Translated Abstract
Objective:
Vitamin K1 injection is commonly used in hemorrhagic disease which are usually caused by vitamin K deficiency. However, vitamin K1 injection can induce severe adverse reactions, which threatened the public health and attracted extensive concerns. The mechanism which vitamin K1 injection induces severe adverse reactions is not clear, so it brings much difficulty for the prevention, diagnosis and treatment. The serious adverse reaction is considered as ＂anaphylaxis＂. Paradoxically, ＂anaphylaxis＂ appears in some patients when they are administered with vitamin K1 injection for the first time. Furthermore, vitamin K1 is born to possess and essential in body, so the ＂anaphylaxis＂ should not occured only after the administration. We hypothesized that the severe adverse reaction is an anaphylactoid reaction instead of an anaphylaxis. The severe adverse reaction may be induced by the solubilizer. The present research aims to clarify the essence and trigger of the severe adverse reactions of vitamin K1 injection, and provide solutions to reduce or eliminate the severe adverse reaction.
Methods:
Behavioristics and vascular permeability were respectively examined by observational survey and spectrophotometry to evaluate the sensitivity of anaphylactoid reaction among beagle dog, guinea pig and mouse. Behavior, blood pressure, the concentration of plasma histamine and immunoglobulin E (IgE) were respectively assayed by observational survey, blood pressure monitor and ELISA to evaluate the anaphylactoid reaction and anaphylaxis of vitamin K1 injection, solubilizer Tween-80 and vitamin K1 fat emulsion in sensitive animal. Histamine and β-hexosaminidase released from RBL-2H3 cells was assayed by fluorospectrophotometry and spectrophotometry, and apoptosis was analyzed using fluorescence microscopy and flow cytometry respectively to research the mechanism of anaphylactoid reaction. Rats were administered with a combination of vitamin K-free diet and the intragastric administration of gentamicin to establish a vitamin K deficiency model. Rat blood clotting function, the levels of plasma PIVKA-II levels, and vitamin K status were assayed using a coagulation analyser, ELISA, and HPLC-fluorescence systems to respectively evaluate the effect of a small dose of vitamin K1 injection on vitamin K deficiency. The behavioral responses of sensitive animal was used for the evaluation of the anaphylactoid reaction of small dose of vitamin K1 injection in sensitive animal.
Results:
1. The selection of a sensitive animal model for anaphylactoid reaction
After Tween-80 was injected to mice tail vein, there was a significant increase of muscle vascular permeability but no increase in the vascular permeability of mice ascites and skin. The guinea pigs showed no significant difference in behaviors between Tween-80 intravenous administration and control groups. The beagle dogs appeared serious IV grade anaphylactoid symptoms after intravenous administration of Tween-80. The symptoms were intense positive anaphylactoid reaction. The beagle dog is more sensitive than mouse and guinea pig for the evaluation of anaphylactoid reaction. So beagle dog is selected as an animal model for anaphylactoid reaction.
2. The anaphylactoid reaction of vitamin K1 injection
1) The beagle dogs who were sensitized at the frist administration and challenged by 0.25 and 1.0 mg/kg of the solubilized-free vitamin K1-fat emulsion did not display any abnormal behavior or significant change in blood pressure, plasma histamine and IgE. It demonstrated that vitamin K1 is not the trigger and cannot induce the anaphylactoid reaction or anaphylaxis.
2) In anaphylactoid experiment, serious IV～V grade anaphylactoid symptoms appeared in beagle dogs of 0.25 mg/kg vitamin K1 injection group with the increase of the concentration of plasma histamine concentration and the sharply decrease of blood pressure. There was also serious IV grad anaphylactoid symptoms in beagle dogs of 0.085 mg/kgvitamin K1 injection group. The symptoms were intense positive anaphylactoid reaction, which demonstrated that vitamin K1 injection could induce an anaphylactoid reaction in beagle dogs.
3) In the sensitization and challenge experiment, serious IV grade anaphylaxis-like symptoms appeared inbeagle dogs in both of 0.085 mg/kg and 0.25 mg/kg vitamin K1 injection group with tolerance responses and without the increase of the concentration of plasma IgE concentration. In cross-challenge experiment, the abnormal reactions did not occur in vitamin K1 injection-sensitized dogs which were challenged with solubilized-free vitamin K1-fat emulsion, which implied vitamin K1 could not induce the anaphylaxis. However, when dogs sensitized by vitamin K1-fat emulsion were administered with vitamin K1 injection, severe IV grade anaphylaxis-like symptoms were observed, which demonstrated the anaphylaxis-like symptoms is an anaphylactoid reaction induced by the solubilizers of vitamin K1 injection.
4) Vitamin K1 injection and Tween-80 increased the release of histamine and β-hexosaminidase and then induced apoptosis of RBL-2H3 cells in a concentration-dependent manner. However, vitamin K1-fat emulsion did not have such effects.
3. The effect of a small dose of vitamin K1 on vitamin K-deficiency in rats
1) There was an undetected vitamin K1 and vitamin K2 in livers, an increase of PIVKA-II levels, a prolonging of PT and APTT, and a decrease in vitamin K-dependent FII, FVII, FIX and FX activities in rats with a combination of vitamin K-free diet and gentamicin for 28 d. It would be selected as a vitamin K-deficient model.
2) Coagulation markers PT, APTT, FVII, and FIX activities returned to normal levels, and FII and FX activities was increased in vitamin K-deficient rats with the treatment of 0.01 mg/kg vitamin K1 injection. Both in the 0.1 and 1.0 mg/kg vitamin K1 injection groups, coagulation functions and the activities of vitamin K-depended coagulation factors completely returned to normal, and there was no significant difference between the two groups.
3) In 0.01 mg/kg vitamin K1 group, the liver vitamin K1 levels increased 5-fold and the liver vitamin K2 levels increased to the normal amount. In 0.1 and 1.0 mg/kg vitamin K1 group, the amount of liver vitamin K1 was 40 and 100 times as in normal rats and vitamin K2 was about 4 and 5 times as the normal amount respectively, which far above the normal one.
4) There was no abnormal behaviors in beagle dogs intravenously administrated with 0.03 mg/kg vitamin K1 injection, which did not induced the anaphylactoid reaction.
Conclusions:
1. The adverse reaction induced by vitamin K1 injection is an anaphylactoid reaction, but not anaphylaxis. Vitamin K1 injection may be triggered by the solubilizer through the release of inflammatory factors via a direct non-IgE-mediated immune pathway in mast cell, for which the trigger may be the solubilizer.
2. The solubilizer-free vitamin K1-fat emulsion does not induce the anaphylactoid reaction or anaphylaxis.
3. Small dose of vitamin K1 injection improves vitamin K deficiency in rats effectively and prevents anaphylactoid reactions in beagle dogs simultaneously.
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