PROTEASES II Potential Role in Health and Disease
Edited by
Walter H. Hörl University of Freiburg
Freiburg, Federal Republic of Germany
and August Heidland University of Würzburg Würzburg, Federal Republic of Germany
PLENUM PRESS • NEW YORK AND LONDON
/
Library of Congress Cataloging in Publication Data International Symposium on Proteases: Potential Role in Health and Disease (2nd: 1987: Rothenburg ob der Tauber, Germany)
Proteases II: potential role in health and disease. (Advances in experimental medicine and biology; v. 240) "Proceedings of the Second International Symposium on Proteases: Potential Role in
Health and Disease, held May 17-20, 1987 in Rothenburg ob der Tauber, Federal Republic of Germany" —T.p. verso.
Includes bibliographies and index. 1. Proteolytic enzymes —Congresses. 2. Proteolytic enzymes —Pathophysiology —
Congresses. 3. Proteolytic enzyme inhibitors —Congresses. I. Horl, Walter H. II. Heidland, August. III. Title. IV. Series. [DNLM: 1. Peptide Hydrolases —congresses. 2. Protease Inhibitors-congresses. Wl AD559v.240 / QU 136161 1987] QP609.P78I57 1987 612'.01516 88-25549 ISBN 0-306-43018-5
Proceedings of the Second International Symposium on Proteases: Potential Role in Health and Disease, held May 17-20, 1987, in Rothenburg ob der Tauber, Federal Republic of Germany
© 1988 Plenum Press, New York A Division of Plenum Publishing Corporation 233 Spring Street, New York, N.Y. 10013 AH rights reserved No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the Publisher
Universität* Bibliothek München
Printed in the United States of America
CONTENTS
I PHYSIOLOGY AND PATHOPHYSIOLOGY OF PROTEASES AND THEIR INHIBITORS
A s p a r t i c P r o t e i n a s e s and I n h i b i t o r s f o r t h e i r C o n t r o l i n H e a l t h and D i s e a s e 1
J. Kay, R. A. Ju p p , C. G. N o r e y , A. D. R i c h a r d s , W. A. R e i d , R. T. T a g g a r t , I . M. S a m l o f f , and B. M . Dunn
Human N e u t r a l E n d o p e p t i d a s e 2 4 . 1 1 (NEP, E n k e p h a l i n a s e ) ; F u n c t i o n , D i s t r i b u t i o n and R e l e a s e 13
E. G. Erdös and R. A. S k i d g e l
N e u t r o p h i l E l a s t a s e and C a t h e p s i n G: S t r u c t u r e , F u n c t i o n and B i o l o g i c a l C o n t r o l 23
W. W a t o r e k , D. F a r l e y , G. S a l v e s e n , and J. T r a v i s
The D e g r a d a t i o n o f C o l l a g e n by a M e t a l l o p r o t e i n a s e f r o m Human L e u c o c y t e s 33
U. K o h n e r t , R. O b e r h o f f , J. F e d r o w i t z , U. Bergmann, J. R a u t e r b e r g , and H. T s c h e s c h e
Plasma Membrane P r o t e a s e s as U s e f u l T o o l i n H i s t o c h e m i c a l T o x i c o l o g y 45
R. G r a f and R. G o s s r a u
A c t i v a t i o n o f L e u k o c y t e s D u r i n g P r o l o n g e d P h y s i c a l E x e r c i s e 57
K. K o k o t , R. M. S c h a e f e r , M. T e s c h n e r , U. G i l g e , R. P l a s s , and A. H e i d l a n d
I n h i b i t i o n o f Human N e u t r o p h i l E l a s t a s e by P o l y g u a n y l i c A c i d and o t h e r S y n t h e t i c P o l y n u c l e o t i d e s 65
S. Simon, M. V e r e d , A. R i n e h a r t , J. C h e r o n i s , and A. J a n o f f
I n h i b i t i o n o f Human N e u t r o p h i l E l a s t a s e by A c i d -S o l u b l e I n t e r - A l p h a - T r y p s i n I n h i b i t o r 75
A. Gast and J. G. B i e t h
D e v e l o p m e n t o f E g l i n c as a D r u g : P h a r m a c o k i n e t i c s 83
H. P. N i c k , A. P r o b s t , and H. P. S c h n e b l i
ix
M o n o c l o n a l A n t i b o d i e s R e c o g n i z i n g I n t e r - A l p h a -T r y p s i n - I n h i b i t o r and i t s R e l a t e d F r a g m e n t s -E v i d e n c e f o r t h e I n v o l v e m e n t o f t h e P r o t e i n a s e I n h i b i t o r i n C u t a n e o u s ( P a t h o - ) P h y s i o l o g y 89
C. J u s t u s , K. H o c h s t r a s s e r , and M. D. Kramer
I n h i b i t i o n o f Human C h y m o t r y p s i n - L i k e P r o t e a s e s by A l p h a - 1 - P r o t e i n a s e I n h i b i t o r and A l p h a - 1 -A n t i c h y m o t r y p s i n 97
A. Hayem, D. Marko, A. L a i n e , and M. D a v r i l
I m m u n o r e a c t i v e P a n c r e a t i c S e c r e t o r y T r y p s i n I n h i b i t o r i n G a s t r o i n t e s t i n a l Mucosa 1 0 1
M. Bohe, C. L i n d s t r ö m , and K. O h l s s o n
I I PROTEASES AND LUNG
S e m i s y n t h e t i c I n h i b i t o r s o f Human L e u k o c y t e E l a s t a s e and t h e i r P r o t e c t i v e E f f e c t on Lung E l a s t i n D e g r a d a t i o n i n v i t r o 107
J. Beckmann, A. M e h l i c h , H. R. W e n z e l , and H. T s c h e s c h e
Human B r o n c h i a l P r o t e i n a s e I n h i b i t o r : R a p i d P u r i f i c a t i o n P r o c e d u r e and I n h i b i t i o n o f L e u c o c y t e E l a s t a s e i n P r e s e n c e and i n Absence o f Human Lung E l a s t i n 115
C. B o u d i e r , D. C a r v a l l o , M. B r u c h , C. R o i t s c h , M. C o u r t n e y , and J. G. B i e t h
F u n c t i o n a l S t u d i e s o f Human S e c r e t o r y L e u k o c y t e P r o t e a s e I n h i b i t o r 123
K. O h l s s o n , M. B e r g e n f e l d t , and P. Björk
The R o l e o f Chymase i n I o n o p h o r e - I n d u c e d H i s t a m i n e R e l e a s e f r o m Human P u l m o n a r y Mast C e l l s 133
T. H u l t s c h , M. E n n i s , and H. H. H e i d t m a n n
P r o t e o l y t i c A c t i v i t i e s i n B r o n c h o a l v e o l a r Lavage F l u i d C o r r e l a t e t o S t a g e and C o u r s e o f I n t e r s t i t i a l Lung D i s e a s e 137
M. S c h m i d t and E. B r u g g e r
B e h a v i o u r o f A n g i o t e n s i n C o n v e r t i n g Enzyme, H y d r o x y p r o l i n e and some P r o t e a s e I n h i b i t o r s i n P u l m o n a r y S a r c o i d o s i s 145
M. M a s i a k , B. P o d w y s o c k i , and A. Gaje w s k a
E x p e r i m e n t a l S t u d i e s on t h e A d u l t R e s p i r a t o r y D i s t r e s s Syndrome: E l a s t a s e I n f u s i o n i n N o r m a l and A g r a n u l o c y t i c M i n i p i g s 149
H. B u r c h a r d i and T. S t o k k e
X
I I I PROTEASES AND LIVER
A r g i n y l a t i o n , S u r f a c e H y d r o p h o b i c i t y and D e g r a d a t i o n o f C y t o s o l P r o t e i n s f r o m Rat H e p a t o c y t e s 159
P. B o h l e y , J. K o p i t z , and G. Adam
P r o t e i n a s e I n h i b i t o r s as A c u t e Phase R e a c t a n t s : R e g u l a t i o n o f S y n t h e s i s and T u r n o v e r 171
A. K o j , D. M a g i e l s k a - Z e r o , A. K u r d o w s k a , and J . B e r e t a
R e g u l a t i o n o f P r o t e i n a s e A c t i v i t y by H i g h M o l e c u l a r W e i g h t I n h i b i t o r s : B i o s y n t h e s i s o f Rat A l p h a -M a c r o g l o b r u l i n s 183
T. G e i g e r , T. Andus, D. Kunz, M. H e i s i g , J. B a u e r , N. N o r t h o f f , F. G a u t h i e r , T.-A. T r a n - T h i , K. D e c k e r , and P. C. H e i n r i c h
I n d u c t i o n o f t h e P r o t e i n a s e I n h i b i t o r A l p h a - 2 -M a c r o g l o b u l i n i n Rat H e p a t o c y t e s by a M o n o c y t e - D e r i v e d F a c t o r 191
T. Andus, H. N o r t h o f f , J. B a u e r , U. G a n t e r , D. M ä n n e l , T.-A. T r a n - T h i , K. D e c k e r , and P. C. H e i n r i c h
A s t r o c y t e s S y n t h e s i z e and S e c r e t e A l p h a - 2 - M a c r o -g l o b u l i n : D i f f e r e n c e s Between t h e R e g u l a t i o n o f A l p h a - 2 - M a c r o j i . . b u l i n S y n t h e s i s i n Rat L i v e r and B r a i n 199
J. B a u e r , P . J . G e o i c k e - H a e r t e r , U. G a n t e r , I . R i c h t e r , and W. Gerok
C h a r a c t e r i z a t i o n o f D i f f e r e n t Forms o f D i p e p t i d y l P e p t i d a s e I V f r o m Rat L i v e r and Hepatoma by M o n o c l o n a l A n t i b o d i e s 207
S. H ä r t e l , C. H a n s k i , R. N e u m e i e r , R. G o s s r a u , and W. R e u t t e r
IV MUSCLE PROTEIN DEGRADATION
N o n - L y s o s o m a l , H i g h - M o l e c u l a r - M a s s C y s t e i n e P r o t e i n a s e s f r o m Rat S k e l e t a l M u s c l e 215
B. Dahlmann, L. Kuehn, F. Kopp, H. R e i n a u e r , and W. T. S t a u b e r
R o l e o f F a c t o r s D e r i v e d f r o m A c t i v a t e d M a c r o p h a g e s i n R e g u l a t i o n o f M u s c l e P r o t e i n T u r n o v e r 225
V . E . B a r a c o s
Responses o f L y s o s o m a l and N o n - L y s o s o m a l P r o t e a s e s t o U n l o a d i n g o f t h e S o l e u s 235
E. J. H e n r i k s e n , S. S a t a r u g , M. E. T i s c h l e r , and P. Fürst
xi
C a t h e p s i n B and D A c t i v i t y i n Human S k e l e t a l M u s c l e i n D i s e a s e S t a t e s 243
G. G u a r n i e r i , G. T o i g o , R. S i t u l i n , M. A. D e l B i a n c o , and L. C r a p e s i
H o r m o n a l R e g u l a t i o n o f M u s c l e P r o t e i n C a t a b o l i s m i n A c u t e l y U r e m i c R a t s : E f f e c t o f A d r e n a l e c t o m y and P a r a t h y r o i d e c t o m y 257
R. M. S c h a e f e r , M. Moser, P. K u l z e r , G. P e t e r , A. H e i d l a n d , W. H. Hö r l , and S. G. Mas s r y
V PROTEASES, KIDNEY AND UREMIA
R e l a t i o n Between U r i n a r y P r o t e i n a s e s and P r o t e i n u r i a i n R a t s w i t h a G l o m e r u l a r D i s e a s e 267
J.-C. D a v i n , M. D a v i e s , J.-M. F o i d a r t , J. B. F o i d a r t , C. A. Dechenne, and P. R. Mahi e u
C h a r a c t e r i z a t i o n and C l i n i c a l R o l e o f G l o m e r u l a r and T u b u l a r P r o t e a s e s f r o m Human K i d n e y 275
J. E. S c h e r b e r i c h , G. W o l f , C. S t u c k h a r d t , P. K u g l e r , and W. Schoeppe
E f f e c t o f G l o m e r u l a r P r o t e i n u r i a on t h e A c t i v i t i e s o f L y s o s o m a l P r o t e a s e s i n I s o l a t e d Segments o f Rat P r o x i m a l T u b u l e 283
C. J. U l b r i c h t
M e p r i n P h e n o t y p e and C y c l o s p o r i n A T o x i c i t y i n Mice 293
J. F. R e c k e l h o f f , S. S. C r a i g , R. J. Beynon, and J. S. Bond
P o t e n t i a l R o l e o f L y s o s o m a l P r o t e a s e s i n G e n t a m i c i n N e p h r o t o x i c i t y 305
C. J. O l b r i c h t , E. G u t j a h r , M. F i n k , and K. M. Koch
U r i n a r y P r o t e i n a s e A c t i v i t y i n P a t i e n t s w i t h A c u t e R e n a l F a i l u r e a f t e r Trauma and K i d n e y T r a n s p l a n t a t i o n 309
C. Wanner, S. G r e i b e r , G. K i r s t e , P. S c h o l l m e y e r , and W. H. Hörl
Mechanisms f o r A c t i v a t i o n o f P r o t e o l y s i s i n Urem i a 315
W. E. M i t c h
E v i d e n c e f o r t h e R o l e o f P r o t e i n a s e s i n U r e m i c C a t a b o l i s m 323
R. M. S c h a e f e r , M. T e s c h n e r , G. P e t e r , J. L e i b o l d , P. K u l z e r , and A. H e i d l a n d
E g l i n C F a i l s t o Reduce C a t a b o l i s m i n A c t u e l y U r e m i c R a t s 3 3 1
M. T e s c h n e r , R. M. S c h a e f e r , C. R u d o l f , P. K u l z e r , G. P e t e r , and A. H e i d l a n d
xii
E v i d e n c e f o r P r o t e i n S p l i t P r o d u c t s i n Plasma o f P a t i e n t s w i t h A c u t e R e n a l F a i l u r e 339
M. Haag, H. E. Meyer, P. S c h o l l m e y e r , and W. H. Hörl
P r o t e a s e s and A n t i p r o t e a s e s a t D i f f e r e n t V a s c u l a r S i t e s i n R e n a l F a i l u r e 345
K. B a u s e w e i n , K. S c h a f f e r h a n s , R. G ö t z , U. G i l g e , E. H e i d b r e d e r , and A. H e i d l a n d
P r o t e a s e H i s t o c h e m i s t r y i n N o r m a l and U r e m i c R a t s 3 5 1
R. G o s s r a u , A. H e i d l a n d , and J. H a u n s c h i l d
T o t a l K i n i n o g e n L e v e l s , Plasma R e n i n A c t i v i t y , D o p a m i n e - B e t a - H y d r o x y l ä s e and Plasma C a t e c h o l a m i n e s i n C h r o n i c and A c u t e R e n a l F a i l u r e 3 6 1
K. M a r c z e w s k i , A. K s i a z e k , J. S o l s k i , and Z. P a c h u c k i
V I PROTEOLYTIC ENZYMES DURING EXTRACORPORAL CIRCULATION
B i o c o m p a t i b i l i t y o f D i a l y s i s Membranes: F a c t o r H B i n d i n g C o r r e l a t e s I n v e r s e l y w i t h Complement A c t i v a t i o n I n d i e - t : :ig a L o c a l I m b a l a n c e o f I n v o l v e d P r o t e a s e s / A n t i - P r o t e a s e s 365
E. W. R a u t e r b e r g and E. R i t z
H e m o d i a l y s i s w i t h C u r o p h a n e Membranes Leads t o A l t e r a t i o n o f G r a n u l o c y t e O x i d a t i v e M e t a b o l i s m and L e u k o c y t e S e q u e s t i o n i n t h e Lung 377
G. K o l b , H. S c h ö n e m a n n , W. F i s c h e r , K. B i t t n e r , H. Lange, H. H ö f f k e n , V. Damann, K. J o s e p h , and K . Havemann
E f f e c t o f I m m u n s u p p r e s s i o n on t h e R e l e a s e o f Main G r a n u l o c y t e Components: I n V i v o and i n V i t r o S t u d i e s 385
C. Wanner, B. Simon, A. G ö s e l e , W. R i e g e l , P. S c h o l l m e y e r , and W. H. Hörl
R e l e a s e o f G r a n u l o c y t e P r o t e i n s D u r i n g C a r d i o p u l m o n a r y B y p a s s : E f f e c t o f D i f f e r e n t P h a r m a c o l o g i c a l I n t e r v e n t i o n s 3 9 1
W. R i e g e l , G. S p i l l n e r , V. S c h l o s s e r , K. Lang, and W. H. Hörl
S i g n i f i c a n t R o l e o f P r o t e a s e I n h i b i t i o n by A p r o t i n i n i n M y o c a r d i a l P r o t e c t i o n f r o m P r o l o n g e d C a r d i o p l e g i a w i t h H y p o t h e r m i a 399
M. S u n a m o r i , R. I n n a m i , H. F u j i w a r a , M. Yokoyama, A. S u z u k i
xiii
F i b r i n o l y s i s Caused by C a r d i o - P u l m o n a r y Bypass and Shed M e d i a s t i n a l B l o o d R e t r a n s f u s i o n -I s i t o f C l i n i c a l R e l e v a n c e ? 405
W. D i e t r i c h , A. B a r a n k a y , P. Wendt, A. S t e m b e r g e r , G. B l ü m e l , M. S p a n n a g l , M. Jochum, and J. A. R i c h t e r
V I I PROTEINASES I N CATABOLIC STATES
N u t r i t i o n and P r o t e a s e A c t i v i t y 4 1 1 J. D. K o p p l e
I n s u l i n D e g r a d a t i o n a f t e r I n j u r y i n Man 4 2 1 S. M. H o a r e , K. N. F r a y n , and R. E. O f f o r d
E n d o t o x i n A b o l i s h e s t h e I n d u c t i o n o f A l p h a - 2 - M a c r o -g l o b u l i n S y n t h e s i s i n C u l t u r e d Human M o n o c y t e s I n d i c a t i n g I n h i b i t i o n o f t h e T e r m i n a l M o n o c y t e M a t u r a t i o n i n t o M a c r o p h a g e s 425
J. B a u e r , U. G a n t e r , and W. Gerok
L o c a l and G e n e r a l D e f e n c e Mechanisms i n B a c t e r i a l and C h e m i c a l P e r i t o n i t i s 433
A. L a s s o n , M. D e l s hammer, and K. O h l s s o n
D e f i c i e n t P h a g o c y t o s i s S e c o n d a r y t o P r o t e o l y t i c B r eakdown o f O p s o n i n s i n P e r i t o n i t i s E x u d a t e 4 4 1
A. B i l l i n g , ü. F r ö h l i c h , M. Jochum, and H. Ko r t m a nn
P r o t e o l y s i s and L i p i d P e r o x i d a t i o n - Two A s p e c t s o f C e l l I n j u r y i n E x p e r i m e n t a l H y p o v o l e m i c -T r a u m a t i c Shock 449
H. R e d l , S. H a l l s t r ö m , C. L i e n e r s , W. F ü r s t , and G. S c h l a g
Plasma L e v e l s o f E l a s t a s e 1 P r o t e a s e I n h i b i t o r Complex i n t h e M o n i t o r i n g o f ARDS and M u l t i -Organ F a i l u r e - A Summary o f T h r e e C l i n i c a l T r i a l s 457
H. R e d l , E. P a u l , R. J. A. G o r i s , R. P a c h e r , W. W o l o s z c z u k , and G. S c h l a g
PMN E l a s t a s e and L e u k o c y t e N e u t r a l P r o t e i n a s e I n h i b i t o r ( L N P I ) f r o m G r a n u l o c y t e s as I n f l a m m a t i o n M a r k e r s i n E x p e r i m e n t a l -S e p t i c e m i a 465
R. G e i g e r , S. S o k a l , G. T r e f z , M. S i e b e c k , and H. H o f f m a n n
Plasma D e r i v a t i v e R e p l a c e m e n t T h e r a p y i n D i s s . I n t r a v a s c . Coag . ( D I C ) I n d u c e d by S e p t i c D i s o r d e r s w i t h h i g h l y E l e v a t e d E l a s t a s e A l p h a - l - A T - C o m p l e x e s 473
R. E g b r i n g , R. S e i t z , M. W o l f , K. Havemann, L. L e r c h , H. B l a n k e , and G. Fuchs
xiv
N e u t r o p h i l E l a s t a s e , T h r o m b i n and P l a s m i n i n S e p t i c Shock 4 8 1
R. S e i t z , M. W o l f , R. E g b r i n g , and K. Havemann
E l a s t a s e - A l p h a - l - P r o t e i n a s e I n h i b i t o r : An E a r l y I n d i c a t o r o f S e p t i c e m i a and B a c t e r i a l M e n i n g i t i s i n C h i l d h o o d 485
C. P. S p e e r , M. R e t h w i l m , and M. Gahr
Serum P a n c r e a t i c S e c r e t o r y T r y p s i n I n h i b i t o r ( P S T I ) i n S e r i o u s l y I n j u r e d and S e p t i c P a t i e n t s 493
H. T a n a k a , M. Ogawa, T. Y o s h i o k a , and T. S u g i m o t o
Changes i n P M N - E l a s t a s e i n B l o o d and i n R e n a l and Plasma K a l l i k r e i n - K i n i n S y s t e m s a f t e r S e v e r e B u r n I n j u r y 499
G. B o n n e r , W. N i e r m a n n , R. F e s t g e , and U. B ü c h s l e r
Serum P a n c r e a t i c S e c r e t o r y T r y p s i n I n h i b i t o r ( P S T I ) i n P a t i e n t s w i t h I n f l a m m a t o r y D i s e a s e s 505
M. Ogawa, T. S h i b a t a , T. N i i n o b u , K. Uda, N. T a k a t a , and T. M o r i
The E f f e c t o f A p r o t i n i n A d m i n i s t r a t i o n on t h e I n t r a o p e r a t i v e H i s t a m i n e R e l e a s e and H a e m o s t a t i c D i s o r d e r s 509
H. H a r k e and S. Rahman
I n c r e a s e d M o r t a l i t y i n S e p t i c R a t s a f t e r L e u p e p t i n A p p l i c a t i o n 515
E. K o v a t s , J. K a r n e r , G. O l l e n s c h l ä g e r , J. K a r n e r , A. S i m m e l , and E. R o t h
L y s o s o m a l Enzymes and G r a n u l o c y t e E l a s t a s e i n S y n o v i a l F l u i d a f t e r M u l t i p l e T r a u m a t i c I n j u r i e s 519
M. Hörl and H. P. B r u c h
A S e r i n e P r o t e i n a s e I n h i b i t o r i n Human A r t i c u l a r C a r t i l a g e - P o s s i b l e R o l e i n t h e P a t h o g e n e s i s o f I n f l a m m a t o r y J o i n t D i s e a s e s 523
H. B u r k h a r d t , M. K a s t e n , and S. R a u l s
D e t e c t i o n o f G r a n u l o c y t e E l a s t a s e S p e c i f i c IgG S p l i t P r o d u c t s i n R h e u m a t o i d S y n o v i a l F l u i d 5 3 1
I . E c k l e , G. K o l b , F. N e u r a t h , and K. Havemann
XV
V I I I PROTEASES AND MALIGNOMA
The T C e l l S p e c i f i c S e r i n e P r o t e i n a s e TSP-1: B i o c h e m i c a l C h a r a c t e r i z a t i o n , G e n e t i c A n a l y s i s , and F u n c t i o n a l R o l e 535
H.-G. Simon, U. F r u t h , R. G e i g e r , M. D. Kramer, and M. M. Simon
P a n c r e a t i c S e c r e t o r y T r y p s i n I n h i b i t o r i n Cancer 547
M. Ogawa, N. T o m i t a , A. H o r i i , N. M a t s u u r a , M. H i g a s h i y a m a , T. Yamamoto, A. M u r a t a , T. M o r i , and K. M a t s u b a r a
P r o t e a s e s and A n t i p r o t e a s e s i n A s c i t e s -D i f f e r e n t i a t i o n o f M a l i g n a n t and Non-m a l i g n a n t A s c i t e s and P r e d i c t i o n o f C o a g u l o p a t h y i n A s c i t e s R e t r a n s f u s i o n 555
J. S c h ö l m e r i c h , E. K ö t t g e n , B. A. V o l k , and W. Gerok
A l p h a - 1 - A n t i t r y p s i n and A l p h a - l - A n t i c h y m o t r y p s i n Serum L e v e l i n R e l a t i o n t o S t a g i n g and P o s t o p e r a t i v e C l i n i c a l C o u r s e o f Human C o l o r e c t a l Cancer 5 6 1
A. K u r y l i s z y n - M o s k a l , K. B e r n a c k a , and S . S i e r a k o w s k i
I n h i b i t i o n o f P r o t e a s e s D u r i n g E x t r a c o r p o r e a l E x t r e m i t y P e r f u s i o n 565
H. W a l t h e r , H. M ü l l e r , and K. R. A i g n e r
INDEX 569
xvi
FIBRINOLYSIS CAUSED BY CARD IO-PULMONARY BYPASS AND SHED
MEDIASTINAL BLOOD RETRANSFUSION - IS IT OF CL IN ICAL RELEVANCE?
W. D i e t r i c h 1 , A. Barankayl, P. Wendt 2, A. stemberger 2, G. Blume! 2, M. Spannagl 3, M. Jochum 3, and J.A. R i c h t e r 1
1 I n s t i t u t e f o r Anesthesiology, German Heart Center, Munich ^Technical U n i v e r s i t y , Munich ^Ludwig Maximilian U n i v e r s i t y , Munich
INTRODUCTION The impo r t a n ce of b lood s a v i n g methods d u r i n g c a r d i a c s u r g e r y
is we l l a c c e p t e d . I t i s commonly known t h a t , i n s p i t e of h e p a r i n t r e a tmen t , s ys t em i c c o a g u l a t i o n a n d f i b r i n o l y s i s w i l l be a c t i v a t e d by c a r d i o - p u I m o n a r y b y pa s s (CPB) . Whether t h i s a c t i v a t i o n is of c l i n i c a l r e l e vance was many t imes a po i n t o f d i s c u s s i o n ( 1 ) . S i m i l a r c hanges were f o u nd i n the shed m e d i a s t i n a l b l ood p o s t o p e r a t i v e l y ( 2 ) , w h i c h was r e t r a n s f u s e d to reduce homologous b l ood r e q u i r emen t ( 3 ) . I t is g e n e r a l l y accep ted now, t h a t t h i s method leads to a r e d u c t i o n of homologous b l ood r e qu i r emen t i n c a r d i a c s u r g e r y ( 4 ) , bu t some r e s e r v a t i o n s were made because of the low q u a l i t y of the chest t u be b lood ( 5 ) .
The a im of ou r s t u d y was to i n v e s t i g a t e the deg ree of f i b r i n o l y s i s i n the shed b l ood and i n p a t i e n t s ' c i r c u l a t i o n , the i n f l u e n c e of lysosomal enzymes of des i n t e g r a t e d o r a c t i v a t e d g r a n u l o c y t e s upon f i b r i n o l y s e s , a nd to answe r the q u e s t i o n , whe t h e r r e t r a n s f u s i o n of shed med i a s t i n a l b l ood causes c l i n i c a l l y r e l e v a n t changes i n p a t i e n t s ' h emos t a s i s .
METHODS In twen t y a d u l t p a t i e n t s u n d e r g o i n g c a r d i a c s u r g e r y p a r ame t e r s
of f i b r i n o l y s i s were a n a l y s e d a t the f o l l o w i n g i n s t a n c e s : 1 . be fo re o p e r a t i o n , 2 . a f t e r CPB ( c ompa r i n g the d a t a o b t a i n e d at these two i n s t ances the e f fec t of CPB on f i b r i n o l y s i s can be e s t i m a t e d ) , 3. in the i n t e n s i v e c a r e u n i t be fo re a n d 4 . 20 m i nu t e s a f t e r r e t r a n s f u s i o n . Samples were t a ken f r om p a t i e n t s ' c i r c u l a t i o n as we l l as f r om the chest tube d r a i n a g e . The a p p l i e d a n a l y t i c a l methods f o r measu remen ts of p l a s m i n o g e n , a n t i p l a s m i n , D - d ime r , e a r l y f i b r i n ( o g e n ) d e g r a d a t i o n p r o du c t s ( N - t e r m i n a l Bß-fragments 1-42 a nd 15-42) a n d e l a s t a s e f r om PMN g r a n u l o c y t e s comp lexed w i t h a ^ - p r o t e i n a s e - i n h i b i t o r ( E - a ^ P I ) a r e shown in Tab l e 1 . Re t r ans f u s i on was o n l y pe r f o rmed when a t leas t 250 cc b lood were co l l e c t ed a nd when i t was i n d i c a t e d by the p a t i e n t ' s c i r c u l a t o r y s t a t e .
405
Tab l e 1 . Methods
p l a sm i nogen a n t i p l a s m i n D-d imer N - t e rm i n a l Bß-fragments E-a PI
ch romogen i c s u b s t r a t e ch r omogen i c s u b s t r a t e monoc lona l a n t i b o d i e s monoc lona l a n t i b o d i e s PMNE (EL ISA /Me rck )
S 2251 ( Kab i ) S 2251 ( K ab i ) (EL ISA /MabCo) (EL ISA /N IH )
For s t a t i s t i c a l a n a l y s i s the p a i r e d t - t e s t c ompa r i n g the mea su remen t s be f o re a nd a f t e r r e t r a n s f u s i o n was a p p l i e d . A p - v a l u e
^ 0,05 was c on s i d e r e d to be s i g n i f i c a n t . Resu l t s a r e g i v e n as mean + SD.
RESULTS The mean amoun t of the f i r s t ches t b l ood r e t r a n s f us i on was 325
+_ 77 cc ( r a n g i n g f r om 250 - 520 c c ) . The mean hemog l ob i n con ten t of the ches t d r a i n a g e was 69 g / l , t he mean hema t o c r i t 21 % ( r a n g i n g f r om 13 - 29 %) , the p r o t e i n con ten t 40 .1 _+ 5 .4 g / l .
F i g u r e 1 shows the cou rse of p l a sm i nogen a n d a n t i p l a s m i n a c t i v i t y , the do t t e d l i n e r e p r e s e n t i n g the v a l u e c o r r e c t e d f o r p r e o p e r a t i v e p r o t e i n . When u s i n g t h i s c o r r e c t i o n f o r h emod i l u t i o n no s t a t i s t i c a l l y s i g n i f i c a n t i n f l u e n c e of CPB on these p a r ame t e r s was f o u n d . Howeve r , a n t i p l a s m i n a c t i v i t y i n the d r a i n a g e f l u i d was s i g n i f i c a n t l y r e d u c e d . No d i f f e r e n c e of a c t i v i t y i n the p a t i e n t s ' b l ood c o u l d be demons t r a t e d be fo re a nd a f t e r r e t r a n s f u s i o n . The s u r p r i s i n g f a c t t h a t no r e d u c t i o n of p l a sm i n ogen a c t i v i t y in the ches t d r a i n a g e was measu red m i gh t be e x p l a i n e d by the i n f l u e n c e of f i b r i n a nd f i b r i n ( o g e n ) s p l i t p r o d u c t s on the measurement of p l a sm i nogen ( 6 ) .
% 130
120
110
100
90
80
70
60
40
30
F i g .
plasminogen
antiplasmin
corrected for
preop protein
drainage
preop end of before r e -ECC transfusion
20 ' after r e - * + SD transfusion
1 Course of p l a sm i nogen and a n t i p l a s m i n . The do t t ed l i n e r e p r e sen t s the v a l u e c o r r ec t ed f o r p r e o p e r a t i v e p r o t e i n .
406
ng/ml 5000
l a,b
4000
3000
2000
1000 drainage
a=p<0.01 vs preop.
b=p<0.01 vs bef. retr.
preop end of ECC
before r e -transfusion
20' after r e -transfusion
x + SEM
F i g . C r o s s - l i n k e d f i b r i n f r a g m e n t s . R e t r a n s -f u s i o n of of shed b l ood caused a s i g n i f i c an t (p ^ 0 ,01) i n c r ea se of the c o n c en t r a t i o n in p a t i e n t s ' c i r c u l a t i o n compa red to v a l u e s be fo re r e t r a n s f u s i o n .
The c r o s s - l i n k e d f i b r i n f r a g m e n t s ( F i g u r e 2) showed a w i d e v a r i a t i o n a f t e r CPB. The c o n c e n t r a t i o n dec reased a f t e r o p e r a t i o n , bu t de ve l oped a t r emendous i n c r ease up to 5,000 n g / c c i n the d r a i n a g e f l u i d . The r e t r a n s f us i on caused a s i g n i f i c a n t i n c r ease of c r o s s - l i n k e d f i b r i n f r a g m e n t s i n p a t i e n t s ' b l o o d .
pM/ml
droinoge n.s. VS before retrons.
preop end of before r e - 20' after r e - x ± SD
ECC transfusion transfusion
F i g . 3 Bß-related p e p t i d e s . Note the i n t e r r u p t i o n of the Y - a x i s . Desp i t e the h i g h c o n c en t r a t i o n in the d r a i n a g e b l ood t he r e was - in c o n t r a s t to t he c r o s s - l i n k e d f i b r i n f r a gmen t s - no s i g n i f i c a n t i n c r ease i n p a t i e n t s ' c i r c u l a t i o n a f t e r r e t r a n s f u s i o n .
407
The Bß-related pep t i d e s ( F i g u r e 3) showed a c ompa r a b l e cou rse d u r i n g CPB w i t h an i n c r ease of t he 1-42 f r a gmen t s w h i c h was not s i g n i f i c a n t . In the ches t t ube d r a i n a g e a more p r onounced i n c r ease of Bß 15-42 p ep t i d e s was f o u n d . Howeve r , t he r e were no d i f f e r e n ce s of Bß-related pep t i d e s i n p a t i e n t s ' b l ood be fo re a n d a f t e r r e t r a n s -f u s i o n .
The PMN E-a^PI comp lex ( F i g u r e 4) showed a t e n f o l d i n c r ease in p a t i e n t s ' b l ood a f t e r CPB, b u t t he r e was an e x t r a o r d i n a r y i n c rease in t he d r a i n a g e f l u i d w i t h a mean c o n c e n t r a t i o n of 13,000 n g / c c - more t h a n h u n d r e d f o l d t he p r e o p e r a t i v e v a l u e . Re t r a n s f us ion a l so caused a s i g n i f i c a n t i n c r ease of the E-a^PI comp lex i n p a t i e n t s ' b l o o d . These v a l u e s were s i g n i f i c a n t l y h i g h e r t h a n those o b t a i n e d p r i o r to r e t r a n s f us i on .
No s i g n i f i c a n t c o r r e l a t i o n be tween e i t h e r b l ood loss o r t ime l ag between o p e r a t i o n a nd r e t r a n s f us ion a nd f i b r i n o l y s i s , r e p r e s en t e d by the a n t i p l a s m i n a c t i v i t y , c o u l d be f o u nd i n the shed b l o o d . A f t e r r e -t r a n s f u s i o n b l ood loss d i d not exceed the a v e r a g e of no rma l r a n g e .
before r e -transfusion
20' after r e -transfusion
x + SD
F i g . PMN E-a^PI c omp l e x , a nd d i f f e r e n t s ca l e of
Note the i n t e r r u p t i o n the Y - a x i s . The re
was a t remendous i n c r ease in the shed b l o o d . Re t r ans f u s i on of shed b l ood caused a s i g n i f i c a n t l y i n c r e a sed leve l of the comp lex i n p a t i e n t s ' b l o o d .
DISCUSSION Shed m e d i a s t i n a l b l ood is not c ompa r a b l e to au t o l ogous o r ho
mologous (7) b l ood i n r e g a r d to hemog l ob i n c o n t e n t , h ema t o c r i t o r c o a g u l a t i o n p r o p e r t i e s . However , in f o rme r i n v e s t i g a t i o n s ( 8 ) , comp a r i n g two g r o u p s of p a t i e n t s w i t h a nd w i t h o u t r e t r a n s f u s i on of shed med i a s t i n a l b l o o d , no d i f f e r e n c e i n the p o s t o p e r a t i v e b l ood loss c ou l d be o b s e r v e d .
408
In the p r esen t s t u d y an a c t i v a t i o n of the f i b r i n o l y t i c sys tem i n shed m e d i a s t i n a l b l ood was f o u n d . The m a g n i t u d e of f i b r i n o l y t i c a c t i v a t i o n i n shed b l ood was c ompa r a b l e to t h a t measu red d u r i n g CPB. T h i s a c t i v a t i o n of the f i b r i n o l y t i c sys tem was i n d i c a t e d b y c ompa r a b l e dec reases of a n t i p l a s m i n a c t i v i t y i n p a t i e n t s ' b l ood a f t e r CPB as we l l as i n the shed b l o o d . Howeve r , r e t r a n s f u s i on of shed b l ood d i d not cause an a d d i t i o n a l dec rease of a n t i p l a s m i n i n the p a t i e n t s ' c i r c u l a t i o n .
Bß-related pep t i d e s a r e a most s e n s i t i v e m a r k e r of t he e ndo genous a c t i v a t i o n of the f i b r i n o l y t i c s y s t em , w h i c h can r e v e a l s u b c l i n i c a l a c t i v a t i o n of f i b r i n o l y s i s ( 9 ) . A p r onounced i n c r e a se of f i b r i n o g e n ) s p l i t p r o d u c t s was f o u n d i n the shed b l o o d . A f t e r r e t r a n s -f u s i o n o n l y the D -d ime rs showed a s i g n i f i c a n t i n c r e a se i n p a t i e n t s ' b l o o d , whe reas the c o n c e n t r a t i o n of Bß-related pep t i d e s showed no i n c r e a s e . T h i s can be e x p l a i n e d by the lower mo l e c u l a r w e i g h t a n d t h e r e f o r e f a s t e r c l e a r i n g r a t e of these p e p t i d e s .
The c o n s t e l l a t i o n of i n c r ea sed f i b r i n ( o g e n ) s p l i t p r o d u c t s a n d s t a b l e a n t i p l a s m i n a c t i v i t y a f t e r r e t r a n s f us i on can be i n t e r p r e t e d as a was t e e f fec t of r e t r a n s f u s i o n . Tha t means , the enhanced f i b r i n o l y t i c o r p r o t e o l y t i c a c t i v i t y w i t h i n the shed b l ood is i n h i b i t e d by the p h y s i o l o g i c i n h i b i t o r s . Some of these comp lexes a nd the s p l i t p r o d u c t s o b v i o u s l y r ema i n i n t he c i r c u l a t i o n a f t e r r e t r a n s f us i on w i t h o u t i n d u c i n g f i b r i n o l y t i c a c t i v i t y w i t h i n the p a t i e n t .
In t h i s s t u d y the e l e v a t e d l e ve l s of comp lexed e l a s t a s e a f t e r CPB c o r r e s pond to the r e s u l t s of o t he r a u t h o r s (10) i n d i c a t i n g an a c t i v a t i o n o r des i n t e g r a t i o n of PMN g r a n u l o c y t e s due to CPB. The e x t r a o r d i n a r y i n c r ease of E-a^PI i n the shed b l ood may be e x p l a i n e d by d e s i n t e g r a t i o n of g r a n u l o c y t e s caused by mechan i c a l a l t e r a t i o n due to p e r i c a r d i a l a n d / o r p l e u r a l movement i n the t h o r a x a n d i n the ches t t u b i n g .
Which c on c l u s i o n s can be d r a w n f r om the r e s u l t s of t h i s s t u d y?
The f i b r i n o l y t i c a nd un s p e c i f i c p r o t e o l y t i c a c t i v i t y i n the d r a i n a g e f l u i d does not i n duce f i b r i n o l y t i c a c t i v a t i o n a f t e r r e t r a n s -f u s i o n . The i n c r ea sed leve l of f i b r i n ( o g e n ) s p l i t p r o d u c t s seems not to be c l i n i c a l l y r e l e v a n t , a t l eas t not w i t h the amoun t s h a v i n g been r e t r a n s f u s e d . I t can be con c l u ded t h a t r e t r a n s f u s i on of shed med i a s t i n a l b l ood is a save method of au t o l o gous vo lume s u b s t i t u t i o n i n the e a r l y p o s t o p e r a t i v e p e r i o d . However , i t has to be t a k e n i n t o a ccoun t t h a t r e t r a n s f us i on of g r e a t e r v o l umes , of shed b l ood may cause a c o n s i d e r a b l e impa i rmen t of c o a g u l a t i o n a n d / o r the f i b r i n o l y t i c s y s t em . T h i s d e t e r i o r a t i o n m i gh t be i n du ced by the i n f u s i o n of f i b r i n ( o g e n ) s p l i t p r o d u c t s a n d / o r t he re l ease of t he con ten t of des i n t e g r a t e d g r a n u l o c y t e s . In t h i s respec t t he pos s i b l e r o l e of p h a r m a c o l o g i c a l i n t e r v e n t i o n by p ro t ease i n h i b i t i o n s h o u l d be ob jec t of f u r t h e r i n v e s t i g a t i o n s .
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