The Next Step: Regadenoson mitigates ischemia reperfusion injury and is renal protective in a 48 hour porcine model of resuscitative ECMO

这是一份职业发展奖的申请书，旨在为PI提供翻译研究方面的培训。 基于他的导师进行的缺血再灌注损伤研究，PI将使用他的急性 复苏猪动物模型，延长至48小时，观察最终器官损伤/恢复情况。这将是 进一步将他的职业道路与他的导师分开，并为他的临床试验提供资金。 心脏骤停是世界范围内主要的死亡原因之一，复苏体外膜 氧合(ECMO)已成为难治性心脏骤停的一种治疗选择，据报道 2017年，全球近4000名患者。目前建议的重点是在我们成功的基础上再接再厉- 建立ECMO猪模型并延长至48小时，以全面评估器官损伤和恢复情况。我们也是 使用FDA批准的A2AR激动剂(瑞格腺苷)来最大限度地提高临床可译性并实现这一点 对病人的治疗。该项目代表了ECMO管理的范式转变，从支持性 作用于积极治疗潜在问题，IRI器官损伤。复苏ECMO是最极端的 IRI的例子，但这种治疗将应用于所有未来的复苏机械循环支持。 特定目标1A将显示，在48个复苏模型中，瑞格腺苷减轻全身器官损伤 ECMO。我们将观察中枢神经系统、心脏、肝脏、肾脏和肠道损伤的几个标志物以及细胞因子 级别。CD3+和CD4+T细胞、单核细胞和中性粒细胞，以及几种损伤相关的分子模式 将评估(DAMP)分子，包括HMGB1、无细胞DNA片段和线粒体DNA。目标 1B组的器官功能在接受瑞格腺苷治疗后有所改善。心功能将会 通过Swan-Ganz导管测量的心脏指数和超声心动图(ECHO)以及 肌力支持量、静脉输液需要量和ECMO流量。尿量将被收集并 通过异硫氰酸荧光素(FITC)灌胃测定肠道通透性。特定的 AIM2将展示瑞格腺苷如何通过以下几个途径减轻器官损伤并改善器官功能 中性粒细胞活化减弱，细胞凋亡减少，膜减少等机制 肝脏、肾脏、肠道、心脏和大脑中的屏障通透性和较少的活性氧物种。这 机械性AIM将为使用A2AR激活来减轻IRI提供额外的科学支持 多个器官系统。劳巴赫博士是一名高级研究员，研究IRI已有二十多年， 将作为这一赠款目标的指导者。特定的Aim3将提出一项临床试验，以确定 瑞格腺苷对心脏骤停后患者多器官系统的持久临床改善 复苏的ECMO再灌流。我将使用我从课程学习和指导中获得的技能 刘博士和克伦博士将在该项目的第四年期间提交FDA的新药研究申请， 因此，我可以在最后一年提交一份R01临床试验资金提案。

This is an application for a career development award to provide the PI with training in translation research. Building on ischemia reperfusion injury research performed by his mentors, the PI will use his acute resuscitative porcine animal model and extend it to 48 hours to look at end organ injury/recovery. This will further separate his career path from his mentors and set him up for funding for a clinical trial. Cardiac arrest is one of the leading causes of death worldwide, and resuscitative extracorporeal membrane oxygenation (ECMO) has emerged as a therapeutic option for refractory cardiac arrest, which was reported in almost 4,000 patients worldwide in 2017. The focus of the current proposal is to build upon our successful 6- hour ECMO porcine model and extend it to 48 hours to fully assess organ injury and recovery. We are also using an FDA-approved A2AR agonist (Regadenoson) to maximize the clinical translatability and to bring this therapy to patients. This project represents a paradigm shift in the management of ECMO from a supportive role to active treatment of the underlying problem, IRI organ injury. Resuscitatve ECMO is the most extreme example of IRI, but this treatment will be applied to all future resuscitative mechanical circulatory support. Specific Aim 1A will show that Regadenoson attenuates systemic organ injury in a 48-model of resuscitative ECMO. We will look at several markers of CNS, cardiac, liver, kidney, and intestinal injury as well as cytokine levels. CD3+ and CD4+ T cells, monocytes and neutrophils, and several damage-associated molecular pattern (DAMP) molecules will be assessed including HMGB1, cell-free DNA fragments and mitochondrial DNA. Aim 1B will show improved organ function in the groups treated with Regadenoson. Cardiac function will be assessed by cardiac index measured by a Swan-Ganz catheter and echocardiographs (ECHO) as well as the amount of inotropic support, IV fluid requirement and ECMO flows. Urine output will be collected and measured, and intestinal permeability will be determined via fluorescein isothiocyanate (FITC) gavage. Specific Aim2 will show how Regadenoson attenuates organ injury and improves organ function through several mechanisms including attenuation of neutrophil activation with reduced apoptosis, decreased membrane barrier permeability and fewer reactive oxygen species in the liver, kidney, intestine, heart, and brain. This mechanistic aim will provide additional scientific support for the use of A2AR activation to attenuate IRI in multiple organ systems. Dr Laubach is a senior researcher who has studied IRI for more than two decades and will serve as a mentor for this aim of the grant. Specific Aim3 will propose a clinical trial to determine if Regadenoson provides a durable clinical improvement in multiple organ systems in patients with post-arrest reperfusion with resuscitative ECMO. I will use the skills obtained from my course work and mentoring from Drs. Lau and Kron to submit a FDA investigational new drug application during the fourth year of this project, so I can submit an R01 proposal for clinical trial funding during the final year.