Enhancement of hypothermic heart preservation with fructose 1, 6-diphosphate

Protective effects of fructose-1,6-bisphosphate postconditioning on myocardial ischaemia-reperfusion injury in patients undergoing valve replacement: a randomized, double-blind, placebo-controlled clinical trial

OBJECTIVES

Pharmacological postconditioning can protect against myocardial ischaemia-reperfusion injury during cardiac surgery with extracorporeal circulation. The aim of this study was to observe the protective effects of fructose-1,6-bisphosphate (FDP) postconditioning on myocardial ischaemia-reperfusion injury in patients undergoing cardiac valve replacement with extracorporeal circulation.

METHODS

Patients undergoing elective mitral valve replacement and/or aortic valve replacement were divided into normal saline postconditioning group (NS group) and FDP postconditioning group (FDP group). The primary outcome was the plasma concentration of creatine kinase-MB (CK-MB). The secondary outcomes were the plasma concentrations of lactate dehydrogenase, CK, high-sensitivity C-reactive protein, alpha-hydroxybutyrate dehydrogenase and cardiac troponin I, the spontaneous cardiac rhythm recovery profile, the extracorporeal circulation time and duration of surgery, intensive care unit and postoperative hospitalization.

RESULTS

Forty patients were randomly assigned to receive intervention and included in the analysis. The serum concentrations of CK-MB, lactate dehydrogenase, CK, cardiac troponin I, alpha-hydroxybutyrate dehydrogenase and high-sensitivity C-reactive protein at T1∼4 were lower in the FDP group than in the NS group (P < 0.001). Compared with the NS group, the dosage of dopamine administered 1-90 min after cardiac resuscitation, the spontaneous cardiac rhythm recovery time and the incidence of ventricular fibrillation were lower in the FDP group (P < 0.001, P < 0.001 and P = 0.040, respectively). The values of ST- changes were increased more significantly in the NS group than in the FDP group (median [standard deviation] 1.3 [0.3] mm vs 0.7 [0.2] mm; P < 0.001). Compared with the NS group, the time of recovery of ST-segment deviations was shorter in the FDP group (50.3 [12.3] min vs 34.6 [6.9] min; P < 0.001).

CONCLUSIONS

The FDP postconditioning could improve both myocardial ischaemia-reperfusion injury and the spontaneous cardiac rhythm recovery during cardiac valve surgery with extracorporeal circulation.

A Roadmap to Cardiac Tissue-Engineered Construct Preservation: Insights from Cells, Tissues, and Organs

Worldwide, over 26 million patients suffer from heart failure (HF). One strategy aspiring to prevent or even to reverse HF is based on the transplantation of cardiac tissue-engineered (cTE) constructs. These patient-specific constructs aim to closely resemble the native myocardium and, upon implantation on the diseased tissue, support and restore cardiac function, thereby preventing the development of HF. However, cTE constructs off-the-shelf availability in the clinical arena critically depends on the development of efficient preservation methodologies. Short- and long-term preservation of cTE constructs would enable transportation and direct availability. Herein, currently available methods, from normothermic- to hypothermic- to cryopreservation, for the preservation of cardiomyocytes, whole-heart, and regenerative materials are reviewed. A theoretical foundation and recommendations for future research on developing cTE construct specific preservation methods are provided. Current research suggests that vitrification can be a promising procedure to ensure long-term cryopreservation of cTE constructs, despite the need of high doses of cytotoxic cryoprotective agents. Instead, short-term cTE construct preservation can be achieved at normothermic or hypothermic temperatures by administration of protective additives. With further tuning of these promising methods, it is anticipated that cTE construct therapy can be brought one step closer to the patient.

Protection of rat cardiac myocytes by fructose-1,6-bisphosphate and 2,3-butanedione

Earlier studies by our group showed that fructose-1,6-bisphosphate (FBP) enhances the hypothermic preservation of rat cardiac myocytes and the functional recovery of animal hearts after hypothermic storage. However, the mechanisms involved were not clear. We extended the cardiomyocyte studies by testing whether the FBP effects were due to chelation of extracellular calcium, leading to lower intracellular levels. We also tested effects of 2,3-butanedione monoxime (BDM), pyruvate, and adenine nucleotide precursors. Cardiomyocytes were incubated in ischemic suspension at 3°C, and aliquots examined over 48 to 72 hours for retention of rod-shaped morphology, a measure of viability. Cytosolic Ca²⁺ levels were measured in some experiments. FBP at 5 mM reduced the death rate even when added after one or two days of incubation. It caused cytosolic calcium levels that were 33% lower than controls in freshly-isolated cells and 70% lower after one day of incubation. EGTA protected against cell death similarly to FBP. These results indicated that one of the mechanisms by which FBP exerts protective effects is through chelation of extracellular calcium. BDM was strongly protective and reduced cytosolic calcium by 30% after one day of incubation. As with FBP, BDM was effective when added after one or two days of incubation. BDM may be useful in combination with FBP in preserving heart tissue. Pyruvate, adenine, and ribose provided little or no protection during hypothermia.

Characterization of the high-affinity uptake of fructose-1,6-bisphosphate by cardiac myocytes

Previously, we reported that fructose-1,6-bisphosphate (FBP) was taken up by rat cardiac myocytes by two processes: a component that was saturable at micromolar levels and a nonsaturable component that dominated at millimolar levels. Here, we continued to characterize the saturable high-affinity component, with the aim of identifying the physiological substrate and role for this activity. ATP, ADP, and AMP inhibited the uptake of FBP with apparent affinities of 0.2-0.5 mM. Fumarate and succinate were very weak inhibitors. Several phosphorylated sugars (ribulose-1,5-phosphate, fructose-1-phosphate, ribose-5-phosphate, and inositol-2-phosphate) inhibited FBP uptake with apparent affinities of 40-500 μM. As in our previous study, no tested compound appeared to bind as well as FBP. The data suggest that the best ligands have two phosphoryl groups separated by at least 8 Å. The rates of FBP uptake were measured from 3° to 37°. The calculated activation energy was 15-50 kJ/mol, similar to other membrane transport processes. Uptake of FBP was tested in several types of cells other than cardiac myocytes, and compared to the uptake of 2-deoxyglucose and L: -glucose. While FBP uptake in excess of that of L: -glucose was observed in some cells, in no case was the uptake as high as in cardiac myocytes. The physiological substrate and role for the high-affinity FBP uptake activity remain unknown.

Fructose-1,6-bisphosphate enhances hypothermic preservation of cardiac myocytes

BACKGROUND

Previous studies from our project found that fructose-1,6-bisphosphate (FBP) enhanced the functional recovery of animal hearts after hypothermic preservation, and that rat cardiac myocytes take up FBP at 3 degrees C. In this study we tested the effects of FBP, as well as other compounds related to glycolysis and pyruvate oxidation, on the hypothermic preservation of myocytes.

METHODS

Isolated myocytes were incubated in ischemic suspensions at 3 degrees C, and aliquots examined over 72 hours for retention of rod-shaped morphology. In some experiments adenine nucleotide levels were measured by high-performance liquid chromatography (HPLC).

RESULTS

FBP at 1 to 10 mmol/liter markedly reduced the death rate (65% reduction at 5 mmol/liter). Glucose at 2 to 10 mmol/liter was less beneficial (20% reduction). Insulin increased the death rate by about 25% when present alone, and it did not enhance the beneficial effects of FBP or glucose. Dichloroacetate (DCA), which stimulates pyruvate dehydrogenase, had little effect at 0.5 to 10 mmol/liter. Glucose and DCA did not increase the beneficial effects of FBP. After 6 to 24 hours of hypothermia, FBP- and glucose-treated cells had 25% to 50% higher ATP levels and 10% to 20% higher ATP:ADP ratios than untreated cells. Effects of FBP on preservation of morphology were much greater than effects on ATP levels.

CONCLUSIONS

The results suggest that the effects of FBP and glucose were through glycolytic ATP production rather than through sugar oxidation via pyruvate dehydrogenase. The divergence in effects on preservation and effects on ATP suggests a role for a sub-cellular compartment of ATP in preservation.

Fructose-1,6 diphosphate as a protective agent for experimental ischemic acute renal failure

Cold ischemia time is a risk factor for the development of acute renal failure in the immediate post-transplant period. In this study, we aimed to determine if intravenous fructose-1,6-diphosphate (FDP), given before nephrectomy, attenuates renal cell injury in a cold ischemia model. Male adult Wistar rats were subjected to infusion of either FDP 350 mg/kg (group F, n=6), an equal volume of 0.9% NaCl (group S, n=6), an equal volume/osmolality of mannitol (group M, n=6) or no infusion (group C, n=7). Kidneys were then perfused in situ with Collins solution and nephrectomy was performed. Other kidney slices were stored in Collins solution at 4 degrees C. Adenosine triphosphate (ATP) levels and lactate dehydrogenase (LDH) release were examined at 0, 24, 48 and 72 h. Other slices, obtained after 50 min immersion in Collins solution at 37 degrees C, were frozen for characterization of cytoskeletal preservation using phalloidin-FITC staining. Apical fluorescence intensity of proximal tubule cells, indicative of the F-actin concentration, was measured in a fluorescence microscope interfaced with computer image analysis system. Adenosine triphosphate levels, after up to 72 h of tissue incubation, were higher (P<0.05) in the FDP group when compared to other groups. In addition, LDH release was smaller (P<0.0001) in the FDP group. The F-actin concentration of proximal tubule cells cells was greater in the FDP group (P<0.0001). Results indicate that FDP is a useful tool to increase tissue viability in a rat kidney subjected to cold ischemia, by maintaining ATP cell content, decreasing LDH release and preventing microfilament disruption of proximal tubule cells.

Supplementation of nucleoside-nucleotide mixture enhances functional recovery and energy metabolism following long-time hypothermic heart preservation

BACKGROUND

OG-VI, a well-balanced mixture of nucleoside and nucleotides, has been demonstrated to have a favorable effect on energy metabolism. In this study, we tested the hypothesis that addition of OG-VI to the University of Wisconsin solution can improve the cardiac functional recovery following long-time hypothermic preservation.

MATERIALS AND METHODS

Forty-two male Wistar rats were randomized into four groups. After 30-min of isolated working heart perfusion, the rat hearts were arrested with St. Thomas cardioplegic solution and preserved at 4 degrees C in saline, OG-VI, UW, and UW+OG-VI, respectively. After 12-h of preservation, the hearts were reperfused for 60-min during which the recovery of cardiac functions were monitored continuously. Myocardial adenine nucleotides were analyzed using high-performance liquid chromomatograph.

RESULTS

In the UW+OG-VI group, the recovery of cardiac output, coronary flow, aortic flow, rate-pressure product, left ventricle stroke volume, and stroke work were significantly higher than other groups (P < 0.05). Furthermore, all phosphate high-energy compounds were significantly higher in the UW+OG-VI group than in the other groups (P < 0.05). Coronary vascular resistance and myocardial wet/dry weight ratio were obviously lower in the UW+OG-VI group, compared to the other groups (P < 0.05).

CONCLUSIONS

Heart function was better recovered when nucleoside-nucleotide mixture was added to UW solution during long-time hypothermic rat heart preservation. The mechanism is not totally clear, but enhancement of high-energy phosphate production is possible.

Apoptosis inhibition during preservation by fructose-1,6-diphosphate and theophylline in rat intestinal transplantation

OBJECTIVE

This study evaluated the effect of fructose-1,6-diphosphate (FDP), theophylline, or the addition of both together to the preservation solution (University of Wisconsin [UW]) on apoptosis during preservation and the effect of apoptosis minimization on the early reperfusion period after transplantation.

DESIGN

Prospective, randomized, and controlled animal study.

SETTING

Laboratory of a research institute.

SUBJECT

Male Wistar rats.

INTERVENTIONS

The jejunum was isolated and preserved for 6 hrs in UW solution. FDP and theophylline were added to the UW solution to evaluate their effects on apoptosis both alone and together. The role of adenosine with respect to FDP was examined by increasing endogenous adenosine. In addition, rats were subjected to intestinal transplantation for the evaluation of the effect of apoptosis on bacterial translocation, histology, and neutrophil infiltration after reperfusion.

MEASUREMENTS AND MAIN RESULTS

Caspase-3 activity, assayed both in vitro or by cleaved caspase-3 levels in Western blots or immunohistochemically, and the number of terminal deoxynucleotidyl transferase-mediated biotin-dUTP nick-end labeling (TUNEL)-positive cells decreased with FDP and with theophylline addition to UW solution. Increase of endogenous adenosine reversed the antiapoptotic effect of FDP. FDP and theophylline together demonstrated a more pronounced antiapoptotic effect and prevented bacterial translocation after transplantation.

CONCLUSION

Supplementary FDP to UW solution decreased apoptosis through an adenosine-independent mechanism. Addition of theophylline to UW solution decreased both apoptosis and bacterial translocation. Concomitant theophylline and FDP addition to preservation solution is recommended to maintain low levels of apoptosis during intestinal hypothermic preservation and to decrease bacterial translocation.

Permeability of fructose-1,6-bisphosphate in liposomes and cardiac myocytes

Fructose-1,6-bisphosphate (FBP) helps preserve heart and other organs under ischemic conditions. Previous studies indicated that it can be taken up by various cell types. Here we extended observations from our group that FBP could penetrate artificial lipid bilayers and be taken up by cardiac myocytes, comparing the uptake of FBP to that of L-glucose. Using liposomes prepared by the freeze-thaw method, FBP entered about 200-fold slower than L-glucose. For liposomes of either soybean or egg lipids, 50 mM FBP enhanced the permeability of FBP itself, with little effect on general permeability (measured by uptake of L-glucose). In experiments with isolated cardiac myocytes at 21 degrees C, FBP uptake exceeded the uptake of L-glucose by several fold and appeared to equilibrate by 60 min. There was both a saturable component at micromolar levels and a nonsaturable component which dominated at millimolar levels. The saturable component was inhibited by Pi and by other phosphorylated sugars, though with lower affinity than FBP. Both saturable and nonsaturable uptakes were also observed at 3 degrees C. The results indicate that FBP enters myocytes not by simple penetration through the lipid bilayer, but via at least two distinct protein-dependent processes. The uptake could lead to intracellular effects important in hypothermic heart preservation.

Using fructose-1,6-diphosphate during hypothermic rabbit-heart preservation: a high-energy phosphate study

BACKGROUND

In this study, we evaluated the effects of fructose-1,6-diphosphate (FDP) on high-energy phosphate metabolism during 18-hour hypothermic rabbit-heart preservation.

METHODS

Under general anesthesia and artificial ventilation, hearts from 42 adult New Zealand white rabbits were harvested, flushed, and preserved in St. Thomas solution at 4(o)C for 18 hours. In the study group (n = 15), FDP (5 mmol/liter) was added to the St. Thomas solution, whereas in the control group (n = 17), fructose (5 mmol/liter) was added. Another 10 hearts did not undergo hypothermic storage, but were used as the normal group for high-energy phosphate concentration comparison.

RESULTS

After 18 hours of hypothermic preservation, myocardial high-energy phosphate content decreased in both preservation groups. In the study group, left ventricular adenosine triphosphate (ATP) content was 33% of that in the normal hearts, but in the control group, ATP decreased to 14% of normal. Adenosine diphosphate (ADP) content, energy charge, and ATP-to-ADP ratio showed similar decreases. The high-energy phosphate profile (content in the atria and ventricles and the ratio of ATP to ADP to AMP) was maintained in the study group but not in the control group. High-energy phosphate metabolites such as inosine monophosphate (IMP), inosine, and hypoxanthine increased in both preservation groups, but the increase was more prominent in the control group.

CONCLUSION

Adding FDP to St. Thomas solution attenuated the depletion of high-energy phosphate concentration in the preserved hearts. This difference was especially prominent in the left and right ventricles. The protective effect of FDP during hypothermic heart preservation deserves further study.

Destabilizing effects of fructose-1,6-bisphosphate on membrane bilayers

Fructose-1,6-bisphosphate (FBP) is a high-energy glycolytic intermediate that decreases the effects of ischemia; it has been used successfully in organ perfusion and preservation. How the cells utilize external FBP to increase energy production and the mechanism by which the molecule crosses the membrane bilayer are unclear. This study examined the effects ofFBP on membrane bilayer permeability, membrane fluidity, phospholipid packing, and membrane potential to determine how FBP crosses the membrane bilayer. Large unilamellar vesicles composed of egg phosphatidylcholine (Egg PC) were made and incubated with 50 mM FBP spiked with 14C-FBP at 30 degrees C. Uptake of FBP was significant (P < 0.05) and dependent on the lipid concentration, suggesting that FBP affects membrane bilayer permeability. With added calcium (10 mM), FBP uptake by lipid vesicles decreased significantly (P < 0.05). Addition of either 5 or 50 mM FBP led to a significant increase (P < 0.05) in Egg PC carboxyfluorescein leakage. We hypothesized that the membrane-permeabilizing effects of FBP may be due to a destabilization of the membrane bilayer. Small unilamellar vesicles composed of dipalmitoyl pC (DPPC) were made containing either diphenyl-1,3,5-hexatriene (DPH) or trimethylammmonia-DPH (TMA-DPH) and the effects of FBP on the fluorescence anisotropy (FA) of the fluorescent labels examined. FBP caused a significant decrease in the FA of DPH in the liquid crystalline state of DPPC (P < 0.05), had no effect on FA of TMA-DPH in the liquid crystalline state of DPPC, but increased the FA of TMA-DPH in the gel state of DPPC. From phase transition measurements with DPPC/DPH or TMA-DPH, we calculated the slope of the phase transition as an indicator of the cooperativity of the DPPC molecules. FBP significantly decreased the slope, suggesting a decrease in fatty acyl chain interaction (P< 0.05). The addition of 50 mM FBP caused a significant decrease (P< 0.05) in the liquid crystalline/gel state fluorescence ratio of merocyanine 540, indicating increased head-group packing. To determine what effects these changes would have on cellular membranes, we labeled human endothelial cells with the membrane potential probe 3,3'-dipropylthiacarbocyanine iodide (DiSC3) and then added FBP. FBP caused a significant, dose-dependent decrease in DiSC3 fluorescence, indicating membrane depolarization. We suggest that FBP destabilizes membrane bilayers by decreasing fatty acyl chain interaction, leading to significant increases in membrane permeability that allow FBP to diffuse into the cell where it can be used as a glycolytic intermediate.

Phosphate supplementation for hypophosphataemia and parenteral nutrition

Routine detection and treatment of acute hypophosphataemia is important in intensive care unit and many other hospitalized patients, but metabolic bone disease and hypophosphataemia are still experienced as a result of parenteral nutrition. A significantly common problem that faces the compounding pharmacist when formulating parenteral nutrition regimens is the difficulty associated with the successful avoidance of calcium phosphate precipitation. Although incorporation of the normal calcium and phosphate requirements into regimens for metabolically stable adults is usually achievable, it can prove impossible in paediatric and neonatal mixtures when using the standard inorganic sources that are currently licensed for use in the UK and USA. In other countries, where organic compounds are routinely available, this problem does not exist.

The uptake and metabolism of fructose-1,6-diphosphate in rat cardiomyocytes

Fructose-1,6-diphosphate (FDP) is a glycolytic intermediate which has been theorized to increase the metabolic activity of ischemic tissues. Here we examine the effects of externally applied FDP on cardiomyocyte uptake and metabolism. Adult rat cardiomyocytes were isolated and exposed to varying concentrations (0, 5, 25 and 50 mM) of FDP for either 1, 16 or 24 h of hypoxia (95% N2/5% CO2), each time period followed by a 1 h reoxygenation (95% air/5% CO2). The uptake of FDP by rat cardiomyocytes was more concentration-dependent than time-dependent. Furthermore, the uptake of FDP by the cardiomyocytes was similar in the hypoxia and normoxia treated cells. Alamar Blue, a redox indicator that is sensitive to metabolic activity, was used to monitor the effects of the FDP on cardiomyocyte metabolism. In the 1 h hypoxia or normoxia group, the 5, 10 and 25 mM FDP showed a significant increase in metabolism compared to the control cells. When the length of hypoxia was extended to 16 h, all doses of FDP were greater than control. And at the 24 h hypoxia or normoxia time period, only the 10, 25 and 50 mM FDP groups were greater than control. The results indicate a non-linear trend between the external concentration of FDP and the changes noted in metabolism. The findings from this study indicate that a narrow concentration range between 5-10 mM augments cardiomyocyte metabolism, but higher or lower doses may have little additional affect.

Fructose-1,6-diphosphate and a glucose-free solution enhances functional recovery in hypothermic heart preservation

BACKGROUND

Fructose-1,6-diphosphate (FDP) has been shown to protect tissue during hypoxia under various ischemic conditions, including isolated heart perfusion. We tested the hypothesis that adding FDP to St. Thomas solution can extend hypothermic heart preservation time.

METHODS

Sixteen adult Sprague-Dawley rats were used. Under general anesthesia, the hearts were removed and preserved at 4 degrees C in St. Thomas solution (30 ml/kg) for 12 hours. FDP (5 mM) was added to the St. Thomas solution in the study group (n = 8), whereas no FDP was used in the control group (n = 10). The hearts were reperfused after 12 hours of preservation using a working heart model.

RESULTS

In the study group, cardiac output ranged from 13.00 +/- 2.34 to 17.66 +/- 1.71 ml/min, maximum aortic flow was 3.40 +/- 1.99 to 9.26 +/- 1.72 ml/min, left ventricular stroke volume ranged from 0.074 +/- 0.014 to 0.092 +/- 0.009 ml, left ventricular stroke work ranged from 6.22 +/- 0.39 to 7.95 +/- 0.44 ml/mmHg, and maximum left ventricular generated power was 14.38 +/- 2.94 to 20.16 +/- 2.49 Joules/min. All of these parameters were higher than those in the control group (p < 0.001). Coronary vascular resistance and myocardial tissue wet/dry weight ratio were lower in the study group than in the control group (p < 0.05).

CONCLUSIONS

Heart function was better preserved when FDP was added to St. Thomas solution during hypothermic rat heart preservation. The mechanism is not totally clear, but enhancement of high-energy phosphate production during ischemia is possible. Key words: heart, procurement, hypothermia, fructose-1,6-diphosphate.