Two Consecutive Invasive Surgeries Utilizing Zymogen Protein C (ZPC) That Enhanced Patient Safety and Reduced Costs.

This case report describes a major surgical procedure for a protein C-deficient, hypercoagulable patient who underwent two back-to-back invasive surgeries, hip replacement, and spinal stenosis correction. The patient, an 84-year-old male with a history of deep vein thromboses (DVT) and pulmonary emboli (PE), was treated pre-, peri-, and postoperatively with zymogen protein C (ZPC-Baxter, International) and recovered without clotting or increased bleeding. During the procedure, the patient was not administered any other anticoagulants. There have now been several case reports on different patients with unrelated teams in various locations worldwide using zymogen protein C during surgical procedures. Thus, this procedure is becoming a viable choice for patients with a high probability of clotting during and after invasive surgery. This case focuses on accomplishing safer surgery and reducing costs, by using less ZPC while accomplishing two surgeries in one procedure. As a result, this procedure might be useful for many medical situations where acquired protein C deficiency could be a problem (e.g., sepsis, pregnancy, etc.). This approach may have greater application to medical conditions other than protein C deficiency, where clotting and inflammation can become issues.

ISOTT from the Beginning: A Tribute to Our Deceased Members (Icons).

ISOTT was founded by Drs. Duane F. Bruley and Haim I. Bicher in the state of South Carolina, USA in 1973. The symposium was jointly held at Clemson University (Clemson, SC, USA) and the Medical College of South Carolina (Charleston, SC, USA), which are geographically located 260 miles apart. This venue resulted from Dr. Bruley's (Clemson University) wish to have a meeting on Oxygen Transport to Tissue and with it to honor the research collaboration between the two universities and Dr. Melvin H. Knisely's accomplishments on studies regarding "blood sludging" in the microcirculation. Because of the unexpected large response to the symposium, Drs. Bruley and Bicher decided to found an international society at this meeting (ISOTT). The purpose of this paper is to summarize the formalization of ISOTT and to honor important contributors to the society who have since passed away. The authors did their best to include a brief overview of our past icons who have excelled in leadership as well as science/engineering, and apologize if someone has been mistakenly left out or if data is inaccurate or incomplete.

A Compelling Case for the Use of Perioperative Zymogen Protein C for Increased Patient Safety.

It is imperative to maintain normal blood flow to provide adequate oxygen supply to specific organs and cells, as well as for the removal of metabolic byproducts. Therefore, any situation that results in blood clotting can injure or kill living tissues. In this paper, we describe a case where a protein C deficient subject who would, by all medical indicators, be at 100 % risk of experiencing thrombophlebitis, deep vein thrombosis, and or lung emboli, is able to escape all pathologies by using perioperative zymogen protein C (ZPC). This protein C deficient patient has a long history of blood clotting, particularly from surgical procedures. The patient is 81 years old and first experienced clotting due to hernia surgery in 1964, when he was hospitalized for 16 days post-surgery with life threatening complications. It was later determined in 1980, after many episodes, that the patient had hereditary protein C deficiency at the 38 % level. In his hernia surgery, perioperative ZPC was used along with accepted anticoagulation procedures with no blood clots or other related side effects occurring. This procedure can greatly benefit protein C deficient patients, and could potentially find use for non-PC deficient patients in surgeries and a variety of other medical treatments. This particular case helps to validate the importance of ZPC in effecting safer surgery in high-risk patients. It also supports the mechanism of ZPC acting as an anticoagulant without causing bleeding. Most importantly, each clinical case study represents a unique combination of surgeon, hematologist, medical staff, and patient functioning as a coordinated team. In this case, smaller amounts of very expensive ZPC achieved safe and efficacious results, which is hugely important for future clinical applications when considering the production cost of ZPC. More studies must be done to establish minimum dosing while achieving safe and efficacious outcomes.

The founding of ISOTT: the Shamattawa of engineering science and medical science.

The founding of ISOTT was based upon the blending of Medical and Engineering sciences. This occurrence is portrayed by the Shamattawa, the joining of the Chippewa and Flambeau rivers. Beginning with Carl Scheele's discovery of oxygen, the medical sciences advanced the knowledge of its importance to physiological phenomena. Meanwhile, engineering science was evolving as a mathematical discipline used to define systems quantitatively from basic principles. In particular, Adolf Fick's employment of a gradient led to the formalization of transport phenomena. These two rivers of knowledge were blended to found ISOTT at Clemson/Charleston, South Carolina, USA, in 1973.The establishment of our society with a mission to support the collaborative work of medical scientists, clinicians and all disciplines of engineering was a supporting step in the evolution of bioengineering. Traditional engineers typically worked in areas not requiring knowledge of biology or the life sciences. By encouraging collaboration between medical science and traditional engineering, our society became one of the forerunners in establishing bioengineering as the fifth traditional discipline of engineering.

Pancreaticoduodenectomy using perioperative zymogen protein C to help prevent blood clotting: a trilogy on increased patient safety.

The blood clotting mechanism is a very important and complex physiologic process. Blood flow must be continuous through the blood vessels to provide essential oxygen and nutrients to the cells of the body. Dr. Melvin H. Knisely (Honorary First President of ISOTT, 1973) named and pioneered research in blood sludging and clotting which led to his nomination for the Nobel Prize by Dr. August Krogh in 1948. Abnormal clotting is a pathological state that can inhibit and prevent normal blood flow, leading to reduced oxygen transport to tissue from the microcirculation. It can result in the death of cells and tissues, including entire organs as well as the patient. Blood clotting and sludging are common occurrences during and after invasive surgery; thus, it is imperative to find safe procedures to reduce or prevent these deadly phenomena. All anticoagulants used today, for clot prevention and dissolution, can cause excessive bleeding that can lead to enormous medical expense to provide control, otherwise causing patient death. Protein C is a natural protein and is the pivotal anticoagulant in the blood. Due to the mechanism of converting the zymogen protein C (ZPC) to active protein C (APC), only when and where it is needed, and their respective half-lives in the body, the natural anticoagulant, antithrombotic characteristics of APC can be utilized without causing bleeds.

Nature's "silver bullet" for anticoagulation: mechanism of Zymogen Protein C to Activated Protein C.

We have defined the Zymogen Protein C (ZPC) to Activated Protein C (APC) process as the "silver bullet" of blood anticoagulation. This definition suggests that the anticoagulation activity occurs when and where it is needed, resulting in local anticoagulation without enhanced bleeding. It is important for man to be able to manufacture an inexpensive ZPC product or to find a substitute drug to duplicate one of God's natural anticoagulant/antithrombotic processes, in vivo, in human blood. After intense research and at great expense scientists have not been able to produce a safe anticoagulant. All products that are now being used can cause bleeding even if dosing is carefully monitored. In fact many professionals in the health care and the pharmaceutical industries define an anticoagulant as a drug that "does" cause bleeding. This results in a large financial burden that has been placed on the health care industry because of necessary emergency treatments for dangerous occurrences. In addition, many patients are dying annually due to internal and external bleeds created or enhanced by presently administered anticoagulants. Since there are no safe drugs available it is necessary to use the existing products when a medical condition calls for an anticoagulant. This paper will discuss the ZPC process and why its mechanistic design is one of nature's unique defenses against unwanted blood clotting. The prevention and lysis of clots allows normal blood flow and therefore results in the required tissue oxygenation for cell function and survival. If clinical research is carried out with great care it could uncover other uses of ZPC that will allow safer medical procedures, in addition to its use with standard PC deficiency cases. An important example might be for some brain surgeries where the use of existing anticoagulants is unsafe because of potential bleeds. Clinical research could reveal an efficacious ZPC level (for instance, 125, 150, or 200% of normal) that would prevent dangerous clotting situations from occurring without unnecessary bleeding.

Zymogen Protein C to prevent clotting without bleeding during invasive medical procedures.

Thrombophilic disorders that predispose patients to develop blood clots can be life-threatening and result in a large economic burden on healthcare expenditures. Venous Thromboembolism(VTE) (deep vein thrombosis and pulmonary embolism) are the third leading cause of death in the United States. Protein C deficiency is a common thrombophilic condition that affects an estimated 1 in 400 Americans. Zymogen Protein C (ZPC) is the precursor to Activated Protein C (APC), a pivotal endogenous anticoagulant in human blood. Patients with protein C deficiency who have roughly half the normal level of protein C are estimated to be at 10-fold increased risk of VTE. We describe the use of protein C concentrate (Ceprotin®, Baxter, Deerfield, IL) in a patient with protein C deficiency and with a previous pulmonary embolism who developed a life-threatening gastrointestinal bleed after polypectomy. The patient is a 75-year-old male at very high risk for deep vein thrombosis and possible lung emboli. He has heterozygous Protein C deficiency (50%) and heterozygosity for the prothrombin gene G20210A mutation. During a routine colonoscopy, a large 3 cm cecal polyp was identified and resected. Eight days post-procedure while performing abdominal exercise he developed a life-threatening GI bleed originating from the polypectomy site as his warfarin was becoming therapeutic on a Low Molecular Weight Heparin (LMWH) periprocedural bridge. The patient's warfarin was reversed with vitamin K, and LMWH and warfarin were discontinued. To prevent thrombosis, he was started on ZPC until anticoagulation could be safely restarted. During endoscopy, the bleeding site was treated with an injection of 1:10,000 dilution of epinephrine, followed by cauterization and placement of endoclips (4 metal staples). Three days after endoscopic repair LMWH was restarted with warfarin. Sixteen months post-bleed, the patient remains on life-long warfarin without further episodes of bleeding or thrombosis. Zymogen Protein C concentrate (Ceprotin®, Baxter Deerfield, IL) should be strongly considered for peri-procedural management of any patient with protein C deficiency and previous thromboembolism.

Safer surgery using zymogen protein C concentrate.

This is the first case (November 12, 2007) of peri-operative use of zymogen protein C (ZPC) for a heterozygote Protein C deficient (50%) patient with heterozygosity for the prothrombin gene mutation. The surgery involved total left hip replacement. The patient was 74 years of age and at very high-risk for Deep Vein Thrombosis (DVT) thus possible lung emboli. He was a survivor of Venous thrombo-embolism (VTE) in 1999.For this case the need for increased heparin to prevent a reoccurrence of thrombosis led to a further concern of internal bleeding and possible infection. As proposed by the authors in previous publications the use of a ZPC concentrate would decrease the chance of a thrombosis, with minimum or no internal bleeding. ZPC is activated at the endothelium cell surface and on the surface of the platelets where and when it is needed, therefore providing a safer procedure.This protocol was implemented by administering ZPC concentrate 1 day prior to surgery and continuing for 10 days after. Slightly higher than normal blood loss occurred, however, a safe procedure was achieved without dangerous side effects while several additional benefits were experienced (level of PC activity as high as 235% above normal were measured during the procedure.). It is felt that positive effects were the result of increased blood flow and oxygen transport to the tissues by reducing blood sludging in the microcirculation. Further studies on Protein C dose levels will be necessary to provide economical, safe and efficacious use of Protein C products.It is suggested that ZPC should be considered for patients with high probability of VTE which could cause thrombotic occlusion of the pulmonary and peripheral vasculature. These phenomena can result in hypoxia and hypo perfusion causing organ failure and death.Our research includes a focused effort to optimize upstream and downstream bio-processing to produce both zymogen and activated Protein C at a lower cost and to examine the medical indications that could benefit from a more available and affordable Protein C product.

Case report: perioperative use of protein c concentrate for protein C deficiency in THA.

BACKGROUND: Perioperative management of patients with heterozygous protein C deficiency is challenging because of the competing risks of bleeding and recurrent thrombosis. CASE DESCRIPTION: We report the case of a 74-year-old man with protein C deficiency and heterozygous prothrombin G20210A gene mutation who had a successful left THA with perioperative administration of human zymogen protein C concentrate in addition to anticoagulation with enoxaparin. LITERATURE REVIEW: Several studies have reported the use of protein C concentrate in severe sepsis-associated purpura fulminans in patients with severe congenital protein C deficiency who have had thrombotic events. We reviewed studies and case reports pertinent to the treatment of patients with protein C deficiency, especially in the perioperative setting. We report the case of a patient undergoing THA in whom we used human zymogen protein C concentrate. PURPOSES AND CLINICAL RELEVANCE: THA, a particularly high-risk procedure, is associated with a 40% to 70% incidence of venographic deep venous thrombosis and a 2% to 3% incidence of symptomatic deep venous thrombosis. These risks are greater in people with thrombophilic defects such as protein C deficiency. The use of human zymogen protein C in our patient with heterozygous protein C deficiency during the perioperative period of a THA was associated with no evidence of excessive bleeding, hematoma, deep venous thrombosis, or pulmonary embolism.

Manipulation of the affinity between protein and metal ions by imidazole and pH for metal affinity purification of protein C from Cohn fraction IV-1.

Protein C (PC) is an important anticoagulant in blood plasma. Cohn Fraction IV-1 (CFIV-1) is an inexpensive PC source but contains a large amount of factor II (FII). Immobilized metal affinity chromatography (IMAC) utilizes metal ions to adsorb proteins primarily via their surface histidine. Two major operation parameters for IMAC are imidazole concentration and pH: imidazole is a histidine analog and pH controls the protein surface protonation level. The effects of these two parameters on the adsorption and elution of PC and FII were studied for each protein individually and also together as a mixture. For the individual proteins, low FII (16%) and high PC (98%) adsorption were achieved at 8 mM imidazole, pH 8.0. At 11 mM imidazole, 92% of the adsorbed FII was eluted, with only a 3% PC loss. At 40 mM, 97% of the adsorbed PC was recovered. For the protein mixture, very similar adsorption and elution results were obtained, but slightly greater PC loss (16%) during elution at 11 mM imidazole. This result shows that there is a high potential for the PC purification from CFIV-1 by appropriately adjusting the imidazole concentration and pH in the IMAC process.

Anticoagulant blood factor deficiencies (protein C).

Anti-coagulant proteins are essential to maintain blood hemostatis for the supply of oxygen and nutrients to tissue cells and for the removal of toxic by-products from metabolism. Hereditary or acquired deficiencies of Protein C, Protein S, or Antithrombin III can lead to disease states such as deep vein thrombosis (DVT) with the possibility of producing lung emboli. Phenomena named Factor V Lieden can produce a similar pathologic condition. Anti-coagulant deficiencies, including Factor V Lieden, are HIDDEN blood conditions that can allow blood clot development, especially with trauma to the tissue and circulatory system. It is proposed that all children between ages twelve to fourteen be checked hereditary deficiencies and Factor V Lieden complications. This would require the development of inexpensive assay equipment12. The present research focuses on the low cost production of Zymogen Protein C via purification from blood plasma Cohn Fraction IV-1. This process is difficult due to the several Homologous Vitamin K dependent proteins in the blood coagulation cascade. Traditional chromatography (ion exchange) cannot achieve the desired separation. Some more exotic technologies are very expensive so our work proposes to use Immobilized Metal Affinity Chromatography (IMAC). It is hoped to produce a lower cost product that can be used prophylactic ally to treat Protein C deficiencies and possibly other coagulation problems.

Effect of pH and imidazole on protein C purification from Cohn fraction IV-1 by IMAC.

Cohn Fraction IV-1 (CFIV-1) is a by-product (often discarded) of a plasma fractionation process. It retains 90% of Protein C (PC) of plasma but contains several coagulants structurally homologous to PC. Of these coagulants, Factor II (FII) has the longest half-life (12 times of PC) and largest quantity (9 times of PC) in CFIV-1. Current purification process for PC is by immunoaffinity chromatography using monoclonal antibodies, which is very expensive. Immobilized metal affinity chromatography (IMAC) is an inexpensive process that uses metal ions to adsorb proteins via their surface histidines. Affinity of PC to the metal ions in IMAC is higher than that of FII because PC has 15 surface histidines and FII has 5. Two important factors in an IMAC process are pH and imidazole concentration. PH controls protonation of histidine, and imidazole, a histidine analog, competitively reacts with metal ions. The effects of pH and imidazole on adsorption and elution of PC and FII during IMAC process were studied. The effect of pH on PC and FII adsorption was similar within the range of 6.0 and 8.0. At concentrations below 15 mM imidazole, little PC or FII eluted. At 15 and 20 mM imidazole 2.5% of PC was eluted, while 20-30% of FII was eluted.