Artificial Organs

36(2):123126, Wiley Periodicals, Inc.

2012, Copyright the Authors
Artificial Organs 2012, International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc.

Guest Editorial

Artificial Oxygen Carriers: Renewed Commercial Interest

and Scientific/Technological Advances
Despite all the current controversies surrounding
artificial oxygen carriers, the fact remains that the
ultimate solution to transfusion medicine problems is
a safe blood substitute (1,2).
Blood transfusions, although having become safer,
will always carry certain risks. The improvements in
pathogen detection techniques over the past three
decades have not entirely eliminated the possibility of contracting transfusion-related blood-borne
diseases. As the infectious risks for HIV and hepatitis
have dropped dramatically (3), newly emerging
pathogens have entered the blood supply. Of particular concern is the possibility of transmission of prion
diseases (Creutzfeldt-Jakob disease [CJD] and
Bovine spongiform encephalopathy [BSE]) (4,5) At
this time, there are no reliable screening tests for
these new pathogens; therefore, their spread poses a
particular threat to the blood supply. In addition,
blood transfusions may also carry noninfectious risks
ranging from fever/allergic reactions to transfusionrelated acute lung injury that is potentially a lifethreatening adverse event (3). However, the most
critical issue facing transfusion medicine today is
the harmful effects of injecting old stored red blood
cells (RBCs) (6). During storage, RBCs increase
their affinity for oxygen and decrease the levels
of S-nitrosylated (SNO) hemoglobin (Hb) and
adenosine-5-triphosphate (ATP) (7,8), which disrupts oxygen delivery and obstructs RBC-regulated
vasodilation (9). Recent studies have tied these biochemical and functional changes with reduced
survival rates of cardiac patients who received transfusions with greater than 2-week-old donor blood
(10). It is frightening that transfusions of stored blood
may no longer be the best treatments for many
medical conditions including anemia. If regulatory
changes for shortening RBC storage time (from the
current 6 weeks) go into effect, the blood banking
and transfusion medicine industry could face catastrophic shortages, particularly in the USA where

1314 million units of blood are used annually and

where seasonal blood shortages already exists (11).
The deleterious effects of stored blood as well as
emerging pathogens that pose threats to the safety of
the blood supply have renewed commercial interest
in blood substitutes to a similar extent as it was in the
mid-1980s due to worries about HIV transmission
through blood transfusions.
Despite tremendous efforts of the research institutions and industry, blood banks are still awaiting
an effective alternative to red cell transfusions. To
date, all attempts to commercialize artificial oxygen
carriers have been unsuccessful due to toxicity and
efficacy problems (1,2). The meta-analysis of clinical
trials with HemAssist (Baxter Healthcare, Round
Lake, IL, USA), Hemolink (Hemosol, Mississauga,
ON, Canada), Hemopure (Biopure Corp., Cambridge, MA, USA), and PolyHeme (Northfield
Laboratories, Inc., Evanston, IL, USA) revealed that
administration of any of these products was associated with serious adverse events including increases
in blood pressure, pulmonary hypertension, systemic
and local inflammation, gastrointestinal disturbances, heart attacks, strokes, and even death (1,2).
Poor clinical performance of these products was
inevitably related to the fact that they were
designed as low oxygen affinity acellular oxygen carriers with prolonged intravascular persistence
without addressing the problems of the intrinsic
heme toxicity: a key mediator of the pathological
responses observed in humans (1,12,13). The crosslinking agents and the Hb chemical modification
techniques used in these products did not represent
any heme detoxification potency; thus, heme toxicity
always overshadowed the resuscitation benefit of
acellular Hb (14).
The attempts to revive some of these products via
novel protective strategies such as coadministration
of nitrovasodilators (i.e., nitroglycerin, nitroprusside,
sodium nitrite, etc.) have been only partially successful (15,16). The latest concept of using the nitrite
reductase activity of Hb that generates nitric
oxide (NO) equivalents to treat vasoconstriction has

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proven to be less clinically promising than anticipated, as the combination of sodium nitrite and
Hb-based oxygen carrier201 (Biopure) appears to
increase the risk of pulmonary complications such as
edema, congestion, and fibrin thrombi (16). Although
it has been suggested that nitroglycerin may reduce
Hb-induced pulmonary hypertension, there are still
many unanswered questions concerning the vasoconstrictive responses of the early generation of
Hb-based oxygen carriers (17). Also, the use of single
antioxidant substances does not fully prevent oxidative reactions following transfusions of redox-active
Hb-based oxygen carriers (18).
Hence, there is an emerging need for a new artificial oxygen carrier that is safe and effective and lacks
toxicity. Many academic and industrial research
centers have already engaged in the development of
a new generation of blood substitutes.
The developers of these new products hope to
eliminate the intrinsic toxic effects of heme. They
utilize recent scientific discoveries in the areas of: (i)
physiologic clearance of plasma Hb via CD163 receptor, (ii) new mechanisms of Hb-mediated vasoconstriction via well-known NO scavenging and the
angiotensin, endothelin, serotonin, and 8-isoprostane
pathways, as well as the autoregulatory theory; (iii)
redox reactions of Hb; (iv) Hb-mediated activation of
nuclear factor-kappa B and local and systemic
inflammation; (v) Hb as a nitrite reductase; (vi)
P50 value and adequate tissue oxygen delivery;
(vii) impact of Hb on hypoxia-inducible factor 1
alpha vis--vis erythropoiesis, cancer treatment, and
wound healing; and (viii) other Hb physiologic and
pathologic responses not quite fully understood
(1,2,1214,1618).
The creation of new products also employs new
technologies as a part of: (i) Hb purification from
emerging blood-borne pathogens, particularly prion
proteins; (ii) new cross-linking and polymerization
techniques that support oxygen delivery in hypothermia; (iii) novel pharmacologic cross-linking and polymerization techniques that add to the Hb molecule
new properties that besides alleviating heme toxicity
and oxygen delivery provide additional treatment;
(iv) modern pegylation and encapsulation techniques; (v) novel molecular and pharmacologic
control of heme redox potential; (vi) prolonged
storage at ambient temperature, etc.
The potential for improvement of artificial oxygen
carriers through new scientific discoveries seems vast.
Although, so far, only a few concepts have been considered, it should be apparent that the present limit
on application of other scientific ideas for blood substitute improvement depends on advancements in
Artif Organs, Vol. 36, No. 2, 2012

biotechnology. In fact, there are some biotechnological limitations that are impossible for us to transcend.
The recombinant Hb-based blood substitute programs, although initially promising, have shown to be
technologically more complicated than anticipated
and now are on the decline. Similarly, a great deal of
optimism about the potential future role for stem
cells as a donorless source of blood for transfusion is
not substantiated yet. Several groups around the
world, including Advanced Cell Technology, Inc.
(Santa Monica, CA, USA), are engaged in brewing
blood from the hematopoietic progenitors. So far,
they have been able to produce under good manufacturing practice conditions only a few milliliters of
RBCs that provided proof of principle of in vitrogenerated RBCs (19). The problem is with the
scale-up process. As production of 1010 RBCs
requires 13 L of culture medium, this technology
brings in a concept that looks surreal.
Because of the limitations in biotechnological processes, the most logical and promising approach in
the development of artificial oxygen carriers seems to
be adequately chemically modified and/or encapsulated cell-free Hb.
There are many new blood substitute products
being invented in the world. Some of them are
already in preclinical or clinical stages of development. They represent different approaches to
prevent not only the clinical sequelae of free Hb in
plasma but also the pathologic reactions associated
with various health conditions (14,20). The regulatory development of these new products does not
necessarily follow the traditional commercialization
path targeting the universal blood replacement
therapy that was chosen by previous developers.
Based on pharmacological characteristics and
preclinical performance, the inventors of the new
products have created a fresh concept of artificial
oxygen carriers with a therapeutic index for
narrow specific clinical indications. Such a strategy
could simplify the regulatory process, reduce costs,
and accelerate the commercialization of blood
substitutes.
Since the publication in 2009 of the Artificial
Organs special issue on artificial oxygen carriers [Vol.
33, no. 2], several new-generation products have been
presented at national and international conferences
including the XIIth International Symposium on
Blood Substitutes (August 2528, 2009, Parma, Italy),
the 55th Annual Conference of the American Society
for Artificial Internal Organs (May 2830, 2009,
Dallas, TX), the 56th Annual Conference of the
American Society for Artificial Internal Organs (May
2729, 2010, Baltimore, MD), the 57th Annual Con-

GUEST EDITORIAL
ference of the American Society for Artificial Internal Organs (June 1012, 2011, Washington, DC), the
XIII International Symposium on Blood Substitutes
and Oxygen Therapeutics, Massachusetts General
Hospital and Harvard Medical School (July 2729,
2011, Boston, MA), and the 4th Joint ESAO-IFAO
Congress (October 912, 2011, Porto, Portugal).
This current Artificial Organs special issue contains
some of the work on artificial oxygen carriers presented at these conferences, particularly newgeneration products that are in the advanced stages
of development.
Polynitroxylation and pegylation of Hb brought a
polynitroxylated pegylated Hb (PNPH) product with
antioxidant enzyme-mimetic activities for the treatment of traumatic brain injury (Synzyme Technologies, LLC, Irvine, CA, USA). The preclinical
performance of PNPH is presented in this current
Artificial Organs special issue (Hsia et al.)
A newly developed product is a non-vasoactive
porcine polymerized Hb created at Northwest
University, Xian, China. The ability of this blood
substitute to inhibit hydrogen peroxide-induced cytotoxicity to human endothelial cells is described in this
issue (Zhang et al.)
Another free-Hb-based product presented in this
issue is an artificial oxygen carrier composed of purified bovine Hb cross-linked intramolecularly with
ATP and intermolecularly with adenosine and combined with reduced glutathione (GSH). In this
composition, while ATP prevents Hb dimerization,
adenosine permits the formation of homogeneous
polymers and counteracts the vasoconstrictive and
pro-inflammatory properties of Hb via stimulation of
adenosine A2 and A3 receptors. GSH introduces electronegative charges onto the Hb molecule surface
that blocks Hbs transglomerular and transendothelial passage and shields heme from NO and reactive
oxygen species, thus enhancing vasodilation and lowering Hbs pro-oxidative potential. The results of preclinical and clinical studies indicate that this product
can work as a physiological oxygen carrier with prolonged intravascular persistence and produces no
adverse nephrotoxic, neurotoxic, oxidative, or inflammatory reactions (21).The erythropoietic potential of
this product is explained in the current Artificial
Organs special issue (Simoni et al.)
Other novel blood substitutes include liposomeencapsulated Hb vesicles. Encapsulation shields
various toxic effects of acellular Hb. Hb vesicles are
able to recreate the respiratory function of RBCs and
their removal from the circulating blood is not associated with toxicity. This aspect of clinical performance is expressed in this special issue (Sakai et al.).

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The liposome-encapsulated Hb takes the therapeutic potential to another level. In this current Artificial Organs special issue, several articles are
dedicated to the use of liposome-encapsulated Hb in
the treatment of hemorrhagic shock, wound healing,
cancer, hearing loss, and skeletal muscle ischemia
(Ikegawa et al., Fukui et al., Murayama et al., Okada
et al., Kurita et al. Kawaguchi et al.).
The new-generation products not presented in the
current Artificial Organs special issue, worthy of
being mentioned, include human albumin-synthetic
heme adduct, which does not appear to induce an
acute increase in blood pressure (22). OxyVita, a
zero-linked Hb polymer with a mean molecular
weight of 17 000 000 Daltons and P50 of 6 mm Hg, is
planned for the treatment of stroke and cancer
(OXYVITA, Inc., New Windsor, NY, USA) (23).
The glutaraldehyde-polymerized bovine Hb with
covalently attached catalase and superoxide dismutase attempts to reduce ischemia-reperfusion injury
by removing and detoxifying reactive oxygen species
(24). The pegylation of Hb has reached a whole new
dimension that resulted in effective products for the
potential treatment of traumatic hemorrhagic shock,
cardiovascular disorders, and cancer (Sanguinate;
Prolonged Pharmaceuticals, South Plainfield, NJ,
USA) and hypotension associated with spinal anesthesia (MP-4; Sangart, San Diego, CA, USA) (25).
IKOR, Inc. (San Francisco, CA), Tohuku University
(Sendai, Japan), and Tokai University (Isehara,
Japan) have introduced SNO and pegylated Hb with
a wide therapeutic index from wound healing to
stroke and cancer treatment (26). SNO Hb possesses
properties that overcome the heme scavenging action
of NO. The preclinical performance of SNO-PEG-Hb
was presented many times during conferences mentioned earlier. A multicenter European team is tackling the NO scavenging and pro-oxidant potential of
heme using recombinant and pegylation technologies
(27).
Because there is increasing understanding of the
Hb molecule, very real hope exists that in the longrun, this will drive successful commercial development of blood substitutes. There is also a new wave of
trust and enthusiasm among the industry as scientists
develop more advanced and efficacious artificial
oxygen carriers. It will be interesting to see, within the
next couple of years, which of these new blood substitute products will be the first to receive regulatory
approval.
Jan Simoni, DVM, PhD
Research Professor
Department of Surgery
Artif Organs, Vol. 36, No. 2, 2012

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GUEST EDITORIAL
School of Medicine
Texas Tech University Health Sciences Center
3601 4th Street
Lubbock, TX 79430, USA
E-mail: jan.simoni@ttuhsc.edu
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