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Laudanski K, Liu D, Gullipalli D, Song WC, Okeke T, Szeto WY. A decline of protective apolipoprotein J and complement factor H concomitant with increase in C5a 3 months after cardiac surgery-Evidence of long-term complement perturbations. Front Cardiovasc Med 2022; 9:983617. [PMID: 36606279 PMCID: PMC9808065 DOI: 10.3389/fcvm.2022.983617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 11/23/2022] [Indexed: 12/24/2022] Open
Abstract
Background Heart surgery results in complement activation with the potential for collateral end-organ damage, especially if the protective elements (complement factor H, Apolipoprotein J) are inadequate. Here, we have investigated if peri-operative stress results in an imbalance between complement activation and its protective mechanisms up to 3 months after heart surgery. Methods 101 patients scheduled for non-emergent cardiac surgery donated blood before the procedure (tbaseline), and 24 h (t24h ), 7 days (t7d ) and 3 months (t3m ) after. Complement activation was measured as a serum level of soluble activated component 5 (sC5a) and soluble terminal complement complex (sTCC). Simultaneously, protective complement factor H (CfH), and apolipoprotein J (ApoJ) were measured. Inflammatory responses were quantified using C-reactive protein (CRP) and interleukin-6 (IL-6). Details regarding anesthesia, intensive care unit (ICU) stay, pre-existing conditions, the incidence of postoperative complications, and mortality were collected from medical records. Results C5a declined at t24h to rebound at t7d and t3m . sTCC was significantly depressed at t24h and returned to baseline at later time points. In contrast, CfH and ApoJ were depressed at t3m . Milieu of complement factors aligned along two longitudinal patterns:cluster#1 (C5a/sTTC continuously increasing and CfH/ApoJ preserved at tbaseline) and cluster#2 (transient sC5a/sTTC increase and progressive decline of CfH). Most patients belonged to cluster #1 at t24h (68%), t7d (74%) and t3m (72%). sTCC correlated with APACHE1h (r 2 =-0.25; p < 0.031) and APACHE24h (r 2 = 0.27; p < 0.049). IL-6 correlated with C5a (r 2 =-0.28; p < 0.042) and sTTC (r 2 =-0.28; p < 0.015). Peri-operative administration of acetaminophen and aspirin altered the complement elements. Prolonged hospital stay correlated with elevated C5a [t (78) = 2.03; p = 0.048] and sTTC serum levels [U (73) = 2.07; p = 0.037]. Patients with stroke had a decreased serum level of C5a at t7d and t3m. Conclusion There is a significant decrease in complement protective factors 3 months after cardiac surgery, while C5a seems to be slightly elevated, suggesting that cardiac surgery affects complement milieu long into recovery.
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Affiliation(s)
- Krzysztof Laudanski
- Department of Anesthesiology and Critical Care, The University of Pennsylvania, Philadelphia, PA, United States,Department of Neurology, The University of Pennsylvania, Philadelphia, PA, United States,Leonard Davis Institute for Health Economics, The University of Pennsylvania, Philadelphia, PA, United States,*Correspondence: Krzysztof Laudanski,
| | - Da Liu
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Damodar Gullipalli
- Department of Systems Pharmacology and Translational Therapeutics, The University of Pennsylvania, Philadelphia, PA, United States
| | - Wen-Chao Song
- Department of Systems Pharmacology and Translational Therapeutics, The University of Pennsylvania, Philadelphia, PA, United States
| | - Tony Okeke
- Department of Bioengineering, Drexel University, Philadelphia, PA, United States
| | - Wilson Y. Szeto
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, United States
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Kefalogianni R, Kamani F, Gaspar M, Aw TC, Donovan J, Laffan M, Pickering MC, Arachchillage DJ. Complement activation during cardiopulmonary bypass and association with clinical outcomes. EJHAEM 2022; 3:86-96. [PMID: 35846208 PMCID: PMC9175769 DOI: 10.1002/jha2.371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 12/02/2021] [Accepted: 12/07/2021] [Indexed: 11/08/2022]
Abstract
In this prospective, single-centre observational study of 30 patients undergoing cardiopulmonary bypass (CPB), the effect of unfractionated heparin (UFH), CPB surgery and protamine sulphate on complement and on post-operative blood loss were assessed. Although C3 and C4 levels decreased significantly immediately following the administration of UFH, C3a, C5a, Bb fragment and SC5b-9 remained unchanged. During CPB, C3 and C4 continued to fall whilst both alternative and classical pathways activation markers, Bb, C3a, C5a and SC5b-9 increased significantly. Protamine sulphate had no effect on classical pathway components or activation markers but decreased alternative pathway activation marker Bb. Over the 12-24 h post-surgery, both classical and alternative pathway activation markers returned to baseline, whilst C3 and C4 levels increased significantly but not to baseline values. Total drain volume 24 h after the surgery showed a moderate inverse correlation with post-protamine C3 (r = -0.46, p = 0.01) and C4 (r = -0.57, p = 0.0009) levels, whilst a moderate positive correlation was observed with post-protamine C3a (r = 0.46, p = 0.009), C5a (r = 0.37, p = 0.04) and SC5b-9 (r = 0.56, p = 0.001) levels but not with Bb fragment (r = 0.25, p = 0.17). Thus, inhibition of complement activation may be a therapeutic intervention to reduce post-operative blood in patients undergoing CPB.
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Affiliation(s)
| | - Farah Kamani
- Department of HaematologyRoyal Brompton HospitalLondonUK
| | - Mihaela Gaspar
- Department of HaematologyRoyal Brompton HospitalLondonUK
| | - TC Aw
- Department of Anesthesia and Critical CareRoyal Brompton HospitalLondonUK
| | - Jackie Donovan
- Department of BiochemistryRoyal Brompton HospitalLondonUK
| | - Mike Laffan
- Centre for HaematologyDepartment of Immunology and InflammationImperial College LondonLondonUK
| | | | - Deepa J. Arachchillage
- Department of HaematologyRoyal Brompton HospitalLondonUK
- Centre for HaematologyDepartment of Immunology and InflammationImperial College LondonLondonUK
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Huang Z, He Y, Li QJ, Wen H, Zhang XY, Tu RH, Zhong GQ. Postconditioning attenuates myocardial ischemia-reperfusion injury by inhibiting complement activation and upregulation of miR-499. Exp Ther Med 2021; 22:684. [PMID: 33986849 PMCID: PMC8111864 DOI: 10.3892/etm.2021.10116] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 02/22/2021] [Indexed: 01/04/2023] Open
Abstract
The complement system plays a vital role in myocardial ischemia/reperfusion (I/R) injury. microRNA (miR)-499 is involved in the cardioprotection of ischemic postconditioning (IPostC). The present study aimed to study the role of the complement system and miR-499 in IPostC. Rat hearts were subjected to coronary ligation for 30 min, followed by reperfusion for 2 h. IPostC was introduced at the onset of reperfusion with three cycles of reperfusion for 30 sec and coronary artery occlusion for 30 sec. To study the role of miR-499 in IPostC, adeno-associated virus (AAV) vectors of miR-499-5p (AAV-miR-499-5p) and miR-499-5p-sponge (AAV-miR-499-5p-sponge) were transfected via tail vein injection, followed by IPostC protocols. Cardiac injury as well as the status of local and systemic complement activation and inflammation were assessed. IPostC significantly attenuated I/R-induced rat cardiomyocyte apoptosis and the myocardial infarct size. These beneficial effects were accompanied by decreased local and circulating complement component (C)3a and C5a levels, decreased inflammatory marker expression, decreased NF-κB signaling and increased cardiac miR-499 expression. AAV-miR-499-5p prevented local and systemic complement activation and inflammation as well as enhanced the cardioprotection of IPostC, whereas AAV-miR-499-5p-sponge produced the opposite effects. In summary, IPostC protected the rat myocardium against I/R injury, by inhibiting local and systemic complement activation; inflammation; NF-κB signaling; and upregulation of miR-499. As such, miR-499 may have a critical role in IPostC-mediated cardioprotection against I/R injury.
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Affiliation(s)
- Zheng Huang
- Department of Cardiology, First Affiliated Hospital, Guangxi Medical University, Nanning, Guangxi 530021, P.R. China
| | - Yan He
- Department of Geriatric Cardiology, First Affiliated Hospital, Guangxi Medical University, Nanning, Guangxi 530021, P.R. China.,Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention, Nanning, Guangxi 530021, P.R. China
| | - Qing-Jie Li
- Department of Cardiology, First Affiliated Hospital, Guangxi Medical University, Nanning, Guangxi 530021, P.R. China
| | - Hong Wen
- Department of Geriatric Cardiology, First Affiliated Hospital, Guangxi Medical University, Nanning, Guangxi 530021, P.R. China.,Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention, Nanning, Guangxi 530021, P.R. China
| | - Xin-Yue Zhang
- Department of Geriatric Cardiology, First Affiliated Hospital, Guangxi Medical University, Nanning, Guangxi 530021, P.R. China
| | - Rong-Hui Tu
- Department of Geriatric Cardiology, First Affiliated Hospital, Guangxi Medical University, Nanning, Guangxi 530021, P.R. China.,Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention, Nanning, Guangxi 530021, P.R. China
| | - Guo-Qiang Zhong
- Department of Cardiology, First Affiliated Hospital, Guangxi Medical University, Nanning, Guangxi 530021, P.R. China.,Guangxi Key Laboratory of Precision Medicine in Cardio-Cerebrovascular Diseases Control and Prevention, Nanning, Guangxi 530021, P.R. China
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Bellomo R, Auriemma S, Fabbri A, D'Onofrio A, Katz N, Mccullough P, Ricci Z, Shaw A, Ronco C. The Pathophysiology of Cardiac Surgery-Associated Acute Kidney Injury (CSA-AKI). Int J Artif Organs 2018; 31:166-78. [DOI: 10.1177/039139880803100210] [Citation(s) in RCA: 199] [Impact Index Per Article: 33.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Cardiac surgery associated acute kidney injury (CSA-AKI) is a significant clinical problem. Its pathogenesis is complex and multifactorial. It likely involved at least six major injury pathways: exogenous and endogenous toxins, metabolic factors, ischemia and reperfusion, neurohormonal activation, inflammation and oxidative stress. These mechanisms of injury are likely to be active at different times with different intensity and probably act synergistically. Because of such complexity and the small number of randomised controlled investigations in this field only limited recommendations can be made. Nonetheless, it appears important to avoid nephrotoxic drugs and desirable to avoid hyperglycemia in the peri-operative period. The duration of cardiopulmonary bypass should be limited whenever possible. Off-pump surgery, when indicated, may decrease the risk of AKI. Invasive hemodynamic monitoring focussed on attention to maintaining euvolemia, an adequate cardiac output and an adequate arterial blood pressure is desirable. Echocardiography may be useful in minimizing atheroembolic complications. The administration of N-acetylcysteine to protect the kidney from oxidative stress is not recommended. There is marked lack of randomised controlled trials in this field.
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Affiliation(s)
- R. Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne - Australia
| | - S. Auriemma
- Department of Cardiac Surgery, San Bortolo Hospital, Vicenza - Italy
| | - A. Fabbri
- Department of Cardiac Surgery, San Bortolo Hospital, Vicenza - Italy
| | - A. D'Onofrio
- Department of Cardiac Surgery, San Bortolo Hospital, Vicenza - Italy
| | - N. Katz
- Department of Surgery, Georgetown University Medical Center, Washington, DC - USA
| | - P.A. Mccullough
- Division of Cardiology, William Beaumont Hospital, Royal Oak, Michigan - USA
| | - Z. Ricci
- Department of Pediatric Cardiosurgery, Ospedale del Bambino Gesù, Rome - Italy
| | - A. Shaw
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina - USA
| | - C. Ronco
- Department of Nephrology, Dialysis and Transplantation, S. Bortolo Hospital - International Renal Research Institute Vicenza (IRRIV), Vicenza - Italy
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Pantazi E, Bejaoui M, Folch-Puy E, Adam R, Roselló-Catafau J. Advances in treatment strategies for ischemia reperfusion injury. Expert Opin Pharmacother 2016; 17:169-79. [PMID: 26745388 DOI: 10.1517/14656566.2016.1115015] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Ischemia-reperfusion injury (IRI) involves a complex sequence of events and limits the outcome of various surgical interventions. Clinical trials, based on the data of experimental models, aim to prove whether a pharmacological or technical approach could be suitable to provide a beneficial effect in humans. Due to the complexity of IRI, few pharmacological treatments have been investigated in clinical Phase III. AREAS COVERED In this review we report clinical trials that test specific drugs in clinical trials of organ transplantation. These studies form part of Phase II trials and examine the administration of caspase inhibitors, P-selectin antagonist or an antioxidant component in order to attenuate cold IRI during transplantation. Moreover, we provide a brief description of drugs tested on trials of different clinical situations associated to IRI, such as the coronary artery bypass graft surgery and percutaneous coronary intervention. EXPERT OPINION Future clinical trials could be centered on the application of techniques suitable for organs with increased vulnerability toward IRI. Furthermore, the standardization of reliable biomarkers and a careful estimation of the impact of high risk factors may be the key in order to achieve a more critical evaluation of the obtained results.
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Affiliation(s)
- Eirini Pantazi
- a Experimental Hepatic Ischemia-Reperfusion Unit , Institute of Biomedical Research of Barcelona (IIBB-CSIC) , Barcelona , Spain
| | - Mohamed Bejaoui
- a Experimental Hepatic Ischemia-Reperfusion Unit , Institute of Biomedical Research of Barcelona (IIBB-CSIC) , Barcelona , Spain
| | - Emma Folch-Puy
- a Experimental Hepatic Ischemia-Reperfusion Unit , Institute of Biomedical Research of Barcelona (IIBB-CSIC) , Barcelona , Spain
| | - René Adam
- b AP-HP Hôpital Paul Brousse , Centre Hepato-Biliaire, Univ Paris-Sud Villejuif , Paris , France
| | - Joan Roselló-Catafau
- a Experimental Hepatic Ischemia-Reperfusion Unit , Institute of Biomedical Research of Barcelona (IIBB-CSIC) , Barcelona , Spain
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Binder A, Ali A, Chawla R, Aziz HA, Abbate A, Jovin IS. Myocardial protection from ischemia-reperfusion injury post coronary revascularization. Expert Rev Cardiovasc Ther 2015. [DOI: 10.1586/14779072.2015.1070669] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Duehrkop C, Rieben R. Ischemia/reperfusion injury: effect of simultaneous inhibition of plasma cascade systems versus specific complement inhibition. Biochem Pharmacol 2013; 88:12-22. [PMID: 24384116 DOI: 10.1016/j.bcp.2013.12.013] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Revised: 11/25/2013] [Accepted: 12/16/2013] [Indexed: 02/06/2023]
Abstract
Ischemia/reperfusion injury (IRI) may occur from ischemia due to thrombotic occlusion, trauma or surgical interventions, including transplantation, with subsequent reestablishment of circulation. Time-dependent molecular and structural changes result from the deprivation of blood and oxygen in the affected tissue during ischemia. Upon restoration of blood flow a multifaceted network of plasma cascades is activated, including the complement-, coagulation-, kinin-, and fibrinolytic system, which plays a major role in the reperfusion-triggered inflammatory process. The plasma cascade systems are therefore promising therapeutic targets for attenuation of IRI. Earlier studies showed beneficial effects through inhibition of the complement system using specific complement inhibitors. However, pivotal roles in IRI are also attributed to other cascades. This raises the question, whether drugs, such as C1 esterase inhibitor, which regulate more than one cascade at a time, have a higher therapeutic potential. The present review discusses different therapeutic approaches ranging from specific complement inhibition to simultaneous inhibition of plasma cascade systems for reduction of IRI, gives an overview of the plasma cascade systems in IRI as well as highlights recent findings in this field.
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Affiliation(s)
- Claudia Duehrkop
- Department of Clinical Research, University of Bern, Murtenstrasse 50, P.O. Box 44, CH-3010 Bern, Switzerland; Graduate School of Cellular and Biomedical Sciences, University of Bern, Switzerland
| | - Robert Rieben
- Department of Clinical Research, University of Bern, Murtenstrasse 50, P.O. Box 44, CH-3010 Bern, Switzerland.
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8
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Targeting the complement system in systemic lupus erythematosus and other diseases. Clin Immunol 2013; 148:313-21. [DOI: 10.1016/j.clim.2013.02.014] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2012] [Revised: 02/22/2013] [Accepted: 02/25/2013] [Indexed: 02/04/2023]
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Abstract
C3a and C5a (also called anaphylatoxins) are inflammatory peptides generated during complement activation. They do not only play important roles in innate immunity through the initiation and regulation of inflammatory responses, but also significantly influence adaptive immune responses. Organ transplantation triggers an initial inflammatory response and subsequent to the specific immune response (also called the alloimmune response), both of which contribute to graft rejection. Emerging evidence suggests that anaphylatoxins, particularly C5a, are significantly involved in both inflammatory and alloimmune responses following organ transplantation, thus influencing graft outcome. This review will provide the information on our current understanding of the roles for anaphylatoxins in ischemia-reperfusion injury, graft rejection, and transplant tolerance, and the therapeutic potential of targeting anaphylatoxin receptors in organ transplantation.
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Abstract
The complement system is an important part of innate immunity; however, as with other parts of the immune system, the complement system can become pathologically activated and create or worsen disease. Anticomplement reagents have been studied for several years, but only recently have they emerged as a viable therapeutic tool. Here, we describe the role of the complement system in a wide array of diseases, as well as the use of anticomplement therapy as treatment for these diseases in animal models and in human clinical trials. Specifically, we will discuss the role of anticomplement therapy in paroxysmal nocturnal hemoglobinuria, glomerulonephritis, and heart disease, including coronary artery disease, myocardial infarction, and coronary revascularization procedures such as percutaneous coronary angioplasty and coronary artery bypass graft surgery.
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Effects of C5 complement inhibitor pexelizumab on outcome in high-risk coronary artery bypass grafting: Combined results from the PRIMO-CABG I and II trials. J Thorac Cardiovasc Surg 2011; 142:89-98. [DOI: 10.1016/j.jtcvs.2010.08.035] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2010] [Revised: 07/26/2010] [Accepted: 08/05/2010] [Indexed: 11/20/2022]
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Busche MN, Stahl GL. Role of the complement components C5 and C3a in a mouse model of myocardial ischemia and reperfusion injury. GERMAN MEDICAL SCIENCE : GMS E-JOURNAL 2010; 8. [PMID: 20930931 PMCID: PMC2940219 DOI: 10.3205/000109] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2010] [Revised: 07/30/2010] [Indexed: 01/17/2023]
Abstract
Objective: Ischemic heart disease is the leading cause of death worldwide. The complement system plays a major role in inflammation and tissue injury following myocardial ischemia and reperfusion (MI/R) injury. Systemic C5 inhibition in clinical studies has resulted in mixed results and the role of earlier complement components (e.g., C3a), upstream from C5 cleavage, has not been elucidated for MI/R injury. Therefore, we evaluated the role of C5 or C3a in a mouse model of MI/R injury. Methods: We performed experimental MI/R with 30 min of ischemia and 4 hr of reperfusion in 8–12 wk old C57BL/6 (WT) mice. Systemic C5 or C3a inhibition was performed with an anti-C5 monoclonal antibody (BB5.1) 30 min prior to reperfusion or with a C3a receptor antagonist (C3aRA). Since the C3aRA induces neutropenia that resolves within 120 min, we administered C3aRA at two different time points in two separate groups: 30 min prior to reperfusion within the neutropenic time frame and 120 min prior to reperfusion, when the neutropenia had resolved, but C3aRA remained active. Following MI/R, cardiac function was assessed via echocardiography, serum troponin I concentrations were measured as an index of myocardial cell death and myocardial inflammation was determined via myocardial polymorphonuclear leukocyte (PMN) infiltration. Results: In wild type mice, MI/R significantly decrease myocardial ejection fraction and increased serum troponin I levels and myocardial PMN infiltration compared to sham-operated animals. Systemic C5 inhibition, 30 min prior to reperfusion, significantly protected mice from MI/R injury, confirming an important role for C5 in murine MI/R injury. Treatment with the C3aRA, 30 min prior to reperfusion (i.e., within the neutropenic time frame), protected mice significantly from MI/R related injury. In contrast, administration of the C3aRA 120 min prior to reperfusion, when the neutropenia had resolved, but C3aRA remained active, did not prevent MI/R injury. Conclusions: These results confirm an important role for C5 cleavage in murine MI/R injury. At the same time, they suggest a minimal role for C3a, since neutropenia rather than C3a receptor antagonism appears to be responsible for C3aRA related amelioration in MI/R injury. While C5 inhibition in the clinical setting of MI/R does not appear to be therapeutic, our results raise the possibility that inhibition of either C5a or C5b-9 may be more advantageous than inhibition of C3a or complete inhibition of C5 in humans.
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Affiliation(s)
- Marc N Busche
- Center for Experimental Therapeutics and Reperfusion Injury, Harvard Institutes of Medicine, Boston, MA, USA
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Complement-mediated ischemia-reperfusion injury: lessons learned from animal and clinical studies. Ann Surg 2009; 249:889-99. [PMID: 19474697 DOI: 10.1097/sla.0b013e3181a38f45] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Ischemia-reperfusion (I/R) injury provides a substantial limitation to further improvements in the development of therapeutic strategies for ischemia-related diseases. Studies in animal I/R models, including intestinal, hindlimb, kidney, and myocardial I/R models, have established a key role of the complement system in mediation of I/R injury using complement inhibitors and knock-out animal models. As complement activation has been shown to be an early event in I/R injury, inhibiting its activation or its components may offer tissue protection after reperfusion. However, clinical study results using complement inhibitors have largely been disappointing. Therefore, identification of a more specific pathogenic target for therapeutic intervention seems to be warranted. For this purpose more detailed knowledge of the responsible pathway of complement activation in I/R injury is required. Recent evidence from in vitro and in vivo models suggests involvement of both the classic and the lectin pathways in I/R injury via exposition of neo-epitopes in ischemic membranes. However, most of these findings have been obtained in knock-out murine models and have for a large part remained unconfirmed in the human setting. The observation that the relative role of each pathway seems to differ among organs complicates matters further. Whether a defective complement system protects from I/R injury in humans remains largely unknown. Most importantly, involvement of mannose-binding lectin as the main initiator of the lectin pathway has not been demonstrated at tissue level in human I/R injury to date. Thus, conclusions drawn from animal I/R studies should be extrapolated to the human setting with caution.
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Impact of intraoperative myocardial tissue acidosis on postoperative adverse outcomes and cost of care for patients undergoing prolonged aortic clamping during cardiopulmonary bypass. Am J Surg 2009; 197:203-10. [DOI: 10.1016/j.amjsurg.2008.01.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2007] [Revised: 01/08/2008] [Accepted: 01/08/2008] [Indexed: 11/20/2022]
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Warren OJ, Watret AL, de Wit KL, Alexiou C, Vincent C, Darzi AW, Athanasiou T. The inflammatory response to cardiopulmonary bypass: part 2--anti-inflammatory therapeutic strategies. J Cardiothorac Vasc Anesth 2008; 23:384-93. [PMID: 19054695 DOI: 10.1053/j.jvca.2008.09.007] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2008] [Indexed: 01/26/2023]
Affiliation(s)
- Oliver J Warren
- Department of BioSurgery and Surgical Technology, Imperial College London, St Mary's Hospital, London, United Kingdom.
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Mehta RH, Alexander JH, Emery R, Ellis SJ, Hasselblad V, Khalil A, Carrier M, Harrington RA, Tardif JC. A randomized, double-blind, placebo-controlled, multicenter study to evaluate the cardioprotective effects of MC-1 in patients undergoing high-risk coronary artery bypass graft surgery: MC-1 to Eliminate Necrosis and Damage in Coronary Artery Bypass Graft Surgery Trial (MEND-CABG) II--study design and rationale. Am Heart J 2008; 155:600-8. [PMID: 18371465 DOI: 10.1016/j.ahj.2008.01.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2007] [Accepted: 01/17/2008] [Indexed: 11/16/2022]
Abstract
BACKGROUND Coronary artery bypass graft (CABG) surgery is effective in relieving angina and improving survival and quality of life in patients with obstructive coronary artery disease; however, recurrent angina, myocardial infarction, neurological injury, and death can occur in the perioperative and postoperative period. MC-1 (pyridoxal 5'-phosphate) is a novel agent that has shown promise in reducing myocardial necrosis by reducing cellular calcium overload after percutaneous coronary intervention and CABG surgery in high-risk patients undergoing these procedures. METHODS MEND-CABG II is a phase III study evaluating the efficacy and safety of MC-1 in reducing cardiovascular morbidity and mortality after CABG. High-risk patients undergoing CABG surgery will be randomly assigned to receive either MC-1 (250 mg/d) or matching placebo immediately before and continuing for 30 days after the procedure. The primary end point is the occurrence of cardiovascular death or nonfatal myocardial infarction through postoperative day 30. A total of 3023 patients were enrolled at 130 sites in Canada, the United States, and Germany between October 2006 and September 2007, with results anticipated shortly after completion of 90-day follow-up in March 2008. CONCLUSIONS The data from the MEND-CABG II trial will establish whether peri- and postoperative treatment with MC-1 can decrease the short- and intermediate-term morbidity and mortality of high-risk patients undergoing CABG surgery.
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Zhang M, Carroll MC. Natural IgM-mediated innate autoimmunity: a new target for early intervention of ischemia-reperfusion injury. Expert Opin Biol Ther 2007; 7:1575-82. [PMID: 17916049 DOI: 10.1517/14712598.7.10.1575] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Recent studies showed that innate autoimmunity is an early mechanism for ischemia-reperfusion (I/R) injury. Results from different animal models showed that reperfusion of ischemic tissues elicits an acute inflammatory response involving a complement system, which is activated by autoreactive natural IgM. Moreover, ischemia-specific self-targets were identified. In contrast to the unsuccessful attempts in the past to treat I/R injury, targeting natural IgM-mediated innate autoimmunity may open a new avenue for early intervention.
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Affiliation(s)
- Ming Zhang
- SUNY-Downstate Medical Center, Department of Anesthesiology, 450 Clarkson Avenue, Brooklyn, NY 11203, USA.
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Lazar HL, Keilani T, Fitzgerald CA, Shapira OM, Hunter CT, Shemin RJ, Marsh HC, Ryan US. Beneficial effects of complement inhibition with soluble complement receptor 1 (TP10) during cardiac surgery: is there a gender difference? Circulation 2007; 116:I83-8. [PMID: 17846331 DOI: 10.1161/circulationaha.106.677914] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND TP10, a potent inhibitor of complement activation during cardiopulmonary bypass (CPB) has been shown to significantly reduce the incidence of death and myocardial infarction (MI) in high-risk male patients undergoing cardiac surgery. However, the effect of TP10 in females was undefined because of the limited number of females studied. To examine the possibility of a gender effect, this phase 2 multi-center trial was undertaken to determine whether TP10 would also limit ischemic damage in a larger sample size of high-risk females undergoing cardiac surgery on cardiopulmonary bypass (CPB). METHODS AND RESULTS This prospective, double-blind, placebo-controlled, multi-center trial involved 297 high-risk (urgent surgery, CABG + Valve, reoperations, ejection fraction <30%) female patients randomized to receive a 5 mg/kg dose of TP10 (n=150) or placebo (n=147) as a 30-minute intravenous infusion before surgery. The primary end point was the incidence of death or MI at 28 days after surgery. Complement activation was assessed by levels of CH50 and SC5b-9 during and after CPB. TP10 was well tolerated and there were no differences in the safety profiles of the 2 groups. Although TP10 effectively suppressed complement activation (at 2 hours after CPB CH50 (mean+SD % change from baseline) 50+/-17% placebo versus 4+/-14% TP10; P=0.0001; SC5b-9 (ng/mL) 917+/-1067 placebo versus 204+/-79 TP10; P=0.0001), there was no difference in the primary end point between the groups (17% placebo versus 21% TP10; P=0.2550). CONCLUSIONS The benefits of TP10 appear to be gender-related. and mechanisms other than complement activation may be responsible for myocardial injury in high-risk female patients during cardiac surgery on CPB.
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Affiliation(s)
- Harold L Lazar
- Department of Cardiothoracic Surgery, Boston University School of Medicine and the Boston Medical Center, 88 East Newton Street, Suite B402, Boston, MA 02118, USA.
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Thrane AS, Skehan JD, Thrane PS. A novel interpretation of immune redundancy and duality in reperfusion injury with important implications for intervention in ischaemic disease. Med Hypotheses 2006; 68:1363-70. [PMID: 17169498 DOI: 10.1016/j.mehy.2006.10.044] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2006] [Accepted: 10/19/2006] [Indexed: 01/04/2023]
Abstract
The majority of ischaemia related injury occurs upon tissue reperfusion. Knock-out mouse models have recently shed light on the underlying molecular mechanisms, and suggest that this may be the result of an innate autoimmune response. Based on these new findings we present a novel model of immune redundancy and duality in reperfusion injury. Natural antibody, mannan-binding lectin and toll-like receptor 4 are three pre-formed innate immune receptors that recognise pathogenic molecular patterns. Removing either significantly ameliorates reperfusion injury. We propose that these three receptors serve as key parallel recognition elements that respond to the same or similar ischaemic neo-antigens, of which at least one may have a lipopolysaccharide-like motif. This would fit both with the ligand preference of the three receptors, and the observation that giving monoclonal antibody to lipopolysaccharide reduces reperfusion injury. The consequent injury caused by receptor activation appears to be mainly related to the complement anaphylatoxins, and less to phagocytes, oxidative radicals, and the membrane attack complex. C5a levels in particular are predictive of overall injury, and we suggest this anaphylatoxin causes most of reperfusion injury via both direct toxic effects and a generalised immune activation. The former is illustrated by the recent observation that excess C5a alone can cause cardiac dysfunction. As for the latter, there is evidence that adaptive immunity (especially CD4+ cells) and other serum cascades (coagulation and kallikrein) are involved, and may have been recruited by complement. Furthermore, excess C5a can cause innate immune overactivation that paralyses neutrophils, reduces complement lytic function, and leads to systemic inflammation. This is analogous to what happens in sepsis, and would explain the passive role in IRI of normal immune effectors. Finally, there is a duality complement's function in reperfusion, as some elements are conductive of damage, whilst others may help inflammatory resolution. Most important among the latter are the opsonins, like C3b and apparently C1q, which help macrophages clear apoptosing cells before they undergo secondary necrosis. This model has important implications for clinical interventions. Firstly, redundancy means that inhibiting multiple receptors may achieve a larger mortality reduction than the small and inconsistent one seen in the published monotherapy trials. Secondly, duality means that a non-specific inhibition of complement would reduce both injury and resolution. Therefore, a specific inhibition of the lectin pathway and/or an inhibition of the downstream effectors upon which the receptors converge (e.g. C5a) seem to be a better interceptive strategy.
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Affiliation(s)
- A S Thrane
- Department of Cardiovascular Sciences, Glenfield Hospital, University of Leicester, United Kingdom
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