Nephrotoxicity of hemoglobin solutions

Stability of Maleimide-PEG and Mono-Sulfone-PEG Conjugation to a Novel Engineered Cysteine in the Human Hemoglobin Alpha Subunit

In order to use a Hemoglobin Based Oxygen Carrier as an oxygen therapeutic or blood substitute, it is necessary to increase the size of the hemoglobin molecule to prevent rapid renal clearance. A common method uses maleimide PEGylation of sulfhydryls created by the reaction of 2-iminothiolane at surface lysines. However, this creates highly heterogenous mixtures of molecules. We recently engineered a hemoglobin with a single novel, reactive cysteine residue on the surface of the alpha subunit creating a single PEGylation site (βCys93Ala/αAla19Cys). This enabled homogenous PEGylation by maleimide-PEG with >80% efficiency and no discernible effect on protein function. However, maleimide-PEG adducts are subject to deconjugation via retro-Michael reactions and cross-conjugation to endogenous thiol species in vivo. We therefore compared our maleimide-PEG adduct with one created using a mono-sulfone-PEG less susceptible to deconjugation. Mono-sulfone-PEG underwent reaction at αAla19Cys hemoglobin with > 80% efficiency, although some side reactions were observed at higher PEG:hemoglobin ratios; the adduct bound oxygen with similar affinity and cooperativity as wild type hemoglobin. When directly compared to maleimide-PEG, the mono-sulfone-PEG adduct was significantly more stable when incubated at 37°C for seven days in the presence of 1 mM reduced glutathione. Hemoglobin treated with mono-sulfone-PEG retained > 90% of its conjugation, whereas for maleimide-PEG < 70% of the maleimide-PEG conjugate remained intact. Although maleimide-PEGylation is certainly stable enough for acute therapeutic use as an oxygen therapeutic, for pharmaceuticals intended for longer vascular retention (weeks-months), reagents such as mono-sulfone-PEG may be more appropriate.

Engineering hemoglobin to enable homogenous PEGylation without modifying protein functionality

In order to infuse hemoglobin into the vasculature as an oxygen therapeutic or blood substitute, it is necessary to increase the size of the molecule to enhance vascular retention. This aim can be achieved by PEGylation. However, using non-specific conjugation methods creates heterogenous mixtures and alters protein function. Site-specific PEGylation at the naturally reactive thiol on human hemoglobin (βCys93) alters hemoglobin oxygen binding affinity and increases its autooxidation rate. In order to avoid this issue, new reactive thiol residues were therefore engineered at sites distant to the heme group and the α/β dimer/dimer interface. The two mutants were βCys93Ala/αAla19Cys and βCys93Ala/βAla13Cys. Gel electrophoresis, size exclusion chromatography and mass spectrometry revealed efficient PEGylation at both αAla19Cys and βAla13Cys, with over 80% of the thiols PEGylated in the case of αAla19Cys. For both mutants there was no significant effect on the oxygen affinity or the cooperativity of oxygen binding. PEGylation at αAla19Cys had the additional benefit of decreasing the rates of autoxidation and heme release, properties that have been considered contributory factors to the adverse clinical side effects exhibited by previous hemoglobin based oxygen carriers. PEGylation at αAla19Cys may therefore be a useful component of future clinical products.

Air-stable, heme-like water-soluble iron(II) porphyrin: in situ preparation and characterization

Preparation of the water-soluble, kinetically labile, high-spin iron(II) tetrakis(4-sulfonatophenyl)porphyrin, Fe(II)TPPS(4-), has been realized in neutral or weakly acidic solutions containing acetate buffer. The buffer played a double role in these systems: it was used for both adjusting pH and, via formation of an acetato complex, trapping trace amounts of iron(III) ions, which would convert the iron(II) porphyrins to the corresponding iron(III) species. Fe(II)TPPS(4-) proved to be stable in these solutions even after saturation with air or oxygen. In the absence of acetate ions, however, iron(II) ions play a catalytic role in the formation of iron(III) porphyrins. While the kinetically inert iron(III) porphyrin, Fe(III)TPPS(3-), is a regular one with no emission and photoredox properties, the corresponding iron(II) porphyrin displays photoinduced features which are typical of sitting-atop complexes (redshifted Soret absorption and blueshifted emission and Q absorption bands, photoinduced porphyrin ligand-to-metal charge transfer, LMCT, reaction). In the photolysis of Fe(II)TPPS(4-) the LMCT process is followed by detachment of the reduced metal center and an irreversible ring-opening of the porphyrin ligand, resulting in the degradation of the complex. Possible oxygen-binding ability of Fe(II)TPPS(4-) (as a heme model) has been studied as well. Density functional theory calculations revealed that in solutions with high acetate concentration there is very little chance for iron(II) porpyrin to bind and release O(2), deviating from heme in a hydrophobic microenvironment in hemoglobin. In the presence of an iron(III)-trapping additive that is much less strongly coordinated to the iron(II) center than the acetate ion, Fe(II)TPPS(4-) may function as a heme model.

Effects of Diaspirin Crosslinked Hemoglobin (DCLHb) on microcirculation and local tissue pO2 of striated skin muscle following resuscitation from hemorrhagic shock

The hemoglobin based oxygen carrier (HBOC) Diaspirin Crosslinked Hemoglobin (DCLHb) has been developed to substitute not only the blood volume, but also to restore the oxygen-carrying properties of blood during hemorrhagic shock. However, it has been suggested that HBOCs may enhance the formation of free oxygen radicals through the release of free iron ions via the Haber-Weiss reaction. The aim of this study was to investigate the effects of DCLHb on the microcirculation, leukocyte-endothelial cell interaction and local tissue oxygenation in striated skin muscle of Syrian golden hamsters during and after resuscitation from hemorrhagic shock. In particular we focused on the local tissue oxygenation after resuscitation with DCLHb (hemoglobin content 10 g%) compared to resuscitation using autologous blood diluted to a hemoglobin content of 10 g%. Hemorrhagic shock was induced for 45 minutes by bleeding the animals at a rate of 33 ml/kg BW maintaining a mean arterial pressure of 30 +/- 5 mmHg. Animals were resuscitated either with 33 ml/kg BW 6% Dextran-60.000 or with 10 g% DCLHb. The control group received shed blood diluted with Ringers to a hemoglobin content of 10 g%. Intravital microscopy was used for investigation of the microcirculatory parameters and a multiwire platinum surface electrode for measurement of local tissue pO2 in striated skin muscle in the dorsal skinfold chamber of Syrian golden hamsters. Resuscitation from hemorrhagic shock with 10 g% AUB revealed significant increase of leukocytes rolling in postcapillary venules at 30 to 120 minutes after resuscitation compared to baseline values. DCLHb turned out to reduce the number of firmly adherent leukocytes after resuscitation compared to 10 g% AUB. Microvascular permeability as an indicator for functional endothelial integrity revealed no significant differences between the groups. DCLHb and 10 g% AUB led to a significant increase in local tissue oxygenation after resuscitation from hemorrhagic shock. However, 10 g% AUB turned out to be most effective to restore the local tissue pO2 compared to Dx-60. Our findings indicate that DCLHb restores microvascular perfusion after critical hemorrhagic shock as efficient as Dx-60 and 10 g% AUB. The absence of enhanced leukocyte-endothelium interaction after resuscitation with DCLHb implies that this HBOC does not exacerbate formation of oxygen free radicals during reperfusion. DCLHb effectively increases local tissue pO2 after resuscitation from hemorrhagic shock; however, not as effectively as 10 g% AUB.

Comparison of a new recirculation thrombectomy catheter with other devices of the same type: in vitro and in vivo evaluations

RATIONALE AND OBJECTIVES

To compare a new 7 Fr. Helix thrombectomy catheter with Amplatz thrombectomy devices (ATD) with respect to clot fragmentation efficiency, hemolytic potential, and risk for vascular trauma.

MATERIALS AND METHODS

Particle size was evaluated following the maceration of 8-to-10-day-old clots, each weighing 6 +/- 0.01 g. The clots were macerated using devices of various sizes, including the 7-Fr. Helix thrombectomy catheter, the 7-Fr. over-the-wire (OTW), 8-Fr. ATD and the 6-Fr. ATD. The number of particles by weight was quantified. The 7-Fr. Helix and the 8-Fr. ATD were tested in the native iliac vein of six dogs without presence of clots. Blood samples were obtained before, during, and at 1, 3, 6, 24, and 48 hours after the procedure, to monitor the hemolytic effects. The treated iliac veins were examined histologically.

RESULTS

Most of the clot was fragmented into particles <10 microm. The mean percentage by weight of the original clot that remained as particles larger than 10 microm was 1.59% in the 7-Fr. Helix group. This was significantly less than 3.10% with the 6-Fr. ATD, 2.57% with 7-Fr. OTW and 2.44% in the 8-Fr. ATD group (<0.01). In vivo results showed a higher plasma free hemoglobin (PFH) level starting 5 minutes after initiating the ATD activation, reaching its peak after completion of the activation, and declining afterward, with return to the baseline at 24 hours. The haptoglobin level tended to decline slightly at 10 minutes, reaching its lowest level at 24 hours, and starting to recover at 48 hours. A similar pattern of PFH and haptoglobin changes was found in both groups. There were no significant differences regarding hemolytic effect of the two tested devices. No significant changes of creatinine were observed for up to 48 hours after procedures. Focal microthrombosis was seen in two sites of two vessels treated with the 7-Fr. Helix and a focal injury of a venous valve was noted in the 8-Fr. ATD group. The media and internal elastic lamina (IEL) were intact in all cases.

CONCLUSION

The newly designed 7-Fr. Helix is more effective in fragmentation in vitro clots than the 6 Fr. ATD, 7-Fr. OTW and the 8-Fr. ATD. The 7-Fr. Helix and the 8-Fr. ATD produced hemolytic effects, but they appeared to be tolerated by the animals. The in vivo results indicated that the 7-Fr. Helix appears to be as safe as the 8-Fr. ATD.

Hemoglobin substitute and cardiopulmonary bypass

The effects of diaspirin crosslinked hemoglobin (DCLHb, Baxter Health Care Corp., Round Lake, IL) on oxygen exchange in the setting of cardiopulmonary bypass (CPB) are unknown. Six calves (71.2 +/- 1.3 kg) were connected to CPB by jugular venous and carotid arterial cannulation for 5 hours. Each 1 hour period included 45 min of partial CPB (mean flow rate of 50 ml/kg per min) followed by 15 min without CPB, at the end of which 500 ml of blood were substituted for with either 500 ml of hydroxyethyl starch (Haes; n = 3) or 500 ml of DCLHb (n = 3). A total of 2 liters of blood was, thus, exchanged (28 ml/kg of blood substitute). Values are expressed as mean +/- 1 SD. Analysis of variance for repeated measurements was used. The cardiac output (CO) values at 1 h, 3 h, and 5 h were in the Haes group: 5.7 +/- 2, 6.7 +/- 2.5, and 7.7 +/- 2.5L/min, and in the DCLHb group: 5.7 +/- 0.6, 4 +/- 1, and 4.7 +/- 1.2 L/min, respectively. The arteriovenous oxygen content difference (Ca-Cvo2) values at 1 h, 3 h, and 5 h were in the Haes group: 4.6 +/- 1, 3.3 +/- 1.5, and 3.5 +/- 1.5 ml/dl, and in the DCLHb group: 4.9 +/- 0.6, 7.4 +/- 0.7, and 6.6 +/- 0.6 ml/dl, respectively. The oxygen consumption (Vo2) values at 1 h, 3 h, and 5 h were in the Haes group: 244 +/- 29, 198 +/- 58, and 249 +/- 42 ml/min, and in the DCLHb group: 273 +/- 28, 296 +/- 75, and 306 +/- 65 ml/min, respectively. CO and Ca-Cvo2 showed a significant difference (p < 0.01), whereas Vo2 did not (p = 0.52). In the DCLHb group of this CPB animal model, the cardiac output is lower and the arteriovenous oxygen content difference higher than in the Haes group, allowing for preserved oxygen consumption.

In vitro interference of the red cell substitute pyridoxalated hemoglobin-polyoxyethylene with blood compatibility, coagulation, and clinical chemistry testing

OBJECTIVES

Pyridoxalated hemoglobin-polyoxyethylene (PHP) is a prototypical red cell substitute approved for phase I studies. Peripheral blood smears of human blood mixed with PHP in 1 to 4 g/dL concentrations showed dose-dependent red cell aggregation and rouleaux. Whether this aggregation limits interpretation of blood compatibility testing and whether the intense coloration of serum or plasma containing PHP affects routine coagulation and clinical chemistry measurements was tested.

DESIGN

In vitro studies.

SETTING

University hospital laboratory.

PARTICIPANTS

Four healthy volunteers, blood types A, B, AB, and O. All were Rh+.

MEASUREMENTS AND MAIN RESULTS

ABO typing, Rh typing, and antibody screening and coagulation studies were performed on blood: PHP admixtures having final concentrations of 1, 2, and 4 g/dL. For clinical chemistry interference studies, known concentrations of analytes were added to a serum matrix containing PHP. ABO (forward) and Rh typing showed no interference in the three concentrations tested. Reverse ABO typing and antibody screening showed rouleaux at 4 g/dL, which corrected with routine saline replacement. Partial thromboplastin time (PTT), prothrombin time (PT), and fibrinogen showed no clinically significant differences from the controls. Results for electrolytes, renal function analytes, and markers of cardiac injury were acceptable by standard laboratory methods. However, results of liver function tests were unacceptable in PHP-containing specimens.

CONCLUSIONS

PHP-induced aggregation was observed with high PHP concentration; however, compatibility testing was not affected because agglutination was corrected by saline replacement, which is standard practice. Although routine blood banking, coagulation, and most clinical chemistry analytes can be measured reliably, alternative methods and strategies are needed for assessing liver function in the presence of PHP.

Effect of polyethylene glycol conjugated bovine hemoglobin in both top-load and exchange transfusion rat models

The purpose of this study was to determine the effect of the hemoglobin based oxygen carrier, polyethylene glycol conjugated bovine hemoglobin (PEG-Hb) on the physiology of the rat. This study was divided into the following 3 parts: pharmacokinetics, cardiovascular, and histopathology. Pharmacokinetic studies evaluated the PEG-Hb circulatory life and the resultant effect on urine composition. Telemetric intravascular blood pressure probes monitored the heart rate and mean arterial pressure. Renal arterial blood flow was determined by intraoperative perivascular ultrasound. Tissue histology was evaluated for both time and model dependent responses. The mean circulatory half-life of PEG-Hb was 17.7+/-0.3 h. Proteinuria and hemoglobinuria were greatly reduced with PEG conjugation. PEG-Hb treated rats produced 8.5 times and 49 times less proteinuria and hemoglobinuria, respectively, than unmodified bovine Hb treated animals. The mean arterial pressure (MAP) in PEG-Hb treated rats was insignificantly different from sham controls undergoing a 30% exchange transfusion while dextran caused an initial reduction and bovine Hb produced a prolonged elevation in the MAP. In these same anesthetized rats, PEG-Hb slightly decreased the heart rate while dextran caused an increase and bovine Hb had no effect. In addition, PEG-Hb was able to maintain the renal arterial blood flow while both Ringer's lactate and bovine Hb caused a reduction in the blood flow. Finally, PEG-Hb treated rats showed a dose and time dependent formation of vacuoles within the renal proximal convoluted tubules and splenic macrophages in both top-load and exchange transfusion models, but no other morphological changes. In conclusion, PEG-Hb had a relatively long vascular persistence that did not cause any significant alterations in the urinalysis, cardiovascular function, or tissue histopathology in the rat.

The impact of polyethylene glycol conjugation on bovine hemoglobin's circulatory half-life and renal effects in a rabbit top-loaded transfusion model

This study compares the effects of polyethylene glycol (PEG) modified bovine hemoglobin on vascular half-life and renal function in rabbits to those of unmodified bovine hemoglobin. Renal function was assessed by the measurement of the glomerular filtration rate, urinalysis, blood chemistries, hemoglobin (Hb) excretion rates, and tissue histology. The influence of infusion rates on hemoglobin excretion rates and organ morphology was also examined. The mean half-life of unmodified bovine hemoglobin was 3.0 +/- 0.1 (mean +/- SEM) h, which was extended 14-fold to 43.2 +/- 1.7 h following PEG conjugation. The glomerular filtration rate, urinalysis, and blood chemistries were not greatly affected by either the unmodified bovine hemoglobin or the PEG modified bovine hemoglobin. However, unmodified bovine hemoglobin did demonstrate significant hemoglobinuria (Hb excretion levels in excess of 1.0% of the infused dose [p < 0.05]) at all infusion rates given while PEG modified bovine hemoglobin did not. In addition, histological examination by light microscopy indicated that the most severe morphological changes occurred in animals that received unmodified bovine hemoglobin. This data suggests that PEG modification of bovine hemoglobin significantly reduced some of the adverse effects of bovine hemoglobin on renal physiology and morphology.

The physiological and histopathological response of dogs to exchange transfusion with polyethylene glycol-modified bovine hemoglobin (PEG-Hb)

The performance of polyethylene glycol-modified bovine hemoglobin (PEG-Hb) was evaluated in dogs following the replacement of 30% or 50% of their blood volume with PEG-Hb or lactated Ringer's solution (LRS). Dogs fully instrumented with catheters and blood pressure probes were transfused by simultaneous bleeding from the jugular vein and infusion of PEG-Hb or LRS via the cephalic vein. Animals were monitored for abnormal behavior and clinical signs for fourteen days. No mortalities, overt toxicity, changes in body weight, food consumption or ophthalmology, or discernable trends in hematology, blood chemistry coagulation, urinalysis or hemodynamic parameters that could be attributed to PEG-Hb were noted. Blood gas analyses were steady and within physiological ranges. Dose-related histopathological findings of vacuolated histiocytes in the femoral bone marrow, splenic parenchyma, the medulla of the mesenteric and mandibular lymph nodes, and vacuolated sinusoidal cells in the liver and the renal tubular epithelial cells were believed to be related to the phagocytosis and degradation of PEG-Hb by the reticulo-endothelial system. The maintenance of high oxygen levels in the circulation for the two-week treatment period, as well as the insignificant physiological and histopathological findings indicate that PEG-Hb could be a successful blood substitute.

Systemic responses to SFHS-infusion in hemorrhaged dogs

Anesthetized mongrel (weight range: 16-27 Kg) dogs were prepared for monitoring hemodynamics, blood flow distribution, plasma colloid osmotic pressure and renal functional parameters at various intervals. Removal of 35 ml/Kg blood resulted in marked drop and only partial spontaneous recovery in systemic and pulmonary arterial pressures, cardiac output and organ blood flows (> 50% flow-decrements occurred in kidney, spleen, heart, gut and pancreas); plasma colloid osmotic pressure as well as urine output and creatinine clearance also fell. Group I (n = 6) of dogs was transfused after 45 minutes of hypovolemia with their own anticoagulated blood, while Group II (n = 6) received an equal volume of unmodified 6% stromafree hemoglobin solution (SFHS). Comparison of the two groups' responses to resuscitation yielded some differences. There was a significant overshoot (30 mmHg) in systemic arterial blood pressure accompanied by bradycardia in Group II only. Cardiac output recovered in both groups but was less well sustained in Group II. Cerebral blood flow rose higher and hepatic arterial flow-increment was less in Group II than in Group I; the responses to resuscitation in the other organs were comparable. Colloid osmotic pressure decreased in Group I whereas it rose immediately after resuscitation in Group II, declining thereafter with a converging trend and 30 minutes thereafter the differences were not significant between the groups. Urine excretion and creatinine clearance recovered to comparable extents in both groups, but N-acetyl-beta-D-glucosaminidase (N.A.G.) excretion rose over 10-fold higher in Group II than in Group I. These experiments have defined the response of bled animals to resuscitation with unmodified, unpurified SFHS, when compared to resuscitation with whole blood, showing a less well sustained but adequate hemodynamic and renal functional recovery while revealing indications of early renal tubular cellular injury, providing baseline comparison for testing highly purified and modified hemoglobin solutions.

Effects of a stroma-free hemoglobin and perfluorochemical combination on ultrastructure and function of the isolated rat kidney

Experimental perfusions of isolated rat kidneys were performed with flow rates adjusted to produce comparable glomerular filtration rates (GFR) in control and experimental groups. The experimental perfusate, consisting of Krebs-Ringer bicarbonate (KRB) containing 3.5% (uncrosslinked) stroma-free hemoglobin (SFH) plus 3.5% of the perfluorochemical (PFC) Fluosol-DA, was found to produce only 48% as much urine as the control perfusate consisting of KRB containing 7% dextran (without either SFH or PFC). Perfusion with the experimental SFH/PFC mixture was associated with mean fractional reabsorptions of sodium 3.3% greater and of potassium 5.1% lesser than perfusion with the control KRB (with dextran) solution (p < .05). The SFH/PFC mixture was localized histochemically to the capillaries and urinary spaces of glomeruli; and to the apical microvilli, basal laminae, and intracytoplasmic vacuoles of proximal renal tubular cells. Since the glomerular filtration rate was not a factor, decremental urine production appears to be associated with increased reabsorption of sodium, excretion of potassium, and proximal tubular uptake of the experimental SFH/PFC mixture by endocytosis.

Oxygen transport and cardiovascular effects of resuscitation from severe hemorrhagic shock using hemoglobin solutions

OBJECTIVE

To test the short-term efficacy of three hemoglobin solutions in restoring cardiac output, intravascular pressures, oxygen transport (DO2), and oxygen consumption (VO2) after resuscitation from severe hemorrhagic shock.

DESIGN

Prospective study.

SETTING

Research laboratory.

SUBJECTS

Beagle dogs.

INTERVENTIONS

After anesthesia and instrumentation, hemorrhagic shock was induced for 2 hrs by blood withdrawal to maintain systolic blood pressure at 50 mm Hg. Resuscitation then occurred with one of four different resuscitation fluids. One group of dogs was not resuscitated. Survival rate was monitored for 8 days.

MEASUREMENTS AND MAIN RESULTS

In 33 beagle dogs, cardiovascular variables (DO2 and VO2) were compared after resuscitation with 8% stroma-free hemoglobin, 4% or 8% pyridoxalated-hemoglobin-polyoxyethylene conjugate (PHP44 and PHP88, respectively), or autologous whole blood. The dogs were anesthetized, paralyzed, mechanically ventilated (FIO2 of 0.21), and instrumented with arterial and pulmonary artery catheters. An average of 63% of estimated blood volume was removed to maintain systolic blood pressure at 50 mm Hg for 2 hrs. The dogs then were either not resuscitated (n = 4) or resuscitated with 8% stroma-free hemoglobin (n = 7), PHP44 (n = 6), PHP88 (n = 8), or whole blood (n = 8), with a volume equivalent to the withdrawn blood. Cardiovascular variables, DO2, VO2, oxygen extraction ratios, and blood concentrations of lactic acid and catecholamines were determined before, and for < or = 6 hrs after, resuscitation from hemorrhagic shock. Blood smears were microscopically examined. In addition, the survival rate was monitored for 8 days after resuscitation. By 2 hrs of hemorrhagic shock, there was a large decrease in DO2 (p < .05) and an increase in oxygen extraction ratio from 0.27 to 0.70 (p < .05). There was a 3.5-fold increase in lactate concentrations and a 25-fold increase in catecholamine concentrations as compared with preshock values. All dogs not resuscitated died within 1.75 hrs after 2 hrs of shock. After resuscitation with whole blood, all cardiovascular and oxygen transport variables returned to approximately prehemorrhage values and remained so throughout the measurement period. After resuscitation with any hemoglobin solution, DO2 returned transiently to control values. However, recovery of DO2 was short-lived in all hemoglobin solution groups, and, by 4 hrs postresuscitation in all groups, DO2 was less than the DO2 of the dogs receiving whole blood (p < .05). These changes were associated with decreases in total hemoglobin concentrations compared with the values immediately before resuscitation (p < .05). In addition, with resuscitation using the PHP solutions, blood smears demonstrated aggregation of red blood cells and platelets. On day 8 after hemorrhagic shock, the survival rate was 100% for whole blood and PHP44, 86% for 8% stroma-free hemoglobin, and 33% for PHP88.

CONCLUSIONS

Resuscitation from severe hemorrhagic shock with 8% stroma-free hemoglobin, PHP44, or PHP88 is equally effective in restoring cardiac index and vascular pressures as using whole blood. However, resuscitation with the three hemoglobin solutions only transiently restored DO2 after hemorrhagic shock. The subsequent reduction of DO2 compared with the DO2 value using whole blood was due mostly to hemodilution. With the two PHP solutions, formation of red blood cell aggregates probably resulted in sequestration of red cell mass and additional loss of oxygen carrying capacity.

Activation of complement by human hemoglobin and by mixtures of hemoglobin and bacterial endotoxin

Purified human hemoglobin is being developed as an alternative to transfusions of homologous erythrocytes. However, toxicity associated with infusion of hemoglobin has limited the development of this resuscitation fluid. Some observed toxicities, including activation of the complement cascade, have been associated with contamination of hemoglobin solutions by bacterial endotoxin. Recent studies have demonstrated complex formation between hemoglobin and endotoxin, and have documented a resultant increase in the ability of endotoxin to activate coagulation, stimulate tissue factor production by human peripheral blood mononuclear cells, and stimulate tissue factor activity and protein synthesis in cultured human endothelial cells. The process of hemoglobin enhancement of endotoxin toxicity suggests a possible mechanism by which the consequences of endotoxin contamination of hemoglobin solutions, including complement activation, could be magnified. Therefore, we studied the potential of hemoglobin to either fix complement directly, or modify the ability of endotoxin to fix complement. Human crosslinked and native hemoglobins, at concentrations between 0.2 mg/ml and 3 mg/ml, were shown to fix complement. Complement fixation by hemoglobin was identical in normal human serum or in factor B-depleted serum, suggesting that fixation occurred via the classical pathway of complement activation. Complement fixation then was examined with a battery of smooth and rough endotoxins tested in the absence and presence of hemoglobin. Addition of hemoglobin to a solution of a rough Salmonella endotoxin partial structure, from which a single fatty acid had been hydrolyzed from the lipid A portion of the macromolecule, resulted in decreased efficiency of complement fixation. However, addition of hemoglobin had little or no effect on the intrinsic complement fixing abilities of eight other smooth endotoxins, rough endotoxins, or endotoxin partial structures. Our results demonstrated the ability of hemoglobin to fix complement at hemoglobin concentrations which would be achieved during infusion for resuscitation, but failed to demonstrate a reproducible effect of hemoglobin on the activation of complement by endotoxin.

Complement activation by liposome-encapsulated hemoglobin in vitro: the role of endotoxin contamination

Incubation of liposome-encapsulated Hb (LEH) with rat serum at 37 degrees C led to accelerated decay of serum hemolytic complement (C) activity (CH50/ml). Empty liposomes (L) caused less decrease of CH50/ml, whereas free Hb had no effect on C activity. The LEH- and L-induced increases in C consumption were unlikely a consequence of endotoxin (LPS) contamination, as spiking of rat serum with LPS caused reduction in C only at levels significantly higher than those detectable in LEH or L. LPS-induced C consumption was not potentiated by free hemoglobin.

Diaspirin cross-linked hemoglobin improves neurological outcome following reversible but not irreversible CNS ischemia in rabbits

BACKGROUND AND PURPOSE

Hemodilution using modified hemoglobin solutions may reduce ischemic central nervous system injury. Purified diaspirin cross-linked hemoglobin (DCLHb) is a cell-free hemoglobin that is intramolecularly cross-linked between the two alpha subunits, resulting in enhanced oxygen offloading to tissues and increased half-life. In the present experiments, we evaluated the ability of DCLHb to reduce neurological damage in two rabbit stroke models.

METHODS

In a reversible spinal cord ischemia model, ischemia of the caudal lumbar spinal cord was produced by temporary occlusion of the abdominal aorta. In an irreversible model of cerebral ischemia, plastic microspheres (50 microns) were injected into the internal carotid artery and lodged in the cerebral microvasculature. DCLHb was administered 5 minutes after initiation of ischemia as either a 10-mL/kg infusion, 10-mL/kg exchange transfusion, or a 20-mL/kg infusion. Control animals received human serum albumin that was oncotically matched to the DCLHb.

RESULTS

In the spinal cord model, DCLHb significantly increased the duration of ischemia required to produce permanent paralysis from 27.33 +/- 8.71 minutes (mean +/- SD) in controls to 42.59 +/- 10.10 minutes in the 10-mL/kg exchange transfusion group and to 40.82 +/- 18.16 minutes in the 20-mL/kg infusion condition (P < .05). DCLHb did not significantly reduce neurological damage in the microsphere embolization model.

CONCLUSIONS

These data suggest that cross-linked hemoglobin reduces neurological damage after reversible central nervous system ischemia and that this is not attributable to hemodilution or hypervolemia only.

Lysophosphatidylcholine, a component of stromal phospholipids, as a candidate vasoconstrictive factor in stroma-free hemoglobin

Stroma-free hemoglobin (SFH) contains a trace amount of phospholipids, which has been implicated in the toxic reactions associated with SFH. We analyzed stromal phospholipids by high-performance liquid chromatography and found that SFH contained small quantities of lysophosphatidylcholine (LPC), which is known to be capable of producing a defect in endothelium-dependent arterial relaxation, in addition to major classes of constituent phospholipids in red cell membrane. LPC content was determined to be 1.65 nmol/ml (hemoglobin 8.1 g/dl). To evaluate the role of these stromal phospholipids in SFH-induced vasoconstriction, we next examined the effect of lipids on vascular tone in rabbit aortic strips. Preincubation with the crude lipid extract or the LPC purified from SFH significantly inhibited acetylcholine-induced relaxation in phenylephrine-precontracted tissues. The LPC-induced inhibition was reversed by incubation of the tissues in the absence of lipids, indicating the functional integrity of endothelium. From these results, we propose a possibility that LPC, a component of stromal phospholipids, is a candidate for vasoconstrictive factors present in SFH.

Acute beneficial effect of Fluosol-DA on urinary excretion of stroma-free hemoglobin in the isolated rat kidney

In a timed study over 75 min, divided into 5 15-min periods, experimental perfusions of isolated rat kidneys using Krebs-Ringer bicarbonate (KRB) containing 3.5% (uncrosslinked) stroma-free hemoglobin (SFH) plus 3.5% of the perfluorochemical Fluosol-DA were found to excrete only 13% as much total hemoglobin (Hb) as control perfusions using KRB containing 7% SFH alone (controls). The glomerular filtration rate was the same for experimentals and controls in 3 periods, and slightly higher in the experimentals in 2 periods. However, urine flow was found to be significantly decreased in all 5 periods for the experimentals relative to the controls. These effects can be explained by reabsorption of glomerular filtrate containing Hb by endocytosis of renal tubular cells.

Current status of injectable oxygen carriers

In this review the current status of what commonly are termed "blood substitutes" is discussed. The term blood substitute is a misnomer because the formulations under development at this time transport respiratory gases but do not perform the metabolic, regulatory, and protective functions of blood. Either hemoglobin or a perfluorochemical form the base to transport oxygen; the advantages and disadvantages of each base are discussed. The availability of a blood substitute in the U.S. will require approval by the Food and Drug Administration (FDA) and, by law, both its efficacy and safety must be demonstrated prior to approval. Showing efficacy of any blood substitute is complicated by the oxygen reserve and the compensatory mechanisms to acute blood loss in man. The challenge is to prove that the administration of these formulations offer clinical advantages compared with replacement of volume alone. Several efficacy models, the most attractive among them being perioperative hemodilution, should provide data that would bring these formulations into clinical practice. When hemoglobin is not within the favorable environment of the red cell, whether the hemoglobin is derived from expression vectors developed through recombinant biotechnology or from lysed human red cells, it acquires a left-shifted oxygen disassociation curve. Further, because the tetramer disassociates when injected intravenously and the resulting dimers are cleared rapidly from the circulation by the kidneys, intravascular dwell time is brief. Hemoglobins have been modified chemically and linked intramolecularly, intermolecularly, and to macromolecules to correct these problems. While these manipulations have normalized the p50 and extended the dwell time significantly, some toxicity problems remain unresolved. The binding of nitric oxide to hemoglobin preparations and the presumably resultant systemic and pulmonary hypertension observed in animals may be the most difficult to overcome, although the implications of these reactions in man is poorly understood. Perfluorochemicals (PFC) provide a fundamentally different and simpler approach to oxygen transport than hemoglobin formulations. Typically, the PFCs used are liquids composed of 8 to 10 carbon atoms that dissolve oxygen and obey Henry's law. Thus, the recipient's inspired oxygen and cardiac output assume importance. Because they are insoluble in water, PFCs are administered as emulsions, that is, as small droplets about 0.1 to 0.2 microns in diameter. In this respect, they are very similar to the lipid emulsions widely used for parenteral nutrition. Egg yolk phospholipid and poloxamers are most commonly used as emulsifiers. PFCs are not metabolized and are excreted unchanged by the lungs, following temporary storage by the monocyte-macrophage system (MMS).(ABSTRACT TRUNCATED AT 400 WORDS)

Transfusion and surgery

In this survey of transfusion in surgery, we have attempted to provide the surgeon with an understanding of the problems associated with homologous transfusion and a practical knowledge of treatment strategies and alternatives designed to reduce homologous blood exposure. Such a review cannot be encyclopedic. Our hope is that it will serve the reader as a stimulus to examine his or her transfusion practices and as a guide for future self-learning.

Effects of intravenous infusions of diaspirin cross-linked hemoglobin (DCLHb) on sheep

The purpose of this study was to compare the cardiopulmonary, hematologic, and immunologic responses of unanesthetized sheep to single, "topload", intravenous infusions of either 10 mL/Kg or 40 mL/Kg of Diaspirin Cross-Linked Hemoglobin, 10 mL/Kg or 40 mL/Kg of a Human Serum Albumin (HSA) solution oncotically adjusted with human serum albumin to approximately match the oncotic pressure of the DCLHb, or 10 mL/Kg of Erythrocyte Hemolysate solution prepared in a manner similar to that commonly described in the literature and referred to as "stroma free hemoglobin". Solutions were infused at a rate of 1 mL/Kg/minute and animals were monitored for 72 hours after infusion. These studies demonstrated that in sheep infusion of either DCLHb or HSA solutions was well tolerated and did not produce a significant increase in plasma C3a levels, an increase in the plasma concentration of thromboxane B2, or unexpected fluid shifts. In contrast, infusion of the Erythrocyte Hemolysate produced a greater than 10-fold increase in plasma C3a concentrations, a greater than 6000-fold increase in plasma TxB2 concentration, significant fluid shifts, and changes in a variety of other parameters consistent with induction of a dramatic inflammatory response. These results indicate that appropriately prepared and purified DCLHb solutions do not elicit an inflammatory reaction in sheep.

Systemic hemodynamic and renal effects of unmodified human SFHS in dogs

Isovolumic exchange transfusion (25% of total estimated blood volume) was carried out in the anesthetized dogs using 9 g/dl of unmodified human stroma-free hemoglobin solution (SFHS). The objective was to determine the systemic hemodynamic, blood distribution and renal effects of SFHS over a 2-3 hour period post-exchange. At 30 minutes after the exchange, blood pressure rose from 114 +/- 117 to 133 +/- 22 mmHg, but this rise was not sustained thereafter. Mean pulmonary arterial blood pressure rose from 8 +/- 3 to 13 +/- 2 mmHg, and remained above the pre-exchange level up to 3 hours post-exchange. Cardiac output remained within normal limits. Significant flow-increments were seen at 30 minutes in heart, brain, liver, gut, and kidney, but these were also not sustained. A fall in glomerular filtration rate (GFR) occurred after the exchange and remained below the pre-exchange level. A reduction in urine flow at 150 minutes post-exchange was observed and was accompanied by a reduction in urinary electrolyte excretion. The findings suggest that the initial effects of the administration of unmodified stroma-free hemoglobin solution are those of peripheral vasoconstriction which does not appear to significantly restrict flow to the vital organs, such as heart and brain. Unmodified hemoglobin was found to cause a decrease in renal function.

Studies on blood substitutes based on hemoglobin and perfluorocarbon

Unmodified, and to a lesser extent, modified stroma-free hemoglobin preparations have been reported to exhibit coronary and renal vasoconstrictor activity in isolated perfused hearts and kidneys. The physiological significance in vivo of such ex vivo demonstrated vasoconstriction has not yet been established. We have conducted a number of in vivo dog experiments designed to elucidate (a) whether free hemoglobin in the plasma phase contributes to diffusive oxygen supply to the tissues and (b) whether excessive vasoconstriction results in functional impairment. Our findings indicate that (a) the infusion of unmodified SFHS does not cause a significant disturbance of central hemodynamics, although it causes an elevation of the arterial blood pressure; the latter is accompanied by vasoconstriction in the skeletal muscle vascular bed and in the renal cortex; (b) there is no significant improvement of diffusive oxygen supply to the tissue at rest; and (c) that glutaraldehyde cross-linked SFHS administered to hypotensive dogs causes a brief further aggravation of hypotension as well as renal vasoconstriction accompanied by renal functional impairment. The findings suggest that coronary autoregulatory mechanisms in vivo can override the vasoconstrictor potency demonstrated in vitro, but the renal effects of SFHS containing unmodified hemoglobin can give rise to significant concern.

Resuscitation of bled dogs with pyridoxalated-polymerized hemoglobin solution

We bled 25% of estimated total blood volume, then infused pyridoxalated polymerized human stroma-free hemoglobin solution (PP-SFH) (10 g/dl) to dogs under anesthesia in a volume equal to the blood removed. Central hemodynamics, blood flow distribution to organs, and renal function were studied up to 2-3 hours following the infusion. Mean arterial pressure was reduced from 120 +/- 3 to 86 +/- 7 mmHg at the end of the 30-minute hypovolumic period and the cardiac output was reduced by 27%. Immediately following the PP-SFH infusion we observed a further fall in blood pressure (43%) caused by a fall in cardiac output which lasted for 10 minutes. Blood pressure was restored gradually with the continuation of the infusion and the cardiac output was restored and maintained well. During the hypovolumic period, blood flow to the heart, renal cortex, and liver were reduced, whereas normal flow to the renal medulla and brain were maintained. After the resuscitation, blood flow to the heart, brain, liver, and renal medulla significantly exceeded the normal range, but remained subnormal in the renal cortex. Glomerular filtration rate (GFR), urine flow, and electrolyte excretion were all reduced during the hypovolumic period and were not restored to the pre-bleed levels after the infusion.

The effects of alpha-alpha cross-linked hemoglobin on the feeding and locomotor activity of rats

The feeding and locomotor activities of rats were used as an assay for the potentially toxic effects of an oxygen-carrying blood substitute. Rats lived in individual cages where they could feed ad lib by pressing a lever once for each small food pellet, drink water, or run in a wheel; a 12-h light/dark cycle was continuously in effect. After being anesthetized and hemorrhaged one-third of their total blood volume, individual rats were resuscitated with one of the following fluids: their own shed blood (OB), bis(3,5-dibromosalicylfumarate) alpha-alpha cross-linked hemoglobin (HbXL), human serum albumin (HSA), or Ringer's lactate (RL). Rats in a fifth group were not resuscitated (NR). During the dark period on the day of hemorrhage, the food intake and running activity of rats in all groups decreased. Food intake and locomotor activity of rats in the HbXL, NR and OB groups were more suppressed than the HSA or RL groups. The food intake of rats in the HbXL and NR groups remained significantly more suppressed during the dark period of the first recovery day; running continued to be suppressed in the HbXL group on the first recovery day, but not the second recovery day. In an effort to determine the extent to which the rats in the HbXL group were impaired, an increasing number of lever presses was required for each food pellet beginning with recovery day number 3 for all treatment groups. As the ratio of presses per pellet was increased, food intake decreased and running increased for all groups; no differences between groups were significant.(ABSTRACT TRUNCATED AT 250 WORDS)