1
|
Kaneko K, Tsutsumi S, Fujita D, Sugiura-Ogasawara M, Mitsuda N, Matsubara K, Atsumi T, Inoue E, Takimoto T, Murashima A. Intravenous immunoglobulin treatment for obstetric antiphospholipid syndrome refractory to conventional therapy: A single-arm, open-labelled multicentre clinical trial. Mod Rheumatol 2024; 34:515-522. [PMID: 37340865 DOI: 10.1093/mr/road062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 06/10/2023] [Accepted: 06/18/2023] [Indexed: 06/22/2023]
Abstract
OBJECTIVES The objective of the study was to compare the efficacy of intravenous immunoglobulin (IVIG) therapy for obstetric antiphospholipid syndrome (APS) refractory to conventional treatment. METHODS We conducted a single-arm, open-label multicentre clinical intervention trial. The enrolled criteria were patients with refractory APS who had a history of still or premature birth before 30 weeks of gestational age, even though they had been treated with conventional treatment, i.e. heparin and low-dose aspirin. After confirming the foetal heartbeats, a single course of IVIG (0.4 g/kg body weight daily for 5 days) was added to conventional treatment. The primary outcome was a live birth ratio of >30 weeks of gestational period, and the secondary outcome included improving pregnancy outcomes compared to previous pregnancy. RESULTS Twenty-five per cent of patients (2 of 8 cases) achieved a live birth after the 30th week of pregnancy by IVIG-only add-on treatment, which is the same prevalence as the historical control. However, by adding other second-line therapy to IVIG and conventional treatment, further three patients (37.5%) achieved improvements in pregnancy outcome compared to previous treatments. In total, five patients (62.5%) were able to achieve preferable pregnancy outcomes through combination treatment including IVIG. CONCLUSIONS This clinical trial could not demonstrate the efficacy of IVIG-only add-on therapy at improving the pregnancy outcomes of patients with obstetric APS refractory to conventional treatment. However, the combination of IVIG with rituximab or statins adding to conventional treatment improved pregnancy outcomes and resulted in more live births. Further studies are needed to investigate the efficacy of multi-targeted therapy to treat obstetric refractory APS.
Collapse
Affiliation(s)
- Kayoko Kaneko
- Division of Maternal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Seiji Tsutsumi
- Department of Obstetrics and Gynecology, Yamagata University Hospital, Yamagata, Japan
| | - Daisuke Fujita
- Department of Obstetrics and Gynecology, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Mayumi Sugiura-Ogasawara
- Department of Obstetrics and Gynecology, Nagoya City University, Graduate School of Medical Science, Nagoya, Japan
| | - Nobuaki Mitsuda
- Department of Obstetrics and Gynecology, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Keiichi Matsubara
- Department of Regional Pediatrics and Perinatology, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Tatsuya Atsumi
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Eisuke Inoue
- Showa University Research Administration Center, Showa University, Tokyo, Japan
| | - Tetsuya Takimoto
- Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
| | - Atsuko Murashima
- Division of Maternal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| |
Collapse
|
2
|
Liebrecht LK, Khoraki J, Li R, Archambault C, Bane J, Deitch R, Broadway M, Eldering G, Mangino MJ. Metabolic Tissue Swelling and Local Microcirculation in Splanchnic Artery Occlusion Shock: Implications for Critical Illness. J Pharmacol Exp Ther 2024; 388:27-36. [PMID: 37739805 PMCID: PMC10765417 DOI: 10.1124/jpet.123.001831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 09/01/2023] [Accepted: 09/08/2023] [Indexed: 09/24/2023] Open
Abstract
Trauma is a leading cause of death in the United States. Advancements in shock resuscitation have been disappointing because the correct upstream mechanisms of injury are not being targeted. Recently, significant advancements have been shown using new cell-impermeant molecules that work by transferring metabolic water from swollen ischemic cells to the capillary, which restores tissue perfusion by microcirculatory decompression. The rapid normalization of oxygen transfer improves resuscitation outcomes. Since poor resuscitation and perfusion of trauma patients also causes critical illness and sepsis and can be mimicked by ischemia-reperfusion of splanchnic tissues, we hypothesized that inadequate oxygenation of the gut during trauma drives development of later shock and critical illness. We further hypothesized that this is caused by ischemia-induced water shifts causing compression no-reflow. To test this, the superior mesenteric artery of juvenile anesthetized swine was occluded for 30 minutes followed by 8 hours of reperfusion to induce mild splanchnic artery occlusion (SAO) shock. One group received the impermeant polyethylene glycol 20,000 Da (PEG-20k) that prevents metabolic cell swelling, and the other received a lactated Ringer's vehicle. Survival doubled in PEG-20k-treated swine along with improved macrohemodynamics and intestinal mucosal perfusion. Villus morphometry and plasma inflammatory cytokines normalized with impermeants. Plasma endotoxin rose over time after reperfusion, and impermeants abolished the rise. Inert osmotically active cell impermeants like PEG-20k improve intestinal reperfusion injury, SAO shock, and early signs of sepsis, which may be due to early restoration of mucosal perfusion and preservation of the septic barrier by reversal of ischemic compression no-reflow. SIGNIFICANCE STATEMENT: Significant advancements in treating shock and ischemia have been disappointing because the correct upstream causes have not been targeted. This study supports that poor tissue perfusion after intestinal ischemia from shock is caused by capillary compression no-reflow secondary to metabolic cell and tissue swelling since selectively targeting this issue with novel polyethylene glycol 20,000 Da-based cell-impermeant intravenous solutions reduces splanchnic artery occlusion shock, doubles survival time, restores tissue microperfusion, and preserves gut barrier function.
Collapse
Affiliation(s)
- Loren K Liebrecht
- Departments of Surgery (L.K.L., J.K., R.L., C.A., J.B., R.D., M.J.M.), Respiratory Therapy (M.B.), and Physiology and Biophysics (M.J.M.), Virginia Commonwealth University, School of Medicine, Richmond, Virginia and Perfusion Medical, Inc. (L.K.L., G.E., M.J.M.), Reston, Virginia
| | - Jad Khoraki
- Departments of Surgery (L.K.L., J.K., R.L., C.A., J.B., R.D., M.J.M.), Respiratory Therapy (M.B.), and Physiology and Biophysics (M.J.M.), Virginia Commonwealth University, School of Medicine, Richmond, Virginia and Perfusion Medical, Inc. (L.K.L., G.E., M.J.M.), Reston, Virginia
| | - Ru Li
- Departments of Surgery (L.K.L., J.K., R.L., C.A., J.B., R.D., M.J.M.), Respiratory Therapy (M.B.), and Physiology and Biophysics (M.J.M.), Virginia Commonwealth University, School of Medicine, Richmond, Virginia and Perfusion Medical, Inc. (L.K.L., G.E., M.J.M.), Reston, Virginia
| | - Caitlin Archambault
- Departments of Surgery (L.K.L., J.K., R.L., C.A., J.B., R.D., M.J.M.), Respiratory Therapy (M.B.), and Physiology and Biophysics (M.J.M.), Virginia Commonwealth University, School of Medicine, Richmond, Virginia and Perfusion Medical, Inc. (L.K.L., G.E., M.J.M.), Reston, Virginia
| | - John Bane
- Departments of Surgery (L.K.L., J.K., R.L., C.A., J.B., R.D., M.J.M.), Respiratory Therapy (M.B.), and Physiology and Biophysics (M.J.M.), Virginia Commonwealth University, School of Medicine, Richmond, Virginia and Perfusion Medical, Inc. (L.K.L., G.E., M.J.M.), Reston, Virginia
| | - Rebecca Deitch
- Departments of Surgery (L.K.L., J.K., R.L., C.A., J.B., R.D., M.J.M.), Respiratory Therapy (M.B.), and Physiology and Biophysics (M.J.M.), Virginia Commonwealth University, School of Medicine, Richmond, Virginia and Perfusion Medical, Inc. (L.K.L., G.E., M.J.M.), Reston, Virginia
| | - Michael Broadway
- Departments of Surgery (L.K.L., J.K., R.L., C.A., J.B., R.D., M.J.M.), Respiratory Therapy (M.B.), and Physiology and Biophysics (M.J.M.), Virginia Commonwealth University, School of Medicine, Richmond, Virginia and Perfusion Medical, Inc. (L.K.L., G.E., M.J.M.), Reston, Virginia
| | - Gerard Eldering
- Departments of Surgery (L.K.L., J.K., R.L., C.A., J.B., R.D., M.J.M.), Respiratory Therapy (M.B.), and Physiology and Biophysics (M.J.M.), Virginia Commonwealth University, School of Medicine, Richmond, Virginia and Perfusion Medical, Inc. (L.K.L., G.E., M.J.M.), Reston, Virginia
| | - Martin J Mangino
- Departments of Surgery (L.K.L., J.K., R.L., C.A., J.B., R.D., M.J.M.), Respiratory Therapy (M.B.), and Physiology and Biophysics (M.J.M.), Virginia Commonwealth University, School of Medicine, Richmond, Virginia and Perfusion Medical, Inc. (L.K.L., G.E., M.J.M.), Reston, Virginia
| |
Collapse
|
3
|
Pichon TJ, White NJ, Pun SH. ENGINEERED INTRAVENOUS THERAPIES FOR TRAUMA. CURRENT OPINION IN BIOMEDICAL ENGINEERING 2023; 27:100456. [PMID: 37456984 PMCID: PMC10343715 DOI: 10.1016/j.cobme.2023.100456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
Trauma leading to severe hemorrhage and shock on average kills patients within 3 to 6 hours after injury. With average prehospital transport times reaching 1-6 hours in low- to middle-income countries, stopping the bleeding and reversing hemorrhagic shock is vital. First-generation intravenous hemostats rely on traditional drug delivery platforms, such as self-assembling systems, fabricated nanoparticles, and soluble polymers due to their active targeting, biodistribution, and safety. We discuss some challenges translating these therapies to patients, as very few have successfully made it through preclinical evaluation in large-animals, and none have translated to the clinic. Finally, we discuss the physiology of hemorrhagic shock, highlight a new low volume resuscitant (LVR) PEG-20k, and end with considerations for the rational design of LVRs.
Collapse
Affiliation(s)
- Trey J. Pichon
- Department of Bioengineering and Molecular Engineering and Sciences Institute, University of Washington, 3720 15 Avenue NE, Box 355061, Seattle, Washington 98105, United States
- Resuscitation Engineering Science Unit (RESCU), Harborview Research and Training Building, Seattle, Washington 98104, United States
| | - Nathan J. White
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle, Washington 98105, United States
- Resuscitation Engineering Science Unit (RESCU), Harborview Research and Training Building, Seattle, Washington 98104, United States
| | - Suzie H. Pun
- Department of Bioengineering and Molecular Engineering and Sciences Institute, University of Washington, 3720 15 Avenue NE, Box 355061, Seattle, Washington 98105, United States
- Resuscitation Engineering Science Unit (RESCU), Harborview Research and Training Building, Seattle, Washington 98104, United States
| |
Collapse
|
4
|
Superior Survival Outcomes of a Polyethylene Glycol-20k Based Resuscitation Solution in a Preclinical Porcine Model of Lethal Hemorrhagic Shock. Ann Surg 2020; 275:e716-e724. [PMID: 32773641 DOI: 10.1097/sla.0000000000004070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare early outcomes and 24-hour survival after LVR with the novel polyethylene glycol-20k-based crystalloid (PEG-20k), WB, or hextend in a preclinical model of lethal HS. BACKGROUND Posttraumatic HS is a major cause of preventable death. Current resuscitation strategies focus on restoring oxygen-carrying capacity (OCC) and coagulation with blood products. Our lab shows that PEG-20k is an effective non-sanguineous, LVR solution in acute models of HS through mechanisms targeting cell swelling-induced microcirculatory failure. METHODS Male pigs underwent splenectomy followed by controlled hemorrhage until lactate reached 7.5-8.5 mmol/L. They were randomized to receive LVR with PEG-20k, WB, or Hextend. Surviving animals were recovered 4 hours post-LVR. Outcomes included 24-hour survival rates, mean arterial pressure, lactate, hemoglobin, and estimated intravascular volume changes. RESULTS Twenty-four-hour survival rates were 100%, 16.7%, and 0% in the PEG-20k, WB, and Hextend groups, respectively (P = 0.001). PEG-20k significantly restored mean arterial press, intravascular volume, and capillary perfusion to baseline, compared to other groups. This caused complete lactate clearance despite decreased OCC. Neurological function was normal after next-day recovery in PEG-20k resuscitated pigs. CONCLUSION Superior early and 24-hour outcomes were observed with PEG-20k LVR compared to WB and Hextend in a preclinical porcine model of lethal HS, despite decreased OCC from substantial volume-expansion. These findings demonstrate the importance of enhancing microcirculatory perfusion in early resuscitation strategies.
Collapse
|