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Lv H, Huang L, Yang X, Zhang C, Yu H, Shang X. The clinical effectiveness of sivelestat in treating sepsis patients with both acute respiratory distress syndrome and septic cardiomyopathy. J Cardiothorac Surg 2024; 19:399. [PMID: 38937755 PMCID: PMC11210008 DOI: 10.1186/s13019-024-02835-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 06/14/2024] [Indexed: 06/29/2024] Open
Abstract
BACKGROUND We aimed to assess the efficacy of the neutrophil elastase inhibitor, sivelestat, in the treatment of sepsis-induced acute respiratory distress syndrome (ARDS) and septic cardiomyopathy (SCM). METHODS Between January 2019 and December 2021, we conducted a randomized trial on patients who had been diagnosed with sepsis-induced acute respiratory distress syndrome (ARDS) and septic cardiomyopathy (SCM) at Wuhan Union Hospital. The patients were divided into two groups by random envelop method, the Sivelestat group and the Control group. We measured the serum concentrations of Interleukin (IL)-6, IL-8, Tumor necrosis factor-α (TNF-α), and High-mobility group box 1 (HMGB1) at five time points, which were the baseline, 12 h, 24 h, 48 h, and 72 h after admission to the ICU. We evaluated the cardiac function by sonography and the heart rate variability (HRV) with 24-hour Holter recording between the time of admission to the intensive care unit (ICU) and 72 h after Sivelestat treatment. RESULTS From January 2019 to December 2021, a total of 70 patients were included in this study. The levels of IL-6, IL-8, and TNF-α were significantly lower in the Sivelestat group at different time points (12 h, 24 h, 48 h, and 72 h). HMGB1 levels were significantly lower at 72 h after Sivelestat treatment (19.46 ± 2.63pg/mL vs. 21.20 ± 2.03pg/mL, P = 0.003). The stroke volume (SV), tricuspid annular plane systolic excursion (TAPSE), early to late diastolic transmitral flow velocity (E/A), early (e') and late (a') diastoles were significantly low in the Control group compared with the Sivelestat group. Tei index was high in the Control group compared with the Sivelestat group (0.60 ± 0.08 vs. 0.56 ± 0.07, P = 0.029). The result of HRV showed significant differences in standard deviation of normal-to-normal intervals (SDNN), low frequency (LF), and LF/HF (high frequency) between the two groups. CONCLUSIONS Sivelestat can significantly reduce the levels of serum inflammatory factors, improve cardiac function, and reduce heart rate variability in patients with Sepsis-induced ARDS and SCM.
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Affiliation(s)
- Hui Lv
- Department of ICU, Wuhan No.1 Hospital, No.215 Zhongshan Avenue, Wuhan, China
| | - Langjing Huang
- Department of Cardiovascular Medicine, Changsha Economic Development Zone Hospital, Changsha, China
| | - Xiuhong Yang
- Department of ICU, Wuhan No.1 Hospital, No.215 Zhongshan Avenue, Wuhan, China
| | - Changdong Zhang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1277 Jiefang Avenue, Jianghan District, Wuhan, 430022, Hubei Province, China
| | - Hao Yu
- Department of Cardiology, Wuhan No.1 Hospital, No.215 Zhongshan Avenue, Wuhan, China
| | - Xiaoke Shang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1277 Jiefang Avenue, Jianghan District, Wuhan, 430022, Hubei Province, China.
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Tang YX, Fan ZW, Li J, Pan HD, Su WX, Matniyaz Y, Zhang HT, Luo YX, Lv ZK, Wang WZ, Gao YX, Pan T, Xu WZ, Wang DJ. Sivelestat in Patients at a High Risk of Postoperative Acute Lung Injury After Scheduled Cardiac Surgery: A Prospective Cohort Study. J Inflamm Res 2024; 17:591-601. [PMID: 38318242 PMCID: PMC10840550 DOI: 10.2147/jir.s442208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 01/20/2024] [Indexed: 02/07/2024] Open
Abstract
Background Sivelestat, a neutrophil elastase inhibitor, is specifically developed to mitigate the occurrence of acute lung injury (ALI) in individuals who are undergoing cardiovascular surgery. However, its impact on patients who are at a heightened risk of developing ALI after scheduled cardiac surgery has yet to be determined. In order to address this knowledge gap, we undertook a study to assess the efficacy of sivelestat in protecting the lungs of these patients. Methods We conducted a prospective cohort study involving 718 patients who were at high risk of developing postoperative acute lung injury (ALI) and underwent scheduled cardiac surgery between April 25th, 2022, and September 7th, 2023. Among them, 52 patients received sivelestat (administered at a dosage of 0.2mg/kg/h for 3 days), while 666 patients served as controls, not receiving sivelestat. The control conditions were the same for all patients, including ventilation strategy, extubating time, and fluid management. Subsequently, a propensity-score matched cohort was established, consisting of 40 patients in both the sivelestat and control groups. The primary outcome measure encompassed a composite of adverse outcomes, including 30-day mortality, ALI, acute respiratory distress syndrome (ARDS), and others. Secondary outcomes assessed included pneumonia, ventricular arrhythmias, mechanical ventilation (MV) time, and more. Results After conducting propensity matching in our study, we observed that there were no significant differences in 30-day mortality between the sivelestat and control groups (0% vs 2.5%, P=0.32). However, the use of sivelestat exhibited a significant reduction in the incidence of acute lung injury/acute respiratory distress syndrome (ALI/ARDS) compared to the control group (0% vs 55%, P<0.01), pneumonia (0 vs 37.5%, P<0.01), MV time (median:8 hours, IQR:4-14.8 hours vs median: 15.2 hours, IQR:14-16.3 hours, P<0.01). Compared to the control group, the sivelestat could significantly decrease white cell count (P<0.01), neutrophile percentage (P<0.01) and C-reactive protein (P<0.01) in the period of postoperative 5 days. Conclusion The prophylactic administration of sivelestat has shown promising results in reducing the occurrence of acute lung injury/acute respiratory distress syndrome (ALI/ARDS) in patients with a heightened risk of developing these conditions after elective cardiac surgery. Our study findings indicate that sivelestat may provide protective effects by suppressing inflammation triggered by neutrophil activation, thereby safeguarding pulmonary function. Registration ChiCTR2200059102, https://www.chictr.org.cn/showproj.html?proj=166643.
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Affiliation(s)
- Yu-Xian Tang
- Department of Cardiac Surgery, Nanjing Drum Tower Hospital, Nanjing Drum Tower Hospital Clinical College, Nanjing University of Chinese Medicine, Nanjing, People’s Republic of China
| | - Zhi-Wei Fan
- Department of Cardiac Surgery, Nanjing Drum Tower Hospital, Nanjing Drum Tower Hospital Clinical College, Nanjing University of Chinese Medicine, Nanjing, People’s Republic of China
| | - Jing Li
- Department of Cardiac Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, People’s Republic of China
| | - Hao-Dong Pan
- Department of Clinical Medicine, Norman Bethune Health Science Center of Jilin University, Changchun, People’s Republic of China
| | - Wen-Xin Su
- Department of Cardiac Surgery, Nanjing Drum Tower Hospital, Nanjing Drum Tower Hospital Clinical College, Nanjing University of Chinese Medicine, Nanjing, People’s Republic of China
| | - Yusanjan Matniyaz
- Department of Cardiac Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, People’s Republic of China
| | - Hai-Tao Zhang
- Department of Cardiac Surgery, Nanjing Drum Tower Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, Nanjing, People’s Republic of China
| | - Yuan-Xi Luo
- Department of Cardiac Surgery, Nanjing Drum Tower Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, Nanjing, People’s Republic of China
| | - Zhi-Kang Lv
- Department of Cardiac Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, People’s Republic of China
| | - Wen-Zhe Wang
- Department of Cardiac Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, People’s Republic of China
| | - Ya-Xuan Gao
- Department of Cardiac Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, People’s Republic of China
| | - Tuo Pan
- Department of Cardiac Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, People’s Republic of China
- Department of Cardiac Surgery, Nanjing Drum Tower Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, Nanjing, People’s Republic of China
| | - Wan-Zi Xu
- Department of Cardiac Surgery, Nanjing Drum Tower Hospital, Nanjing Drum Tower Hospital Clinical College, Nanjing University of Chinese Medicine, Nanjing, People’s Republic of China
- Department of Cardiac Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, People’s Republic of China
| | - Dong-Jin Wang
- Department of Cardiac Surgery, Nanjing Drum Tower Hospital, Nanjing Drum Tower Hospital Clinical College, Nanjing University of Chinese Medicine, Nanjing, People’s Republic of China
- Department of Cardiac Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, People’s Republic of China
- Department of Clinical Medicine, Norman Bethune Health Science Center of Jilin University, Changchun, People’s Republic of China
- Department of Cardiac Surgery, Nanjing Drum Tower Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, Nanjing, People’s Republic of China
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3
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Pan T, Tuoerxun T, Chen X, Yang CJ, Jiang CY, Zhu YF, Li ZS, Jiang XY, Zhang HT, Zhang H, Wang YP, Chen W, Lu LC, Ge M, Cheng YQ, Wang DJ, Zhou Q. The neutrophil elastase inhibitor, sivelestat, attenuates acute lung injury in patients with cardiopulmonary bypass. Front Immunol 2023; 14:1082830. [PMID: 36761773 PMCID: PMC9902923 DOI: 10.3389/fimmu.2023.1082830] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 01/09/2023] [Indexed: 01/26/2023] Open
Abstract
Background The sivelestat is a neutrophil elastase inhibitor thought to have an effect against acute lung injury (ALI) in patients after scheduled cardiac surgery. However, the beneficial effect of sivelestat in patients undergoing emergent cardiovascular surgery remains unclear. We aim to evaluate the effect of sivelestat on pulmonary protection in patients with ALI after emergent cardiovascular surgery. Methods Firstly, a case-control study in 665 patients undergoing emergent cardiovascular surgery from January 1st, 2020 to October 26th, 2022 was performed. 52 patients who received sivelestat (0.2mg/kg/h for 3 days) and 613 age- and sex-matched controls. Secondly, a propensity-score matched cohort (sivelestat vs control: 50 vs 50) was performed in these 665 patients. The primary outcome was a composite of adverse outcomes, including 30-day mortality, ECMO, continuous renal replacement therapy (CRRT) and IABP, etc. The secondary outcome included pneumonia, ventricular arrhythmias and mechanical ventilation time, etc. Results In propensity-matched patients, the 30-day mortality (16% vs 24%, P=0.32), stroke (2% vs 8%, P=0.17), ECMO(6% vs 10%, P=0.46), IABP(4% vs 8%, P=0.40) and CRRT(8% vs 20%, P=0.08) had no differences between sivelestat and control group; sivelestat could significantly decrease pneumonia (40% vs 62%, P=0.03), mechanical ventilation time (median: 96hours, IQR:72-120hours vs median:148hours, IQR:110-186hours, P<0.01), bilateral pulmonary infiltrates (P<0.01), oxygen index (P<0.01), interleukin-6(P=0.02), procalcitonin(P<0.01) and C-reactive protein(P<0.01). Conclusion Administration of sivelestat might improve postoperative outcomes in patients with ALI after emergent cardiovascular surgery. Our results show that sivelestat may be considered to protect pulmonary function against inflammatory injury by CPB. Registration http://www.chictr.org.cn/showproj.aspx?proj=166643, identifier ChiCTR2200059102.
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Affiliation(s)
- Tuo Pan
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China.,Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, Nanjing, China
| | - Tayierjiang Tuoerxun
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Xi Chen
- The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Cheng-Jin Yang
- Department of Pediatric Surgery, Sanya Women and Children's Hospital, Sanya, China
| | - Chen-Yu Jiang
- Department of Cardio-Thoracic Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yi-Fan Zhu
- Department of Cardio-Thoracic Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Ze-Shi Li
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, Nanjing, China
| | - Xin-Yi Jiang
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, Nanjing, China
| | - Hai-Tao Zhang
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, Nanjing, China
| | - He Zhang
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, Nanjing, China
| | - Ya-Peng Wang
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, Nanjing, China
| | - Wei Chen
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Li-Chong Lu
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Min Ge
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Yong-Qing Cheng
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Dong-Jin Wang
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China.,Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, Nanjing, China
| | - Qing Zhou
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
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Baptista de Barros Ribeiro Dourado LP, Santos M, Moreira-Gonçalves D. Nets, pulmonary arterial hypertension, and thrombo-inflammation. J Mol Med (Berl) 2022; 100:713-722. [PMID: 35441845 DOI: 10.1007/s00109-022-02197-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 12/28/2021] [Accepted: 03/31/2022] [Indexed: 02/07/2023]
Abstract
Pulmonary arterial hypertension (PAH) is a progressive and fatal vascular disease in which high blood pressure in the pulmonary artery and remodeling of the pulmonary vasculature ensues. This disorder is characterized by the presence of thrombotic lesions, resulting from chronic platelet, coagulation factors, and endothelium activation, which translate into platelet aggregation, vasoconstriction, and medial thickening. Neutrophil extracellular traps (NETs), a network of chromatin and cytoplasmatic enzymes (myeloperoxidase and neutrophil elastase) forming after neutrophil programmed cell death, were described in multiple cardiovascular diseases as thrombotic mediators, by creating a scaffold or by surface receptor interaction. In this review, we analyze the possible involvement of NETs in PAH, to enlighten future studies to explore this hypothesis. NETs may have a determining role in pulmonary hypertension through activation of platelets and endothelial cells. Simultaneously, NETosis may be induced by endothelial signaling and/or cell-cell interaction between platelets and primed neutrophils, creating a positive feedback loop. Confirming its role in the pathophysiology and prognosis of PAH may represent a new opportunity to explore new therapeutic options. KEY MESSAGES: Thrombosis and innate immunity are relevant axes in PAH. Patients with PAH display elevated levels of NETs. NETs could activate platelets/endothelium with proliferative and thrombotic effects. Activated platelets and endothelium could contribute to NETosis. NETs could open new therapy research avenues.
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Affiliation(s)
| | - Mário Santos
- Cardiology Department, Hospital Santo António, Centro Hospitalar Universitário do Porto, Largo do Prof. Abel Salazar, 4099-001, Porto, Portugal.,Unit of Multidisciplinary Research in Biomedicine, Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, R. Jorge de Viterbo Ferreira 228, 4050-313, Porto, Portugal
| | - Daniel Moreira-Gonçalves
- CIAFEL, Faculty of Sport, University of Porto, R. Dr. Plácido da Costa 91, 4200-450, Porto, Portugal.,ITR - Laboratory for Integrative and Translational Research in Population Health, Porto, Portugal
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5
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Colakerol A, Suzan S, Temiz MZ, Gonultas S, Aykan S, Ozsoy S, Kucuk SH, Yuruk E, Kandırali E, Semercioz A. Tissue neutrophil elastase contributes to extracorporeal shock wave lithotripsy-induced kidney damage and the neutrophil elastase inhibitor, sivelestat, attenuates kidney damage with gratifying immunohistopathological and biochemical findings: an experimental study. Urolithiasis 2022; 50:103-112. [PMID: 34778918 DOI: 10.1007/s00240-021-01287-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 10/20/2021] [Indexed: 02/07/2023]
Abstract
Although the efficacy of extracorporeal shock wave lithotripsy (ESWL) has been well established within the literature, debate continues on the safety of the procedure while focusing on cellular injury and its long-term consequences. Here, we describe the role of neutrophil elastase (NE) in ESWL-related rat kidney damage and investigate the protective effects of sivelestat, an inhibitor of NE, during the early and late phases. Four groups including control, ESWL alone, ESWL with sivelestat 50 mg/kg and ESWL with treatment of 100 mg/kg, each consisting of ten rats were created. Biochemical parameters of kidney function and damage and immunohistopathological findings were compared in the early (72 h after ESWL) and late (1 week after ESWL) periods between the groups. During the early period, serum and urine creatinine levels and urine kidney injury molecule-1 (KIM-1) levels and the KIM-1/creatinine ratio increased in rats treated with ESWL compared to the control group. Furthermore, increased tissue inflammation, ductal dilatation and hemorrhage, and glomerular, tubular, and interstitial damage with increased NE staining were also detected in the ESWL treatment group. During the late phase, although urine KIM-1 levels remained stable at high levels, other parameters showed significant improvements. On the other hand, the administration of sivelestat 50 mg/kg decreased serum creatinine and urine KIM-1 and KIM-1/creatinine levels significantly in rats treated with ESWL, during the early and late periods. Significant decreases in tissue inflammation, tubular, and interstitial tissue damage were also observed during the early period. In conclusion, ESWL-related kidney tissue damage occurs primarily during the early period, and NE is involved in this process. On the other hand, the NE inhibitor sivelestat attenuated this ESWL-induced kidney damage.
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Affiliation(s)
- Aykut Colakerol
- Department of Urology, Bagcilar Training and Research Hospital, Merkez Mah., Dr. Sadik Ahmet Cad., Bagcilar, Istanbul, Turkey
| | - Serhat Suzan
- Department of Urology, Bagcilar Training and Research Hospital, Merkez Mah., Dr. Sadik Ahmet Cad., Bagcilar, Istanbul, Turkey
| | - Mustafa Zafer Temiz
- Department of Urology, Bagcilar Training and Research Hospital, Merkez Mah., Dr. Sadik Ahmet Cad., Bagcilar, Istanbul, Turkey
| | - Serkan Gonultas
- Department of Urology, Bagcilar Training and Research Hospital, Merkez Mah., Dr. Sadik Ahmet Cad., Bagcilar, Istanbul, Turkey
| | - Serdar Aykan
- Department of Urology, Bagcilar Training and Research Hospital, Merkez Mah., Dr. Sadik Ahmet Cad., Bagcilar, Istanbul, Turkey
| | - Sule Ozsoy
- Department of Pathology, Bagcilar Training and Research Hospital, Bagcilar, Istanbul, Turkey
| | - Suat Hayri Kucuk
- Department of Biochemistry, Bagcilar Training and Research Hospital, Bagcilar, Istanbul, Turkey
| | - Emrah Yuruk
- Department of Urology, Bagcilar Training and Research Hospital, Merkez Mah., Dr. Sadik Ahmet Cad., Bagcilar, Istanbul, Turkey
| | - Engin Kandırali
- Department of Urology, Bagcilar Training and Research Hospital, Merkez Mah., Dr. Sadik Ahmet Cad., Bagcilar, Istanbul, Turkey
| | - Atilla Semercioz
- Department of Urology, Bagcilar Training and Research Hospital, Merkez Mah., Dr. Sadik Ahmet Cad., Bagcilar, Istanbul, Turkey.
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6
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Involvement of Progranulin and Granulin Expression in Inflammatory Responses after Cerebral Ischemia. Int J Mol Sci 2019; 20:ijms20205210. [PMID: 31640144 PMCID: PMC6829276 DOI: 10.3390/ijms20205210] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 10/19/2019] [Accepted: 10/19/2019] [Indexed: 01/17/2023] Open
Abstract
Progranulin (PGRN) plays a crucial role in diverse biological processes, including cell proliferation and embryonic development. PGRN can be cleaved by neutrophil elastase to release granulin (GRN). PGRN has been found to inhibit inflammation. Whereas, GRN plays a role as a pro-inflammatory factor. However, the pathophysiological roles of PGRN and GRN, at early stages after cerebral ischemia, have not yet been fully understood. The aim of this study was to obtain further insight into the pathologic roles of PGRN and GRN. We demonstrated that the amount of PGRN was significantly increased in microglial cells after cerebral ischemia in rats and that neutrophil elastase activity was also increased at an early stage after cerebral ischemia, resulting in the production of GRN. The inhibition of neutrophil elastase activity suppressed PGRN cleavage and GRN production, as well as the increase in pro-inflammatory cytokines, after cerebral ischemia. The administration of an elastase inhibitor decreased the number of injured cells and improved the neurological deficits test scores. Our findings suggest that an increase in the activity of elastase to cleave PGRN, and to produce GRN, was involved in an inflammatory response at the early stages after cerebral ischemia, and that inhibition of elastase activity could suppress the progression of cerebral ischemic injury.
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7
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Ferreira GC, Duran AFA, da Silva FRS, Bomediano LDM, Machado GC, Sasaki SD. Neutrophil elastase inhibitor purification strategy from cowpea seeds. PLoS One 2019; 14:e0223713. [PMID: 31600323 PMCID: PMC6786636 DOI: 10.1371/journal.pone.0223713] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 09/27/2019] [Indexed: 01/09/2023] Open
Abstract
Serine proteases and its inhibitors are involved in physiological process and its deregulation lead to various diseases like Chronic Obstructive Pulmonary Disease (COPD), pulmonary emphysema, skin diseases, atherosclerosis, coagulation diseases, cancer, inflammatory diseases, neuronal disorders and other diseases. Serine protease inhibitors have been described in many species, as well as in plants, including cowpea beans (Vigna unguiculata (L.) Walp). Here, we purified and characterized a protease inhibitor, named VuEI (Vigna unguiculata elastase inhibitor), from Vigna unguiculata, with inhibitory activity against HNE (human neutrophil elastase) and chymotrypsin but has no inhibitory activity against trypsin and thrombin. VuEI was obtained by alkaline protein extraction followed by three different chromatographic steps in sequence. First, an ion exchange chromatography using Hitrap Q column was employed, followed by two reversed-phase chromatography using Source15RPC and ACE18 columns. The molecular mass of VuEI was estimated in 10.99 kDa by MALDI-TOF mass spectrometry. The dissociation constant (Ki) to HNE was 9 pM. These data indicate that VuEI is a potent inhibitor of human neutrophil elastase, besides to inhibit chymotrypsin.
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Affiliation(s)
- Graziele Cristina Ferreira
- Centro de Ciências Naturais e Humanas, Universidade Federal do ABC, São Bernardo do Campo, São Paulo, Brazil
| | | | | | - Livia de Moraes Bomediano
- Centro de Ciências Naturais e Humanas, Universidade Federal do ABC, São Bernardo do Campo, São Paulo, Brazil
| | - Gabriel Capella Machado
- Centro de Ciências Naturais e Humanas, Universidade Federal do ABC, São Bernardo do Campo, São Paulo, Brazil
| | - Sergio Daishi Sasaki
- Centro de Ciências Naturais e Humanas, Universidade Federal do ABC, São Bernardo do Campo, São Paulo, Brazil
- * E-mail:
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8
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Kam AYF, Piryani SO, McCall CM, Park HS, Rizzieri DA, Doan PL. Targeting High Mobility Group Box-1 (HMGB1) Promotes Cell Death in Myelodysplastic Syndrome. Clin Cancer Res 2019; 25:4155-4167. [PMID: 30952643 PMCID: PMC6800136 DOI: 10.1158/1078-0432.ccr-18-3517] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 02/15/2019] [Accepted: 03/28/2019] [Indexed: 12/18/2022]
Abstract
PURPOSE Myelodysplastic syndrome (MDS) is associated with a dysregulated innate immune system. The purpose of this study was to determine whether modulation of the innate immune system via high mobility group box-1 (HMGB1) could reduce cell viability in MDS. EXPERIMENTAL DESIGN We quantified HMGB1 in an MDS cell line MDS-L and in primary MDS cells compared with nonmalignant hematopoietic cells. We performed loss-of-function studies of HMGB1 using pooled siRNAs and a small-molecule inhibitor sivelestat compared with standard chemotherapy. We measured levels of engraftment of MDS-L cells in NOD-scidIL2Rgnull (NSG) mice following treatment with sivelestat. Mechanistically, we interrogated cell survival pathways and 45 targets within the NFκB pathway using both protein analysis and a proteome profiler array. RESULTS We discovered that HMGB1 had increased expression in both MDS-L cells and in primary CD34+ MDS cells compared with healthy CD34+ hematopoietic cells. Sivelestat impaired MDS cell expansion, increased cellular death, and spared healthy hematopoietic cells. MDS-L marrow engraftment is reduced significantly at 17 weeks following treatment with sivelestat compared with control mice. Treatment of CD34+ MDS cells with sivelestat and azacitidine or decitabine was additive to increase apoptotic cell death compared with chemotherapy alone. Sivelestat promoted apoptosis with increased expression of PUMA, activated caspase 3, and increased DNA double-strand breaks. Inhibition of HMGB1 reduced levels of Toll-like receptors (TLR) and suppressed activation of NFκB in MDS-L cells. CONCLUSIONS Inhibition of HMGB1 could promote MDS cell death and alter innate immune responses via suppression of NFκB pathways.
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Affiliation(s)
- Angel Y F Kam
- Division of Hematologic Malignancies and Cellular Therapy, Duke University, Durham, North Carolina
| | - Sadhna O Piryani
- Division of Hematologic Malignancies and Cellular Therapy, Duke University, Durham, North Carolina
| | - Chad M McCall
- Department of Pathology, Duke University, Durham, North Carolina
| | - Hee Su Park
- Division of Hematologic Malignancies and Cellular Therapy, Duke University, Durham, North Carolina
| | - David A Rizzieri
- Division of Hematologic Malignancies and Cellular Therapy, Duke University, Durham, North Carolina.,Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Phuong L Doan
- Division of Hematologic Malignancies and Cellular Therapy, Duke University, Durham, North Carolina. .,Duke Cancer Institute, Duke University, Durham, North Carolina
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9
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Voisin MB, Leoni G, Woodfin A, Loumagne L, Patel NS, Di Paola R, Cuzzocrea S, Thiemermann C, Perretti M, Nourshargh S. Neutrophil elastase plays a non-redundant role in remodeling the venular basement membrane and neutrophil diapedesis post-ischemia/reperfusion injury. J Pathol 2019; 248:88-102. [PMID: 30632166 PMCID: PMC6850085 DOI: 10.1002/path.5234] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 11/09/2018] [Accepted: 12/23/2018] [Indexed: 12/20/2022]
Abstract
Ischemia/reperfusion (I/R) injury is a severe inflammatory insult associated with numerous pathologies, such as myocardial infarction, stroke and acute kidney injury. I/R injury is characterized by a rapid influx of activated neutrophils secreting toxic free radical species and degrading enzymes that can irreversibly damage the tissue, thus impairing organ functions. Significant efforts have been invested in identifying therapeutic targets to suppress neutrophil recruitment and activation post‐I/R injury. In this context, pharmacological targeting of neutrophil elastase (NE) has shown promising anti‐inflammatory efficacy in a number of experimental and clinical settings of I/R injury and is considered a plausible clinical strategy for organ care. However, the mechanisms of action of NE, and hence its inhibitors, in this process are not fully understood. Here we conducted a comprehensive analysis of the impact of NE genetic deletion on neutrophil infiltration in four murine models of I/R injury as induced in the heart, kidneys, intestine and cremaster muscle. In all models, neutrophil migration into ischemic regions was significantly suppressed in NE−/− mice as compared with wild‐type controls. Analysis of inflamed cremaster muscle and mesenteric microvessels by intravital and confocal microscopy revealed a selective entrapment of neutrophils within venular walls, most notably at the level of the venular basement membrane (BM) following NE deletion/pharmacological blockade. This effect was associated with the suppression of NE‐mediated remodeling of the low matrix protein expressing regions within the venular BM used by transmigrating neutrophils as exit portals. Furthermore, whilst NE deficiency led to reduced neutrophil activation and vascular leakage, levels of monocytes and prohealing M2 macrophages were reduced in tissues of NE−/− mice subjected to I/R. Collectively our results identify a vital and non‐redundant role for NE in supporting neutrophil breaching of the venular BM post‐I/R injury but also suggest a protective role for NE in promoting tissue repair. © 2019 The Authors. The Journal of Pathology published by John Wiley & Sons Ltd on behalf of Pathological Society of Great Britain and Ireland.
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Affiliation(s)
- Mathieu-Benoit Voisin
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Giovanna Leoni
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK.,Institute for Cardiovascular Prevention (IPEK), Ludwig-Maximilian University (LMU), Munich, Germany
| | - Abigail Woodfin
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Laure Loumagne
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Nimesh Sa Patel
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Rosanna Di Paola
- Department of Chemical, Biological, Pharmaceutical and Environmental Sciences, University of Messina, Messina, Italy
| | - Salvatore Cuzzocrea
- Department of Chemical, Biological, Pharmaceutical and Environmental Sciences, University of Messina, Messina, Italy
| | - Christoph Thiemermann
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Mauro Perretti
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Sussan Nourshargh
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Ogawa R, Mori R, Iida K, Uchida Y, Oshiro M, Kageyama M, Kato Y, Tanaka T, Nakata Y, Nishimura Y, Hokuto I, Bonno M, Matsumoto N, Ito M, Takahashi N, Namba F. Effects of the early administration of sivelestat sodium on bronchopulmonary dysplasia in infants: A retrospective cohort study. Early Hum Dev 2017; 115:71-76. [PMID: 28950234 DOI: 10.1016/j.earlhumdev.2017.09.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 09/18/2017] [Accepted: 09/18/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Chorioamnionitis, or infiltration of the chorioamnion by neutrophils, is a risk factor associated with the development of bronchopulmonary dysplasia. Increased neutrophil elastase levels are observed in the tracheal aspirates of these patients. AIMS To examine the effects of early administration of the selective neutrophil elastase inhibitor sivelestat, which is used to treat acute lung injury in adults, on bronchopulmonary dysplasia in extremely premature infants. STUDY DESIGN Retrospective cohort study. SUBJECTS This study included extremely low-birth-weight infants born at a gestational age<28weeks. Patients were divided into groups based on the receipt of sivelestat. OUTCOME MEASURES The primary outcome was the rate of bronchopulmonary dysplasia-free survival at a postmenstrual age of 36weeks, and the secondary outcomes included various clinically significant factors of neonatal mortality and morbidity and adverse events. RESULTS Of the 1031 included neonates, 124 (12.0%) were treated with sivelestat. Significant differences between the groups were noted for gestational age, delivery method, fetal number, the frequency of chorioamnionitis, immunoglobulin M levels, and WBC counts. No differences were identified concerning the bronchopulmonary dysplasia-free survival rate at a postmenstrual age of 36weeks (adjusted odds ratio for sivelestat to control, 0.83; 95% confidence interval=0.53-1.30). Secondary outcomes did not significantly differ between the groups. CONCLUSIONS In extremely premature infants, early sivelestat use was not associated with an improved rate of survival without bronchopulmonary dysplasia at a postmenstrual age of 36weeks.
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Affiliation(s)
- Ryo Ogawa
- Saitama Medical Center, Saitama Medical University,1981 Kamoda Kawagoe, Saitama, Japan.
| | - Rintaro Mori
- National Center for Child Health and Development, 2-10-1, Okura, Setagaya, Tokyo, Japan.
| | - Koichi Iida
- Oita Prefectural Hospital, 476, Bunyo, Oita, Japan.
| | - Yumiko Uchida
- Nara Medical University Hospital, Center of Perinatal Medicine, 840, shijyo, Kashihara, Nara, Japan.
| | - Makoto Oshiro
- Japanese Red Cross Nagoya Daiichi Hospital, 3-35, Douge, Nakamura, Nagoya, Japan.
| | - Misao Kageyama
- Okayama Medical Center, 1711-1, Tamasu, Kita, Okayama, Japan.
| | - Yuichi Kato
- Anjo Kosei Hospital, 28, Higashikurokute, Anjo, Aichi, Japan.
| | - Taihei Tanaka
- Japanese Red Cross Nagoya Daini Hospital, 2-9, Myoken, ShowaNagoya, Aichi, Japan.
| | - Yusei Nakata
- Kochi Health Sciences Center, 2125, Ike, Kochi, Japan.
| | - Yutaka Nishimura
- Hiroshima City Hiroshima Citizens Hospital, 7-33, Motomachi, Naka, Hiroshima, Hiroshima, Japan.
| | - Isamu Hokuto
- St. Marianna University School of Medical Hospital, 2-16-1, Sugao, Miyamae, Kanagawa, Japan.
| | - Motoki Bonno
- Mie Chuo Medical Center, 2158-5, Hisaimyojin, Tsu, Mie, Japan.
| | - Naoko Matsumoto
- Kitakyushu Municipal Medical Center, Kitakyushu Kokurakita, Fukuoka, Japan.
| | - Masato Ito
- Saitama Medical Center, Saitama Medical University,1981 Kamoda Kawagoe, Saitama, Japan.
| | - Noriko Takahashi
- National Center for Child Health and Development, 2-10-1, Okura, Setagaya, Tokyo, Japan.
| | - Fumihiko Namba
- Saitama Medical Center, Saitama Medical University,1981 Kamoda Kawagoe, Saitama, Japan.
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11
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The neutrophil elastase inhibitor, sivelestat, attenuates sepsis-related kidney injury in rats. Int J Mol Med 2016; 38:767-75. [PMID: 27430552 PMCID: PMC4990314 DOI: 10.3892/ijmm.2016.2665] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 06/24/2016] [Indexed: 12/18/2022] Open
Abstract
Sepsis-induced acute kidney injury (AKI) represents a major cause of mortality in intensive care units. Sivelestat, a selective inhibitor of neutrophil elastase (NE), can attenuate sepsis-related acute lung injury. However, whether sivelestat can preserve kidney function during sepsis remains unclear. In this study, we thus examined the effects of sivelestat on sepsis-related AKI. Cecal ligation and puncture (CLP) was performed to induce multiple bacterial infection in male Sprague-Dawley rats, and subsequently, 50 or 100 mg/kg sivelestat were administered by intraperitoneal injection immediately after the surgical procedure. In the untreated rats with sepsis, the mean arterial pressure (MAP) and glomerular filtration rate (GFR) were decreased, whereas serum blood urea nitrogen (BUN) and neutrophil gelatinase-associated lipocalin (NGAL) levels were increased. We found that sivelestat promoted the survival of the rats with sepsis, restored the impairment of MAP and GFR, and inhibited the increased BUN and NGAL levels; specifically, the higher dose was more effective. In addition, sivelestat suppressed the CLP-induced macrophage infiltration, the overproduction of pro-inflammatory mediators (tumor necrosis factor-α, interleukin-1β, high-mobility group box 1 and inducible nitric oxide synthase) and serine/threonine kinase (Akt) pathway activation in the rats. Collectively, our data suggest that the inhibition of NE activity with the inhibitor, sivelestat, is beneficial in ameliorating sepsis-related kidney injury.
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12
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Muley MM, Reid AR, Botz B, Bölcskei K, Helyes Z, McDougall JJ. Neutrophil elastase induces inflammation and pain in mouse knee joints via activation of proteinase-activated receptor-2. Br J Pharmacol 2015; 173:766-77. [PMID: 26140667 DOI: 10.1111/bph.13237] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Revised: 06/05/2015] [Accepted: 06/30/2015] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND AND PURPOSE Neutrophil elastase plays a crucial role in arthritis. Here, its potential in triggering joint inflammation and pain was assessed, and whether these effects were mediated by proteinase-activated receptor-2 (PAR2). EXPERIMENTAL APPROACH Neutrophil elastase (5 μg) was injected into the knee joints of mice and changes in blood perfusion, leukocyte kinetics and paw withdrawal threshold were assessed. Similar experiments were performed in animals pretreated with the neutrophil elastase inhibitor sivelestat, the PAR2 antagonist GB83, the p44/42 MAPK inhibitor U0126 and in PAR2 receptor knockout (KO) mice. Neutrophil elastase activity was also evaluated in arthritic joints by fluorescent imaging and sivelestat was assessed for anti-inflammatory and analgesic properties. KEY RESULTS Intra-articular injection of neutrophil elastase caused an increase in blood perfusion, leukocyte kinetics and a decrease in paw withdrawal threshold. Sivelestat treatment suppressed this effect. The PAR2 antagonist GB83 reversed neutrophil elastase-induced synovitis and pain and these responses were also attenuated in PAR2 KO mice. The MAPK inhibitor U0126 also blocked neutrophil elastase-induced inflammation and pain. Active neutrophil elastase was increased in acutely inflamed knees as shown by an activatable fluorescent probe. Sivelestat appeared to reduce neutrophil elastase activity, but had only a moderate anti-inflammatory effect in this model. CONCLUSIONS AND IMPLICATIONS Neutrophil elastase induced acute inflammation and pain in knee joints of mice. These changes are PAR2-dependent and appear to involve activation of a p44/42 MAPK pathway. Blocking neutrophil elastase, PAR2 and p44/42 MAPK activity can reduce inflammation and pain, suggesting their utility as therapeutic targets.
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Affiliation(s)
- Milind M Muley
- Department of Pharmacology, Dalhousie University, Halifax, NS, Canada
| | - Allison R Reid
- Department of Pharmacology, Dalhousie University, Halifax, NS, Canada
| | - Bálint Botz
- Department of Pharmacology and Pharmacotherapy, University of Pécs, School of Medicine, Pécs, Hungary.,János Szentágothai Research Centre, University of Pécs, Molecular Pharmacology Research Team, Pécs, Hungary
| | - Kata Bölcskei
- Department of Pharmacology and Pharmacotherapy, University of Pécs, School of Medicine, Pécs, Hungary.,János Szentágothai Research Centre, University of Pécs, Molecular Pharmacology Research Team, Pécs, Hungary
| | - Zsuzsanna Helyes
- Department of Pharmacology and Pharmacotherapy, University of Pécs, School of Medicine, Pécs, Hungary.,MTA NAP B Pain Research Group, University of Pécs, School of Medicine, Pécs, Hungary.,János Szentágothai Research Centre, University of Pécs, Molecular Pharmacology Research Team, Pécs, Hungary
| | - Jason J McDougall
- Department of Pharmacology, Dalhousie University, Halifax, NS, Canada.,Department of Anaesthesia, Pain Management & Perioperative Medicine, Dalhousie University, Halifax, NS, Canada
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13
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Kim DH, Chung JH, Son BS, Kim YJ, Lee SG. Effect of a neutrophil elastase inhibitor on ventilator-induced lung injury in rats. J Thorac Dis 2015; 6:1681-9. [PMID: 25589960 DOI: 10.3978/j.issn.2072-1439.2014.11.10] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2014] [Accepted: 08/14/2014] [Indexed: 12/23/2022]
Abstract
OBJECTIVE We hypothesized that pretreatment with sivelestat therapy could attenuate ventilator-induced lung injury (VILI) and lung inflammation in a rat model. METHODS The neutrophil elastase inhibitor was administered intraperitoneally 30 min before and at the initiation of ventilation. The rats were categorized as (I) sham group; (II) VILI group; (III) sivelestat group; (IV) early sivelestat group. Wet-to-dry weight ratio, bronchoalveolar lavage fluid (BALF) neutrophil and protein, tissue malondialdehyde (MDA) and histologic VILI scores were investigated. RESULTS The ratio of wet-to-dry weight, BALF neutrophil and protein, tissue MDA and VILI scores were significantly increased in the VILI group compared to the sham group [3.85±0.32 vs. 9.05±1.02, P<0.001; (0.89±0.93)×10(4) vs. (7.67±1.41)×10(4) cells/mL, P<0.001; 2.34±0.47 vs. 23.01±3.96 mg/mL, P<0.001; 14.43±1.01 vs. 36.56±5.45 nmol/mg protein, P<0.001; 3.78±0.67 vs. 7.00±1.41, P<0.001]. This increase was attenuated in the early sivelestat group compared with the sivelestat group [wet-to-dry ratio: 6.76±2.01 vs. 7.39±0.32, P=0.032; BALF neutrophil: (5.56±1.13)×10(4) vs. (3.89±1.05)×10(4) cells/mL, P=0.021; BALF protein: 15.57±2.32 vs. 18.38±2.00 mg/mL, P=0.024; tissue MDA: 29.16±3.01 vs. 26.31±2.58, P=0.049; VILI scores: 6.33±1.41 vs. 5.00±0.50, P=0.024]. CONCLUSIONS Pretreatment with a neutrophil elastase inhibitor attenuates VILI in a rat model.
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Affiliation(s)
- Do-Hyung Kim
- 1 Department of Thoracic and Cardiovascular Surgery, Pusan National University Yangsan Hospital, Pusan, Korea ; 2 Division of Pulmonology, Department of Internal Medicine, International St. Mary's Hospital, Catholic Kwandong University College of Medicine, Incheon, Korea
| | - Jae Ho Chung
- 1 Department of Thoracic and Cardiovascular Surgery, Pusan National University Yangsan Hospital, Pusan, Korea ; 2 Division of Pulmonology, Department of Internal Medicine, International St. Mary's Hospital, Catholic Kwandong University College of Medicine, Incheon, Korea
| | - Bong Soo Son
- 1 Department of Thoracic and Cardiovascular Surgery, Pusan National University Yangsan Hospital, Pusan, Korea ; 2 Division of Pulmonology, Department of Internal Medicine, International St. Mary's Hospital, Catholic Kwandong University College of Medicine, Incheon, Korea
| | - Yeon Ji Kim
- 1 Department of Thoracic and Cardiovascular Surgery, Pusan National University Yangsan Hospital, Pusan, Korea ; 2 Division of Pulmonology, Department of Internal Medicine, International St. Mary's Hospital, Catholic Kwandong University College of Medicine, Incheon, Korea
| | - Sang Gwon Lee
- 1 Department of Thoracic and Cardiovascular Surgery, Pusan National University Yangsan Hospital, Pusan, Korea ; 2 Division of Pulmonology, Department of Internal Medicine, International St. Mary's Hospital, Catholic Kwandong University College of Medicine, Incheon, Korea
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