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Motoyoshi N, Tsutsui M, Soman K, Shirasaka T, Narita T, Kunioka S, Naya K, Yamazaki D, Narita M, Kamiya H. Neuron-specific enolase levels immediately following cardiovascular surgery is modulated by hemolysis due to cardiopulmonary bypass, making it unsuitable as a brain damage biomarker. J Artif Organs 2024; 27:100-107. [PMID: 37120686 PMCID: PMC11126439 DOI: 10.1007/s10047-023-01398-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 04/15/2023] [Indexed: 05/01/2023]
Abstract
Neuron-specific enolase (NSE) is one of the biomarkers used as an indicator of brain disorder, but since it is also found in blood cell components, there is a concern that a spurious increase in NSE may occur after cardiovascular surgery, where cardiopulmonary bypass (CPB) causes hemolysis. In the present study, we investigated the relationship between the degree of hemolysis and NSE after cardiovascular surgery and the usefulness of immediate postoperative NSE values in the diagnosis of brain disorder. A retrospective study of 198 patients who underwent surgery with CPB in the period from May 2019 to May 2021 was conducted. Postoperative NSE levels and Free hemoglobin (F-Hb) levels were compared in both groups. In addition, to verify the relationship between hemolysis and NSE, we examined the correlation between F-Hb levels and NSE levels. We also examined whether different surgical procedures could produce an association between hemolysis and NSE. Among 198 patients, 20 had postoperative stroke (Group S) and 178 had no postoperative stroke (Group U). There was no significant difference in postoperative NSE levels and F-Hb levels between Group S and Group U (p = 0.264, p = 0.064 respectively). F-Hb and NSE were weakly correlated (r = 0.29. p < 0.01). In conclusion, NSE level immediately after cardiac surgery with CPB is modified by hemolysis rather than brain injury, therefore it would be unreliable as a biomarker of brain disorder.
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Affiliation(s)
- Nobuya Motoyoshi
- Department of Clinical Engineering, Asahikawa Medical University Hospital, Asahikawa, 078-8510, Japan
| | - Masahiro Tsutsui
- Department of Cardiac Surgery, Asahikawa Medical University, Midorigaokahigashi2, Asahikawa, Hokkaido, 078-8510, Japan.
| | - Kouji Soman
- Department of Clinical Engineering, Asahikawa Medical University Hospital, Asahikawa, 078-8510, Japan
| | - Tomonori Shirasaka
- Department of Cardiac Surgery, Asahikawa Medical University, Midorigaokahigashi2, Asahikawa, Hokkaido, 078-8510, Japan
| | - Takayuki Narita
- Department of Clinical Engineering, Asahikawa Medical University Hospital, Asahikawa, 078-8510, Japan
| | - Shingo Kunioka
- Department of Cardiac Surgery, Asahikawa Medical University, Midorigaokahigashi2, Asahikawa, Hokkaido, 078-8510, Japan
| | - Katsuyuki Naya
- Department of Clinical Engineering, Asahikawa Medical University Hospital, Asahikawa, 078-8510, Japan
| | - Daisuke Yamazaki
- Department of Clinical Engineering, Asahikawa Medical University Hospital, Asahikawa, 078-8510, Japan
| | - Masahiko Narita
- Department of Cardiac Surgery, Asahikawa Medical University, Midorigaokahigashi2, Asahikawa, Hokkaido, 078-8510, Japan
| | - Hiroyuki Kamiya
- Department of Cardiac Surgery, Asahikawa Medical University, Midorigaokahigashi2, Asahikawa, Hokkaido, 078-8510, Japan
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2
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Maeda A, Pandey D, Inokuchi R, Spano S, Chaba A, Phongphithakchai A, Eastwood G, Jahanabadi H, Vo H, Seevanayagam S, Motley A, Bellomo R. Carboxyhemoglobin in Cardiac Surgery Patients and Its Association with Risk Factors and Biomarkers of Hemolysis. Anesth Analg 2024:00000539-990000000-00780. [PMID: 38446702 DOI: 10.1213/ane.0000000000006915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Abstract
BACKGROUND Cardiac surgery with cardiopulmonary bypass (CPB) is associated with hemolysis. Yet, there is no easily available and frequently measured marker to monitor this hemolysis. However, carboxyhemoglobin (CO-Hb), formed by the binding of carbon monoxide (a product of heme breakdown) to hemoglobin, may reflect such hemolysis. We hypothesized that CO-Hb might increase after cardiac surgery and show associations with operative risk factors and indirect markers for hemolysis. METHODS We conducted a retrospective descriptive cohort study of data from on-pump cardiac surgery patients. We analyzed temporal changes in CO-Hb levels and applied a generalized linear model to assess patient characteristics associated with peak CO-Hb levels. Additionally, we examined their relationship with red blood cell (RBC) transfusion and bilirubin levels. RESULTS We studied 38,487 CO-Hb measurements in 1735 patients. CO-Hb levels increased significantly after cardiac surgery, reaching a peak CO-Hb level 2.1 times higher than baseline (P < .001) at a median of 17 hours after the initiation of surgery. Several factors were independently associated with higher peak CO-Hb, including age (P < .001), preoperative respiratory disease (P = .001), New York Heart Association Class IV (P = .019), the number of packed RBC transfused (P < .001), and the duration of CPB (P = .002). Peak CO-Hb levels also significantly correlated with postoperative total bilirubin levels (Rho = 0.27, P < .001). CONCLUSIONS CO-Hb may represent a readily obtainable and frequently measured biomarker that has a moderate association with known biomarkers of and risk factors for hemolysis in on-pump cardiac surgery patients. These findings have potential clinical implications and warrant further investigation.
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Affiliation(s)
- Akinori Maeda
- From the Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
- Department of Emergency and Critical Care Medicine, The University of Tokyo, Tokyo, Japan
| | - Dinesh Pandey
- Data Analytics Research and Evaluation Centre, The University of Melbourne and Austin Hospital, Melbourne, Victoria, Australia
- Clinical Analytics and Reporting, Austin Health, Melbourne, Victoria, Australia
| | - Ryota Inokuchi
- Department of Emergency and Critical Care Medicine, The University of Tokyo, Tokyo, Japan
- Department of Clinical Engineering, The University of Tokyo, Tokyo, Japan
| | - Sofia Spano
- From the Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Anis Chaba
- From the Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | | | - Glenn Eastwood
- From the Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Hossein Jahanabadi
- Data Analytics Research and Evaluation Centre, The University of Melbourne and Austin Hospital, Melbourne, Victoria, Australia
- Clinical Analytics and Reporting, Austin Health, Melbourne, Victoria, Australia
| | - Hung Vo
- Data Analytics Research and Evaluation Centre, The University of Melbourne and Austin Hospital, Melbourne, Victoria, Australia
- Clinical Analytics and Reporting, Austin Health, Melbourne, Victoria, Australia
| | - Siven Seevanayagam
- Department of Cardiac Surgery, Austin Hospital, Melbourne, Victoria, Australia
| | - Andrew Motley
- Department of Haematology and Blood Bank, Austin Hospital, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- From the Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
- Data Analytics Research and Evaluation Centre, The University of Melbourne and Austin Hospital, Melbourne, Victoria, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia; and
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
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3
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Vallelian F, Buehler PW, Schaer DJ. Hemolysis, free hemoglobin toxicity, and scavenger protein therapeutics. Blood 2022; 140:1837-1844. [PMID: 35660854 PMCID: PMC10653008 DOI: 10.1182/blood.2022015596] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 05/27/2022] [Indexed: 11/20/2022] Open
Abstract
During hemolysis, erythrophagocytes dispose damaged red blood cells. This prevents the extracellular release of hemoglobin, detoxifies heme, and recycles iron in a linked metabolic pathway. Complementary to this process, haptoglobin and hemopexin scavenge and shuttle the red blood cell toxins hemoglobin and heme to cellular clearance. Pathological hemolysis outpaces macrophage capacity and scavenger synthesis across a diversity of diseases. This imbalance leads to hemoglobin-driven disease progression. To meet a void in treatment options, scavenger protein-based therapeutics are in clinical development.
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Affiliation(s)
- Florence Vallelian
- Division of Internal Medicine, University Hospital, University of Zurich, Zurich, Switzerland
| | - Paul W. Buehler
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD
- Center for Blood Oxygen Transport and Hemostasis, University of Maryland School of Medicine, Baltimore, MD
| | - Dominik J. Schaer
- Division of Internal Medicine, University Hospital, University of Zurich, Zurich, Switzerland
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4
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Lakhal K, Rozec B, Souab F, Senage T, Leroy M, Legrand A, Boissier E, Bigot-Corbel E. Plasma haemolysis index and interleukine-6 for the early prediction of cardiac surgery-associated acute kidney injury. A proof-of-concept study. Perfusion 2022; 38:807-817. [PMID: 35430909 DOI: 10.1177/02676591221083791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction Haemolysis and inflammation contribute to cardiac surgery-associated acute kidney injury (CS-AKI). We aimed to assess the performance of plasma haemolysis index (HI) and interleukine-6 (IL-6) for the prediction of all-stage CS-AKI. We also assessed their ability to predict moderate-to-severe CS-AKI and to discriminate persistent from transient CS-AKI. Methods Adult patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) were prospectively included. Haemolysis index and IL-6 were measured immediately after the end of CPB and 6 hours later. Correction for haemodilution relied upon changes in albuminaemia. Persistent CS-AKI was defined as a steady/increasing CS-AKI stage between the 48th and the 60th postoperative hour as compared with the worst stage observed within the 48 first hours. Results Among 82 patients, CS-AKI occurred in 37 (45%) patients. Postoperative HI and IL-6 were positively correlated to the duration of CPB (r ≤ 0.51, p ≤ 0.0003). Whether we considered isolated measurements of HI or IL-6, their indexation to haemodilution or not, their kinetics and/or their combination, the prediction of all stage CS-AKI was inaccurate (area under the receiver operating characteristic curve [AUCROC]≤ 0.68) whereas moderate-to-severe CS-AKI (6 patients only) was predicted with an honourable performance (AUCROC = 0.77 [95%CI 0.67;0.86] and 0.87 [95%CI 0.77;0.93] for HI and IL-6, respectively). The persistent/transient nature of CS-AKI was inaccurately predicted (AUCROC ≤ 0.68). Conclusions In a population in which most CS-AKI cases were mild, although they frequently (41%) persisted >48 hours, CS-AKI was inaccurately predicted by HI and/or IL-6. A better performance for moderate-to-severe CS-AKI prediction is likely. These preliminary findings are yet to be validated.
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Affiliation(s)
- Karim Lakhal
- Service d’Anesthésie-Réanimation, Hôpital Laënnec, Centre Hospitalier Universitaire de Nantes, France
| | - Bertrand Rozec
- Service d’Anesthésie-Réanimation, Hôpital Laënnec, Centre Hospitalier Universitaire de Nantes, France
- Institut du Thorax, Institut National de la Santé et de la Recherche Médicale (INSERM), Centre National de la Recherche Scientifique (CNRS), Université de Nantes, France
| | - Fouzia Souab
- Service d’Anesthésie-Réanimation, Hôpital Laënnec, Centre Hospitalier Universitaire de Nantes, France
| | - Thomas Senage
- Service de Chirurgie Cardiaque, Hôpital Laënnec, Centre Hospitalier Universitaire de Nantes, France
- Institut National de la Santé et de la Recherche Médicale (INSERM) N°1246, Study of Perinatal, Paediatric and Adolescent Health, Epidemiological Research and Evaluation (SPHERE) Unit, Centre National de la Recherche Scientifique (CNRS), Université de Nantes, France
| | - Maxime Leroy
- direction de la Recherche Clinique et de l’Innovation, Centre Hospitalier Universitaire de Nantes, France
| | - Arnaud Legrand
- direction de la Recherche Clinique et de l’Innovation, Centre Hospitalier Universitaire de Nantes, France
| | - Elodie Boissier
- laboratoire d’Hématologie, Hôpital laënnec, Centre Hospitalier Universitaire de Nantes, France
| | - Edith Bigot-Corbel
- Laboratoire de Biochimie, Hôpital Laënnec, Centre Hospitalier Universitaire de Nantes, France
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5
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Hu J, Rezoagli E, Zadek F, Bittner EA, Lei C, Berra L. Free Hemoglobin Ratio as a Novel Biomarker of Acute Kidney Injury After On-Pump Cardiac Surgery: Secondary Analysis of a Randomized Controlled Trial. Anesth Analg 2021; 132:1548-1558. [PMID: 33481401 DOI: 10.1213/ane.0000000000005381] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Cardiac surgery with cardiopulmonary bypass (CPB) is associated with a high risk of postoperative acute kidney injury (AKI). Due to limitations of current diagnostic strategies, we sought to determine whether free hemoglobin (fHb) ratio (ie, levels of fHb at the end of CPB divided by baseline fHb) could predict AKI after on-pump cardiac surgery. METHODS This is a secondary analysis of a randomized controlled trial comparing the effect of nitric oxide (intervention) versus nitrogen (control) on AKI after cardiac surgery (NCT01802619). A total of 110 adult patients in the control arm were included. First, we determined whether fHb ratio was associated with AKI via multivariable analysis. Second, we verified whether fHb ratio could predict AKI and incorporation of fHb ratio could improve predictive performance at an early stage, compared with prediction using urinary biomarkers alone. We conducted restricted cubic spline in logistic regression for model development. We determined the predictive performance, including area under the receiver-operating-characteristics curve (AUC) and calibration (calibration plot and accuracy, ie, number of correct predictions divided by total number of predictions). We also used AUC test, likelihood ratio test, and net reclassification index (NRI) to compare the predictive performance between competing models (ie, fHb ratio versus neutrophil gelatinase-associated lipocalin [NGAL], N-acetyl-β-d-glucosaminidase [NAG], and kidney injury molecule-1 [KIM-1], respectively, and incorporation of fHb ratio with NGAL, NAG, and KIM-1 versus urinary biomarkers alone), if applicable. RESULTS Data stratified by median fHb ratio showed that subjects with an fHb ratio >2.23 presented higher incidence of AKI (80.0% vs 49.1%; P = .001), more need of renal replacement therapy (10.9% vs 0%; P = .036), and higher in-hospital mortality (10.9% vs 0%; P = .036) than subjects with an fHb ratio ≤2.23. fHb ratio was associated with AKI after adjustment for preestablished factors. fHb ratio outperformed urinary biomarkers with the highest AUC of 0.704 (95% confidence interval [CI], 0.592-0.804) and accuracy of 0.714 (95% CI, 0.579-0.804). Incorporation of fHb ratio achieved better discrimination (AUC test, P = .012), calibration (likelihood ratio test, P < .001; accuracy, 0.740 [95% CI, 0.617-0.832] vs 0.632 [95% CI, 0.477-0.748]), and significant prediction increment (NRI, 0.638; 95% CI, 0.269-1.008; P < .001) at an early stage, compared with prediction using urinary biomarkers alone. CONCLUSIONS Results from this exploratory, hypothesis-generating retrospective, observational study shows that fHb ratio at the end of CPB might be used as a novel, widely applicable biomarker for AKI. The use of fHb ratio might help for an early detection of AKI, compared with prediction based only on urinary biomarkers.
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Affiliation(s)
- Jie Hu
- From the Department of Critical Care Medicine, Chinese PLA General Hospital, Beijing, China.,Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Emanuele Rezoagli
- School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Francesco Zadek
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Edward A Bittner
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Chong Lei
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Lorenzo Berra
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
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6
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Dekker NAM, van Leeuwen ALI, van Meurs M, Moser J, Pankras JE, van der Wel NN, Niessen HW, Vervloet MG, Vonk ABA, Hordijk PL, Boer C, van den Brom CE. Preservation of renal endothelial integrity and reduction of renal edema by aprotinin does not preserve renal perfusion and function following experimental cardiopulmonary bypass. Intensive Care Med Exp 2021; 9:30. [PMID: 34169407 PMCID: PMC8225734 DOI: 10.1186/s40635-021-00393-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 05/04/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Acute kidney injury is a severe complication following cardiopulmonary bypass (CPB) and is associated with capillary leakage and microcirculatory perfusion disturbances. CPB-induced thrombin release results in capillary hyperpermeability via activation of protease-activated receptor 1 (PAR1). We investigated whether aprotinin, which is thought to prevent thrombin from activating PAR1, preserves renal endothelial structure, reduces renal edema and preserves renal perfusion and reduces renal injury following CPB. METHODS Rats were subjected to CPB after treatment with 33.000 KIU/kg aprotinin (n = 15) or PBS (n = 15) as control. A secondary dose of 33.000 KIU/kg aprotinin was given 60 min after initiation of CPB. Cremaster and renal microcirculatory perfusion were assessed using intravital microscopy and contrast echography before CPB and 10 and 60 min after weaning from CPB. Renal edema was determined by wet/dry weight ratio and renal endothelial structure by electron microscopy. Renal PAR1 gene and protein expression and markers of renal injury were determined. RESULTS CPB reduced cremaster microcirculatory perfusion by 2.5-fold (15 (10-16) to 6 (2-10) perfused microvessels, p < 0.0001) and renal perfusion by 1.6-fold (202 (67-599) to 129 (31-292) au/sec, p = 0.03) in control animals. Both did not restore 60 min post-CPB. This was paralleled by increased plasma creatinine (p < 0.01), neutrophil gelatinase-associated lipocalin (NGAL; p = 0.003) and kidney injury molecule-1 (KIM-1; p < 0.01). Aprotinin treatment preserved cremaster microcirculatory perfusion following CPB (12 (7-15) vs. 6 (2-10) perfused microvessels, p = 0.002), but not renal perfusion (96 (35-313) vs. 129 (31-292) au/s, p > 0.9) compared to untreated rats. Aprotinin treatment reduced endothelial gap formation (0.5 ± 0.5 vs. 3.1 ± 1.4 gaps, p < 0.0001), kidney wet/dry weight ratio (4.6 ± 0.2 vs. 4.4 ± 0.2, p = 0.046), and fluid requirements (3.9 ± 3.3 vs. 7.5 ± 3.0 ml, p = 0.006) compared to untreated rats. In addition, aprotinin treatment reduced tubulointerstitial neutrophil influx by 1.7-fold compared to untreated rats (30.7 ± 22.1 vs. 53.2 ± 17.2 neutrophil influx/section, p = 0.009). No differences were observed in renal PAR1 expression and plasma creatinine, NGAL or KIM-1 between groups. CONCLUSIONS Aprotinin did not improve renal perfusion nor reduce renal injury during the first hour following experimental CPB despite preservation of renal endothelial integrity and reduction of renal edema.
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Affiliation(s)
- Nicole A M Dekker
- Department of Anesthesiology, Experimental Laboratory for Vital Signs, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands. .,Department of Cardiothoracic Surgery, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands. .,Department of Physiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands.
| | - Anoek L I van Leeuwen
- Department of Anesthesiology, Experimental Laboratory for Vital Signs, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands.,Department of Cardiothoracic Surgery, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands.,Department of Physiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Matijs van Meurs
- Department of Pathology and Medical Biology, University Medical Center Groningen, Groningen, The Netherlands.,Department of Critical Care Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | - Jill Moser
- Department of Pathology and Medical Biology, University Medical Center Groningen, Groningen, The Netherlands.,Department of Critical Care Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | - Jeannette E Pankras
- Department of Medical Biology, Electron Microscopy Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Nicole N van der Wel
- Department of Medical Biology, Electron Microscopy Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Hans W Niessen
- Department of Pathology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Marc G Vervloet
- Department of Nephrology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Alexander B A Vonk
- Department of Cardiothoracic Surgery, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Peter L Hordijk
- Department of Physiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Christa Boer
- Department of Anesthesiology, Experimental Laboratory for Vital Signs, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Charissa E van den Brom
- Department of Anesthesiology, Experimental Laboratory for Vital Signs, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands.,Department of Physiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands.,Department of Intensive Care Medicine, Laboratory for Experimental Intensive Care and Anesthesiology (LEICA), Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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7
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Hokka M, Egi M, Kubota K, Mizobuchi S. Perioperative Serum Free Hemoglobin and Haptoglobin Levels in Valvular and Aortic Surgery With Cardiopulmonary Bypass: Their Associations With Postoperative Kidney Injury. J Cardiothorac Vasc Anesth 2021; 35:3207-3214. [PMID: 34052069 DOI: 10.1053/j.jvca.2021.04.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 04/16/2021] [Accepted: 04/19/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To observe the perioperative free hemoglobin and haptoglobin levels and to assess their associations with the risk of postoperative acute kidney injury (pAKI) in adult patients undergoing valvular and aortic surgery requiring cardiopulmonary bypass (CPB). DESIGN A single-center, prospective, observational study. SETTING Public teaching hospital. PARTICIPANTS The study comprised 74 adult patients without chronic renal failure who underwent cardiovascular surgery requiring CPB from 2014 to 2020. MEASUREMENTS AND MAIN RESULTS Perioperative free hemoglobin and haptoglobin levels during the study period were obtained from study participants. The primary outcome was pAKI defined by the Kidney Disease: Improving Global Outcomes criteria. Of the 74 patients in this study, pAKI occurred in 25 patients (33.8%). The free hemoglobin level began to increase after the initiation of CPB and reached a peak level at 30 minutes after weaning from CPB. It returned to the baseline level on postoperative day one. Haptoglobin levels were the highest after anesthesia induction and decreased continuously until postoperative day one. In the multivariate analysis, maximum free hemoglobin and minimum haptoglobin were associated independently with increased risk of pAKI (adjusted odds ratio 1.33 [95% confidence interval 1.12-1.58; p = 0.001] and 0.95 [95% confidence interval 0.91-1.00; p = 0.03], respectively). The free hemoglobin level began to have an independent association with pAKI at one hour after commencement of CPB, and the independent association disappeared at postoperative day one. CONCLUSIONS This study found that the perioperative increase of the free hemoglobin level and the decrease of the haptoglobin level had independent associations with the risk of pAKI.
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Affiliation(s)
- Mai Hokka
- Department of Anesthesiology, Kobe University Hospital, Kobe, Hyogo Japan
| | - Moritoki Egi
- Department of Anesthesiology, Kobe University Hospital, Kobe, Hyogo Japan.
| | - Kenta Kubota
- Department of Anesthesiology, Kobe University Hospital, Kobe, Hyogo Japan
| | - Satoshi Mizobuchi
- Department of Anesthesiology, Kobe University Hospital, Kobe, Hyogo Japan
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8
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Influence of hemoadsorption during cardiopulmonary bypass on blood vesicle count and function. J Transl Med 2020; 18:202. [PMID: 32414386 PMCID: PMC7229608 DOI: 10.1186/s12967-020-02369-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Accepted: 05/07/2020] [Indexed: 11/10/2022] Open
Abstract
Background Extracorporeal circulation during major cardiac surgery triggers a systemic inflammatory response affecting the clinical course and outcome. Recently, extracellular vesicle (EV) research has shed light onto a novel cellular communication network during inflammation. Hemoadsorption (HA) systems have shown divergent results in modulating the systemic inflammatory response during cardiopulmonary bypass (CPB) surgery. To date, the effect of HA on circulating microvesicles (MVs) in patients undergoing CPB surgery is unknown. Methods Count and function of MVs, as part of the extracellular vesicle fraction, were assessed in a subcohort of a single-center, blinded, controlled study investigating the effect of the CytoSorb device during CPB. A total of 18 patients undergoing elective CPB surgery with (n = 9) and without (n = 9) HA device were included in the study. MV phenotyping and counting was conducted via flow cytometry and procoagulatory potential was measured by tissue factor-dependent MV assays. Results Both study groups exhibited comparable counts and post-operative kinetics in MV subsets. Tissue factor-dependent procoagulatory potential was not detectable in plasma at any timepoint. Post-operative course and laboratory parameters showed no correlation with MV counts in patients undergoing CPB surgery. Conclusion Additional artificial surfaces to the CPB-circuit introduced by the use of the HA device showed no effect on circulating MV count and function in these patients. Larger studies are needed to assess and clarify the effect of HA on circulating vesicle counts and function. Trial registration ClinicalTrials.Gov Identifier: NCT01879176; registration date: June 17, 2013; https://clinicaltrials.gov/ct2/show/NCT01879176
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9
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Natanov R, Khalikov A, Gueler F, Maus U, Boyle EC, Haverich A, Kühn C, Madrahimov N. Four hours of veno-venous extracorporeal membrane oxygenation using bi-caval cannulation affects kidney function and induces moderate lung damage in a mouse model. Intensive Care Med Exp 2019; 7:72. [PMID: 31845103 PMCID: PMC6915191 DOI: 10.1186/s40635-019-0285-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 11/27/2019] [Indexed: 12/15/2022] Open
Abstract
Background Improvement of single site cannulation for extracorporeal membrane oxygenation (ECMO) therapy is pivotal for reduction of patient morbidity and mortality in respiratory failure. To further improve the cardiopulmonary outcomes and reduce end organ damage, we established a murine model for single site cannulation with a double lumen cannula. Results We created a hemodynamically stable double lumen cannula and successfully implanted it through the jugular vein into the upper and lower vena cava. This allowed adequate drainage of the blood. Blood gas analysis showed excellent oxygenation and CO2 reduction. There was no excessive bleeding. No signs of right heart congestion were present which was confirmed in the histological analysis of the liver. Histology demonstrated moderate lung damage and mild acute kidney injury. Neutrophil infiltration was similar in ECMO and sham kidneys. Conclusions Veno-venous extracorporeal circulation deteriorates kidney function and promotes moderate pulmonary damage.
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Affiliation(s)
- Ruslan Natanov
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Abdurasul Khalikov
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Faikah Gueler
- Department of Nephrology, Hannover Medical School, Hannover, Germany
| | - Ulrich Maus
- Department of Pneumology, Hannover Medical School, Hannover, Germany
| | - Erin C Boyle
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Axel Haverich
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Christian Kühn
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Nodir Madrahimov
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany. .,Clinic of Cardiothoracic Surgery, University Clinic of Würzburg, Oberdürrbacher Strasse 6, 97080, Würzburg, Germany.
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Rubio-Navarro A, Vázquez-Carballo C, Guerrero-Hue M, García-Caballero C, Herencia C, Gutiérrez E, Yuste C, Sevillano Á, Praga M, Egea J, Cannata P, Cortegano I, de Andrés B, Gaspar ML, Cadenas S, Michalska P, León R, Ortiz A, Egido J, Moreno JA. Nrf2 Plays a Protective Role Against Intravascular Hemolysis-Mediated Acute Kidney Injury. Front Pharmacol 2019; 10:740. [PMID: 31333462 PMCID: PMC6619398 DOI: 10.3389/fphar.2019.00740] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Accepted: 06/07/2019] [Indexed: 12/20/2022] Open
Abstract
Massive intravascular hemolysis is associated with acute kidney injury (AKI). Nuclear factor erythroid-2-related factor 2 (Nrf2) plays a central role in the defense against oxidative stress by activating the expression of antioxidant proteins. We investigated the role of Nrf2 in intravascular hemolysis and whether Nrf2 activation protected against hemoglobin (Hb)/heme-mediated renal damage in vivo and in vitro. We observed renal Nrf2 activation in human hemolysis and in an experimental model of intravascular hemolysis promoted by phenylhydrazine intraperitoneal injection. In wild-type mice, Hb/heme released from intravascular hemolysis promoted AKI, resulting in decreased renal function, enhanced expression of tubular injury markers (KIM-1 and NGAL), oxidative and endoplasmic reticulum stress (ER), and cell death. These features were more severe in Nrf2-deficient mice, which showed decreased expression of Nrf2-related antioxidant enzymes, including heme oxygenase 1 (HO-1) and ferritin. Nrf2 activation with sulforaphane protected against Hb toxicity in mice and cultured tubular epithelial cells, ameliorating renal function and kidney injury and reducing cell stress and death. Nrf2 genotype or sulforaphane treatment did not influence the severity of hemolysis. In conclusion, our study identifies Nrf2 as a key molecule involved in protection against renal damage associated with hemolysis and opens novel therapeutic approaches to prevent renal damage in patients with severe hemolytic crisis. These findings provide new insights into novel aspects of Hb-mediated renal toxicity and may have important therapeutic implications for intravascular hemolysis-related diseases.
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Affiliation(s)
- Alfonso Rubio-Navarro
- Renal, Vascular and Diabetes Research Lab, Instituto de Investigación Sanitaria-Fundación Jiménez Díaz, Autónoma University, Madrid, Spain
| | - Cristina Vázquez-Carballo
- Renal, Vascular and Diabetes Research Lab, Instituto de Investigación Sanitaria-Fundación Jiménez Díaz, Autónoma University, Madrid, Spain
| | - Melania Guerrero-Hue
- Renal, Vascular and Diabetes Research Lab, Instituto de Investigación Sanitaria-Fundación Jiménez Díaz, Autónoma University, Madrid, Spain
| | - Cristina García-Caballero
- Renal, Vascular and Diabetes Research Lab, Instituto de Investigación Sanitaria-Fundación Jiménez Díaz, Autónoma University, Madrid, Spain
| | - Carmen Herencia
- Renal, Vascular and Diabetes Research Lab, Instituto de Investigación Sanitaria-Fundación Jiménez Díaz, Autónoma University, Madrid, Spain
| | | | - Claudia Yuste
- Department of Nephrology, Hospital 12 de Octubre, Madrid, Spain
| | - Ángel Sevillano
- Department of Nephrology, Hospital 12 de Octubre, Madrid, Spain
| | - Manuel Praga
- Department of Nephrology, Hospital 12 de Octubre, Madrid, Spain
| | - Javier Egea
- Instituto de Investigación Sanitaria-Hospital Universitario de la Princesa, Madrid, Spain.,Instituto Teófilo Hernando, Departamento de Farmacología y Terapéutica, Facultad de Medicina, UAM, Madrid, Spain.,Hospital Santa Cristina, Madrid, Spain
| | - Pablo Cannata
- Pathology Department, Fundación Instituto de Investigaciones Sanitarias-Fundación Jiménez Díaz, Autónoma University, Madrid, Spain
| | - Isabel Cortegano
- Immunology Department, Centro Nacional de Microbiologìa, Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Belén de Andrés
- Immunology Department, Centro Nacional de Microbiologìa, Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - María Luisa Gaspar
- Immunology Department, Centro Nacional de Microbiologìa, Instituto de Salud Carlos III (ISCIII), Madrid, Spain
| | - Susana Cadenas
- Centro de Biología Molecular "Severo Ochoa" (CSIC-UAM), Departamento de Biología Molecular, Universidad Autónoma de Madrid, Madrid, Spain
| | - Patrycja Michalska
- Instituto de Investigación Sanitaria-Hospital Universitario de la Princesa, Madrid, Spain.,Instituto Teófilo Hernando, Departamento de Farmacología y Terapéutica, Facultad de Medicina, UAM, Madrid, Spain
| | - Rafael León
- Instituto de Investigación Sanitaria-Hospital Universitario de la Princesa, Madrid, Spain.,Instituto Teófilo Hernando, Departamento de Farmacología y Terapéutica, Facultad de Medicina, UAM, Madrid, Spain
| | - Alberto Ortiz
- Renal, Vascular and Diabetes Research Lab, Instituto de Investigación Sanitaria-Fundación Jiménez Díaz, Autónoma University, Madrid, Spain
| | - Jesús Egido
- Renal, Vascular and Diabetes Research Lab, Instituto de Investigación Sanitaria-Fundación Jiménez Díaz, Autónoma University, Madrid, Spain
| | - Juan Antonio Moreno
- Renal, Vascular and Diabetes Research Lab, Instituto de Investigación Sanitaria-Fundación Jiménez Díaz, Autónoma University, Madrid, Spain.,Department of Cell Biology, Physiology and Immunology, Maimonides Biomedical Research Institute of Cordoba (IMIBIC), University of Cordoba, Cordoba, Spain
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Summerfield DD, Hartung KJ, Wiese CR, Wockenfus AM, Katzman BM, Donato LJ, Karon BS. Relationship between free hemoglobin (hemolysis), potassium and ionized calcium in lithium heparin blood gas samples collected intraoperatively. Clin Biochem 2019; 70:46-48. [PMID: 31059687 DOI: 10.1016/j.clinbiochem.2019.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 04/12/2019] [Accepted: 05/01/2019] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Develop sample acceptability rules by determining the relationship between free hemoglobin level (hemolysis) and potassium or ionized calcium in blood gas samples collected intraoperatively. DESIGN AND METHODS Hemolysis was assessed visually or by H index for lithium heparin blood gas samples collected intraoperatively. During periods one and three this was done using two different rules for visual assessment of centrifuged lithium heparin plasma. During period two H index was measured for all visually hemolyzed samples on a Roche Cobas c501 analyzer to determine acceptability. Potassium and ionized calcium were measured in 75 lithium heparin whole blood samples on a Radiometer ABL90 to correlate H index and potassium or ionized calcium. RESULTS During period one 35 of 5808 (0.6%) blood gas samples had visual hemolysis levels exceeding tolerance for reporting of potassium. By switching to measured H index using a laboratory-established threshold, during period 2 we estimate that 171 of 5396 (3.2%) blood gas samples exceeded the H index threshold for reporting of potassium. In 75 intraoperative blood gas samples with H index and whole blood potassium and ionized calcium measured; we observed no relationship between H index and potassium or ionized calcium. During period 3 we switched to visual assessment of hemolysis with a greater tolerance for hemolysis; with only 3 of 5345 (0.06%) samples exceeding the new visual hemolysis threshold. CONCLUSION For blood gas samples collected intraoperatively, there is no relationship between hemolysis and measured potassium or ionized calcium. The results suggest that only grossly hemolyzed intraoperative blood gas samples should be rejected for measurement of whole blood potassium and ionized calcium.
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Affiliation(s)
- Daniel D Summerfield
- Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Katherine J Hartung
- Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Cynthia R Wiese
- Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Amy M Wockenfus
- Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Brooke M Katzman
- Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Leslie J Donato
- Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Brad S Karon
- Department of Laboratory Medicine and Pathology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America.
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Holzer JC, Birngruber T, Mautner S, Graff A, Kamolz LP. Topical application of haemoglobin: a safety study. J Wound Care 2019; 28:148-153. [PMID: 30840547 DOI: 10.12968/jowc.2019.28.3.148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Ischaemia is one of the biggest problems in wound healing. It causes chronic wounds and also prevents normal wound healing because the tissue is oxygen deprived. Most oxygen-supplying therapies are only feasible in a clinical setting, but topical haemoglobin applications, such as Granulox, can be used in a non-clinical setting. For home application, the haemoglobin solution is sprayed topically onto the wound using a pressurised ready-to-use device with a bag-on-valve system. Although this system does not mix product and propellant, the risk of product inhalation by the patient, user or bystanders has to be minimised. This safety study aimed to determine particle size and product concentration in the surroundings after application to determine if there is a risk that product particles enter the respiratory tract. METHODS Measurements were performed using a laser scattered light photometer and a Scanning Mobility Particle Sizer (SMPS)-Spectrometer at different distances from the measuring devices to determine the inhalation risk for a possible user, patient and bystander. At all measuring points the amount of particles, their size and the formation of dust were measured. RESULTS No nanoparticles or dust were created during the application of the haemoglobin spray. The concentrations of the measured particles are below the allowed limits defined by Austrian law. CONCLUSION There is no risk of inhaling nanoparticles or being exposed to harmful concentrations of larger particles of the tested product. All the product's ingredients can be degraded and excreted by the human body through natural pathways.
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Affiliation(s)
- Judith Cj Holzer
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria.,COREMED - Cooperative Centre for Regenerative Medicine, Joanneum Research Forschungsgesellschaft mbH, Graz, Austria
| | - Thomas Birngruber
- HEALTH - Institute for Biomedicine and Health Sciences, Joanneum Research Forschungsgesellschaft mbH, Graz, Austria
| | - Selma Mautner
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria.,HEALTH - Institute for Biomedicine and Health Sciences, Joanneum Research Forschungsgesellschaft mbH, Graz, Austria
| | - Alexander Graff
- Technical Department, Austrian Dust-Silicosis Control Center (ÖSBS), Leoben, Austria
| | - Lars-Peter Kamolz
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria.,COREMED - Cooperative Centre for Regenerative Medicine, Joanneum Research Forschungsgesellschaft mbH, Graz, Austria
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Abstract
Cardiopulmonary bypass (CPB) induces hemolysis, which manifests as plasma free hemoglobin. We investigated in a post hoc analysis of a single-center, blinded, controlled study whether the use of a novel hemoadsorption device (CytoSorb, CytoSorbents Europe GmbH, Berlin, Germany) affects hemolysis during CPB. A total of 35 patients undergoing elective CPB surgery with an expected CPB duration of more than 120 min were included in the analysis. The hemoadsorption device was used in 17 patients (intervention group) and not used in 18 patients (control group). The primary outcome was differences of postoperative free hemoglobin and haptoglobin levels. As secondary outcomes, we investigated differences in postoperative lactate dehydrogenase and bilirubin levels. Postoperative free hemoglobin levels were not significantly different between the groups. However, there were statistically significant differences between the treatment and control groups in the median levels of haptoglobin (58.4 vs. 17.9 mg/dL, respectively; P < 0.01) and lactate dehydrogenase (353.0 vs. 432.0 U/L, respectively; P < 0.05) on postoperative day 1. Thus, in this study, we did not find an effect on hemolysis in patients treated with hemoadsorption, though lower haptoglobin level and higher secondary hemolysis markers on postoperative day 1 in patients not treated with the hemoadsorber may be an indication of some moderate effect of the device. Studies with larger samples are needed to clarify the significance of the small differences detected in this study.
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