2. A NEW HORIZON IN
NEUROPROTECTION:
ERYTHROPOIETIN?
Reza Nejat, M.D.,
Anesthesiologist, FCCM
former Assistant Professor, SBMU,
Bazarganan Hospital, IRAN
2
3. Neuro-protection and EPO
EPO:
A must for
survival,
Proliferation,
differentiation
of erythroid
progenitor cells
Prevents apoptosis in
progenitor cells
3
4. Neuro-protection and EPO
EPO, produced by:
Renal interstitial cells
similar to neurons
express marker antigens found
in neuronal cells
Ito cells in the liver;
very similar to the EPO-
producing renal fibroblast-like
interstitial cells,
4
5. Neuro-protection and EPO
EPO and EPO-R can be
found in the:
Nervous system,
Cardiovascular system,
Digestive system,
Endocrine system,
Female and male
reproductive system,
Respiratory system
Spleen
5
6. Neuro-protection and EPO
EPO production and secretion regulated
by:
the tissue O2 supply (kidney, liver, brain)
HIF-1 pathway
6
7. Neuro-protection and EPO
the expression of EPO-R is:
sensitive or not to hypoxia???
regulated by:
pro-inflammatory cytokines:
TNFα, IL-1β
Erythropoietin
probably other unidentified factors:
Janus Kinase 2 (JAK2)?
7
8. Neuro-protection and EPO
Ischemic/hypoxic/hemorrhagic
and other types of brain injuries:
lack of oxygen and nutrients
pro-inflammatory mediators in
neurovascular unit:
TNF-α, IL-1, IL-6,
BBB dysfunction, brain edema and
hemorrhagic transformation
neural cell apoptosis and death
REPERFUSION???
8
9. Neuro-protection and EPO
Strategy against CNS
insults:
restore delivery of
oxygen and nutrients
(angiogenesis)
⇊ edema and saving the
integrity of BBB, {ASAP}
⇊ apoptosis and
supporting the cells
supporting neurogenesis
and synaptogenesis
(ECM)
9
10. Neuro-protection and EPO
Low amount of EPO is produced
de novo in the CNS
tissue hypoxia in the CNS increases:
EPO concentration
EPO-R expression
10
11. Neuro-protection and EPO
EPO and EPO-R:
In healthy brain ⇊
In injured brain ⇈
EPO vs EPOL
EPOR vs EPORβ
11
Redox Biology. 2018; 14: 285- 294
12. Neuro-protection and EPO
auto-phosphorylation of
JAK-2 results in activation
of:
RAS/MAPK
STAT5
PI3K/AKT
PKC
up-regulating anti-apoptotic
proteins Bcl-2 and Bcl-XL
EPO+EPO-R
activates
JAK-2
RAS/MAPK
STAT5
upregulation of
Bcl-2, Bcl-XL
12
13. Neuro-protection and EPO
auto-phosphorylation
of JAK-2 results in
activation of:
PI3K/AKT:
inhibits pro-apoptotic
molecules:
BAD, GSK-3β,
caspase-3/-9
PI3K/AKT
inhibition of
activation of
JAK-2
EPO+EPO-R
GSK-3β
caspase -3/-9
BAD
13
14. Neuro-protection and EPO
auto-phosphorylation
of JAK-2 results in
activation of:
PI3K/AKT:
Expression of eNOS
(endothelial Nitric
Oxide Synthase)
eNOS
PI3K/AKT
EPO+EPO-R
JAK-2
NO
vasodilatation
NADPH oxidase inhibition
ROS
14
15. Neuro-protection and EPO
auto-phosphorylation of
JAK-2 results in activation
of several signaling
pathways:
PI3K/AKT:
Down-regulation of NF-ƙB??:
suppresses pro-inflammatory
cytokines likeTNF-α and IL-6
and simultaneously
increases anti-inflammatory
cytokine IL-10 level.
EPO+EPO-R
JAK-2
NF-ƙB
Downregulation?
Upregulation?
TNF-α
IL-6
IL-10
anti-
inflammatory
effect
15
16. Neuro-protection and EPO
a multicenter double blinded
clinical study in Germany:
EPO had no cell-protective
effect or even might be
hazardous in humans.
Ehrenreich H, Weissenborn K, Prange H.
Recombinant Human Erythropoietin in the
Treatment of Acute Ischemic Stroke. Stroke. 2009;
40: e647-e656
16
17. Neuro-protection and EPO
phase II double blinded placebo
controlled study in infants with
moderate to severe hypoxic/ischemic
encephalopathy:
High Dose EPO with HypoT could:
1) diminish MRI brain injury,
2) improve the motor function of
the infants after 1 year,
3) the mortality did not differ
significantly
Pediatrics. 2016; 137(6): e20160191
17
18. Neuro-protection and EPO
EPO expression in the nervous system
is regulated by:
the tissue O2 supply
HIF-1 pathway
In non-hypoxic circumstances:
mechanical damage
infection
metabolic stress (glucose , insulin?)
oxidative stress
elevated temperature
intense neural activity
enriched environment
pro-inflammatory cytokines
18
19. Neuro-protection and EPO
EPO, Protects the neural
cells against:
oxygen tension,
calcium channel
dysfunction
excitotoxicity,
ROS or other free
radicals
19
20. Neuro-protection and EPO
EPO
facilitates energy production
in mitochondria:
stabilizing mitochondrial
membrane potential
20
21. Neuro-protection and EPO
EPO in the nervous system:
apoptosis,
inflammatory responses
re-establishment of compromised
functions by support of :
1) proliferation,
2) migration,
3) differentiation
4) survival
of progenitor/stem cells to
compensate for the lost or injured
cells
21
22. Neuro-protection and EPO
EPO, protects BBB
through:
its effects against VEGF-
induced injury
having cytoprotective
effect on endothelial cells
in ischemic insults
inhibiting AQP-4-induced
astrocyte swelling through
activating JNK and MAPK
22
23. Neuro-protection and EPO
rhEPO could protect BBB:
By up-regulating theTJ
proteins through
MMP,
glial cell inflammatory
reactions,
TNF-α levels,
NF–кβ activation.
23
24. Neuro-protection and EPO
EPO through activating
PI3K/Akt pathway
regulates:
TIMP-1 gene transcription,
TIMP-1 mRNA induction,
TIMP-1 expression
24
25. Neuro-protection and EPO
EPO supports
regenerating neurons
and astroglial cells by:
regulating MMP-2, MMP-9
andVEGF
VEGF receptors 1, 2 and
3 in hypoxia
25
26. Neuro-protection and EPO
EPO has pro-angiogenic
property:
Induces endothelial cell to:
proliferate,
migrate,
produce nitric oxide (NO),
degrade ECM delicately,
differentiate
Mobilizes the endothelial
progenitor cells,
26
27. Neuro-protection and EPO
activation of EPOR in
cultured young rat
cerebellar and hippocampal
neurons:
reduces glutamate release
by inhibiting calcium-
dependent exocytosis of this
excitatory amino acid
27
28. Neuro-protection and EPO
rhEPO in reperfusion injury:
Prevents from up-regulation
of IL-1β and IL-18, MMP-2 and
MMP-9
Protects against oxygen
toxicity and free radicals
(ROS, RNS) through:
pro-inflammatory
mediators
28
29. Neuro-protection and EPO
EPO :
TNF-α, IL-6, and
monocyte chemo-attractant
protein-1 (MCP-1)
TNF-α, IL-1:
Inhibits EPO production
29
30. Neuro-protective effects of EPO
EPO, in neonatal rats after:
hypoxic/ischemic injury
stimulated:
Oligodendrogenesis,
attenuated white matter
damage
EPO, in adult rats after:
stroke
amplified myelinating
oligodendrocytes,
increased myelinated axons in
peri-infarct white matter,
improved functional outcome
30
42. Neuro-protection and EPO
42
The 4th case:
Post tonsilectomy hemorrhage due to carotid
artery rupture in a 6-yr-old boy
Vascular surgeon ligated and repaired the left
CA
Left side infarction (MCA territory)
LOC
EPO started immediately 1st POD and continued
for 40 days
44. Neuro-protection and EPO
44
The 4th case:
On day 7 extubation was done unsuccessfully
which traumatized trachea which ended in fast
progressive emphysema with futile re-
intubation.
As to the delay in intubation hypoxic
encephalopathy occurred with widespread
edema of the brain with eventual multiple sites
of infarction in the brain
Once again EPO
48. Neuro-protection and EPO
The 5th case:
49 yrs, woman
Hx: headache for 4
months, treated for
migraine
Sudden LOC
First CT: widespread
brain edema and infarct
MRI: edema and infarct,
suspicious of aneurysm
48
56. Neuro-protection and EPO
The 6th case:
47 yrs, female
LOC after 3 days of headache
Hx of epilepsia
No apparent hx of head
trauma
SDH (subacute)
Double midriasis 5 minutes
before craniotomy and fixed
midsize pupils without reflex
to light postop
56
61. Neuro-protection and EPO
Till now EPO:
anti-apoptotic,
anti-oxidant,
anti-inflammatory
neuro-protective by
stimulation of :
Angiogenesis
Neurogenesis
synaptogenesis
61