Human urinary kallidinogenase in acute ischemic stroke: A single-arm, multicenter, phase IV study (RESK study)

Recombinant Human Tissue Kallikrein-1 for Treating Acute Ischemic Stroke and Preventing Recurrence

Novel strategies are needed for the treatment of acute ischemic stroke when revascularization therapies are not clinically appropriate or are unsuccessful. rKLK1 (recombinant human tissue kallikrein-1), a bradykinin-producing enzyme, offers a promising potential solution. In animal studies of acute stroke, there is a marked 36-fold increase in bradykinin B2 receptor on brain endothelial cells of the ischemic region. Due to this environment, rKLK1-generated bradykinin will exert a potent local vasodilation and increase brain perfusion via 3 synergistic signaling pathways downstream to the B2 receptor. Because of its preferential effect on ischemic tissue, systemic adverse effects such as hypotension are avoided with proper dosing. In addition, with initial vasodilation through recruitment of preexisting collaterals, rKLK1 promotes long-term benefit of brain perfusion by promoting new collateral formation. With an extended course of therapy for weeks after acute ischemic stroke, these multifaceted effects may also reduce the risk of stroke recurrence. A prior phase II trial demonstrated a favorable impact on clinical outcomes and recurrent strokes, particularly among patients who were not eligible for mechanical thrombectomy. A phase II/III trial has launched in this population, though opportunities for combination revascularization therapies deserve further investigation.

The effectiveness and safety of human urinary kallidinogenase in acute ischemic stroke patients undergoing endovascular therapy

The effectiveness and safety of human urinary kallidinogenase (HUK) in acute ischemic stroke (AIS) patients undergoing endovascular therapy (EVT) due to large vessel occlusion (LVO) was unclear. A pooled analysis was performed using individual data from the DEVT and RESCUE BT trials. Patients were divided into two groups based on HUK treatment. The primary outcome was the 90-day modified Rankin Scale (mRS) score. Safety outcomes included 90-day mortality and symptomatic intracranial hemorrhage (sICH) within 48 hours. A total of 1174 patients were included in the study. Of these, 150 (12.8%) patients received HUK. The adjusted common odds ratio (OR) of the mRS score was 1.458 (95% confidence interval [CI] = 1.072-1.983; p = 0.016) favoring HUK. The incidence of sICH (2.0% vs. 8.6%; adjusted OR: 0.198; 95% CI: 0.061-0.638; p = 0.007) and mortality (11.3% vs.18.5%; adjusted OR: 0.496; 95% CI: 0.286-0.862; p = 0.013) was lower in HUK group than non-HUK group. This association was consistent with propensity score-matching and the inverse probability of treatment weighting analysis. In conclusion, HUK was safe and associated with a preferable prognosis in AIS patients due to LVO in the anterior circulation.

The Role of the Complement System in Synaptic Pruning after Stroke

Stroke is a serious disease that can lead to local neurological dysfunction and cause great harm to the patient's health due to blood cerebral circulation disorder. Synaptic pruning is critical for the normal development of the human brain, which makes the synaptic circuit completer and more efficient by removing redundant synapses. The complement system is considered a key player in synaptic loss and cognitive impairment in neurodegenerative disease. After stroke, the complement system is over-activated, and complement proteins can be labeled on synapses. Microglia and astrocytes can recognize and engulf synapses through corresponding complement receptors. Complement-mediated excessive synaptic pruning can cause post-stroke cognitive impairment (PSCI) and secondary brain damage. This review summarizes the latest progress of complement-mediated synaptic pruning after stroke and the potential mechanisms. Targeting complement-mediated synaptic pruning may be essential for exploring therapeutic strategies for secondary brain injury (SBI) and neurological dysfunction after stroke.

Multimodal imaging evaluation of early neurological deterioration following acute ischemic stroke

Background

Early neurologic deterioration occurs in up to one-third of patients with acute ischemic stroke (IS), often leading to poor functional outcomes. At present, few studies have applied amide proton transfer (APT) imaging to the evaluation of early neurological deterioration (END). This study analyzed the value of computed tomography perfusion (CTP) combined with multimodal magnetic resonance imaging (MRI) in patients with acute IS with END.

Methods

This retrospective study included patients with acute IS who were admitted to the neurology inpatient department in a tertiary hospital from October 2021 to June 2023. Patients with acute IS underwent CTP within 24 hours of stroke onset and MRI [arterial spin labeling (ASL), susceptibility-weighted imaging (SWI), and APT] within 7 days. END was defined as an elevation of ≥2 points on the National Institute of Health Stroke Scale (NIHSS) within 7 days of stroke onset. Univariable and multivariable analyses were used to compare clinical and imaging biomarkers in patients with acute IS with and without END. The performance of potential biomarkers in distinguishing between the two groups was evaluated using receiver operating characteristic (ROC) curve analysis.

Results

Among the 70 patients with acute IS, 20 (29%) had END. After conducting univariable analysis, variables were selected for entry into a binary logistic regression analysis based on our univariable analysis results, previous research findings, clinical experience, and methodological standards. The results indicated that relative cerebral blood volume (CBV) on CTP, relative cerebral blood flow (CBF) on ASL, and relative signal intensity on amide proton transfer-weighted (APTw) imaging were independent risk factors for END. The areas under the ROC curves for these risk factors were 0.710 [95% confidence interval (CI): 0.559-0.861, P=0.006], 0.839 (95% CI: 0.744-0.933, P<0.001), and 0.804 (95% CI: 0.676-0.932, P<0.001), respectively. The combined area under the curve (AUC), sensitivity, and specificity of the four indices (0.941, 100%, and 78%, respectively) were higher than those of the four indices alone.

Conclusions

CTP combined with multi-modal MRI better evaluated hemodynamics, tissue metabolism, and other relevant patient information, providing an objective basis for the clinical assessment of patients with acute IS with END and facilitating the development of accurate and personalized treatment plans.

Recent advances in the discovery and development of drugs targeting the kallikrein-kinin system

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.

Cost-effectiveness of edaravone dexborneol versus human urinary kallidinogenase for acute ischemic stroke in China

BACKGROUND

Clinical trials have demonstrated the efficacy of edaravone dexborneol in the treatment of acute ischemic stroke. This study aims to determine the cost-effectiveness of edaravone dexborneol compared with human urinary kallidinogenase from China's healthcare system perspective.

METHODS

A combination of the decision tree and Markov model was constructed to evaluate the cost-effectiveness of edaravone dexborneol versus human urinary kallidinogenase in the treatment of acute ischemic stroke over a lifetime horizon. Efficacy data were derived from pivotal clinical trials of edaravone dexborneol and human urinary kallidinogenase (TASTE trial and RESK trial, respectively) and adjusted using matching-adjusted indirect comparison. Cost and health utility inputs were extracted from published literature and open databases. One-way deterministic sensitivity and probabilistic sensitivity analyses were performed to examine the robustness of the results.

RESULTS

Compared with human urinary kallidinogenase, edaravone dexborneol generated 0.153 incremental quality-adjusted life years (QALYs) with an incremental cost of ¥856, yielding an incremental cost-effectiveness ratio of ¥5,608 per QALY gained under the willingness-to-pay threshold (one-time gross domestic product per capita). Both one-way deterministic sensitivity analysis and probabilistic sensitivity analysis demonstrated the robustness of the base case results.

CONCLUSIONS

Edaravone dexborneol is a cost-effective treatment choice for acute ischemic stroke patients compared with human urinary kallidinogenase in China.

Efficacy of Urinary Kallidinogenase Plus Intravenous Recombinant Tissue Plasminogen Activator for Stroke Patients With Extended Window: A Retrospective Analysis

BACKGROUND

To assess the outcome of human urinary kallidinogenase (HUK) plus recombinant tissue plasminogen activator (rT-PA) intravenous thrombolysis for stroke patients with an extended time window(4.5 to 9 h).

METHODS

A total of 92 acute ischemic stroke patients who fulfilled the criteria were included in this study. All patients received basic treatment and intravenous rT-PA, and 49 patients received additional injections of HUK (HUK group) once a day for 14 consecutive days. Outcomes were indicated by the thrombolysis in cerebral infarction score as the primary endpoint and the National Institute of Health Stroke Scale, modified Rankin Scale, and Barthel Index as the secondary endpoints. The safety outcomes were the rate of symptomatic intracranial hemorrhage, bleeding, angioedema, and mortality.

RESULTS

The National Institute of Health Stroke Scale scores were significantly lower in the HUK group at hospital discharge (4.55 ± 3.78 vs 7.88 ± 7.31, P = 0.009) and day 90 (4.04 ± 3.51 vs 8.12 ± 9.53, P = 0.011). The improvements in the Barthel Index scores were more obvious in the HUK group. Patients in the HUK group achieved favorable functional independence (67.35% vs 46.51%; odds ratio: 2.37; 95% CI: 1.01-5.53) at 90 days. The recanalization rate of the HUK group was 64.10%, whereas that was 41.48% in the control group ( P = 0.050). The complete reperfusion rates were 42.9% and 23.3% in the HUK group and the control group, respectively. No significant differences were observed for adverse events between the two groups.

CONCLUSIONS

Combination therapy of HUK plus rT-PA in patients with acute ischemic stroke with an extended time window can safely improve their functional outcomes.

A comprehensive review of stroke-related signaling pathways and treatment in western medicine and traditional Chinese medicine

This review provides insight into the complex network of signaling pathways and mechanisms involved in stroke pathophysiology. It summarizes the historical progress of stroke-related signaling pathways, identifying potential interactions between them and emphasizing that stroke is a complex network disease. Of particular interest are the Hippo signaling pathway and ferroptosis signaling pathway, which remain understudied areas of research, and are therefore a focus of the review. The involvement of multiple signaling pathways, including Sonic Hedgehog (SHH), nuclear factor erythroid 2-related factor 2 (Nrf2)/antioxidant response element (ARE), hypoxia-inducible factor-1α (HIF-1α), PI3K/AKT, JAK/STAT, and AMPK in pathophysiological mechanisms such as oxidative stress and apoptosis, highlights the complexity of stroke. The review also delves into the details of traditional Chinese medicine (TCM) therapies such as Rehmanniae and Astragalus, providing an analysis of the recent status of western medicine in the treatment of stroke and the advantages and disadvantages of TCM and western medicine in stroke treatment. The review proposes that since stroke is a network disease, TCM has the potential and advantages of a multi-target and multi-pathway mechanism of action in the treatment of stroke. Therefore, it is suggested that future research should explore more treasures of TCM and develop new therapies from the perspective of stroke as a network disease.

Clinical efficacy analysis of butylphthalide combined with urinary kallidinogenase in treating chronic cerebral circulatory insufficiency

OBJECTIVE

To investigate the clinical effect of butylphthalide combined with urinary kallidinogenase in the treatment of chronic cerebral circulatory insufficiency (CCCI).

METHODS

A total of 102 CCCI patients admitted to our hospital from October 2020 to December 2021 were retrospectively enrolled in this study. According to the different therapeutic strategy, the patients were divided into combined group (treated with butylphthalide combined with urinary kallidinogenase, n = 51) and butylphthalide group (treated with butylphthalide, n = 51). Blood flow velocity and cerebral blood flow perfusion before and after treatment between the two groups were compared. The clinical efficacy and adverse events of the two groups were analyzed.

RESULTS

After treatment, the effective rate of the combined group was significantly higher than the butylphthalide group (p = .015). Before treatment, the blood flow velocity of middle cerebral artery (MCA), vertebral artery (VA), basilar artery (BA) were comparable (p > .05, respectively), while after treatment, the blood flow velocity of MCA, VA, and BA in combined group were faster than those in butylphthalide group (p < .001, respectively). Before treatment, the relative cerebral blood flow (rCBF), relative cerebral blood volume (rCBV), relative mean transmit time (rMTT) of the two groups were comparable (p > .05, respectively). After treatment, rCBF and rCBV in combined group were higher than those in butylphthalide group (p < .001, respectively), and rMTT in combined group was lower than that in butylphthalide group (p = .001). The rate of adverse events in the two groups were comparable (p = .558).

CONCLUSION

Butylphthalide combined with urinary kallidinogenase can improve the clinical symptoms of CCCI patients, and the effect is promising, which is worthy of clinical application.

Evolution of ischemic stroke drug clinical trials in mainland China from 2005 to 2021

BACKGROUND

To assess the temporal changes in the characteristics of ischemic stroke drug clinical trials conducted in mainland China in 2005-2021.

METHODS

A statistical analysis of registered clinical trials on ischemic stroke was performed using the platform of the Center for Drug Evaluation of China National Medical Products Administration, the Chinese Clinical Trial Registry, and ClinicalTrials.gov websites.

RESULTS

From January 1, 2005 to August 1, 2021, a total of 384 registered drug clinical trials on ischemic stroke were identified in mainland China. Over time, the number of trials gradually increased each year, with a significant growth in 2014, from 16 in 2013 to 42 in 2014. Phase IV trials (31.8%) accounted for the majority, followed by phase II (16.4%), phase I (10.9%), and phase III (8.6%). In terms of sponsorship, the proportion of investigator-initiated trials (IITs) (60.7%) was higher than industry-sponsored trials (ISTs) (39.3%). Additionally, trials involving traditional Chinese medicines (TCMs) (36.2%) accounted for the largest proportion, followed by trials involving antithrombotic therapy (19.5%) and cerebral protection agents (16.7%). Furthermore, over the past 17 years, the number of leading drug clinical trial units for ischemic stroke in mainland China has continuously increased. The leading principal units from Beijing, Shanghai, Guangdong, Jiangsu, and Liaoning accounted for the majority of the trials (67.4%).

CONCLUSION

In the past 17 years, great progress has been made in the research and development (R&D) of drugs and clinical trials for ischemic stroke in mainland China. The most extensive progress was observed in TCMs, antithrombotic therapy, and cerebral protection agents. More clinical trials are needed to confirm whether the newly developed drugs can improve the clinical efficacy of ischemic stroke. Simultaneously, more pharmaceutical R&D efforts of innovative drugs are warranted.

Human urinary kallidinogenase in acute ischemic stroke: A single-arm, multicenter, phase IV study (RESK study)

Aims

Human urinary kallidinogenase (HUK) has shown favorable efficacies in acute ischemic stroke (AIS) treatment. We sought confirmation of the safety and efficacy of HUK for AIS in a large population.

Methods

RESK study enrolled patients with AIS of anterior circulation to receive HUK infusion. The primary endpoint was the incidence of treatment‐emergent adverse events (AEs). Secondary endpoints assessed neurological and functional improvements and stroke recurrent rate.

Results

Of 1206 eligible patients, 1202 patients received at least one dose of HUK infusion and 983 (81.5%) completed the study. The incidence of treatment‐emergent AEs and serious AEs were 55.99% and 2.41%, respectively. Pre‐specified AEs of special interest occurred in 21.71% of patients, but the majority were mild and unrelated to therapy. Hypertension, age, treatment time, and drug combination were identified to be associated with drug‐related blood pressure reduction. Neurological and functional evaluations revealed favorable outcomes from baseline to post‐treatment assessment. The cumulative recurrence rate of stroke was 2.50% during the 90‐day assessment.

Conclusion

HUK had an acceptable safety and tolerability profile in AIS patients. Besides, HUK demonstrated the neurological and functional improvements in AIS, further confirming its clinical efficacy in a real‐world large population.