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Vadivel K, Zaiss AK, Kumar Y, Fabian FM, Ismail AEA, Arbing MA, Buchholz WG, Velander WH, Bajaj SP. Enhanced Antifibrinolytic Efficacy of a Plasmin-Specific Kunitz-Inhibitor (60-Residue Y11T/L17R with C-Terminal IEK) of Human Tissue Factor Pathway Inhibitor Type-2 Domain1. J Clin Med 2020; 9:E3684. [PMID: 33212896 PMCID: PMC7698382 DOI: 10.3390/jcm9113684] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 10/21/2020] [Indexed: 12/13/2022] Open
Abstract
Current antifibrinolytic agents reduce blood loss by inhibiting plasmin active sites (e.g., aprotinin) or by preventing plasminogen/tissue plasminogen activator (tPA) binding to fibrin clots (e.g., ε-aminocaproic acid and tranexamic acid); however, they have adverse side effects. Here, we expressed 60-residue (NH2NAE…IEKCOOH) Kunitz domain1 (KD1) mutants of human tissue factor pathway inhibitor type-2 that inhibit plasmin as well as plasminogen activation. A single (KD1-L17R-KCOOH) and a double mutant (KD1-Y11T/L17R- KCOOH) were expressed in Escherichia coli as His-tagged constructs, each with enterokinase cleavage sites. KD1-Y11T/L17R-KCOOH was also expressed in Pichia pastoris. KD1-Y11T/L17R-KCOOH inhibited plasmin comparably to aprotinin and bound to the kringle domains of plasminogen/plasmin and tPA with Kd of ~50 nM and ~35 nM, respectively. Importantly, compared to aprotinin, KD1-L17R-KCOOH and KD1-Y11T/L17R-KCOOH did not inhibit kallikrein. Moreover, the antifibrinolytic potential of KD1-Y11T/L17R-KCOOH was better than that of KD1-L17R-KCOOH and similar to that of aprotinin in plasma clot-lysis assays. In thromboelastography experiments, KD1-Y11T/L17R-KCOOH was shown to inhibit fibrinolysis in a dose dependent manner and was comparable to aprotinin at a higher concentration. Further, KD1-Y11T/L17R-KCOOH did not induce cytotoxicity in primary human endothelial cells or fibroblasts. We conclude that KD1-Y11T/L17R-KCOOH is comparable to aprotinin, the most potent known inhibitor of plasmin and can be produced in large amounts using Pichia.
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Affiliation(s)
- Kanagasabai Vadivel
- Department of Orthopedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA; (K.V.); (A.K.Z.); (Y.K.)
| | - Anne K. Zaiss
- Department of Orthopedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA; (K.V.); (A.K.Z.); (Y.K.)
| | - Yogesh Kumar
- Department of Orthopedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA; (K.V.); (A.K.Z.); (Y.K.)
| | - Frank M. Fabian
- Department of Chemical and Biomolecular Engineering, University of Nebraska, Lincoln, NE 68588, USA; (F.M.F.); (A.E.A.I.); (W.G.B.); (W.H.V.)
- Chemistry Department, Walla Walla University, College Place, WA 99324, USA
| | - Ayman E. A. Ismail
- Department of Chemical and Biomolecular Engineering, University of Nebraska, Lincoln, NE 68588, USA; (F.M.F.); (A.E.A.I.); (W.G.B.); (W.H.V.)
| | - Mark A. Arbing
- Protein Expression Technology Center, UCLA-DOE Institute, University of California, Los Angeles, CA 90095, USA;
| | - Wallace G. Buchholz
- Department of Chemical and Biomolecular Engineering, University of Nebraska, Lincoln, NE 68588, USA; (F.M.F.); (A.E.A.I.); (W.G.B.); (W.H.V.)
| | - William H. Velander
- Department of Chemical and Biomolecular Engineering, University of Nebraska, Lincoln, NE 68588, USA; (F.M.F.); (A.E.A.I.); (W.G.B.); (W.H.V.)
| | - S. Paul Bajaj
- Department of Orthopedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA; (K.V.); (A.K.Z.); (Y.K.)
- Molecular Biology Institute, University of California, Los Angeles, CA 90095, USA
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Eshghpour M, Samieirad S, Attar AS, Kermani H, Seddigh S. Propofol Versus Remifentanil: Which One Is More Effective in Reducing Blood Loss During Orthognathic Surgery? A Randomized Clinical Trial. J Oral Maxillofac Surg 2018; 76:1882.e1-1882.e7. [PMID: 29902418 DOI: 10.1016/j.joms.2018.05.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Revised: 04/14/2018] [Accepted: 05/08/2018] [Indexed: 11/30/2022]
Abstract
PURPOSE Propofol and remifentanil are 2 useful drugs used in induced hypotensive anesthesia. The purpose of this study was to compare the effects of these drugs on intraoperative blood loss, transfusion requirements, and hemodynamic status during standardized orthognathic surgical procedures. MATERIALS AND METHODS In this double-blind randomized clinical trial, 50 consecutive healthy patients with Class III skeletal deformity were candidates for bimaxillary orthognathic surgery at Qaem Hospital, Mashhad University of Medical Sciences (Mashhad, Iran), from November 2016 until December 2017. These patients were randomly assigned to 2 equal-number groups to receive hypotensive anesthesia with propofol or remifentanil. Neither the surgeon nor the patients were aware of the study groups, whereas both the student and anesthesiologist were not blinded. Age and gender were recorded, and mean blood loss, mean arterial pressure, and mean heart rate, as well as duration of surgery and duration of general anesthesia, were monitored intraoperatively. The hypotensive anesthetic drugs were the primary predictor variables and the mean blood loss volume was the main outcome in this research. The independent t test and χ2 test were performed for data analysis using SPSS software (version 16; SPSS, Chicago, IL). RESULTS In this study, 25 patients with a mean age of 22.25 ± 3.31 years were investigated in each group. The mean blood loss volume was 578.26 ± 95.14 mL and 366.67 ± 64.92 mL in the propofol and remifentanil groups, respectively. The independent-samples t test showed that mean blood loss was significantly lower in the remifentanil group than in the propofol group (P = .001). Furthermore, the mean arterial blood pressure was significantly lower in the remifentanil group than in the propofol group (85 ± 20 mm Hg vs 95 ± 15 mm Hg, P < .001). CONCLUSIONS Hypotensive anesthesia with remifentanil, in comparison with propofol, significantly reduces mean blood loss during orthognathic surgery, which decreases the transfusion requirements and disadvantages of transfusion and blood loss.
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Affiliation(s)
- Majid Eshghpour
- Associate Professor, Oral and Maxillofacial Diseases Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Sahand Samieirad
- Assistant Professor, Oral and Maxillofacial Diseases Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Alireza Sharifian Attar
- Associate Professor, Endoscopic & Minimally Invasive Surgery Research Center, Department of Anesthesiology, Qaem Hospital, and Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hamed Kermani
- Assistant Professor, Oral and Maxillofacial Diseases Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Sadaf Seddigh
- Dental Student, Student Research Committee, Dentistry Faculty, Mashhad University of Medical Sciences, Mashhad, Iran.
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Walley H, Yacoub M, Saad H. Pharmacological management of perioperative bleeding in cardiac surgery. Glob Cardiol Sci Pract 2017; 2017:12. [PMID: 29644224 PMCID: PMC5871403 DOI: 10.21542/gcsp.2017.12] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 05/29/2017] [Indexed: 01/04/2023] Open
Abstract
[first paragraph of article]In spite of the growing discoveries in cardiac surgery, perioperative bleeding remains one of the most common causes of morbidity and mortality. Around 50-60% of cardiac surgery patients receive blood transfusions, which are harmful and strongly associated with increased morbidity, mortality, hospital stay, and hospital cost. Patients taken back to the OR for re-exploration and control of bleeding after cardiac surgery, have a four-fold increase in the incidence of sternal infection and mortality.
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Myles PS. Antifibrinolytics, aspirin and cardiac surgery: evidence, guidelines and implications for current research. Anaesth Intensive Care 2014; 42:293-7. [PMID: 24847551 DOI: 10.1177/0310057x1404200303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Kumar Y, Vadivel K, Schmidt AE, Ogueli GI, Ponnuraj SM, Rannulu N, Loo JA, Bajaj M, Bajaj SP. Decoy plasminogen receptor containing a selective Kunitz-inhibitory domain. Biochemistry 2014; 53:505-17. [PMID: 24383758 PMCID: PMC3985851 DOI: 10.1021/bi401584b] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Revised: 12/31/2013] [Indexed: 11/29/2022]
Abstract
Kunitz domain 1 (KD1) of tissue factor pathway inhibitor-2 in which P2' residue Leu17 (bovine pancreatic trypsin inhibitor numbering) is mutated to Arg selectively inhibits the active site of plasmin with ∼5-fold improved affinity. Thrombin cleavage (24 h extended incubation at a 1:50 enzyme-to-substrate ratio) of the KD1 mutant (Leu17Arg) yielded a smaller molecule containing the intact Kunitz domain with no detectable change in the active-site inhibitory function. The N-terminal sequencing and MALDI-TOF/ESI data revealed that the starting molecule has a C-terminal valine (KD1L17R-VT), whereas the smaller molecule has a C-terminal lysine (KD1L17R-KT). Because KD1L17R-KT has C-terminal lysine, we examined whether it could serve as a decoy receptor for plasminogen/plasmin. Such a molecule might inhibit plasminogen activation as well as the active site of generated plasmin. In surface plasmon resonance experiments, tissue plasminogen activator (tPA) and Glu-plasminogen bound to KD1L17R-KT (Kd ∼ 0.2 to 0.3 μM) but not to KD1L17R-VT. Furthermore, KD1L17R-KT inhibited tPA-induced plasma clot fibrinolysis more efficiently than KD1L17R-VT. Additionally, compared to ε-aminocaproic acid KD1L17R-KT was more effective in reducing blood loss in a mouse liver-laceration injury model, where the fibrinolytic system is activated. In further experiments, the micro(μ)-plasmin-KD1L17R-KT complex inhibited urokinase-induced plasminogen activation on phorbol-12-myristate-13-acetate-stimulated U937 monocyte-like cells, whereas the μ-plasmin-KD1L17R-VT complex failed to inhibit this process. In conclusion, KD1L17R-KT inhibits the active site of plasmin as well as acts as a decoy receptor for the kringle domain(s) of plasminogen/plasmin; hence, it limits both plasmin generation and activity. With its dual function, KD1L17R-KT could serve as a preferred agent for controlling plasminogen activation in pathological processes.
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Affiliation(s)
- Yogesh Kumar
- Department
of Orthopaedic Surgery, UCLA School of Medicine, Los Angeles, California 90095, United States
| | - Kanagasabai Vadivel
- Department
of Orthopaedic Surgery, UCLA School of Medicine, Los Angeles, California 90095, United States
| | - Amy E. Schmidt
- Department
of Pathology and Laboratory Medicine, Indiana
University School of Medicine, Indianapolis, Indiana 46202, United States
| | - Godwin I. Ogueli
- Department
of Orthopaedic Surgery, UCLA School of Medicine, Los Angeles, California 90095, United States
| | - Sathya M. Ponnuraj
- Department
of Orthopaedic Surgery, UCLA School of Medicine, Los Angeles, California 90095, United States
| | - Nalaka Rannulu
- Department
of Chemistry and Biochemistry, UCLA, Los Angeles, California 90095, United States
| | - Joseph A. Loo
- Department
of Chemistry and Biochemistry, UCLA, Los Angeles, California 90095, United States
- Molecular
Biology Institute, UCLA, Los Angeles, California 90095, United States
| | - Madhu
S. Bajaj
- Department
of Medicine, Division of Pulmonary, and Critical Care Medicine, David
Geffen School of Medicine, UCLA, Los Angeles, California 90095, United States
| | - S. Paul Bajaj
- Department
of Orthopaedic Surgery, UCLA School of Medicine, Los Angeles, California 90095, United States
- Molecular
Biology Institute, UCLA, Los Angeles, California 90095, United States
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Sepah YJ, Umer M, Ahmad T, Nasim F, Chaudhry MU, Umar M. Use of tranexamic acid is a cost effective method in preventing blood loss during and after total knee replacement. J Orthop Surg Res 2011; 6:22. [PMID: 21600028 PMCID: PMC3117744 DOI: 10.1186/1749-799x-6-22] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2010] [Accepted: 05/21/2011] [Indexed: 02/07/2023] Open
Abstract
Background & Purpose Allogenic blood transfusion in elective orthopaedic surgery is best avoided owing to its associated risks. Total knee replacement often requires blood transfusion, more so when bilateral surgery is performed. Many strategies are currently being employed to reduce the amount of peri-operative allogenic transfusions. Anti-fibrinolytic compounds such as aminocaproic acid and tranexamic acid have been used systemically in perioperative settings with promising results. This study aimed to evaluate the effectiveness of tranexamic acid in reducing allogenic blood transfusion in total knee replacement surgery. Methodology This was a retrospective cohort study conducted on patients undergoing total knee replacement during the time period November 2005 to November 2008. Study population was 99 patients, of which 70 underwent unilateral and 29 bilateral knee replacement. Forty-seven patients with 62 (49.5%) knees (group-I) had received tranexamic acid (by surgeon preference) while the remaining fifty-two patients with 66 (51.5%) knees (group-II) had did not received any tranexamic acid either pre- or post-operatively. Results The mean drop in the post-operative haemoglobin concentration in Group-II for unilateral and bilateral cases was 1.79 gm/dl and 2.21 gm/dl, with a mean post-operative drainage of 1828 ml (unilateral) and 2695 ml (bilateral). In comparison, the mean drop in the post-op haemoglobin in Group-I was 1.49 gm/dl (unilateral) and 1.94 gm/dl (bilateral), with a mean drainage of 826 ml (unilateral) and 1288 ml (bilateral) (p-value < 0.001). Interpretation Tranexamic acid is effective in reducing post-operative drainage and requirement of blood transfusion after knee replacement.
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Affiliation(s)
- Yasir J Sepah
- Aga Khan University Medical College, Karachi-74800, Pakistan
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Bajaj MS, Ogueli GI, Kumar Y, Vadivel K, Lawson G, Shanker S, Schmidt AE, Bajaj SP. Engineering kunitz domain 1 (KD1) of human tissue factor pathway inhibitor-2 to selectively inhibit fibrinolysis: properties of KD1-L17R variant. J Biol Chem 2010; 286:4329-40. [PMID: 21115497 DOI: 10.1074/jbc.m110.191163] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Tissue factor pathway inhibitor-2 (TFPI-2) inhibits factor XIa, plasma kallikrein, and factor VIIa/tissue factor; accordingly, it has been proposed for use as an anticoagulant. Full-length TFPI-2 or its isolated first Kunitz domain (KD1) also inhibits plasmin; therefore, it has been proposed for use as an antifibrinolytic agent. However, the anticoagulant properties of TFPI-2 or KD1 would diminish its antifibrinolytic function. In this study, structure-based investigations and analysis of the serine protease profiles revealed that coagulation enzymes prefer a hydrophobic residue at the P2' position in their substrates/inhibitors, whereas plasmin prefers a positively charged arginine residue at the corresponding position in its substrates/inhibitors. Based upon this observation, we changed the P2' residue Leu-17 in KD1 to Arg (KD1-L17R) and compared its inhibitory properties with wild-type KD1 (KD1-WT). Both WT and KD1-L17R were expressed in Escherichia coli, folded, and purified to homogeneity. N-terminal sequences and mass spectra confirmed proper expression of KD1-WT and KD1-L17R. Compared with KD1-WT, the KD1-L17R did not inhibit factor XIa, plasma kallikrein, or factor VIIa/tissue factor. Furthermore, KD1-L17R inhibited plasmin with ∼6-fold increased affinity and effectively prevented plasma clot fibrinolysis induced by tissue plasminogen activator. Similarly, in a mouse liver laceration bleeding model, KD1-L17R was ∼8-fold more effective than KD1-WT in preventing blood loss. Importantly, in this bleeding model, KD1-L17R was equally or more effective than aprotinin or tranexamic acid, which have been used as antifibrinolytic agents to prevent blood loss during major surgery/trauma. Furthermore, as compared with aprotinin, renal toxicity was not observed with KD1-L17R.
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Affiliation(s)
- Madhu S Bajaj
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine, UCLA, Los Angeles, California 90095, USA
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Abstract
Blood conservation, specifically the avoidance of allogeneic blood transfusion, is becoming an important aspect of preoperative planning and intraoperative decision making in orthopaedic surgery. Knee and hip arthroplasty, as well as certain spine procedures, place patients at risk of significant blood loss. Fibrin sealants are topically applied hemostatic agents that reduce the time required to achieve hemostasis as well as the volume of blood loss. Fibrin sealants may provide additional benefits beyond hemostasis, such as improvements in wound healing and postoperative range of motion as well as lower rates of wound infections.
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Abstract
Aprotinin has been associated with increased renal failure and mortality when used in cardiac surgery. The purpose of this retrospective study was to compare the incidence of renal failure and mortality in our patient population to the published rates, accounting for risk factors associated with renal failure. After IRB approval; using the STS Database and cardiopulmonary bypass pump records, a total of 2292 cardiac patients were identified from January 2004 through June 2008. Forty-nine patients were excluded because they were on renal dialysis preoperatively. There were 1226 coronary artery bypass patients. Patients were separated into groups, according to which antifibrinolytic agent was used. This study included a total of 716 patients, divided into three groups; aprotinin ( n = 436), tranexamic acid ( n = 61), and off-pump coronary artery bypass (OPCAB) ( n = 219). Epsilon aminocaproic acid (AMICAR) was given by the anesthesiologist to the majority of the remaining 510 patients and was not recorded on the bypass record. Therefore, patients given AMICAR were not included in this study. Outcomes included renal dialysis after surgery and mortality. Risk factors were identified and compared to patients in a study published by Mangano in the New England Journal of Medicine (N Engl J Med 2006; 354: 353–365). Aprotinin vs. control group showed no significant difference in risk factors for diabetes mellitus, hypertension, creatinine level above 1.3 mg/dl, or low ejection fraction. The percentage of patients requiring renal dialysis and mortality was less in Medical University of South Carolina (MUSC) patients than the other published study. Overall, the patients in the MUSC study had greater risk factors for renal failure, with the exception of patients with preoperative serum creatinine of >1.3 mg/dl (8.3 vs. 15.1%). This study does not show the same risk for renal failure associated with aprotinin that has been published elsewhere.
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Affiliation(s)
- JL Barnum
- Division of Cardiovascular Perfusion, College of Health Professions, Medical University of South Carolina, USA
| | - JJ Sistino
- Division of Cardiovascular Perfusion, College of Health Professions, Medical University of South Carolina, USA
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Nguyen MT, Dent CL, Ross GF, Harris N, Manning PB, Mitsnefes MM, Devarajan P. Urinary aprotinin as a predictor of acute kidney injury after cardiac surgery in children receiving aprotinin therapy. Pediatr Nephrol 2008; 23:1317-26. [PMID: 18506488 DOI: 10.1007/s00467-008-0827-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2008] [Revised: 02/14/2008] [Accepted: 02/14/2008] [Indexed: 12/24/2022]
Abstract
Proteomic analysis has revealed potential early biomarkers of acute kidney injury (AKI) in children undergoing cardiopulmonary bypass (CPB), the most prominent one with a mass-to-charge ratio of 6.4 kDa. The objective of this study was to identify this protein and test its utility as a biomarker of AKI. Trypsin-digested protein bands were analyzed by tandem mass spectrometry (MS/MS) to identify the protein in urine samples. Surface-enhanced laser desorption/ionization time-of-flight analysis and a functional activity assay were performed to quantify urinary levels in a pilot study of 106 pediatric patients undergoing CPB. The protein was identified as aprotinin. Urinary aprotinin levels 2 h after initiation of CPB were predictive of AKI (for functional assay: 92% sensitivity, 96% specificity, area under the curve of 0.98). By multivariate analysis, the urinary aprotinin level 2 h after CPB was an independent predictor of AKI (beta = 0.001, P < 0.0001). The 2 h urinary aprotinin level correlated with serum creatinine, duration of AKI, and length of hospital stay. We concluded that urinary aprotinin levels 2 h after initiation of CPB predict the development of AKI and adverse clinical outcomes.
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Abstract
Systemic haemostatic agents play an important role in the management of blood loss during major surgery where significant blood loss is likely and their use has increased in recent times as a consequence of demand for blood products outstripping supply and the risks associated with transfusions. Their main application is as prophylaxis to reduce bleeding in major surgery, including cardiac and orthopaedic surgery and orthotopic liver transplantation. Aprotinin has been the predominant agent used in this setting; of the other antifibrinolytic agents that have been studied, tranexamic acid is the most effective and epsilon-aminocaproic acid may also have a role. Eptacog alfa (recombinant factor VIIa) has also shown promise. Tranexamic acid, epsilon-aminocaproic acid and eptacog alfa are generally well tolerated; however, when considering the methods to reduce or prevent blood loss intra- and postoperatively, the benefits of these agents need to be weighed against the risk of adverse events. Recently, concerns have been raised about the safety of aprotinin after an association between increased renal dysfunction and mortality was shown in retrospective observational studies and an increase in all-cause mortality with aprotinin relative to tranexamic acid or epsilon-aminocaproic acid was seen after a pre-planned periodic analysis of the large BART (Blood conservation using Antifibrinolytics in a Randomized Trial) study. The latter finding resulted in the trial being halted, and aprotinin has subsequently been withdrawn from the market pending detailed analysis of efficacy and safety results from the study. Part 1 of this benefit-risk review examines the efficacy and adverse effect profiles of systemic haemostatic agents commonly used in surgery, and provides individual benefit-risk profiles that may assist clinicians in selecting appropriate pharmacological therapy in this setting.
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Affiliation(s)
- Ian S Fraser
- Department of Obstetrics and Gynaecology, University of Sydney, Sydney, New South Wales, Australia.
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Lindvall G, Sartipy U, Ivert T, van der Linden J. Aprotinin is Not Associated With Postoperative Renal Impairment After Primary Coronary Surgery. Ann Thorac Surg 2008; 86:13-9. [DOI: 10.1016/j.athoracsur.2008.03.033] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2008] [Revised: 03/14/2008] [Accepted: 03/18/2008] [Indexed: 11/26/2022]
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Abstract
Many coronary patients on antiplatelet (PLT) drugs require coronary artery bypass grafting surgery under conditions that may not allow sufficient time for or warrant discontinuation of anti-PLT treatment. Recent clinical data show that intraoperative aprotinin significantly reduces postoperative bleeding and transfusion requirements in this patient population. If surgical bleeding persists, the administration of Factor VIIa should be considered.
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Affiliation(s)
- Jan van der Linden
- Department of Cardiothoracic Surgery and Anesthesiology, Karolinska University Hospital, Stockholm, Sweden.
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Abstract
Evidence-based medicine depends on research that is reliable, well conducted, and free of influence from interest groups (which are not confined to industry). There are many ways to influence the outcome of clinical research, and the history of influence in research related to tobacco is illuminating in this regard. Health care depends on industry, and if properly managed, the relationship between industry and medical academia can be symbiotic. Achieving positive outcomes from such relationships depends on ensuring the presence of the elements needed for reasonable independence on the part of investigators, and on understanding the ways in which influence can be exerted over the production and publication of evidence. Regulation cannot substitute for integrity, particularly the integrity of the investigators. Pushing the limits of ethics in research threatens to undermine not only the reputation of those conducting the research but also the standing of science itself.
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Affiliation(s)
- Alan F Merry
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand.
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Pagano D, Howell NJ, Freemantle N, Cunningham D, Bonser RS, Graham TR, Mascaro J, Rooney SJ, Wilson IC, Cramb R, Keogh BE. Bleeding in cardiac surgery: The use of aprotinin does not affect survival. J Thorac Cardiovasc Surg 2008; 135:495-502. [DOI: 10.1016/j.jtcvs.2007.11.045] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2007] [Revised: 10/16/2007] [Accepted: 11/08/2007] [Indexed: 11/29/2022]
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Affiliation(s)
- Derek J Hausenloy
- The Hatter Cardiovascular Institute, University College London Hospital and Medical School, London WC1E 6HX, UK.
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Myles PS, Smith J, Knight J, Cooper DJ, Silbert B, McNeil J, Esmore DS, Buxton B, Krum H, Forbes A, Tonkin A. Aspirin and Tranexamic Acid for Coronary Artery Surgery (ATACAS) Trial: rationale and design. Am Heart J 2008; 155:224-30. [PMID: 18215590 DOI: 10.1016/j.ahj.2007.10.003] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2007] [Accepted: 10/01/2007] [Indexed: 12/24/2022]
Abstract
BACKGROUND Despite some concern that recent aspirin ingestion increases blood loss after coronary artery surgery, there is some evidence that this may reduce thrombotic complications. In contrast, antifibrinolytic drugs can reduce blood loss in this setting, but there is concern that they may increase thrombotic complications. Published guidelines are limited by a lack of large randomized trials addressing the risks and benefits of each of these commonly used therapies in cardiac surgery. The ATACAS Trial is a study comparing aspirin, tranexamic acid, or both, with placebo in patients undergoing on-pump or off-pump coronary artery surgery. METHODS We discuss the rationale for conducting ATACAS, a 4600-patient, multicenter randomized trial in at-risk coronary artery surgery, and the features of the ATACAS study design (objectives, end points, target population, allocation, treatments, patient follow-up, and analysis). CONCLUSIONS The ATACAS Trial will be the largest study yet conducted to ascertain the benefits and risks of aspirin and antifibrinolytic therapy in coronary artery surgery. Results of the trial will guide the routine clinical care of patients in this setting.
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Affiliation(s)
- Paul S Myles
- Department of Anaesthesia and Perioperative Medicine, Alfred Hospital, Melbourne, Victoria, Australia.
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de Cássia Dias S, Sakauchi D, Abreu PAE, de Lima Netto S, Iourtov D, Raw I, Kubrusly FS. Purification and characterization of aprotinin from porcine lungs. Biotechnol Lett 2007; 30:807-12. [PMID: 18071638 DOI: 10.1007/s10529-007-9622-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2007] [Revised: 11/27/2007] [Accepted: 11/27/2007] [Indexed: 11/30/2022]
Abstract
Aprotinin, the most studied serine proteinase inhibitor, was isolated from porcine lung for the first time. The purified porcine aprotinin had an Mr value of approximately 7 kDa. It cross-reacted with polyclonal serum anti-commercial aprotinin. About 1 microg porcine aprotinin inhibited 6 microg trypsin whereas 1 microg commercial soybean inhibitor inhibited only 1 microg trypsin. The aprotinin gene was also isolated from porcine lung: the deduced amino acid sequence showed 74% identity to bovine aprotinin.
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Affiliation(s)
- Sandra de Cássia Dias
- Centro de Biotecnologia, Avenida Vital Brasil, 1500, 05503-900, Sao Paulo, SP, Brazil
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Backer CL, Kelle AM, Stewart RD, Suresh SC, Ali FN, Cohn RA, Seshadri R, Mavroudis C. Aprotinin is safe in pediatric patients undergoing cardiac surgery. J Thorac Cardiovasc Surg 2007; 134:1421-6; discussion 1426-8. [DOI: 10.1016/j.jtcvs.2007.08.006] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2007] [Revised: 07/19/2007] [Accepted: 08/07/2007] [Indexed: 10/22/2022]
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Van der Linden PJ, Hardy JF, Daper A, Trenchant A, De Hert SG. Cardiac surgery with cardiopulmonary bypass: does aprotinin affect outcome? Br J Anaesth 2007; 99:646-52. [PMID: 17855736 DOI: 10.1093/bja/aem252] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Aprotinin, a non-specific serine protease inhibitor, has been used for two decades to reduce perioperative blood loss and the risk for allogeneic transfusion in cardiac surgery. This study evaluated the effects of aprotinin on outcome (mortality, cardiac events, renal failure, and cerebrovascular events) in such patients undergoing cardiac surgery with cardiopulmonary bypass. METHODS Data were obtained in patients who received a strict blood conservation protocol: no antifibrinolytic therapy when at low risk (n = 854) and aprotinin (n = 1210) when at high risk for blood transfusion. Relative risk of different pre- and intra-operative variables was calculated for the different outcome variables. Backward stepwise logistic regression analysis was used to identify the independent risk factors associated with the different outcome variables. Statistical significance was accepted at P < 0.01. RESULTS Postoperative mortality and morbidity were higher in the aprotinin group but this was related to an increased incidence of perioperative risk factors. Mortality was similar to that predicted by the Euroscore. Complex surgery was the only independent variable associated with postoperative cardiac events. Preoperative heart failure, preoperative creatinine > 1.5 mg dl(-1), urgent, and redo surgery were the independent variables associated with postoperative haemodialysis. Age > 70 yr was identified as the only independent variable associated with neurologic dysfunction. CONCLUSIONS In the present study, patients receiving aprotinin as part of a strict blood conservation strategy represent a population at high risk for postoperative complications. For the outcome variables studied, aprotinin administration was not identified as an independent risk factor.
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Affiliation(s)
- P J Van der Linden
- Department of Anaesthesiology, Centre Hospitalier Universitaire Brugmann, Hôpital Universitaire des Enfants Reine Fabiola, Brussels, Belgium
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Abstract
Correct management of anaphylaxis during anaesthesia requires a multidisciplinary approach with prompt recognition and treatment of the acute event by the attending anaesthesiologist, and subsequent determination of the responsible agent(s) with strict avoidance of subsequent administration of all incriminated and/or cross-reacting compounds. However, correct identification of the causative compound(s) and safe alternatives is not always straightforward and, too often, not done. This review is not intended to discuss acute management of anaesthesia-related anaphylaxis but summarizes the major causes of anaphylaxis during anaesthesia and the diagnostic approach of this rare but potentially life-threatening complication. Apart from general principles about the diagnostic approach, history taking and importance of tryptase quantification, more specific confirmatory diagnostic procedures are organized on the basis of the major causes of perioperative anaphylactic reactions.
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Affiliation(s)
- D G Ebo
- Department of Immunology, Allergology and Rheumatology, University of Antwerp, Antwerpen, Belgium
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