Prognostic Value of B-Type Natriuretic Peptide in Liver Transplant Patients: Implication in Posttransplant Mortality.

BACKGROUND AND AIMS: Despite frequent cirrhotic cardiomyopathy or subclinical heart failure (HF), the prognostic value of peri-liver transplant (LT) B-type natriuretic peptide (BNP) has been poorly studied in advanced liver disease. We examined the association between BNP and mortality in a large cohort of LT patients and identified risk factors for peri-LT BNP increase. APPROACH AND RESULTS: Using prospectively collected data from the Asan LT Registry between 2008 and 2019, 3,811 patients who measured serial pretransplant BNP (preBNP) and peak BNP levels within the first 3 posttransplant days (postBNPPOD3 ) were analyzed. Thirty-day all-cause mortality predicted by adding preBNP and/or postBNPPOD3 to the traditional Revised Cardiac Risk Index (RCRI) was evaluated. PreBNP > 400 pg/mL (known cutoff of acute HF) was found in 298 (7.8%); however, postBNPPOD3  > 400 pg/mL was identified in 961 (25.2%) patients, specifically in 40.4% (531/1,315) of those with a Model for End-Liver Disease score (MELDs) > 20. Strong predictors of postBNPPOD3  > 400 pg/mL were preBNP, hyponatremia, and MELDs, whereas those of preBNP > 400 pg/mL were MELDs, kidney failure, and respiratory failure. Among 100 (2.6%) post-LT patients who died within 30 days, patients with postBNPPOD3  ≤ 150 pg/mL (43.1%, reference group), 150-400 pg/mL (31.7%), 400-1,000 pg/mL (18.5%), 1,000-2,000 pg/mL (4.7%), and >2,000 pg/mL (2.0%) had 30-day mortalities of 0.9%, 2.2%, 4.0%, 7.7%, and 22.4%, respectively. Adding preBNP, postBNPPOD3 , and both BNP to RCRI improved net reclassification index to 22.5%, 29.5%, and 33.1% of 30-day mortality, respectively. CONCLUSIONS: PostBNPPOD3  > 400 pg/mL after LT was markedly prevalent in advanced liver disease and mainly linked to elevated preBNP. Routine monitoring of peri-LT BNP provides incremental prognostic information; therefore, it could help risk stratification for mortality as a practical and useful biomarker in LT.

Exendin-4-encapsulated dissolving microneedle arrays for efficient treatment of type 2 diabetes.

Dissolving microneedles (DMNs) are microscopic needles capable of delivering encapsulated compounds and releasing them into the skin in a minimally invasive manner. Most studies indicate that encapsulating therapeutics in DMNs is an efficacious approach; however, the importance of evaluating the activity of encapsulated compounds, during the fabrication process, has not been examined in detail. Conducting an analysis of thermal, chemical, and physical stress factors, including temperature, pH, and the interaction of the polymer and therapeutics mixture during preparation, is essential for retaining the activity of encapsulated therapeutics during and after fabrication. Here, we optimised the thermal, chemical, and physical parameters for the fabrication of exendin-4 (Ex-4)-encapsulated DMNs (Ex-4 DMNs). Ex-4, a peptide agonist of glucagon-like peptide (GLP) receptor, is used for glycaemic control in patients with type 2 diabetes. Our findings indicate that optimising the parameters involved in DMN fabrication retained the activity of Ex-4 by up to 98.3 ± 1.5%. Ex-4 DMNs reduced the blood-glucose level in diabetic mice with efficiency similar to that of a subcutaneous injection. We believe that this study paves way for the commercialisation of an efficient and minimally invasive treatment for patients with type 2 diabetes.

Effects of two droplet-based dissolving microneedle manufacturing methods on the activity of encapsulated epidermal growth factor and ascorbic acid.

Dissolving microneedle (DMN) is an attractive, minimally invasive transdermal drug delivery technology. The drugs encapsulated in the DMNs are exposed to a series of thermal, chemical, and physical stresses during the fabrication process, decreasing their therapeutic activity. Current DMN fabrication methods, such as micro-molding, drawing lithography, droplet-born air blowing, and centrifugal lithography, undergo different manufacturing processes involving differing stress conditions. Among the methods, we compared the effects of two droplet-based methods, droplet-born air blowing and centrifugal lithography, on the activity of encapsulated drugs using epidermal growth factor and ascorbic acid as model drugs. Although the appearance and physical properties of DMNs fabricated by the two methods were similar, the immunoreactivity of encapsulated epidermal growth factor in centrifugal lithography and droplet-born air blowing was 92.08±2.86% and 80.67±8.00%, respectively, at baseline, and decreased to 75.32±19.40% and 41.75±16.17%, respectively, 24h after drug-loading. The free-radical scavenging activity of ascorbic acid was maintained at 88.24±0.78% in DMNs fabricated by centrifugal lithography, but decreased over time to 67.02±1.11% in DMNs fabricated by droplet-born air blowing. These findings indicate that the manufacturing conditions of centrifugal lithography exert less stress on the drug-loaded DMNs, minimizing activity loss over time, and therefore that centrifugal lithography is suitable for fabricating DMNs loaded with fragile biological drugs.

Physicochemical study of ascorbic acid 2-glucoside loaded hyaluronic acid dissolving microneedles irradiated by electron beam and gamma ray.

A dissolving microneedle (DMN) patch encapsulated with ascorbic acid 2-glucoside (AA2G) in a needle-shaped hyaluronic acid (HA) backbone was fabricated and sterilized by electron beam (e-beam, 5-40kGy) and gamma ray (γ-ray, 5-30kGy). DMN structures maintained their morphologies and fracture force regardless of e-beam and γ-ray irradiation doses. Both e-beam (40kGy) and γ-ray (20 and 30kGy) met the product sterility requirements for cosmetics and vaccines; however, γ-ray irradiation significantly degraded the encapsulated AA2G, while e-beam maintained AA2G activity. Thus, an e-beam dose of 40kGy, which satisfied the sterility requirements without loss of AA2G, is suitable for terminal sterilization of DMNs. Moreover, we confirmed that the optimized irradiation (e-beam, 40kGy) did not affect dissolution rate and drug release profile of DMNs. Further, we confirmed that HA, the backbone polymer of DMNs, could be utilized as a stabilizer that inhibits degradation of encapsulated AA2G by irradiation. This detailed analysis can be developed further to optimize various biological drugs in transdermal drug delivery systems.

Anti-obesity effect of a novel caffeine-loaded dissolving microneedle patch in high-fat diet-induced obese C57BL/6J mice.

Natural products such as caffeine have been found to be effective in reducing body weight through lipolysis. Here, we report the successful loading of caffeine onto dissolving microneedle following inhibition of its crystal growth by hyaluronic acid (HA), the matrix material of the dissolving microneedle (DMN). Further, the anti-obesity activity of caffeine was evaluated in high-fat diet-induced obese C57BL/6J mice. After 6weeks of caffeine loaded dissolving microneedle patch (CMP) administration, lipolysis improved significantly as shown by leptin and adiponectin activity, which resulted in considerable weight loss of about 12.8±0.75% in high-fat diet-induced obese mice. Comparison of the levels of triglyceride, total cholesterol, high-density lipoprotein (HDL)-cholesterol, and low-density lipoprotein (LDL)-cholesterol after CMP administration with the initial levels in obese mice indicated significant anti-obesity activity of CMP. These findings suggested that a novel CMP with an increased amount of caffeine loaded onto DMN has therapeutic activity against obesity.

Development of a quantitative method for active epidermal growth factor extracted from dissolving microneedle by solid phase extraction and liquid chromatography electrospray ionization mass spectrometry.

Dissolving microneedle (DMN), a transdermal drug delivery in which biological drugs are encapsulated in biodegradable and biocompatible polymers, was fabricated using epidermal growth factor (EGF) as a model drug and hyaluronic acid (HA) as a backbone polymeric matrix. After mixing calibration and DMN samples with insulin, an internal standard, solid phase extraction (SPE) was performed to separate EGF and insulin from HA, and then liquid chromatography electrospray ionization mass spectrometry (LC-ESI-MS) was conducted for microgram-scale quantitation. The method showed good linearity (R2=0.997) within a specified range (1-4µg). Additionally, the decrease in EGF levels during DMN fabrication was compared using the SPE/LC-ESI-MS and enzyme-linked immunosorbent assay (ELISA), a traditional analytical method. The ELISA method detected an EGF loss of only 3.88±4.67%, whereas SPE/LC-ESI-MS detected a loss of 16.75±4.39%. Qualitative analysis by circular dichroism showed wavelength shift and splitting after DMN fabrication indicating that EGF was denatured during DMN fabrication and cell viability test showed SPE/LC-ESI-MS is more accurate and reliable for detecting the amount of active EGF loaded into the DMN than ELISA.

Rapid implantation of dissolving microneedles on an electrospun pillar array.

Dissolving microneedles (DMNs), designed to release drugs and dissolve after skin insertion, have been spotlighted as a novel transdermal delivery system due to their advantages such as minimal pain and tissue damage, ability to self-administer, and no associated hazardous residues. The drug delivery efficacy of DMNs, however, is limited by incomplete insertion and the extended period required for DMN dissolution. Here, we introduce a novel DMN delivery system, DMN on an electrospun pillar array (DEPA), which can rapidly implant DMNs into skin. DMNs were fabricated on a pillar array covered by a fibrous sheet produced by electrospinning PLGA solution (14%, w/v). DMNs were implanted into the skin by manual application (press and vibration for 10 s) by tearing of the fibers hung on the 300-µm pillars. Separation of DMNs from the fibrous sheet was dependent on both pillar height and the properties of the fibrous sheet. After evaluation of the implantation and dissolution of DMNs with diffusion of red dye by taking cross-sectional images of porcine skin, the hypoglycemic effect of insulin loaded DEPA was examined using a healthy mouse model. This DMN array overcomes critical issues associated with the low penetration efficiency of flat patch-based DMNs, and will allow realization of patient convenience with the desired drug efficacy.

Laboratory variables associated with low near-infrared cerebral oxygen saturation in icteric patients before liver transplantation surgery.

BACKGROUND: Although regional cerebral oxygen saturation (rSO2) measurements can detect disturbances in cerebral oxygenation, their usefulness is limited in patients with hyperbilirubinemia. We examined the relationship between rSO2 and other laboratory variables that may affect interpretation of low rSO2 in awake patients with end-stage liver disease before liver transplantation surgery. METHODS: Before induction of general anesthesia, rSO2 was measured in 164 patients with liver cirrhosis (Child class A/B/C = 19/41/104) and 8 with fulminant hepatic failure. Patients with West Haven hepatic encephalopathy of grade 3 or 4 were excluded. Relationships between rSO2 and laboratory variables were evaluated by correlation and multivariate regression, and by receiver operating characteristic curve analysis. RESULTS: Univariate analyses showed that rSO2 (median 58.5%, range 15% to 82%) correlated with serum total bilirubin, hemoglobin (Hb), creatinine, sodium, and magnesium concentrations, and prothrombin time (P < 0.001 each), but not with serum concentrations of glucose, albumin, potassium, and ammonia. Multiple logistic regression analysis showed that only elevated total bilirubin (range 0.4 to 66 mg/dL; odds ratio [OR] = 1.31; 95% confidence interval [CI] = 1.18 to 1.45) and low Hb (range 5.3 to 15.7 g/dL; OR = 0.21; 95% CI = 0.11 to 0.43) were independently related to rSO2 <50%. The optimum cutoff points for observing an rSO2 < 50% were total bilirubin >7.2 mg/dL (sensitivity 89%, specificity 90%) and Hb <9.6 g/dL (sensitivity 70%, specificity 82%). CONCLUSIONS: High total bilirubin and low Hb concentrations were independently associated with rSO2 values below 50% in end-stage liver disease patients awaiting liver transplantation. The results of this study identify patients in whom a low rSO2 may be an artifact rather than cerebral ischemia.

Altered autonomic cardiovascular regulation after combined deep and superficial cervical plexus blockade for carotid endarterectomy.

Compromised cardiac autonomic modulation can produce cardiovascular disturbances. We investigated whether combined deep and superficial cervical plexus (CP) blockade for carotid endarterectomy (CEA) produces changes in autonomic cardiovascular regulation. To estimate alterations in cardiovascular autonomic control before and after combined CP blockade in 22 patients undergoing CEA, the heart rate (HR) variability, systolic blood pressure (SBP) variability, and baroreflex sensitivity were analyzed. We found that SBP (157 +/- 28 mm Hg versus 191 +/- 38 mm Hg before and after combined CP blockade, respectively) and HR (68 +/- 10 bpm versus 84 +/- 9 bpm) increased after combined CP blockade. The high frequency power of HR variability (3.7 +/- 0.9 versus 2.2 +/- 1.2 ln/ms2) decreased (decrease in parasympathetic drive), whereas the low frequency power of SBP variability (5.5 +/- 4.7 versus 8.6 +/- 9.4 mm Hg2) increased (increase in vascular sympathetic outflow). Baroreflex sensitivity decreased, and this decrease was negatively correlated with a SBP increase (r = -0.455). The present results suggest that combined CP blockade impairs autonomic cardiovascular homeostasis and suggests an association between combined CP blockade and intraoperative or postoperative adverse cardiovascular events in high-risk cardiac patients undergoing CEA that merits further studies.

Low-dose atropine amplifies cardiac vagal modulation and increases dynamic baroreflex function in humans.

It has been previously known that low-dose atropine (LDA) enhances vagal outflow to the heart. To demonstrate the importance of vagal cardiac modulation in arterial blood pressure (ABP) stability, we evaluated the effect of vagal cardiac stimulation with administration of LDA on ABP fluctuation during dynamic hypertensive and hypotensive stimuli. We assessed changes in RR interval (RRI), ABP, power spectral densities of heart rate variability (HRV) and ABP variability, and spontaneous baroreflex sensitivity (BRS) in 16 healthy volunteers before and after administration of LDA (2 microg/kg). Transient hypertension was induced by phenylephrine (2 microg/kg), whereas hypotension was induced by bilateral thigh cuff deflation after a 3-min suprasystolic occlusion. LDA elicited bradycardia and significantly increased high-frequency (HF, 0.15-0.4 Hz) power of HRV and spontaneous BRS, as determined by transfer function analysis. The increase in systolic blood pressure (SBP) after phenylephrine administration was significantly attenuated by LDA (16+/-2 to 11+/-3 mmHg, P<0.005) and was associated with the augmented reflex bradycardia, whereas the decrease in SBP after cuff deflation was not affected (14+/-5 to 13+/-5 mmHg) with the augmented reflex tachycardia. Increases of HF HRV were correlated significantly and negatively with the increased SBP induced by phenylephrine before and after LDA (r=-0.502, P<0.05). These data suggest that the increased vagal cardiac function induced by LDA augments HR buffering effects, and is important in minimizing arterial pressure fluctuation during dynamic hypertensive stimuli.