Effects of pyridoxalated hemoglobin polyoxyethylene conjugate and other hemoglobin-related substances on arterial blood pressure in anesthetized and conscious rats

Short-term hypoxic vasodilation in vivo is mediated by bioactive nitric oxide metabolites, rather than free nitric oxide derived from haemoglobin-mediated nitrite reduction

Local increases in blood flow--'hypoxic vasodilation'--confer cellular protection in the face of reduced oxygen delivery. The physiological relevance of this response is well established, yet ongoing controversy surrounds its underlying mechanisms. We sought to confirm that early hypoxic vasodilation is a nitric oxide (NO)-mediated phenomenon and to study putative pathways for increased levels of NO, namely production from NO synthases, intravascular nitrite reduction, release from preformed stores and reduced deactivation by cytochrome c oxidase. Experiments were performed on spontaneously breathing, anaesthetized, male Wistar rats undergoing short-term systemic hypoxaemia, who received pharmacological inhibitors and activators of the various NO pathways. Arterial blood pressure, cardiac output, tissue oxygen tension and the circulating pool of NO metabolites (oxidation, nitrosation and nitrosylation products) were measured in plasma and erythrocytes. Hypoxaemia caused a rapid and sustained vasodilation, which was only partially reversed by non-selective NO synthase inhibition. This was associated with significantly lower plasma nitrite, and marginally elevated nitrate levels, suggestive of nitrite bioinactivation. Administration of sodium nitrite had little effect in normoxia, but produced significant vasodilation and increased nitrosylation during hypoxaemia that could not be reversed by NO scavenging. Methodological issues prevented assessment of the contribution, if any, of reduced deactivation of NO by cytochrome c oxidase. In conclusion, acute hypoxic vasodilation is an adaptive NO-mediated response conferred through bioactive metabolites rather than free NO from haemoglobin-mediated reduction of nitrite.

Blood substitutes: evolution from noncarrying to oxygen- and gas-carrying fluids

The development of oxygen (O2)-carrying blood substitutes has evolved from the goal of replicating blood O2 transport properties to that of preserving microvascular and organ function, reducing the inherent or potential toxicity of the material used to carry O2, and treating pathologies initiated by anemia and hypoxia. Furthermore, the emphasis has shifted from blood replacement fluid to "O2 therapeutics" that restore tissue oxygenation to specific tissues regions. This review covers the different alternatives, potential and limitations of hemoglobin-based O2 carriers (HBOCs) and perfluorocarbon-based O2 carriers (PFCOCs), with emphasis on the physiologic conditions disturbed in the situation that they will be used. It describes how concepts learned from plasma expanders without O2-carrying capacity can be applied to maintain O2 delivery and summarizes the microvascular responses due to HBOCs and PFCOCs. This review also presents alternative applications of HBOCs and PFCOCs namely: 1) How HBOC O2 affinity can be engineered to target O2 delivery to hypoxic tissues; and 2) How the high gas solubility of PFCOCs provides new opportunities for carrying, dissolving, and delivering gases with biological activity. It is concluded that the development of current blood substitutes has amplified their applications horizon by devising therapeutic functions for O2 carriers requiring limited O2 delivery capacity restoration. Conversely, full, blood-like O2-carrying capacity reestablishment awaits the control of O2 carrier toxicity.

Interaction between hemoglobin and glutathione in the regulation of blood flow in normal and septic pigs

BACKGROUND

Hemoglobin (Hb) induces vasoconstriction by heme group binding nitric oxide in an irreversible fashion. Recent in vitro studies indicate that the thiol groups in Hb reversibly bind nitric oxide and participate in trans-nitrosylation reactions with other thiols. Sepsis is a pathophysiologic state characterized by vasodilation mediated, at least in part, by an excessive release of nitric oxide. The role of nitrosothiols (RSNOs) in these changes is unknown.

OBJECTIVES

We tested the following in a porcine model of sepsis: (i) whether glutathione (GSH) reverses the hemodynamic effects of Hb; (ii) whether GSH induces an increase in blood flow in sepsis; (iii) whether RSNO plasma concentration increases in sepsis and is related to hypotension.

DESIGN

Nonrandomized animal controlled study.

SETTING

Animal research facility in a university hospital.

SUBJECTS

Anesthetized pigs were monitored with a pulmonary artery catheter and ultrasonic blood flow probes in the mesenteric artery and the portal vein for measurement of systemic, mesenteric, and portal blood flows (Q(TOT), Q(MES), and Q(POR), respectively). Four groups of pigs were studied: nonseptic, septic, nonseptic treated with Hb (stroma-free purified porcine hemoglobin), and septic treated with Hb (n = 6 in each group).

INTERVENTIONS

Sepsis was induced at 0 min by the administration of live Escherichia coli. Hb (400 mg/kg/hr) was administered at 240 mins, followed by glutathione (1 g iv).

MEASUREMENTS AND MAIN RESULTS

Hb induced a pressor response and a decrease in Q(TOT), Q(MES), and Q(POR). Glutathione reversed the effects of Hb on Q(MES) and Q(POR). In septic pigs not treated with Hb, GSH induced an increase in Q(POR). RSNO plasma concentration increased after the induction of sepsis and correlated significantly with blood pressure.

CONCLUSIONS

These results indicate the reversibility of the effects of Hb by GSH, probably by interactions between nitric oxide and the reduced sulfhydryl groups in Hb, and suggest a role of RSNOs in the cardiovascular changes of sepsis.

Rate of NO scavenging alters effects of recombinant hemoglobin solutions on pulmonary vasoreactivity

Many hemoglobin-based oxygen carriers (HBOCs) produce systemic and pulmonary hypertension and may increase microvascular permeability as a consequence of nitric oxide (NO) scavenging. In this study, we examined the effects of two recombinant human hemoglobin solutions, rHb1.1 and rHb2.0 for injection (rHb2.0), with different rates of NO scavenging on vasoconstrictor reactivity and vascular permeability in isolated, saline-perfused rat lungs. We hypothesized that rHb1.1, a first-generation HBOC with an NO scavenging rate similar to that of native human hemoglobin, would exacerbate pulmonary vasoconstriction and permeability and that rHb2.0, a second-generation HBOC with an NO scavenging rate approximately 20- to 30-fold lower than that of rHb1.1, would minimally influence these responses. Consistent with this hypothesis, rHb1.1 enhanced pulmonary vasoconstrictor reactivity to both hypoxia and thromboxane mimetic U-46619 in a dose-dependent fashion. In contrast, rHb2.0 produced little or no change in reactivity to these stimuli. Furthermore, whereas rHb1.1 abrogated pulmonary vasodilation to the NO-donor S-nitroso-N-acetyl-penicillamine (SNAP), dose-dependent responses to SNAP were preserved, albeit attenuated, in lungs treated with rHb2.0. Finally, the capillary filtration coefficient was unaltered by either rHb1.1 or rHb2.0. We conclude that pulmonary hemodynamic responses to rHb2.0 are greatly reduced compared with those observed with rHb1.1, consistent with rHb2.0 having a diminished capacity to scavenge NO. In addition, neither hemoglobin solution measurably altered microvascular permeability in this preparation.

Pyridoxalated hemoglobin polyoxyethylene: a nitric oxide scavenger with antioxidant activity for the treatment of nitric oxide-induced shock

Hemoglobins modified for therapeutic use as either hemoglobin-based oxygen carriers or scavengers of nitric oxide are currently being evaluated in clinical trials. One such product, pyridoxalated hemoglobin polyoxyethylene conjugate (PHP), is a human-derived and chemically modified hemoglobin that has yielded promising results in Phase II clinical trials, and is entering a pivotal Phase III clinical trial for the treatment of shock associated with systemic inflammatory response syndrome (SIRS). Shock associated with SIRS is a NO-induced shock. PHP, a new mechanism-based therapy, has been demonstrated in clinical trials to have the expected hemodynamic activity of raising blood pressure and reducing catecholamine use, consistent with its mechanism of action as a NO scavenger. PHP is conjugated with polyoxyethylene, which results in a surface-decorated molecule with enhanced circulation time and stability as well as in attachment of soluble red blood cell enzymes, including catalase and superoxide dismutase. PHP thus contains an antioxidant profile similar to the intact red blood cell and is therefore resistant to both initial oxidative modification by oxidants such as hydrogen peroxide and subsequent ferrylhemoglobin formation. These studies suggest both that the redox activity of modified hemoglobins can be attenuated and that modified hemoglobins containing endogenous antioxidants, such as PHP, may have reduced pro-oxidant potential. These antioxidant properties, in addition to the NO-scavenging properties, may allow the use of PHP in other indications in which excess NO, superoxide, or hydrogen peroxide is involved, including ischemia-reperfusion injury and hemorrhagic shock.

Blood pressure changes after intravenous administration of cell-free hemoglobin A and hemoglobin H in the rat

Hemoglobin H (HbH) is a tetramer of four beta chains (present in erythrocytes of alpha thalassemia), whereas hemoglobin A is a tetramer of two alpha and two beta chains. Since HbH is known to bind four times more nitric oxide (a vasodilator) at its sulfhydryls compared to HbA, the present studies were conducted to see the effect of HbH and HbA on rat blood pressure. The acute administration (20-2000 nmol/kg) of both HbH and HbA produced a dose-dependent effect on blood pressure. The net change in mean arterial pressure was significantly higher with HbH compared to HbA. Partially nitrosylated (in which SH groups are occupied with NO) HbH retained the property of raising blood pressure to some extent while HbA lost this property. Completely nitrosylated (in which both heme and SH groups are occupied with NO) derivatives of both HbH and HbA reduced the blood pressure to the same extent. The preliminary studies with chronic administration of HbA and HbH resulted in nonsignificant increase in blood pressure. It is concluded that these findings may explain the earlier observations of increased risk of hypertension in individuals with alpha thalassemia.

Current aspects in pharmacology of modified hemoglobins

Blood substitutes are products that are designed to replace whole blood (or) red blood cells in the field of transfusion medicine. There are two major classes that belong to this new therapeutics: (i) modified hemoglobins and (ii) perfluorocarbons. Modified hemoglobins have made tremendous progress in the past decade and are being considered for a wide variety of conditions like trauma, elective surgery, oxygenation of tumors to make them more sensitive to radiation therapy, stroke etc. Although, these agents are primarily used for oxygen delivery, their pharmacological actions have been significantly important. Several mechanisms are being explored to explain these pharmacological effects. Modified hemoglobins suffer several drawbacks including hypertension, renal toxicity, and pulmonary hypertension that restrict their development. This review deals with the clinical status and pharmacological actions of modified hemoglobins presently in advanced stages of development and some of the newer generation hemoglobin based therapeutics are also discussed.

Nitric oxide scavengers in the treatment of shock associated with systemic inflammatory response syndrome

Shock associated with systemic inflammatory response syndrome (SIRS) is a form of distributive shock affecting over 200,000 patients per year in the US that results in 50% mortality. The role of NO in a variety of shock states has been extensively studied and has been shown to be the primary effector in endotoxin lipopolysaccharide (LPS)-induced hypotension attendant to shock associated with sepsis or presumed sepsis. NO has also been shown to be a myocardial depressant, an inhibitor of mitochondrial electron transport, an inducer of vascular leakage and an enhancer of LPS-induced cytokine release. Hence, it is involved in a wide variety of shock-related pathologies and is a key target for therapeutic intervention. Mechanism of action based therapies using NO scavengers represent a promising new approach. However, because NO is involved in such a wide variety of both physiological and pathophysiological processes, a therapy directed at NO must be selective in order to be both safe and effective. NO scavengers are comprised of two basic classes: organic molecules and metal complexes. Pyridoxalated haemoglobin polyoxyethylene conjugate (PHP) is a chemically-modified haemoglobin. It is the furthest advanced NO scavenger in clinical trials and is about to enter pivotal Phase 3 trials in patients with shock associated with SIRS.

Permeability characteristics of hemoglobin derivatives across cultured endothelial cell monolayers

To better understand the vascular activity of hemoglobin-based (Hb-based) oxygen carriers, the endothelial permeability characteristics of Hb derivatives having various molecular masses were defined by using monolayers of bovine endothelial cells cultured on microporous membranes. The endothelial permeability of unmodified bovine Hb was almost twice that of bovine serum albumin. Intramolecularly cross-linked human Hb showed slightly but significantly reduced permeability as compared with unmodified bovine Hb. Polyethyleneglycol modification or haptoglobin binding to Hb further reduced the permeability. These properties were intensified in conditions in which the endothelial barrier function was reduced by pretreatment with either interleukin-6 (100 ng/mL, 21 hours) or lipopolysaccharide (1 microg/mL, 10 hours). In contrast, there was little permeability of liposome-encapsulated Hb, and it was almost unaffected by the pretreatments. These data provide the first information that Hb derivatives with smaller molecular masses show larger transendothelial flux. Because Hb is a potent scavenger of endothelium-derived relaxing factor (EDRF), our observations support the idea that smaller Hb-based acellular oxygen carriers are potent vasoconstrictors as a result of abluminal EDRF scavenging.

The effects of cross-linked hemoglobin on regional vascular conductance in dogs

Hemoglobin (Hgb) solutions cause systemic vasoconstriction, which might limit their use as intraoperative blood substitutes. This constriction is thought to be caused by interaction between Hgb and nitric oxide (NO). To determine whether alpha-alpha cross-linked hemoglobin (XL-Hgb) interferes with NO-mediated vasodilation caused by acetylcholine (ACh) and sodium nitroprusside (NTP), we infused these compounds into the femoral, superior mesenteric, and circumflex coronary arteries of anesthetized dogs (n = 6) before and after partial exchange transfusion with XL-Hgb. Additional animals (n = 6) were studied after treatment with 5% albumin. XL-Hgb administration increased mean arterial pressure (MAP) from 81 +/- 5 to 112 +/- 8 (P < 0.05). Albumin reduced MAP from 84 +/- 4 mm Hg to 76 +/- 4 mm Hg (P < 0.05). Vascular conductance after XL-Hgb decreased in the femoral artery, was not changed in the mesenteric bed, and increased modestly in the coronary artery (from 0.19 +/- 0.03 to 0.26 +/- 0.02 mL x mm Hg(-1) x min(-1), P < 0.05). After albumin, conductance was unchanged in the femoral artery and increased in the mesenteric artery. Conductance also increased in the coronary bed (from 0.25 +/- 0.02 to 0.49 +/- 0.03 mL x mm Hg(-1) x min(-1), P < 0.05). The vasodilator response to ACh in the femoral or mesenteric beds was either unaffected or augmented by either XL-Hgb or albumin. In the coronary bed, XL-Hgb blunted the dilator responses to ACh and NTP, while albumin augmented the coronary dilator responses to ACh. In five additional dogs, the NO synthase inhibitor N(G)-monomethyl L-arginine caused MAP to increase from 85 +/- 4 to 90 +/- 8 mm Hg and blunted the coronary dilator responses to ACh by approximately 25%. Subsequent XL-Hgb administration caused a further increase in MAP to 112 +/- 19 mm Hg (P < 0.05) and also further blunted ACh-mediated vasodilator responses in the coronary circulation. XL-Hgb has complex effects on the circulatory system, including a reduction in the vasodilator responses to ACh and NTP in canine coronary arteries in vivo. The potential impact of these events on patients with significant coexisting disease is unclear.

Effects of polymerization on the hypertensive action of diaspirin cross-linked hemoglobin in rats

It is believed that the hypertensive effect of diaspirin crosslinked hemoglobin, a viable blood substitute, can be resolved by polymerization, which reduces the diffusion of this derivative into the interstitial space between nitric oxide-producing endothelium and the target vascular smooth muscle. We studied the systemic and renal responses to infusion of three cell-free human hemoglobins in anesthetized isovolemic rats: unmodified (HbA0), crosslinked (alpha-DBBF), and polymerized crosslinked (poly alpha-DBBF). HbA0 produced a significant increase in mean arterial blood pressure (MAP) throughout the 60-minute infusion. alpha-DBBF, on the other hand, produced a more marked and prolonged increase in MAP over 120 minutes. Only a moderate increase in MAP was observed in rats after a 30-minute infusion with poly alpha-DBBF. The extent of renal insufficiency produced by these proteins, as determined by the glomerular filtration rate, was in the following order: HbA0 > poly alpha-DBBF > alpha-DBBF. Infusion of poly alpha-DBBF, under hypovolemic but not isovolemic conditions in rats, produced an increase in heart rate, cardiac output, and stroke volume and a decrease in total peripheral resistance after 60 minutes. Chemical polymerization to increase the size of alpha-DBBF does not appear to improve its hemodynamic properties in rats, especially under partial exchange transfusion, a more clinically relevant indication for a hemoglobin-based blood substitute.

Oxalated pyridoxalated hemoglobin polyoxyethylene conjugate normalizes the hyperdynamic circulation in septic sheep

OBJECTIVE

Excessive production of nitric oxide significantly contributes to the hyperdynamic state associated with sepsis. The ability of hemoglobin to scavenge nitric oxide may therefore be beneficial in the treatment of sepsis. In this study, we determined the effects of different doses of the modified human pyridoxalated hemoglobin polyoxyethylene conjugate in an ovine model of hyperdynamic sepsis.

DESIGN

Prospective, experimental study.

SETTING

Large animal research laboratory at a university medical center.

INTERVENTIONS

Sheep (n = 23) were surgically prepared for chronic study. After a 5-day recovery period, all animals received a continuous infusion of live Pseudomonas aeruginosa (2.5 x 10(6) colony-forming units/min) for the next 48 hrs. After 24 hrs of sepsis, the animals were divided into four groups: a) six sheep were used as controls and received a bolus of 200-mL vehicle; b) three sheep received a bolus of 50 mg/kg hemoglobin; c) six sheep received 100 mg/kg of hemoglobin; d) six sheep received 200 mg/kg of hemoglobin.

MEASUREMENTS AND MAIN RESULTS

All animals that survived the first 24 hrs of sepsis (n = 21) developed a hyperdynamic circulation. All three doses of hemoglobin reversed this hyperdynamic state by increasing mean arterial pressure and systemic vascular resistance while decreasing cardiac index. Pulmonary arterial pressure increased after hemoglobin infusion. Increased pulmonary arterial pressure did not affect arterial oxygen saturation nor result in the development of pulmonary edema. Infusion of hemoglobin also caused a 30-fold increase in endothelin-1 plasma concentrations and significantly decreased nitrate and nitrite plasma concentrations.

CONCLUSIONS

The infusion of low doses of pyridoxalated hemoglobin polyoxyethylene conjugate in septic sheep reverses the hyperdynamic circulatory state. An increase in pulmonary arterial pressure was the only observed hemodynamic side effect; changes in the structure or function of other organ systems, or their biochemical correlates were not investigated in this study. In addition to a possible nitric oxide scavenging effect, pyridoxalated hemoglobin polyoxyethylene may affect the nitric oxide synthase and endothelin systems.

Inhibition of endothelium-dependent relaxation by hemoglobin in rabbit aortic strips: comparison between acellular hemoglobin derivatives and cellular hemoglobins

Hemoglobin (Hb)-based artificial oxygen carriers are supposed to induce vasoconstriction through the inactivation of endothelium-derived relaxing factor (EDRF). We examined the vasoconstrictive activity of acellular Hb and cellular Hb solutions in rabbit aortic strips. Unmodified Hb, pyridoxalated Hb, bovine unmodified Hb, haptoglobin-Hb complex (Hp-Hb), and polyoxyethylene glycol-conjugated Hb (PEG-Hb) were used as acellular Hbs having different molecular masses. Cellular Hbs included liposome-encapsulated Hb and red blood cells (RBC). In the first experiment, Hb (10 ng/ml to 1 mg/ml) was cumulatively added to the tissues in which steady-state relaxation was evoked by acetylcholine (ACh) after precontraction induced by phenylephrine. Although all Hb solutions induced a dose-dependent reversal of ACh-induced relaxation, the most potent vasoconstrictive effect was noted with acellular Hbs, and their contractile activities were almost the same independent of molecular mass. On the other hand, liposome-Hb and RBC showed reduced potencies in this order. These results indicate the importance of cellularity as the major factor determining Hb-related EDRF inactivation. In another experiment, the tissues were exposed to Hb at 0.01, 0.1, or 1 mg/ml for 30 min and ACh-induced relaxation was recorded after the complete removal of Hb in an organ bath chamber. Exposure to unmodified Hb at > 0.1-mg/ml concentrations significantly reduced the ACh-induced relaxation, whereas the relaxation was not affected by PEG-Hb, Hp-Hb, liposome-Hb, or RBC. These results suggest that unmodified Hb might be persistently associated with tissues and thereby inhibit ACh-induced relaxation. From these findings, we propose two attributes of Hb-related inhibition of endothelium-dependent relaxation: Acellular Hbs inhibit EDRF more efficiently in the luminal space than cellular Hbs, and unmodified Hb can also inhibit it adluminally and/or adventitially.

Intraarterial perfusion of the hindlimb with pyridoxalated hemoglobin polyoxyethylene conjugate solution in anesthetized dogs

To evaluate the potential clinical usefulness of a modified hemoglobin, pyridoxalated hemoglobin polyoxyethylene conjugate (PHP), the hindlimb vascular bed was perfused with PHP solution while monitoring tissue oxygen tension (PtO2) in anesthetized dogs. The hindlimb region was perfused through the external iliac artery with a roller pump at a varying perfusion rate. PtO2 was measured using a PO2-monitoring probe inserted into the gracial muscle. After surgical preparation for perfusion, the iliac arterial flow rate was 19.9 +/- 5.6 ml/min, and baseline PtO2 was 38.4 +/- 1.3 mm Hg. Perfusion with autologous arterial blood with the pump increased PtO2 and perfusion pressure (PP) in a perfusion rate-dependent manner. Perfusion with PHP solution at 20 ml/min decreased PtO2 from the initial baseline level, but an increase in the flow rate to 40-55 ml/min restored or induced an elevation of PtO2. Results demonstrated that PHP solution can deliver oxygen to local tissue and maintain tissue oxygen tension at the same level as autologous arterial blood at a high enough flow rate.