Red cell substitutes from hemoglobin--do we start all over again?

Red cells are the oxygen-carrying components of blood. In modern medical practice, transfusions are given as suspensions of type-matched red cells in saline to replace lost blood, preventing organ damage and allowing for recovery. Since red cells cannot be stored for more than about 40 days and because they can transmit infections, alternative materials for transfusions were developed to replace the oxygenation function of the red cells. One approach involves chemically stabilizing hemoglobin, the oxygen-carrying protein of the red cell, while also adjusting its oxygenation properties to replicate that of the red cell. Evaluation of clinical trials of all products led to the conclusion that none that were tested would be suitable for clinical use [Natanson C, Kern SJ, Lurie P, Banks SM, Wolfe SM: Cell-free hemoglobin-based blood substitutes and risk of myocardial infarction and death: a meta-analysis. J Am Med Assoc 2008, 299:2304-2312]. Most notably, the materials increased blood pressure and some were associated with increased risk of heart attacks. More recently, it was found that materials from covalent addition of polyethylene glycol polymers (PEG) to hemoglobin do not elicit the undesired effects on blood pressure [Vandegriff K, Bellelli A, Samaja M, Malavalli A, Brunori M, Winslow RM: Rates of NO binding to MP4, a non-hypertensive polyethylene glycol-conjugated hemoglobin. FASEB J 2003, 17:A183; Vandegriff KD, Malavalli A, Wooldridge J, Lohman J, Winslow RM: MP4: a new nonvasoactive PEG-Hb conjugate. Transfusion 2003, 43:509-516]. Also, materials with higher oxygen affinity than red cells are able to provide oxygenation at the sites in capillaries that have the most critical need for oxygen [Villela NR, Cabrales P, Tsai AG, Intaglietta M: Microcirculatory effects of changing blood hemoglobin oxygen affinity during hemorrhagic shock resuscitation in an experimental model. Shock 2009, 31:645-652]. It had been considered that the origin of the negative effects of the tested hemoglobin derivatives was because of their scavenging of endogenous nitric oxide (NO), the signal for vasodilation. It has been observed that an increase in the concentration of nitrite in circulation leads to an increase in NO concentration. This is consistent with the well-known reaction of hemoglobin with nitrite that produces NO and oxidized hemoglobin [Cannon RO 3rd, Schechter AN, Panza JA, Ognibene FP, Pease-Fye ME, Waclawiw MA, Shelhamer JH, Gladwin MT: Effects of inhaled nitric oxide on regional blood flow are consistent with intravascular nitric oxide delivery. J Clin Invest 2001, 108:279-287; Cosby K, Partovi KS, Crawford JH, Patel RP, Reiter CD, Martyr S, Yang BK, Waclawiw MA, Zalos G, Xu X, et al.: Nitrite reduction to nitric oxide by deoxyhemoglobin vasodilates the human circulation. Nat Med 2003, 9:1498-1505]. The PEG-hemoglobin and nitrite results are especially interesting as the hemoglobin to which PEG has been conjugated produces NO from nitrite at an enhanced rate [Lui FE, Dong P, Kluger R: Polyethylene glycol conjugation enhances the nitrite reductase activity of native and cross-linked hemoglobin. Biochemistry 2008, 47:10773-10780; Lui FE, Kluger R: Enhancing nitrite reductase activity of modified hemoglobin: bis-tetramers and their PEGylated derivatives. Biochemistry 2009, 48:11912-11919].