Therapeutic Application of Intravascular Nitrite for Sickle Cell Disease

血管内亚硝酸盐在镰状细胞病中的治疗应用

• 批准号: 8557984
• 负责人: Gregory Kato
• 金额: $ 2.78万
• 依托单位: NATIONAL HEART, LUNG, AND BLOOD INSTITUTE
• 依托单位国家: 美国
• 资助国家: 美国
• 起止时间: 至
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/8557984
• 关键词: Address; Affect; African American; Animal Model; Anions; Antidotes; Biological Availability; Blood; Blood Circulation; Blood Pressure; Blood Vessels; Blood flow; Cardiac; Catheters; Cells; Cerebrovascular Spasm; Clinical; Clinical Research; Contralateral; Cyanides; Cyanosis; Data; Dose; Enrollment; Failure; Flow-It; Forearm; Functional disorder; Hemoglobin; Human; Hypotension; Hypoxia; Individual; Infarction; Infusion procedures; Intravenous; Liver; Measures; Methemoglobin; Modeling; Nausea; Nitric Oxide; Nitric Oxide Donors; Nitric Oxide Synthase; Nitrite Reductase; Nitrites; Oxygen; Oxygen measurement, partial pressure, arterial; Patients; Pharmaceutical Preparations; Phase I/II Trial; Physiological; Plasma; Primates; Proxy; Publishing; Pulmonary artery structure; Regional Blood Flow; Reperfusion Injury; Reporting; Resistance; Rest; Rosa; Sampling; Sheep; Shortness of Breath; Sickle Cell; Sickle Cell Anemia; Sodium Nitrite; Subarachnoid Hemorrhage; Symptoms; Therapeutic; Time; Tissues; Toxic effect; Vasodilation; Vasodilator Agents; Veins; Venous; arm; blood flow measurement; design; hydroxyurea; improved; in vivo; inhibitor/antagonist; mouse model; neonatal pulmonary hypertension; novel; omega-N-Methylarginine; oxidant stress; pressure; prevent; response; trend; vaso-occlusive pain

Nitrite infusions induce regional vasodilation in patients with SCD: Baseline blood flow measurements were performed in each patient prior to the infusion of drug. The baseline forearm blood flow in our 14 patients was 5.36 +/- 0.49 ml/min/100 ml of forearm tissue (mean SEM). Forearm blood flow in patients with SCD increased to 5.65 +/- 0.43, 6.50 +/- 0.58 and 9.04 +/- 0.53 ml/min/100 ml of forearm tissue with infusions of 0.4, 4 and 40 micromol/min respectively (P < 00001, anova with repeated measures). These values yielded calculated nitrite-induced increase in blood flow over baseline by 7.9 +/- 4.1, 25.1 +/- 7.1 and 77.4 +/- 11.2% respectively following infusions of 0.4, 4 and 40 micromol/min infusions of sodium nitrite (P < 00001, anova). Vascular responses were not significantly different in patients on hydroxycarbamide compared to those who were not. These data indicate that sodium nitrite infusions produce significant vasodilation in the regional circulation of the forearm in patients with SCD, the prospectively defined primary hypothesis in this study. Plasma nitrite levels in patients with SCD: The mean baseline plasma nitrite concentration sampled from the intravenous catheter in the antecubital vein of the infused arm was 0.17 +/- 0.02 micromol/l. The mean plasma nitrite concentrations following the 0.4, 4 and 40 micromol/min infusions were 2.4 +/- 0.36, 16.9 +/- 3.6 and 132.2 +/- 23 micromol/l respectively (P < 00001, anova). The systemic mean plasma nitrite level 5 min after the infusion of the maximal dose of sodium nitrite was 9.7 +/- 3.5 micromol/l. The venous mean plasma nitrite level in the infused arm 30 min after the maximum sodium nitrite infusion was 5.3 +/- 0.9 micromol/l. The individual regional plasma nitrite levels correlated with the dose of sodium nitrite administered (Spearman correlation r = 0.93, P < 00001). Forearm blood flow is related to plasma nitrite: Forearm blood flow in patients with SCD, expressed as percentage increase over baseline, correlated positively with the infused dose of sodium nitrite dose in micromol/kg (Spearman correlation r = 0.70, P < 0.0001. Absolute forearm blood flow, expressed as ml/min/100 ml of forearm tissue, correlated positively with plasma nitrite levels achieved with the infusions (Spearman correlation r = 0.51, P = 0.0003. This relationship suggests that sodium nitrite infusions induced vasodilation in patients with SCD in a concentration-dependent fashion. There was no statistically significant correlation between baseline plasma nitrite concentration and baseline forearm blood flow. Blunted nitrite response compared with controls: Vasodilatory responses in patients with SCD were blunted compared to control subjects, even though the sickle cell patients received a 10% higher nitrite dose. Mean arterial pressures did not change significantly after nitrite infusion, which suggests that systemic nitrite administration at these doses does not cause hypotension in patients with SCD. This systemic blood pressure response was blunted compared to healthy controls. The nitrite levels in patients with SCD were comparable to healthy controls at baseline (0.16 +/- 0.02 micromol/l vs. 0.18 +/- 0.17 micromol/l, P = 0.7) and after low dose nitrite infusions (2.4 +/- 0.4 vs. 2.6 +/- 0.5, P = 0.8). The patients with SCD demonstrated somewhat lower regional (132 +/- 23 micromol/l vs. 221 +/- 58 micromol/l, P = 02) and systemic (5.3 +/- 0.9 micromol/l vs. 16 micromol/l) plasma nitrite levels after the highest dose of sodium nitrite infused, but none of these differences were statistically significant. SNP responsiveness in patients with SCD: Consistent with our previously published data (Gladwin et al, 2003), forearm blood flow increase during infusions of the exogenous NO donor, SNP, in patients with SCD was blunted in comparison to 10 African American healthy control subjects. In the patients with SCD, 30 min after the nitrite infusion, the level of forearm blood flow rose globally higher during infusion of SNP at baseline (0), 0.8, 1.6 and 3.2 microg/min, compared to the SNP responses prior to nitrite treatment (prenitrite 5.18 +/- 0.48, 6.45 +/- 0.60, 7.25 +/- 0.48, 8.37 +/- 0.44 ml/min/100 ml vs. postnitrite 5.86 +/- 0.59, 7.40 +/- 0.69, 8.70 +/- 0.77, 9.69 +/- 0.77 ml/min/100 ml, respectively, P < 00001, anova with repeated measures). However, nitrite infusion did not improve the SNP responsiveness, as indicated by percentage increase in forearm blood flow. The postnitrite global increase in forearm blood flow remained, but was smaller and no longer statistically significant by approximately 90 min after the nitrite administration, as seen duringinfusions of the NO synthase inhibitor L-NMMA at 0, 4 and 8 micromol/min, compared to the prenitrite L-NMMA infusions (prenitrite 5.57 +/- 0.52, 4.32 +/- 0.45, 4.26 +/- 0.39 ml/min/100 ml vs. postnitrite 5.75 +/- 0.55, 4.70 +/- 0.42, 4.62 +/- 0.50 ml/min/100 ml, respectively, n = 13, P = 02, anova with repeated measures). The failure of NO synthase blockade to eliminate this small trend toward globally increased blood flow suggests that the nitrite-induced increase in blood flow is NOS-independent, but this is not conclusive. At this 90-min time point, the percentage of blood flow that was NO synthase-dependent was not changed significantly by nitrite, as assessed by L-NMMA infusion at 4 micromol/min (-21 +/- 5% vs. -17 +/- 4%), and 8 micromol/min (-21 +/- 4% vs. -20 +/- 3%). These results suggest that nitrite globally increases regional blood flow, but it does not specifically decrease resistance to either exogenous or endogenous NO. The vasodilatory response to the maximal dose of SNP before the nitrite infusion correlated strongly with the response to the maximal dose of nitrite (Spearman r = 075, P = 0002). This indicates that those patients whose vascular response demonstrates resistance to SNP manifest proportional resistance to sodium nitrite. This correlation is consistent with a model in which sodium nitrite, like SNP, functions as an NO donor. Toxicity assessment: The mean prenitrite methaemoglobin level was 1.2 +/- 0.16%. The regional venous methaemoglobin level was not significantly affected by the lowest dose of nitrite (1.3 +/- 0.16%), although small but statistically significant increases from baseline were induced by the infusion of sodium nitrite at 4 micromol/min (1.7 +/- 0.21%, P < 005). Regional methaemoglobin levels rose further at 40 micromol/min (4.0 +/- 0.40%, P < 0001), which was significantly higher than control subjects at a comparable dose (0.2%, P < 0.0001). The systemic methaemoglobin level, measured from venous blood drawn from the contralateral arm, 5 min after infusion of the maximal sodium nitrite dose was 1.8 +/- 0.25%, trending slightly higher than the initial baseline level (P = 006). The regional methaemoglobin level in the infused arm 30 min later was also slightly above baseline, (1.95 +/- 0.2%, P = 001). None of the patients demonstrated clinical signs or symptoms related to elevated methaemoglobin levels (30 - 50%), such as cyanosis or shortness of breath. The venous plasma nitrite levels correlated positively with the venous methaemoglobin level, sampled at the corresponding time point in the study (r = 0.62, P < 0.0001). This indicates that blood methaemoglobin levels are a reasonable proxy for plasma nitrite levels. One patient reported transient nausea at the highest dose of nitrite, with no other apparent ill effects. No other symptoms were reported by the patients. This study is closed to enrollment, but remains open for management of clinical research data and biospecimens.

亚硝酸盐输注诱导SCD患者的区域血管舒张：在注入药物之前，对每位患者进行了基线血流测量。 我们14例患者的基线前臂血流为5.36 +/- 0.49 mL/min/100 ml前臂组织（平均SEM）。 SCD患者的前臂血流增加到5.65 +/- 0.43、6.50 +/- 0.58和9.04 +/- 0.53 ml/min/min/100 ml前臂组织，分别输注0.4、4和40 micromol/min（P <00001，ANOVA，ANOVA，重复度量）。 这些值在0.4、4和40 micromol/min/min的亚硝酸盐输注后分别产生了计算的亚硝酸盐引起的基线上的血流增加7.9 +/- 4.1、25.1、25.1 +/- 7.1和77.4 +/- 11.2％（P <00001，Anova）。 与没有的患者相比，羟基甲酰胺患者的血管反应没有显着差异。 这些数据表明，亚硝酸钠输注在SCD患者的前臂循环中产生显着的血管舒张，这是本研究的前瞻性原发假设。 SCD患者的血浆亚硝酸盐水平：从静脉内静脉静脉中从静脉内静脉静脉静脉静脉中采样的平均基线亚硝酸盐浓度为0.17 +/- 0.02 micromol/L。 在0.4、4和40 micromol/min输注后，平均血浆亚硝酸盐浓度分别为2.4 +/- 0.36、16.9 +/- 3.6和132.2 +/- 23 micromol/l（P <00001，ANOVA）。 输注最大剂量亚硝酸钠后5分钟后5分钟，全身平均血浆亚硝酸盐水平为9.7 +/- 3.5 micromol/l。 最大亚硝酸钠输注后30分钟注入的静脉平均血浆亚硝酸盐水平为5.3 +/- 0.9 micromol/l。 单个区域血浆亚硝酸盐水平与给予的亚硝酸钠剂量相关（Spearman相关性r = 0.93，p <00001）。 Forearm blood flow is related to plasma nitrite: Forearm blood flow in patients with SCD, expressed as percentage increase over baseline, correlated positively with the infused dose of sodium nitrite dose in micromol/kg (Spearman correlation r = 0.70, P < 0.0001. Absolute forearm blood flow, expressed as ml/min/100 ml of forearm tissue, correlated positively with输注（Spearman相关性r = 0.51，p = 0.0003）达到的血浆亚硝酸盐水平。这种关系表明，亚硝酸钠输注诱导SCD患者的血管舒张。浓度依赖于浓度依赖性的SCD患者。基线基线等离子体的基线浓度没有统计学上的显着相关性。 与对照组相比，亚硝酸盐反应钝化：与对照组受试者相比，SCD患者的血管舒张反应被钝化，即使镰状细胞患者接受了亚硝酸盐剂量的10％。 亚硝酸盐输注后平均动脉压没有显着变化，这表明这些剂量的全身亚硝酸盐给药不会引起SCD患者的低血压。 与健康对照组相比，这种系统性血压反应钝化。 SCD患者的亚硝酸盐水平与基线时的健康对照组相当（0.16 +/- 0.02 micromol/L vs. 0.18 +/- 0.17 Micromol/L，P = 0.7）和低剂量亚硝酸盐输注后（2.4 +/- 0.4 +/- 0.4 vs. 2.6 +/- 0.5 +/- 0.5，p = 0.8）。 SCD患者的区域性较低（132 +/- 23 micromol/L vs. 221 +/- 58 micromol/L，P = 02）和全身性（5.3 +/- 0.9 micromol/L vs. 16 micromol/L）等离子体硝酸盐水平后，在最高剂量的氮气剂量的氮气中含有钠含量的氮，但不存在这些差异。 SCD患者的SNP反应能力与我们先前发表的数据一致（Gladwin等，2003），与10名非裔美国人健康对照受试者相比，SCD患者的外源无供体输注期间的前臂血流增加SNP。 在亚硝酸盐输注后30分钟的SCD患者中，在基线（0），0.8、1.6和3.2 microg/min的SNP期间，前臂血流的水平上升了全球范围更高，与亚硝酸盐治疗前的SNP反应相比ml/min/100 ml vs. 5.86 +/- 0.59，7.40 +/- 0.69，8.70 +/- 0.77，9.69 +/- 0.77 ml/min/min/100 ml，p <00001，p <00001，ANOVA，重复度量）。 但是，亚硝酸盐输注并不能提高SNP的反应性，这表明前臂血流的增加百分比。 前臂血流的全球全球增加保持较小，但在亚硝酸盐给药后大约90分钟时较小，在统计学上不再具有统计学意义，如NO合酶抑制剂L-NMMA在0、4和8 micromol/min时所见，与前L-NMMA/min相比，与前L-NMMA输注相比+/- 0.39 ml/min/100 ml vs.持续后5.75 +/- 0.55，4.70 +/- 0.42，4.62 +/- 0.50 ml/min/min/100 ml，n = 13，p = 02，p = 02，ANOVA，ANOVA具有重复度量）。 没有合成酶阻断消除这种小趋势的全球血流趋势的失败表明，亚硝酸盐诱导的血流量增加是NOS独立的，但这不是确定的。 在这个90分钟的时间点，非合酶依赖性的血流百分比没有通过亚硝酸盐发生重大改变，如L-NMMA输注4 micromol/min（-21 +/- 5％vs. -17 +/- 4％）和8 micromol/min/min（-21 +/- 4％vs.-2.-4％vs. -20 +/ -20 +/-3％）所评估。 这些结果表明，亚硝酸盐全球增加了区域血流，但并不能特别降低对外源或内源性NO的耐药性。 亚硝酸盐输注之前对SNP最大剂量的血管舒张反应与对亚硝酸盐最大剂量的反应密切相关（Spearman r = 075，p = 0002）。 这表明那些血管反应的患者表现出对SNP的耐药性，对亚硝酸钠的比例耐药性。这种相关性与一个模型一致，在该模型中，像SNP这样的亚硝酸钠是无供体。 毒性评估：平均前甲氧人群水平为1.2 +/- 0.16％。 尽管最低剂量的亚硝酸盐剂量（1.3 +/- 0.16％），区域静脉甲型血红蛋白水平并未显着影响，尽管在4 micromol/min/min/min/min（1.7 +/- 0.21％，p <005）中输注亚硝酸钠，从基线造成了较小但统计学上的显着增加。 区域甲脂蛋白水平以40 micromol/min（4.0 +/- 0.40％，p <0001）进一步增长，在可比剂量下（0.2％，p <0.0001）显着高于对照组受试者。从对侧臂中抽出的静脉血液测量的全身甲基血红蛋白水平在输注最大硝酸钠剂量后5分钟为1.8 +/- 0.25％，趋势略高于初始基线水平（P = 006）。 30分钟后，注入臂中的甲氧蛋白蛋白水平也略高于基线（1.95 +/- 0.2％，p = 001）。没有患者显示出与甲基血红蛋白水平升高（30-50％）相关的临床体征或症状，例如氰化物或呼吸急促。 静脉血浆亚硝酸盐水平与研究相应的时间点采样（r = 0.62，p <0.0001），与静脉甲型血红蛋白水平正相关。 这表明血液甲血红蛋白水平是血浆亚硝酸盐水平的合理替代方案。 一名患者报告了最高剂量的亚硝酸盐的瞬时恶心，没有其他明显的影响。 患者没有报告其他症状。 这项研究因入学而封闭，但仍在管理临床研究数据和生物测量。