Mechanisms and Limits of Induced Postnatal Lung Growth

Natural history of lung function in health and diseases

PURPOSE OF REVIEW

To outline major advances in the understanding of factors that influence lung function development through childhood.

RECENT FINDINGS

New study approaches such as adjusting for 'tracking' or analysing without predefined phenotypes suggest that reduced lung function reported with several pre or coexisting features such as lower respiratory tract infections and early allergic sensitization may be spurious rather than causative. Also, two large, recent studies have clearly demonstrated that living close to major roads causes significant lung function deficits in school children, with the possible long-term impact this can have on health in adult life. Furthermore, it is becoming clear that we need to focus upon early life events that can cause harm as well as have a potential for catch-up growth or development in postnatal life.

SUMMARY

The implications of these findings are clearly that there is a potential for intervening in a potential pathological development. Furthermore, there is a clear need to focus research upon early life events that can improve lung growth in the damaged lung and prevent damage to the potentially healthy lung at the very start of life.

Effects of leptin deficiency on postnatal lung development in mice

Leptin modulates energy metabolism and lung development. We hypothesize that the effects of leptin on postnatal lung development are volume dependent from 2 to 10 wk of age and are independent of hypometabolism associated with leptin deficiency. To test the hypotheses, effects of leptin deficiency on lung maturation were characterized in age groups of C57BL/6J mice with varying Lep(ob) genotypes. Quasi-static pressure-volume curves and respiratory impedance measurements were performed to profile differences in respiratory system mechanics. Morphometric analysis was conducted to estimate alveolar size and number. Oxygen consumption was measured to assess metabolic rate. Lung volume at 40-cmH(2)O airway pressure (V(40)) increased with age in each genotypic group, and V(40) was significantly (P < 0.05) lower in leptin-deficient (ob/ob) mice beginning at 2 wk. Differences were amplified through 7 wk of age relative to wild-type (+/+) mice. Morphometric analysis showed that alveolar surface area was lower in ob/ob compared with +/+ and heterozygote (ob/+) mice beginning at 2 wk. Unlike the other genotypic groups, alveolar size did not increase with age in ob/ob mice. In another experiment, ob/ob at 4 wk received leptin replacement (5 microg.g(-1) x day(-1)) for 8 days, and expression levels of the Col1a1, Col3a1, Col6a3, Mmp2, Tieg1, and Stat1 genes were significantly increased concomitantly with elevated V(40). Leptin-induced increases in V(40) corresponded with enlarged alveolar size and surface area. Gene expression suggested a remodeling event of lung parenchyma after exogenous leptin replacement. These data support the hypothesis that leptin is critical to postnatal lung remodeling, particularly related to increased V(40) and enlarged alveolar surface area.

Regulation of alveologenesis: clinical implications of impaired growth

During its development that begins in intrauterine life, the lung is transformed from a simple epithelial lined sac that emerges from the foregut into a complex arrangement of blood vessels, airways, and alveoli that make up the mature lung structure. This remarkable transformation that continues for several years postnatally, is achieved by the influence of several genes, transcription factors, growth factors and hormones upon the cells and proteins of the lung bud. A seminal event in this process is the formation of the air-blood barrier within the alveolar wall, an evolutionary modification that permits independent air-breathing existence in mammals. Molecular biological techniques have enabled elucidation of the mechanistic pathways contributing to alveologenesis and have provided probable molecular bases for examples of impaired alveologenesis encountered by the paediatric pathologist.

Predictors of the persistence of childhood asthma

BACKGROUND

The factors relevant to the prognosis of childhood asthma differ from one population to another.

OBJECTIVES

To characterize the course of childhood asthma in the catchment area of our hospital, and to identify prognostic factors for this population.

METHODS

All children given a diagnosis of asthma in the paediatric pulmonology service of a tertiary hospital were followed up for 5 years.

RESULTS

Satisfactory control of asthma was achieved in 69 % of cases. The factors identified as associated with poor control were allergy to cats and pollen, a large number of crises in the year prior to diagnosis, and younger age at onset.

CONCLUSIONS

In our region, childhood asthma has a relatively favourable prognosis. The subsequent course of the disease appears to be determined in childhood. The persistence of symptoms appears to depend to a significant extent on the degree of atopy.

Airway geometry models of children's lungs for use in dosimetry modeling

Single-path whole-lung and lobar models of the lungs of 11 children between 3 mo and 21 yr of age were developed based on a combination of cast data and published information on distal airway dimensions. The cast data used to generate these models were taken from one of the largest databases of actual measurements in children. The methods used to develop the children's models were based on techniques that have been used to develop adult single-path airway geometry models. Model dimensions for the conducting airways, as well as the estimated dead space, for all children fell within the range of the limited published information. Thus, the method for estimating airway dimensions in adults may be successfully applied to develop estimates of airway dimensions in children. The predicted total lung capacity (TLC) for the older children (aged 8 to 21 yr) fell within or near the range arising from published scaling equations. The assumptions used to generate the gas exchange region for children 8 yr and older produced results that were reasonably consistent with available physiological data. However, these assumptions do not result in a physiologically consistent gas exchange region for children 3 yr of age and younger; also, to maintain physiologically reasonable relationships between dead space and alveolar volume, the models for children 3 yr of age and younger resulted in predicted TLCs well below those predicted using published scaling equations. These discrepancies may be reflective of dysanaptic growth, in which the alveolar region is growing more rapidly than the airways. The results for children 3 yr of age and under suggest the need for a greater understanding of lung development during this critical period. This is particularly important considering the increasing evidence that exposure to pollutants and other toxicants and allergens during the first 2 yr of life may have long-term consequences on respiratory disease outcomes. Our results suggest that the geometry model airway dimensions for all ages are appropriate for use with dosimetry models, but dosimetry modelers need to assess carefully the reasonableness of TLC and functional residual capacity volumes to which airway dimensions are scaled for children 3 yr of age and under.

Deconvoluting lung evolution: from phenotypes to gene regulatory networks

Speakers in this symposium presented examples of respiratory regulation that broadly illustrate principles of evolution from whole organ to genes. The swim bladder and lungs of aquatic and terrestrial organisms arose independently from a common primordial "respiratory pharynx" but not from each other. Pathways of lung evolution are similar between crocodiles and birds but a low compliance of mammalian lung may have driven the development of the diaphragm to permit lung inflation during inspiration. To meet the high oxygen demands of flight, bird lungs have evolved separate gas exchange and pump components to achieve unidirectional ventilation and minimize dead space. The process of "screening" (removal of oxygen from inspired air prior to entering the terminal units) reduces effective alveolar oxygen tension and potentially explains why nonathletic large mammals possess greater pulmonary diffusing capacities than required by their oxygen consumption. The "primitive" central admixture of oxygenated and deoxygenated blood in the incompletely divided reptilian heart is actually co-regulated with other autonomic cardiopulmonary responses to provide flexible control of arterial oxygen tension independent of ventilation as well as a unique mechanism for adjusting metabolic rate. Some of the most ancient oxygen-sensing molecules, i.e., hypoxia-inducible factor-1alpha and erythropoietin, are up-regulated during mammalian lung development and growth under apparently normoxic conditions, suggesting functional evolution. Normal alveolarization requires pleiotropic growth factors acting via highly conserved cell-cell signal transduction, e.g., parathyroid hormone-related protein transducing at least partly through the Wingless/int pathway. The latter regulates morphogenesis from nematode to mammal. If there is commonality among these diverse respiratory processes, it is that all levels of organization, from molecular signaling to structure to function, co-evolve progressively, and optimize an existing gas-exchange framework.

Effects of overinflation on procollagen type III expression in experimental acute lung injury

Introduction

In acute lung injury (ALI), elevation of procollagen type III (PC III) occurs early and has an adverse impact on outcome. We examined whether different high-inflation strategies of mechanical ventilation (MV) in oleic acid (OA) ALI alter regional expression of PC III.

Methods

We designed an experimental, randomized, and controlled protocol in which rats were allocated to two control groups (no injury, recruited [alveolar recruitment maneuver after tracheotomy without MV; n = 4 rats] and control [n = 5 rats]) or four injured groups (one exposed to OA only [n = 10 rats] and three OA-injured and ventilated). The three OA-injured groups were ventilated for 1 hour according to the following strategies: LVHP-S (low volume-high positive end-expiratory pressure [PEEP], supine; n = 10 rats, tidal volume [V_T] = 8 ml/kg, PEEP = 12 cm H₂O), HVLP-S (high volume-low PEEP, supine; n = 10 rats, V_T = 20 ml/kg, PEEP = 5 cm H₂O), and HVLP-P (high volume-low PEEP, prone; n = 10 rats). Northern blot analysis for PC III and interleukin-1-beta (IL-1β) and polymorphonuclear infiltration index (PMI) counting were performed in nondependent and dependent regions. Regional differences between groups were assessed by two-way analysis of variance after logarithmic transformation and post hoc tests.

Results

A significant interaction for group and region effects was observed for PC III (p = 0.012) with higher expression in the nondependent region for HVLP-S and LVHP-S, intermediate for OA and HVLP-P, and lower for control (group effect, p < 0.00001, partial η² = 0.767; region effect, p = 0.0007, partial η² = 0.091). We found high expression of IL-1β (group effect, p < 0.00001, partial η² = 0.944) in the OA, HVLP-S, and HVLP-P groups without regional differences (p = 0.16). PMI behaved similarly (group effect, p < 0.00001, partial η² = 0.832).

Conclusion

PC III expression is higher in nondependent regions and in ventilatory strategies that caused overdistension. This response was partially attenuated by prone positioning.

Matrix metalloproteinases in lung: multiple, multifarious, and multifaceted

The matrix metalloproteinases (MMPs), a family of 25 secreted and cell surface-bound neutral proteinases, process a large array of extracellular and cell surface proteins under normal and pathological conditions. MMPs play critical roles in lung organogenesis, but their expression, for the most part, is downregulated after generation of the alveoli. Our knowledge about the resurgence of the MMPs that occurs in most inflammatory diseases of the lung is rapidly expanding. Although not all members of the MMP family are found within the lung tissue, many are upregulated during the acute and chronic phases of these diseases. Furthermore, potential MMP targets in the lung include all structural proteins in the extracellular matrix (ECM), cell adhesion molecules, growth factors, cytokines, and chemokines. However, what is less known is the role of MMP proteolysis in modulating the function of these substrates in vivo. Because of their multiplicity and substantial substrate overlap, MMPs are thought to have redundant functions. However, as we explore in this review, such redundancy most likely evolved as a necessary compensatory mechanism given the critical regulatory importance of MMPs. While inhibition of MMPs has been proposed as a therapeutic option in a variety of inflammatory lung conditions, a complete understanding of the biology of these complex enzymes is needed before we can reasonably consider them as therapeutic targets.

Special topics issue of microcirculation: ion channels and pulmonary vascular function

Unique features of the pulmonary circulation impact its function in health and disease, not the least of which is the existence of developmentally distinct, functionally heterogeneous extra-alveolar and septal capillary networks. The impact of ion channel expression and regulation in lung vascular smooth muscle or endothelium in these vascular compartments provides a focus for this special topics issue. Reviews and original contributions from experts in the field discuss two broad groups of ion channels, drawing on studies utilizing biophysical and molecular approaches in heterologous expression systems, in vitro approaches in pulmonary vascular smooth muscle and endothelial cells, and physiologic studies in animal models of chronic pulmonary hypertension. First, channels involved in membrane depolarization and related alterations in vascular tone, and shear sensing or exocytosis by endothelium are discussed: voltage-gated potassium channels, ATP-regulated potassium channels and L- and T- type voltage-gated calcium channels. The second series of reviews discusses the role of calcium influx pathways provided by transient receptor potential channels in regulation of pulmonary vascular tone or vascular remodeling, and endothelial barrier function. Understanding the role of ion channels in pulmonary vascular pathophysiology may be critical to development of new therapeutic strategies.

High torquetenovirus loads are correlated with bronchiectasis and peripheral airflow limitation in children

BACKGROUND

The aim of the study was to evaluate the prevalence of torquetenovirus (TTV) infection in a group of children with recurrent lower respiratory tract infections and radiologic evidence of bronchiectasis. Correlations between TTV loads and severity of bronchiectasis and between TTV loads and lung function were evaluated.

METHODS

In 38 subjects, high-resolution computed tomography (HRCT) and plasma tests for TTV detection and quantification were done. In 21/38 subjects, spirometry was also performed.

RESULTS

TTV was found in 31/38 (81.6%) patients. The correlation between TTV loads and severity of bronchiectasis was statistically significant (r = 0.548; P = 0.01). TTV loads showed inverse correlation with FEF25-75% (r = -0.541; P = 0.011), and FEF25-75%/FVC (r = -0.512; P = 0.018). Inverse correlation was found also between severity of bronchiectasis and functional lung parameters: FEF25-75% (r = -0.635; P = 0.002), FEV1/FVC (r = -0.541; P = 0.011), and FEF25-75%/FVC (r = -0.645; P = 0.002).

CONCLUSIONS

This study demonstrated the high prevalence of TTV infection in children with bronchiectasis. Moreover, we have shown a significant correlation between TTV loads and airflow limitation within the peripheral airways, as well as between severity of bronchiectasis and decrease of lung function.

Challenges for Future Research in Exercise Physiology as Applied to the Respiratory System

Some of the major unresolved questions in the respiratory physiology and pathophysiology of exercise are addressed. To solve many of these difficult basic problems and to understand how systems operate alone and in combination in an integrated fashion, truly experimental integrative physiological approaches are required in both humans and animals.

Lung function tests in neonates and infants with chronic lung disease: forced expiratory maneuvers

This fourth paper in a review series on the role of lung function testing in infants and young children with acute neonatal disorders and chronic lung disease of infancy (CLDI) addresses measurements of forced expiration using rapid thoraco-abdominal compression (RTC) techniques and the forced deflation technique. Following orientation of the reader to the subject area, we focus our comments on the areas of inquiry proposed in the introductory paper to this series. The quality of the published literature is reviewed critically, and recommendations are provided to guide future investigation in this field. All studies on infants and young children with CLDI using forced expiratory or deflation maneuvers demonstrated that forced flows at low lung volume remain persistently low through the first 3 years of life. Measurement of maximal flow at functional residual capacity (V'maxFRC) is the most commonly used method for assessing airway function in infants, but is highly dependent on lung volume and airway tone. Recent studies suggested that the raised volume RTC technique, which assesses lung function over an extended volume range as in older children, may be a more sensitive means of discriminating changes in airway function in infants with respiratory disease. The forced deflation technique allows investigation of pulmonary function during the early development of CLDI in intubated subjects, but its invasive nature precludes its use in the routine setting. For all techniques, there is an urgent need to establish suitable reference data and evaluate within- and between-occasion repeatability, prior to establishing the clinical usefulness of these techniques in assessing baseline airway function and/or response to interventions in subjects with CLDI.

Nitric oxide donor restores lung growth factor and receptor expression in hyperoxia-exposed rat pups

Exposure of newborn rats to hyperoxia impairs alveolarization. Nitric oxide (NO) may prevent this evolution. Angiogenesis and factors involved in this process, but also other growth factors (GFs) involved in alveolar development, are likely potential therapeutic targets for NO. We studied the effects of the NO donor, [Z]-1-[N-(2-aminoethyl)-N-(2-ammonioethyl)aminio]diazen-1-ium-1, 2-diolate, also termed DETANONOate (D-NO), on hyperoxia-induced changes in key regulatory factors of alveolar development in neonatal rats, and its possible preventive effect on the physiologic consequences of hyperoxia. Newborn rat pups were randomized at birth to hyperoxia (> 95% O2) or room air exposure for 6 or 10 d, while receiving D-NO or its diluent. On Day 6, several GFs and their receptors were studied at pre- and/or post-translational levels. Elastin transcript determination on Day 6, and elastin deposition in tissue and morphometric analysis of the lungs on Day 10, were also performed. Hyperoxia decreased the expression of vascular endothelial growth factor (VEGF) receptor (VEGFR) 2, fibroblast growth factor (FGF)-18, and FGF receptors (FGFRs) FGFR3 and FGFR4, increased mortality, and impaired alveolarization and capillary growth. D-NO treatment of hyperoxia-exposed pups restored the expression level of FGF18 and FGFR4, induced an increase of both VEGF mRNA and protein, enhanced elastin expression, and partially restored elastin deposition in alveolar walls. Although, under the present conditions, D-NO failed to prevent the physiologic consequences of hyperoxia in terms of survival and lung alveolarization, our findings demonstrate molecular effects of NO on GFs involved in alveolar development that may have contributed to the protective effects previously reported for NO.

Gene Transfer of the Vascular Endothelial Growth Factor Receptor flt-1 Suppresses Pulmonary Metastasis Associated with Lung Growth

Growth of solid tumor metastases is critically dependent on angiogenesis. We hypothesized that an "angiogenic-rich" milieu, as in pneumonectomy-induced lung growth, would be conducive to growth of pulmonary metastases, and that transfer of an antiangiogenic gene would suppress tumor growth. Two weeks after left pneumonectomy in BALB/c mice, right lung mass increased 1.5-fold compared with controls (P < 0.0001). Our pulmonary metastases model, intravenous administration of beta-galactosidase (betagal)-marked CT26.CL25 colon carcinoma cells, resulted in diffuse metastases at 12 d after administration. However, if left pneumonectomy was performed 1 d before tumor cell administration, right lung mass was increased 1.7-fold after 12 d (P < 0.001 compared with the right + left lung of controls), and betagal activity was greater (2.8-fold, P < 0.05). To assess antiangiogenesis therapy, tumor cells were administered 1 d after pneumonectomy and 1 d later, 5 x 10(8) plaque-forming units of Adsflt (an Ad vector expressing the extracellular portion of the flt-1 vascular endothelial growth factor [VEGF] receptor) was administered. Compared with controls, mice receiving Adsflt via intranasal or intravenous routes showed suppression of pneumonectomy-induced tumor growth (P < 0.01, both routes compared with controls). Postpneumonectomy lung growth enhances growth of lung metastases, but this can be suppressed with Adsflt antiangiogenesis therapy.

Gas mixing efficiency from birth to adulthood measured by multiple-breath washout

Efficient mixing of inspired gas with the resident gas of the lung is an essential requirement of effective respiration. This review focuses on one method for quantifying ventilation inhomogeneity: the multiple-breath inert gas washout (MBW). MBW has been employed as a research tool in adults and school age children for more than 50 years. Modifications allowing data collection in infants and preschoolers have been described recently. Indices of overall ventilation inhomogeneity, such as the lung clearance index and moment ratios, are raised in many infants with lung disease of prematurity, and in young children with cystic fibrosis. These indices may be more sensitive than other lung function measures for the early detection of airway disease. We describe, for the first time, a development of the MBW analysis that allows calculation of acinar and conductive zone inhomogeneity indices in spontaneously breathing children. Although methodological and analytical issues remain, the future clinical and research applications of MBW justify accelerated research in this field.

Long-term enhancement of pulmonary gas exchange after high-altitude residence during maturation

In a previous study, our laboratory showed that young dogs born at sea level (SL) and raised from 2.5 mo of age to beyond somatic maturity at a high altitude (HA) of 3,100 m show enhanced resting lung function (Johnson RL Jr, Cassidy SS, Grover RF, Schutte JE, and Epstein RH. J Appl Physiol 59: 1773-1782, 1985). To examine whether HA-induced adaptation improves pulmonary gas exchange during exercise and whether adaptation is reversible when animals return to SL before somatic maturity, we raised 2.5-mo-old foxhounds at HA (3,800 m) for 5 mo (to age 7.5 mo) before returning them to SL. Lung function was measured under anesthesia 1 mo and 2 yr after return to SL and during exercise approximately 1 yr after return. In animals exposed to HA relative to simultaneous litter-matched SL controls, resting circulating blood and erythrocyte volumes, lung volumes, septal volume estimated by a rebreathing technique, and lung tissue volume estimated by high-resolution computed tomography scan were persistently higher. Lung diffusing capacity, membrane diffusing capacity, and pulmonary capillary blood volume estimated at a given cardiac output were significantly higher in animals exposed to HA, whereas maximal oxygen uptake and hematocrit were similar between groups. We conclude that relatively short exposure to HA during somatic maturation improves long-term lung function into adulthood.

Analysis of tumor vessel supply in Lewis lung carcinoma in mice by fluorescent microsphere distribution and imaging with micro- and flat-panel computed tomography

In lung carcinomas the blood supply varies depending on tumor type and stage and can develop from pulmonary or bronchial circulation, or both. To examine this in vivo, primary bronchogenic Lewis lung carcinoma cells were intratracheally instilled in C57BL/6 mice. Within 7 days, histological examinations showed progressive tumor growth at the peripheral parenchymal region. The relative contribution of tumor blood supply via the pulmonary and systemic arteries was studied in detail using fluorescent microspheres (10 microm). When compared to healthy lung parenchyma (13:1), Lewis lung carcinoma tumor tissue (52:1) showed a fourfold increase in pulmonary to systemic microspheres, indicating that the pulmonary arteries are the predominant tumor-feeding vessels. After filling the vessels with a vascular cast, the microanatomy of vessels being derived from the pulmonary artery was visualized with micro computed tomography. Flat-panel volumetric computed tomography provided longitudinal visualization of tissue bridges between the growing tumor and the pulmonary vasculature. In this model of peripheral parenchymal malignancy, new imaging techniques allowed effective visualization of lung tumor growth and vascularization in living mice, demonstrating a pulmonary blood supply for lung tumors.

Effects of viral respiratory infections on lung development and childhood asthma

Viral infections are closely linked to wheezing in infancy, and those children with recurrent virus-induced wheezing episodes are at great risk for chronic childhood asthma. Infancy is a time of increased susceptibility to viral infections, and this stage is also characterized by pulmonary alveolar multiplication and extensive remodeling of the airways to accommodate growth. This coincidence, together with the observation that children with asthma can have structural lung changes and functional deficits at an early age, suggests that viral infections could adversely affect lung development. Inflammatory mediators induced by viral infection are known to have effects on the remodeling process, suggesting a plausible mechanism to support this theory. Furthermore, animal models of viral infection during lung growth and development suggest that developmental factors are important in determining the consequences of infection on long-term lung function. Greater understanding of the effects of viral infections on lung development and growth in early childhood might lead to the discovery of additional strategies for the prevention of recurrent wheezing and chronic asthma.

Interleukin-1beta causes pulmonary inflammation, emphysema, and airway remodeling in the adult murine lung

The production of the inflammatory cytokine interleukin (IL)-1 is increased in lungs of patients with chronic obstructive pulmonary disease (COPD) or asthma. To characterize the in vivo actions of IL-1 in the lung, transgenic mice were generated in which human IL-1beta was expressed in the lung epithelium with a doxycycline-inducible system controlled by the rat Clara cell secretory protein (CCSP) promoter. Induction of IL-1beta expression in the lungs of adult mice caused pulmonary inflammation characterized by neutrophil and macrophage infiltrates. IL-1beta caused distal airspace enlargement, consistent with emphysema. IL-1beta caused disruption of elastin fibers in alveolar septa and fibrosis in airway walls and in the pleura. IL-1beta increased the thickness of conducting airways, enhanced mucin production, and caused lymphocytic aggregates in the airways. Decreased immunostaining for the winged helix transcription factor FOXA2 was associated with goblet cell hyperplasia in IL-1beta-expressing mice. The production of the neutrophil attractant CXC chemokines KC (CXCL1) and MIP-2 (CXCL2), and of matrix metalloproteases MMP-9 and MMP-12, was increased by IL-1beta. Chronic production of IL-1beta in respiratory epithelial cells of adult mice causes lung inflammation, enlargement of distal airspaces, mucus metaplasia, and airway fibrosis in the adult mouse.

Upregulation of hypoxia-induced mitogenic factor in compensatory lung growth after pneumonectomy

After pneumonectomy, the remaining lung increases in size. This process is referred to as compensatory lung growth. Various pathways likely play important roles in this growth response. The molecular mechanisms involved in compensatory lung growth, however, remain poorly understood. Hypoxia-induced mitogenic factor (HIMF), also called FIZZ1 or RELM-alpha, possesses mitogenic, vasoconstrictive, angiogenic, and antiapoptotic effects. In this study, we examined the expression of HIMF in mouse lung after pneumonectomy to test the hypothesis that HIMF expression is upregulated during compensatory lung growth. Results showed that HIMF is upregulated from Day 1 after pneumonectomy and peaking at Day 7 in the lung. HIMF upregulation is temporally and spatially related to lung cell proliferation, as demonstrated by expression of proliferating cell nuclear antigen. Immunohistochemical staining and in situ hybridization showed that upregulated HIMF protein and mRNA are mainly distributed in airway epithelium, alveolar type II cells, and endothelial cells of the pulmonary vessels. Intratracheal instillation of recombinant HIMF resulted in widespread cell proliferation, including airway epithelium, alveolar type II cells, and cells in the alveolar septa. These results indicate a new role for HIMF in compensatory lung growth, which is that HIMF may act as a lung-specific growth factor and participate in lung regeneration after pneumonectomy.