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Kubyshkin V, Rubini M. Proline Analogues. Chem Rev 2024; 124:8130-8232. [PMID: 38941181 DOI: 10.1021/acs.chemrev.4c00007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2024]
Abstract
Within the canonical repertoire of the amino acid involved in protein biogenesis, proline plays a unique role as an amino acid presenting a modified backbone rather than a side-chain. Chemical structures that mimic proline but introduce changes into its specific molecular features are defined as proline analogues. This review article summarizes the existing chemical, physicochemical, and biochemical knowledge about this peculiar family of structures. We group proline analogues from the following compounds: substituted prolines, unsaturated and fused structures, ring size homologues, heterocyclic, e.g., pseudoproline, and bridged proline-resembling structures. We overview (1) the occurrence of proline analogues in nature and their chemical synthesis, (2) physicochemical properties including ring conformation and cis/trans amide isomerization, (3) use in commercial drugs such as nirmatrelvir recently approved against COVID-19, (4) peptide and protein synthesis involving proline analogues, (5) specific opportunities created in peptide engineering, and (6) cases of protein engineering with the analogues. The review aims to provide a summary to anyone interested in using proline analogues in systems ranging from specific biochemical setups to complex biological systems.
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Affiliation(s)
| | - Marina Rubini
- School of Chemistry, University College Dublin, Belfield, Dublin 4, Ireland
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2
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Wisniewski P, Gangnus T, Burckhardt BB. Recent advances in the discovery and development of drugs targeting the kallikrein-kinin system. J Transl Med 2024; 22:388. [PMID: 38671481 PMCID: PMC11046790 DOI: 10.1186/s12967-024-05216-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 04/16/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND The kallikrein-kinin system is a key regulatory cascade involved in blood pressure maintenance, hemostasis, inflammation and renal function. Currently, approved drugs remain limited to the rare disease hereditary angioedema. However, growing interest in this system is indicated by an increasing number of promising drug candidates for further indications. METHODS To provide an overview of current drug development, a two-stage literature search was conducted between March and December 2023 to identify drug candidates with targets in the kallikrein-kinin system. First, drug candidates were identified using PubMed and Clinicaltrials.gov. Second, the latest publications/results for these compounds were searched in PubMed, Clinicaltrials.gov and Google Scholar. The findings were categorized by target, stage of development, and intended indication. RESULTS The search identified 68 drugs, of which 10 are approved, 25 are in clinical development, and 33 in preclinical development. The three most studied indications included diabetic retinopathy, thromboprophylaxis and hereditary angioedema. The latter is still an indication for most of the drug candidates close to regulatory approval (3 out of 4). For the emerging indications, promising new drug candidates in clinical development are ixodes ricinus-contact phase inhibitor for thromboprophylaxis and RZ402 and THR-149 for the treatment of diabetic macular edema (all phase 2). CONCLUSION The therapeutic impact of targeting the kallikrein-kinin system is no longer limited to the treatment of hereditary angioedema. Ongoing research on other diseases demonstrates the potential of therapeutic interventions targeting the kallikrein-kinin system and will provide further treatment options for patients in the future.
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Affiliation(s)
- Petra Wisniewski
- Individualized Pharmacotherapy, Institute of Pharmaceutical and Medicinal Chemistry, University of Münster, Corrensstr. 48, 48149, Münster, Germany
| | - Tanja Gangnus
- Individualized Pharmacotherapy, Institute of Pharmaceutical and Medicinal Chemistry, University of Münster, Corrensstr. 48, 48149, Münster, Germany
| | - Bjoern B Burckhardt
- Individualized Pharmacotherapy, Institute of Pharmaceutical and Medicinal Chemistry, University of Münster, Corrensstr. 48, 48149, Münster, Germany.
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3
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Safwat A, Helmy A, Gupta A. The Role of Substance P Within Traumatic Brain Injury and Implications for Therapy. J Neurotrauma 2023; 40:1567-1583. [PMID: 37132595 DOI: 10.1089/neu.2022.0510] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2023] Open
Abstract
This review examines the role of the neuropeptide substance P within the neuroinflammation that follows traumatic brain injury. It examines it in reference to its preferential receptor, the neurokinin-1 receptor, and explores the evidence for antagonism of this receptor in traumatic brain injury with therapeutic intent. Expression of substance P increases following traumatic brain injury. Subsequent binding to the neurokinin-1 receptor results in neurogenic inflammation, a cause of deleterious secondary effects that include an increased intracranial pressure and poor clinical outcome. In several animal models of TBI, neurokinin-1 receptor antagonism has been shown to reduce brain edema and the resultant rise in intracranial pressure. A brief overview of the history of substance P is presented, alongside an exploration into the chemistry of the neuropeptide with a relevance to its functions within the central nervous system. This review summarizes the scientific and clinical rationale for substance P antagonism as a promising therapy for human TBI.
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Affiliation(s)
- Adam Safwat
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Adel Helmy
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Arun Gupta
- Neurosciences Critical Care Unit, Addenbrooke's Hospital, Cambridge, United Kingdom
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4
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van Erp IAM, Michailidou I, van Essen TA, van der Jagt M, Moojen W, Peul WC, Baas F, Fluiter K. Tackling Neuroinflammation After Traumatic Brain Injury: Complement Inhibition as a Therapy for Secondary Injury. Neurotherapeutics 2023; 20:284-303. [PMID: 36222978 PMCID: PMC10119357 DOI: 10.1007/s13311-022-01306-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2022] [Indexed: 11/30/2022] Open
Abstract
Traumatic brain injury (TBI) is a leading cause of mortality, sensorimotor morbidity, and neurocognitive disability. Neuroinflammation is one of the key drivers causing secondary brain injury after TBI. Therefore, attenuation of the inflammatory response is a potential therapeutic goal. This review summarizes the most important neuroinflammatory pathophysiology resulting from TBI and the clinical trials performed to attenuate neuroinflammation. Studies show that non-selective attenuation of the inflammatory response, in the early phase after TBI, might be detrimental and that there is a gap in the literature regarding pharmacological trials targeting specific pathways. The complement system and its crosstalk with the coagulation system play an important role in the pathophysiology of secondary brain injury after TBI. Therefore, regaining control over the complement cascades by inhibiting overshooting activation might constitute useful therapy. Activation of the complement cascade is an early component of neuroinflammation, making it a potential target to mitigate neuroinflammation in TBI. Therefore, we have described pathophysiological aspects of complement inhibition and summarized animal studies targeting the complement system in TBI. We also present the first clinical trial aimed at inhibition of complement activation in the early days after brain injury to reduce the risk of morbidity and mortality following severe TBI.
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Affiliation(s)
- Inge A M van Erp
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and HaGa Hospital, Leiden and The Hague, Albinusdreef 2, J-11-R-83, 2333 ZA, Leiden, The Netherlands.
| | - Iliana Michailidou
- Department of Clinical Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - Thomas A van Essen
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and HaGa Hospital, Leiden and The Hague, Albinusdreef 2, J-11-R-83, 2333 ZA, Leiden, The Netherlands
| | - Mathieu van der Jagt
- Department of Intensive Care Adults, Erasmus MC - University Medical Center, Rotterdam, The Netherlands
| | - Wouter Moojen
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and HaGa Hospital, Leiden and The Hague, Albinusdreef 2, J-11-R-83, 2333 ZA, Leiden, The Netherlands
| | - Wilco C Peul
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and HaGa Hospital, Leiden and The Hague, Albinusdreef 2, J-11-R-83, 2333 ZA, Leiden, The Netherlands
| | - Frank Baas
- Department of Clinical Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - Kees Fluiter
- Department of Clinical Genetics, Leiden University Medical Center, Leiden, The Netherlands
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5
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Rex DAB, Vaid N, Deepak K, Dagamajalu S, Prasad TSK. A comprehensive review on current understanding of bradykinin in COVID-19 and inflammatory diseases. Mol Biol Rep 2022; 49:9915-9927. [PMID: 35596055 PMCID: PMC9122735 DOI: 10.1007/s11033-022-07539-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 04/28/2022] [Indexed: 12/28/2022]
Abstract
Bradykinin, a member of the kallikrein–kinin system (KKS), is a potent, short-lived vasoactive peptide that acts as a vasodilator and an inflammatory mediator in a number of signaling mechanisms. Bradykinin induced signaling is mediated through kinin B1 (BDKRB1) and B2 (BDKRB2) transmembrane receptors coupled with different subunits of G proteins (Gαi/Gα0, Gαq and Gβ1γ2). The bradykinin-mediated signaling mechanism activates excessive pro-inflammatory cytokines, including IL-6, IL-1β, IL-8 and IL-2. Upregulation of these cytokines has implications in a wide range of clinical conditions such as inflammation leading to fibrosis, cardiovascular diseases, and most recently, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). In SARS-CoV-2 infection, bradykinin is found to be at raised levels and is reported to trigger a diverse array of symptoms. All of this brings bradykinin to the core point as a molecule of immense therapeutic value. Our understanding of its involvement in various pathways has expanded with time. Therefore, there is a need to look at the overall picture that emerges from the developments made by deciphering the bradykinin mediated signaling mechanisms involved in the pathological conditions. It will help devise strategies for developing better treatment modalities in the implicated diseases. This review summarizes the current state of knowledge on bradykinin mediated signaling in the diverse conditions described above, with a marked emphasis on the therapeutic potential of targeting the bradykinin receptor.
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Affiliation(s)
- Devasahayam Arokiar Balaya Rex
- Center for Systems Biology and Molecular Medicine, Yenepoya Research Centre, Yenepoya (Deemed to be University), Mangalore, 575018, India
| | - Neelanchal Vaid
- Center for Systems Biology and Molecular Medicine, Yenepoya Research Centre, Yenepoya (Deemed to be University), Mangalore, 575018, India
| | - K Deepak
- Center for Systems Biology and Molecular Medicine, Yenepoya Research Centre, Yenepoya (Deemed to be University), Mangalore, 575018, India
| | - Shobha Dagamajalu
- Center for Systems Biology and Molecular Medicine, Yenepoya Research Centre, Yenepoya (Deemed to be University), Mangalore, 575018, India
| | - T S Keshava Prasad
- Center for Systems Biology and Molecular Medicine, Yenepoya Research Centre, Yenepoya (Deemed to be University), Mangalore, 575018, India.
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6
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Bajaj J, Ratre S, Parihar V, Yadav YR. Superspeciality Surgical Education: Developing a New Subspecialty. Indian J Surg 2022. [DOI: 10.1007/s12262-021-02881-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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7
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Perez JJ. Exploiting Knowledge on Structure-Activity Relationships for Designing Peptidomimetics of Endogenous Peptides. Biomedicines 2021; 9:651. [PMID: 34200402 PMCID: PMC8229937 DOI: 10.3390/biomedicines9060651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 06/03/2021] [Accepted: 06/04/2021] [Indexed: 12/01/2022] Open
Abstract
Endogenous peptides are important mediators in cell communication, being consequently involved in many physiological processes. Their use as therapeutic agents is limited due to their poor pharmacokinetic profile. To circumvent this drawback, alternative diverse molecules based on the stereochemical features that confer their activity can be synthesized, using them as guidance; from peptide surrogates provided with a better pharmacokinetic profile, to small molecule peptidomimetics, through cyclic peptides. The design process requires a competent use of the structure-activity results available on individual peptides. Specifically, it requires synthesis and analysis of the activity of diverse analogs, biophysical information and computational work. In the present work, we show a general framework of the process and show its application to two specific examples: the design of selective AT1 antagonists of angiotensin and the design of selective B2 antagonists of bradykinin.
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Affiliation(s)
- Juan J Perez
- Department of Chemical Engineering, Universitat Politecnica de Catalunya, 08028 Barcelona, Spain
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8
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Lau J, Rousseau J, Kwon D, Bénard F, Lin KS. A Systematic Review of Molecular Imaging Agents Targeting Bradykinin B1 and B2 Receptors. Pharmaceuticals (Basel) 2020; 13:ph13080199. [PMID: 32824565 PMCID: PMC7464927 DOI: 10.3390/ph13080199] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 08/11/2020] [Accepted: 08/13/2020] [Indexed: 12/22/2022] Open
Abstract
Kinins, bradykinin and kallidin are vasoactive peptides that signal through the bradykinin B1 and B2 receptors (B1R and B2R). B2R is constitutively expressed in healthy tissues and mediates responses such as vasodilation, fluid balance and retention, smooth muscle contraction, and algesia, while B1R is absent in normal tissues and is induced by tissue trauma or inflammation. B2R is activated by kinins, while B1R is activated by kinins that lack the C-terminal arginine residue. Perturbations of the kinin system have been implicated in inflammation, chronic pain, vasculopathy, neuropathy, obesity, diabetes, and cancer. In general, excess activation and signaling of the kinin system lead to a pro-inflammatory state. Depending on the disease context, agonism or antagonism of the bradykinin receptors have been considered as therapeutic options. In this review, we summarize molecular imaging agents targeting these G protein-coupled receptors, including optical and radioactive probes that have been used to interrogate B1R/B2R expression at the cellular and anatomical levels, respectively. Several of these preclinical agents, described herein, have the potential to guide therapeutic interventions for these receptors.
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Affiliation(s)
- Joseph Lau
- Department of Molecular Oncology, BC Cancer, Vancouver, BC V5Z 1L3 Canada
| | - Julie Rousseau
- Department of Molecular Oncology, BC Cancer, Vancouver, BC V5Z 1L3 Canada
| | - Daniel Kwon
- Department of Molecular Oncology, BC Cancer, Vancouver, BC V5Z 1L3 Canada
| | - François Bénard
- Department of Molecular Oncology, BC Cancer, Vancouver, BC V5Z 1L3 Canada
- Department of Radiology, University of British Columbia, Vancouver, BC V6T 1Z4, Canada
| | - Kuo-Shyan Lin
- Department of Molecular Oncology, BC Cancer, Vancouver, BC V5Z 1L3 Canada
- Department of Radiology, University of British Columbia, Vancouver, BC V6T 1Z4, Canada
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9
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Lesage A, Gibson C, Marceau F, Ambrosi HD, Saupe J, Katzer W, Loenders B, Charest-Morin X, Knolle J. In Vitro Pharmacological Profile of a New Small Molecule Bradykinin B 2 Receptor Antagonist. Front Pharmacol 2020; 11:916. [PMID: 32636746 PMCID: PMC7316994 DOI: 10.3389/fphar.2020.00916] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 06/05/2020] [Indexed: 12/18/2022] Open
Abstract
We here report the discovery and early characterization of Compound 3, a representative of a novel class of small molecule bradykinin (BK) B2 receptor antagonists, and its superior profile to the prior art B2 receptor antagonists Compound 1 and Compound 2. Compound 3, Compound 2, and Compound 1 are highly potent antagonists of the human recombinant B2 receptor (Kb values 0.24, 0.95, and 1.24 nM, respectively, calcium mobilization assay). Compound 3 is more potent than the prior art compounds and icatibant in this assay (Kb icatibant 2.81 nM). The compounds also potently inhibit BK-induced contraction of endogenous B2 receptors in a human isolated umbilical vein bioassay. The potencies of Compound 3, Compound 2, Compound 1, and icatibant are (pA2 values) 9.67, 9.02, 8.58, and 8.06 (i.e. 0.21, 0.95, 2.63, and 8.71 nM), respectively. Compound 3 and Compound 2 were further characterized. They inhibit BK-induced c-Fos signaling and internalization of recombinant human B2 receptors in HEK293 cells, and do not antagonize the venous effects mediated by other G protein-coupled receptors in the umbilical vein model, including the bradykinin B1 receptor. Antagonist potency of Compound 3 at cloned cynomolgus monkey, dog, rat, and mouse B2 receptors revealed species selectivity, with a high antagonist potency for human and monkey B2 receptors, but several hundred-fold lower potency for the other B2 receptors. The in vitro off-target profile of Compound 3 demonstrates a high degree of selectivity over a wide range of molecular targets, including the bradykinin B1 receptor. Compound 3 showed a lower intrinsic clearance in the microsomal stability assay than the prior art compounds. With an efflux ratio of 1.0 in the Caco-2 permeability assay Compound 3 is predicted to be not a substrate of efflux pumps. In conclusion, we discovered a novel chemical class of highly selective and very potent B2 receptor antagonists, as exemplified by Compound 3. The compound showed excellent absorption in the Caco-2 assay, predictive of good oral bioavailability, and favourable metabolic stability in liver microsomes. Compound 3 has provided a significant stepping stone towards the discovery of the orally bioavailable B2 antagonist PHA-022121, currently in phase 1 clinical development.
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Affiliation(s)
- Anne Lesage
- Pharvaris Netherlands B.V., Leiden, Netherlands
| | | | - François Marceau
- Axe Microbiologie-Infectiologie et Immunologie, Research Center, CHU de Québec-Université Laval, Québec, QC, Canada
| | | | - Jörn Saupe
- AnalytiCon Discovery GmbH, Potsdam, Germany
| | | | | | - Xavier Charest-Morin
- Axe Microbiologie-Infectiologie et Immunologie, Research Center, CHU de Québec-Université Laval, Québec, QC, Canada
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10
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Marceau F, Bachelard H, Bouthillier J, Fortin JP, Morissette G, Bawolak MT, Charest-Morin X, Gera L. Bradykinin receptors: Agonists, antagonists, expression, signaling, and adaptation to sustained stimulation. Int Immunopharmacol 2020; 82:106305. [PMID: 32106060 DOI: 10.1016/j.intimp.2020.106305] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 02/10/2020] [Indexed: 01/23/2023]
Abstract
Bradykinin-related peptides, the kinins, are blood-derived peptides that stimulate 2 G protein-coupled receptors, the B1 and B2 receptors (B1R, B2R). The pharmacologic and molecular identities of these 2 receptor subtypes will be succinctly reviewed herein, with emphasis on drug development, receptor expression, signaling, and adaptation to persistent stimulation. Peptide and non-peptide antagonists and fluorescent ligands have been produced for each receptor. The B2R is widely and constitutively expressed in mammalian tissues, whereas the B1R is mostly inducible under the effect of cytokines during infection and immunopathology. The B2R is temporarily desensitized by a cycle of phosphorylation/endocytosis followed by recycling, whereas the nonphosphorylable B1R is relatively resistant to desensitization and translocated to caveolae on activation. Both receptor subtypes, mainly coupled to protein G Gq, phospholipase C and calcium signaling, mediate the vascular aspects of inflammation (vasodilation, edema formation). On this basis, icatibant, a peptide antagonist of the B2R, is approved in the management of hereditary angioedema attacks. This disease is the therapeutic showcase of the kallikrein-kinin system, with an orally bioavailable B2R antagonist under development, as well as other agents that inhibit the kinin forming protease, plasma kallikrein. Other clinical applications are still elusive despite the maturity of the medicinal chemistry efforts applied to kinin receptors.
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Affiliation(s)
- François Marceau
- Division of Infectious Disease and Immunity, Centre de Recherche du CHU de Québec, Université Laval, Québec, QC, Canada.
| | - Hélène Bachelard
- Division of Endocrinology and Nephrology, Centre de Recherche du CHU de Québec, Université Laval, Québec, QC, Canada
| | - Johanne Bouthillier
- Division of Infectious Disease and Immunity, Centre de Recherche du CHU de Québec, Université Laval, Québec, QC, Canada
| | - Jean-Philippe Fortin
- Division of Infectious Disease and Immunity, Centre de Recherche du CHU de Québec, Université Laval, Québec, QC, Canada
| | - Guillaume Morissette
- Division of Infectious Disease and Immunity, Centre de Recherche du CHU de Québec, Université Laval, Québec, QC, Canada
| | - Marie-Thérèse Bawolak
- Division of Infectious Disease and Immunity, Centre de Recherche du CHU de Québec, Université Laval, Québec, QC, Canada
| | - Xavier Charest-Morin
- Division of Infectious Disease and Immunity, Centre de Recherche du CHU de Québec, Université Laval, Québec, QC, Canada
| | - Lajos Gera
- Department of Biochemistry, University of Colorado Denver, Aurora, CO, USA
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11
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Affiliation(s)
- Andrew P Cap
- US Army Institute of Surgical Research, Fort Sam Houston, TX 78234, USA.
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12
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Sun M, Brady RD, Casillas-Espinosa PM, Wright DK, Semple BD, Kim HA, Mychasiuk R, Sobey CG, O'Brien TJ, Vinh A, McDonald SJ, Shultz SR. Aged rats have an altered immune response and worse outcomes after traumatic brain injury. Brain Behav Immun 2019; 80:536-550. [PMID: 31039431 DOI: 10.1016/j.bbi.2019.04.038] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 03/28/2019] [Accepted: 04/26/2019] [Indexed: 12/14/2022] Open
Abstract
Initial studies suggest that increased age is associated with worse outcomes after traumatic brain injury (TBI), though the pathophysiological mechanisms responsible for this remain unclear. Immunosenescence (i.e., dysregulation of the immune system due to aging) may play a significant role in influencing TBI outcomes. This study therefore examined neurological outcomes and immune response in young-adult (i.e., 10 weeks old) compared to middle-aged (i.e., 1 year old) rats following a TBI (i.e., fluid percussion) or sham-injury. Rats were euthanized at either 24 h or one-week post-injury to analyze immune cell populations in the brain and periphery via flow cytometry, as well as telomere length (i.e., a biomarker of neurological health). Behavioral testing, as well as volumetric and diffusion-weighted MRI, were also performed in the one-week recovery rats to assess for functional deficits and brain damage. Middle-aged rats had worse sensorimotor deficits and shorter telomeres after TBI compared to young rats. Both aging and TBI independently worsened cognitive function and cortical volume. These changes occurred in the presence of fewer total leukocytes, fewer infiltrating myeloid cells, and fewer microglia in the brains of middle-aged TBI rats compared to young rats. These findings indicate that middle-aged rats have worse sensorimotor deficits and shorter telomeres after TBI than young rats, and this may be related to an altered neuroimmune response. Although further studies are required, these findings have important implications for understanding the pathophysiology and optimal treatment strategies in TBI patients across the life span.
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Affiliation(s)
- Mujun Sun
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia; Department of Medicine, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, VIC, Australia
| | - Rhys D Brady
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia; Department of Medicine, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, VIC, Australia
| | - Pablo M Casillas-Espinosa
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia; Department of Medicine, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, VIC, Australia
| | - David K Wright
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Bridgette D Semple
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia; Department of Medicine, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, VIC, Australia
| | - Hyun Ah Kim
- Department of Physiology, Anatomy and Microbiology, La Trobe University, Bundoora, VIC, Australia
| | - Richelle Mychasiuk
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia; Department of Psychology, University of Calgary, Calgary, AB, Canada
| | - Christopher G Sobey
- Department of Physiology, Anatomy and Microbiology, La Trobe University, Bundoora, VIC, Australia
| | - Terence J O'Brien
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia; Department of Medicine, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, VIC, Australia
| | - Antony Vinh
- Department of Physiology, Anatomy and Microbiology, La Trobe University, Bundoora, VIC, Australia
| | - Stuart J McDonald
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia; Department of Physiology, Anatomy and Microbiology, La Trobe University, Bundoora, VIC, Australia
| | - Sandy R Shultz
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia; Department of Medicine, The Royal Melbourne Hospital, The University of Melbourne, Melbourne, VIC, Australia.
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13
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Kassi AAY, Mahavadi AK, Clavijo A, Caliz D, Lee SW, Ahmed AI, Yokobori S, Hu Z, Spurlock MS, Wasserman JM, Rivera KN, Nodal S, Powell HR, Di L, Torres R, Leung LY, Rubiano AM, Bullock RM, Gajavelli S. Enduring Neuroprotective Effect of Subacute Neural Stem Cell Transplantation After Penetrating TBI. Front Neurol 2019; 9:1097. [PMID: 30719019 PMCID: PMC6348935 DOI: 10.3389/fneur.2018.01097] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 12/03/2018] [Indexed: 12/13/2022] Open
Abstract
Traumatic brain injury (TBI) is the largest cause of death and disability of persons under 45 years old, worldwide. Independent of the distribution, outcomes such as disability are associated with huge societal costs. The heterogeneity of TBI and its complicated biological response have helped clarify the limitations of current pharmacological approaches to TBI management. Five decades of effort have made some strides in reducing TBI mortality but little progress has been made to mitigate TBI-induced disability. Lessons learned from the failure of numerous randomized clinical trials and the inability to scale up results from single center clinical trials with neuroprotective agents led to the formation of organizations such as the Neurological Emergencies Treatment Trials (NETT) Network, and international collaborative comparative effectiveness research (CER) to re-orient TBI clinical research. With initiatives such as TRACK-TBI, generating rich and comprehensive human datasets with demographic, clinical, genomic, proteomic, imaging, and detailed outcome data across multiple time points has become the focus of the field in the United States (US). In addition, government institutions such as the US Department of Defense are investing in groups such as Operation Brain Trauma Therapy (OBTT), a multicenter, pre-clinical drug-screening consortium to address the barriers in translation. The consensus from such efforts including “The Lancet Neurology Commission” and current literature is that unmitigated cell death processes, incomplete debris clearance, aberrant neurotoxic immune, and glia cell response induce progressive tissue loss and spatiotemporal magnification of primary TBI. Our analysis suggests that the focus of neuroprotection research needs to shift from protecting dying and injured neurons at acute time points to modulating the aberrant glial response in sub-acute and chronic time points. One unexpected agent with neuroprotective properties that shows promise is transplantation of neural stem cells. In this review we present (i) a short survey of TBI epidemiology and summary of current care, (ii) findings of past neuroprotective clinical trials and possible reasons for failure based upon insights from human and preclinical TBI pathophysiology studies, including our group's inflammation-centered approach, (iii) the unmet need of TBI and unproven treatments and lastly, (iv) present evidence to support the rationale for sub-acute neural stem cell therapy to mediate enduring neuroprotection.
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Affiliation(s)
- Anelia A Y Kassi
- Department of Neurological Surgery, The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Anil K Mahavadi
- Department of Neurological Surgery, The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Angelica Clavijo
- Neurosurgery Service, INUB-MEDITECH Research Group, El Bosque University, Bogotá, CO, United States
| | - Daniela Caliz
- Neurosurgery Service, INUB-MEDITECH Research Group, El Bosque University, Bogotá, CO, United States
| | - Stephanie W Lee
- Department of Neurological Surgery, The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Aminul I Ahmed
- Wessex Neurological Centre, University Hospitals Southampton, Southampton, United Kingdom
| | - Shoji Yokobori
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Zhen Hu
- Department of Neurosurgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Markus S Spurlock
- Department of Neurological Surgery, The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Joseph M Wasserman
- Department of Neurological Surgery, The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Karla N Rivera
- Department of Neurological Surgery, The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Samuel Nodal
- Department of Neurological Surgery, The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Henry R Powell
- Department of Neurological Surgery, The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Long Di
- Department of Neurological Surgery, The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Rolando Torres
- Department of Neurological Surgery, The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Lai Yee Leung
- Branch of Brain Trauma Neuroprotection and Neurorestoration, Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, MD, United States.,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Andres Mariano Rubiano
- Neurosurgery Service, INUB-MEDITECH Research Group, El Bosque University, Bogotá, CO, United States
| | - Ross M Bullock
- Department of Neurological Surgery, The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Shyam Gajavelli
- Department of Neurological Surgery, The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, United States
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15
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Carbonara M, Fossi F, Zoerle T, Ortolano F, Moro F, Pischiutta F, Zanier ER, Stocchetti N. Neuroprotection in Traumatic Brain Injury: Mesenchymal Stromal Cells can Potentially Overcome Some Limitations of Previous Clinical Trials. Front Neurol 2018; 9:885. [PMID: 30405517 PMCID: PMC6208094 DOI: 10.3389/fneur.2018.00885] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 10/01/2018] [Indexed: 12/12/2022] Open
Abstract
Traumatic brain injury (TBI) is a leading cause of death and disability worldwide. In the last 30 years several neuroprotective agents, attenuating the downstream molecular and cellular damaging events triggered by TBI, have been extensively studied. Even though many drugs have shown promising results in the pre-clinical stage, all have failed in large clinical trials. Mesenchymal stromal cells (MSCs) may offer a promising new therapeutic intervention, with preclinical data showing protection of the injured brain. We selected three of the critical aspects identified as possible causes of clinical failure: the window of opportunity for drug administration, the double-edged contribution of mechanisms to damage and recovery, and the oft-neglected role of reparative mechanisms. For each aspect, we briefly summarized the limitations of previous trials and the potential advantages of a newer approach using MSCs.
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Affiliation(s)
- Marco Carbonara
- Neuroscience Intensive Care Unit, Department of Anaesthesia and Critical Care, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesca Fossi
- Laboratory of Acute Brain Injury and Therapeutic Strategies, Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy.,School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - Tommaso Zoerle
- Neuroscience Intensive Care Unit, Department of Anaesthesia and Critical Care, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Fabrizio Ortolano
- Neuroscience Intensive Care Unit, Department of Anaesthesia and Critical Care, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Federico Moro
- Laboratory of Acute Brain Injury and Therapeutic Strategies, Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Francesca Pischiutta
- Laboratory of Acute Brain Injury and Therapeutic Strategies, Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Elisa R Zanier
- Laboratory of Acute Brain Injury and Therapeutic Strategies, Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Nino Stocchetti
- Neuroscience Intensive Care Unit, Department of Anaesthesia and Critical Care, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplants, Milan University, Milan, Italy
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16
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Marceau F, Bawolak MT, Fortin JP, Morissette G, Roy C, Bachelard H, Gera L, Charest-Morin X. Bifunctional ligands of the bradykinin B 2 and B 1 receptors: An exercise in peptide hormone plasticity. Peptides 2018; 105:37-50. [PMID: 29802875 DOI: 10.1016/j.peptides.2018.05.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 05/14/2018] [Accepted: 05/15/2018] [Indexed: 12/24/2022]
Abstract
Kinins are the small and fragile hydrophilic peptides related to bradykinin (BK) and derived from circulating kininogens via the action of kallikreins. Kinins bind to the preformed and widely distributed B2 receptor (B2R) and to the inducible B1 receptor (B1R). B2Rs and B1Rs are related G protein coupled receptors that possess natural agonist ligands of nanomolar affinity (BK and Lys BK for B2Rs, Lys-des-Arg9-BK for B1R). Decades of structure-activity exploration have resulted in the production of peptide analogs that are antagonists, one of which is clinically used (the B2R antagonist icatibant), and also non-peptide ligands for both receptor subtypes. The modification of kinin receptor ligands has made them resistant to extracellular or endosomal peptidases and/or produced bifunctional ligands, defined as agonist or antagonist peptide ligands conjugated with a chemical fluorophore (emitting in the whole spectrum, from the infrared to the ultraviolet), a drug-like moiety, an epitope, an isotope chelator/carrier, a cleavable sequence (thus forming a pro-drug) and even a fused protein. Dual molecular targets for specific modified peptides may be a source of side effects or of medically exploitable benefits. Biotechnological protein ligands for either receptor subtype have been produced: they are enhanced green fluorescent protein or the engineered peroxidase APEX2 fused to an agonist kinin sequence at their C-terminal terminus. Antibodies endowed with pharmacological actions (agonist, antagonist) at B2R have been reported, though not monoclonal antibodies. These findings define classes of alternative ligands of the kinin receptor of potential therapeutic and diagnostic value.
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Affiliation(s)
| | | | | | | | - Caroline Roy
- CHU de Québec - Université Laval, Québec, QC, G1 V 4G2, Canada
| | | | - Lajos Gera
- Department of Biochemistry, University of Colorado Denver, Aurora, CO, 80045, USA
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17
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Synnot A, Bragge P, Lunny C, Menon D, Clavisi O, Pattuwage L, Volovici V, Mondello S, Cnossen MC, Donoghue E, Gruen RL, Maas A. The currency, completeness and quality of systematic reviews of acute management of moderate to severe traumatic brain injury: A comprehensive evidence map. PLoS One 2018; 13:e0198676. [PMID: 29927963 PMCID: PMC6013193 DOI: 10.1371/journal.pone.0198676] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 05/23/2018] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE To appraise the currency, completeness and quality of evidence from systematic reviews (SRs) of acute management of moderate to severe traumatic brain injury (TBI). METHODS We conducted comprehensive searches to March 2016 for published, English-language SRs and RCTs of acute management of moderate to severe TBI. Systematic reviews and RCTs were grouped under 12 broad intervention categories. For each review, we mapped the included and non-included RCTs, noting the reasons why RCTs were omitted. An SR was judged as 'current' when it included the most recently published RCT we found on their topic, and 'complete' when it included every RCT we found that met its inclusion criteria, taking account of when the review was conducted. Quality was assessed using the AMSTAR checklist (trichotomised into low, moderate and high quality). FINDINGS We included 85 SRs and 213 RCTs examining the effectiveness of treatments for acute management of moderate to severe TBI. The most frequently reviewed interventions were hypothermia (n = 17, 14.2%), hypertonic saline and/or mannitol (n = 9, 7.5%) and surgery (n = 8, 6.7%). Of the 80 single-intervention SRs, approximately half (n = 44, 55%) were judged as current and two-thirds (n = 52, 65.0%) as complete. When considering only the most recently published review on each intervention (n = 25), currency increased to 72.0% (n = 18). Less than half of the 85 SRs were judged as high quality (n = 38, 44.7%), and nearly 20% were low quality (n = 16, 18.8%). Only 16 (20.0%) of the single-intervention reviews (and none of the five multi-intervention reviews) were judged as current, complete and high-quality. These included reviews of red blood cell transfusion, hypothermia, management guided by intracranial pressure, pharmacological agents (various) and prehospital intubation. Over three-quarters (n = 167, 78.4%) of the 213 RCTs were included in one or more SR. Of the remainder, 17 (8.0%) RCTs post-dated or were out of scope of existing SRs, and 29 (13.6%) were on interventions that have not been assessed in SRs. CONCLUSION A substantial number of SRs in acute management of moderate to severe TBI lack currency, completeness and quality. We have identified both potential evidence gaps and also substantial research waste. Novel review methods, such as Living Systematic Reviews, may ameliorate these shortcomings and enhance utility and reliability of the evidence underpinning clinical care.
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Affiliation(s)
- Anneliese Synnot
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- National Trauma Research Institute, The Alfred, Monash University, Melbourne, Victoria, Australia
- Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Cochrane Consumers and Communication, School of Psychology and Public Health, La Trobe University, Melbourne, Victoria, Australia
| | - Peter Bragge
- BehaviourWorks Australia, Monash Sustainable Development Institute, Monash University, Melbourne, Victoria, Australia
| | - Carole Lunny
- Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - David Menon
- Division of Anaesthesia, University of Cambridge; Neurosciences Critical Care Unit, Addenbrooke’s Hospital; Queens’ College, Cambridge, United Kingdom
| | - Ornella Clavisi
- National Trauma Research Institute, The Alfred, Monash University, Melbourne, Victoria, Australia
- MOVE: Muscle, Bone and Joint Health Ltd, Melbourne, Victoria, Australia
| | - Loyal Pattuwage
- National Trauma Research Institute, The Alfred, Monash University, Melbourne, Victoria, Australia
- Monash Centre for Occupational and Environmental Health (MonCOEH), Monash University, Melbourne, Victoria, Australia
| | - Victor Volovici
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Department of Neurosurgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Stefania Mondello
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Maryse C. Cnossen
- Center for Medical Decision Making, Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Emma Donoghue
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Russell L. Gruen
- Nanyang Technical University, Singapore
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Andrew Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
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Nokkari A, Abou-El-Hassan H, Mechref Y, Mondello S, Kindy MS, Jaffa AA, Kobeissy F. Implication of the Kallikrein-Kinin system in neurological disorders: Quest for potential biomarkers and mechanisms. Prog Neurobiol 2018; 165-167:26-50. [PMID: 29355711 PMCID: PMC6026079 DOI: 10.1016/j.pneurobio.2018.01.003] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 01/15/2018] [Indexed: 01/06/2023]
Abstract
Neurological disorders represent major health concerns in terms of comorbidity and mortality worldwide. Despite a tremendous increase in our understanding of the pathophysiological processes involved in disease progression and prevention, the accumulated knowledge so far resulted in relatively moderate translational benefits in terms of therapeutic interventions and enhanced clinical outcomes. Aiming at specific neural molecular pathways, different strategies have been geared to target the development and progression of such disorders. The kallikrein-kinin system (KKS) is among the most delineated candidate systems due to its ubiquitous roles mediating several of the pathophysiological features of these neurological disorders as well as being implicated in regulating various brain functions. Several experimental KKS models revealed that the inhibition or stimulation of the two receptors of the KKS system (B1R and B2R) can exhibit neuroprotective and/or adverse pathological outcomes. This updated review provides background details of the KKS components and their functions in different neurological disorders including temporal lobe epilepsy, traumatic brain injury, stroke, spinal cord injury, Alzheimer's disease, multiple sclerosis and glioma. Finally, this work will highlight the putative roles of the KKS components as potential neurotherapeutic targets and provide future perspectives on the possibility of translating these findings into potential clinical biomarkers in neurological disease.
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Affiliation(s)
- Amaly Nokkari
- Department of Biochemistry and Molecular Genetics, Faculty of Medicine, American University of Beirut, Lebanon
| | - Hadi Abou-El-Hassan
- Faculty of Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Yehia Mechref
- Department of Chemistry and Biochemistry, Texas Tech University, Lubbock, TX, USA
| | - Stefania Mondello
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Mark S Kindy
- Department of Pharmaceutical Science, College of Pharmacy, University of South Florida, Tampa, FL, USA; James A. Haley VA Medical Center, Tampa, FL, USA
| | - Ayad A Jaffa
- Department of Biochemistry and Molecular Genetics, Faculty of Medicine, American University of Beirut, Lebanon; Department of Medicine, Medical University of South, Charleston, SC, USA.
| | - Firas Kobeissy
- Department of Biochemistry and Molecular Genetics, Faculty of Medicine, American University of Beirut, Lebanon; Center for Neuroproteomics & Biomarkers Research, Department of Psychiatry, McKnight Brain Institute, University of Florida, Gainesville, FL, USA.
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19
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Mateo J, Payen D, Ghout I, Vallée F, Lescot T, Welschbillig S, Tazarourte K, Azouvi P, Weiss JJ, Aegerter P, Vigué B. Impact of extended monitoring-guided intensive care on outcome after severe traumatic brain injury: A prospective multicentre cohort study (PariS-TBI study). Brain Inj 2017; 31:1642-1650. [PMID: 28925746 DOI: 10.1080/02699052.2017.1370554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE We evaluated whether an integrated monitoring with systemic and specific monitoring affect mortality and disability in adults with severe traumatic brain injury (sTBI). METHODS Adults with severeTBI (Glasgow Coma Scale [GCS] ≤ 8) admitted alive in intensive care units (ICUs) were prospectively included. Primary endpoints were in-hospital 30-day mortality and extended Glasgow outcome score (GOSE) at 3 years. Association with the intensity of monitoring and outcome was studied by comparing a high level of monitoring (HLM) (systemic and ≥3 specific monitoring) and low level of monitoring (LLM) (systemic and 0-2 specific monitoring) and using inverse probability weighting procedure. RESULTS 476 patients were included and IPW was used to improve the balance between the two groups of treatments (HLM/LMM). Overall hospital mortality (at 30 days) was 43%, being significantly lower in HLM than LLM group (27% vs. 53%: RR, 1.63: 95% CI: 1.23-2.15). The 14-day hospital mortality was also lower in the HLM group than expected, based upon the CRASH prediction model (35%). At 3 years, disability was not significantly different between the monitoring groups. CONCLUSIONS After adjustment, HLM group improved short-term mortality but did not show any improvement in the 3-year outcome compared with LLM.
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Affiliation(s)
- Joaquim Mateo
- a Department of Anesthesiology and Critical Care , Lariboisière University Hospital, Assistance Publique-Hôpitaux de Paris, University Paris 7 Diderot , Paris , France
| | - Didier Payen
- a Department of Anesthesiology and Critical Care , Lariboisière University Hospital, Assistance Publique-Hôpitaux de Paris, University Paris 7 Diderot , Paris , France
| | - Idir Ghout
- b Unité de Recherche Clinique Paris-Ouest , Hôpital Ambroise Paré, AP-HP , Boulogne , France
| | - Fabrice Vallée
- a Department of Anesthesiology and Critical Care , Lariboisière University Hospital, Assistance Publique-Hôpitaux de Paris, University Paris 7 Diderot , Paris , France
| | - Thomas Lescot
- c Department of Anesthesiology and Critical Care , Pitié-Salpêtrière University Hospital, APHP, University Paris 6 , Paris , France
| | - Stephane Welschbillig
- a Department of Anesthesiology and Critical Care , Lariboisière University Hospital, Assistance Publique-Hôpitaux de Paris, University Paris 7 Diderot , Paris , France
| | - Karim Tazarourte
- d SAMU 77, Mobile Care Unit , Marc Jacquet Hospital , Melun , France
| | - Philippe Azouvi
- e Department of Physical Medicine and Rehabilitation , Raymond Poincaré Hospital, Assistance Publique-Hôpitaux de Paris , Garches , France
| | - Jean-Jacques Weiss
- f Department of Public Health , Centre Ressources Francilien du Traumatisme Crânien , Paris , France
| | - Philippe Aegerter
- g UMR-S 1168, INSERM , Université Versailles St-Quentin , Paris , France
| | - Bernard Vigué
- h Department of Anesthesiology and Intensive Care , Bicêtre University Hospital, Assistance Publique-Hôpitaux de Paris, University Paris Sud , Le Kremlin Bicêtre , France
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20
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Simon DW, McGeachy M, Bayır H, Clark RS, Loane DJ, Kochanek PM. The far-reaching scope of neuroinflammation after traumatic brain injury. Nat Rev Neurol 2017; 13:171-191. [PMID: 28186177 PMCID: PMC5675525 DOI: 10.1038/nrneurol.2017.13] [Citation(s) in RCA: 593] [Impact Index Per Article: 84.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The 'silent epidemic' of traumatic brain injury (TBI) has been placed in the spotlight as a result of clinical investigations and popular press coverage of athletes and veterans with single or repetitive head injuries. Neuroinflammation can cause acute secondary injury after TBI, and has been linked to chronic neurodegenerative diseases; however, anti-inflammatory agents have failed to improve TBI outcomes in clinical trials. In this Review, we therefore propose a new framework of targeted immunomodulation after TBI for future exploration. Our framework incorporates factors such as the time from injury, mechanism of injury, and secondary insults in considering potential treatment options. Structuring our discussion around the dynamics of the immune response to TBI - from initial triggers to chronic neuroinflammation - we consider the ability of soluble and cellular inflammatory mediators to promote repair and regeneration versus secondary injury and neurodegeneration. We summarize both animal model and human studies, with clinical data explicitly defined throughout this Review. Recent advances in neuroimmunology and TBI-responsive neuroinflammation are incorporated, including concepts of inflammasomes, mechanisms of microglial polarization, and glymphatic clearance. Moreover, we highlight findings that could offer novel therapeutic targets for translational and clinical research, assimilate evidence from other brain injury models, and identify outstanding questions in the field.
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Affiliation(s)
- Dennis W. Simon
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine; The Children’s Hospital of Pittsburgh of UPMC, and the Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA 15261, USA
- Department of Pediatrics, University of Pittsburgh School of Medicine; The Children’s Hospital of Pittsburgh of UPMC, and the Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA 15261, USA
| | - Mandy McGeachy
- Department of Medicine, University of Pittsburgh School of Medicine; The Children’s Hospital of Pittsburgh of UPMC, and the Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA 15261, USA
| | - Hülya Bayır
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine; The Children’s Hospital of Pittsburgh of UPMC, and the Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA 15261, USA
- Department of Environmental and Occupational Health, University of Pittsburgh School of Medicine; The Children’s Hospital of Pittsburgh of UPMC, and the Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA 15261, USA
| | - Robert S.B. Clark
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine; The Children’s Hospital of Pittsburgh of UPMC, and the Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA 15261, USA
- Department of Pediatrics, University of Pittsburgh School of Medicine; The Children’s Hospital of Pittsburgh of UPMC, and the Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA 15261, USA
- Department of Anesthesiology, University of Pittsburgh School of Medicine; The Children’s Hospital of Pittsburgh of UPMC, and the Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA 15261, USA
- Clinical and Translational Science Institute, University of Pittsburgh School of Medicine; The Children’s Hospital of Pittsburgh of UPMC, and the Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA 15261, USA
| | - David J. Loane
- Department of Anesthesiology and Shock, Trauma and Anesthesiology Research (STAR) Center, University of Maryland School of Medicine, Baltimore, MA 21201, USA
| | - Patrick M. Kochanek
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine; The Children’s Hospital of Pittsburgh of UPMC, and the Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA 15261, USA
- Department of Pediatrics, University of Pittsburgh School of Medicine; The Children’s Hospital of Pittsburgh of UPMC, and the Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA 15261, USA
- Department of Anesthesiology, University of Pittsburgh School of Medicine; The Children’s Hospital of Pittsburgh of UPMC, and the Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA 15261, USA
- Department of Neurological Surgery, University of Pittsburgh School of Medicine; The Children’s Hospital of Pittsburgh of UPMC, and the Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA 15261, USA
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21
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Bragge P, Synnot A, Maas AI, Menon DK, Cooper DJ, Rosenfeld JV, Gruen RL. A State-of-the-Science Overview of Randomized Controlled Trials Evaluating Acute Management of Moderate-to-Severe Traumatic Brain Injury. J Neurotrauma 2016; 33:1461-78. [PMID: 26711675 PMCID: PMC5003006 DOI: 10.1089/neu.2015.4233] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Moderate-to-severe traumatic brain injury (TBI) remains a major global challenge, with rising incidence, unchanging mortality and lifelong impairments. State-of-the-science reviews are important for research planning and clinical decision support. This review aimed to identify randomized controlled trials (RCTs) evaluating interventions for acute management of moderate/severe TBI, synthesize key RCT characteristics and findings, and determine their implications on clinical practice and future research. RCTs were identified through comprehensive database and other searches. Key characteristics, outcomes, risk of bias, and analysis approach were extracted. Data were narratively synthesized, with a focus on robust (multi-center, low risk of bias, n > 100) RCTs, and three-dimensional graphical figures also were used to explore relationships between RCT characteristics and findings. A total of 207 RCTs were identified. The 191 completed RCTs enrolled 35,340 participants (median, 66). Most (72%) were single center and enrolled less than 100 participants (69%). There were 26 robust RCTs across 18 different interventions. For 74% of 392 comparisons across all included RCTs, there was no significant difference between groups. Positive findings were broadly distributed with respect to RCT characteristics. Less than one-third of RCTs demonstrated low risk of bias for random sequence generation or allocation concealment, less than one-quarter used covariate adjustment, and only 7% employed an ordinal analysis approach. Considerable investment of resources in producing 191 completed RCTs for acute TBI management has resulted in very little translatable evidence. This may result from broad distribution of research effort, small samples, preponderance of single-center RCTs, and methodological shortcomings. More sophisticated RCT design, large multi-center RCTs in priority areas, increased focus on pre-clinical research, and alternatives to RCTs, such as comparative effectiveness research and precision medicine, are needed to fully realize the potential of acute TBI research to benefit patients.
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Affiliation(s)
- Peter Bragge
- Centre of Excellence in Traumatic Brain Injury Research, National Trauma Research Institute, Monash University and The Alfred Hospital, Victoria, Australia
- BehaviourWorks Australia, Monash Sustainability Institute, Monash University, Victoria, Australia
| | - Anneliese Synnot
- Centre of Excellence in Traumatic Brain Injury Research, National Trauma Research Institute, Monash University and The Alfred Hospital, Victoria, Australia
- Cochrane Consumers and Communication Review Group, Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Melbourne, Australia; Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Victoria, Australia
| | - Andrew I. Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - David K. Menon
- Division of Anaesthesia, University of Cambridge; Neurosciences Critical Care Unit, Addenbrooke's Hospital; Queens' College, Cambridge, United Kingdom
| | - D. James Cooper
- Department of Intensive Care, Alfred Hospital, Victoria, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Victoria, Australia
| | - Jeffrey V. Rosenfeld
- Centre of Excellence in Traumatic Brain Injury Research, National Trauma Research Institute, Monash University and The Alfred Hospital, Victoria, Australia
- Monash Institute of Medical Engineering (MIME); Division of Clinical Sciences and Department of Surgery, Central Clinical School, Monash University, Victoria, Australia; Department of Neurosurgery, Alfred Hospital, Victoria, Australia; F. Edward Hébert School of Medicine, Uniformed Services University of The Health Sciences (USUHS), Bethesda, Maryland
| | - Russell L. Gruen
- Centre of Excellence in Traumatic Brain Injury Research, National Trauma Research Institute, Monash University and The Alfred Hospital, Victoria, Australia
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
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22
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Albert-Weissenberger C, Mencl S, Hopp S, Kleinschnitz C, Sirén AL. Role of the kallikrein-kinin system in traumatic brain injury. Front Cell Neurosci 2014; 8:345. [PMID: 25404891 PMCID: PMC4217500 DOI: 10.3389/fncel.2014.00345] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Accepted: 10/06/2014] [Indexed: 12/26/2022] Open
Abstract
Traumatic brain injury (TBI) is a major cause of mortality and morbidity worldwide. Despite improvements in acute intensive care, there are currently no specific therapies to ameliorate the effects of TBI. Successful therapeutic strategies for TBI should target multiple pathophysiologic mechanisms that occur at different stages of brain injury. The kallikrein-kinin system is a promising therapeutic target for TBI as it mediates key pathologic events of traumatic brain damage, such as edema formation, inflammation, and thrombosis. Selective and specific kinin receptor antagonists and inhibitors of plasma kallikrein and coagulation factor XII have been developed, and have already shown therapeutic efficacy in animal models of stroke and TBI. However, conflicting preclinical evaluation, as well as limited and inconclusive data from clinical trials in TBI, suggests that caution should be taken before transferring observations made in animals to humans. This review summarizes current evidence on the pathologic significance of the kallikrein-kinin system during TBI in animal models and, where available, the experimental findings are compared with human data.
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Affiliation(s)
| | - Stine Mencl
- Department of Neurology, University Hospital of Würzburg Würzburg, Germany
| | - Sarah Hopp
- Department of Neurology, University Hospital of Würzburg Würzburg, Germany
| | | | - Anna-Leena Sirén
- Department of Neurosurgery, University Hospital of Würzburg Würzburg, Germany
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Abstract
Cerebral oedema (CO) after brain injury can occur from different ways. The vasogenic and cytotoxic oedema are usually described but osmotic and hydrostatic CO, respectively secondary to plasmatic hypotonia or increase in blood pressure, can also be encountered. Addition of these several mechanisms can worsen injuries. Consequences are major, leading quickly to death secondary to intracerebral hypertension and later to neuropsychic sequelae. So therapeutic care to control this phenomenon is essential and osmotherapy is actually the only way. A better understanding of physiopathological disorders, particularly energetic ways (lactate), aquaporine function, inflammation lead to new therapeutic hopes. The promising experimental results need now to be confirmed by clinical data.
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Kunz M, Nussberger J, Holtmannspötter M, Bitterling H, Plesnila N, Zausinger S. Bradykinin in blood and cerebrospinal fluid after acute cerebral lesions: correlations with cerebral edema and intracranial pressure. J Neurotrauma 2014; 30:1638-44. [PMID: 23638655 DOI: 10.1089/neu.2012.2774] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Bradykinin (BK) was shown to stimulate the production of physiologically active metabolites, blood-brain barrier disruption, and brain edema. The aim of this prospective study was to measure BK concentrations in blood and cerebrospinal fluid (CSF) of patients with traumatic brain injury (TBI), subarachnoid hemorrhage (SAH), intracerebral hemorrhage (ICH), and ischemic stroke and to correlate BK levels with the extent of cerebral edema and intracranial pressure (ICP). Blood and CSF samples of 29 patients suffering from acute cerebral lesions (TBI, 7; SAH,: 10; ICH, 8; ischemic stroke, 4) were collected for up to 8 days after insult. Seven patients with lumbar drainage were used as controls. Edema (5-point scale), ICP, and the GCS (Glasgow Coma Score) at the time of sample withdrawal were correlated with BK concentrations. Though all plasma-BK samples were not significantly elevated, CSF-BK levels of all patients were significantly elevated in overall (n=73) and early (≤72 h) measurements (n=55; 4.3±6.9 and 5.6±8.9 fmol/mL), compared to 1.2±0.7 fmol/mL of controls (p=0.05 and 0.006). Within 72 h after ictus, patients suffering from TBI (p=0.01), ICH (p=0.001), and ischemic stroke (p=0.02) showed significant increases. CSF-BK concentrations correlated with extent of edema formation (r=0.53; p<0.001) and with ICP (r=0.49; p<0.001). Our results demonstrate that acute cerebral lesions are associated with increased CSF-BK levels. Especially after TBI, subarachnoid and intracerebral hemorrhage CSF-BK levels correlate with extent of edema evolution and ICP. BK-blocking agents may turn out to be effective remedies in brain injuries.
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Affiliation(s)
- Mathias Kunz
- 1 Department of Neurosurgery, Klinikum Großhadern, Ludwig-Maximilians University Munich , Germany
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25
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Abstract
OPINION STATEMENT After brain injury, neurologic intensive care focuses on the detection and treatment of secondary brain insults that may compound the initial injury. Increased intracranial pressure (ICP) contributes to secondary brain injury by causing brain ischemia, hypoxia, and metabolic dysfunction. Because ICP is easily measured at the bedside, it is the target of numerous pharmacologic and surgical interventions in efforts to improve brain physiology and limit secondary injury. However, ICP may not adequately reflect the metabolic health of the underlying brain tissue, particularly in cases of focal brain injury. As a result, ICP control alone may be insufficient to impact patients' long-term recovery. Further studies are needed to better understand the combination of cerebral, hemodynamic, and metabolic markers that are best utilized to ensure optimal brain and systemic recovery and overall patient outcome after brain injury.
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26
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da Costa PLN, Sirois P, Tannock IF, Chammas R. The role of kinin receptors in cancer and therapeutic opportunities. Cancer Lett 2013; 345:27-38. [PMID: 24333733 DOI: 10.1016/j.canlet.2013.12.009] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Revised: 11/29/2013] [Accepted: 12/02/2013] [Indexed: 12/20/2022]
Abstract
Kinins are generated within inflammatory tissue microenvironments, where they exert diverse functions, including cell proliferation, leukocyte activation, cell migration, endothelial cell activation and nociception. These pleiotropic functions depend on signaling through two cross talking receptors, the constitutively expressed kinin receptor 2 (B2R) and the inducible kinin receptor 1 (B1R). We have reviewed evidence, which supports the concept that kinin receptors, especially kinin receptor 1, are promising targets for cancer therapy, since (1) many tumor cells express aberrantly high levels of these receptors; (2) some cancers produce kinins and use them as autocrine factors to stimulate their growth; (3) activation of kinin receptors leads to activation of macrophages, dendritic cells and other cells from the tumor microenvironment; (4) kinins have pro-angiogenic properties; (5) kinin receptors have been implicated in cancer migration, invasion and metastasis; and (6) selective antagonists for either B1R or B2R have shown anti-proliferative, anti-inflammatory, anti-angiogenic and anti-migratory properties. The multiple cross talks between kinin receptors and renin-angiotensin system (RAS) as well as its implications for targeting KKS or RAS for the treatment of malignancies are also discussed. It is expected that B1R antagonists would interfere less with housekeeping functions and therefore would be attractive compounds to treat selected types of cancer. Reliable clinical studies are needed to establish the translatability of these data to human settings and the usefulness of kinin receptor antagonists.
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Affiliation(s)
- Patrícia L N da Costa
- Laboratório de Oncologia Experimental, Faculdade de Medicina da Universidade de São Paulo and Instituto do Câncer do Estado de São Paulo, Brazil
| | - Pierre Sirois
- CHUL Research Center, Laval University, Quebec City, Canada
| | - Ian F Tannock
- Princess Margaret Cancer Centre and University of Toronto, Toronto, ON, Canada
| | - Roger Chammas
- Laboratório de Oncologia Experimental, Faculdade de Medicina da Universidade de São Paulo and Instituto do Câncer do Estado de São Paulo, Brazil.
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27
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Radosevich JJ, Patanwala AE, Erstad BL. Emerging pharmacological agents to improve survival from traumatic brain injury. Brain Inj 2013; 27:1492-9. [DOI: 10.3109/02699052.2013.823658] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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28
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Easton AS. Regulation of permeability across the blood-brain barrier. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2013; 763:1-19. [PMID: 23397617 DOI: 10.1007/978-1-4614-4711-5_1] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The blood-brain barrier refers to the very low permeability across microvessels in the Central Nervous System (CNS), created by the interaction between vascular endothelial cells and surrounding cells of the neurovascular unit. Permeability can be modulated (increased and decreased) by a variety of factors including inflammatory mediators, inflammatory cells such as neutrophils and through alterations in the phenotype of blood vessels during angiogenesis and apoptosis. In this chapter, some of these factors are discussed as well as the challenge of treating harmful increases in permeability that result in brain swelling (vasogenic cerebral edema).
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Affiliation(s)
- Alexander S Easton
- Department of Pathology, Dalhousie University, Halifax, Nova Scotia, Canada.
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29
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Albert-Weißenberger C, Sirén AL, Kleinschnitz C. Ischemic stroke and traumatic brain injury: the role of the kallikrein-kinin system. Prog Neurobiol 2012; 101-102:65-82. [PMID: 23274649 DOI: 10.1016/j.pneurobio.2012.11.004] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Revised: 11/15/2012] [Accepted: 11/20/2012] [Indexed: 12/16/2022]
Abstract
Acute ischemic stroke and traumatic brain injury are a major cause of mortality and morbidity. Due to the paucity of therapies, there is a pressing clinical demand for new treatment options. Successful therapeutic strategies for these conditions must target multiple pathophysiological mechanisms occurring at different stages of brain injury. In this respect, the kallikrein-kinin system is an ideal target linking key pathological hallmarks of ischemic and traumatic brain damage such as edema formation, inflammation, and thrombosis. In particular, the kinin receptors, plasma kallikrein, and coagulation factor XIIa are highly attractive candidates for pharmacological development, as kinin receptor antagonists or inhibitors of plasma kallikrein and coagulation factor XIIa are neuroprotective in animal models of stroke and traumatic brain injury. Nevertheless, conflicting preclinical evaluation as well as limited and inconclusive data from clinical trials suggest caution when transferring observations made in animals into the human situation. This review summarizes current evidence on the pathological significance of the kallikrein-kinin system during ischemic and traumatic brain damage, with a particular focus on experimental data derived from animal models. Experimental findings are also compared with human data if available, and potential therapeutic implications are discussed.
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30
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Whalley ET, Figueroa CD, Gera L, Bhoola KD. Discovery and therapeutic potential of kinin receptor antagonists. Expert Opin Drug Discov 2012; 7:1129-48. [DOI: 10.1517/17460441.2012.729038] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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31
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Albert-Weissenberger C, Stetter C, Meuth SG, Göbel K, Bader M, Sirén AL, Kleinschnitz C. Blocking of bradykinin receptor B1 protects from focal closed head injury in mice by reducing axonal damage and astroglia activation. J Cereb Blood Flow Metab 2012; 32:1747-56. [PMID: 22569191 PMCID: PMC3434625 DOI: 10.1038/jcbfm.2012.62] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The two bradykinin receptors B1R and B2R are central components of the kallikrein-kinin system with different expression kinetics and binding characteristics. Activation of these receptors by kinins triggers inflammatory responses in the target organ and in most situations enhances tissue damage. We could recently show that blocking of B1R, but not B2R, protects from cortical cryolesion by reducing inflammation and edema formation. In the present study, we investigated the role of B1R and B2R in a closed head model of focal traumatic brain injury (TBI; weight drop). Increased expression of B1R in the injured hemispheres of wild-type mice was restricted to the later stages after brain trauma, i.e. day 7 (P<0.05), whereas no significant induction could be observed for the B2R (P>0.05). Mice lacking the B1R, but not the B2R, showed less functional deficits on day 3 (P<0.001) and day 7 (P<0.001) compared with controls. Pharmacological blocking of B1R in wild-type mice had similar effects. Reduced axonal injury and astroglia activation could be identified as underlying mechanisms, while inhibition of B1R had only little influence on the local inflammatory response in this model. Inhibition of B1R may become a novel strategy to counteract trauma-induced neurodegeneration.
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32
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Fraser PA. The role of free radical generation in increasing cerebrovascular permeability. Free Radic Biol Med 2011; 51:967-77. [PMID: 21712087 DOI: 10.1016/j.freeradbiomed.2011.06.003] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2011] [Revised: 06/01/2011] [Accepted: 06/02/2011] [Indexed: 12/31/2022]
Abstract
The brain endothelium constitutes a barrier to the passive movement of substances from the blood into the cerebral microenvironment, and disruption of this barrier after a stroke or trauma has potentially fatal consequences. Reactive oxygen species (ROS), which are formed during these cerebrovascular accidents, have a key role in this disruption. ROS are formed constitutively by mitochondria and also by the activation of cell receptors that transduce signals from inflammatory mediators, e.g., activated phospholipase A₂ forms arachidonic acid that interacts with cyclooxygenase and lipoxygenase to generate ROS. Endothelial NADPH oxidase, activated by cytokines, also contributes to ROS. There is a surge in ROS following reperfusion after cerebral ischemia and the interaction of the signaling pathways plays a role in this. This review critically evaluates the literature and concludes that the ischemic penumbra is a consequence of the initial edema resulting from the ROS surge after reperfusion.
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Affiliation(s)
- Paul A Fraser
- BHF Centre of Research Excellence, Cardiovascular Division, King's College London, London SE19NH, UK.
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33
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Kinin receptor antagonists as potential neuroprotective agents in central nervous system injury. Molecules 2010; 15:6598-618. [PMID: 20877247 PMCID: PMC6257767 DOI: 10.3390/molecules15096598] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2010] [Revised: 09/10/2010] [Accepted: 09/14/2010] [Indexed: 11/17/2022] Open
Abstract
Injury to the central nervous system initiates complex physiological, cellular and molecular processes that can result in neuronal cell death. Of interest to this review is the activation of the kinin family of neuropeptides, in particular bradykinin and substance P. These neuropeptides are known to have a potent pro-inflammatory role and can initiate neurogenic inflammation resulting in vasodilation, plasma extravasation and the subsequent development of edema. As inflammation and edema play an integral role in the progressive secondary injury that causes neurological deficits, this review critically examines kinin receptor antagonists as a potential neuroprotective intervention for acute brain injury, and more specifically, traumatic brain and spinal cord injury and stroke.
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Abstract
PURPOSE OF REVIEW Although a number of factors contribute to the high mortality and morbidity associated with traumatic brain injury (TBI), the development of cerebral edema with brain swelling remains the most significant predictor of outcome. The present review summarizes the most recent advances in the understanding of mechanisms associated with development of posttraumatic cerebral edema, and highlights areas of therapeutic promise. RECENT FINDINGS Despite the predominance of cytotoxic (or cellular) edema in the first week after traumatic brain injury, brain swelling can only occur with addition of water to the cranial vault from the vasculature. As such, regulation of blood-brain barrier permeability has become a focus of recent research seeking to manage brain edema. Aquaporins, matrix metalloproteinases and vasoactive inflammatory agents have emerged as potential mediators of cerebral edema following traumatic brain injury. In particular, kinins (bradykinins) and tachykinins (substance P) seem to play an active physiological role in modulating blood-brain barrier permeability after trauma. Substance P neurokinin-1 receptor antagonists show particular promise as novel therapeutic agents. SUMMARY Attenuating blood-brain barrier permeability has become a promising approach to managing brain edema and associated swelling given that increases in cranial water content can only be derived from the vasculature. Inflammation, both classical and neurogenic, offers a number of attractive targets.
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Simmon VF. Response to: The BRAIN TRIAL: a randomised, placebo controlled trial of a Bradykinin B2 receptor antagonist (Anatibant) in patients with traumatic brain injury. Trials 2009; 10:110; author reply 111. [PMID: 19958522 PMCID: PMC2797007 DOI: 10.1186/1745-6215-10-110] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2009] [Accepted: 12/03/2009] [Indexed: 11/16/2022] Open
Abstract
A response to and comment on The BRAIN TRIAL: a randomised, placebo controlled trial of a Bradykinin B2 receptor antagonist (Anatibant) in patients with traumatic brain injury, by Haleema Shakur, Ian Roberts, et al.
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36
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Roberts I, Shakur H. Response to: The BRAIN TRIAL: a randomized, placebo controlled trial of a Bradykinin B2 receptor antagonist (Anatibant) in patients with traumatic brain injury - authors' reply. Trials 2009. [PMCID: PMC2797008 DOI: 10.1186/1745-6215-10-111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
A response to the letter regarding The BRAIN TRIAL: a randomized, placebo controlled trial of a Bradykinin B2 receptor antagonist (Anatibant) in patients with traumatic brain injury, by Mr Vincent Simmon President and CEO of Xytis Inc.
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37
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Abstract
BACKGROUND Traumatic brain injury (TBI) is a leading cause of death and disability worldwide. Cerebral oedema, the accumulation of fluid within the brain, is believed to be an important contributor to the secondary brain damage that occurs following injury. The release of kinins is thought to be an important factor in the development of cerebral vasogenic oedema and the use of beta-2 receptor antagonists, which prevent the release of these kinins, have been proposed as a potential therapeutic intervention. OBJECTIVES The objective was to assess the safety and effectiveness of beta-2 receptor antagonists for TBI. SEARCH STRATEGY We searched the Cochrane Injuries Group's specialised register, CENTRAL, MEDLINE, EMBASE, National Research Register, LILACs, Zetoc, Web of Knowledge and Current Controlled Trials. We also searched the internet and checked the reference lists of relevant papers to identify any further studies. The searches were conducted in March 2007. SELECTION CRITERIA Randomised controlled trials of beta-2 receptor antagonists versus placebo for TBI. DATA COLLECTION AND ANALYSIS Two authors independently screened search results and assessed the full texts of potentially relevant studies for inclusion. Data were extracted and methodological quality was examined. Relative risks (RR) and 95% confidence intervals (CIs) were calculated and data were pooled using a fixed effect model. MAIN RESULTS Three studies were included, involving 178 participants. All three studies reported the effects of beta-2 receptor antagonists on mortality. The pooled RR for mortality was 0.63 (95% CI 0.36 to 1.10). Two studies measured disability, the RR of death or severe disability with beta-2 receptor antagonists was 0.81 (95% CI 0.59 to 1.09). Two studies measured the effect on intracranial pressure (ICP), although in only one did this finding reach statistical significance. There was no evidence for the presence of heterogeneity. AUTHORS' CONCLUSIONS There is no reliable evidence that beta-2 receptor antagonists are effective in reducing mortality or disability after TBI. Further well conducted randomised controlled trials are required.
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Affiliation(s)
- K Ker
- London School of Hygiene and Tropical Medicine, Nutrition & Public Health Intervention Research Unit, Room 280, North Courtyard, Keppel Street, London, UK, WC1E 7HT.
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