixer shows good potential as a new method to produce Hb-V.
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Affiliation(s)
- Tomoko Kure
- Department of Chemistry, Nara Medical University, 840 Shijo-cho, Kashihara 634-8521, Japan
| | - Hiromi Sakai
- Department of Chemistry, Nara Medical University, 840 Shijo-cho, Kashihara 634-8521, Japan
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Kitagishi H, Kano K. Synthetic heme protein models that function in aqueous solution. Chem Commun (Camb) 2021; 57:148-173. [DOI: 10.1039/d0cc07044k] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Supramolecular porphyrin–cyclodextrin complexes act as biomimetic heme protein models in aqueous solution.
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Affiliation(s)
- Hiroaki Kitagishi
- Department of Molecular Chemistry and Biochemistry
- Faculty of Science and Engineering
- Doshisha University
- Kyoto 610-0321
- Japan
| | - Koji Kano
- Department of Molecular Chemistry and Biochemistry
- Faculty of Science and Engineering
- Doshisha University
- Kyoto 610-0321
- Japan
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Coll-Satue C, Bishnoi S, Chen J, Hosta-Rigau L. Stepping stones to the future of haemoglobin-based blood products: clinical, preclinical and innovative examples. Biomater Sci 2021; 9:1135-1152. [DOI: 10.1039/d0bm01767a] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Critical overview of the different oxygen therapeutics developed so far to be used when donor blood is not available.
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Affiliation(s)
- Clara Coll-Satue
- Department of Health Technology
- Centre for Nanomedicine and Theranostics
- DTU Health Tech
- Technical University of Denmark
- 2800 Lyngby
| | - Shahana Bishnoi
- Department of Health Technology
- Centre for Nanomedicine and Theranostics
- DTU Health Tech
- Technical University of Denmark
- 2800 Lyngby
| | - Jiantao Chen
- Department of Health Technology
- Centre for Nanomedicine and Theranostics
- DTU Health Tech
- Technical University of Denmark
- 2800 Lyngby
| | - Leticia Hosta-Rigau
- Department of Health Technology
- Centre for Nanomedicine and Theranostics
- DTU Health Tech
- Technical University of Denmark
- 2800 Lyngby
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Abstract
In blood, the primary role of red blood cells (RBCs) is to transport oxygen via highly regulated mechanisms involving hemoglobin (Hb). Hb is a tetrameric porphyrin protein comprising of two α- and two β-polypeptide chains, each containing an iron-containing heme group capable of binding one oxygen molecule. In military as well as civilian traumatic exsanguinating hemorrhage, rapid loss of RBCs can lead to suboptimal tissue oxygenation and subsequent morbidity and mortality. In such cases, transfusion of whole blood or RBCs can significantly improve survival. However, blood products including RBCs present issues of limited availability and portability, need for type matching, pathogenic contamination risks, and short shelf-life, causing substantial logistical barriers to their prehospital use in austere battlefield and remote civilian conditions. While robust research is being directed to resolve these issues, parallel research efforts have emerged toward bioengineering of semisynthetic and synthetic surrogates of RBCs, using various cross-linked, polymeric, and encapsulated forms of Hb. These Hb-based oxygen carriers (HBOCs) can potentially provide therapeutic oxygenation when blood or RBCs are not available. Several of these HBOCs have undergone rigorous preclinical and clinical evaluation, but have not yet received clinical approval in the USA for human use. While these designs are being optimized for clinical translations, several new HBOC designs and molecules have been reported in recent years, with unique properties. The current article will provide a comprehensive review of such HBOC designs, including current state-of-the-art and novel molecules in development, along with a critical discussion of successes and challenges in this field.
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Abstract
Hemoglobin based oxygen carriers (HBOCs) have been developed as alternative oxygen transporting formulations for the acute treatment of anemia and ischemia. Efficacy has been demonstrated in a variety of preclinical models and selected human patients; however, a higher overall incidence of mortality and myocardial infarction in those dosed with HBOCs in later stage clinical trials has prevented widespread regulatory approval. Diagnosis of myocardial infarction is confounded by the fact that HBOCs interfere with troponin assays, as well as other clinical chemistry measurements. Analysis of data pertaining to potential toxicity mechanisms suggests that coronary vasoconstriction is an unlikely contributor, but promotion of intravascular thrombosis may occur by several mechanisms. In addition, fluid and anemia management in patients infused with HBOCs has been suboptimal. Elucidation of potential toxicity mechanisms, refinement of use protocols, and definition of improved patient inclusion/exclusion criteria remain active areas of inquiry in understanding the best manner in which to utilize HBOCs.
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Recent and prominent examples of nano- and microarchitectures as hemoglobin-based oxygen carriers. Adv Colloid Interface Sci 2018; 260:65-84. [PMID: 30177214 DOI: 10.1016/j.cis.2018.08.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Revised: 08/21/2018] [Accepted: 08/22/2018] [Indexed: 12/16/2022]
Abstract
Blood transfusions, which usually consist in the administration of isolated red blood cells (RBCs), are crucial in traumatic injuries, pre-surgical conditions and anemias. Although RBCs transfusion from donors is a safe procedure, donor RBCs can only be stored for a maximum of 42 days under refrigerated conditions and, therefore, stockpiles of RBCs for use in acute disasters do not exist. With a worldwide shortage of donor blood that is expected to increase over time, the creation of oxygen-carriers with long storage life and compatibility without typing and cross-matching, persists as one of the foremost important challenges in biomedicine. However, research has so far failed to produce FDA approved RBCs substitutes (RBCSs) for human usage. As such, due to unacceptable toxicities, the first generation of oxygen-carriers has been withdrawn from the market. Being hemoglobin (Hb) the main component of RBCs, a lot of effort is being devoted in assembling semi-synthetic RBCS utilizing Hb as the oxygen-carrier component, the so-called Hb-based oxygen carriers (HBOCs). However, a native RBC also contains a multi-enzyme system to prevent the conversion of Hb into non-functional methemoglobin (metHb). Thus, the challenge for the fabrication of next-generation HBOCs relies in creating a system that takes advantage of the excellent oxygen-carrying capabilities of Hb, while preserving the redox environment of native RBCs that prevents or reverts the conversion of Hb into metHb. In this review, we feature the most recent advances in the assembly of the new generation of HBOCs with emphasis in two main approaches: the chemical modification of Hb either by cross-linking strategies or by conjugation to other polymers, and the Hb encapsulation strategies, usually in the form of lipidic or polymeric capsules. The applications of the aforementioned HBOCs as blood substitutes or for oxygen-delivery in tissue engineering are highlighted, followed by a discussion of successes, challenges and future trends in this field.
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Meng F, Kassa T, Jana S, Wood F, Zhang X, Jia Y, D’Agnillo F, Alayash AI. Comprehensive Biochemical and Biophysical Characterization of Hemoglobin-Based Oxygen Carrier Therapeutics: All HBOCs Are Not Created Equally. Bioconjug Chem 2018; 29:1560-1575. [DOI: 10.1021/acs.bioconjchem.8b00093] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Fantao Meng
- Laboratory of Biochemistry and Vascular Biology, Division of Blood Components and Devices, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland 20993, United States
| | - Tigist Kassa
- Laboratory of Biochemistry and Vascular Biology, Division of Blood Components and Devices, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland 20993, United States
| | - Sirsendu Jana
- Laboratory of Biochemistry and Vascular Biology, Division of Blood Components and Devices, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland 20993, United States
| | - Francine Wood
- Laboratory of Biochemistry and Vascular Biology, Division of Blood Components and Devices, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland 20993, United States
| | - Xiaoyuan Zhang
- Laboratory of Biochemistry and Vascular Biology, Division of Blood Components and Devices, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland 20993, United States
| | - Yiping Jia
- Laboratory of Biochemistry and Vascular Biology, Division of Blood Components and Devices, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland 20993, United States
| | - Felice D’Agnillo
- Laboratory of Biochemistry and Vascular Biology, Division of Blood Components and Devices, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland 20993, United States
| | - Abdu I. Alayash
- Laboratory of Biochemistry and Vascular Biology, Division of Blood Components and Devices, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland 20993, United States
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Sen Gupta A. Bio-inspired nanomedicine strategies for artificial blood components. WILEY INTERDISCIPLINARY REVIEWS. NANOMEDICINE AND NANOBIOTECHNOLOGY 2017; 9:10.1002/wnan.1464. [PMID: 28296287 PMCID: PMC5599317 DOI: 10.1002/wnan.1464] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 01/23/2017] [Accepted: 01/29/2017] [Indexed: 11/12/2022]
Abstract
Blood is a fluid connective tissue where living cells are suspended in noncellular liquid matrix. The cellular components of blood render gas exchange (RBCs), immune surveillance (WBCs) and hemostatic responses (platelets), and the noncellular components (salts, proteins, etc.) provide nutrition to various tissues in the body. Dysfunction and deficiencies in these blood components can lead to significant tissue morbidity and mortality. Consequently, transfusion of whole blood or its components is a clinical mainstay in the management of trauma, surgery, myelosuppression, and congenital blood disorders. However, donor-derived blood products suffer from issues of shortage in supply, need for type matching, high risks of pathogenic contamination, limited portability and shelf-life, and a variety of side-effects. While robust research is being directed to resolve these issues, a parallel clinical interest has developed toward bioengineering of synthetic blood substitutes that can provide blood's functions while circumventing the above problems. Nanotechnology has provided exciting approaches to achieve this, using materials engineering strategies to create synthetic and semi-synthetic RBC substitutes for enabling oxygen transport, platelet substitutes for enabling hemostasis, and WBC substitutes for enabling cell-specific immune response. Some of these approaches have further extended the application of blood cell-inspired synthetic and semi-synthetic constructs for targeted drug delivery and nanomedicine. The current study provides a comprehensive review of the various nanotechnology approaches to design synthetic blood cells, along with a critical discussion of successes and challenges of the current state-of-art in this field. WIREs Nanomed Nanobiotechnol 2017, 9:e1464. doi: 10.1002/wnan.1464 For further resources related to this article, please visit the WIREs website.
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Affiliation(s)
- Anirban Sen Gupta
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, USA
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Kitagishi H, Kawasaki H, Kano K. Bioconjugation of Serum Albumin to a Maleimide-appended Porphyrin/Cyclodextrin Supramolecular Complex as an Artificial Oxygen Carrier in the Bloodstream. Chem Asian J 2015; 10:1768-75. [DOI: 10.1002/asia.201500451] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Indexed: 12/17/2022]
Affiliation(s)
- Hiroaki Kitagishi
- Department of Molecular Chemistry and Biochemistry; Faculty of Science and Engineering; Doshisha University; 1-3 Tatara Miyakodani, Kyotanabe Kyoto 610-0321 Japan
| | - Hiroki Kawasaki
- Department of Molecular Chemistry and Biochemistry; Faculty of Science and Engineering; Doshisha University; 1-3 Tatara Miyakodani, Kyotanabe Kyoto 610-0321 Japan
| | - Koji Kano
- Department of Molecular Chemistry and Biochemistry; Faculty of Science and Engineering; Doshisha University; 1-3 Tatara Miyakodani, Kyotanabe Kyoto 610-0321 Japan
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Denny JT, Burr AT, Balzer F, Tse JT, Denny JE, Chyu D. Methylene blue treatment for cytokine release syndrome-associated vasoplegia following a renal transplant with rATG infusion: A case report and literature review. Exp Ther Med 2015; 9:1915-1920. [PMID: 26136914 DOI: 10.3892/etm.2015.2349] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Accepted: 03/03/2015] [Indexed: 12/29/2022] Open
Abstract
Rabbit anti-thymocyte globulin (rATG) is an infusion of polyclonal rabbit-derived antibodies against human thymocyte markers, which can be used to prevent and treat acute rejection following organ transplantation. However, the product monograph issued by the manufacturer (Sanofi Canada) reports that serious immune-mediated reactions have been observed following the use of rATG, consisting of anaphylaxis or severe cytokine release syndrome (CRS), which is a form of vasoplegic syndrome (VS), in which distributive shock occurs refractory to norepinephrine (NE) and vasopressin (VP). Severe infusion-associated reactions are consistent with CRS and can cause serious cardiac or respiratory problems, or in certain cases, mortality. CRS is a form of systemic inflammatory response syndrome (SIRS). In SIRS, the substantial activation of endothelial inducible nitric oxide synthase (iNOS) and smooth muscle guanylate cyclase (GC) is observed, which can produce severe hypotension that is unresponsive to conventional vasopressors. Methylene blue (MB) is a direct inhibitor of iNOS and GC and has been used as an effective treatment for VS following cardiothoracic surgery. In the present study, the successful use of MB as a rescue therapy for CRS in a patient receiving rATG following a renal transplant was reported. Following an uneventful cadaveric kidney transplant involving the intravenous (IV) administration of rATG for the induction of immunological tolerance, the patient became markedly hypotensive and tachycardic. The patient required high doses of VP and NE infusions. Following the protocol described for treating refractory VS in post-cardiac surgery patients, the decision was made to initiate the patient on an IV MB infusion. This treatment protocol was shown to improve the hemodynamic status of the patient, which enabled the withdrawal of vasopressors and suggests an important role for methylene blue in the management of refractory VS.
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Affiliation(s)
- John T Denny
- Department of Anesthesia, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ 08901, USA
| | - Andrew T Burr
- Department of Anesthesia, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ 08901, USA
| | - Fred Balzer
- Virtua Memorial Hospital, Department of Anesthesia, Mount Holly, NJ 08060, USA
| | - James T Tse
- Department of Anesthesia, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ 08901, USA
| | - Julia E Denny
- Department of Anesthesia, New York University Medical Center, New York, NY 10016, USA
| | - Darrick Chyu
- Department of Anesthesia, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ 08901, USA
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