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Ulinastatin is a glycoprotein that is isolated from healthy human urine or synthetically produced. It is discovered for the first time from clinical study in Japan that urine from patients or healthy subjects exhibits weak inhibition to trypsin. Due to its ability to inhibit most trypsin, ulinastatin is also referred to as urinary trypsin inhibitor (UTI). It also has other names, including urinastatin and mingin. To prevent confusion among researchers, several researchers proposed a new name-bikunin in1990 in the literature.

Physiological Property
The AMBP gene is in charge of ulinastatin translation. Its cDNA sequence contains a precursor protein which has ulinastatin covalently attached to α1-microglobulin. Ulinastatin is generated in the endoplasmic reticulum of hepetocytes as complexed form. Under multiple pathological conditions, including rheumatoid arthritis, preeclampsia and surgical trauma, level of ulinastatin might increase in urine. In this sense, it is regarded as candidate biomarker for diagnosis of inflammation and sepsis. Up to 2014, there might be no clinical evaluation in western countries to confirm its role as biomarker for diagnosis. Quantitation of mRNA shows liver might be the only place where ulinastatin expressed. It might also be expressed in kidney and organs in digestive system by RT-PCR. Ulinastatin protein has been found in the brain, liver, kidney, gastrointestinal tract, cartilage, plasma, ovarian follicular fluid, amniotic fluid, and urine. In 1991, scientist in Sweden labeled purified ulinastatin with 125I and Intravenously injected it into male volunteers. In this pharmacokinetic studies, its half-life in plasma is 3-40 min over 3h and kidney might be major site for metabolism. Later research on this indicates ulinastatin pass through kidney by glomerular filtration. Like other proteins, only small amount would be reabsorbed in the tubuli. Mechanism of filtration in kidney is its ability to elongate and orient in a way parallel with liquid flow. .

Structural Property
UTI belongs to member of Inter-alpha-trypsin inhibitors (IαI). Even mixed with moderate concentration of strong acids, it remains active and inhibitory on trypsin. Therefore it is also named as acid stable trypsin inhibitor (ASTI). UTI consists of 143 amino acid residues containing two Kunitz domains of 10-25 amino acids at C-terminus (kI domains) and N-terminus (kII domains), which are very important binding site for proteinase enzymes or cell surface receptors. A group of amino acids close to kI domains form hydrophobic patch which is very important for cell surface binding. This domain is well preserved in the evolution that there is similarity among mammals, such as human and plaices. Structural analysis indicates short peptides connect these two domains and two terminal also extends with other components. Especially for N terminus, it is extended by chondroitin sulfate chain susceptible to proteolytic cleavage. Molecular mass of ulinastatin is 25-26kDa. However different conformations of chondroitin sulfate chain increase apparent molecular mass in gel filtration and SDS-PAGE. It is reported that inhibitory effects are partially lost when Met36 at N terminus or Arg92 at C terminus are modified and blocking both amino acids cause complete loss of inhibitory activity.

Mechanism of action (Edit on Original Page)
Ulinastatin is an acid-resistant protease inhibitor found in human urine and released from the high-molecular-weight precursor I alpha T1. It is a broad-spectrum protease inhibitor that inactivates many serine proteases, including trypsin, chymotrypsin, kallikrein, plasmin, granulocyte elastase, cathepsin, thrombin, and factors IXa, Xa, XIa, and XlIa. However, its affinity toward proteolytic enzyme is relatively weak. On cell surface, ulinastatin might bind to two types proteins: one is hyaluronan-binding proteins and another is unknown bikunin-binding protein. Ulinastatin also potentiates local anti-proteolytic activity on the extracellular matrix (ECM) during tissue remodeling, possibly through noncovalent binding to Link module of TSG-6. While binding motif remains unknown, Link module is presented during inflammation process.

Ulinastatin is an endogenous anti-inflammatory substance. Its secretion is upregulated by pro-inflammatory cytokines, including IL-6, IL-1beta, and TNF-alpha. These cytokines also enhance the synthesis of intracellular I alpha T1 proteins and IL-1beta upregulated ulinastatin. In turn, ulinastatin might be downregulating or suppressing the production of these pro-inflammatory cytokines. However, the mechanism of this downregulation process is still under investigation. Ulinastatin also suppresses neutrophil accumulation and activity. The genes and proteins regulated by ulinastatin are implicated in the inflammatory process. There are several models to explain how it works. Ulinastatin might directly interact with lipopolysaccharides (LPS), impair LPS-induced cytokine synthesis or decrease calcium influx. It might also deactivate LPS receptor and suppressing TLR4-dependent pro-inflammation. Not only cytokines, ulinastatin can also inhibit intercellular adhesion molecule, inducible nitric oxide synthase and tissue factor which participated in different pathological process in inflammation. Therefore, ulinastatin is not just a protease inhibitor. It can also prevent inflammation and protect organ injury from serious damage. In preclinical and clinical studies, ulinastatin protected against acute lung injury, graft ischemia/reperfusion injury, renal failure after cardiopulmonary bypass, severe burn injury, septic shock.

Ulinatsatin could also prevent tumor invasion and metastasis. Its anti-metastatic properties may come from the inhibition of cell-bound plasmin activity. Ulinastatin also prevents tumor progression, partially by inhibiting cathepsin B activity. In particular, ulinastatin is thought to inhibit CD44 dimerization and suppress the MAP kinase signaling cascade, thus preventing ECM degradation, tumor cell invasion, and angiogenesis. Altogether, ulinastatin plays an important role not only in the protection of organ injury during severe inflammation, but also in the inhibition of tumor invasion and metastasis.

Effectiveness (Edit on Original Page)
Like IαI Highly purified ulinastatin has been clinically used for the treatment of acute pancreatitis, chronic pancreatitis, Stevens–Johnson syndrome, burns, septic shock, and toxic epidermal necrolysis (TEN). The drug is used in Japan, where its brand name is Miraclid, as well as in South Korea, China, and India. In India, where it is approved to treat severe sepsis and acute pancreatitis, it is marketed by Bharat Serums and Vaccines Ltd. under the brand name Ulinase and U-Tryp.

Even some studies on ulinastatin have poor quality, its clinical use shows association with decrease in mortality, improved oxygenation and hospital stay. In Japan, It is clinically used to treat endoscopic retrograde cholangiopancreatography (ERCP). Studies in Japan have documented a reduction in the incidence of ERCP-induced pancreatitis with the use of ulinastatin. In one study, the incidence of hyperenzymemia and pancreatitis was significantly lower in the ulinastatin group than in the placebo group. In another study, ulinastatin reduced serum, drain amylase, and the incidence of postoperative pancreatitis following pancreaticoduodenectomy.

A study conducted in India found that mortality from all causes over 22 days in subjects with severe pancreatitis was lower among those receiving ulinastatin than those receiving placebo (2.8% versus 18.8%; p=0.048), resulting in a 16% absolute reduction in the risk of death and a relative reduction of 85%. The results indicated that in this population, one life would be saved for every 6.25 subjects treated with ulinastatin. New organ dysfunction was seen in 12 subjects with severe pancreatitis on ulinastatin and 29 on placebo (p=0.0026).

Another clinical condition where ulinastatin would be used is systemic inflammatory response syndrome (SIRS), such as burns, acute respiratory distress syndrome (ARDS), and sepsis. In a recent randomized-controlled trail with small-size sample size (114 subjects), ulinastatin group shown association with significant reduction in mortality compared to those treated with placebo (7.3 versus 20.3%) for patients with severe sepsis. This arouses interest of clinical application of ulinastatin as single treatment for sepsis. Not limited to that, unilastatin combined with thymosin-α1 has been evaluated as therapy for sepsis. It is hard to explain the efficacy of unilastatin as single treatment from those studies. However, subjects treated with combinatorial therapy displayed significant drop in inflammatory markers and decreased mortality over 28 days in contrast to placebo.

Dosage and administration
Patients are typically given one or two 100,000 I.U. vials of ulinastatin (reconstituted in 100 ml of dextrose 5% or 100 ml of 0.9% normal saline) by intravenous infusion over the course of one hour, one to three times per day for three to five days. The dosage may be adjusted according to patients' age and the severity of symptoms.