1. Ulinastatin & Continuous hemodiafiltration The Impact of Inhibiting Cytokines on Circulation after Cardiac Surgery Susumu Ishikawa, MD Associate Professor of Surgery, Teikyo University, Tokyo, Japan 24 th Korean Society for Thoracic & Cardiovascular Surgery

2. Teikyo University Hospital Located at the center at the center of Tokyo city of Tokyo city 2,000 beds in Total

3. Background Systemic inflammatory responses after cardiac surgery using cardiopulmonary bypass (CPB) may be responsible for the postoperative organ dysfunction. Systemic inflammatory responses after cardiac surgery using cardiopulmonary bypass (CPB) may be responsible for the postoperative organ dysfunction. Therefore, over-induction of cytokines and polymorphonuclear elastase (PMNE) should be prevented especially in critical patients. Therefore, over-induction of cytokines and polymorphonuclear elastase (PMNE) should be prevented especially in critical patients.

4. Today’s Contents Clinical Study 1. Mechanical removal of cytokines 1. Mechanical removal of cytokines by continuous hemodiafiltration (CHDF) by continuous hemodiafiltration (CHDF) 2. Pharmacological suppression of cytokines 2. Pharmacological suppression of cytokines by Ulinastatin (a protease inhibitor) by Ulinastatin (a protease inhibitor)

5. Introduction

6. Cardiac Surgery & Organ Dysfunction Cardiopulmonary Bypass Controlled Shock Controlled Shock Systemic Inflammatory Responses Systemic Inflammatory Responses Cytokine induction, Leukocyte activation Cytokine induction, Leukocyte activation Acute circulatory failure

7. CPB Time and Cytokine Granulocyte Elastase μg /L 6,000 4,000 2,000 CPB time (min.) Interleukin 8 (IL-8) Pg/ml 90 70 50 30 Preop. AfterCPB POD1 POD3 POD6 ■ : CPB > 120 min. ▲ : CPB < 120 min. * * P<0.01 Hurunaga H, 1995 Doi H, 1988

8. Ulinastatin: A Protease Inhibitor (Urinary Trypsin Inhibitor) Antecedent Neutrophil Elastase Liver Ulinastatin Features 1) exists naturally in the human body. 2) plays an important role in host defense during stress. 2) plays an important role in host defense during stress. Synthesis in Human Body ・ Ulinastatin antecedent (IαTI ) is produced mainly in Liver. ・ During stress, IαTI is influenced by activated Neutriphil Elastase, changing into Ulinastatin. Elastase, changing into Ulinastatin. Interαtripsin inhibitor (MW 67,000)

9. Stress Stress Monocyte ・ Macrophage Neutrophil Cell/Organ Injury MOFCytokines InternalUlinastatin ExternalUlinastatin Elastase (Timing/Dosage) (Timing/Dosage) Effects of Ulinastatin Replacement Therapy Replacement Therapy (Supplement) (Supplement)

10. Dose-dependent Effect of Ulinastatin - Experiments using shock models- Ulinastatin (LPS induced peritonitis) Neutrophil elastase Neutrophil elastase Ulinastatin Free radical Kato K. 1995 Dose-dependent suppression of inflammatory responses of inflammatory responses LPS: lipopolysaccharide

11. Indications of Ulinastatin 1 ． Acute circulatory failure 1 ． Acute circulatory failure hemorrhagic shock, bacterial shock, hemorrhagic shock, bacterial shock, traumatic shock, febrile shock traumatic shock, febrile shock 2. Acute pancreatitis includin ｇ traumatic includin ｇ traumatic acute pancreatitis after operation acute pancreatitis after operation endoscopic retrograde pancreatography endoscopic retrograde pancreatography Same as the indication in Japan

12. 1. Mechanical Removal of Cytokines by CHDF - Clinical Study - Continuous Hemodiafiltration

13. Background We sometimes experience the circulatory improvement after the initiation of CHDF. Why ??

14. Objective Prolonged CPB sometimes causes postoperative circulatory collapse especially in critical patients. Prolonged CPB sometimes causes postoperative circulatory collapse especially in critical patients. The efficacy of CHDF on the circulation was evaluated focusing on the inflammatory The efficacy of CHDF on the circulation was evaluated focusing on the inflammatory reactive substances. reactive substances.

15. Patients & Methods No. of Patients: 12 (Jan 2007~) * Exclusion: chronic renal failure, sepsis * Exclusion: chronic renal failure, sepsis circulatory assist device circulatory assist device Age : 67 ± 2 (57-85) years M/ F : 11/ 1 Operation : CABG 3, Acute aortic dissection 3, MVP/R 3, AVR 3 MVP/R 3, AVR 3 CPB time : 286 ± 32 (171 -552) min. Dialyzer : polysulfone membrane (SH 1.3, Tore Co.Ltd., Japan) (SH 1.3, Tore Co.Ltd., Japan)

16. Circulation before CHDF mean ± SE Range mean ± SE Range SBP (mmHg) 96 ± 5 57 - 85 HR ( /min) 101 ± 6 95 - 147 CI (L/min/m 2 ) 2.9 ± 0.1 2.4 - 3.4 CVP (mmHg) 11 ± 1 6 - 16 SPAP (mmHg) 32 ± 2 21 - 39 SVRI (dynes ・ sec ・ cm -5 ・ m 2 ) 1452 ± 153 1007 - 2206 UV (ml/4hrs) 169 ± 44 10 - 550

17. Systemic Blood Pressure (SBP) mmHg * * * * p<0.05 96 ± 5 120± 5

18. Urine Volume ml * * * p<0.05 69±75 371±108

19. Serum IL-6 Concentration Pg/dl * p<0.05 * * 717±152 353±92

20. Serum IL-8 Concentration Pg/dl * * p<0.05 86±31 53±10

21. Systemic Vascular Resistance Index dynes ・ sec ・ cm-5 ・ m2 **** ** ** p<0.01 1452±153 1898±198

22. Summary 1 Continuous hemodiafiltration removed inflammatory cytokines and improved systemic circulation.

23. 2. Pharmacological Suppression of Cytokines by Ulinastatin - Clinical Trial -

24. Patients & Methods Group Ulinastatin Control p Group Ulinastatin Control p (n=7) (n=8) (n=7) (n=8) Age (yr) 65 ± 5 65 ± 3 NS Operation CABG 3 3 AVR 3 2 AVR 3 2 MVR 1 3 MVR 1 3 CPB time (min) 165 ± 16 191 ± 15 NS Ao-clamp time (min) 88 ± 10 99± 12 NS

25. Protocol in the Ulinastatin Group Dosage Dosage 1) CPB priming solution : 600,000 U 1) CPB priming solution : 600,000 U 2) Addition to CPB : 300,000 U 2) Addition to CPB : 300,000 U (just before the removal of aortic cross-clamping) (just before the removal of aortic cross-clamping) 3) After Surgery : 300,000 U/day 3) After Surgery : 300,000 U/day (5days) (5days) Each amp.(2ml) contains : Ulinastatin 100,000 U

26. Serum Ulinastatin Concentration Preop. after CPB POD 1 2 5 P<0.01 P<0.05

27. Serum IL-6 Concentration Pg/dl * p<0.05 * *

28. Serum IL-8 Concentration Pg/dl * p<0.05 * *

29. Serum Concentration of Polymorphonuclear elastase (PMNE) μ ｇ /dl * * * p<0.05

30. Correlation between IL-8 & PMNE - Maximum Levels after Cardiac Surgery- r = 0.556, p<0.05 Sato Y, Ishikawa S, 2000

31. Respiratory Index * * * p<0.05

32. Summary 2 Urinastatin reduces the overinduction of cytokines and PMNE during cardiac surgery

33. Comparison of Ulinastatin & Aprotinin

34. Suppression of intracellular elastase activity Ulinastatin Aprotinin

35. Recovery from Shock 1. Improvement of Blood pressure (normal range: systolic ≥ 100mmhg) 86.5% Ulinastatin (n=52) Aprotinin (n=51) Yamamura H, 1984

36. Recovery from Shock 2.Urine Volume (normal range: Urine Volume ≥ 50mL/hr) 74.0% Ulinastatin (n=52) Dosage 10,000unit x 3 / 3days Aprotinin (n=51) Dosage 20,000unit x 3 / 3days

37. Recovery from Shock 3. Serum Creatinin P <0.05 (mg/dl)

38. Effects of Ulinastatin in Other Organs - Summary of previous reports-

39. 1.Lung - A-aDO2 after Cardiac Surgery - Before CPB After surgery ■ Control □ Ulinastatin 400 300 200 100 mmHg A-aDO2 * p<0.05 * * Bingyang J, 2007

40. 2. Kidney –Renal Function after Cardiac Surgery- POD 2.0 1.5 1.0 0.5 0 mg/dl * * * p<0.05 * Control Ulinastatin Control Ulinastatin Ueki M, 1995 Serun creatinine N-Acetyl-β-D-Glucosaminidase (urine)

41. 3. Liver –post hepatic resection- IL-6 (pg/ml) IL-6 (pg/ml) Pre-Albumine (mg/dl) Pre-Albumine (mg/dl) UST ntrol Control UST Control 180100 50 50 0 Preop. POD 1 3 7 14 25201510 5 0 Miyazaki K. 2000

42. Prevention of Organ Failure - Our Strategy in Cardiac Surgery- Case Critical Severe Usual Case Critical Severe Usual Mechanical Mechanical Intraoperative Hemodialysis Intraoperative Hemodialysis Postoperative CHDF Postoperative CHDF Pharmacological Pharmacological Intraoperative ◎ ◎ Intraoperative ◎ ◎ Postoperative ◎ ◎ ◎ Postoperative ◎ ◎ ◎ (Ulinastatin, 300,000 U/day) (Ulinastatin, 300,000 U/day)

43. Conclusion Urinastain and CHDF suppressed acute-phase reactive substances and improved systemic circulation after cardiac surgery. Urinastain and CHDF suppressed acute-phase reactive substances and improved systemic circulation after cardiac surgery. Perioperative active suppression of inflammatory cytokines improves the surgical outcome especially in critical patients. Perioperative active suppression of inflammatory cytokines improves the surgical outcome especially in critical patients.

44. New Buildings of Teikyo University Hospital Cardiovascular Center will open in April, 2009.

45. Welcome to Japan Mt. Fuji : Scenery Kyoto : Tradition Tokyo Disney Land : Fantasy

46. If you may have any questions concerning Today’s lecture Visiting Teikyo University Traveling in Japan Please let me know ! Ishikawa S, Tokyo → CTS net

47. 또, 여러분을 만날 수 있는 것을 기대하고 있습니다.