**3. Adsorptive hemoperfusion therapy for ARS**

Sorption detoxification types, quite widely used today in medicine, are: (1) hemoperfusion (when blood is filtered through the column with activated carbon); (2) enterosorption—enteral use of oral adsorbents of a different type and (3) application-sorption therapy - use of carbon dressing for the healing of the burns and wounds.

The ground for use of direct perfusion of the blood through an adsorbent column for its purification (hemoperfusion) was the Kuzin A.M. Structural-Metabolic Theory in Radiobiology (1970) [29]. Organs and tissues exposed to ionizing radiation and radiomimetic influences are damaged by radiotoxins, which affect radiosensitive structures, and direct radiation-dependent changes in the macromolecules of the genome. Further investigations demonstrated that "radiotoxins" are reactive oxygen species (ROS) formed by water radiolysis. Oxidative stress causes DNA, protein and lipid oxidation and is responsible for the whole range of signs and syndromes of ARS [29]. Because of excessive lipid peroxidation, a lot of damaged cells appear that deepens the primary radiation injury repeatedly. In summary, ARS is a sum of primary damage due to oxidative stress plus so-called bystander effects [18], when cells exposed to ionizing radiation or radiomimetics can release signals that induce very similar effects on non-targeted neighboring cells.

Our first research of adsorptive therapy effects for acute radiation sickness (ARS) started in 1976 [30]. In this study, 69 inbred dogs were irradiated by external X-ray at the dose of 525 Rad (5.25 Gy). They were randomly assigned to three groups: first control group (n = 31), which received standard antibiotics therapy; second group (n = 19) got antibiotics + hemoperfusion 2 hours after irradiation and third group (n = 19) underwent saline infusion 4–5 hours after irradiation plus furosemide, and hemoperfusion 24 hours later. The results are presented in **Table 1**.

The highest survival rate was in the second group—68.4%, while in the control group, it was only 3.2%. Late hemoperfusion also resulted in a high survival rate—62.4%. Only 16% of an animal with hemoperfusion treatment (three dogs in each group) had critical leukopenia. In the control group, it was 93.5% of animals.

It is noteworthy, that mitotic index (a marker of the rate of cells division) (**Figure 1**) was significantly higher in the second group compared to the control one

*Cells of the Immune System*

considered as a potential risk of injuries also.

dose-dense and dose-intense tumoricidal chemotherapy.

Federation and Ukraine, which are contaminated with radionuclides, still experience the consequences of pollution [1–3]. An earthquake and tsunami struck Fukushima Dai-ichi NPP in 2011 contaminated the soil and water with radioactive cesium, iodine, etc. It poses significant risks of exposure to the residents [4, 5]. Terroristic threats or military conflicts with the use of radioactive weapons could be

One more source of contact with myelosuppressive factors is radiation therapy, which is routinely used in oncology (up to 70% of patients with malignant tumors are treated with) as well as anti-cancer chemotherapy with cytostatics [6–8]. Medical use of radiation accounts for 98% of the population dose contribution from all artificial sources and represents approximately 20% of the total exposure. Annually worldwide, more than 3600 million diagnostic radiology examinations are performed, 37 million nuclear medicine procedures are carried out and 7.5 million radiotherapy treatments are given [9]. In spite of side effects, the concomitant use of radiotherapy and chemotherapy resulted in significantly improved clinical outcomes [10–12]. Different radiomimetics have effects similar to ionizing irradiation. Among them, a lot of anti-cancer drugs and leukopenia is a common side effect of

The organs and tissues with high speed cell proliferation is the most sensitive for radiation- and radiomimetic damage. Leukopenia, because of aggressive direct ionizing irradiation or anti-cancer chemotherapy with cytostatics, is an important prognostic factor for overall survival [13, 14]. The association between chemotherapy-induced leukopenia and clinical outcome has been reported for several types of cancer. The development of such health impairments gains more and more attention, especially after the success of modern techniques such as stem cell transplantation and cytokine treatment to restore hematopoietic functions. But

In last decades, we observe combined injury by ionizing radiation and toxic effects of xenobiotic, thermal burns, mechanical trauma, etc. Despite significant achievements in oncology, precise and targeted irradiation of tumors, the development of effective means for enhancement of bone marrow cell and peripheral blood cells proliferation (granulocyte colony stimulating factors (G-CSF), erythropoietin, interleukin-11 and others), the problems of fighting the negative consequences of

In this chapter, the results of early and recent research and prospects for the use of carbon adsorption therapy for the treatment of myelosuppression caused by

Acute radiation syndrome is a definition to reflect severe damage to specific organs that occurs because of whole-body or significant partial-body irradiation greater than 1 Gy, over a short time period (high dose rate) [15]. The main syndromes are hematopoietic (doses >2–3 Gy), gastrointestinal (doses 5–12 Gy) and cerebrovascular one (doses 10–20 Gy) [16]. Depending on exposed and absorbed doses and its duration, cells exposed to ionizing radiation or radiomimetics present DNA mutations, apoptosis, necrosis, chromosomal aberrations or increased mutation frequency [17, 18]. The most profound injury is to lymphoid organs (lymphatic nodes, spleen and thyroid gland), bone marrow, testicles, ovaries, gastrointestinal mucosa.

Parenchymal organs, namely liver, adrenal glands, kidneys, salivary glands and lungs possess quite high radioresistance. According to World Health Organization (WHO), acute radiation sickness (ARS) is composed of the hematopoietic subsyndrome

even now, it is not enough for the treatment of acute radiation sickness.

ionizing radiation and radiomimetics remain very important.

acute radiation sickness and cytostatics use are discussed.

**2. About radiation injuries**

**216**


#### **Table 1.**

*Hemoperfusion for ARS treatment [30].*

#### **Figure 1.**

*Mitotic index (‰) in the bone marrow of the dogs, exposed to external ionizing and hemoperfusion. Notes: \* p ≤ 0.05 compared to the initial level; \*\* p ≤ 0.05 compared to the control group.*

(6 hours after irradiation) and even to the initial level (14th day after exposure to ionizing irradiation) [31].

Hemoperfusion with activated carbon also provided survival of 50% of dogs exposed to ionizing irradiation at the doses of 3.46 and 3.65 Gy [32]. These results were re-tested and developed within a special closed program of Research institutions of the Ministry of Health and the Ministry of Defense of USSR. Hemoperfusion methods were implemented into clinics [33, 34].

A team of researchers who carried out the experiment on dogs by irradiating them at the dose of 5.25 Gy, witnesses that perfusions of the blood through the column with a carbon adsorbent were quite short. Slugging of columns was the main reason for incomplete procedures (only 0.3-0.5 of circulating blood volume was purified) [35]. Despite these factors, the survival rate and other studied parameters were quite successful. We suppose that it could be explained by washout of dust particles from the surface of the adsorbent in the moment of primary contact with the blood, and viscosity changes inside the column after the replacement of rinsing solution to the blood also contributed to it. We think that positive secondary effects could be provided by nano- and microparticles (1–2 μ) of activated carbon, which contact with the blood. Their content is not controlled according to the standards of British (BP) and American (USP) Pharmacopeia.

Today, we have a lot of evidence that positive curative effects of carbon nanoparticles, alone or as a part of a composite, are obliged to their ability to scavenge the ROS and simulate suppose the effects of free oxygen radical scavenging enzymes. Sandhir R. et al. [36] believe that nanoantioxidants (inorganic nanoparticles possessing intrinsic antioxidant properties) would be more effective against

**219**

*Sorption Detoxification as an Addition to Conventional Therapy of Acute Radiation Sickness…*

ROS-induced damage because they cross the blood-brain barrier. It is a potential application in treating and preventing neurodegenerative conditions [36]. Arifa R.D. et al. research demonstrated that nanocomposite with fullerol decreases the intensity of irinotecan-induced leukopenia and gastrointestinal damage in mice and do not diminish the tumoricidal effects of the drug [37]. The aftertreatment with the same nanocomposite ameliorates the graft-versus-host disease reactions in mice and reduces intestinal lesions and bacterial translocation; prevents mortality and morbidity [38]. Nano-fullerenes promote osteogenesis of human adipose-derived

Encouraging results have been found concerning the amelioration of side effects of one more radiomimetic—anthracycline antibiotic doxorubicin (DOX), which also is known by its ability to cause oxidative stress and leukopenia. Fullerenol C60(OH)24 nanoparticles improved the myocardial morphology of DOX-treated animals, but cause a certain degree of parenchymal degeneration by itself [40]. Such and similar cases [41] evidence the need for designing and searching for the nanocomposites with specific features, which will possess antioxidant capacity without notable cytotoxicity. One of the solutions could be the conjugation of carbon nanomaterials with albumin [42]. It was found that C60(OH)24 decreases the consequences of DOX-induced excessive oxidation in the tissues of kidneys, testis and lungs in mice [43]. An aqueous solution of fullerenol was quite effective to fight experimental arthritis in rats [44]. Andrievsky G.V. et al. demonstrated significant (but only by 15%) radioprotective properties of hydrate C60 fullerene in X-ray irradiation of the mice at the lethal dose of 7 Gy [45]. Water-soluble polyvinilpyrroli done-wrapped fullerene derivative showed to significantly inhibit UVA-promoted melanogenesis in normal human epidermis melanocytes and human melanoma HMV-II cells within a non-cytotoxicity dose range [46]. Huq R. et al. showed that nontoxic poly(ethylene glycol)-functionalized hydrophilic carbon clusters, known scavengers of the ROS superoxide and hydroxyl radical, are preferentially internalized by T lymphocytes over other splenic immune cells [47]. It was successfully used to reduce T-lymphocyte-mediated inflammation in experimental autoimmune

*DOI: http://dx.doi.org/10.5772/intechopen.85690*

stem cells and possess a great antioxidant capacity [39].

encephalomyelitis (an animal model of multiple sclerosis) [47].

methicillin-resistant *Staphylococcus aureus* (MRSA) [53].

new method of mass treatment of acute radiation sickness.

Another type of carbon material—carboxylated nanodiamonds, diminish the biochemical and histological signs of damage of γ-irradiated human erythrocytes [48]. On the other hand, hydrogenated nanodiamonds dramatically increase the sensitivity to radiation effects of human radioresistant cancer cell lines [49]. The same effect was seen considering the radiomimetic neocarcinostatin. Single-walled carbon nanotubes were found to be the efficient nanocarriers for drug delivery in the murine model of breast cancer [50, 51]. The team of researchers [52] synthesized the magnetic particles Fe3O4 in the shell from partially graphitized carbon and demonstrated their high intrinsic peroxidase-like catalytic activity, which promotes oxidative stress in human prostate cancer PC-3 cells in the presence of ascorbic acid. One more interesting study with a composite system of reduced graphene oxide—iron oxide nanoparticles showed that such a combination can synergistically induce physical and chemical damage to

We must notice, that carbon nanoparticles possess great antioxidant properties and could be perspective for designing the nanopharmaceutical means and drugs to treat the disorders, when oxidative stress is an intrinsic part of pathogenesis, for leukopenia also. It means that further studies of carbon micro- and nanoparticles effects at parenteral routes of administration could finalize the discovery of quite a

Recently, several detailed reviews have been published on the pharmacological potential and prospects for the therapeutic use of cerium nanoparticles as traps of highly reactive oxygen (ROS) and nitrogen species (RNS) [54–56]. These reviews

#### *Sorption Detoxification as an Addition to Conventional Therapy of Acute Radiation Sickness… DOI: http://dx.doi.org/10.5772/intechopen.85690*

ROS-induced damage because they cross the blood-brain barrier. It is a potential application in treating and preventing neurodegenerative conditions [36]. Arifa R.D. et al. research demonstrated that nanocomposite with fullerol decreases the intensity of irinotecan-induced leukopenia and gastrointestinal damage in mice and do not diminish the tumoricidal effects of the drug [37]. The aftertreatment with the same nanocomposite ameliorates the graft-versus-host disease reactions in mice and reduces intestinal lesions and bacterial translocation; prevents mortality and morbidity [38]. Nano-fullerenes promote osteogenesis of human adipose-derived stem cells and possess a great antioxidant capacity [39].

Encouraging results have been found concerning the amelioration of side effects of one more radiomimetic—anthracycline antibiotic doxorubicin (DOX), which also is known by its ability to cause oxidative stress and leukopenia. Fullerenol C60(OH)24 nanoparticles improved the myocardial morphology of DOX-treated animals, but cause a certain degree of parenchymal degeneration by itself [40]. Such and similar cases [41] evidence the need for designing and searching for the nanocomposites with specific features, which will possess antioxidant capacity without notable cytotoxicity. One of the solutions could be the conjugation of carbon nanomaterials with albumin [42]. It was found that C60(OH)24 decreases the consequences of DOX-induced excessive oxidation in the tissues of kidneys, testis and lungs in mice [43]. An aqueous solution of fullerenol was quite effective to fight experimental arthritis in rats [44]. Andrievsky G.V. et al. demonstrated significant (but only by 15%) radioprotective properties of hydrate C60 fullerene in X-ray irradiation of the mice at the lethal dose of 7 Gy [45]. Water-soluble polyvinilpyrroli done-wrapped fullerene derivative showed to significantly inhibit UVA-promoted melanogenesis in normal human epidermis melanocytes and human melanoma HMV-II cells within a non-cytotoxicity dose range [46]. Huq R. et al. showed that nontoxic poly(ethylene glycol)-functionalized hydrophilic carbon clusters, known scavengers of the ROS superoxide and hydroxyl radical, are preferentially internalized by T lymphocytes over other splenic immune cells [47]. It was successfully used to reduce T-lymphocyte-mediated inflammation in experimental autoimmune encephalomyelitis (an animal model of multiple sclerosis) [47].

Another type of carbon material—carboxylated nanodiamonds, diminish the biochemical and histological signs of damage of γ-irradiated human erythrocytes [48]. On the other hand, hydrogenated nanodiamonds dramatically increase the sensitivity to radiation effects of human radioresistant cancer cell lines [49]. The same effect was seen considering the radiomimetic neocarcinostatin. Single-walled carbon nanotubes were found to be the efficient nanocarriers for drug delivery in the murine model of breast cancer [50, 51]. The team of researchers [52] synthesized the magnetic particles Fe3O4 in the shell from partially graphitized carbon and demonstrated their high intrinsic peroxidase-like catalytic activity, which promotes oxidative stress in human prostate cancer PC-3 cells in the presence of ascorbic acid. One more interesting study with a composite system of reduced graphene oxide—iron oxide nanoparticles showed that such a combination can synergistically induce physical and chemical damage to methicillin-resistant *Staphylococcus aureus* (MRSA) [53].

We must notice, that carbon nanoparticles possess great antioxidant properties and could be perspective for designing the nanopharmaceutical means and drugs to treat the disorders, when oxidative stress is an intrinsic part of pathogenesis, for leukopenia also. It means that further studies of carbon micro- and nanoparticles effects at parenteral routes of administration could finalize the discovery of quite a new method of mass treatment of acute radiation sickness.

Recently, several detailed reviews have been published on the pharmacological potential and prospects for the therapeutic use of cerium nanoparticles as traps of highly reactive oxygen (ROS) and nitrogen species (RNS) [54–56]. These reviews

*Cells of the Immune System*

**Group Survival** 

**rate, %**

*Hemoperfusion for ARS treatment [30].*

ionizing irradiation) [31].

**Figure 1.**

**Table 1.**

British (BP) and American (USP) Pharmacopeia.

(6 hours after irradiation) and even to the initial level (14th day after exposure to

**Animals with critical hematological indices, %**

**Leukopenia <1.0 × 109 /L**

**Thrombocytopenia, <50.0 × 109**

**/L**

A team of researchers who carried out the experiment on dogs by irradiating them at the dose of 5.25 Gy, witnesses that perfusions of the blood through the column with a carbon adsorbent were quite short. Slugging of columns was the main reason for incomplete procedures (only 0.3-0.5 of circulating blood volume was purified) [35]. Despite these factors, the survival rate and other studied parameters were quite successful. We suppose that it could be explained by washout of dust particles from the surface of the adsorbent in the moment of primary contact with the blood, and viscosity changes inside the column after the replacement of rinsing solution to the blood also contributed to it. We think that positive secondary effects could be provided by nano- and microparticles (1–2 μ) of activated carbon, which contact with the blood. Their content is not controlled according to the standards of

Today, we have a lot of evidence that positive curative effects of carbon nanoparticles, alone or as a part of a composite, are obliged to their ability to scavenge the ROS and simulate suppose the effects of free oxygen radical scavenging enzymes. Sandhir R. et al. [36] believe that nanoantioxidants (inorganic nanoparticles possessing intrinsic antioxidant properties) would be more effective against

Hemoperfusion with activated carbon also provided survival of 50% of dogs exposed to ionizing irradiation at the doses of 3.46 and 3.65 Gy [32]. These results were re-tested and developed within a special closed program of Research institutions of the Ministry of Health and the Ministry of Defense of USSR. Hemoperfusion methods were implemented into clinics [33, 34].

*Mitotic index (‰) in the bone marrow of the dogs, exposed to external ionizing and hemoperfusion.* 

*Notes: \* p ≤ 0.05 compared to the initial level; \*\* p ≤ 0.05 compared to the control group.*

**Bone marrow cellularity <1.0 × 109 /L**

1 (n = 31) 3.2 13.4 ± 1.1 93.5 70 2 (n = 19) 68.4 17.0 ± 1.6 16.0 52.6 3 (n = 19) 62.4 16.6 ± 1.9 16.0 38.9

**218**

are based on a variety of experimental studies both *in vitro* and *in vivo*. Not less interesting results for use of nanocrystal cerium dioxide (CeO2) on the model of DOX-induced cardiomyopathy in rats we got [57]. Cardiomyocytes mostly are damaged because of the radiomimetic impact of the drug, and the violation of blood components was quite similar to the effects of ionizing irradiation. It is known that oxidative stress is an intrinsic part of the cytotoxic effects of DOX, and heart tissues are vulnerable because of a lack of intracellular antioxidant defense factors compared to other organs and systems [58].

In this study, we used 21 female white mongrel rats, which were randomly assigned to the next groups (n = 7): first control groups got weekly intraperitoneal (IP) injection of saline; rats of second (DOX) and third groups got three times a week IP injections of doxorubicin at a dose of 2.5 mg/kg (n = 7); rats of third (DOX + CeO2) group got twice weekly IP injections of nanodisperse CeO2 (0.2 mg/kg) next day after doxorubicin injections additionally. Treatments lasted for 2 weeks (**Figure 2**).

Injections of nanodisperse CeO2 caused positive changes in myocardium structure. We observed improvement of a structure, decreased vacuolization of sarcoplasm, a number of cells with nuclei pathology was much lower (**Figure 4**) compared to the second group (**Figure 3**). A part of myocardium cells still had pyknotic nuclei with karyolysis signs. But mostly, the intensity of dystrophy and necrosis reduced and nuclei acquired oval shape again.

**Figure 2.** *Myocardium tissue of rat of the control group. H&E. ×600.*

**221**

**Figure 6.**

**Figure 4.**

**Figure 5.**

*Sorption Detoxification as an Addition to Conventional Therapy of Acute Radiation Sickness…*

Also, we observed an increased number of lymphoid follicles in the spleen,

There were no significant positive changes in the structure of liver parenchyma. We may just note restoring nuclei sizes and shape and a little bit lighter pale pink

which restored a circle-like shape (**Figures 5**–**7**).

*Spleen structure of rat of the DOX group. H&E. ×600.*

*DOI: http://dx.doi.org/10.5772/intechopen.85690*

*Myocardium tissue of rat of the DOX + CeO2 group. H&E. ×600.*

*Spleen structure of rat of the control group. H&E. ×600.*

**Figure 3.** *Myocardium tissue of rat of the DOX group. H&E. ×600.*

*Sorption Detoxification as an Addition to Conventional Therapy of Acute Radiation Sickness… DOI: http://dx.doi.org/10.5772/intechopen.85690*

#### **Figure 4.**

*Cells of the Immune System*

are based on a variety of experimental studies both *in vitro* and *in vivo*. Not less interesting results for use of nanocrystal cerium dioxide (CeO2) on the model of DOX-induced cardiomyopathy in rats we got [57]. Cardiomyocytes mostly are damaged because of the radiomimetic impact of the drug, and the violation of blood components was quite similar to the effects of ionizing irradiation. It is known that oxidative stress is an intrinsic part of the cytotoxic effects of DOX, and heart tissues are vulnerable because of a lack of intracellular antioxidant defense

In this study, we used 21 female white mongrel rats, which were randomly assigned to the next groups (n = 7): first control groups got weekly intraperitoneal (IP) injection of saline; rats of second (DOX) and third groups got three times a week IP injections of doxorubicin at a dose of 2.5 mg/kg (n = 7); rats of third (DOX + CeO2) group got twice weekly IP injections of nanodisperse CeO2 (0.2 mg/kg) next day after

doxorubicin injections additionally. Treatments lasted for 2 weeks (**Figure 2**). Injections of nanodisperse CeO2 caused positive changes in myocardium structure. We observed improvement of a structure, decreased vacuolization of sarcoplasm, a number of cells with nuclei pathology was much lower (**Figure 4**) compared to the second group (**Figure 3**). A part of myocardium cells still had pyknotic nuclei with karyolysis signs. But mostly, the intensity of dystrophy and

factors compared to other organs and systems [58].

necrosis reduced and nuclei acquired oval shape again.

**220**

**Figure 3.**

**Figure 2.**

*Myocardium tissue of rat of the DOX group. H&E. ×600.*

*Myocardium tissue of rat of the control group. H&E. ×600.*

*Myocardium tissue of rat of the DOX + CeO2 group. H&E. ×600.*

**Figure 5.** *Spleen structure of rat of the control group. H&E. ×600.*

#### **Figure 6.** *Spleen structure of rat of the DOX group. H&E. ×600.*

Also, we observed an increased number of lymphoid follicles in the spleen, which restored a circle-like shape (**Figures 5**–**7**).

There were no significant positive changes in the structure of liver parenchyma. We may just note restoring nuclei sizes and shape and a little bit lighter pale pink

**Figure 7.** *Spleen structure of rat of the DOX + CeO2 group. H&E. ×600.*

color of cytoplasm. It witnesses that the synthetic function of the liver was partly restored. Concerning the kidneys, no positive changes had been found.

Biochemical indices of lipid and protein peroxidation, antioxidant defense system showed that CeO2 increased the activity of catalase by 24.6%, raised the level of reduced glutathione by 10.9% and decreased the level of oxidative modification of protein and lipids by 28.1 and 23.6%, respectively (compared to the group with untreated DOX-induced cardiomyopathy).

Bakht M.K. et al. proposed to reduce the actual radiation burden in patients exposed to radioisotope studies by arranging radiolabels for cerium oxide [59], and Colon J. et al. could achieve a good prophylactic result for radiation pneumonitis in mice that received nanocrystalline dioxide Ce [60]. One more fact should be mentioned here: because of bone marrow suppression and leukopenia development, lungs are fragile to injury by ionizing irradiation. They have their own host defense system, based on alveolar macrophages. Because of leukocytes toxic damage (by ionizing injury or radiation therapy or as the side effects of anti-cancer chemotherapy), resting macrophages can no longer be transformed which lead to radiation pneumonitis [24]. Heslet L. et al. showed that systemic administration of myelo stimulative cytokines was not helpful to prevent it because they do not penetrate the alveoli. That is why we suggest that oral adsorbents and/or parenteral use of CeO2 (it penetrated the alveoli and prevents radiation pneumonitis on mice model) will enhance the prophylaxis and treatment of ARS and decrease the intensity of side effects of radiation therapy and cytostatic drugs.
