The Influence of a Serine Protease Inhibitor, Nafamostat Mesilate, on Plasma Coagulation, and Platelet Activation during Experimental Extracorporeal Life Support (ECLS)

Summary

Introduction: During extracorporeal circulation the contact between blood and the artificial surface of the circuit induces several changes in the hemostatic system. The objective of the present study was to assess the effect of a serine protease inhibitor – Nafamostat mesilate (FUT-175) – on coagulation and on platelets during experimental extracorpo-real circulation. Methods: Two identical Extra Corporeal Life Support (ECLS) circuits were primed with fresh, heparinized human blood and circulated for 24 h. FUT-175 was added to one of the paired circuits and the other was used as a control. The following FUT-175 concentrations were employed: (1) 7.1 mg/l/h, (2) 14.2 mg/l/h, (3) 14.2 mg/l/h + 85.5 mg given as an initial bolus, (4) 28.5 mg/l/h + 171 mg given as an initial bolus. Blood samples were collected from the circuits before the start of the perfusion and at 0.5, 1, 3, 12, and 24 h of perfusion, and analysed for platelet count, plasma betathromboglobulin ( -TG), platelet membrane glycoprotein (GP) Ib and GPIIb/IIIa expression, thrombin/ antithrombin III complex (TAT), prothrombin fragment 1+2 (F1+2), fibrinogen, D-dimer, and plasminogen activator inhibitor 1 activity (PAI-1). Results: Significantly higher platelet membrane GPIb expression and lower plasma -thromboglobulin levels were observed in the circuits holding FUT-175, suggesting a lower degree of platelet activation. Also, a reduced activation of the coagulation system was observed in the “FUT-circuits”, as reflected by the levels of F1+2 and TAT, and the PAI-1 activity that was rapidly inactivated. Conclusion: FUT-175 reduces the activation of platelets and plasma coagulation in an in vitro ECLS model.

• References

• 1 Plötz FB, van Oeveren W, Bartlett RH, Wildevuur CRH. Blood activation during neonatal extra corporeal life support. J Thorac Cardiovasc Surg 1993; 105: 823-32.
• 2 Woodman RC, Harker LA. Bleeding complications associated with cardio-pulmonary bypass. Blood 1990; 76: 1680-97.
• 3 Zwichenberger JB, Nguyen TT, Upp JR. et al. Complications of neonatal extracorporeal membrane oxygenation: Collective experience from the Extra corporeal Life Support Organisation. J Thorac Cardiovasc Surg 1994; 107: 838-49.
• 4 Moront MG, Katz NM, Keszler M. et al. Extracorporeal membrane oxygenation for neonatal respiratory failure: a report of 50 cases. J Thorac Cardiovasc Surg 1989; 97: 706-14.
• 5 Harker LA, Malpass TW, Branson HE, Hessel II EA, Slichter SJ. Mechanism of abnormal bleeding in patients undergoing cardiopulmonary bypass: Acquired transient platelet dysfunction associated with selective alpha-granule release. Blood 1980; 56: 824-33.
• 6 Mellgren K, Friberg LG, Hedner T, Mellgren G, Wadenvik H. Blood platelet activation and membrane glycoprotein changes during extracorporeal life support (ECLS). In vitro studies. Int J Artif Organs 1995; 18: 315-21.
• 7 Rinder CS, Gaal D, Student LA, Smith BR. Platelet-leukocyte activation and modulation of adhesion receptors in paediatric patients with congenital heart disease undergoing cardiopulmonary bypass. J Thorac Surg 1994; 107: 280-8.
• 8 Wachtfogel YT, Kucich U, Hack CE, Gluszko P, Niewiarowski S, Colman RW, Edmunds Jr LH. Aprotinin inhibits the contact, neutrophil, and plate-let activation systems during simulated extracorporeal perfusion. J Thorac Cardiovasc Surg 1993; 106: 1-10.
• 9 Tanaka K, Kondo C, Takagi I, Sato T, Yada I, Yvasa H, Kusagawa M. Effects of nafamostat mesilate on platelets and coagulofibrinolysis during cardiopulmonary bypass surgery. ASAIO J 1993; 39: M545-9.
• 10 Sundaram S, Gikakis N, Hack E, Niewiarowski S, Edmunds Jr. LH, Rao A, Sun L, Cooper SL, Colman R. Nafamostat Mesilate, a broad spectrum protease inhibitor, modulates platelet, neutrophil and contact activation in simulated extracorporeal circulation. Thromb Haemost 1996; 75: 76-82.
• 11 Swolin B, Roberts D, Waldenström J. Quantitative determination of plasma haemoglobin using dicarboxidine. Clin Chim Acta 1982; 121: 389-91.
• 12 Clauss A. Rapid physiological coagulation method for the determination of fibrinogen. Acta Haematol 1957; 17: 237-46.
• 13 Sawa Y, Shimazaka Y, Kadoba K, Masai T, Fukuda H, Ohata T, Taniguchi K, Matsuda H. Attenuation of cardiopulmonary bypass-derived inflammatory reactions reduces myocardial reperfusion injury in cardiac operations. J Thorac Cardiovasc Surg 1996; 111: 29-35.
• 14 Murase M, Usui A, Tomita Y, Maeda M, Koyama T, Abe T. Nafamostat mesilate reduces blood loss during open heart surgery. Circulation 1993; 88: 432-6.
• 15 Akizava T, Koshikawa S, Ota K, Kazama M, Mimura N, Hirasawa Y. Nafamostat Mesilate; A regional anticoagulant for hemodialysis in patients at high risk for bleeding. Nephron 1993; 64: 376.
• 16 Okamoto T, Chung YK, Choi H, Terasaki H, Morioka T. Experimental results using nafamostat mesilate as anticoagulant during extracorporeal lung assist for 24 hours in dogs. Artif Organs 1993; 17: 30-5.
• 17 Coller BS, Kalomiris E, Steinberg M, Scudder LE. Evidence that glycocalicin circulates in normal plasma. J Clin Invest 1984; 73: 794-9.
• 18 Wachtfogel YT, Bischoff R, Bauer R, Hack CE, Nuijens JH, Kucich U, Niewiarowski S, Edmunds Jr LH, Colman RW. 1-Antitrypsin Pittsburgh (Met³⁵⁸ Arg) inhibits the contact pathway of intrinsic coagulation and alters the release of human neutrophil elastase during simulated extracorpo-real circulation. Thromb Haemost 1994; 72: 843-7.
• 19 George JN, Pickett EB, Saucerman S, McEver RP, Kunicki TJ, Kieffer N, Newman PJ. Platelet surface glycoproteins. Studies on resting and activated platelets and platelet membrane microparticles in normal subjects and observations in patients during adult respiratory distress syndrome and cardiac surgery. J Clin Invest 1986; 78: 340-8.
• 20 Michelson AD, Adelman B, Barnard MR, Carroll E, Handin RI. Platelet storage result in a redistribution of glycoprotein Ib molecules. Evidence for a large pool of glycoprotein Ib. J Clin Invest 1988; 81: 1734-40.
• 21 Mellgren K, Friberg LG, Mellgren G, Hedner T, Wennmalm Å, Wadenvik H. Nitric oxide in the oxygenator sweep gas reduces platelet activation during experimental perfusion. Ann Thorac Surg 1996; 61: 1194-8.
• 22 Mellgren K. The platelets in extracorporeal circulation. Thesis. Vasastadens bokbinderi. Göteborg: 1997
• 23 van Meijer M. Structure of plasminogen activator inhibitor 1 (PAI-1) and its function in fibrinolysis: an update. Fibrinolysis 1995; 9: 263-76.
• 24 Fink SM, Bockman DE, Howell CG, Falls DG, Kanto Jr WP. Bypass circuit as the source of thromboemboli during extracorporeal membrane oxygenation. J Pediatr 1989; 115: 621-4.
• 25 Wachtfogel YT, Harpel PC, Edmunds Jr LH, Colman RW. Formation of C1s-C1-inhibitor, kallikrein-C1-inhibitor, and plasmin-alpha 2-plasmin-inhibitor complexes during cardiopulmonary bypass. Blood 1989; 73: 468-71.
• 26 Wachtfogel YT, Hack CE, Nuijens JH, Kettner CK, Reilly TM, Knabb RM, Bishoff R, Tschesche H, Wenzel H, Kucich U, Edmunds Jr LH, Colman RW. Selective kallikrein inhibitors alter human neutrophil elastase release during extracorporeal circulation. Am J Physiol 1995; 268: H1352-7.
• 27 Colman RW. Activation of plasminogen by human plasma kallikrein. Biochem Biophys Res Commun 1969; 35: 273-9.