Running title : In vitro and in vivo safety studies on R 15 22 Abbreviations : 23 UFH : Unfractionated heparin 24 PS : Protamine sulfate 25

through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1002/2211-5463.13240 FEBS Open Bio (2020) © 2020 The Authors. Published by FEBS Press and John Wiley & Sons Ltd. This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. 1 2 PROF. GUIFANG DOU (Orcid ID : 0000-0002-9090-5094) 3 4 5 Received Date : 08-May-2021 6 Revised Date : 03-Jun-2021 7 Accepted Date : 28-Jun-2021 8 Article type : Research Article 9 10 11 In vitro and in vivo safety studies indicate that R15, a synthetic poly-arginine 12 peptide, could safely reverse the effects of unfractionated heparin

[1]  A. Willems,et al.  Anti-Xa versus time-guided anticoagulation strategies in extracorporeal membrane oxygenation: a systematic review and meta-analysis , 2020, Perfusion.

[2]  W. Dager,et al.  Activated Partial Thromboplastin Time Versus Anti-Factor Xa Monitoring of Heparin Anticoagulation in Adult Venoarterial Extracorporeal Membrane Oxygenation Patients. , 2020, ASAIO journal.

[3]  G. Ness,et al.  Andexanet Alfa, the Possible Alternative to Protamine for Reversal of Unfractionated Heparin , 2020, The Annals of pharmacotherapy.

[4]  Leila Moosavi,et al.  Mean Corpuscular Volume (MCV) , 2019 .

[5]  B. Madden,et al.  Cardiac arrest following protamine administration: a case series. , 2019, Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology.

[6]  J. Gris,et al.  Dendrigraft of Poly-l-lysine as a Promising Candidate To Reverse Heparin-based Anticoagulants in Clinical Settings. , 2019, ACS medicinal chemistry letters.

[7]  C. Boer,et al.  Anticoagulant and side‐effects of protamine in cardiac surgery: a narrative review , 2018, British journal of anaesthesia.

[8]  V. Richard,et al.  Inactivated antithombin as anticoagulant reversal in a rat model of cardiopulmonary bypass: a potent and potentially safer alternative to protamine , 2018, British Journal of Haematology.

[9]  C. Haynes,et al.  A Polymer Therapeutic Having Universal Heparin Reversal Activity: Molecular Design and Functional Mechanism. , 2017, Biomacromolecules.

[10]  W. Banya,et al.  Should we abandon the APTT for monitoring unfractionated heparin? , 2017, Thrombosis research.

[11]  K. Shiraki,et al.  Aggregative protein-polyelectrolyte complex for high-concentration formulation of protein drugs. , 2017, International journal of biological macromolecules.

[12]  E. Ollier,et al.  Pharmacokinetic/pharmacodynamic model for unfractionated heparin dosing during cardiopulmonary bypass , 2017, British journal of anaesthesia.

[13]  Richard Hoogenboom,et al.  Cytotoxicity of polycations: Relationship of molecular weight and the hydrolytic theory of the mechanism of toxicity. , 2017, International journal of pharmaceutics.

[14]  C. Haynes,et al.  Alteration of blood clotting and lung damage by protamine are avoided using the heparin and polyphosphate inhibitor UHRA. , 2017, Blood.

[15]  A. Greinacher,et al.  Platelet activation in the presence of neutral protamine Hagedorn insulin: a new feature of antibodies against protamine/heparin complexes , 2017, Journal of thrombosis and haemostasis : JTH.

[16]  Jae Hyun Kim,et al.  Catastrophic Bronchial Spasm Due to a Severe Anaphylactic Reaction to Protamine , 2016, The Korean journal of thoracic and cardiovascular surgery.

[17]  B. Kalaska,et al.  The toxicology of heparin reversal with protamine: past, present and future , 2016, Expert opinion on drug metabolism & toxicology.

[18]  Deepak Tiwari,et al.  Life-threatening protamine allergic reaction in a patient with extra-adrenal pheochromocytoma undergoing off-pump coronary artery bypass grafting , 2016, Annals of cardiac anaesthesia.

[19]  I. Kasacka,et al.  The Toxicokinetic Profile of Dex40-GTMAC3—a Novel Polysaccharide Candidate for Reversal of Unfractionated Heparin , 2016, Front. Pharmacol..

[20]  V. Iyer,et al.  Fatal right ventricular failure and pulmonary hypertension after protamine administration during cardiac transplantation , 2016, Indian journal of critical care medicine : peer-reviewed, official publication of Indian Society of Critical Care Medicine.

[21]  O. Cohen,et al.  Antibodies against heparin-protamine complexes: Effect and clinical relevance. , 2015, The Journal of thoracic and cardiovascular surgery.

[22]  N. Uriel,et al.  Anti-factor Xa and activated partial thromboplastin time measurements for heparin monitoring in mechanical circulatory support. , 2015, JACC. Heart failure.

[23]  R. Bu,et al.  Protamine-containing insulin allergy and renal dysfunction in a patient with type 2 diabetes , 2015, Journal of diabetes investigation.

[24]  B. Steinlechner,et al.  Serological features of antibodies to protamine inducing thrombocytopenia and thrombosis , 2015, Clinical chemistry and laboratory medicine.

[25]  C. Haynes,et al.  Affinity-based design of a synthetic universal reversal agent for heparin anticoagulants , 2014, Science Translational Medicine.

[26]  T. Ortel,et al.  High incidence of antibodies to protamine and protamine/heparin complexes in patients undergoing cardiopulmonary bypass. , 2012, Blood.

[27]  Robert B. Harris,et al.  Reversal of heparin-induced increases in aPTT in the rat by PM102, a novel heparin antagonist. , 2010, European journal of pharmacology.

[28]  M. Vert,et al.  Biocompatibility of Polycations: In Vitro Agglutination and Lysis of Red Blood Cells And In Vivo Toxicity , 2002, Journal of drug targeting.

[29]  A. Chu,et al.  Protamine inhibits tissue factor‐initiated extrinsic coagulation , 2001, British journal of haematology.

[30]  S. Yao,et al.  [Effect of complement 4 genetic polymorphism on complement activation during cardiopulmonary bypass in open heart surgery among children]. , 2001, Zhonghua yi xue za zhi.

[31]  C. Hack,et al.  Heparin-protamine Complexes and C-reactive Protein Induce Activation of the Classical Complement Pathway: Studies in Patients Undergoing Cardiac Surgery and In Vitro , 2000, Thrombosis and Haemostasis.

[32]  A. A. Rakhnyanskaya,et al.  MODULATION OF INTERACTION OF POLYCATIONS WITH NEGATIVE UNILAMELLAR LIPID VESICLES , 1999 .

[33]  J. Ramsay,et al.  Protamine Reversal of Heparin Affects Platelet Aggregation and Activated Clotting Time After Cardiopulmonary Bypass , 1998, Anesthesia and analgesia.

[34]  A. Wunder,et al.  Complexes of a modified low-molecular-weight heparin with protamine are predominantly cleared by a macrophage scavenger receptor-mediated process in rats. , 1995, The Journal of surgical research.

[35]  J. Stoltz,et al.  Rheologic Effects of Plasma Substitutes Used for Preoperative Hemodilution , 1994, Anesthesia and analgesia.

[36]  P. Andrews,et al.  Efficacy and toxicity of differently charged polycationic protamine-like peptides for heparin anticoagulation reversal. , 1993, Journal of vascular surgery.

[37]  T. Wakefield,et al.  Tissue distribution, circulating half-life, and excretion of intravenously administered protamine sulfate. , 1993, ASAIO journal.

[38]  J. Horrow.  Protamine: A Review of its Toxicity , 1985, Anesthesia and analgesia.

[39]  S. Adler,et al.  Electrical charge. Its role in the pathogenesis and prevention of experimental membranous nephropathy in the rabbit. , 1983, The Journal of clinical investigation.

[40]  A M Robson,et al.  Glomerular charge and urinary protein excretion: effects of systemic and intrarenal polycation infusion in the rat. , 1982, Kidney international.

[41]  V. Singh,et al.  Detection of circulating immune complexes by a C1q-microplate ELISA system. , 1982, Journal of immunological methods.

[42]  R. Sheridan,et al.  A Study on the Erythrocyte Aggregating Properties of Polybrene and Protamine Sulphate , 1978, Transfusion.

[43]  K. Al‐Jamal,et al.  Anti-angiogenic poly-L-lysine dendrimer binds heparin and neutralizes its activity. , 2012, Results in pharma sciences.

[44]  P. Loubser.  Effect of methylprednisolone on complement activation during heparin neutralization. , 1997, Journal of cardiovascular pharmacology.

[45]  K. Suzuki,et al.  Protamines , 1973, Molecular Biology Biochemistry and Biophysics.

[46]  A. Klos,et al.  Biological Crystallography Structural and Functional Characterization of Human and Murine C5a Anaphylatoxins , 2022 .