Mary Lou Wratten

A pilot study of coupled plasma filtration with adsorption in septic shock

ObjectiveTo test the hypothesis that nonselective plasma adsorption by a hydrophobic resin (coupled plasmafiltration and adsorption) could improve hemodynamics and restore leukocyte responsiveness in patients with septic shock. DesignProspective, pilot, crossover clinical trial. SettingGeneral intensive care unit in a teaching hospital. SubjectsTen patients with hyperdynamic septic shock. InterventionsPatients were randomly allocated to 10 hrs of either coupled plasma filtration adsorption plus hemodialysis (treatment A) or continuous venovenous hemodiafiltration (treatment B) in random order. We measured the change in mean arterial pressure, norepinephrine requirements, and leukocyte tumor necrosis factor-&agr; (TNF-&agr;) production (both spontaneous and lipopolysaccharide-stimulated) after 10 hrs of each treatment. We also tested TNF-&agr; production from normal human adherent monocytes incubated with patients’ plasma obtained before and after the resin, both with or without incubation with an anti-interleukin-10 monoclonal antibody. ResultsMean arterial pressure increased after 10 hr by 11.8 mm Hg with treatment A and by 5.5 mm Hg with treatment B (p = .001). There was an average decrease of norepinephrine requirement of 0.08 &mgr;g/kg/min with treatment A and 0.0049 &mgr;g/kg/min with treatment B (p = .003). All patients but one survived. Spontaneous and lipopolysaccharide-induced TNF-&agr; production from patients’ whole blood increased over time with treatment A. This increase was more marked in blood drawn after the device (plasmafiltrate-sorbent plus hemodialyzer) (p = .009). Preresin plasma suppressed lipopolysaccharide-stimulated production of TNF-&agr; by 1 × 106 cultured adherent monocytes from healthy donors. This suppressive effect was significantly reduced after passage of plasma through the resin (p = .019) and after incubation with anti-interleukin-10 monoclonal antibodies (p = .028). ConclusionsIn patients with septic shock, coupled plasmafiltration-adsorption combined with hemodialysis was associated with improved hemodynamics compared with continuous venovenous hemodiafiltration. This result might be related to its ability to restore leukocyte responsiveness to lipopolysaccharide. These findings suggest a potential role for blood purification in the treatment of septic shock.

Lipid peroxidation and phospholipase A2 activity in liposomes composed of unsaturated phospholipids: a structural basis for enzyme activation

The effect of lipid peroxidation on membrane structure and phospholipase A2 activity was studied using liposomes composed of bovine liver phosphatidylcholine (PC) and phosphatidylethanolamine (PE). The phospholipids were mixed at set ratios and sonicated to yield small unilamellar vesicles. The liposome preparations were subjected to lipid peroxidation as induced by cumene hydroperoxide and hematin. Under these conditions, a sharp increase in lipid peroxidation was noted over a 30 min incubation period and was accompanied by loss of polyunsaturated fatty acids (PUFA). Liposomes enriched in PE were most extensively peroxidized with a preferred oxidation of this phospholipid. The extent of PC oxidation was also greater in liposomes containing the largest proportions of PE. Analysis of liposome anisotropy, via steady-state fluorescence polarization of diphenylhexatriene indicated that progressive increases in either PE content or the level of lipid peroxidation increased the apparent microviscosity of the vesicles. Moreover, lipid peroxidation increased anisotropy more effectively than variations in the ratios of PE vs. PC. Thus, peroxidation of 5-10% of the phospholipids produced the same anisotropy increase as a 20% increase in the ratio of PE vs. PC. Analysis of vesicle turbidity suggested that fusion was also more readily achieved through lipid peroxidation. When liposomes were incubated with 0.4 U/ml of snake venom phospholipase A2, a direct correlation was found between the degree of lipid peroxidation and the extent of phospholipid hydrolysis. The more unsaturated phospholipid, PE, was most extensively hydrolyzed following peroxidation. Increasing the proportion of PE also resulted in more extensive phospholipid hydrolysis. These findings indicate that lipid peroxidation produces a general increase in membrane viscosity which is associated with vesicle instability and enhanced phospholipase A2 attack. A structural basis for membrane phospholipase A2 activation as a consequence of lipid peroxidation is discussed in light of these findings.

Coupled plasma filtration-adsorption in a rabbit model of endotoxic shock.

Objective: To test the hypothesis that nonselective adsorption by a hydrophobic resin of cytokines and other proinflammatory mediators could improve 72‐hr survival in a rabbit model of endotoxic shock. Design: Prospective, randomized, controlled animal trial. Setting: Animal care facility at a research institution. Subjects: A total of 109 New Zealand white male rabbits. Interventions: Anesthetized rabbits were cannulated with indwelling femoral arterial and venous lines. Septic shock was induced by a single intravenous injection of Escherichia coli lipopolysaccharide. The dose was experimentally assessed in 40 rabbits receiving 1.0, 0.5, 0.1, and 0.05 mg/kg body weight to determine LD80 at 72 hrs. Extracorporeal circulation consisted of plasma filtration coupled with passage of the plasma filtrate through a hydrophobic sorbent and reinfusion into the venous line. The extracorporeal treatment lasted for 3 hrs. Rabbits injected with endotoxin (0.05 mg/kg) were submitted to plasma filtration with (19 rabbits) or without (20 rabbits) sorbent adsorption. As controls, rabbits injected with vehicle alone were treated with plasma filtration (ten rabbits) or without (ten rabbits) sorbent adsorption. Ten rabbits were monitored under anesthesia to determine basal survival. Measurements and Main Results: Plasma concentrations of endotoxin, bioactive tumor necrosis factor, resin‐adsorbed platelet‐activating factor, mean arterial pressure, base excess, and white cell count were assessed and a global severity score was established. At 72 hrs, cumulative survival was significantly (p = .0041) improved in septic rabbits treated with coupled plasma filtration‐adsorption. Circulating tumor necrosis factor bioactivity remained similar in control and treated rabbits. Biologically significant amounts of platelet activating factor were eluted from the sorbent during the entire treatment time. The severity score inversely correlated with survival (p < .001). Conclusions: Coupled plasma filtration‐adsorption improved survival in a rabbit model of endotoxic shock. Coupled plasma filtration‐adsorption may be an extracorporeal treatment capable of removing structurally different inflammatory mediators associated with sepsis.

Coupled Plasma Filtration Adsorption: Rationale, Technical Development and Early Clinical Experience

The adjuvant treatment of sepsis remains a major therapeutic challenge. Blood purification is theoretically appealing if the humoral theory of sepsis is accepted as the basis for intervention. In this setting, blood purification would provide a broad-based restoration of humoral homeostasis thereby avoiding both excessive inflammation and counterinflammation. Several techniques of blood purification have been tried or are under active investigation. One of these is the so-called coupled plasma filtration adsorption (CPFA). CPFA is a novel extracorporeal blood purification therapy aimed at nonselectively reducing the circulating levels and activities of both pro- and anti-inflammatory mediators during sepsis and multiorgan failure. In vitro studies have shown CPFA to be effective in binding a broad range of such mediators proving its technical efficacy. Subsequent animal models have shown a beneficial effect on survival in endotoxemia. These studies have provided the necessary technical developments and biologic rationale for initial human studies. Two phase I/IIa clinical studies have now been performed. Both studies have shown that CPFA improves blood pressure and restores immune function in patients with severe sepsis and multiorgan dysfunction. In this article, we will discuss some of the basic principles involved in sorbent technology, and how these may contribute to treatment efficacy, review animal experiments with CPFA and finally discuss the results of recent human studies and their implications.

OXIDATION OF ALBUMIN IS ENHANCED IN THE PRESENCE OF UREMIC TOXINS

Albumin has been considered a “sacrificial plasma antioxidant” due to the high reactivity of the protein sulfhydryl groups with oxidants such as hydrogen peroxide (H2O2) and hypochlorous acid (HOCl). Based on its large quantity and high turnover. It is considered as one of the most important plasma antioxidants for protecting key cellular and regulatory proteins. Since hemodialysis patients have lower overall levels of albumin and possible protein modifications due to uremic toxins, we investigated whether modifications by various uremic toxins would affect the susceptibility of albumin to an oxidative challenge. We incubated bovine serum albumin in the presence of carboxymethyllysine (CML) (10 μmol/L–1 mmol/L), methyl glyoxal (50 μmol/L–5 mmol/L), p-cresol (100 μmol/L–10 mmol/L) or hippuric acid (200 μmol/L–20 mmol/L) for 16 hours at 37°C and then subsequently added 0.5 mmol/L–1 mmol of H2O2/HOCl. We measured the extent of protein modification by the loss of protein sulfhydryl groups, dityrosine formation and the formation of advanced oxidation protein products (AOPP). Incubation of albumin with the uremic toxins caused a loss of protein sulfhydryl groups and an increase in dityrosines and AOPP. The presence of uremic toxins had no effect on the loss of protein sulfhydryl groups after addition of H2O2/HOCl; however, low levels of CML, p-cresol and methyl glyoxal inhibited the formation of AOPP and dityrosines. We suggest that uremic toxins may possibly play a role in mediating free radical initiated protein damage.

Evolution of oxidative stress and inflammation during hemodialysis and their contribution to cardiovascular disease.

End-stage renal disease patients have increased cardiovascular morbidity and mortality. These patients have many unique risk factors, such as an accumulation of uremic toxins, electrolyte imbalances, metabolic disturbances, anemia, chronic inflammation, and thrombogenic disturbances. Oxidative stress has been implicated in many of these disturbances. This review will focus on some of the factors that may accelerate cardiovascular disease in uremic patients, with an emphasis on mechanisms and interactions of various components of oxidative stress and inflammation. Understanding the mechanisms of these pathways may be useful in developing effective prevention and treatment strategies.

Oxidative stress during ex vivo hemodialysis of blood is decreased by a novel hemolipodialysis procedure utilizing antioxidants.

The high cardiovascular mortality in patients receiving hemodialysis (HD) has been attributed, in part, to oxidative stress. Here we examined the effectiveness of antioxidants introduced by means of a novel hemolipodialysis (HLD) procedure in terms of reducing oxidative stress during ex vivo blood circulation. Oxidative stress was studied in a model HD system resembling the extracorporeal circulation of blood during clinical HD. Blood circulation produced an increase of up to 280% in free hemoglobin levels and an increase of 320% in electronegative LDL (LDL(-)) subfraction. A significant correlation between LDL(-) and free hemoglobin levels confirmed previous findings that LDL(-) formation during ex vivo circulation of blood can be mediated by the oxidative activity of free hemoglobin. These effects were significantly attenuated during HLD using a dialysis circuit containing vitamin E with or without vitamin C. By contrast, HLD with vitamin C alone had a marked pro-oxidant effect. TBARS, lipid hydroperoxides, vitamin E and beta-carotene content in LDL were not significantly altered by the HD procedure. These findings demonstrate the occurrence of oxidative stress in human plasma where lipoproteins are a target and indicate antioxidant-HLD treatment as a specific new approach to decreasing the adverse oxidative stress frequently associated with cardiovascular complications in high-risk populations of uremic patients.

Coupled Plasma Filtration Adsorption

Sepsis is one of the main causes of death in critically ill patients worldwide, and in many cases it is associated with renal and/or other organ failure. However, we do not have a unique efficient therapy to reduce this extremely high mortality rate. In the last years interest around the use of extracorporeal blood purification techniques has increased. One of the emerging treatments in patients with severe sepsis and septic shock is coupled plasma filtration adsorption (CPFA), a novel extracorporeal blood purification therapy aimed at a nonselective reduction of the circulating levels and activities of both pro- and anti-inflammatory mediators. Early experimental studies and the following clinical trials have demonstrated impressive results regarding hemodynamics and respiratory parameters, even in patients without concomitant acute renal injury, paralleled by a quick tapering of vasoactive drugs. Considering the still high morbidity and mortality rates in septic shock patients, this new blood purification technique seems to have benefits when applied early in the course of sepsis, also without renal indications, suggesting that it might be performed to prevent rather than to treat acute kidney injury.

Future technology for continuous renal replacement therapies

Abstract Critically ill patients are increasingly treated with continuous hemofiltration and derived techniques, now grouped under the term of continuous renal replacement therapy (CRRT). CRRT can provide adequate blood purification and correction of electrolyte derangements. They also seem to prevent further injury to the patient by maintaining a stable level of homeostasis. Recently, newer indications have been proposed for CRRT, including the treatment of neonates, patients with heart disease, and septic patients. It has been hypothesized that continuous therapies might contribute to the removal of noxious substances in the middle molecular-weight range, such as cytokines or autocoids. According to these new indications, technical developments are making available new forms of treatment, new materials, and specially designed machines.

DPH lifetime distributions in vesicles containing phospholipid hydroperoxides

Multifrequency phase fluorometry was used to determine the lifetime distributions of 1,6 diphenyl-1,3,5-hexatriene in 1-palmitoyl-2 linoleoyl phosphatidylcholine small unilamellar vesicles containing 2% incorporation of phospholipid hydroperoxides. A biexponential decay was observed in both vesicle preparations over a temperature range of 5 to 35 degrees C. Vesicles containing phospholipid hydroperoxides showed an overall longer lifetime as well as a greater distribution in width. These findings suggest that phospholipid hydroperoxides create structural heterogeneity in membrane structure.