A Novel Peritoneal Packing Method for Management of Hyperkalemia During Acute Kidney Injury in Trauma

INTRODUCTION

United States Military operations in resource limited areas are increasing. Furthermore, future peer or near-peer conflicts will require caring for larger numbers of casualties with limited resources. In this setting, traditional renal replacement therapy is not feasible and novel methods are required to address severe acute kidney injury in austere environments lacking definitive therapies. Here, we describe experiments designed to determine the efficacy of a novel peritoneal packing material (Potassium Binding Pack-PBP, CytoSorbents INC) for the acute management of severe hyperkalemia.

MATERIALS AND METHODS

Male swine (52 ±1 kg) were nephrectomized via midline laparotomy under a plane of anesthesia and randomized into one of two experimental groups (PBP & CON). Exogenous potassium was infused to achieve a serum potassium level of 7.5 mEq/L. Novel potassium absorbing packs (PBP) or sham packs (CON) were placed in the right and left upper quadrants, and the right and left paracolic gutters of the abdomen to simulate four-quadrant packing (n = 6, n = 5, respectively). Two liters of peritoneal dialysis fluid was instilled into the abdomen and temporary closure performed. Animals were observed for 12 hours. Serum and peritoneal fluid (dialysate) potassium levels were sampled at T = 15, 30, 60 min, and Q60min thereafter. Animals were humanely euthanized at the end of the observation period.

RESULTS

Baseline characteristics were similar between groups. Pairwise analysis showed that serum potassium concentrations were significantly lower in the PBP group compared to CON at T = 540 and T = 720 (P = 0.006 and P = 0.015, respectively). Potassium concentrations were significantly lower in dialysate of the PBP group compared to CON at all time points after T = 15 (T = 30, P = 0.017; T = 60 through T = 720, P < 0.001).

CONCLUSIONS

This is the first demonstration of an effective technology for the management of hyperkalemia in trauma in the absence of standard of care; renal replacement therapy. We identified that PBP was able to consistently maintain a concentration gradient between dialysate in the peritoneum and system potassium concentration throughout the experiment. Furthermore, systemic potassium concentrations were reduced in a clinically relevant manner in the PBP group compared to CON. This suggests that peritoneal packing technology for the management of metabolic disturbances in trauma has potential for clinical application. These results are preliminary and should be interpreted with caution.

K+ontrol rapidly and efficiently reduces potassium in donor blood during ex vivo circulation

BACKGROUND

Patients with kidney failure are at risk for lethal complications from hyperkalemia. Resuscitation, medications, and hemodialysis are used to mitigate increased potassium (K+) levels in circulating blood; however, these approaches may not always be readily available or effective, especially in a resource limited environment. We tested a sorbent cartridge (KC, K+ontrol CytoSorbents Medical Inc., Monmouth Junction, New Jersey) which contains a resin adsorber for K+. The objective of this study was to test the utility of KC in an ex vivo circulation system. We hypothesized that KC reduces K+ levels in extracorporeal circulation of donor swine whole blood infused with KCl.

METHODS

A six-hour circulation study was carried out using KC, a NxStage (NxStage Medical, Inc., Lawrence, MA) membrane, blood bag containing heparinized whole blood with KCl infusion, 3/16-inch ID tubing, a peristaltic pump, and flow sensors. The NxStage permeate line was connected back to the main circuit in the Control group (n = 6), creating a recirculation loop. For KC group (n = 6), KC was added to the recirculation loop, and a continuous infusion of KCl at 10 mEq/hour was administered for two hours. Blood samples were acquired at baseline and every hour for 6 h.

RESULTS

In the control group, K+ levels remained at ∼9 mmol/L; 9.1 ± 0.4 mmol/L at 6 h. In the KC group, significant decreases in K+ at hour 1 (4.3 ± 0.3 mmol/L) and were sustained for the experiment duration equilibrating at 4.6 ± 0.4 mmol/L after 6 h (p = 0.042). Main loop blood flow was maintained under 400 mL/min; recirculation loop flow varied between 60 and 70 mL/min in the control group and 45-55 mL/min in the KC group. Decreases in recirculation loop flow in KC group required 7% increase of pump RPM.

CONCLUSIONS

During ex-vivo extracorporeal circulation using donor swine blood, KC removed approximately 50% of K+, normalizing circulating levels.

Thiourea Dioxide As a Green and Affordable Reducing Agent for the ARGET ATRP of Acrylates, Methacrylates, Styrene, Acrylonitrile, and Vinyl Chloride

Thiourea dioxide, a green and inexpensive compound used at industrial scale, was employed as reducing agent for the controlled polymerization of a wide range of monomer families, namely, acrylates (methyl acrylate, 2-hydroxyethyl acrylate, butyl acrylate, methacrylates (2-(dimethylamino)ethyl methacrylate, 2-aminoethyl methacrylate hydrochloride, and methyl methacrylate), styrene, acrylonitrile, and vinyl chloride (nonactivated monomer) by ATRP. Mechanistic studies confirmed that the polymerizations are ruled by the activators regenerated by electron transfer (ARGET) mechanism. It is worth noting that vinyl chloride has never been polymerized by ARGET ATRP. The system proved to be very versatile and robust, working in organic solvents, organic/water mixtures, and aqueous medium at near room temperature with low metal catalyst concentration. Chain extension experiments confirmed the high chain-end functionality of the polymers, allowing the preparation of several well-defined block copolymers.

Broad adsorption of sepsis-related PAMP and DAMP molecules, mycotoxins, and cytokines from whole blood using CytoSorb® sorbent porous polymer beads

Objective

Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. In sepsis and septic shock, pathogen-associated molecular pattern molecules (PAMPS), such as bacterial exotoxins, cause direct cellular damage and/or trigger an immune response in the host often leading to excessive cytokine production, a maladaptive systemic inflammatory response syndrome response (SIRS), and tissue damage that releases DAMPs, such as activated complement and HMGB-1, into the bloodstream causing further organ injury. Cytokine reduction using extracorporeal blood filtration has been correlated with improvement in survival and clinical outcomes in experimental studies and clinical reports, but the ability of this technology to reduce a broader range of inflammatory mediators has not been well-described. This study quantifies the size-selective adsorption of a wide range of sepsis-related inflammatory bacterial and fungal PAMPs, DAMPs and cytokines, in a single compartment, in vitro whole blood recirculation system.

Measurements and main results

Purified proteins were added to whole blood at clinically relevant concentrations and recirculated through a device filled with CytoSorb^® hemoadsorbent polymer beads (CytoSorbents Corporation, USA) or control (no bead) device in vitro. Except for the TNF-α trimer, hemoadsorption through porous polymer bead devices reduced the levels of a broad spectrum of cytokines, DAMPS, PAMPS and mycotoxins by more than 50 percent.

Conclusions

This study demonstrates that CytoSorb^® hemoadsorbent polymer beads efficiently remove a broad spectrum of toxic PAMPS and DAMPS from blood providing an additional means of reducing the uncontrolled inflammatory cascade that contributes to a maladaptive SIRS response, organ dysfunction and death in patients with a broad range of life-threatening inflammatory conditions such as sepsis, toxic shock syndrome, necrotizing fasciitis, and other severe inflammatory conditions.

Addressing the role of triphenylphosphine in copper catalyzed ATRP

A new Atom Transfer Radical Polymerization (ATRP) process with triphenylphosphine (PPh₃) and [Cu^IIMe₆TREN]²⁺ as the catalyst system is reported.

Mechanism of Supplemental Activator and Reducing Agent Atom Transfer Radical Polymerization Mediated by Inorganic Sulfites: Experimental Measurements and Kinetic Simulations

The mechanism of atom transfer radical polymerization (ATRP) mediated by sodium dithionite (Na2S2O4), with CuIIBr2/Me6TREN as catalyst (Me6TREN: tris[2-(dimethylamino)ethyl]amine)) in ethanol/water mixtures, was investigated experimentally and by kinetic simulations. A kinetic model was proposed and the rate coefficients of the relevant reactions were measured. The kinetic model was validated by the agreement between experimental and simulated results. The results indicated that the polymerization followed the SARA ATRP mechanism, with a SO2•- radical anion derived from Na2S2O4, acting as both supplemental activator (SA) of alkyl halides and reducing agent (RA) for CuII/L to regenerate the main activator CuI/L. This is similar to the reversible-deactivation radical polymerization (RDRP) procedure conducted in the presence of Cu0. The electron transfer from SO2•-, to either CuIIBr2/Me6TREN or R-Br initiator, appears to follow an outer sphere electron transfer (OSET) process. The developed kinetic model was used to study the influence of targeted degree of polymerization, concentration of CuIIBr2/Me6TREN and solubility of Na2S2O4 on the level of polymerization control. The presence of small amounts of water in the polymerization mixtures slightly increased the reactivity of the CuI/L complex, but markedly increased the reactivity of sulfites.

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine: Brussels, Belgium. 15-18 March 2016

[This corrects the article DOI: 10.1186/s13054-016-1208-6.].

Cyclopentyl methyl ether as a green solvent for reversible-addition fragmentation chain transfer and nitroxide-mediated polymerizations

Cyclopentyl methyl ether (CPME) was successfully used as an environmentally friendly alternative to regularly employed organic solvents (e.g., THF, DMSO, DCM and DMF) for the RAFT and NMP polymerizations of vinyl chloride (VC) and styrene (S).

Getting faster: low temperature copper-mediated SARA ATRP of methacrylates, acrylates, styrene and vinyl chloride in polar media using sulfolane/water mixtures

Supplemental activator and reducing agent atom transfer radical polymerization (SARA ATRP) of acrylates, methacrylates, styrene and vinyl chloride was successfully performed in sulfolane/water mixtures using ppm amounts of soluble copper.

Synthesis of functionalized poly(vinyl acetate) mediated by alkyne-terminated RAFT agents

Two new xanthates with alkyne functionalities were synthesized for the reversible addition fragmentation chain transfer (RAFT) polymerization of vinyl acetate (VAc).

Sulfolane: an Efficient and Universal Solvent for Copper-Mediated Atom Transfer Radical (co)Polymerization of Acrylates, Methacrylates, Styrene, and Vinyl Chloride

A very fast and controlled atom transfer radical (co)polymerization (ATRP) of acrylates, methacrylates, styrene, and vinyl chloride is reported in a single dipolar aprotic solvent, sulfolane, with the use of ppm amount of the copper catalyst. The observed rates of polymerization (k_p^app) of the monomers studied are similar to those reported using dimethyl sulfoxide (DMSO) and other polar solvents typically employed in single electron transfer (SET)-mediated atom transfer radical polymerization (ATRP) processes. As proof-of-concept, ABA type block copolymers of polystyrene-b-poly(vinyl chloride)-b-polystyrene and poly(methyl acrylate)-b-poly(vinyl chloride)-b-poly(methyl acrylate) were prepared for the first time using a reversible deactivation radical polymerization (RDRP) method in a single solvent. The quantitative preservation of halide chain-ends was confirmed by ¹H NMR and MALDI-TOF analysis as well as by the complete shift of the GPC traces. The results presented establish an innovative and robust system to afford a vast portfolio of (co)polymers in a single widely used industrial solvent.

Synergistic Effect of 1-Butyl-3-methylimidazolium Hexafluorophosphate and DMSO in the SARA ATRP at Room Temperature Affording Very Fast Reactions and Polymers with Very Low Dispersity

An unusual synergistic effect between 1-butyl-3-methylimidazolium hexafluorophosphate (BMIM-PF6) and dimethyl sulfoxide (DMSO) mixtures is reported for the supplemental activator and reducing agent atom transfer radical polymerization (SARA ATRP) of methyl acrylate (MA) using a catalytic system composed by sodium dithionate (Na2S2O4) and CuBr2/Me6TREN (Me6TREN: tris[2-(dimethylamino)ethyl]amine) at room temperature. To the best of our knowledge, the use of ionic liquids (IL) has never been reported for the SARA ATRP. The kinetic data obtained for a broad range of target molecular weights revealed very fast polymerization rates, low dispersity values (Đ < 1.05) and well-defined chain-end functionalities.

The first intramolecular silene Diels-Alder reactions

The synthesis of silaheterocycles through the first examples of an intramolecular silene Diels-Alder reaction is described.

Synthesis of cationic poly((3-acrylamidopropyl)trimethylammonium chloride) by SARA ATRP in ecofriendly solvent mixtures

Successful supplemental activator and reducing agent atom transfer radical polymerization of (3-acrylamidopropyl)trimethylammonium chloride under ecofriendly conditions.

Improvement of the control over SARA ATRP of 2-(diisopropylamino)ethyl methacrylate by slow and continuous addition of sodium dithionite

The kinetics and detailed mechanism of SARA ATRP of 2-(diisopropylamino)ethyl methacrylate (DPA) were investigated.

Synthesis of well-defined functionalized poly(2-(diisopropylamino)ethyl methacrylate) using ATRP with sodium dithionite as a SARA agent

2-(Diisopropylamino)ethyl methacrylate was polymerized by Atom Transfer Radical Polymerization using sodium dithionite as a reducing agent and supplemental activator with a Cu(ii)Br₂/Me₆TREN catalytic system.

Computational Evaluation of the Sulfonyl Radical as a Universal Leaving Group for RAFT Polymerisation

The present study investigates the performance of the sulfonyl radical, i.e. •SO2Ph, as a universal leaving group in reversible addition–fragmentation chain-transfer (RAFT) polymerisation. The sulfonyl radical is widely used as a radical initiator and has already been proved successful as a leaving group in an atom-transfer radical polymerisation. Our results, obtained using high-level ab initio computational methodology under relevant experimental conditions, indicate superior performance of the sulfonyl compared with a reference cyanoisopropyl group in controlling RAFT of a wide range of monomers. Importantly, the presence of sulfonyl chain ends in the polymers so formed opens attractive possibilities for further functionalisation. Potential synthetic routes to the R-sulfonyl RAFT agents are discussed.

Inorganic Sulfites: Efficient Reducing Agents and Supplemental Activators for Atom Transfer Radical Polymerization

Inorganic sulfites such as sodium dithionite (Na₂S₂O₄), sodium metabisulfite (Na₂S₂O₅), and sodium bisulfite (NaHSO₃) have been studied as reducing agents for atom transfer radical polymerization (ATRP). They act not only as very efficient reducing agents but also as supplemental activators for SARA (supplemental activator and reducing agent) ATRP of methyl acrylate in DMSO at ambient temperature. In combination with Cu(II)Br₂/Me₆TREN, they produced poly(methyl acrylate) with controlled molecular weight, low dispersity (M_w/M_n = 1.05), and well-defined chain-end functionality. Sulfites are eco-friendly, approved by FDA as food and beverage additives, and used commercially in many industrial processes.

Ultrafast Synthesis of Ultrahigh Molar Mass Polymers by Metal-Catalyzed Living Radical Polymerization of Acrylates, Methacrylates, and Vinyl Chloride Mediated by SET at 25 °C

Conventional metal-catalyzed organic radical reactions and living radical polymerizations (LRP) performed in nonpolar solvents, including atom-transfer radical polymerization (ATRP), proceed by an inner-sphere electron-transfer mechanism. One catalytic system frequently used in these polymerizations is based on Cu(I)X species and N-containing ligands. Here, it is reported that polar solvents such as H(2)O, alcohols, dipolar aprotic solvents, ethylene and propylene carbonate, and ionic liquids instantaneously disproportionate Cu(I)X into Cu(0) and Cu(II)X(2) species in the presence of a diversity of N-containing ligands. This disproportionation facilitates an ultrafast LRP in which the free radicals are generated by the nascent and extremely reactive Cu(0) atomic species, while their deactivation is mediated by the nascent Cu(II)X(2) species. Both steps proceed by a low activation energy outer-sphere single-electron-transfer (SET) mechanism. The resulting SET-LRP process is activated by a catalytic amount of the electron-donor Cu(0), Cu(2)Se, Cu(2)Te, Cu(2)S, or Cu(2)O species, not by Cu(I)X. This process provides, at room temperature and below, an ultrafast synthesis of ultrahigh molecular weight polymers from functional monomers containing electron-withdrawing groups such as acrylates, methacrylates, and vinyl chloride, initiated with alkyl halides, sulfonyl halides, and N-halides.

Evidence for formation of silenes strongly influenced by reversed Si[double bond]C bond polarity

[reaction: see text] Transient silenes that are strongly influenced by reversed Si[double bond]C bond polarization are formed upon heating of tris(trimethylsilyl)silylamides. The silenes are trapped with 2,3-dimethyl-1,3-butadiene to quantitatively yield only one of the possible diastereomers of the functionalized cyclic allylsilanes.