Delivery of PAI-1-targeted intrapleural fibrinolytic therapy for empyema

总结 仅在美国就有大约65，000名患者发生脓胸（EMP）或 并发胸膜炎性胸腔积液电磁脉冲的发病率正在上升 国际吧EMP与严重的发病率相关，死亡率约为20%， 患者护理费用约为5亿美元。胸膜内纤溶治疗（IPFT）已被用于 60多年来，它一直在加速胸膜引流和防止肺限制，但它的疗效和 安全性特征，尤其是在成人中，仍然不确定。出血发生在高达15%的患者中。 目前的IPFT方案使用经验性给药、标签外干预， 了解EMP中IPFT的调节及其发病机制。这些差距已经减缓 为EMP或其他形式的患者开发更可靠，更安全的IPFT 为我们的课题提供了科学的前提。我们的初步数据 验证了活性纤溶酶原激活物抑制剂1（派-1）作为生物标志物和治疗靶点 对于IPFT。我们提供了概念证明，并表明三种不同形式的机械 派-1靶向的IPFT有效逆转了四环素诱导的家兔胸膜机化。 这些干预措施允许IPFT中纤溶酶的剂量减少多达8倍，从而 降低出血风险。我们设计了一个伴随诊断测试：纤溶潜能 检测（FPA），以监测派-1靶向或其他形式的IPFT的结果。我们的假设是 派-1靶向的IPFT能有效清除EMP胸膜内机化。我们也 FPA可以预测派-1靶向IPFT的结果，并最终用于选择 最有可能受益的对象。为了验证这一假设，我们开发并表征了一种新的 S. pneumoniae兔EMP模型，其模拟来自急性肺炎的人EMP的关键特征。 (96h)到一个有组织的慢性（7-21天）阶段，具有多房样组织， 胸膜明显增厚。我们的目的是测试派-1靶向治疗的有效性和安全性， IPFT在S.肺炎EMP模型，并确定FPA是否预测胸膜损伤 结果。这一假设将在四个具体目标，这是：1。提高 使用派-1靶向递送的IPFT在兔EMP中的功效; 2.测定分子 EMP中胸膜内纤溶的机制以及高水平的 派-1靶向IPFT上的胞外DNA; 3.选择最有效的派-1形式 EMP中的目标IPFT，使用来自 模型和患者; 4.优化一种新型EMP IPFT的结构和共配方 并评价其安全性和有效性。一系列最先进的生化生理组织 分析和成像技术将用于完成这项工作。我们独特 多学科团队包括纤溶、胸膜损伤等领域的领先专家， 作为药物配方和开发。该项目旨在解决目前尚未满足的需求： 新的、可能更有效和更安全的IPFT候选药物的鉴定和临床前审查 和FPA诊断EMP，临床上易于处理，最终可以改善 临床结果。

Summary Approximately 65,000 patients in the United States alone develop empyema (EMP) or complicated parapneumonic pleural effusions each year. The incidence of EMP is increasing worldwide. EMP is associated with serious morbidity, a mortality of about 20%, and annual patient care costs of roughly $500 million. Intrapleural fibrinolytic therapy (IPFT) has been used for over sixty years to expedite pleural drainage and prevent lung restriction, but its efficacy and safety profile, especially in adults, remains uncertain. Bleeding occurs in up to 15% of patients. Current IPFT protocols use empirically dosed, off-label interventions and reflect rudimentary knowledge about the regulation of IPFT in EMP and its pathogenesis. These gaps have slowed the development of more reliable and safer IPFT for patients with EMP or other forms of loculated pleural injury and form the scientific premise for our project. Our preliminary data validates active plasminogen activator inhibitor 1 (PAI-1) as a biomarker and therapeutic target for IPFT. We provide proof of concept and show that three mechanistically different forms of PAI-1 targeted IPFT effectively reverse tetracycline-induced pleural organization in rabbits. These interventions allow for up to an 8-fold reduction of the dose of fibrinolysin in IPFT, thereby mitigating bleeding risk. We designed a companion diagnostic test; the Fibrinolytic Potential Assay (FPA), to monitor outcomes of PAI-1-targeted or other forms of IPFT. Our hypothesis is that PAI-1 targeted IPFT can effectively clear intrapleural organization in EMP. We also posit that FPA can predict outcomes of PAI-1-targeted IPFT and ultimately be used to select the subjects most likely to benefit. To test this hypothesis, we developed and characterized a new S. pneumoniae rabbit EMP model which simulates key features of human EMP from an acute (96h) to an organized chronic (7-21 days) phase with multiloculation-like organization and significant pleural thickening. Our objective is to test the efficacy and safety of PAI-1 targeted IPFT in the S. pneumoniae EMP model and determine if the FPA predicts pleural injury outcomes. This hypotheses will be tested in four Specific Aims, which are to: 1. Improve the efficacy of IPFT in rabbit EMP using PAI-1 targeted delivery; 2. Determine the molecular mechanisms governing intrapleural fibrinolysis in EMP and the effects of high levels of extracellular DNA on PAI-1 targeted IPFT; 3. Select the single most effective form of PAI-1 targeted IPFT in EMP, develop and validate the companion FPA test using EMP fluids from the model and patients; and 4. Optimize the structure and co-formulation of a novel IPFT for EMP and evaluate its safety and efficacy. A range of state-of-the-art biochemical, physiologic, tissue analysis, and imaging techniques will be used to accomplish the work. Our unique multidisciplinary team includes leading experts in the fields of fibrinolysis, pleural injury, as well as drug formulation and development. This project addresses current unmet needs: the identification and preclinical vetting of new, potentially more effective and safer IPFT candidates and FPA diagnostics for EMP that are clinically tractable and that could ultimately improve clinical outcomes.