Hemoglobin-Based Oxygen Carriers: Where Are We Now in 2023?

Advanced delivery systems for oxygen therapeutics: center around red blood cells

Oxygen therapeutics hold great potential as alternatives to red blood cell/whole blood transfusions. The development of hemoglobin-based oxygen carriers began in the 1930s, but, regrettably, none have received FDA approval. This review starts with an overview of red blood cell physiology and then focuses on hemoglobin-based oxygen therapeutics (including modified and encapsulated hemoglobin) as well as red blood cell mimetics, particularly regarding their size and shape. The review also addresses the different approaches to hemoglobin-based oxygen carriers.

Pro-Oxidative and Inflammatory Actions of Extracellular Hemoglobin and Heme: Molecular Events and Implications for Alzheimer's and Parkinson Disease

Hemoglobin (Hb) and heme, which are typically confined within red blood cells (RBCs), are essential for intravascular transport of gases and nutrients. However, these molecules acquire secondary functions upon exposure to the extracellular environment. Hb and heme generate reactive oxygen species (ROS), which are potent pro-inflammatory agents that contribute to oxidative stress and cellular damage. These events are relevant to neurodegenerative processes, where oxidative stress, irregular deposition of protein aggregates, and chronic inflammation are key pathological features. Extracellular Hb, heme, and oxidative stress derived from hemorrhagic events or RBC lysis may contribute to increased blood-brain barrier (BBB) permeability. These events allow Hb and heme to interact with neuroimmune cells and pathological protein aggregates, further amplifying pro-inflammatory signaling and the progression of Alzheimer's disease (AD) and Parkinson disease (PD). Chronic neuroinflammation, oxidative stress, and mitochondrial dysfunction lead to neuronal degeneration. Here, we sought to elucidate the pro-oxidative and inflammatory actions of extracellular Hb and heme, emphasizing their potential impact on AD and PD development.

Effect of Lipid Composition and Stirring Dynamics on Oxygen Microbubble Stability and Oxygen Release

Lipid-coated oxygen microbubbles (OMBs) are being investigated for biomedical applications to alleviate hypoxia such as systemic oxygenation and image-guided radiosensitization therapy. Additionally, they hold potential for boarder application as oxygen carriers beyond the biomedical filed. Understanding the stability and oxygen release properties of OMBs in dynamic aqueous environments is critical for these applications. In this study, we found that OMBs composed of longer acyl chain phospholipids (DSPC and DBPC) were stable in storage for at least 1 week, unlike the shorter acyl chain phospholipid (DPPC). OMBs were also more stable with a diacyl PEG-PE emulsifier compared with single-chain PEG-40 stearate. Dilution of OMBs did not alter the average diameter. While previous studies have examined the theoretical and experimental aspects of oxygen release from OMBs under static conditions, quantitative evaluations of OMB dispersions under dynamic stirring conditions remain limited. Here, we introduce a novel oxygen measurement method that quantitatively tracks the transition of the dissolved oxygen concentration in an aqueous medium upon mixing with a bolus of OMBs. Our results indicate that a 50 vol % OMB dispersion releases more than 330 mg/L of oxygen, surpassing arterial oxygen levels, and that more than 95% of this oxygen is released within 30 s. The rate of oxygenation of the OMB dispersions was comparable to that of a bolus injection of oxygen-saturated water under sufficient agitation, indicating that convection in the aqueous medium is the limiting transport mechanism. However, the lipid shell had a measurable effect on the oxygen release rate, which correlated with its oxygen permeability. Increasing the stirring speed increased both oxygen release rate and total amount of oxygen released. Overall, this study elucidates the fundamental stability and mass transport properties of the OMB dispersions under practical stirring conditions.

An Evaluation of the Safety of Intravenous Injections of the Natural Extracellular Hemoglobin M101 in Dogs and Monkeys

Hemoglobin-based oxygen carriers have been developed to compensate the needs of blood for transfusions. Most of them were based on intracellular hemoglobin extracted from bovine or human blood, but unfortunately, this type of hemoglobin did not pass through the last steps of clinical trials. In this context, HEMARINA discovered a natural extracellular hemoglobin, possessing several advantages avoiding intracellular hemoglobin-related side effects. Many preclinical studies assessed the safety of M101 used in intravenous (IV) injection in rodents. To explore the safety of IV injections of M101 in large mammals, six dogs received each a single injection of liquid M101 according to a dose escalation with a 48 h follow-up. Then, two monkeys received multiple IV injections of the same dose of M101 every hour for seven hours. This study showed that single and multiple IV injections in dogs and monkeys did not cause clinical or histological lesions, nor did they induce immunological reactions. This makes M101 the best candidate to date for human use in emergency situations requiring blood and, in several diseases, causing hypoxia problems.

Therapeutic delivery of oxygen using artificial oxygen carriers demonstrates the possibility of treating a wide range of diseases

Artificial oxygen carriers have emerged as potential substitutes for red blood cells in situations of major blood loss, including accidents, surgical procedures, trauma, childbirth, stomach ulcers, hemorrhagic shock, and blood vessel ruptures which can lead to sudden reduction in blood volume. The therapeutic delivery of oxygen utilizing artificial oxygen carriers as red blood cell substitutes presents a promising avenue for treating a spectrum of disease models. Apart from that, the recent advancement of artificial oxygen carriers intended to supplant conventional blood transfusions draws significant attention due to the exigencies of warfare and the ongoing challenges posed by the COVID-19 pandemic. However, there is a pressing need to formulate stable, non-toxic, and immunologically inert oxygen carriers. Even though numerous challenges are encountered in the development of artificial oxygen carriers, their applicability extends to various medical treatments, encompassing elective and cardiovascular surgeries, hemorrhagic shock, decompression illness, acute stroke, myocardial infarction, sickle cell crisis, and proficient addressing conditions such as cerebral hypoxia. Therefore, this paper provides an overview of therapeutic oxygen delivery using assorted types of artificial oxygen carriers, including hemoglobin-based, perfluorocarbon-based, stem cell-derived, and oxygen micro/nanobubbles, in the treatment of diverse disease models. Additionally, it discusses the potential side effects and limitations associated with these interventions, while incorporating completed and ongoing research and recent clinical developments. Finally, the prospective solutions and general demands of the perfect artificial oxygen carriers were anticipated to be a reference for subsequent research endeavors.

Fluid resuscitation in trauma: What you need to know

ABSTRACT

There have been numerous changes in resuscitation strategies for severely injured patients over the last several decades. Certain strategies, such as aggressive crystalloid resuscitation, have largely been abandoned because of the high incidence of complications and worsening of trauma-induced coagulopathy. Significant emphasis has been placed on restoring a normal coagulation profile with plasma or whole blood transfusion. In addition, the importance of the lethal consequences of trauma-induced coagulopathy, such as hyperfibrinolysis, has been easily recognized by the use of viscoelastic testing, and its treatment with tranexamic acid has been extensively studied. Furthermore, the critical role of early intravenous calcium administration, even before blood transfusion administration, has been emphasized. Other adjuncts, such as fibrinogen supplementation with fibrinogen concentrate or cryoprecipitate and prothrombin complex concentrate, are being studied and incorporated in some of the institutional massive transfusion protocols. Finally, balanced blood component transfusion (1:1:1 or 1:1:2) and whole blood have become commonplace in trauma centers in North America. This review provides a description of recent developments in resuscitation and a discussion of recent innovations and areas for future investigation.

Oxygenation by Intravascular Photosynthesis Reduces Kidney Damage During ex Vivo Preservation

Several clinical issues are associated with reduced oxygen delivery to tissues due to impaired vascular perfusion; moreover, organs procured for transplantation are subjected to severe hypoxia during preservation. Consequently, alternative tissue oxygenation is an active field in biomedical research where several innovative approaches have been recently proposed. Among these, intravascular photosynthesis represents a promising approach as it relies on the intrinsic capacity of certain microorganisms to produce oxygen upon illumination. In this context, this work aims at the development of photosynthetic perfusable solutions that could be applied to preserve organs for transplantation purposes. Our findings demonstrate that a biocompatible physiological solution containing the photosynthetic microalgae Chlamydomonas reinhardtii can fulfill the metabolic oxygen demand of rat kidney slices in vitro. Furthermore, intravascular administration of this solution does not induce tissue damage in the rat kidneys. Moreover, kidney slices obtained from these algae-perfused organs exhibited significantly improved preservation after 24 h of incubation in hypoxia while exposed to light, resulting in reduced tissue damage and enhanced metabolic status. Overall, the results presented here contribute to the development of alternative strategies for tissue oxygenation, supporting the use of perfusable photosynthetic solutions for organ preservation in transplantation.

A multifaceted approach to investigate interactions of thifluzamide with haemoglobin

This study explores the interaction between the pesticide thifluzamide (TF) and haemoglobin (Hb) to understand potential structural changes that might affect Hb's function. Using a combination of UV-Visible and fluorescence spectroscopy, circular dichroism (CD), molecular docking, molecular dynamics (MD) simulations, and electrochemical methods, we investigated these interactions in detail. Spectroscopy results indicated the formation of a stable TF-Hb complex, with a binding constant of 6.64 × 105 M-1 at 298 K and a 1:1 binding ratio. The stability of this complex was confirmed by a free energy change (∆G) of -34.491 kJ mol-1. CD spectroscopy was employed to confirm structural changes in Hb due to thifluzamide binding. Molecular docking studies revealed that TF interacts with specific amino acids in Hb like ALA, HIS, VAL, LYS, and LEU, with a binding energy of -25.10 kJ mol-1. MD simulations supported these findings by showing conformational changes in Hb upon TF binding, as indicated by RMSD and RMSF analyses. Electrochemical experiments further confirmed the interaction, evidenced by a consistent decrease in the TF's peak in the presence of Hb. Overall, our findings shed light to understand the binding of TF with Hb, causing structural changes that could potentially impact its normal function. This research enhances our understanding of the biochemical effects of TF on Hb, which could have significant implications for biological systems.

Next generation preservation solution using synthetic enzymes added to polyhemoglobin to protect warm ischemic human hepatocytes and cardiomyocytes

This study investigates the potential improvement of polyhemoglobin's protective properties by the addition of 3 synthetic enzymes (neo-carbonic anhydrase, neo-catalase and neo-superoxide dismutase) to polyhemoglobin after 90 and 180 min of warm in-vitro ischemia (100% Nitrogen at 37 °C). Following the warm ischemic shock, cell cultures were subjected to various treatment solutions: Controls; PolyHb; 3 neoenzymes; PolyHb + 3 neoenzymes; PolyHb + 2 neoenzymes. The cultures were then incubated (Oxygen, 5% CO2 at 37 °C) for 24 h followed by several analyses. Compared to polyhemoglobin alone, this novel solution containing polyhemoglobin + 3 neoeznymes significantly increased the viability, cell growth, albumin production, protection against oxidative stress and cellular injury of human hepatocytes. Moreover, this also protects the viability of human cardiomyocytes. These findings suggest that it could be useful as a pre-transplant cell/organ preservation solution which, in the long-term, could contribute to the development of blood substitutes.

Engineering Synthetic Erythrocytes as Next-Generation Blood Substitutes

Blood scarcity is one of the main causes of healthcare disruptions worldwide, with blood shortages occurring at an alarming rate. Over the last decades, blood substitutes has aimed at reinforcing the supply of blood, with several products (e.g., hemoglobin-based oxygen carriers, perfluorocarbons) achieving a limited degree of success. Regardless, there is still no widespread solution to this problem due to persistent challenges in product safety and scalability. In this Review, we describe different advances in the field of blood substitution, particularly in the development of artificial red blood cells, otherwise known as engineered erythrocytes. We categorize the different strategies into natural, synthetic, or hybrid approaches, and discuss their potential in terms of safety and scalability. We identify synthetic engineered erythrocytes as the most powerful approach, and describe erythrocytes from a materials engineering perspective. We review their biological structure and function, as well as explore different methods of assembling a material-based cell. Specifically, we discuss how to recreate size, shape, and deformability through particle fabrication, and how to recreate the functional machinery through synthetic biology and nanotechnology. We conclude by describing the versatile nature of synthetic erythrocytes in medicine and pharmaceuticals and propose specific directions for the field of erythrocyte engineering.

OMX: A NOVEL OXYGEN DELIVERY BIOTHERAPEUTIC IMPROVES OUTCOMES IN AN OVINE MODEL OF CONTROLLED HEMORRHAGIC SHOCK

ABSTRACT

Hemorrhagic shock is a major source of morbidity and mortality worldwide. While whole blood or blood product transfusion is a first-line treatment, maintaining robust supplies presents significant logistical challenges, particularly in austere environments. OMX is a novel nonhemoglobin (Hb)-based oxygen carrier derived from the H-NOX (heme-nitric oxide/oxygen binding) protein family. Because of their engineered oxygen (O 2 ) affinities, OMX proteins only deliver O 2 to severely hypoxic tissues. Additionally, unlike Hb-based oxygen carriers, OMX proteins do not scavenge nitric oxide in the vasculature. To determine the safety and efficacy of OMX in supporting tissue oxygen delivery and cardiovascular function in a large animal model of controlled hemorrhage, 2-3-week-old lambs were anesthetized, intubated, and mechanically ventilated. Hypovolemic shock was induced by acute hemorrhage to obtain a 50% reduction over 30 min. Vehicle (n = 16) or 400 mg/kg OMX (n = 13) treatment was administered over 15 min. Hemodynamics, arterial blood gases, and laboratory values were monitored throughout the 6-h study. Comparisons between groups were made using t tests, Wilcoxon rank sum test, and Fisher's exact test. Survival was assessed using Kaplan-Meier curves and the log-rank test. We found that OMX was well-tolerated and significantly improved lactate and base deficit trends, and hemodynamic indices ( P < 0.05). Median survival time was greater in the OMX-treated group (4.7 vs. 6.0 h, P < 0.003), and overall survival was significantly increased in the OMX-treated group (25% vs. 85%, P = 0.004). We conclude that OMX is well-tolerated and improves metabolic, hemodynamic, and survival outcomes in an ovine model of controlled hemorrhagic shock.

Nanomaterial-related hemoglobin-based oxygen carriers, with emphasis on liposome and nano-capsules, for biomedical applications: current status and future perspectives

Oxygen is necessary for life and plays a key pivotal in maintaining normal physiological functions and treat of diseases. Hemoglobin-based oxygen carriers (HBOCs) have been studied and developed as a replacement for red blood cells (RBCs) in oxygen transport due to their similar oxygen-carrying capacities. However, applications of HBOCs are hindered by vasoactivity, oxidative toxicity, and a relatively short circulatory half-life. With advancements in nanotechnology, Hb encapsulation, absorption, bioconjugation, entrapment, and attachment to nanomaterials have been used to prepare nanomaterial-related HBOCs to address these challenges and pend their application in several biomedical and therapeutic contexts. This review focuses on the progress of this class of nanomaterial-related HBOCs in the fields of hemorrhagic shock, ischemic stroke, cancer, and wound healing, and speculates on future research directions. The advancements in nanomaterial-related HBOCs are expected to lead significant breakthroughs in blood substitutes, enabling their widespread use in the treatment of clinical diseases.

Controlled oxygen delivery to power tissue regeneration

Oxygen plays a crucial role in human embryogenesis, homeostasis, and tissue regeneration. Emerging engineered regenerative solutions call for novel oxygen delivery systems. To become a reality, these systems must consider physiological processes, oxygen release mechanisms and the target application. In this review, we explore the biological relevance of oxygen at both a cellular and tissue level, and the importance of its controlled delivery via engineered biomaterials and devices. Recent advances and upcoming trends in the field are also discussed with a focus on tissue-engineered constructs that could meet metabolic demands to facilitate regeneration.

The Application of Drugs and Nano-Therapies Targeting Immune Cells in Hypoxic Inflammation

Immune cells are pivotal in the dynamic interplay between hypoxia and inflammation. During hypoxic conditions, HIF-1α, a crucial transcription factor, facilitates the adaptation of immune cells to the hypoxic micro-environment. This adaptation includes regulating immune cell metabolism, significantly impacting inflammation development. Strategies for anti-inflammatory and hypoxic relief have been proposed, aiming to disrupt the hypoxia-inflammation nexus. Research extensively focuses on anti-inflammatory agents and materials that target immune cells. These primarily mitigate hypoxic inflammation by encouraging M2-macrophage polarization, restraining neutrophil proliferation and infiltration, and maintaining Treg/TH17 balance. Additionally, oxygen-releasing nano-materials play a significant role. By alleviating hypoxia and clearing reactive oxygen species (ROS), these nano-materials indirectly influence immune cell functions. This paper delves into the response of immune cells under hypoxic conditions and the resultant effects on inflammation. It provides a comprehensive overview of various therapies targeting specific immune cells for anti-inflammatory purposes and explores nano-materials that either carry or generate oxygen to alleviate anoxic micro-environments.

Research Progress in Oxygen Carrier Design and Application

Ischemia or hypoxia can lead to pathological changes in the metabolism and function of tissues and then lead to various diseases. Timely and effective blood resuscitation or improvement of hypoxia is very important for the treatment of diseases. However, there is a need to develop stable, nontoxic, and immunologically inert oxygen carriers due to limitations such as blood shortages, different blood types, and the risk of transmitting infections. With the development of various technologies, oxygen carriers based on hemoglobin and perfluorocarbon have been widely studied in recent years. This paper reviews the development and application of hemoglobin and perfluorocarbon oxygen carriers. The design of oxygen carriers was analyzed, and their application as blood substitutes or oxygen carriers in various hypoxic diseases was discussed. Finally, the characteristics and future research of ideal oxygen carriers were prospected to provide reference for follow-up research.

The artificial oxygen carrier erythrocruorin-characteristics and potential significance in medicine

The diminishing supply and increasing costs of donated blood have motivated research into novel hemoglobin-based oxygen carriers (HBOCs) that can serve as red blood cell (RBC) substitutes. HBOCs are versatile agents that can be used in the treatment of hemorrhagic shock. However, many of the RBC substitutes that are based on mammalian hemoglobins have presented key limitations such as instability and toxicity. In contrast, erythrocruorins (Ecs) are other types of HBOCs that may not suffer these disadvantages. Ecs are giant metalloproteins found in annelids, crustaceans, and some other invertebrates. Thus far, the Ecs of Lumbricus terrestris (LtEc) and Arenicola marina (AmEc) are the most thoroughly studied. Based on data from preclinical transfusion studies, it was found that these compounds not only efficiently transport oxygen and have anti-inflammatory properties, but also can be modified to further increase their effectiveness. This literature review focuses on the structure, properties, and application of Ecs, as well as their advantages over other HBOCs. Development of methods for both the stabilization and purification of erythrocruorin could confer to enhanced access to artificial blood resources.

Renal glomerular and tubular responses to glutaraldehyde- polymerized human hemoglobin

Hemoglobin-based oxygen carriers (HBOCs) are being developed as oxygen and volume replacement therapeutics, however, their molecular and cellular effects on the vasculature and different organ systems are not fully defined. Using a guinea pig transfusion model, we examined the renal glomerular and tubular responses to PolyHeme, a highly characterized glutaraldehyde-polymerized human hemoglobin with low tetrameric hemoglobin content. PolyHeme-infused animals showed no major changes in glomerular histology or loss of specific markers of glomerular podocytes (Wilms tumor 1 protein, podocin, and podocalyxin) or endothelial cells (ETS-related gene and claudin-5) after 4, 24, and 72 h. Relative to sham controls, PolyHeme-infused animals also showed similar expression and subcellular distribution of N-cadherin and E-cadherin, two key epithelial junctional proteins of proximal and distal tubules, respectively. In terms of heme catabolism and iron-handling responses, PolyHeme induced a moderate but transient expression of heme oxygenase-1 in proximal tubular epithelium and tubulointerstitial macrophages that was accompanied by increased iron deposition in tubular epithelium. Contrary to previous findings with other modified or acellular hemoglobins, the present data show that PolyHeme does not disrupt the junctional integrity of the renal glomerulus and tubular epithelium, and triggers moderate activation of heme catabolic and iron sequestration systems likely as part of a renal adaptive response.