1
|
Günter CI, Machens HG, Ilg FP, Hapfelmeier A, Jelkmann W, Egert-Schwender S, Giri S, Bader A. A Randomized Controlled Trial: Regenerative Effects, Efficacy and Safety of Erythropoietin in Burn and Scalding Injuries. Front Pharmacol 2018; 9:951. [PMID: 30429786 PMCID: PMC6220439 DOI: 10.3389/fphar.2018.00951] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 08/02/2018] [Indexed: 01/12/2023] Open
Abstract
In adult’s burn injuries belong to the top 15 causes of injury. Annually more than a million patients receive specialized treatment. Improving burned patients’ outcomes is still a challenge. Effects of erythropoietin (EPO) are reported to be pro-angiogenic, pro-regenerative, anti-inflammatory, immunomodulatory and hypoxia/ischemia protective. Study objectives were to demonstrate cytoprotective and regenerative effects of EPO in burned patients in terms of improved wound healing, reduced morbidity and mortality. This was a prospective, placebo-controlled, randomized, double-blind trial. The trial was conducted in 13 specialized burn care centers in Germany. Adult Patients with 2b° or 3° burn injuries were included. Patients received state of the art burn care including obligatory split skin graft transplantation. Study medication was EPO or placebo every other day for 21 days. Between 12/08 and 06/14, 116 patients were randomized, 84 received study medication (EPO 45, Placebo 39). Primary endpoint analysis revealed inconclusive results, as only a minority of patients reached the primary endpoint [100% re-epithelialization: EPO: 23% (9/40); Placebo 30% (11/37)]. Several secondary endpoints such as SOFA score (morbidity), EPO level in blood and wound healing onset revealed clinical, and statistically significant results in favor of the EPO group. Adverse Events (AEs) and Severe Adverse Events (SAEs) were in expected ranges; AEs EPO: 80%, (36/45), Placebo: 77%, (30/39); SAEs EPO: 24%, (11/45), Placebo: 24%, (8/39). Out of 84 patients two died, one per group, thus mortality was lower than expected. Results (SOFA score) indicate a lower morbidity of the EPO group, suggesting pro-regenerative effects of EPO in burned patients. Higher EPO levels might influence the faster onset of re-epithelialization in the first 10 days of the treatment. Both effects could reveal new therapeutic options. Clinical Trial Registration: ISRCT Number: ISRCTN95777824 and EudraCT Number: 2006-002886-38, Protocol Number: 0506.
Collapse
Affiliation(s)
- Christina I Günter
- Clinic for Plastic Surgery and Hand Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Hans-Günther Machens
- Clinic for Plastic Surgery and Hand Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Felicitas P Ilg
- Clinic for Plastic Surgery and Hand Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Alexander Hapfelmeier
- Institute of Medical Informatics, Statistics and Epidemiology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | | | - Silvia Egert-Schwender
- Münchner Studienzentrum, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Shibashish Giri
- Applied Stem Cell Biology and Cell Technology, Biomedical and Biotechnological Center, Leipzig University, Leipzig, Germany.,Department of Plastic Surgery and Hand Surgery, University Hospital Rechts der Isar, Technische Universität München, Munich, Germany
| | | | - Augustinus Bader
- Institute for Cell Techniques and Applied Stem Cell Biology, Leipzig University, Leipzig, Germany
| |
Collapse
|
2
|
Kao R, Xenocostas A, Rui T, Yu P, Huang W, Rose J, Martin CM. Erythropoietin improves skeletal muscle microcirculation and tissue bioenergetics in a mouse sepsis model. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 11:R58. [PMID: 17509156 PMCID: PMC2206412 DOI: 10.1186/cc5920] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/30/2007] [Revised: 04/17/2007] [Accepted: 05/18/2007] [Indexed: 11/22/2022]
Abstract
Introduction The relationship between oxygen delivery and consumption in sepsis is impaired, suggesting a microcirculatory perfusion defect. Recombinant human erythropoietin (rHuEPO) regulates erythropoiesis and also exerts complex actions promoting the maintenance of homeostasis of the organism under stress. The objective of this study was to test the hypothesis that rHuEPO could improve skeletal muscle capillary perfusion and tissue oxygenation in sepsis. Methods Septic mice in three experiments received rHu-EPO 400 U/kg subcutaneously 18 hours after cecal ligation and perforation (CLP). The first experiment measured the acute effects of rHuEPO on hemodynamics, blood counts, and arterial lactate level. The next two sets of experiments used intravital microscopy to observe capillary perfusion and nicotinamide adenine dinucleotide (NADH) fluorescence post-CLP after treatment with rHuEPO every 10 minutes for 40 minutes and at 6 hours. Perfused capillary density during a three-minute observation period and NADH fluorescence were measured. Results rHuEPO did not have any effects on blood pressure, lactate level, or blood cell numbers. CLP mice demonstrated a 22% decrease in perfused capillary density compared to the sham group (28.5 versus 36.6 capillaries per millimeter; p < 0.001). Treatment of CLP mice with rHuEPO resulted in an immediate and significant increase in perfused capillaries in the CLP group at all time points compared to baseline from 28.5 to 33.6 capillaries per millimeter at 40 minutes; p < 0.001. A significant increase in baseline NADH, suggesting tissue hypoxia, was noted in the CLP mice compared to the sham group (48.3 versus 43.9 fluorescence units [FU]; p = 0.03) and improved with rHuEPO from 48.3 to 44.4 FU at 40 minutes (p = 0.02). Six hours after treatment with rHuEPO, CLP mice demonstrated a higher mean perfused capillary density (39.4 versus 31.7 capillaries per millimeter; p < 0.001) and a lower mean NADH fluorescence as compared to CLP+normal saline mice (49.4 versus 52.7 FU; p = 0.03). Conclusion rHuEPO produced an immediate increase in capillary perfusion and decrease in NADH fluorescence in skeletal muscle. Thus, it appears that rHuEPO improves tissue bioenergetics, which is sustained for at least six hours in this murine sepsis model.
Collapse
Affiliation(s)
- Raymond Kao
- Department of National Defense, Canadian Forces Medical Group, 1745 Alta Vista Drive, Ottawa, Ontario, K1A 0K6, Canada
- London Health Sciences Center, Divisions of Critical Care & Hematology; Center for Critical Illness Research; Lawson Health Research Institute; University of Western Ontario, 800 Commissioner's Rd. E., London, Ontario, N6A 5W9, Canada
| | - Anargyros Xenocostas
- London Health Sciences Center, Divisions of Critical Care & Hematology; Center for Critical Illness Research; Lawson Health Research Institute; University of Western Ontario, 800 Commissioner's Rd. E., London, Ontario, N6A 5W9, Canada
| | - Tao Rui
- London Health Sciences Center, Divisions of Critical Care & Hematology; Center for Critical Illness Research; Lawson Health Research Institute; University of Western Ontario, 800 Commissioner's Rd. E., London, Ontario, N6A 5W9, Canada
| | - Pei Yu
- London Health Sciences Center, Divisions of Critical Care & Hematology; Center for Critical Illness Research; Lawson Health Research Institute; University of Western Ontario, 800 Commissioner's Rd. E., London, Ontario, N6A 5W9, Canada
| | - Weixiong Huang
- London Health Sciences Center, Divisions of Critical Care & Hematology; Center for Critical Illness Research; Lawson Health Research Institute; University of Western Ontario, 800 Commissioner's Rd. E., London, Ontario, N6A 5W9, Canada
| | - James Rose
- London Health Sciences Center, Divisions of Critical Care & Hematology; Center for Critical Illness Research; Lawson Health Research Institute; University of Western Ontario, 800 Commissioner's Rd. E., London, Ontario, N6A 5W9, Canada
| | - Claudio M Martin
- London Health Sciences Center, Divisions of Critical Care & Hematology; Center for Critical Illness Research; Lawson Health Research Institute; University of Western Ontario, 800 Commissioner's Rd. E., London, Ontario, N6A 5W9, Canada
| |
Collapse
|
3
|
Coleman TR, Westenfelder C, Tögel FE, Yang Y, Hu Z, Swenson L, Leuvenink HGD, Ploeg RJ, d’Uscio LV, Katusic ZS, Ghezzi P, Zanetti A, Kaushansky K, Fox NE, Cerami A, Brines M. Cytoprotective doses of erythropoietin or carbamylated erythropoietin have markedly different procoagulant and vasoactive activities. Proc Natl Acad Sci U S A 2006; 103:5965-70. [PMID: 16585502 PMCID: PMC1458681 DOI: 10.1073/pnas.0601377103] [Citation(s) in RCA: 102] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Recombinant human erythropoietin (rhEPO) is receiving increasing attention as a potential therapy for prevention of injury and restoration of function in nonhematopoietic tissues. However, the minimum effective dose required to mimic and augment these normal paracrine functions of erythropoietin (EPO) in some organs (e.g., the brain) is higher than for treatment of anemia. Notably, a dose-dependent risk of adverse effects has been associated with rhEPO administration, especially in high-risk groups, including polycythemia-hyperviscosity syndrome, hypertension, and vascular thrombosis. Of note, several clinical trials employing relatively high dosages of rhEPO in oncology patients were recently halted after an increase in mortality and morbidity, primarily because of thrombotic events. We recently identified a heteromeric EPO receptor complex that mediates tissue protection and is distinct from the homodimeric receptor responsible for the support of erythropoiesis. Moreover, we developed receptor-selective ligands that provide tools to assess which receptor isoform mediates which biological consequence of rhEPO therapy. Here, we demonstrate that rhEPO administration in the rat increases systemic blood pressure, reduces regional renal blood flow, and increases platelet counts and procoagulant activities. In contrast, carbamylated rhEPO, a heteromeric receptor-specific ligand that is fully tissue protective, increases renal blood flow, promotes sodium excretion, reduces injury-induced elevation in procoagulant activity, and does not effect platelet production. These preclinical findings suggest that nonerythropoietic tissue-protective ligands, which appear to elicit fewer adverse effects, may be especially useful in clinical settings for tissue protection.
Collapse
Affiliation(s)
- Thomas R. Coleman
- *The Kenneth S. Warren Institute
- Warren Pharmaceuticals, Ossining, NY 10562
| | - Christof Westenfelder
- Departments of Medicine and Physiology, University of Utah and Veterans Affairs Medical Centers, Salt Lake City, UT 84148
| | - Florian E. Tögel
- Departments of Medicine and Physiology, University of Utah and Veterans Affairs Medical Centers, Salt Lake City, UT 84148
| | - Ying Yang
- Departments of Medicine and Physiology, University of Utah and Veterans Affairs Medical Centers, Salt Lake City, UT 84148
| | - Zhuma Hu
- Departments of Medicine and Physiology, University of Utah and Veterans Affairs Medical Centers, Salt Lake City, UT 84148
| | - LeAnne Swenson
- Departments of Medicine and Physiology, University of Utah and Veterans Affairs Medical Centers, Salt Lake City, UT 84148
| | | | - Rutger J. Ploeg
- University of Groningen, 9700 AB, Groningen, The Netherlands
| | | | | | - Pietro Ghezzi
- *The Kenneth S. Warren Institute
- **Mario Negri Institute, 20157 Milan, Italy; and
| | | | | | | | - Anthony Cerami
- *The Kenneth S. Warren Institute
- Warren Pharmaceuticals, Ossining, NY 10562
| | - Michael Brines
- *The Kenneth S. Warren Institute
- Warren Pharmaceuticals, Ossining, NY 10562
| |
Collapse
|
4
|
Allegra A, Giacobbe MS, Corvaia E, Cinquegrani M, Corvaja E, Giorgianni G, Buemi M. Possible role of erythropoietin in the pathogenesis of chronic cor pulmonale. Nephrol Dial Transplant 2005; 20:2866-7. [PMID: 16115846 DOI: 10.1093/ndt/gfi098] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
5
|
Jones MA, Kingswood JC, Dallyn PE, Sharpstone P. Haemodynamic changes measured by transthoracic bioimpedance during treatment with recombinant human erythropoietin. Clin Exp Hypertens 1996; 18:51-64. [PMID: 8822233 DOI: 10.3109/10641969609082606] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Hypertension complicates the treatment of anaemia of chronic renal failure with recombinant human erythropoietin (EPO) in some patients. We conducted a prospective study measuring changes in cardiac index (CI) and systemic vascular resistance index (SVRI) in 29 patients from before commencement of EPO to attainment of target haemoglobin concentration. We used the operator-independent technique of trans-thoracic bioimpedance. The group of patients who developed EPO-induced hypertension (EpHT) were separately analysed and compared with the group who had no change in blood pressure (NC). Our results showed there was a significant rise in SVRI after treatment in EpHT group patients but in the NC group there was a small fall. CI increased significantly in the NC group after treatment but no change was recorded in the EpHT group. These findings clearly demonstrate how the cardiovascular changes differ in patients who develop EPO-induced hypertension.
Collapse
Affiliation(s)
- M A Jones
- Trafford Department of Renal Medicine, Royal Sussex County Hospital, Brighton, United Kingdom
| | | | | | | |
Collapse
|
6
|
Rendell MS, McIntyre SF, Terando JV, Kelly ST, Finney DA, Milliken BK, Kingsley DW, Satterlee M. The effect of polycythemia on skin blood flow in hypertensive rats. ACTA ACUST UNITED AC 1995. [DOI: 10.1016/0300-9629(95)02003-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
7
|
Farrington K, Sweny P. Nephrology, dialysis and transplantation. Postgrad Med J 1993; 69:516-46. [PMID: 8415341 PMCID: PMC2399887 DOI: 10.1136/pgmj.69.813.516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
|
8
|
Roger SD, Grasty MS, Baker LR, Raine AE. Effects of oxygen breathing and erythropoietin on hypoxic vasodilation in uremic anemia. Kidney Int 1992; 42:975-80. [PMID: 1453590 DOI: 10.1038/ki.1992.376] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Loss of hypoxic vasodilation has been proposed as a causative factor in the development of hypertension in dialysis patients treated with recombinant human erythropoietin (rHuEPO). Venous occlusion plethysmography was therefore performed on 22 dialysis patients (aged 23 to 71 years, dialysis duration 6 to 260 months, 8 males) before and after correction of anemia with rHuEPO, 50 U/kg 3x/week (Hb: 7.4 +/- 0.3 vs. 10.8 +2- 0.3 g/dl, P less than 0.0001). Hypertension (greater than 15 mm Hg rise in mean BP) occurred in 11 patients. The study was performed while breathing room air and repeated after breathing 60% O2 for 10 to 12 minutes. Before rHuEPO therapy, total blood O2 content increased from 10.01 +/- 0.39 to 10.32 +/- 0.29 ml O2/100 ml blood with breathing 60% O2 (P less than 0.01). After correction of anemia it was 14.65 +/- 0.40 ml O2/100 ml blood on room air (P less than 0.001). There was a significant decrease in forearm blood flow (7.9 +/- 0.5 vs. 6.5 +/- 0.6 ml/min/100 ml tissue, P less than 0.05) and increase in forearm vascular resistance (12.8 +/- 0.1 vs. 16.8 +/- 0.2 mm Hg/ml/min/100 ml tissue, P less than 0.05) with O2 breathing prior to rHuEPO therapy in the blood pressure responders, but no change in these parameters in the group in which blood pressure remained unchanged. When all patients were studied on room air, forearm vascular resistance rose significantly after correction of anemia (13.0 +/- 0.8 vs. 16.3 +/- 0.8 mm Hg/ml/min/100 ml tissue, P less than 0.05), compared with that prior to rHuEPO therapy.(ABSTRACT TRUNCATED AT 250 WORDS)
Collapse
Affiliation(s)
- S D Roger
- Department of Nephrology, St. Bartholomew's Hospital, London, England, United Kingdom
| | | | | | | |
Collapse
|
9
|
Postiglione A, Faccenda F, Gallotta G, Rubba P, Federico S. Changes in middle cerebral artery blood velocity in uremic patients after hemodialysis. Stroke 1991; 22:1508-11. [PMID: 1962325 DOI: 10.1161/01.str.22.12.1508] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND PURPOSE Strokes are a frequent complication in uremic patients on dialysis. We wanted to evaluate the effect of this treatment on cerebral hemodynamic parameters, particularly those of patients with carotid stenosis, who are at higher risk for atherothrombotic ischemic events. METHODS We used transcranial Doppler ultrasonography to evaluate blood velocity of the middle cerebral artery in 18 uremic patients before and after hemodialysis. Carotid stenosis was evaluated by echo-Doppler investigation. Six patients were also studied before and after recombinant human erythropoietin treatment. RESULTS Dialysis treatment decreased mean blood velocity in all patients (p less than 0.001). Eight of 18 patients (44%) with mild (16-50%), moderate (51-80%), or severe (greater than 80%) carotid stenosis had lower velocity than patients with normal carotid arteries (p less than 0.01), and they experienced a further decrease to even lower levels after hemodialysis (p less than 0.05). In patients treated with recombinant human erythropoietin, hematocrit increased from 28 +/- 8% to 37 +/- 5% (p less than 0.001), and blood velocity had a further decrease by 11%. All changes were associated with modifications toward normality of pH, PaCO2, and hematocrit. CONCLUSIONS Transcranial Doppler ultrasonography represents a useful method for monitoring cerebral circulation of uremic patients, especially of those at possible risk for ischemia.
Collapse
Affiliation(s)
- A Postiglione
- Institute of Internal Medicine and Metabolic Diseases, University of Naples, Italy
| | | | | | | | | |
Collapse
|