Cell Free Hemoglobin and the Pathogenesis of ARDS

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1 Cell Free Hemoglobin and the Pathogenesis of ARDS New therapeutic target? Lorraine B. Ware M.D. Vanderbilt University Nashville, TN Financial disclosures: Dr. Ware receives research funding from Boehringer Ingelheim and Global Blood Therapeutics unrelated to this presentation

2 Intra-alveolar hemorrhage is a prominent feature of ARDS

3 Are red blood cells more than innocent bystanders in the pathogenesis of ARDS and sepsis?

4 Method for Sampling Pulmonary Edema Fluid 14 Fr Tracheal suction catheter Gentle aspiration of alveolar edema

5 Edema Fluid Hemoglobin (mg/dl) Edema Fluid Hemoglobin (mg/dl) Cell-free hemoglobin levels are elevated in the airspace in ARDS * P = P p = 0.17 n = 9 n = 14 Hospital Mortality Bastarache et al. Thorax 67:1032-9, 2012

6 In-Hospital Mortality (%) In 391 patients with severe sepsis, plasma levels of free hemoglobin are associated with hospital mortality * P = *p = Undetectable (n = 75) mg/dl (n = 118) mg/dl (n = 68) 30 mg/dl (n = 130) Plasma Free Hemoglobin Janz DR et al, Crit Care Med 2013

7 Cell-Free Hemoglobin potent vasoconstrictor binds nitric oxide Hemoglobin mediates vascular injury in hemolytic states such as sickle cell disease Ferryl (4 + ) hemoglobin may be a critical mediator of injury Globin Heme Ferrous 2+ Hyperoxia H 2 O 2 RO S Ferric 3+ Ferryl 4+

8 Ferryl-Hemoglobin in Pulmonary Edema Fluid Measured by EPR Positive Control for Ferryl-Hemoglobin Protein Radical Ferryl hemoglobin can be detected in pulmonary Ferryl-hemoglobin edema Ferryl-Hemoglobin fluid in Hemoglobin Pulmonary from Edema ARDS Fluid Measured patients by EPR A by EPR Positive Control for Ferryl-Hemoglobin + H 2 O 2 Protein Radical B Ferryl-hemoglobin Hemoglobin + HHemoglobin 2 O 2 Ferryl-Hemoglobin B A - A Hemoglobin + H 2 O 2 Human Pulmonary Fluid Hemoglobin Ferryl-Hemoglobin Transferrin + H 2 O 2 hpef_v1003_ef2 Human hpef_v0207_ef1 Pulmonary Fluid Transferrin hpef_v0804_ef2 hpef_v1003_ef2 hpef_v0207_ef1 hpef_v0306_ef B B - A C D C E D F Hydrostatic Edema Fluid ARDS Edema Fluid Methemoglobin hpef_v0804_ef2 Ferryl-hemoglobin E Methemoglobin hpef_v0306_ef Magnetic Field, Gauss EPR Spectra Ferryl-hemoglobin Magnetic Field, Gauss F

9 In mice, cell-free hemoglobin is released into the airspace in ventilator and pneumonia-induced ARDS VILI Model * P < 0.03 vs others * Pneumonia Model * P = 0.05 * * Shaver CM et al, AJP Lung 2016, 310(6):L532-41

10 BAL Cell Count (x 100,000/ml) BAL Protein (ug/ml) Intra-tracheal instillation of cell-free hemoglobin causes lung inflammation and increased permeability * * P = * P < * Control Cell-free hemoglobin Control Cell-free hemoglobin PBS CF-Hgb Shaver CM et al, AJP Lung 2016, 310(6):L532-41

11 BAL Protein (ug/ml) BAL Cell Count (x100,000/ml) *" B Intravenous cellfree hemoglobin potentiates mortality and ALI in sepsis due to peritonitis ** C A * P = A * * * B B ** ** * P = * Slurry Slurry + Hemoglobin Slurry Slurry + Hemoglobin

12 Isolated perfused human lung model + Evans Blue-labeled Albumin + cell-free hemoglobin

13 Cell-free hemoglobin (CFH) in the perfusate increases vascular permeability in the isolated human lung N = 5 per group, * p = N = 5 per group, * p = 0.027

14 Hyperoxia potentiates the effect of cell-free hemoglobin on vascular permeability CFH in Paired Donor Lungs 21% vs 95% FiO2 N = 5 lung pairs, *p =0.043 N = 5 lung pairs, *p =0.043

15 Acetaminophen is a specific hemoprotein reductant that reduces oxidized hemoglobin!

16 In the human lung, acetaminophen (APAP) prevents cell-free hemoglobin/hyperoxia induced vascular permeability n=6 per group n=6 per group

17 ACROSS Trial: ACetaminophen for the Reduction of Oxidative Stress in Sepsis Phase IIa randomized placebo-controlled clinical trial 40 patients with severe sepsis Acetaminophen 1g enterally q6h vs. placebo Primary outcome: plasma F2 isoprostane levels Secondary outcomes: organ dysfunction, ventilator-free days, mortality Janz et al Crit Care Med. 2015;43:534-41

18 lity of Survival ility of Survival Ferryl-Hgb (Arbitrary Units) Ferryl-Hgb (Arbitrary Units) Plasma F2-Isoprostanes (pg/ml) Plasma F2-Isoprostanes (pg/ml) Creatinine (mg/dl) Creatinine (mg/dl) 48 hour treatment with acetaminophen reduces plasma ferryl (4+) hemoglobin and lipid peroxidation products in severe sepsis A A B B p = p = p = 0.04 p = C 3 2 C * p = 0.04 * p = * p * p = 0.01 * p H Study Day Study Day Com D D 100 Acetaminop Ac 100 Placebo Placebo APAP APAP Placebo Placebo APAP APAP Janz et al Crit Care Med. 2015;43:

19 Probability of Survival Probability of Survival Ferryl-Hgb (Arbitrary Units) Plasma F2-Isoprostanes (pg/ml) Plasma F2-Isoprostanes (pg/ml) Creatinine (mg/dl) Creatinine (mg/dl) A Placebo p = p = Placebo APAP Acetaminophen reduces serum creatinine and has no adverse effects on mortality in Placebo severe sepsis APAP B B Placebo p = 0.04 p = 0.04 APAP APAP 3 3 C C Placebo Acetaminophen * p = Placebo Acetaminophen * p = * p = 0.01 * p = 0.01 * p = * p = * p = * p = Highest At Discharge 0 After or Death 0 1 Study 2 Day Completion Highest At Discharge D Study Day After or Death Acetaminophen 100 Completion D Acetaminophen Placebo Days Placebo Days p = p = Janz et al Crit Care Med. 2015;43:534-41

20 PARACETAMOL EFFECT ON RENAL FUNCTION IN SEVERE AND MODERATELY SEVERE FALCIPARUM MALARIA WITH INTRAVASCULAR HAEMOLYSIS: A RANDOMISED CONTROLLED TRIAL KATHERINE PLEWES ET AL. HYPOTHESIS: Paracetamol will reduce kidney dysfunction in patients with severe and moderately severe malaria complicated by intravascular haemolysis Ramu

21 PARACETAMOL REDUCES RISK OF DEVELOPING AKI

22 PARACETAMOL REDUCES CREATININE IN PATIENTS WITH ELEVATED CELL-FREE HAEMOGLOBIN All patients High CFH Low CFH

23 Summary Cell-free hemoglobin is present both in the circulation and the airspace in patients with ARDS and sepsis Studies in mice suggest that cell-free hemoglobin may potentiate both pulmonary and nonpulmonary organ dysfunction in ARDS and sepsis In vitro, cell-free hemoglobin increases endothelial and epithelial permeability Therapies that target free hemoglobin may be beneficial in ARDS and sepsis

24 Red blood cells more than innocent bystanders Release of cell-free hemoglobin in both the circulation and the airspace potentiates ARDS and other organ dysfunction and is a potential therapeutic target

25 Funding NIH, Vanderbilt Institute for Clinical and Translational Research UCSF Michael Matthay Carolyn Calfee Kathleen Liu LSU New Orleans David Janz Vanderbilt Julie Bastarache Ciara Shaver Shaina Johnson Eric Kerchberger Nathan Putz Stuart Landstreet Brennan McNeil Nancy Wickersham Anna Reding Melinda Paul Sergey Dikalov James May Josh Fessell Jack Roberts John Oates Tatsuki Koyama Zhiguo Zhao Gordon Bernard Addison May