Redox concerns in the use of acellular hemoglobin-based therapeutic oxygen carriers: the role of plasma components

Within the past decade, most research efforts in the red blood cell substitute area have revolved about the development of acellular hemoglobin-based oxygen carriers (HBOC) as clinical replacements and/or augmentation of human blood's carrying and delivery function. A major requirement for all HBOC is the maintenance of the heme-Fe+2 in this reduced state for normal physiological behavior. Oxidation of hemoglobin results in the formation of methemoglobin (heme-Fe+3). MetHb is unable to bind oxygen thus effectively lowering the carrying capacity of the Hb-based substitute. In addition, met Hb gives rise to free radicals that have the potential to cause endothelial and surrounding tissue damage. Results of this study suggest that the normal endogenous reducing agents of human plasma have the capacity to provide redox protection and stability to specific acellular-types of HBOC. The effectiveness of these reducing agents may be related to the formal reduction potential of the HBOC being considered. The choice of buffer for HBOC storage is critical and specific to the HBOC product.     

Acellular invertebrate hemoglobins as model therapeutic oxygen carriers: unique redox potentials

Natural acellular polymeric hemoglobins (Hb) provide oxygen transport and delivery within many terrestrial and marine invertebrate organisms. It has been our premise that these natural acellular Hbs may serve as models of therapeutic hemoglobin-based oxygen carriers (HBOC). Our attention has focused on the acellular Hb from the terrestrial invertebrate, Lumbricus terrestris (Lt), which possesses a unique hierarchical structure and a unique ability to function extracellularly without oxidative damage. Lumbricus Hb and Arenicola Hb are resistant to autoxidation, chemical oxidation by potassium ferricyanide, and have little or no capacity to transfer electrons to Fe(+3)-complexes at 37 degrees C. An understanding of how these invertebrate acellular oxygen carriers maintain their structural integrity and redox stability in vivo is vital for the design of a safe and effective red cell substitute. We report here a positive redox potential for these giant hemoglobins that may lie at the basis for its resistance to oxidation.     

Numerical investigation of oxygen transport by hemoglobin-based carriers through microvessels

The small size of hemoglobin-based oxygen carriers (HBOCs) may expand the realm of new treatment possibilities for various circulatory diseases. The parametric evaluation of HBOC performance for oxygen transport within tissue is essential for effectively characterizing its performance for each circulatory disease assessed. Thus, the overarching objective of this present study was to numerically investigate the reaction–diffusion phenomenon of oxygenated HBOCs and oxygen on tissues through microvessels. We considered dissociation rate coefficients, oxygen affinity, and diffusion coefficients due to Brownian motion as the biophysical parameters for estimating HBOC performance for oxygen transport. A two-dimensional computational domain, including vessel and tissue regions, was, therefore, accordingly assumed. It was observed that HBOC flows in a microvessel with a diameter of 25 μm and a length of 1 mm, and that the dissociated oxygen diffuses to the tissue region. The results indicated that oxyhemoglobin saturation and partial oxygen tension in a downstream region changed according to each biophysical parameter of HBOC. Moreover, the change in oxygen consumption rate in the tissue region had considerable influence on the oxyhemoglobin saturation level within the vessel. Comparison between simulation results and existing in vitro experimental data of actual HBOCs and RBC showed qualitatively good agreement. These results provide important information for the effective design of robust HBOCs in future.     

A comparison of the acute hemodynamic and delayed effects of 50% exchange transfusion with two different cross-linked hemoglobin based oxygen carrying solutions and Pentastarch

BACKGROUND: Hemoglobin based oxygen carrying solutions (HBOC) have been designed to combine the beneficial effects of colloidal solutions with oxygen carrying capacity. Clinical trials in humans using HBOCs have had variable results. METHODS: We used a rodent 50% exchange model to compare Hemolink and Hemopure HBOC to autologous blood and Pentastarch solution. We monitored hemodynamic parameters, hemoglobin clearance, weight gain and hematocrit over a five-day period. RESULTS: Acute hemodynamic effects between the two HBOCs were similar with mild vasoconstriction. Cardiac output, systemic vascular resistance and renal function were similar to that seen with blood. HBOC's were associated with hemoglobinuria with a half-life in the circulation of 13.8 hrs for Hemolink and 19.2 hrs for Hemopure. Animals resuscitated with HBOCs exhibited delayed weight gain. CONCLUSION: Hemodynamic effects in rodents exchange-transfused with blood, Hemolink, or Hemopure were similar. The delayed weight gain observed with the HBOCs must be investigated.     

Immune effects of decreasing low-molecular weight hemoglobin components of hemoglobin-based oxygen carriers (HBOC) in a swine model of severe controlled hemorrhagic shock

Hemoglobin-based oxygen carriers (HBOCs) show potential as safe, efficacious, pre-hospital resuscitation fluids. The major criticism of HBOC-201 is its vasoactive property, attributed partially to low-molecular weight (low-MW) tetrameric/dimeric (TD) hemoglobin (Hb) in HBOC solution. Here we sought to determine whether resuscitation with decreasing concentrations of low-MW Hb component of HBOC affects immune responses in hemorrhagic swine. 28 anesthetized swine underwent a soft muscle crush and controlled hemorrhage of 55% blood volume, followed by resuscitation with HBOC containing 31%, 2%, or 0.4% low-MW Hb in four 10 ml/kg infusions at 20, 30, 45 and 60 minutes before hospital arrival at 75 minutes. IL-10, cell activation and adhesion markers and CD4:CD8 ratio remained unchanged in all 3 groups compared to baseline. Leukocyte apoptosis was equally elevated across all groups. Purification from 31% to 0.4% low-MW Hb in HBOC solution did not alter immune effects in a swine model of severe controlled hemorrhagic shock.     

Effects of the resuscitation fluid and the hemoglobin based oxygen carrier (HBOC) excipient on the toxicity of the HBOC: Ringer's D,L-lactate, Ringer's L-lactate, and Ringer's ketone solutions

Hemoglobin based oxygen carriers (HBOC) are resuspended in "excipients" consisting of Ringer's D,L-lactate containing antioxidants to prevent methemoglobin formation during storage.Investigators have reported cardiac arrhythmias following infusion of Ringer's D,L-lactate solution. Studies have shown that D-lactate stimulates human granulocytes to generate oxygen free radicals and L-lactate inhibits glycolysis.Patients receiving HBOC in Ringer's D,L-lactate excipient are also resuscitated or hemodiluted with Ringer's lactate solution. Oxygen-free radicals generated by Ringer's D,L-lactate and HBOC may oxidize nitric oxide in endothelial cells, causing the vasoconstrictor effects reported following HBOC infusion, and activate NF-kappab and the apoptotic cascade. The combination of Ringer's D,L-lactate and HBOC in Ringer's D,L-lactate excipient may be responsible for the severe adverse events observed in clinical studies of HBOC.Veech has recommended replacing the 27 mM of lactate in Ringer's with 27 mM D-betahydroxybutyrate (BHB). BHB reduces the generation of oxygen free radicals by mitochondria and human granulocytes.     

Autologous blood sequestration using a double venous reservoir bypass circuit and polymerized hemoglobin prime

Cardiac surgery often necessitates transfusion of homologous blood. Hemoglobin based oxygen carrying solutions (HBOCs) transport oxygen, suggesting use in cardiopulmonary bypass. HBOC was used in a novel oxygenator double-reservoir circuit that permits acute sequestration of a portion of the autologous blood volume during bypass. Two groups of seven mongrel dogs each were studied in an experimental bypass model using global myocardial ischemia and cardioplegia protection: HBOC group, initial venous return drained to a separate reservoir and hypothermic bypass was conducted with HBOC containing perfusate in a second bypass reservoir; Control group, crystalloid prime in a conventional circuit. Hemodynamics and metabolic and hematologic parameters were measured before and 60 min after aortic clamp removal and reinfusion of sequestered autologous blood. Blood gases, base excess, hematocrit, total hemoglobin, and platelet counts were measured. In the HBOC group, metabolic acidosis did not occur, and ventricular function was preserved. Net conservation of platelets was noted at study conclusion: control 33+/-13 x 10(3) per mm3 versus HBOC 48+/-13 x 10(3), p < 0.05. HBOC based priming in a double venous reservoir system permits bypass at very low hematocrit, with preservation of cardiac function. Net conservation of the platelet mass occurs, a portion of which is not exposed to the deleterious effects of hypothermia and cardiopulmonary bypass.     

Cross-linked hemoglobin as a potential membrane for an artificial red blood cell

A cross-linked hemoglobin membrane has been created with discerning permeability between dissolved hemoglobin and small molecules. Such a membrane could be used to enclose a sphere of hemoglobin solution thereby allowing the entire "cell" to transport oxygen. The hemoglobin membrane was cross-linked on a polycarbonate support; the mechanical support was necessary for diffusion experiments in this study and would not be used during any sphere preparation. A 30% methemoglobin solution in phosphate buffer was used to fill the pores of the 10 microm polycarbonate support, then cross-linked with a homobifunctional cross-linking agent. The cross-linked hemoglobin within the support was evaluated for hemoglobin and benzoic acid permeability in a side-by-side diffusion cell. Disuccinimidyl glutarate, disuccinimidyl suberate and disuccinimidyl tartrate were used as cross-linking agents. Disuccinimidyl glutarate, 4.65 mM, created a hemoglobin-impermeable membrane after cross-linking for 20 minutes, reducing the concentration to 0.46 mM required a cross-linking time to 60 minutes. Benzoic acid, representing a typical small molecule, was capable of diffusing through the disuccinimidyl glutarate cross-linked hemoglobin membrane at 87.2% of its diffusion through buffer.     

Effects of nutrient and hemoglobin enriched cell free perfusates upon ex vivo isolated rat heart preparation

We evaluated the effects of nutrient enriched medium and hemoglobin based oxygen carrier (HBOC) upon myocardial functional recovery after 15 minutes of warm ischemia in an isovolumic Langendorff rat heart model. Hearts (n = 8/group) were perfused at constant pressure (90 mm Hg) with Krebs-Henseleit buffer or HEPES modified cell culture medium (M199) in the absence and presence of HBOC. Hearts received 15 minutes of normothermic no flow ischemia followed by 60 minutes reperfusion. Hemodynamics, coronary flow, and tissue water content were measured, and microscopic evidence of injury including TUNEL assay was assessed. Preischemic left ventricular performance (left ventricular developed pressure and maximum rate of positive and negative change in systolic pressure) and coronary flow were similar among groups. At 60 minutes of reperfusion, M199 alone provided more stable and complete left ventricular systolic and diastolic functional recovery than any other perfusate. Coronary flow rates reflected left ventricular function observed under each perfusate condition. TUNEL assay showed arterial endothelial cell death in some hearts perfused with HBOC. Tissue water content did not reflect functional recovery. The combination of M199 and HBOC was associated with poor recovery and elevated perfusate methemoglobin. In this system, postischemic dysfunction is prevented by components in M199. Added HBOC does not improve functional recovery and negates the salutary effects of M199, possibly by augmenting methemoglobin formation.     

A Review of Blood Substitutes: Examining The History,Clinical Trial Results,and Ethics of Hemoglobin-Based Oxygen Carriers

The complications associated with acquiring and storing whole blood for transfusions have launched substantial efforts to develop a blood substitute. The history of these efforts involves a complicated mixture of science, ethics, and business. This review focuses on clinical trials of the three hemoglobin-based oxygen carriers (HBOC) that have progressed to Phase II or III clinical trials: He-mAssist (Baxter; Deerfield, IL, US), PolyHeme (Northfield; Evanston, IL, US), and Hemopure (Biopure; Cambridge, MA, US). Published animal studies and clinical trials carried out in a perioperative setting have demonstrated that these products successfully transport and deliver oxygen, but all may induce hypertension and lead to unexpectedly low cardiac outputs. Overall, these studies suggest that HBOCs resulted in only modest blood saving during and after surgery, no improvement in mortality and an increased incidence of adverse reactions. To date, the results from these perioperative studies have not led to regulatory approval. All three companies instead chose to focus their efforts on large trials of trauma patients in the pre-hospital setting.Baxter abandoned the development of HemAssist after a trial in the U.S. was prematurely halted when the first 100 patients showed significantly increased mortality rates as compared to patients treated with blood products. Northfield’s PolyHeme trial demonstrated a non-significant trend towards increased mortality and a very modest reduction in the subsequent need for blood. The testing of Biopure’s Hemopure for trauma patients has been halted for several years because of FDA concerns over trial design and study justification. Ethical concerns have also been raised regarding the design and implementation of all HBOC clinical trials.Thus, the available evidence suggests that HemAssist, Polyheme, and Hemopure are associated with a significant level of cardiovascular dysfunction. The next generation of HBOCs remains under development.     

Effects of hemoglobin C and S traits on the results of 14 commercial glycated hemoglobin assays

Glycated hemoglobin is widely used in the management of diabetes mellitus. At least 300,000 Americans with diabetes mellitus have the hemoglobin (Hb) C or S trait. The accuracy of HbA1c methods can be adversely affected by the presence of these traits. We evaluated the effects of HbC and HbS traits on the results of 14 commercial HbA1c methods that use boronate affinity, enzymatic, immunoassay, and ion exchange methods. Whole blood samples from people homozygous for HbA or heterozygous for HbC or HbS were analyzed for HbA1c. Results for each sample type were compared with those from the CLC 330 comparative method (Primus Diagnostics, Kansas City, MO). After correcting for calibration bias by comparing results from the homozygous HbA group, method bias attributable to the presence of HbC or HbS trait was evaluated with a clinically significant difference being more than 10% (ie, 0.6% at 6% HbA1c). One immunoassay method exhibited clinically significant differences owing to the presence of HbC and HbS traits.     

Basic science offers a challenge for developing hemoglobin based oxygen carriers into therapeutic agents

Experimental data, obtained during the course of several years, are connected into a coherent picture, which may help research for the development of HBOCs as therapeutic agents. Oxygen affinity, scavenging of nitric oxide, and yield of production of hemoglobin based oxygen carriers were the areas under consideration.     

Hemoglobin-based oxygen carriers and trials to substitute red blood cells

The idea to develop a blood substitute was stimulated by the need of military in the last two world wars and by transmission of pathogenic germs (Hepatitis B in 1960, HIV in 1980 and Hepatitis C in 1990) during blood transfusion that limited the donor blood transfusion. There are two main groups of blood substitutes: perfluorocarbon emulsions and hemoglobin-based oxygen carriers (HBOC). These latter are of natural origin: human, bovine or recombinant and undergo three modifications types: chemicals (intramolecular cross-linking, polymerisation, conjugation to macromolecules and combination of several chemical modifications), genetics or technological by microencapsulation. HBOCs are in different phases of clinical trials and some of them present side effects (hemodynamic and oxidative). The understanding of these effects and the possibility of correcting them, condition their use on a large scale and the economic consequences, which they can generate.     

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)     

Expectations and implications of blood sparing with hemoglobin based oxygen carriers

To gain insight into the degree to which hemoglobin based oxygen carriers may replace the need for transfusion in surgical patients experiencing blood loss, a simple mathematical model was developed. This model predicts the amount of blood sparing resulting from a bolus infusion of different doses of hemoglobin solution as a function of circulating hemoglobin half-life and degree of erythropoesis enhancement subsequent to treatment. The results of this analysis are consistent with published clinical data and imply that blood sparing increases with increasing oxygen carrier dose and half-life, as well as increasing levels of erythropoesis enhancement. The analysis also predicts that the total circulating hemoglobin content in patients infused with HBOC solutions may reach a minimum value up to ten days after treatment.     

Virus inactivation in hemoglobin solution by heat treatment.

To increase the safety of stroma-free hemoglobin solution (SFH) as an artificial oxygen carrier source, we investigated the effect of heat treatment on virus inactivation in hemoglobin solution. The hemoglobin solution spiked with vesicular stomatitis virus (VSV) was treated at 60 degrees C for 1 hr under either an air or CO atmosphere. VSV was inactivated at >5.8 log10 and >6.0 log10 under the air and CO atmosphere, respectively. Although the methemoglobin rate increased after the heat treatment under the air atmosphere, no methemoglobin formation was observed by the treatment under the CO atmosphere. Isoelectric focusing analysis revealed the denaturation of hemoglobin after the heat treatment under the air, while hemoglobin banding was not altered in the carbonylated condition. Some protein bands other than hemoglobin were weakened or disappeared on SDS-PAGE after the heat treatment under both conditions. In addition, the hemoglobin concentration in the SFH was higher after the heat treatment than before the treatment. These findings indicate that the heat treatment under the CO atmosphere inactivates viruses without hemoglobin denaturation, and hence, this method is a promising approach to prepare a safer SFH as artificial oxygen carriers.     

The effects of preserved red blood cells on the severe adverse events observed in patients infused with hemoglobin based oxygen carriers

The severe adverse events observed in patients who received hemoglobin based oxygen carriers (HBOCs) were associated with the Ringer's D.L lactate resuscitative solution administered and to the excipient used in the HBOCs containing Ringer's D,L lactate and the length of storage of the preserved RBC administered to the patient at the time that the HBOCs were infused. This paper reports the quality of the red blood cells preserved in the liquid state at 4 degrees C and that of previously frozen RBCs stored at 4 degrees C with regard to their survival, function and safety. Severe adverse events have been observed related to the length of storage of the liquid preserved RBC stored at 4 degrees C prior to transfusion. The current methods to preserve RBC in the liquid state in additive solutions at 4 degrees C maintain their survival and function for only 2 weeks. The freezing of red blood cells with 40% W/V glycerol and storage at -80 degrees C allows for storage at -80 degrees C for 10 years and following thawing, deglycerolization and storage at 4 degrees C in the additive solution (AS-3, Nutricel) for 2 weeks with acceptable 24 hour posttransfusion survival, less than 1% hemolysis, and moderately impaired oxygen transport function with no associated adverse events. Frozen deglycerolized RBCs are leukoreduced and contain less than 5% of residual plasma and non-plasma substances. Frozen deglycerolized RBCs are the ideal RBC product to transfuse patients receiving HBOCs.     

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.     

Incidental findings of variant hemoglobin during hemoglobin a1c testing

A variant hemoglobin fraction may be an incidental finding during HbA(1c) analysis using the G8 Tosoh HPLC analyzer, but it is unclear if the retention times and fraction patterns can reliably predict the findings of a high-performance liquid chromatography (HPLC) β-thalassemia program (Bio Rad Variant II analyzer). We chose 100 samples sent for HbA(1c) determinations (G8 Tosoh) with an incidental finding of variant hemoglobin and did a reflex test using the Bio Rad Variant II analyzer (β-thalassemia program). Two observers attempted to predict the results with that analyzer from fraction patterns and retention times of the hemoglobin variants detected with the G8. They independently identified all hemoglobin variants (HbS, Hb Setif, HbC, and HbD) by their patterns and retention times. We conclude that HPLC confirmation of certain variant hemoglobin fractions found incidentally during HbA(1c) testing on the G8 Tosoh is not necessary.