A new resuscitation fluid "stabilized hemoglobin" preparation and characteristics

Translational research of hemoglobin vesicles as a transfusion alternative

Clinical situations arise in which blood for transfusion becomes scarce or unavailable. Considerable demand for a transfusion alternative persists because of various difficulties posed by blood donation and transfusion systems. Hemoglobin-vesicles (HbV) are artificial oxygen carriers being developed for use as a transfusion alternative. Just as biomembranes of red blood cells (RBCs) do, phospholipid vesicles (liposomes) for Hb encapsulation can protect the human body from toxic effects of molecular Hb. The main HbV component, Hb, is obtained from discarded human donated blood. Therefore, HbV can be categorized as a biologic agent targeting oxygen for peripheral tissues. The purification procedure strictly eliminates the possibility of viral contamination. It also removes all concomitant unstable enzymes present in RBC for utmost safety from infection. The deoxygenated HbVs, which are storable for over years at ambient temperature, can function as an alternative to blood transfusion for resuscitation from hemorrhagic shock and O₂ therapeutics. Moreover, a recent study clarified beneficial effects for anti-oxidation and anti-inflammation by carbon monoxide (CO)-bound HbVs. Autoxidation of HbV (HbO₂ → metHb + O₂-.) is unavoidable after intravenous administration. Co-injection of methylene blue can extract the intraerythrocytic glycolytic electron energy effectively and reduce metHb. Other phenothiazine dyes can also function as electron mediators to improve the functional life span of HbV. This review paper summarizes recent progress of the research and development of HbV, aimed at clinical applications.

Hemoglobin Vesicles prolong the time to circulatory collapse in rats during apnea

Background

Hemoglobin vesicles (HbV) are hemoglobin-based oxygen carriers manufactured by liposome encapsulation of hemoglobin molecules. We hypothesised that the infusion of oxygenated HbV could prolong the time to circulatory collapse during apnea in rats.

Methods

Twenty-four Sprague-Dawley rats were randomly divided into four groups (Air, Oxy, NS and HbV). The rats were anaesthetized with isoflurane and the trachea was intubated using 14-gauge intravenous catheters. Rats in the Air group were mechanically ventilated with 1.5% isoflurane in room air, and those in other groups received 1.5% isoflurane in 100% oxygen. Mechanical ventilation was withdrawn 1 min after the administration of rocuronium bromide to induce apnea. After 30 s, 6 mL saline and HbV boluses were infused at a rate of 0.1 mL/s in the NS and HbV groups, respectively. Circulatory collapse was defined as a pulse pressure < 20 mmHg and the time to reach this point (PP₂₀) was compared between the groups. The results were analysed via a one-way analysis of variance and post-hoc Holm–Sidak test.

Results

PP₂₀ times were 30.4 ± 4.2 s, 67.5 ± 9.7 s, 95 ± 17.3 s and 135 ± 38.2 s for the Air (ventilated in room air with no fluid bolus), Oxy (ventilated with 100% oxygen with no fluid bolus), NS (ventilated with 100% oxygen with a normal saline bolus), and HbV (ventilated in 100% oxygen with an HbV bolus) groups, respectively, and differed significantly between the four groups (P = 0.0001). The PP₂₀ times in the HbV group were significantly greater than in the Air (P = 0.0001), Oxy (P = 0.007) and NS (P = 0.04) groups.

Conclusion

Infusion of oxygenated HbV prolongs the time to circulatory collapse during apnea in rats.

Electronic supplementary material

The online version of this article (doi:10.1186/s12871-017-0338-y) contains supplementary material, which is available to authorized users.

Highly loaded hemoglobin spheres as promising artificial oxygen carriers

Seeking safe and effective artificial blood substitutes based on hemoglobin (Hb) as oxygen carriers is an important topic. A significant challenge is to enhance the loading content of Hb in a well-defined structure. Here we report a facile and controllable avenue to fabricate Hb spheres with a high loading content by templating decomposable porous CaCO(3) particles in collaboration with covalent layer-by-layer assembly technique. The surface of the Hb spheres was further chemically modified by biocompatible polyethylene glycol to protect and stabilize the system. Multiple characterization techniques were employed to reveal the loading and density of Hb in an individual CaCO(3) particle. The results demonstrate that the strategy developed in this work is effective and flexible for construction of the highly loaded Hb spheres. More importantly, such Hb spheres retain their carrying-releasing oxygen function. It may thus have great potential to develop Hb spheres with highly loaded content as realistic artificial blood substitutes in the future.

Evolution of Artificial Cells Using Nanobiotechnology of Hemoglobin Based RBC Blood Substitute as an Example

The original artificial red blood cells have evolved into oxygen carriers in the form of polyhemoglobin and conjugated hemoglobin. Clinical conditions requiring only oxygen carriers are responding well to these types of oxygen carriers without the need for a complete artificial red blood cell. For those conditions requiring more than just oxygen carriers, new generations of polyhemoglobin containing antioxidant enzymes are being developed. Though a complete artificial red blood cell comparable to red blood cell is still a dream, development in lipid membrane artificial red blood cells and biodegradable polymeric nano artificial red blood cells are steps towards this possibility. The many years of neglect on basic research in the area of blood substitutes have resulted in the lack of important basic knowledge needed for the rapid development of blood substitutes suitable for clinical use. This is further hampered by the mistaken conception that blood substitute is a single entity. We need to look at blood substitutes as consisting of progressively more complicated entities, e.g. oxygen carriers, oxygen carriers with antioxidant activity, and complete red blood cell substitutes. Each of these entities is not applicable to all clinical conditions, but is suitable for specific applications.

Immunogenicity of Heme Complexes of Peptides Designed to Mimic the Heme Environment of Myoglobin and Hemoglobin

In the preceding paper (Protein J. 25, pages 37-49, 2005), we reported the preparation and oxygen-binding properties of peptides that form stable complexes with heme mimic. The design of the peptides was based on the natural environment of the heme group in myoglobin (Mb) and in the alpha- and beta-subunits of human adult hemoglobin (Hb). In the present work, the heme-peptides were each administered into mice, either as emulsions in adjuvant (both for injections and boosters) or intravenously as solutions in phosphate-buffered saline. Antibody (Ab) responses, monitored up to 14 weeks after the first administration, showed that when the heme-peptides were injected with adjuvant they stimulated Ab responses against the immunizing peptide, which in most cases bound to the correlate protein (Mb or Hb). However these heme-peptides were non-immunogenic when administered in PBS intravenously. It is concluded that heme-peptides:(a) would not trigger an adverse immune response if used for transfusion purposes.

Oxygen-binding Heme Complexes of Peptides Designed to Mimic the Heme Environment of Myoglobin and Hemoglobin

Development of effective resuscitation agents for blood-loss replacement in trauma or surgery is extremely important despite substantial improvements in screening methods of blood from human donors. This paper reports the design and synthesis of peptides that mimic the natural environment of the heme group in myoglobin (Mb) and in the alpha- and beta-subunits of human adult hemoglobin (Hb). The designs were based on the fact that the heme group in the aforementioned proteins is sandwiched between helices E and F. Fifteen test peptides and six control peptides were synthesized, and their ability to form stable complexes with heme was investigated. It was found that none of the control peptides or proteins was able to bind heme. However, each of the peptides that were designed to mimic the E-F helices, and even shorter designs, which removed from this region residues that do not contribute to contacts with the heme group, were each able to bind one mole of heme per mole of peptide forming peptide heme complexes that were stable to manipulation and behaved as single molecular species. Oxygen binding measurements on the reduced peptide-heme complexes showed that these compounds bind oxygen and give visible spectra that were typical of oxygenated heme-proteins. In oxygen binding measurements done under different partial pressures of oxygen, the heme peptide complexes gave hyperbolic oxygen-saturation curves, but showed slight differences in their P50 values. The P50 values ranged from 3.8 mmHg for the heme peptide B7 complex to 13.7 mmHg for the heme peptide D13 complex (under the same conditions, P50 values for Hb and Mb were 34.0 and 5.5 mmHg, respectively). It is concluded that peptide constructs designed to mimic the heme-binding regions of Mb or the Hb subunits were able to form coordinate 1:1 complexes with heme, and these complexes bind oxygen in a manner expected for single subunit heme proteins.

Pharmacokinetics of PEG-hemoglobin SB1, a hemoglobin-based oxygen carrier, after its intravenous administration in beagle dogs

The purpose of the present study was to investigate the pharmacokinetics of PEG-hemoglobin SB1, a modified bovine hemoglobin with polyethylene glycol, after its single and multiple administration in beagle dogs. For this purpose, the analytical method of free hemoglobin in the plasma was developed and validated. Excellent linearity (r2=0.999) was observed in the calibration curve data, with the limit of quantification of 0.005 g/dL. The precision and the deviation of the theoretical values for accuracy were always within +/-15% in both the between- and the within-day results. The method was tested by measuring the plasma concentrations following intravenous administration to beagle dogs and was shown to be suitable for pharmacokinetic studies. In a single dose study, the plasma half-life (t1/2) increased and the total body clearance (CLt) decreased with the dose (i.e., 0.017 to 0.75 gHb/kg as PEG-hemoglobin SB1) in both sexes. The volume of distribution at steady-state (Vd(ss)) showed no difference with the dose. In contrast, the values of t1/2, CLt and the area under the plasma concentration-time curve (AUC) after the multiple dose were significantly different from those of the single dose administration. The values of t1/2 in the multiple administration were about two times higher than that of the single dose. As a result, t1/2 of hemoglobin after the administration of PEG-hemoglobin SB1 was about 15-30 h, indicating the PEG modification of the hemoglobin lead to a prolongation of plasma concentration of the protein. Therefore, these observations suggested that the PEG modification of hemoglobin is potentially applicable in the hemoglobin-based therapeutics.

Hemoglobin-based Red Blood Cell Substitutes

Polyhemoglobin is already well into the final stages of clinical trials in humans with one approved for routine clinical use in South Africa. Conjugated hemoglobin is also in ongoing clinical trials. Meanwhile, recombinant Hb has been modified to modulate the effects of nitric oxide. Other systems contain antioxidant enzymes for those clinical applications that may have potential problems related to ischemia-reperfusion injuries. Other developments are based on hemoglobin-lipid vesicles and also the use of nanotechnology and biodegradable copolymers to prepare nanodimension artificial red blood cells containing hemoglobin and complex enzyme systems.

Future generations of red blood cell substitutes

Polyhaemoglobins (PolyHb) and perfluorochemicals are in advanced phase III clinical trials and conjugated haemoglobins in phase II clinical trial. New recombinant human haemoglobin with no vasoactivity is being developed. A soluble macromolecule of PolyHb-catalase-superoxide dismutase is being studied as an oxygen carrier with antioxidant properties. New artificial red blood cells that are more like RBC are being developed. One is based on haemoglobin lipid vesicles. A more recent one is based on nano-dimension artificial red blood cells containing haemoglobin and RBC enzymes with membrane formed from composite copolymer of polyethylene glycol-polylactic acid. Their circulation time is double that of PolyHb.

Hemoglobin-based oxygen carriers

Three types of materials have been studied as candidate blood substitutes: the perfluorocarbons, modified hemoglobins, and liposome-encapsulated hemoglobin. Progress has been greatest with the hemoglobin-based oxygen carriers. Hemoglobin is a highly active molecule; hence, modification has been required to avoid potential deleterious effects. Although there has been considerable progress toward bringing such a product to the clinic, its development has challenged understanding of oxygen delivery and use. The study of these molecules has provided new insights into basic physiologic processes.

Red blood cell substitutes

Soluble polymerized haemoglobin (polyhaemoglobin) is now in a phase III clinical trials. Patients have received up to 20 units (10 litres) in trauma surgery and other surgery. Polyhaemoglobin can be stored for more than 1 year. Haemoglobin solutions have no blood group antigen and can be used as a 'universal donor' oxygen carrier. They can also be sterilized. With a circulation half-life of 24 hours they are undergoing trials for peri-operative use. For conditions with potential for ischaemia-reperfusion injuries, a new polyhaemoglobin-superoxide dismutase-catalase, which can reduce oxygen radicals, is being developed. Recombinant human haemoglobin has been tested in clinical trials, and a new type of recombinant human haemoglobin that has low affinity for nitric oxide is being developed for clinical trials. To increase the circulation time, artificial red blood cells have been prepared with a bilayer lipid membrane (haemoglobin liposomes) or with a biodegradable polymer membrane-like polylactide (haemoglobin nanocapsules). Synthetic chemicals such as perfluorochemicals are also being developed and tested in clinical trials as red blood cell substitutes.

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.

Chemical characterization of pyridoxalated hemoglobin polyoxyethylene conjugate

Pyridoxalated hemoglobin polyoxyethylene conjugate (PHP) was developed in the 1980s as an oxygen carrier and is now under development for treatment of nitric oxide-dependent, volume refractory shock. PHP is made by derivatizing human stroma-free hemoglobin with pyridoxal-5-phosphate and polyoxyethylene (POE). A unique aspect of using POE for modification is that unlike its mono-methoxy polyethylene glycol (PEG) relatives, POE is bifunctional. The result of derivatization of stroma-free hemoglobin is a complex mixture of modified hemoglobin and other red cell proteins. The molecular weight profile, based on size exclusion chromatography, is bimodal and has a number average molecular weight of approximately 105¿ omitted¿000 and a weight average molecular weight of approximately 187¿ omitted¿000. The mixture of hemoglobin molecules has on average 3.3 pyridoxal and 5.0 polyoxyethylene units per tetramer. A portion of the tetramers are linked by POE crosslinks. The hemoglobin tetramers retain their ability to dissociate into dimer pairs and only a small percentage of the dimer pairs are not modified with POE. The SDS-PAGE profile exhibits the ladder-like appearance commonly associated with polyethylene glycol-modified proteins. The isoelectric focusing profile is broad, demonstrating a pI range of 5.0-6.5. The hydrodynamic size of PHP was determined to be approximately 7.2 nm by dynamic light scattering. Soluble red blood cell proteins, such as catalase, superoxide dismutase, and carbonic anhydrase, are present in PHP and are also modified by POE.

Artificial cells with emphasis on cell encapsulation of genetically engineered cells

Artificial cells are prepared in the laboratory for medical and biotechnological applications. Encapsulated cells are being studied for the treatment of diabetes, liver failure, and other conditions. More recently, there have been extensive studies into the use of encapsulated genetically engineered cells for gene therapy. We recently found that daily orally administered artificial cells, each containing a genetically engineered microorganism, can lower the elevated urea level in uremic rats to normal levels. This may solve the final obstacle of the lack of an effective oral urea removal system for the simple and inexpensive oral treatment of uremia. This is important because 85% of the world's uremic population cannot afford standard dialysis. Other areas of artificial cell application include use in hemoperfusion. Red blood cell substitutes based on modified hemoglobin are already in Phase 3 clinical trials in patients. Artificial cells containing enzymes are being developed for clinical trial in hereditary enzyme deficiency disease and other diseases. They are also being investigated for drug delivery and for use in other applications in biotechnology, chemical engineering, and medicine.

Autoxidation of pyridoxalated hemoglobin polyoxyethylene conjugate

Hemoglobin-based therapeutics are currently in clinical trials in the United States and abroad as blood replacement solutions, nitric oxide scavengers, and radiation sensitizers. The potency of the therapeutics may be influenced by the oxidation state of the iron in the heme moiety. The oxidation state is dependent upon the physical environment of the molecule and is influenced by parameters such as the chemical nature of the hemoglobin therapeutic and its formulation. Pyridoxalated hemoglobin polyoxyethylene conjugate (PHP) is one such compound currently in clinical trials in the U.S. for treatment of nitric oxide-dependent, volume refractory shock. The autoxidation rates for PHP have been determined over a range of temperatures. The oxidation events were shown to be biphasic and were similar to those observed for purified human hemoglobin (HbAo). The initial fast oxidation events were modeled with first order rate constants at 37 degrees C and determined to be 0.022 hr-1 and 0.025 hr-1 for PHP and HbAo, respectively. The autoxidation of PHP was shown to be independent of concentration from approximately 5 to 100 mg/mL.

Modified hemoglobin-based blood substitutes: crosslinked, recombinant and encapsulated hemoglobin

Native hemoglobin in the form of stroma-free hemoglobin cannot be used as blood substitute. Hemoglobin has to be modified either molecularly or encapsulated. First generation molecularly modified ultrapure hemoglobins are now in clinical trial--some in Phase III. There are a number of these. Polyhemoglobin is formed by crosslinking hemoglobin molecules intermolecularly and intramolecularly. A crosslinked single hemoglobin molecule is formed by crosslinking hemoglobin intramolecularly. Recombinant hemoglobin from E.coli is formed by fusion of the subunits of each hemoglobin molecule. Conjugated hemoglobin is formed by crosslinking each hemoglobin molecule to soluble polymers. A second generation system formed by crosslinking hemoglobin-superoxide dismutase-catalase is being developed. A third generation hemoglobin-based blood substitute is based on microencapsulated hemoglobin, artificial red blood cells, that more closely resemble a complete red blood cell.

Detection of residual polyethylene glycol derivatives in pyridoxylated-hemoglobin-polyoxyethylene conjugate

Purified hemoglobin solutions have been shown to cause renal toxicity in animals. Safe use of hemoglobin based therapeutics in humans requires modification of the hemoglobin molecule to prevent this toxicity. Hemoglobin modification may be accomplished by crosslinking the dimers within the hemoglobin tetramer or by derivatization of the alpha and/or beta subunits such that their size and/or charge prevents filtration by the glomeruli. Pyridoxylated hemoglobin polyoxyethylene conjugate (PHP) consists of hemoglobin molecules modified with alpha-carboxymethyl, omega-carboxymethoxy polyoxyethylene (POE). We have developed a high performance liquid chromatography-based (HPLC) method which can quantitate residual POE at levels of 0.1 mg/ml or greater. The detection of POE at this level of sensitivity requires the use of an evaporative light scattering detector (ELSD). A differential refractometer may also be used for POE detection, however the limit of quantitation for this detector is approximately 10 fold greater than that observed for the evaporative light scattering detector, resulting in a reduction in sensitivity. The successful use of this method requires sample deproteination using trichloroacetic acid. The reliability of the method has been demonstrated by spike recovery, precision, and reproducibility studies in PHP and buffer solutions.

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

The effects of pyridoxalated hemoglobin polyoxyethylene conjugate (PHP) and other hemoglobin-related substances on arterial blood pressure (ABP) and heart rate (HR) were examined. Infusion of PHP and other hemoglobin-related substances elevated ABP and increased HR. The degree of the increase in ABP and HR did not differ among the groups. There were species' differences in responses to PHP. Pretreatment with various blockers did not abolish the elevation of ABP. The pretreatment of NG-monomethyl-L-arginine dose-dependently reduced the elevation of ABP but did not completely abolish it. PHP also elevated ABP in conscious rats. The magnitude of the ABP elevation was significantly smaller than in the anesthetized rats. Results indicate that inhibition of nitric oxide (NO) might be responsible in part for the elevation of ABP, and the degree of the elevation would be dependent on the degree of contribution of NO to the regulation of ABP.

Recombinant haemoglobin in the development of red-blood-cell substitutes

Increasing concern over viral contamination of blood is spurring the development of a blood substitute which can effectively replace the oxygen-carrying capabilities of transfused erythrocytes. Solutions of chemically modified haemoglobin represent one option being evaluated for this role. More recently, recombinant-DNA techniques have enabled production of human haemoglobin in host expression systems, and progress is being made towards the creation of a genetically engineered molecule incorporating the properties required of a blood substitute.

Blood substitutes based on modified hemoglobin prepared by encapsulation or crosslinking: an overview

Modified hemoglobin consists of (1) encapsulated hemoglobin and (2) crosslinked hemoglobin (polyhemoglobin, intramolecularly cross-linked hemoglobin and conjugated hemoglobin). There have been new advances in all types of modified hemoglobins. Modified hemoglobins are effective in hemorrhagic shock. However, it is important to define hemorrhagic shock models and experimental designs. Important progress has been made in research on vasoactivities, organ perfusion, organ preservation, biodistribution, hematology, complement activation immunology and other areas. A preclinical screening test may bridge the gap between animal safety studies and injection into human. Potential new sources of hemoglobin included bovine hemoglobin, recombinant human hemoglobin and synthetic heme.