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

脓胸是一种胸膜腔细菌感染，是肺炎的严重并发症，携带 死亡率高达20%，其发病率在全球范围内继续上升。胸膜腔内纤溶 包括输送纤溶酶原激活剂的治疗(IPFT)已被用于加速房室积液的引流 胸腔积液，包括脓胸。肺炎链球菌致脓胸新模型的建立 我们研制了一种带有纤溶酶原激活物抑制物1(PAI-1)靶向辅助物的单剂IPFT，它 对急性脓胸的治疗效果是单独使用PA的8倍。我们还验证了我们的能力 纤溶潜力分析(FPA)预测脓胸患者行IPFT治疗的成功率。有趣的是， 在我们的晚期脓胸模型中，IPFT的疗效降低了40%-50%，与已有的相似 在病人身上观察。这在一定程度上是由于胸腔内纤溶率的显著下降。至 减少与增加PA剂量相关的出血并发症的风险，我们建议 小剂量PAI-1靶向IPFT注射治疗晚期脓胸。我们的目标是找出 有效的PAI-1靶向IPFT治疗晚期脓胸。我们的假设是，成功的IPFT 晚期脓胸需要较长时间的纤溶活性和中和。 PAI-1。这一假设将在四个具体目标中得到检验：1.最大限度地发挥IPFT在晚期- 以纤溶慢速和纤溶酶原激活物抑制物-1为靶点的兔脓胸模型，2.开发新型纤溶酶原激活物-1 靶向多肽优化IPFT治疗晚期脓胸，3.确定导致 晚期脓胸患者对IPFT的抵抗力增加，以及4.使用纤溶电位测定 在治疗前确定IPFT的候选者。我们将选择给药计划并使用两个经过验证的PAI-1 靶向辅助物(单抗和对接部位肽)以减少PA的剂量，测试 这些机制使PAI-1靶向的可加性最大化，并测试PAI-1靶向的有效性 利用噬菌体展示技术筛选多肽。我们将使用FPA来分析第二阶段临床的样本 试验“在感染的、非引流性胸腔积液患者中评估LTI-01的研究”(ClinicalTrials.gov； NCT04159831)。我们将使用最先进的生化技术来分析胸水和血浆 人类患者和我们独特的脓胸模型来研究纤维蛋白溶解的分子相互作用 晚期脓胸。我们的团队拥有生化、肺部和技术方面的专业知识，能够成功 完成建议的工作。该项目解决了我们目前对发病机制了解中的主要空白。 胸膜组织、IPFT的优化和预测预后的新诊断方法的开发 IPFT的一部分。这个项目的定位是改变广泛胸膜患者的治疗模式 恶露，引流失败，晚期脓胸。

Empyema is a bacterial infection of the pleural space, a serious complication of pneumonia that carries a mortality rate of up to 20%, the incidence of which continues to increase worldwide. Intrapleural fibrinolytic therapy (IPFT) involving the delivery of plasminogen activators has been used to expedite drainage of loculated pleural effusions, including empyema. Using a new model of Streptococcus pneumoniae-induced empyema in rabbits we developed a single-dose IPFT with a plasminogen activator inhibitor 1 (PAI-1)-targeted adjunct, which is 8-fold more effective than PA alone for treatment acute empyema. We also validated the ability of our Fibrinolytic Potential Assay (FPA) to predict the success of IPFT in patients with empyema. Interestingly, the efficacy of IPFT in our model of advanced-stage empyema is decreased by 40-50%, similar to what has been observed in patients. This is, in part, due to a significant decrease in the rate of intrapleural fibrinolysis. To mitigate the risk of bleeding complications associated with an increase in the dose of PA, we propose multiple injections of low-dose PAI-1-targeted IPFT to treat advanced-stage empyema. Our objective is to identify effective PAI-1-targeted IPFT for advanced-stage empyema. Our hypothesis is that successful IPFT in advanced-stage empyema requires fibrinolytic activity sustained over a longer period of time and neutralization of PAI-1. The hypothesis will be tested in four Specific Aims: 1. Maximize the efficacy of IPFT in advanced- stage empyema in rabbits by targeting both the slow rate of fibrinolysis and PAI-1, 2. Develop novel PAI-1 targeting peptides to optimize IPFT in advanced-stage empyema, 3. Determine the mechanisms that result in increased resistance to IPFT in advanced-stage empyema, and 4. Using the Fibrinolytic Potential Assay to identify candidates for IPFT prior to treatment. We will select a dosing schedule and use two validated PAI-1 targeting adjuncts (monoclonal antibodies (mAbs), and a docking site peptide) to decrease the dose of PA, test these mechanisms for additivity in PAI-1 targeting to maximize efficacy, and test the efficacy of PAI-1 targeting peptides selected using phage display technology. We will use the FPA to analyze samples from Phase 2 Clinical Trial “A Study to Evaluate LTI-01 in Patients with Infected, Non-draining Pleural Effusions” (ClinicalTrials.gov; NCT04159831). We will use state of the art biochemical techniques to analyze pleural fluid and plasma from human patients and our unique model of empyema to investigate the molecular interactions of fibrinolysis of advanced-stage empyema. Our team has the biochemical, pulmonary and technical expertise to successfully accomplish the proposed work. The project addresses key gaps in our current understanding of the pathogenesis of pleural organization, optimization of IPFT and development of a new diagnostic approach to predict outcomes of IPFT. This project is positioned to shift the paradigm of treatments available for patients with extensive pleural loculation, failed drainage, and advanced-stage empyema.