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Gonul Y, Kazandı S, Kocak A, Ahsen A, Bal A, Karavelioglu A, Hazman O, Turamanlar O, Kokulu S, Yuksel S. Interleukin-18 Binding Protein Pretreatment Attenuates Kidney Injury Induced by Hepatic Ischemia Reperfusion. Am J Med Sci 2016; 352:200-7. [DOI: 10.1016/j.amjms.2016.04.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 03/16/2016] [Accepted: 04/15/2016] [Indexed: 12/13/2022]
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Wiesen P, Massion PB, Joris J, Detry O, Damas P. Incidence and risk factors for early renal dysfunction after liver transplantation. World J Transplant 2016; 6:220-232. [PMID: 27011921 PMCID: PMC4801799 DOI: 10.5500/wjt.v6.i1.220] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Revised: 10/20/2015] [Accepted: 12/18/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To determine renal dysfunction post liver transplantation, its incidence and risk factors in patients from a Belgian University Hospital.
METHODS: Orthotopic liver transplantations performed from January 2006 until September 2012 were retrospectively reviewed (n = 187). Patients with no renal replacement therapy (RRT) before transplantation were classified into four groups according to their highest creatinine plasma level during the first postoperative week. The first group had a peak creatinine level below 12 mg/L, the second group between 12 and 20 mg/L, the third group between 20 and 35 mg/L, and the fourth above 35 mg/L. In addition, patients who needed RRT during the first week after transplantation were also classified into the fourth group. Perioperative parameters were recorded as risk factors, namely age, sex, body mass index (BMI), length of preoperative hospital stay, prior bacterial infection within one month, preoperative ascites, preoperative treatment with β-blocker, angiotensin-converting enzyme inhibitor or non steroidal anti-inflammatory drugs, preoperative creatinine and bilirubin levels, donor status (cardiac death or brain death), postoperative lactate level, need for intraoperative vasopressive drugs, surgical revision, mechanical ventilation for more than 24 h, postoperative bilirubin and transaminase peak levels, postoperative hemoglobin level, amount of perioperative blood transfusions and type of immunosuppression. Univariate and multivariate analysis were performed using logistic ordinal regression method. Post hoc analysis of the hemostatic agent used was also done.
RESULTS: There were 78 patients in group 1 (41.7%), 46 in group 2 (24.6%), 38 in group 3 (20.3%) and 25 in group 4 (13.4%). Twenty patients required RRT: 13 (7%) during the first week after transplantation. Using univariate analysis, the severity of renal dysfunction was correlated with presence of ascites and prior bacterial infection, preoperative bilirubin, urea and creatinine level, need for surgical revision, use of vasopressor, postoperative mechanical ventilation, postoperative bilirubin and urea, aspartate aminotransferase (ASAT), and hemoglobin levels and the need for transfusion. The multivariate analysis showed that BMI (OR = 1.1, P = 0.004), preoperative creatinine level (OR = 11.1, P < 0.0001), use of vasopressor (OR = 3.31, P = 0.0002), maximal postoperative bilirubin level (OR = 1.44, P = 0.044) and minimal postoperative hemoglobin level (OR = 0.059, P = 0.0005) were independent predictors of early post-liver transplantation renal dysfunction. Neither donor status nor ASAT levels had significant impact on early postoperative renal dysfunction in multivariate analysis. Absence of renal dysfunction (group 1) was also predicted by the intraoperative hemostatic agent used, independently of the extent of bleeding and of the preoperative creatinine level.
CONCLUSION: More than half of receivers experienced some degree of early renal dysfunction after liver transplantation. Main predictors were preoperative renal dysfunction, postoperative anemia and vasopressor requirement.
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Doi K, Rabb H. Impact of acute kidney injury on distant organ function: recent findings and potential therapeutic targets. Kidney Int 2016; 89:555-64. [PMID: 26880452 DOI: 10.1016/j.kint.2015.11.019] [Citation(s) in RCA: 114] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 11/03/2015] [Accepted: 11/18/2015] [Indexed: 12/18/2022]
Abstract
Acute kidney injury (AKI) is a common complication in critically ill patients and subsequently worsens outcomes. Although many drugs to prevent and treat AKI have shown benefits in preclinical models, no specific agent has been shown to benefit AKI in humans. Moreover, despite remarkable advances in dialysis techniques that enable management of AKI in hemodynamically unstable patients with shock, dialysis-requiring severe AKI is still associated with an unacceptably high mortality rate. Thus, focusing only on kidney damage and loss of renal function has not been sufficient to improve outcomes of patients with AKI. Recent data from basic and clinical research have begun to elucidate complex organ interactions in AKI between kidney and distant organs, including heart, lung, spleen, brain, liver, and gut. This review serves to update the topic of organ cross talk in AKI and focuses on potential therapeutic targets to improve patient outcomes during AKI-associated multiple organ failure.
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Affiliation(s)
- Kent Doi
- Department of Emergency and Critical Care Medicine, The University of Tokyo, Tokyo, Japan.
| | - Hamid Rabb
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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Yao HC, Zhou M, Zhou YH, Wang LH, Zhang DY, Han QF, Liu T, Wu L, Tian KL, Zhang M. Intravenous high mobility group box 1 upregulates the expression of HIF-1α in the myocardium via a protein kinase B-dependent pathway in rats following acute myocardial ischemia. Mol Med Rep 2015; 13:1211-9. [PMID: 26648172 PMCID: PMC4732844 DOI: 10.3892/mmr.2015.4648] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2015] [Accepted: 11/10/2015] [Indexed: 12/23/2022] Open
Abstract
The effects of intravenous high mobility group box 1 (HMGB1) on myocardial ischemia/reperfusion (I/R) injury remains to be elucidated. The purpose of the present study was to investigate the effects of intravenous HMGB1 on the expression of hypoxia inducible factor-1α (HIF-1α) in the myocardium of rats following acute myocardial ischemia, and to examine the effects of intravenous HMGB1 on myocardial I/R injury. Male Wistar rats were divided into the following groups: Sham operation group (n=10), a group exposed to ischemia for 30 min and reperfusion for 4 h (I/R group) as a control (n=10), an HMGB group, in which 100 ng/kg HMGB was administered intravenously 30 min prior to ischemia (n=10), an LY group, in whic LY294002, an inhibitor of phosphoinositide 3-kinase (PI3K), was administered intravenously (0.3 mg/kg) 40 min prior to ischemia (n=10), and the HMGB1+LY group, in which HMGB1 (100 ng/kg) and LY294002 (0.3 mg/kg) were administered intravenously 30 min and 40 min prior to ischemia, respectively (n=10). The serum levels of cardiac troponin I (cTnI) and tumor necrosis factor-α (TNF-α), and myocardial infarct size were measured. The expression levels of phosphorylated Akt and HIF-1α were investigated using western blot analyses. The results showed that pre-treatment with HMGB1 significantly decreased serum levels of cTnI, and TNF-α, and reduced myocardial infarct size following 4 h reperfusion (all P<0.05). HMGB1 also increased the expression levels of HIF-1α and p-Akt induced by I/R (P<0.05). LY294002 was found to eliminate the effects of intravenous HMGB1 on myocardial I/R injury (P<0.05). These results suggest that intravenous pre-treatment with HMGB1 may exert its cardioprotective effects via the upregulation of the myocardial expression of HIF-1α, which may be regulated by the PI3K/Akt signaling pathway, in rats following acute myocardial I/R.
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Affiliation(s)
- Heng-Chen Yao
- Department of Cardiology, Qilu Hospital of Shandong University School of Medicine, Jinan, Shandong 250012, P.R. China
| | - Min Zhou
- Department of Cardiology, Liaocheng People's Hospital and Clinical School of Taishan Medical University, Liaocheng, Shandong 252000, P.R. China
| | - Yan-Hong Zhou
- Department of Cardiology, Liaocheng People's Hospital and Clinical School of Taishan Medical University, Liaocheng, Shandong 252000, P.R. China
| | - Lan-Hua Wang
- Department of Cardiology, Liaocheng People's Hospital and Clinical School of Taishan Medical University, Liaocheng, Shandong 252000, P.R. China
| | - De-Yong Zhang
- Department of Cardiology, Liaocheng People's Hospital and Clinical School of Taishan Medical University, Liaocheng, Shandong 252000, P.R. China
| | - Qian-Feng Han
- Department of Cardiology, Liaocheng People's Hospital and Clinical School of Taishan Medical University, Liaocheng, Shandong 252000, P.R. China
| | - Tao Liu
- Department of Cardiology, Liaocheng People's Hospital and Clinical School of Taishan Medical University, Liaocheng, Shandong 252000, P.R. China
| | - Lei Wu
- Department of Cardiology, Liaocheng People's Hospital and Clinical School of Taishan Medical University, Liaocheng, Shandong 252000, P.R. China
| | - Ke-Li Tian
- Department of Biochemistry and Molecular Biology, Shandong University School of Medicine, Jinan, Shandong 250012, P.R. China
| | - Mei Zhang
- Department of Cardiology, Qilu Hospital of Shandong University School of Medicine, Jinan, Shandong 250012, P.R. China
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Oxidative Stress and Lung Ischemia-Reperfusion Injury. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2015; 2015:590987. [PMID: 26161240 PMCID: PMC4487720 DOI: 10.1155/2015/590987] [Citation(s) in RCA: 177] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/19/2014] [Revised: 01/19/2015] [Accepted: 01/20/2015] [Indexed: 01/04/2023]
Abstract
Ischemia-reperfusion (IR) injury is directly related to the formation of reactive oxygen species (ROS), endothelial cell injury, increased vascular permeability, and the activation of neutrophils and platelets, cytokines, and the complement system. Several studies have confirmed the destructiveness of the toxic oxygen metabolites produced and their role in the pathophysiology of different processes, such as oxygen poisoning, inflammation, and ischemic injury. Due to the different degrees of tissue damage resulting from the process of ischemia and subsequent reperfusion, several studies in animal models have focused on the prevention of IR injury and methods of lung protection. Lung IR injury has clinical relevance in the setting of lung transplantation and cardiopulmonary bypass, for which the consequences of IR injury may be devastating in critically ill patients.
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Abstract
PURPOSE OF REVIEW Renal dysfunction causes significant morbidity in cirrhotic patients. Diagnosis is challenging because it is based on serum creatinine, which is used to calculate estimated glomerular filtration rate, which itself is not an ideal measure of renal function in patients with cirrhosis. Finding the exact cause of renal injury in patients with cirrhosis remains problematic due to the limitations of the current diagnostic tests. The purpose of this review is to highlight studies used to diagnose renal dysfunction in patients with renal dysfunction and review current treatments. RECENT FINDINGS New diagnostic criteria and classification of renal dysfunction, especially for acute kidney injury (AKI), have been proposed in hopes of optimizing treatment and improving outcomes. New biomarkers that help to differentiate structural from functional AKI in cirrhotic patients have been developed, but require further investigation. Vasoconstrictors are the most commonly recommended treatment of hepatorenal syndrome (HRS). Given the high mortality in patients with type 1 HRS, all patients with HRS should be evaluated for liver transplantation. When renal dysfunction is considered irreversible, combined liver-kidney transplantation is advised. SUMMARY Development of new biomarkers to differentiate the different types of AKI in cirrhosis holds promise. Early intervention in cirrhotic patients with renal dysfunction offers the best hope of improving outcomes.
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Affiliation(s)
- Nathalie H. Urrunaga
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Ayse L. Mindikoglu
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Don C. Rockey
- Department of Internal Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
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Farag E, Maheshwari K, Morgan J, Sakr Esa WA, Doyle DJ. An update of the role of renin angiotensin in cardiovascular homeostasis. Anesth Analg 2015; 120:275-92. [PMID: 25602448 DOI: 10.1213/ane.0000000000000528] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The renin angiotensin system (RAS) is thought to be the body's main vasoconstrictor system, with physiological effects mediated via the interaction of angiotensin II with angiotensin I receptors (the "classic" RAS model). However, since the discovery of the heptapeptide angiotensin 1-7 and the development of the concept of the "alternate" RAS system, with its ability to reduce arterial blood pressure, our understanding of this physiologic system has changed dramatically. In this review, we focus on the newly discovered functions of the RAS, particularly the potential clinical significance of these developments, especially in the realm of new pharmacologic interventions for treating cardiovascular disease.
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Affiliation(s)
- Ehab Farag
- From the Departments of *General Anesthesia and †Outcomes Research, Cleveland Clinic, Cleveland, Ohio; ‡Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio; and §Cleveland Clinic Lerner College of Medicine of Case Western Reserve University/Department of General Anesthesia, Cleveland Clinic, Cleveland, Ohio
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Harnoss JM, Strowitzki MJ, Radhakrishnan P, Platzer LK, Harnoss JC, Hank T, Cai J, Ulrich A, Schneider M. Therapeutic inhibition of prolyl hydroxylase domain-containing enzymes in surgery: putative applications and challenges. HYPOXIA 2015; 3:1-14. [PMID: 27774478 PMCID: PMC5045068 DOI: 10.2147/hp.s60872] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Oxygen is essential for metazoans to generate energy. Upon oxygen deprivation adaptive and protective pathways are induced, mediated by hypoxia-inducible factors (HIFs) and prolyl hydroxylase domain-containing enzymes (PHDs). Both play a pivotal role in various conditions associated with prolonged ischemia and inflammation, and are promising targets for therapeutic intervention. This review focuses on aspects of therapeutic PHD modulation in surgically relevant disease conditions such as hepatic and intestinal disorders, wound healing, innate immune responses, and tumorigenesis, and discusses the therapeutic potential and challenges of PHD inhibition in surgical patients.
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Affiliation(s)
- Jonathan Michael Harnoss
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Moritz Johannes Strowitzki
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Praveen Radhakrishnan
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Lisa Katharina Platzer
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Julian Camill Harnoss
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Thomas Hank
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Jun Cai
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Alexis Ulrich
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Martin Schneider
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
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Lei Q, Qiang F, Chao D, Di W, Guoqian Z, Bo Y, Lina Y. Amelioration of hypoxia and LPS-induced intestinal epithelial barrier dysfunction by emodin through the suppression of the NF-κB and HIF-1α signaling pathways. Int J Mol Med 2014; 34:1629-39. [PMID: 25318952 DOI: 10.3892/ijmm.2014.1965] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2014] [Accepted: 09/25/2014] [Indexed: 12/22/2022] Open
Abstract
Intestinal barrier dysfunction occurs in critical illnesses and involves the inflammatory and hypoxic injury of intestinal epithelial cells. Researchers are still defining the underlying mechanisms and evaluating therapeutic strategies for restoring intestinal barrier function. The anti-inflammatory drug, emodin, has been shown to exert a protective effect on intestinal barrier function; however, its mechanisms of action remain unknown. In this study, we investigated the protective effects of emodin on intestinal barrier function and the underlying mechanisms in intestinal epithelial cells challenged with lipopolysaccharide (LPS) and hypoxia/reoxygenation (HR). To induce barrier dysfunction, Caco-2 monolayers were subjected to HR with or without LPS treatment. Transepithelial electrical resistance and paracellular permeability were measured to evaluate barrier function. The expression of the tight junction (TJ) proteins, zonula occludens (ZO)-1, occludin, and claudin-1, as well as that of hypoxia-inducible factor (HIF)-1α, phosphor-IκB-α, phosphor-nuclear factor (NF)-κB p65 and cyclooxygenase (COX)-2 was determined by western blot analysis. The results revealed that emodin markedly attenuated the decrease in transepithelial electrical resistance and the increase in paracellular permeability in the Caco-2 monolayers treated with LPS and subjected to HR. Emodin also markedly alleviated the damage caused by LPS and HR (manifested by a decrease in the expression of the TJ protein, ZO-1), and inhibited the expression of HIF-1α, IκB-α, NF-κB and COX-2 in a dose-dependent manner. In conclusion, our data suggest that emodin attenuates LPS- and HR-induced intestinal epithelial barrier dysfunction by inhibiting the HIF-1α and NF-κB signaling pathways and preventing the damage caused to the TJ barrier (shown by the decrease in the expression of ZO-1).
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Affiliation(s)
- Qi Lei
- Department of ICU, Tianjin Huanhu Hospital, Tianjin, P.R. China
| | - Fu Qiang
- Department of ICU, Tianjin 4th Central Hospital, Tianjin, P.R. China
| | - Du Chao
- Department of ICU, Tianjin Medical University, Nankai Hospital, Tianjin, P.R. China
| | - Wu Di
- Department of ICU, Tianjin Huanhu Hospital, Tianjin, P.R. China
| | - Zhang Guoqian
- Clinical Laboratory, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, P.R. China
| | - Yuan Bo
- Graduate College, Tianjin Medical University, Tianjin, P.R. China
| | - Yan Lina
- Graduate College, Tianjin Medical University, Tianjin, P.R. China
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Adebayo D, Morabito V, Davenport A, Jalan R. Renal dysfunction in cirrhosis is not just a vasomotor nephropathy. Kidney Int 2014; 87:509-15. [PMID: 25296092 PMCID: PMC4346614 DOI: 10.1038/ki.2014.338] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Revised: 04/17/2014] [Accepted: 04/17/2014] [Indexed: 12/13/2022]
Abstract
The short-term mortality of cirrhotic patients who develop renal dysfunction remains unacceptably high, and as such the treatment of this condition is an unmet need. Although features of kidney injury are well recognized in these patients, the pathophysiology is complex and not completely understood. Improved understanding of the pathophysiological mechanisms involved in renal dysfunction occurring on a background of cirrhosis is key to developing effective treatment strategies to improve survival. Renal dysfunction due to hepatorenal syndrome (HRS) is characteristic of cirrhosis. Our current understanding is that HRS is functional in nature and occurs as a consequence of hemodynamic changes associated with portal hypertension. However, there is evidence in the literature suggesting that, histologically, the kidneys are not always normal in the vast majority of patients who present with renal dysfunction on the background of cirrhosis. Furthermore, there is emerging data implicating nonvasomotor mechanisms in the pathophysiology of renal dysfunction in cirrhosis. This mini-review aims to present the evidence suggesting that factors other than hemodynamic dysregulation have an important role in the development of this major complication for patients with progressive cirrhosis.
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Affiliation(s)
- Danielle Adebayo
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free Hospital, London, UK
| | - Vincenzo Morabito
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free Hospital, London, UK
| | - Andrew Davenport
- UCL Centre for Nephrology, Royal Free London NHS Foundation Trust, London, UK
| | - Rajiv Jalan
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free Hospital, London, UK
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Leithead JA, Armstrong MJ, Corbett C, Andrew M, Kothari C, Gunson BK, Mirza D, Muiesan P, Ferguson JW. Split liver transplant recipients do not have an increased frequency of acute kidney injury. Transpl Int 2014; 27:1125-34. [DOI: 10.1111/tri.12376] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2014] [Revised: 03/28/2014] [Accepted: 06/17/2014] [Indexed: 12/14/2022]
Affiliation(s)
- Joanna A. Leithead
- Liver Unit; Queen Elizabeth Hospital; Birmingham UK
- NIHR Biomedical Research Unit and Centre for Liver Research; University of Birmingham; Birmingham UK
| | - Matthew J. Armstrong
- NIHR Biomedical Research Unit and Centre for Liver Research; University of Birmingham; Birmingham UK
| | - Christopher Corbett
- NIHR Biomedical Research Unit and Centre for Liver Research; University of Birmingham; Birmingham UK
| | - Mark Andrew
- Liver Unit; Queen Elizabeth Hospital; Birmingham UK
| | | | - Bridget K. Gunson
- Liver Unit; Queen Elizabeth Hospital; Birmingham UK
- NIHR Biomedical Research Unit and Centre for Liver Research; University of Birmingham; Birmingham UK
| | - Darius Mirza
- Liver Unit; Queen Elizabeth Hospital; Birmingham UK
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Day YJ, Liou JT, Lee CM, Lin YC, Mao CC, Chou AH, Liao CC, Lee HC. Lack of interleukin-17 leads to a modulated micro-environment and amelioration of mechanical hypersensitivity after peripheral nerve injury in mice. Pain 2014; 155:1293-1302. [DOI: 10.1016/j.pain.2014.04.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Revised: 03/17/2014] [Accepted: 04/03/2014] [Indexed: 01/06/2023]
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Zarbock A, Eroglu A, Erturk E, Ince C, Westphal M. Ischemia-reperfusion injury and anesthesia. BIOMED RESEARCH INTERNATIONAL 2014; 2014:980318. [PMID: 25050382 PMCID: PMC4090471 DOI: 10.1155/2014/980318] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Accepted: 05/18/2014] [Indexed: 02/07/2023]
Affiliation(s)
- Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, Münster University Hospital, Albert-Schweitzer-Campus 1, Building A1, 48149 Münster, Germany
| | - Ahmet Eroglu
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, Karadeniz Technical University, 61000 Trabzon, Turkey
| | - Engin Erturk
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, Karadeniz Technical University, 61000 Trabzon, Turkey
| | - Can Ince
- Department of Intensive Care Adults, Erasmus University Medical Center, 3000 CA Rotterdam, The Netherlands
| | - Martin Westphal
- Department of Anesthesiology, Intensive Care and Pain Medicine, Münster University Hospital, Albert-Schweitzer-Campus 1, Building A1, 48149 Münster, Germany
- Fresenius Kabi Aktiengesellschaft, Bad Homburg vor der Höhe, Germany
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The evolving use of higher risk grafts is associated with an increased incidence of acute kidney injury after liver transplantation. J Hepatol 2014; 60:1180-6. [PMID: 24631601 DOI: 10.1016/j.jhep.2014.02.019] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Revised: 02/06/2014] [Accepted: 02/22/2014] [Indexed: 01/09/2023]
Abstract
BACKGROUND & AIMS The growing discrepancy between supply and demand for liver transplantation has necessitated a greater use of higher risk grafts. Donation after Circulatory Death (DCD) liver transplant recipients have an increased frequency of acute kidney injury (AKI). We hypothesised that other higher risk grafts might also impact negatively on renal function. Our aim was to examine the effect of the evolving use of higher risk grafts on the incidence of post liver transplant AKI. METHODS Single-centre study of 1152 patients undergoing first-single-organ liver transplantation for chronic liver disease 01/2000-12/2011. To assess the impact of the evolution of graft quality over time; donor/graft/recipient variables were compared over three 4-year periods. RESULTS Pretransplant recipient renal function improved during follow-up (p<0.001), and the median postoperative day-1 (p<0.001), -2 (p<0.001), and -3 (p<0.001) tacrolimus trough levels fell. The proportion of patients receiving a higher risk graft was 31.8% in 2000-2003, 40.9% in 2004-2007, and 59.1% in 2008-2011 (p<0.001). There was a progressive increase in AKI (2000-2003, OR 1.00; 2004-2007, OR 1.43; 2008-2011, OR 2.40, p<0.001). After adjusting for recipient variables increasing recipient warm ischaemic time (p=0.019), DCD transplantation (p<0.001), donor age ≥60 years (p=0.020), and donor body mass index ≥30 kg/m(2) (p<0.001) were independent predictors of AKI. CONCLUSIONS The increasing use of higher risk liver grafts is associated with an increased incidence of AKI. These findings support the need for therapies that minimise the hepatic ischaemia-reperfusion injury.
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Abstract
PURPOSE OF REVIEW Ischemia and reperfusion injuries occur in multiple clinical settings and contribute to organ dysfunction/failures. Despite the innate inflammatory immune nature, T cells that are critically involved in the pathogenesis of ischemia reperfusion injury (IRI), include not only CD4+ T cells, but also CD8+ and γδT cells. This review focuses on questions of how putative Ag-specific T cells are involved, which include whether they function in an Ag-dependent manner; how they function, cytokine-mediated or costimulatory molecule-mediated mechanisms; and whether different T-cell subsets, Th1, Th17, regulatory T cell (Treg), are all involved and play distinctive roles? RECENT FINDINGS Specific T-cell populations, such as effector memory CD4 T cells, promote inflammatory immune activation by ischemia reperfusion independent of their adaptive properties, that is Ag-independently. They function by secreting cytokines and expressing costimulatory molecules to either promote or inhibit innate immune activation, or facilitate tissue repair/homeostasis, as exemplified by Th1, Th17 or Th2, Treg cells, respectively. SUMMARY T-cell-targeted therapies need to be refined with strategies to maximally eliminate the proinflammatory but spare the anti-inflammatory/immune regulatory properties of T cells, for future clinical application to ameliorate IRI.
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Global consequences of liver ischemia/reperfusion injury. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2014; 2014:906965. [PMID: 24799983 PMCID: PMC3995148 DOI: 10.1155/2014/906965] [Citation(s) in RCA: 190] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Revised: 01/02/2014] [Accepted: 01/13/2014] [Indexed: 12/11/2022]
Abstract
Liver ischemia/reperfusion injury has been extensively studied during the last decades and has been implicated in the pathophysiology of many clinical entities following hepatic surgery and transplantation. Apart from its pivotal role in the pathogenesis of the organ's post reperfusion injury, it has also been proposed as an underlying mechanism responsible for the dysfunction and injury of other organs as well. It seems that liver ischemia and reperfusion represent an event with “global” consequences that influence the function of many remote organs including the lung, kidney, intestine, pancreas, adrenals, and myocardium among others. The molecular and clinical manifestation of these remote organs injury may lead to the multiple organ dysfunction syndrome, frequently encountered in these patients. Remote organ injury seems to be in part the result of the oxidative burst and the inflammatory response following reperfusion. The present paper aims to review the existing literature regarding the proposed mechanisms of remote organ injury after liver ischemia and reperfusion.
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Bartels K, Karhausen J, Clambey ET, Grenz A, Eltzschig HK. Perioperative organ injury. Anesthesiology 2014; 119:1474-89. [PMID: 24126264 DOI: 10.1097/aln.0000000000000022] [Citation(s) in RCA: 125] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Despite the fact that a surgical procedure may have been performed for the appropriate indication and in a technically perfect manner, patients are threatened by perioperative organ injury. For example, stroke, myocardial infarction, acute respiratory distress syndrome, acute kidney injury, or acute gut injury are among the most common causes for morbidity and mortality in surgical patients. In the current review, the authors discuss the pathogenesis of perioperative organ injury, and provide select examples for novel treatment concepts that have emerged over the past decade. Indeed, the authors are of the opinion that research to provide mechanistic insight into acute organ injury and identification of novel therapeutic approaches for the prevention or treatment of perioperative organ injury represent the most important opportunity to improve outcomes of anesthesia and surgery.
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Affiliation(s)
- Karsten Bartels
- * Fellow in Critical Care Medicine and Cardiothoracic Anesthesiology, † Assistant Professor of Anesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina. ‡ Assistant Professor of Anesthesiology, § Associate Professor of Anesthesiology, ‖ Professor of Anesthesiology, Department of Anesthesiology, University of Colorado Denver, Aurora, Colorado
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Intestinal mast cells mediate gut injury and systemic inflammation in a rat model of deep hypothermic circulatory arrest. Crit Care Med 2013; 41:e200-10. [PMID: 23478660 DOI: 10.1097/ccm.0b013e31827cac7a] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Cardiac surgery, especially when employing cardiopulmonary bypass and deep hypothermic circulatory arrest, is associated with systemic inflammatory responses that significantly affect morbidity and mortality. Intestinal perfusion abnormalities have been implicated in such responses, but the mechanisms linking local injury and systemic inflammation remain unclear. Intestinal mast cells are specialized immune cells that secrete various preformed effectors in response to cellular stress. We hypothesized that mast cells are activated in a microenvironment shaped by intestinal ischemia/reperfusion, and investigated local and systemic consequences. DESIGN Rat model of deep hypothermic circulatory arrest. SETTING University research laboratory. SUBJECTS Twelve- to 14-week-old male Sprague-Dawley rats. INTERVENTIONS Rats were anesthetized and cooled to 16°C to 18°C on cardiopulmonary bypass before instituting deep hypothermic circulatory arrest for 45 minutes. Specimens were harvested following rewarming and 2 hours of recovery. MEASUREMENTS AND MAIN RESULTS Significant intestinal barrier disruption was found, together with macro- and microscopic evidence of ischemia/reperfusion injury in ileum and colon, but not in the lungs or kidneys. Immunofluorescence and toluidine blue staining revealed increased numbers of mast cells and their activation in the gut. In animals pretreated with the mast cell stabilizer, cromolyn sodium, mast cell degranulation was blocked, and intestinal morphology and barrier function were preserved following deep hypothermic circulatory arrest. Furthermore, cromolyn sodium treatment was associated with reduced intestinal neutrophil influx and blunted systemic release of proinflammatory cytokines. CONCLUSION Our data provide primary evidence that intestinal ischemia/reperfusion is a leading pathophysiologic process in a rat model of deep hypothermic circulatory arrest, and that intestinal injury, and local and systemic inflammatory responses are critically dependent on mast cell activation. This identifies intestinal mast cells as central players in deep hypothermic circulatory arrest-associated responses, and opens novel therapeutic possibilities for patients undergoing this procedure.
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Abstract
PURPOSE OF REVIEW This review will summarize the recent advances in our understanding of the relationship between liver and kidney function. It will outline the new concepts of the pathophysiology of renal dysfunction in chronic liver disease and examine novel renal biomarkers to detect acute kidney injury (AKI) in cirrhosis and following liver transplantation. We will further review new treatments for hepatorenal syndrome (HRS) and approaches to kidney dysfunction in liver transplantation recipients. RECENT FINDINGS Recent studies evaluated the effect of the renin-angiotensin system on hepatic fibrosis and the role of the gut in mediating AKI after hepatic ischemia reperfusion injury. Multiple studies have investigated novel biomarkers such as neutrophil gelatinase-associated lipocalin to predict AKI (and HRS) in cirrhosis and after liver transplantation. Furthermore, there were recent advances in the management of kidney dysfunction including management of HRS with vasopressin analogs and kidney-sparing immunosuppression after liver transplantation. SUMMARY Greater knowledge of the physiologic relationship between kidney and liver may open avenues for specific therapies of liver and kidney injury. Renal biomarkers may allow early diagnosis and targeted treatment of AKI, and improved management of kidney disease in the preliver and postliver transplantation setting will be crucial to improving long-term outcomes in these patients.
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Leithead JA, Armstrong MJ, Corbett C, Andrew M, Kothari C, Gunson BK, Muiesan P, Ferguson JW. Hepatic ischemia reperfusion injury is associated with acute kidney injury following donation after brain death liver transplantation. Transpl Int 2013; 26:1116-25. [PMID: 24033747 DOI: 10.1111/tri.12175] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Revised: 06/23/2013] [Accepted: 07/28/2013] [Indexed: 02/06/2023]
Abstract
Donation after cardiac death liver transplant recipients have an increased frequency of acute kidney injury (AKI). This suggests that hepatic ischemia-reperfusion injury may play a critical role in the pathogenesis of AKI after liver transplantation. The aim of this single-center study was to determine if hepatic ischemia-reperfusion injury, estimated by peak peri-operative serum amino-transferase (AST), is associated with AKI following donation after brain death (DBD) liver transplantation. A total of 296 patients received 298 DBD liver transplants from January 2007 to June 2011. The incidence of AKI was 35.9%. AKI was a risk factor for chronic kidney disease (P = 0.037) and mortality (P = 0.002). On univariate analysis, peak AST correlated with peak creatinine (P < 0.001) and peak change in creatinine from baseline (P < 0.001). Peak AST was higher in AKI patients (P < 0.001). The incidence of AKI in patients with a peak AST of <1500, 1500-2999 and ≥ 3000 U/l was 26.1%, 39.8% and 71.2%, respectively (P < 0.001). On multiple logistic regression analysis, peak AST was independently associated with the development of AKI (P < 0.001). In conclusion, hepatic ischemia-reperfusion injury demonstrates a strong relationship with peri-operative AKI in DBD liver transplant recipients.
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Affiliation(s)
- Joanna A Leithead
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK; NIHR Biomedical Research Unit and Centre for Liver Research, University of Birmingham, Birmingham, UK
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72
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Abstract
Paneth cells are highly specialized epithelial cells of the small intestine, where they coordinate many physiological functions. First identified more than a century ago on the basis of their readily discernible secretory granules by routine histology, these cells are located at the base of the crypts of Lieberkühn, tiny invaginations that line the mucosal surface all along the small intestine. Investigations over the past several decades determined that these cells synthesize and secrete substantial quantities of antimicrobial peptides and proteins. More recent studies have determined that these antimicrobial molecules are key mediators of host-microbe interactions, including homeostatic balance with colonizing microbiota and innate immune protection from enteric pathogens. Perhaps more intriguing, Paneth cells secrete factors that help sustain and modulate the epithelial stem and progenitor cells that cohabitate in the crypts and rejuvenate the small intestinal epithelium. Dysfunction of Paneth cell biology contributes to the pathogenesis of chronic inflammatory bowel disease.
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Affiliation(s)
- Hans C Clevers
- Hubrecht Institute-KNAW, University Medical Center Utrecht, Uppsalalaan, Utrecht 3584CT, The Netherlands.
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73
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New insights in intestinal ischemia-reperfusion injury: implications for intestinal transplantation. Curr Opin Organ Transplant 2013; 18:298-303. [PMID: 23449345 DOI: 10.1097/mot.0b013e32835ef1eb] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE OF REVIEW Ischemia-reperfusion injury is inevitable during intestinal transplantation and can negatively affect the transplant outcome. Here, an overview is provided of the recent advances in the pathophysiological mechanisms of intestinal ischemia-reperfusion injury and how this may impact graft survival. RECENT FINDINGS The intestine hosts a wide range of microorganisms and its mucosa is heavily populated by immune cells. Intestinal ischemia-reperfusion results in the disruption of the epithelial lining, affecting also protective Paneth cells (antimicrobials) and goblet cells (mucus), and creates a more hostile intraluminal microenvironment. Consequently, both damage-associated molecular patterns as well as pathogen-associated molecular patterns are released from injured tissue and exogenous microorganisms, respectively. These 'danger' signals may synergistically activate the innate immune system. Exaggerated innate immune responses, involving neutrophils, mast cells, platelets, dendritic cells, as well as Toll-like receptors and complement proteins, may shape the adaptive T-cell response, thereby triggering the destructive alloimmune response toward the graft and resulting in transplant rejection. SUMMARY Innate immune activation as a consequence of ischemia-reperfusion injury may compromise engraftment of the intestine. More dedicated research is required to further establish this concept in man and to design more effective therapeutic strategies to better tolerize intestinal grafts.
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Eggenhofer E, Rovira J, Sabet-Baktach M, Groell A, Scherer MN, Dahlke MH, Farkas SA, Loss M, Koehl GE, Lang SA, Melter M, Schlitt HJ, Geissler EK, Kroemer A. Unconventional RORγt+ T Cells Drive Hepatic Ischemia Reperfusion Injury. THE JOURNAL OF IMMUNOLOGY 2013; 191:480-7. [DOI: 10.4049/jimmunol.1202975] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Tan Z, Jiang R, Wang X, Wang Y, Lu L, Liu Q, Zheng SG, Sun B, Ryffel B. RORγt+IL-17+ neutrophils play a critical role in hepatic ischemia-reperfusion injury. J Mol Cell Biol 2013; 5:143-6. [PMID: 23362310 DOI: 10.1093/jmcb/mjs065] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
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Abstract
Hepato-renal syndrome (HRS) is one of the most detrimental conditions in patients with end stage liver failure. Historically, HRS was considered a terminal disease associated with cirrhosis and was termed "liver-death syndrome". Furthermore, despite the improved understanding of pathophysiology and the reversibility of renal dysfunction in HRS, mortality remains extremely high especially for type 1 HRS. This review summarizes the recent advances in the pathophysiology, diagnosis and management of HRS and also provides an evolving area of research in the pathophysiologic mechanisms of HRS, which may open the door for new therapeutic approaches.
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Affiliation(s)
- Kyota Fukazawa
- Department of Anesthesiology, College of Physicians and Surgeons of Columbia University, NY, USA
| | - H Thomas Lee
- Department of Anesthesiology, College of Physicians and Surgeons of Columbia University, NY, USA
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Lee HT, Kim M, Kim JY, Brown KM, Ham A, D'Agati VD, Mori-Akiyama Y. Critical role of interleukin-17A in murine intestinal ischemia-reperfusion injury. Am J Physiol Gastrointest Liver Physiol 2013; 304:G12-25. [PMID: 23125155 DOI: 10.1152/ajpgi.00201.2012] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Intestinal ischemia-reperfusion (I/R) injury causes severe illness frequently complicated by remote multiorgan dysfunction and sepsis. Recent studies implicated interleukin-17A (IL-17A) in regulating inflammation, autoimmunity, and I/R injury. Here, we determined whether IL-17A is critical for generation of intestinal I/R injury and subsequent liver and kidney injury. Mice subjected to 30 min of superior mesenteric artery ischemia not only developed severe small intestinal injury (necrosis, apoptosis, and neutrophil infiltration) but also developed significant renal and hepatic injury. We detected large increases in IL-17A in the small intestine, liver, and plasma. IL-17A is critical for generating these injuries, since genetic deletion of IL-17A- or IL-17A-neutralizing antibody treatment markedly protected against intestinal I/R injury and subsequent liver and kidney dysfunction. Intestinal I/R caused greater increases in portal plasma and small intestine IL-17A, suggesting an intestinal source for IL-17A generation. We also observed that intestinal I/R caused rapid small intestinal Paneth cell degranulation and induced murine α-defensin cryptdin-1 expression. Furthermore, genetic or pharmacological depletion of Paneth cells significantly attenuated the intestinal I/R injury as well as hepatic and renal dysfunction. Finally, Paneth cell depletion significantly decreased small intestinal, hepatic, and plasma IL-17A levels after intestinal I/R. Taken together, we propose that Paneth cell-derived IL-17A may play a critical role in intestinal I/R injury as well as extraintestinal organ dysfunction.
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Affiliation(s)
- H Thomas Lee
- Department of Anesthesiology, College of Physicians and Surgeons, Columbia University, New York, NY 10032-3784, USA.
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Park SW, Kim M, Kim JY, Ham A, Brown KM, Mori-Akiyama Y, Ouellette AJ, D'Agati VD, Lee HT. Paneth cell-mediated multiorgan dysfunction after acute kidney injury. THE JOURNAL OF IMMUNOLOGY 2012; 189:5421-33. [PMID: 23109723 DOI: 10.4049/jimmunol.1200581] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Acute kidney injury (AKI) is frequently complicated by extrarenal multiorgan injury, including intestinal and hepatic dysfunction. In this study, we hypothesized that a discrete intestinal source of proinflammatory mediators drives multiorgan injury in response to AKI. After induction of AKI in mice by renal ischemia-reperfusion or bilateral nephrectomy, small intestinal Paneth cells increased the synthesis and release of IL-17A in conjunction with severe intestinal apoptosis and inflammation. We also detected significantly increased IL-17A in portal and systemic circulation after AKI. Intestinal macrophages appear to transport released Paneth cell granule constituents induced by AKI, away from the base of the crypts into the liver. Genetic or pharmacologic depletion of Paneth cells decreased small intestinal IL-17A secretion and plasma IL-17A levels significantly and attenuated intestinal, hepatic, and renal injury after AKI. Similarly, portal delivery of IL-17A in macrophage-depleted mice decreased markedly. In addition, intestinal, hepatic, and renal injury following AKI was attenuated without affecting intestinal IL-17A generation. In conclusion, AKI induces IL-17A synthesis and secretion by Paneth cells to initiate intestinal and hepatic injury by hepatic and systemic delivery of IL-17A by macrophages. Modulation of Paneth cell dysregulation may have therapeutic implications by reducing systemic complications arising from AKI.
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Affiliation(s)
- Sang Won Park
- Department of Anesthesiology, College of Physicians and Surgeons, Columbia University, New York, NY 10032, USA
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Abstract
PURPOSE OF REVIEW During critical illness, alterations of intestinal blood supply and inflammatory activation can result in severe intestinal hypoxia (limited oxygen availability). Conditions of hypoxia lead to the activation of a transcriptional program that is under the control of the transcription factor hypoxia-inducible factor (HIF). In many instances, HIF-dependent alterations of gene expression represent endogenous adaptive responses that dampen pathologic inflammation and could be targeted to treat intestinal injury. RECENT FINDINGS Post-translational stabilization of the HIF transcription factor and corresponding changes in gene expression are central to the resolution of intestinal injury. Examples for such responses that we discuss in this review include hypoxia-elicited increases in extracellular adenosine production and signaling, particularly through the A2B adenosine receptor, and intestinal protection provided by hypoxia-inducible netrin-1. SUMMARY The present review focuses on HIF-elicited anti-inflammatory pathways that result in intestinal protection during critical illness. Many of these pathways represent novel therapeutic targets for attenuating multiorgan failure and critical illness. Whereas these therapeutic approaches are currently being investigated in cell culture models or in genetic mouse models, we are optimistic that at least some of these novel targets can be translated from bench to bedside in the near future.
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Affiliation(s)
- Almut Grenz
- Mucosal Inflammation Program, Department of Anesthesiology, University of Colorado, Aurora, Colorado 80045, USA.
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Leithead JA, Tariciotti L, Gunson B, Holt A, Isaac J, Mirza DF, Bramhall S, Ferguson JW, Muiesan P. Donation after cardiac death liver transplant recipients have an increased frequency of acute kidney injury. Am J Transplant 2012; 12:965-75. [PMID: 22226302 DOI: 10.1111/j.1600-6143.2011.03894.x] [Citation(s) in RCA: 103] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Donation after cardiac death (DCD) liver transplantation is associated with an increased frequency of hepato-biliary complications. The implications for renal function have not been explored previously. The aims of this single-center study of 88 consecutive DCD liver transplant recipients were (1) to compare renal outcomes with propensity-risk-matched donation after brain death (DBD) patients and (2) in the DCD patients specifically to examine the risk factors for acute kidney injury (AKI; peak creatinine ≥2 times baseline) and chronic kidney disease (CKD; eGFR <60 mL/min/1.73 m(2) ). During the immediate postoperative period DCD liver transplantation was associated with an increased incidence of AKI (DCD, 53.4%; DBD 31.8%, p = 0.004). In DCD patients AKI was a risk factor for CKD (p = 0.035) and mortality (p = 0.017). The cumulative incidence of CKD by 3 years post-transplant was 53.7% and 42.1% for DCD and DBD patients, respectively (p = 0.774). Importantly, increasing peak perioperative aspartate aminotransferase, a surrogate marker of hepatic ischemia reperfusion injury, was the only consistent predictor of renal dysfunction after DCD transplantation (AKI, p < 0.001; CKD, p = 0.032). In conclusion, DCD liver transplantation is associated with an increased frequency of AKI. The findings suggest that hepatic ischemia reperfusion injury may play a critical role in the pathogenesis of post-transplant renal dysfunction.
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Affiliation(s)
- J A Leithead
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK.
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Lee CY, Yeh HC, Lin CY. Treatment of critically ill children with kidney injury by sustained low-efficiency daily diafiltration. Pediatr Nephrol 2012; 27:2301-9. [PMID: 22903659 PMCID: PMC3491203 DOI: 10.1007/s00467-012-2254-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2011] [Revised: 06/09/2012] [Accepted: 06/11/2012] [Indexed: 01/13/2023]
Abstract
BACKGROUND Continuous renal replacement therapy (CRRT) and intermittent hemodialysis (IHD) offer diverse benefits and drawbacks for critically ill children with acute kidney injury (AKI). Sustained low-efficiency daily diafiltration (SLEDD-f) involves a conceptual and technical hybrid of CRRT and IHD. We report our SLEDD-f application to critically ill children in the pediatric intensive care unit (PICU). METHODS SLEDD-f was delivered by the new Fresenius 5008 therapy system with blood flow 5 ml/kg/min, dialysate flow 260 ml/min, hemofiltration 35 ml/kg/h for 8-10 h daily. Changes in blood pressure, blood gas, electrolyte, hemoglobulin (Hb), and hematocrit (Hct) were closely monitored. RESULTS From February 2010 to June 2011, 14 critical patients with a total of 60 SLEDD-f sessions were studied retrospectively. Heparin was used in 46 sessions (76.6%) with no bleeding complications. Hypertension above 135 mmHg returned to normal, hypotension below 90 mmHg showed no drop. Metabolic acidosis and hyperkalemia normalized. Elevated Hb, Hct, and their ratio revealed improving hemodilution. Three episodes of intradialytic hypotension (5.0%) and one of circuit clotting (1.7%) led to premature termination. The 28-day survival rate was 71.4%. CONCLUSIONS This pilot investigation demonstrates that SLEDD-f provides good hemodynamic tolerance and correction of fluid overload, pH, and electrolyte imbalance for critically ill children with AKI.
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Affiliation(s)
- Chia-Ying Lee
- Division of Pediatric Nephrology, Children’s Medical Center, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Huang-Chieh Yeh
- Division of Nephrology, Department of Medicine, China Medical University and Hospital, Taichung, Taiwan
| | - Ching-Yuang Lin
- Division of Pediatric Nephrology, Children’s Medical Center, China Medical University Hospital, China Medical University, Taichung, Taiwan ,College of Medicine, China Medical University, No.2, Yuh-Der Rd., Taichung, 40402 Taiwan ,Clinical Immunology Center, China Medical University Hospital, No.2, Yuh-Der Road, Taichung, 40402 Taiwan
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Abstract
PURPOSE OF REVIEW Hypoxia represents one of the strongest transcriptional stimuli known to us. In most cases, hypoxia-induced changes in gene expression are directed towards adapting tissues to conditions of limited oxygen availability. RECENT FINDINGS As a well known example, physical exercise at high altitude results in the transcriptional induction of erythropoietin that functions to increase oxygen carrying capacity and red cell volume. Studies of the transcriptional pathway responsible for the induction of erythropoietin during conditions of hypoxia led to the discovery of the transcription factor hypoxia-inducible factor (HIF) that is known today as the key transcription factor for hypoxia adaptation. Surgical patients are frequently at risk for experiencing detrimental effects of hypoxia or ischemia, for example, in the context of acute kidney injury, myocardial, intestinal or hepatic ischemia, acute lung injury, or during organ transplantation. SUMMARY In the present review, we discuss the mechanisms of transcriptional adaptation to hypoxia and provide evidence supporting the hypothesis that targeting hypoxia-induced inflammation can represent novel pharmacologic strategies to improve perioperative outcomes. Currently, such strategies are being explored at an experimental level, but we hope that some of these targets can be translated into perioperative patient care within the next decade.
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Abstract
Ischemia and reperfusion-elicited tissue injury contributes to morbidity and mortality in a wide range of pathologies, including myocardial infarction, ischemic stroke, acute kidney injury, trauma, circulatory arrest, sickle cell disease and sleep apnea. Ischemia-reperfusion injury is also a major challenge during organ transplantation and cardiothoracic, vascular and general surgery. An imbalance in metabolic supply and demand within the ischemic organ results in profound tissue hypoxia and microvascular dysfunction. Subsequent reperfusion further enhances the activation of innate and adaptive immune responses and cell death programs. Recent advances in understanding the molecular and immunological consequences of ischemia and reperfusion may lead to innovative therapeutic strategies for treating patients with ischemia and reperfusion-associated tissue inflammation and organ dysfunction.
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Affiliation(s)
- Holger K Eltzschig
- Department of Anesthesiology, Mucosal Inflammation Program, University of Colorado, Aurora, Colorado, USA.
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