Elamipretide mitigates ischemia-reperfusion injury in a swine model of hemorrhagic shock

Background: Ischemia-reperfusion injury (IRI) after hemorrhage is potentiated by aortic occlusion or resuscitative endovascular balloon occlusion of the aorta (REBOA). Given the central role of mitochondrial injury in shock, we hypothesized that Elamipretide, a peptide that protects mitochondria, would mitigate IRI after hemorrhagic shock and REBOA. Methods: Twelve pigs were subjected to hemorrhagic shock and 45 minutes of REBOA. After 25 minutes of REBOA, animals received either saline or Elamipretide. Animals were transfused with autologous blood during balloon deflation and pigs were resuscitated with isotonic crystalloids and norepinephrine for 4.25 hours. Results: Elamipretide-treated animals required less crystalloids than the controls (62.5 [50-90] and 25 [5-30] mL/kg, respectively), but similar amounts of norepinephrine (24.7 [8.6-39.3] and 9.7 [2.1-12.5] mcg/kg, respectively). Treatment animals had a significant reduction in serum creatinine (control: 2.7 [2.6-2.8]; Elamipretide: 2.4 [2.4-2.5] mg/dL; p=0.04), troponin (control: 3.20 [2.14-5.47] ng/mL, Elamipretide: 0.22 [0.1-1.91] ng/mL; p=0.03), and interleukin-6 concentrations at the end of the study. There were no differences in final plasma lactate concentration. Conclusions: Elamipretide reduced fluid requirements and protected the kidney and heart after profound IRI. Further understanding the subcellular consequences of REBOA and mitochondrial rescue will open new therapeutic avenues for patients suffering from IRI after hemorrhage.