Vasoactive side effects of intravenous immunoglobulin preparations in a rat model and their treatment with recombinant platelet-activating factor acetylhydrolase.

Previously, we observed in a rat model that intravenous administration of intramuscular immunoglobulin preparations induced a long-lasting hypotension, which appeared to be associated with the presence of IgG polymers and dimers in the preparations, but unrelated to complement activation. We found evidence that this hypotensive response is mediated by platelet-activating factor (PAF) produced by macrophages. In this study, we compared the vasoactive effects of 16 intravenous immunoglobulin (IVIG) products from 10 different manufacturers, in anesthetized rats. Eight of the IVIG preparations showed no hypotensive effects (less than 15% decrease), whereas the other 8 had relatively strong effects (15%-50% decrease). The hypotensive effects correlated with the IgG dimer content of the preparations. Pretreatment of the rats with recombinant PAF acetylhydrolase completely prevented the hypotensive reaction on IVIG infusion, and administration after the onset of hypotension resulted in normalization of the blood pressure. We also observed PAF production on in vitro incubation of human neutrophils with IVIG, which could be blocked by anti-Fcgamma receptor antibodies. This indicates that induction of PAF generation may also occur in a human system. Our findings support the hypothesis that the clinical side effects of IVIG in patients may be caused by macrophage and neutrophil activation through interaction of IgG dimers with Fcgamma receptors. Because phagocyte activation may also lead to the release of other inflammatory mediators, recombinant PAF acetylhydrolase (rPAF-AH) provides a useful tool to determine whether PAF plays a role in the clinical side effects of IVIG. If so, rPAF-AH can be used for the treatment of those adverse reactions. (Blood. 2000;95:1856-1861)

Clearance of human factor XIa-inhibitor complexes in rats.

The serpins C1 esterase inhibitor (C1Inh), antithrombin (AT), alpha 1-antitrypsin (alpha 1AT) and alpha 2-antiplasmin (alpha 2AP) are known inhibitors of coagulation factor XIa (FXIa). Although initial studies suggested alpha 1AT to be the main inhibitor of FXIa, we recently demonstrated C1Inh to be a predominant inhibitor of FXIa in vitro in human plasma. The present study was performed to investigate the plasma elimination kinetics of preformed human FXIa-FXIa inhibitor complexes injected in rats. The amounts of complexes remaining in circulation were measured using enzyme-linked immunosorbent assays. The plasma half-life time of clearance (t1/2) was 98 min for FXIa-alpha 1AT complexes, whereas it was considerably shorter, i.e. 19, 18 and 15 min for FXIa-C1Inh, FXIa-alpha 2AP and FXIa-AT complexes, respectively. Thus, due to this different plasma t1/2, preferentially FXIa-alpha 1AT complexes may be detected in clinical samples. Furthermore, measuring FXIa-FXIa inhibitor complexes in patient samples may not help to clarify the relative contribution of the individual serpins to inactivation of FXIa in vivo.

Evaluation of the immunogenicity of polymerized hemoglobin solutions in a rabbit model.

Chemical modification of proteins carries the risk that neo-antigens are introduced. To investigate the potential immunogenicity of human glutaraldehyde-polymerized hemoglobin (polyHbX1), we analyzed the antibody responses of rabbits after hyperimmunization with complete Freund's adjuvant. In view of the species difference, we also tested rabbit hemoglobin that was modified in the same way as human polyHbX1. Thereafter, we studied the antibody response after weekly intravenous infusion of clinically relevant doses of polyHbX1 to evaluate whether an immune response is likely to occur when modified hemoglobin is used as blood substitute. The occurrence of an antibody response was tested by using an enzyme immunoassay (ELISA). To find out whether antibodies were directed against neo-epitopes on human polyHbX1 we used a competitive ELISA. The results showed that polymerized hemoglobin may weakly activate the immune system in special conditions, but is unlikely to do so when it is used as blood substitute.

Prevention of side effects by hemoglobin solutions; the selection of optimal test models, especially concerning thrombogenicity.

Modification of hemoglobin (Hb) by crosslinking and polymerization results in an improved oxygen release capacity and a prolonged vascular retention time. Modification improves the efficacy and prevents certain side effects. It eliminates leakage of Hb through the kidneys and accumulation in the tubuli. Another important issue is the degree of purification of Hb solutions. Traces of membrane fragments may cause immunogenic and thrombogenic side effects. To determine the contamination with erythrocyte membrane fragments, we developed assays for glycophorin-alpha and phospholipids. Special models were evaluated for testing the maximum allowable level of membrane contamination. As an in vitro model for thrombogenicity we used confluent monolayers of human umbilical vein endothelial cells. These cells were incubated with Hb solutions and subsequently tested on tissue factor (TF) procoagulant activity. TF was tested by the factor VII-catalyzed activation of factor X. The lower detection limit of this assay for endotoxin was 0.5 ng/ml. Hb did not cause any tissue factor expression even after prolonged incubation. No cooperation was found within endotoxin. As an in vivo test on thrombogenicity we developed a guinea pig model in which we can follow the generation of fibrinopeptide A (FPA). This is one of the most sensitive markers for thrombin activation in vivo. When slightly contaminated Hb solutions (phospholipid content 2 nmol/ml) were infused in the presence of factor Xa at a dose (9 micrograms/kg) which in itself did not induce FPA generation, we observed an increase in FPA levels in the plasma from 1.2 +/- 0.4 ng/ml to 5.2 +/- 0.7 ng/ml. Factor Xa is used to mimic a stressed clinical condition with activated coagulation.(ABSTRACT TRUNCATED AT 250 WORDS)

Clearance of human native, proteinase-complexed, and proteolytically inactivated C1-inhibitor in rats.

C1-inhibitor is the only known inhibitor of the classical pathway of complement and the major inhibitor of the contact pathway of coagulation. Like other serine proteinase inhibitors, C1-inhibitor can exist in three conformations, ie, the native, the proteinase-complexed, and the proteolytically inactivated form. Here we studied the plasma elimination kinetics of these three forms of human C1-inhibitor in rats. The clearance of the complexed form of C1-inhibitor appeared to be the most rapid and depended in part on the proteinase involved (observed plasma t1/2 was 20 minutes for C1s-C1-inhibitor, 32 minutes for kallikrein-C1-inhibitor, and 47 minutes for beta XIIa-C1-inhibitor), whereas that of native C1-inhibitor was the slowest (observed plasma t1/2 4.5 hours). Inactivated C1-inhibitor was cleared with an apparent plasma t1/2 of 1.6 hours. Thus, the short plasma t1/2 of complexed relative to native C1-inhibitor explains why in patients only low concentrations of C1-inhibitor complexes may be observed despite activation of the contact and/or complement systems.

Protective effect of antithrombin III in acute experimental pancreatitis in rats.

In the present study we investigated the therapeutic action of antithrombin III (AT III) in taurocholate-induced experimental pancreatitis with high lethality in rats. High-dose AT III treatment greatly improved the survival rate not only when given as pretreatment but also when given 2 hr after induction. No favorable effect on survival rate was observed on administration after 5 hr. Both intravascular and intraperitoneal AT III administration locally restored decreased AT III levels in the peritoneal cavity and increased plasma AT III to supranormal levels. The primary pancreatic insult seemed to be unaffected by the treatment, because neither the rise in plasma lipase nor the development of ascites or the extension of the pancreatic necrosis were diminished. Because heparin pretreatment of the rats was also effective, the mechanism of the beneficial action was probably mediated by inhibition of the proteases of the coagulation cascade, thereby preventing intravascular coagulation in the pancreas and distant organs and subsequent systemic complications. The high efficacy of AT III treatment in this experimental model may stimulate clinical studies evaluating the efficacy of AT III treatment in an early stage of acute pancreatitis.

Intravascular reduction of methemoglobin in plasma of the rat in vivo.

The formation and reduction of extracellular methemoglobin (metHb) in plasma was studied in vivo in conscious rats after isovolemic exchange transfusions with polymerized hemoglobin solutions. After exchange transfusions of 40 and 70% of the blood volume with hemoglobin solutions, containing less than 6% methemoglobin, the methemoglobin level remained below 15%, whereas exchange transfusions of greater than 90% resulted in an increase in the metHb level to about 30% after 24 hours. The reduction of metHb was studied after exchange transfusions with fully oxidized hemoglobin. A gradual decrease in the metHb level to 20% was observed after exchanges of 5 or 40%. A higher exchange transfusion (70%) resulted also in a decrease in the metHb level but only to approximately 40% in 24 hours. In another series of experiments the reduction of metHb was studied in vitro with isolated human erythrocytes. Incubation of the erythrocytes in the presence of oxidized polymerized hemoglobin (3 g%) resulted in a decrease in the percentage of metHb from 91% to 64%. In the presence of 0.2 mM ascorbic acid the metHb level declined to 22%, suggesting a synergistic effect. These results indicate (1) that there is a potent reducing mechanism present in blood that can reduce extracellular oxidized polymerized hemoglobin and (2) that isolated erythrocytes have a large capacity to reduce extracellular metHb, and may also play an important role in the reduction of extracellular metHb in vivo.

Effect of polymerization on clearance and degradation of free hemoglobin.

In the present study we investigated the mechanism of prolongation of the plasma retention of free hemoglobin by polymerization. Polymerization of intramolecularly crosslinked hemoglobin with glutaraldehyde yields a mixture of large polymers, small polymers and monomers. In exchange transfusion experiments in rats we analyzed plasma samples by gel filtration to determine the clearance of polymers of different size. A positive correlation was found between polymer size and vascular retention. Furthermore, the clearance of large polymers appeared to be highly dose-dependent: after 20% and 70% exchange transfusions, we observed for large polymers a plasma half-life of 12 and 26 hours, respectively, whereas the half-life for 64 kD monomers was 4 hours in both cases. The degradation of hemoglobin was followed by measuring the bilirubin excretion. The infused heme was recovered as bilirubin within 72 hours. The delay between the disappearance of free hemoglobin from the plasma and the recovery as bilirubin was about six hours and was not affected by polymerization or dose. We conclude that polymerization prevents the operation of certain clearance mechanisms, while still allowing a route of clearance that is easily saturated. The intracellular degradation of heme into bilirubin is not affected by the modifications of hemoglobin and is not easily saturated.

Biophysical characteristics of hemoglobin intramolecularly cross-linked and polymerized.

Hemoglobin modified by intramolecular cross-linking with 2-nor-2-formylpyridoxal 5'-phosphate (NFPLP) has potential application as an oxygen-carrying plasma expander with improved vascular retention time (threefold) and oxygen-transporting properties compared to native hemoglobin. Under some conditions a further prolongation is required. In this study polymerization of the purified modified hemoglobin (HbNFPLP) with glutaraldehyde was investigated. The influence of the degree of polymerization on the iso-oncotic concentration and the viscosity of the polymerized Hb-NFPLP (polyHbNFPLP) was investigated with three products polymerized to an increasing extent. Exchange transfusions in rats followed by gel filtration analyses of plasma samples provided information on the vascular retention time of four separate polymer fractions (i.e., monomers, dimers, trimers/tetramers, and polymers). The vascular retention time of these fractions correlated with their size. For lightly and highly polymerized HbNFPLP we found fivefold and sevenfold increases, respectively, compared to the retention time for native hemoglobin. This finding and the different shapes of the clearance curves suggested a different clearance mechanism from the vascular system for the monomer and polymer fractions. By polymerizing HbNFPLP the oxygen affinity was enhanced (oxygen half-saturation pressure shifted from 45 to 22 mm Hg), and it appeared to be independent of the degree of polymerization. Because hemoglobin was undetectable in the urine of the rats after the exchange transfusions, no accumulation of polyHbNFPLP will occur in the tubules of the kidney.(ABSTRACT TRUNCATED AT 250 WORDS)

Key role of macrophages in hypotensive side effects of immunoglobulin preparations. Studies in an animal model.

Intravenous administration of certain immunoglobulin preparations may cause severe adverse reactions, especially in hypogammaglobulinaemic patients. Because the exact mechanism of the adverse reactions is still unknown, we investigated the severe, prolonged hypotension induced in anaesthetized rats on rapid i.v. infusion of standard immunoglobulin preparations. The hypotensive response was previously shown to be associated with IgG aggregates in the preparations but independent of complement activation. We found that the hypotension could be prevented by treating the rats with a specific receptor antagonist of platelet-activating factor; or by depletion of the macrophages of the rats; or by pretreatment with monomeric IgG. This provided evidence that the hypotension is initiated by interaction of IgG-aggregates with Fc-receptors on macrophages, leading to the production of platelet-activating factor. We conclude that the rat model provides a sensitive and reproducible test system for macrophage-activating properties of immunoglobulin preparations for i.v. administration which may lead to vasoactive side effects.

In vivo distribution and elimination of hemoglobin modified by intramolecular cross-linking with 2-nor-2-formylpyridoxal 5'-phosphate.

Modified hemoglobin solutions have potential application as plasma expanders with oxygen-transporting capacity. In a previous study it was found that modification of hemoglobin by intramolecular cross-linking with 2-nor-2-formylpyridoxal 5'-phosphate (NFPLP) improves the vascular retention time by a factor of three, and it also improves the oxygen-transporting properties. In the present study we investigated in rats how, after exchange transfusion of a clinically relevant dose, the modified hemoglobin (HbNFPLP) was distributed in the body compared with how the unmodified hemoglobin was distributed. By using a new technetium 99m labeling technique, we found in a scintigraphic study that accumulation of hemoglobin in the kidneys was greatly diminished by the intramolecular cross-linking with NFPLP. These findings were confirmed by light-microscopic observations after diaminobenzidine staining. It was concluded that the impairment of kidney function caused by blockade of the tubuli is not to be expected from HbNFPLP. In the liver and spleen, where the free HbNFPLP is possibly eliminated, some accumulation of 99mTc label was observed, but the major part of the extravascular label was diffusely spread throughout the body. This led to the conclusion that important accumulation of undegraded HbNFPLP does not occur in the liver and spleen. Rapid appearance of both hemoglobin and HbNFPLP in the lymph showed that cross-linking with NFPLP does not prevent the distribution of hemoglobin over the interstitial space in the first hours after administration. However, pharmacokinetic analysis demonstrated that transcapillary transfer contributes only to a limited extent to the disappearance from the circulation. During 24-hour infusions of HbNFPLP, a steady state with a constant plasma concentration was easily reached. The latter experiment indicated that the eliminating system does not become saturated during prolonged administration of large doses of HbNFPLP.

Hemoglobin radiolabeling: in vitro and in vivo comparison of iodine labeling with iodogen and a new method for technetium labeling.

Radiolabeled hemoglobin may be a useful tool in the study of the body distribution of hemoglobin solutions developed as plasma expanders with oxygen-transporting capacity. The present investigation compares the suitability of two radiolabeling techniques for hemoglobin. 125I labeling of hemoglobin with Iodogen as iodinating agent caused major changes in the chromatographic behaviour and an accelerated plasma clearance of the labeled hemoglobin in rats. A recently developed two-step procedure for 99mTc labeling gave better results. The label had only minimal influence on the chromatographic behaviour of hemoglobin. In vivo, no free label occurred in the circulation and no transfer of the label to other plasma proteins took place. The plasma clearance of 99mTc-labeled hemoglobin in rats was slowed. However, this could be explained entirely by diminishing glomerular filtration, probably by inhibition of the dissociation of the hemoglobin molecule into dimers. The plasma clearance of hemoglobin modified by intramolecular cross-linking, which prevents dissociation of the molecule into dimers and thus excretion by the kidney, was not influenced by the label. We conclude that the 99mTc labeling procedure is suitable for in vivo distribution studies of hemoglobin when it is taken into account that the urinary excretion is underestimated. For cross-linked hemoglobin, which is more promising as plasma expander, no such restriction exists.

An animal model for the detection of hypotensive side effects of immunoglobulin preparations.

Intravenous administration of certain immunoglobulin preparations may cause severe adverse reactions, especially in immunodeficient patients. These reactions are generally assumed to be related to the anticomplementary activity of the preparations, caused by IgG aggregates. Because the exact mechanism of the adverse reaction is unknown, we investigated the reactions induced in anesthetized rats on rapid intravenous administration of different human immunoglobulin preparations. The most conspicuous observation was a severe, long-lasting hypotension, induced by standard immunoglobulin preparations (for intramuscular use), which appeared to be independent from the concomitant complement and neutrophil activation. The long-lasting hypotension was not related to the presence of prekallikrein activator, which induced a transient hypotensive reaction only after sensitizing the rats to bradykinin. The reactions appeared to be associated with IgG aggregates. It was found that certain aggregates induced mainly complement activation, whereas others had mainly a hypotensive effect or no effect at all. It was concluded that the rat model provides a sensitive and reproducible test system for vasoactive properties of immunoglobulin preparations for intravenous administration that cannot be predicted from in vitro measurements, such as anticomplementary activity, aggregate content or prekallikrein activator activity. It is suggested that the test may also be used for other plasma products for intravenous administration.

Prolonged vascular retention of a hemoglobin solution modified by cross-linking with 2-nor-2-formylpyridoxal 5'-phosphate.

The usefulness of hemoglobin solutions as plasma expanders with oxygen-carrying capacity is limited by a high oxygen affinity and a rapid clearance from the circulation. A large amount of the hemoglobin is cleared by the kidneys, because the hemoglobin can pass the glomeruli after dissociation into dimers. This dissociation can be prevented by cross-linking the beta chains with 2-nor-2-formylpyridoxal 5'-phosphate (NFPLP), a modification that also diminishes the oxygen affinity. In the present study, the vascular retention of modified hemoglobin (HbNFPLP) compared with unmodified hemoglobin (Hb) was investigated in rats and rabbits by replacing half the blood volume with a mixture of Hb and HbNFPLP (7 gm/100 ml). The amount of free hemoglobin in the circulation was determined from the plasma concentration, corrected for the decrease in plasma volume. The decrease in plasma volume was calculated from the increase in hematocrit (in the rats, 30% to 40% in 3 hours). The ratio Hb/HbNFPLP was determined by high-performance anion-exchange chromatography. The half-disappearance times for HbNFPLP and Hb were found to be 3 hours and 1 hour in rats and 7 hours and 2.5 hours in rabbits, respectively. In the rats, one third of the unmodified Hb was found in the urine 5 hours after the exchange, against only 5% of the HbNFPLP. In rats without kidneys, the ratio of Hb/HbNFPLP in the circulation remained constant. The results demonstrate that intramolecular cross-linking of hemoglobin with NFPLP prevents excretion by the kidneys, but does not influence other clearance mechanisms.