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Guo B, Liu W, Ji X, Xi B, Meng X, Xie W, Sun Y, Zhang M, Liu P, Zhang W, Yan X, Chen B. CSF3 aggravates acute exacerbation of pulmonary fibrosis by disrupting alveolar epithelial barrier integrity. Int Immunopharmacol 2024; 135:112322. [PMID: 38788452 DOI: 10.1016/j.intimp.2024.112322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 05/03/2024] [Accepted: 05/19/2024] [Indexed: 05/26/2024]
Abstract
Idiopathic pulmonary fibrosis (IPF) is a chronic and progressive respiratory disorder characterized by poor prognosis, often presenting with acute exacerbation. The primary cause of death associated with IPF is acute exacerbation of IPF (AE-IPF). However, the pathophysiology of acute exacerbation has not been clearly elucidated yet. This study aims to investigate the underlying pathophysiological molecular mechanism in a mouse AE-PF model. C57BL/6J mice were intratracheally administered bleomycin (BLM, 5 mg/kg) to induce pulmonary fibrosis. After 14 days, lipopolysaccharide (LPS, 2 mg/kg) was injected via the trachea route. Histological assessments, including H&E and Masson staining, as well as inflammatory indicators, were included to evaluate the induction of AE-PF by BLM and LPS in mice. Transcriptomic profiling of pulmonary tissues identified CSF3 as one of the top 10 upregulated DEGs in AE-PF mice. Indeed, administration of exogenous CSF3 protein exacerbated AE-PF in mice. Mechanistically, CSF3 disrupted alveolar epithelial barrier integrity and permeability by regulating specialized cell adhesion complexes such as tight junctions (TJs) and adherens junctions (AJs) via PI3K/p-Akt/Snail pathway, contributing to the aggravation of AE-PF in mice. Moreover, the discovery of elevated sera CSF3 indicated a notable increase in IPF patients during the exacerbation of the disease. Pearson correlation analysis in IPF patients revealed significant positive associations between CSF3 levels and KL-6 levels, LDH levels, CRP levels, respectively. These results provide mechanistic insights into the role of CSF3 in exacerbating of lung fibrotic disease and indicate monitoring CSF3 levels may aid in early clinical decisions for alternative therapy in the management of rapidly progressing IPF.
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Affiliation(s)
- Bingnan Guo
- The Laboratory of Emergency Medicine, School of Second Clinical Medicine, Xuzhou Medical University, Department of Emergency Medicine, the Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu 221000, China
| | - Wenwen Liu
- Department of Respiratory and Critical Care Medicine, the Affiliated Hospital of Xuzhou Medical University, Department of Respiratory Medicine, School of First Clinical Medicine, Xuzhou Medical University, Xuzhou, Jiangsu 221000, China
| | - Xuan Ji
- Department of Respiratory and Critical Care Medicine, the Affiliated Hospital of Xuzhou Medical University, Department of Respiratory Medicine, School of First Clinical Medicine, Xuzhou Medical University, Xuzhou, Jiangsu 221000, China; Department of Respiratory Medicine, Yancheng Third People's Hospital, Yancheng, Jiangsu 224000, China
| | - Bin Xi
- Department of Respiratory and Critical Care Medicine, the Affiliated Hospital of Xuzhou Medical University, Department of Respiratory Medicine, School of First Clinical Medicine, Xuzhou Medical University, Xuzhou, Jiangsu 221000, China
| | - Xiao Meng
- Department of Respiratory and Critical Care Medicine, the Affiliated Hospital of Xuzhou Medical University, Department of Respiratory Medicine, School of First Clinical Medicine, Xuzhou Medical University, Xuzhou, Jiangsu 221000, China
| | - Wanwan Xie
- Department of Respiratory and Critical Care Medicine, the Affiliated Hospital of Xuzhou Medical University, Department of Respiratory Medicine, School of First Clinical Medicine, Xuzhou Medical University, Xuzhou, Jiangsu 221000, China
| | - Yitian Sun
- Department of Respiratory and Critical Care Medicine, the Affiliated Hospital of Xuzhou Medical University, Department of Respiratory Medicine, School of First Clinical Medicine, Xuzhou Medical University, Xuzhou, Jiangsu 221000, China
| | - Maowei Zhang
- Department of Respiratory and Critical Care Medicine, the Affiliated Hospital of Xuzhou Medical University, Department of Respiratory Medicine, School of First Clinical Medicine, Xuzhou Medical University, Xuzhou, Jiangsu 221000, China
| | - Pingli Liu
- Department of Respiratory and Critical Care Medicine, the Affiliated Hospital of Xuzhou Medical University, Department of Respiratory Medicine, School of First Clinical Medicine, Xuzhou Medical University, Xuzhou, Jiangsu 221000, China
| | - Wenhui Zhang
- Department of Respiratory and Critical Care Medicine, the Affiliated Hospital of Xuzhou Medical University, Department of Respiratory Medicine, School of First Clinical Medicine, Xuzhou Medical University, Xuzhou, Jiangsu 221000, China
| | - Xianliang Yan
- The Laboratory of Emergency Medicine, School of Second Clinical Medicine, Xuzhou Medical University, Department of Emergency Medicine, the Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu 221000, China; Department of Emergency Medicine, Suining People's Hospital, Xuzhou 221225, Jiangsu, China.
| | - Bi Chen
- Department of Respiratory and Critical Care Medicine, the Affiliated Hospital of Xuzhou Medical University, Department of Respiratory Medicine, School of First Clinical Medicine, Xuzhou Medical University, Xuzhou, Jiangsu 221000, China.
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2
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Lawler PR, Derde LPG, van de Veerdonk FL, McVerry BJ, Huang DT, Berry LR, Lorenzi E, van Kimmenade R, Gommans F, Vaduganathan M, Leaf DE, Baron RM, Kim EY, Frankfurter C, Epelman S, Kwan Y, Grieve R, O'Neill S, Sadique Z, Puskarich M, Marshall JC, Higgins AM, Mouncey PR, Rowan KM, Al-Beidh F, Annane D, Arabi YM, Au C, Beane A, van Bentum-Puijk W, Bonten MJM, Bradbury CA, Brunkhorst FM, Burrell A, Buzgau A, Buxton M, Cecconi M, Cheng AC, Cove M, Detry MA, Estcourt LJ, Ezekowitz J, Fitzgerald M, Gattas D, Godoy LC, Goossens H, Haniffa R, Harrison DA, Hills T, Horvat CM, Ichihara N, Lamontagne F, Linstrum KM, McAuley DF, McGlothlin A, McGuinness SP, McQuilten Z, Murthy S, Nichol AD, Owen DRJ, Parke RL, Parker JC, Pollock KM, Reyes LF, Saito H, Santos MS, Saunders CT, Seymour CW, Shankar-Hari M, Singh V, Turgeon AF, Turner AM, Zarychanski R, Green C, Lewis RJ, Angus DC, Berry S, Gordon AC, McArthur CJ, Webb SA. Effect of Angiotensin-Converting Enzyme Inhibitor and Angiotensin Receptor Blocker Initiation on Organ Support-Free Days in Patients Hospitalized With COVID-19: A Randomized Clinical Trial. JAMA 2023; 329:1183-1196. [PMID: 37039790 PMCID: PMC10326520 DOI: 10.1001/jama.2023.4480] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 03/07/2023] [Indexed: 04/12/2023]
Abstract
IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non-critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support-free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support-free days among critically ill patients was 10 (-1 to 16) in the ACE inhibitor group (n = 231), 8 (-1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support-free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02735707.
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Affiliation(s)
- Patrick R Lawler
- Peter Munk Cardiac Centre at University Health Network, Toronto, Canada
- McGill University Health Centre, Montreal, QC, Canada
| | | | | | | | | | | | | | | | - Frank Gommans
- Radboud University Medical Centre, Nijmegen, Netherlands
| | | | - David E Leaf
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Rebecca M Baron
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Edy Y Kim
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Slava Epelman
- Peter Munk Cardiac Centre at University Health Network, Toronto, Canada
| | - Yvonne Kwan
- Peter Munk Cardiac Centre at University Health Network, Toronto, Canada
| | - Richard Grieve
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Stephen O'Neill
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Zia Sadique
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | | | | | - Paul R Mouncey
- Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | - Kathryn M Rowan
- Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | | | - Djillali Annane
- Hospital Raymond Poincaré (Assistance Publique Hôpitaux de Paris), Garches, France
- Université Versailles SQY - Université Paris Saclay, Montigny-le-Bretonneux, France
| | - Yaseen M Arabi
- King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Carly Au
- Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | - Abi Beane
- University of Oxford, Oxford, England
| | | | | | | | | | | | | | - Meredith Buxton
- Global Coalition for Adaptive Research, Larkspur, California
| | | | | | - Matthew Cove
- Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | | | | | | | | | - David Gattas
- The George Institute for Global Health, Sydney, Australia
| | - Lucas C Godoy
- Peter Munk Cardiac Centre at University Health Network, Toronto, Canada
| | | | - Rashan Haniffa
- University of Oxford, Bangkok, Thailand
- National Intensive Care Surveillance (NICST), Colombo, Sri Lanka
| | - David A Harrison
- Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | - Thomas Hills
- Medical Research Institute of New Zealand (MRINZ), Wellington, New Zealand
| | | | | | | | | | - Daniel F McAuley
- Queen's University Belfast, Belfast, Northern Ireland
- Royal Victoria Hospital, Belfast, Northern Ireland
| | | | - Shay P McGuinness
- Monash University, Melbourne, Australia
- Auckland City Hospital, Auckland, New Zealand
| | | | | | - Alistair D Nichol
- Monash University, Melbourne, Australia
- University College Dublin, Dublin, Ireland
| | - David R J Owen
- Department of Brain Sciences, Imperial College London, London, United Kingdom
- UK Dementia Research Institute of Imperial College London, London, United Kingdom
| | - Rachael L Parke
- Auckland City Hospital, Auckland, New Zealand
- University of Auckland, Auckland, New Zealand
| | | | | | - Luis Felipe Reyes
- Universidad de La Sabana, Chia, Colombia
- Clinica Universidad de La Sabana, Chia, Colombia
| | - Hiroki Saito
- St Marianna University School of Medicine, Yokohama City Seibu Hospital, Yokohama, Japan
| | | | | | | | | | | | - Alexis F Turgeon
- Université Laval, Québec City, Canada
- CHU de Québec-Université Laval Research Center, Québec City, Canada
| | - Anne M Turner
- Medical Research Institute of New Zealand (MRINZ), Wellington, New Zealand
| | | | | | - Roger J Lewis
- Berry Consultants, Austin, Texas
- Harbor-UCLA Medical Center, Torrance, California
- Statistical Editor, JAMA
| | - Derek C Angus
- University of Pittsburgh, Pittsburgh, Pennsylvania
- Senior Editor, JAMA
| | | | - Anthony C Gordon
- Imperial College London, London, United Kingdom
- Imperial College Healthcare NHS Trust, St Mary's Hospital, London, United Kingdom
| | | | - Steve A Webb
- Monash University, Melbourne, Australia
- St John of God Hospital, Subiaco, Australia
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Banerjee A, Ganguly U, Saha S, Chakrabarti S, Saini RV, Rawal RK, Saso L, Chakrabarti S. Vitamin D and immuno-pathology of COVID-19: many interactions but uncertain therapeutic benefits. Expert Rev Anti Infect Ther 2021; 19:1245-1258. [PMID: 33739215 PMCID: PMC8022339 DOI: 10.1080/14787210.2021.1905519] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 03/16/2021] [Indexed: 02/06/2023]
Abstract
Introduction: COVID-19 pandemic has caused huge loss of human lives and extensive socio-economic damages. The immuno-pathology of this disease is neither clearly understood nor there are effective drugs for severe cases of COVID-19. Repurposing of available drugs for the treatment of COVID-19 is imperative.Areas Covered: This review has gathered the evidence from PubMed, Google Scholar, WHO, and other reliable websites on COVID-19 and summarized the existing knowledge of the immuno-pathology of COVID-19. We elucidated how vitamin D through its diverse actions on immune effector cells, epithelial cells, or renin-angiotensin-aldosterone system could have a modulatory role on the pathogenic mechanisms of COVID-19. The epidemiological evidence associating vitamin D deficiency with the severity and incidence of COVID-19 is also presented. However, the evidence of clinical benefit to patients of COVID-19 from randomized controlled trials with vitamin D has not come as yet.Expert opinion: It is now established that fatality of COVID-19 is primarily determined by hyperactivation of the host's innate immune system in response to SARS-CoV-2 invasion, and thus the research on the immuno-modulatory and other roles of vitamin D against viral infections should be pursued vigorously. This would be also useful for future pandemics caused by other novel viruses.
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Affiliation(s)
- Anindita Banerjee
- Department of Biochemistry, Institute of Post Graduate Medical Education and Research, Kolkata, India
| | - Upasana Ganguly
- Department of Biochemistry & Central Research Cell, M.M. Institute of Medical Sciences and Research, Maharishi Markandeshwar (Deemed to Be University), Mullana, India
| | - Sarama Saha
- Department of Biochemistry, All India Institute of Medical Sciences, Rishikesh, India
| | | | - Reena V Saini
- Department of Biotechnology, M.M Engineering College, Maharishi Markandeshwar (Deemed to Be University), Mullana, India
| | - Ravindra K Rawal
- Department of Chemistry, M.M Engineering College, Maharishi Markandeshwar (Deemed to Be University), Mullana, India
| | - Luciano Saso
- Department of Physiology and Pharmacology “Vittorio Erspamer”, Sapienza University of Rome, Rome, Italy
| | - Sasanka Chakrabarti
- Department of Biochemistry & Central Research Cell, M.M. Institute of Medical Sciences and Research, Maharishi Markandeshwar (Deemed to Be University), Mullana, India
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Higham A, Mathioudakis A, Vestbo J, Singh D. COVID-19 and COPD: a narrative review of the basic science and clinical outcomes. Eur Respir Rev 2020; 29:200199. [PMID: 33153991 PMCID: PMC7651840 DOI: 10.1183/16000617.0199-2020] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 10/02/2020] [Indexed: 01/08/2023] Open
Abstract
The 2019 coronavirus disease (COVID-19) pandemic is caused by severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2). Clinical outcomes, including mortality, are worse in males, older individuals and patients with comorbidities. COPD patients are included in shielding strategies due to their susceptibility to virus-induced exacerbations, compromised pulmonary function and high prevalence of associated comorbidities. Using evidence from basic science and cohort studies, this review addresses key questions concerning COVID-19 and COPD. First, are there mechanisms by which COPD patients are more susceptible to SARS-CoV-2 infection? Secondly, do inhaled corticosteroids offer protection against COVID-19? And, thirdly, what is the evidence regarding clinical outcomes from COVID-19 in COPD patients? This up-to-date review tackles some of the key issues which have significant impact on the long-term outlook for COPD patients in the context of COVID-19.
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Affiliation(s)
- Andrew Higham
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester and Manchester University NHS Foundation Trust, Manchester, UK
| | - Alexander Mathioudakis
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester and Manchester University NHS Foundation Trust, Manchester, UK
| | - Jørgen Vestbo
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester and Manchester University NHS Foundation Trust, Manchester, UK
| | - Dave Singh
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester and Manchester University NHS Foundation Trust, Manchester, UK
- Medicines Evaluation Unit, Manchester, UK
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Malaguarnera L. Vitamin D3 as Potential Treatment Adjuncts for COVID-19. Nutrients 2020; 12:E3512. [PMID: 33202670 PMCID: PMC7697253 DOI: 10.3390/nu12113512] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 11/11/2020] [Accepted: 11/12/2020] [Indexed: 02/07/2023] Open
Abstract
Severe acute respiratory syndrome coronavirus type (SARS-CoV2, also known as COVID-19), which is the latest pandemic infectious disease, constitutes a serious risk to human health. SARS-CoV2 infection causes immune activation and systemic hyperinflammation which can lead to respiratory distress syndrome (ARDS). ARDS victims are characterized by a significant increase in IL-6 and IL-1. Macrophage activation, associated with the "cytokine storm", promotes the dysregulation of the innate immunity. So far, without vaccines or specific therapy, all efforts to design drugs or clinical trials are worthwhile. Vitamin D and its receptor vitamin D receptor (VDR) exert a critical role in infections due to their remarkable impact on both innate and adaptive immune responses and on the suppression of the inflammatory process. The protective properties of vitamin D supplementation have been supported by numerous observational studies and by meta-analysis of clinical trials for prevention of viral acute respiratory infection. In this review, we compare the mechanisms of the host immune response to SARS-CoV2 infection and the immunomodulatory actions that vitamin D exerts in order to consider the preventive effect of vitamin D supplementation on SARS-CoV2 viral infection.
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Affiliation(s)
- Lucia Malaguarnera
- Department of Biomedical and Biotechnological Sciences, University of Catania, 95124 Catania, Italy
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Elkahloun AG, Saavedra JM. Candesartan could ameliorate the COVID-19 cytokine storm. Biomed Pharmacother 2020; 131:110653. [PMID: 32942152 PMCID: PMC7439834 DOI: 10.1016/j.biopha.2020.110653] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 08/07/2020] [Accepted: 08/17/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Angiotensin receptor blockers (ARBs) reducing inflammation and protecting lung and brain function, could be of therapeutic efficacy in COVID-19 patients. METHODS Using GSEA, we compared our previous transcriptome analysis of neurons injured by glutamate and treated with the ARB Candesartan (GSE67036) with transcriptional signatures from SARS-CoV-2 infected primary human bronchial epithelial cells (NHBE) and lung postmortem (GSE147507), PBMC and BALF samples (CRA002390) from COVID-19 patients. RESULTS Hundreds of genes upregulated in SARS-CoV-2/COVID-19 transcriptomes were similarly upregulated by glutamate and normalized by Candesartan. Gene Ontology analysis revealed expression profiles with greatest significance and enrichment, including proinflammatory cytokine and chemokine activity, the NF-kappa B complex, alterations in innate and adaptive immunity, with many genes participating in the COVID-19 cytokine storm. CONCLUSIONS There are similar injury mechanisms in SARS-CoV-2 infection and neuronal injury, equally reduced by ARB treatment. This supports the hypothesis of a therapeutic role for ARBs, ameliorating the COVID-19 cytokine storm.
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Affiliation(s)
- Abdel G Elkahloun
- Comparative Genomics and Cancer Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD 20892, USA.
| | - Juan M Saavedra
- Department of Pharmacology and Physiology, Georgetown University Medical Center, SE402 Med/Dent, 3900 Reservoir Road, Washington, DC 20057, USA.
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7
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Offringa A, Montijn R, Singh S, Paul M, Pinto YM, Pinto-Sietsma* SJ. The mechanistic overview of SARS-CoV-2 using angiotensin-converting enzyme 2 to enter the cell for replication: possible treatment options related to the renin-angiotensin system. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2020; 6:317-325. [PMID: 32464637 PMCID: PMC7314063 DOI: 10.1093/ehjcvp/pvaa053] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 04/25/2020] [Accepted: 05/07/2020] [Indexed: 01/08/2023]
Abstract
The SARS-CoV-2 pandemic is a healthcare crisis caused by insufficient knowledge applicable to effectively combat the virus. Therefore, different scientific discovery strategies need to be connected, to generate a rational treatment which can be made available as rapidly as possible. This relies on a solid theoretical understanding of the mechanisms of SARS-CoV-2 infection and host responses, which is coupled to the practical experience of clinicians that are treating patients. Because SARS-CoV-2 enters the cell by binding to angiotensin-converting enzyme 2 (ACE2), targeting ACE2 to prevent such binding seems an obvious strategy to combat infection. However, ACE2 performs its functions outside the cell and was found to enter the cell only by angiotensin II type 1 receptor (AT1R)-induced endocytosis, after which ACE2 is destroyed. This means that preventing uptake of ACE2 into the cell by blocking AT1R would be a more logical approach to limit entry of SARS-CoV-2 into the cell. Since ACE2 plays an important protective role in maintaining key biological processes, treatments should not disrupt the functional capacity of ACE2, to counterbalance the negative effects of the infection. Based on known mechanisms and knowledge of the characteristics of SARS-CoV we propose the hypothesis that the immune system facilitates SARS-CoV-2 replication which disrupts immune regulatory mechanisms. The proposed mechanism by which SARS-CoV-2 causes disease immediately suggests a possible treatment, since the AT1R is a key player in this whole process. AT1R antagonists appear to be the ideal candidate for the treatment of SARS-CoV-2 infection. AT1R antagonists counterbalance the negative consequences of angiotesnin II and, in addition, they might even be involved in preventing the cellular uptake of the virus without interfering with ACE2 function. AT1R antagonists are widely available, cheap, and safe. Therefore, we propose to consider using AT1R antagonists in the treatment of SARS-CoV-2.
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Affiliation(s)
- Annette Offringa
- Microbiology and System Biology, Netherlands Organisation for Applied Scientific Research, The Hague, The Netherlands
| | - Roy Montijn
- Microbiology and System Biology, Netherlands Organisation for Applied Scientific Research, The Hague, The Netherlands
| | - Sandeep Singh
- Vascular Medicine, Amsterdam UMC, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
- Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam UMC, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | - Martin Paul
- Faculty of Health Medicine and Life Sciences, University of Maastricht, Maastricht, The Netherlands
| | - Yigal M Pinto
- Cardiology, Amsterdam UMC, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | - Sara-Joan Pinto-Sietsma*
- Vascular Medicine, Amsterdam UMC, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
- Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam UMC, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
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8
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Negative Regulation of Tec Kinase Alleviates LPS-Induced Acute Kidney Injury in Mice via theTLR4/NF- κB Signaling Pathway. BIOMED RESEARCH INTERNATIONAL 2020; 2020:3152043. [PMID: 32685466 PMCID: PMC7322586 DOI: 10.1155/2020/3152043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 05/19/2020] [Indexed: 02/07/2023]
Abstract
Tec kinase is an important mediator in inflammatory immune response that enhances the activity of neutrophils and macrophages. However, information on its function in lipopolysaccharide- (LPS-) induced acute kidney injury (AKI) is limited. This study is aimed at determining whether Tec kinase was a regulator in AKI. An AKI model in mice was successfully established using intraperitoneal LPS. Results showed that the serum levels of creatinine (Cr), blood urea nitrogen (BUN), and cystatin-C (Cys-C) increased after intraperitoneal LPS injection. Renal tissue sustained significantly severe injury as measured by pathological scores. Pretreatment with LFM-A13 improved the function of the kidney in mice and decreased the renal injury score. Enzyme-linked immunosorbent assay showed that LFM-A13 significantly reduced the release of IL-1β and TNF-α in mice exposed to LPS. LFM-A13 can evidently abrogate the expression of Tec protein, MyD88, TLR4, NF-κB p65, and Tec's phosphorylated protein as determined by Western blot. Immunohistochemistry analysis revealed that LFM-A13 markedly downregulated the expression of Tec kinase in renal tubular epithelial cells. In vitro, Tec kinase protein was expressed highly in NRK-52E cells after LPS exposure. Tec-siRNA also decreased IL-1β and TNF-α production and obviously abolished phospho-p65 and phospho-IκBα expression in NRK-52E cell stimulated by LPS; however, Tec-siRNA increased the IκBα level. Altogether, these data suggested that Tec kinase can be a modulating protein in AKI through TLR4/NF-κB activation.
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9
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Repeated Porphyromonas gingivalis W83 exposure leads to release pro-inflammatory cytokynes and angiotensin II in coronary artery endothelial cells. Sci Rep 2019; 9:19379. [PMID: 31852912 PMCID: PMC6920421 DOI: 10.1038/s41598-019-54259-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 10/08/2019] [Indexed: 12/17/2022] Open
Abstract
The role of Porphyromonas gingivalis (P. gingivalis) or its virulence factors, including lipopolysaccharide (LPS) not only has been related with periodontitis but also with endothelial dysfunction, a key mechanism involved in the genesis of atherosclerosis and hypertension that involving systemic inflammatory markers as angiotensin II (Ang II) and cytokines. This study compares the effect of repeated and unique exposures of P. gingivalis W83 LPS and live bacteria on the production and expression of inflammatory mediators and vasoconstrictor molecules with Ang II. Human coronary artery endothelial cells (HCAEC) were stimulated with purified LPS of P. gingivalis (1.0, 3.5 or 7.0 μg/mL) or serial dilutions of live bacteria (MOI 1: 100 - 1:0,1) at a single or repeated exposure for a time of 24 h. mRNA expression levels of AGTR1, AGTR2, IL-8, IL-1β and MCP-1 were determined by RT-qPCR, and IL-6, MCP-1, IL-8, IL-1β and GM-CSF levels were measured by flow cytometry, ELISA determined Ang II levels. Live bacteria in a single dose increased mRNA levels of AGTR1, and repeated doses increased mRNA levels of IL-8 and IL-1β (p < 0.05). Repeated exposure of live-P. gingivalis induced significant production IL-6, MCP-1 and GM-CSF (p < 0.05). Moreover, these MCP-1, IL-6 and GM-CSF levels were greater than in cells treated with single exposure (p < 0.05), The expression of AGTR1 and production of Ang II induced by live-P. gingivalis W83 showed a vasomotor effect of whole bacteria in HCAEC more than LPS. In conclusion, the findings of this study suggest that repeated exposure of P. gingivalis in HCAEC induces the activation of proinflammatory and vasoconstrictor molecules that lead to endothelial dysfunction being a key mechanism of the onset and progression of arterial hypertension and atherosclerosis.
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Abstract
BACKGROUND Angiotensin II plays a vital role in the pathogenesis of acute respiratory distress syndrome (ARDS). However, its mechanism is not well defined. Angiotensin II upregulates the expression of soluble epoxide hydrolase (sEH; Ephx2). sEH is suggested as a potential pharmacologic target for ARDS. The present study investigates whether the sEH is involved in the angiotensin II-triggered pulmonary inflammation and edema using an angiotensin II-induced lung injury animal model. METHODS Lung injury was induced by angiotensin II intratracheally instillation in wild-type or Ephx2 deficient mice. RESULTS sEH activities were markedly increased in wild-type mice treated with angiotensin II. Angiotensin II markedly increased the levels of tumor necrosis factor-α and interleukin-1β in bronchoalveolar lavage fluid, worsened alveolar capillary protein leak and lung histological alterations, and elevated activity of activator protein-1 and nuclear factor-κB. However, these changes were significantly improved in Ephx2 deficient mice. Moreover, Losartan, an angiotensin II receptor 1 antagonist, abolished the sEH induction and improved mortality. CONCLUSIONS Angiotensin II-induced lung injury was improved in sEH gene deleted mice. The angiotensin II-triggered pulmonary inflammation is mediated, at least in part, through the sEH.
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Morris G, Maes M, Berk M, Puri BK. Myalgic encephalomyelitis or chronic fatigue syndrome: how could the illness develop? Metab Brain Dis 2019; 34:385-415. [PMID: 30758706 PMCID: PMC6428797 DOI: 10.1007/s11011-019-0388-6] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 01/23/2019] [Indexed: 12/19/2022]
Abstract
A model of the development and progression of chronic fatigue syndrome (myalgic encephalomyelitis), the aetiology of which is currently unknown, is put forward, starting with a consideration of the post-infection role of damage-associated molecular patterns and the development of chronic inflammatory, oxidative and nitrosative stress in genetically predisposed individuals. The consequences are detailed, including the role of increased intestinal permeability and the translocation of commensal antigens into the circulation, and the development of dysautonomia, neuroinflammation, and neurocognitive and neuroimaging abnormalities. Increasing levels of such stress and the switch to immune and metabolic downregulation are detailed next in relation to the advent of hypernitrosylation, impaired mitochondrial performance, immune suppression, cellular hibernation, endotoxin tolerance and sirtuin 1 activation. The role of chronic stress and the development of endotoxin tolerance via indoleamine 2,3-dioxygenase upregulation and the characteristics of neutrophils, monocytes, macrophages and T cells, including regulatory T cells, in endotoxin tolerance are detailed next. Finally, it is shown how the immune and metabolic abnormalities of chronic fatigue syndrome can be explained by endotoxin tolerance, thus completing the model.
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Affiliation(s)
- Gerwyn Morris
- IMPACT Strategic Research Centre, School of Medicine, Barwon Health, Deakin University, Geelong, Victoria, Australia
| | - Michael Maes
- IMPACT Strategic Research Centre, School of Medicine, Barwon Health, Deakin University, Geelong, Victoria, Australia
- Department of Psychiatry, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Michael Berk
- IMPACT Strategic Research Centre, School of Medicine, Barwon Health, Deakin University, Geelong, Victoria, Australia
- Department of Psychiatry, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
- Florey Institute for Neuroscience and Mental Health, University of Melbourne, Parkville, Victoria, Australia
- Orygen, The National Centre of Excellence in Youth Mental Health, Parkville, Victoria, Australia
| | - Basant K Puri
- Department of Medicine, Imperial College London, Hammersmith Hospital, London, England, W12 0HS, UK.
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Wang F, Zhang W, Wang C, Fang X, Cheng H, Liu S, Chen XL. Inhibitor of Tec kinase, LFM-A13, decreases pro-inflammatory mediators production in LPS-stimulated RAW264.7 macrophages via NF-κB pathway. Oncotarget 2018; 8:34099-34110. [PMID: 28415764 PMCID: PMC5470954 DOI: 10.18632/oncotarget.16212] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 03/03/2017] [Indexed: 11/25/2022] Open
Abstract
Tec kinase, a prototypical member of the Tec tyrosine kinases family, was shown to mainly govern lymphocyte proliferation. In the present study, we investigated the role of Tec kinase in acute inflammatory response in lipopolysaccharide (LPS) challenge. First, we demonstrate that Tec kinase activity was observed in RAW264.7 macrophages exposed to LPS. Tec and phosphorylated Tec expression were upregulated in a dose- and time-dependent manner after LPS stimulation. LPS increased monocyte chemotactic protein (MCP)-1 secretion and intercellular adhesion molecule (ICAM)-1 expression, and increasing mRNA expression was consistently observed. LPS also induced IκBα phoshporylaytion and its degradation, increased NF-κB p65 phoshporylaytion and translocation to nuclei in RAW264.7 cells. Pretreatment with LFM-A13 decreased LPS-induced cytokines and chemokines production and mRNA levels, blocked NF-κB transactivation. These effects of LPS were also prevented by Tec-siRNA. Additionally, LFM-A13 or Tec-siRNA obviously inhibited LPS-induced TGFβ-activated kinase 1(TAK1) phosphorylation. Taken together, our results suggest that Tec kinase involves in acute inflammation process in LPS-stimulated RAW264.7 cells, at least mediated by activating TAK1/ NF-κB signal pathway.
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Affiliation(s)
- Fei Wang
- Department of Burns, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, PR China
| | - Wei Zhang
- Department of Nephrology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, PR China
| | - Chao Wang
- Department of Burns, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, PR China
| | - Xu Fang
- Department of Burns, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, PR China
| | - Hao Cheng
- Department of Burns, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, PR China
| | - Sheng Liu
- Department of Burns, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, PR China
| | - Xu-Lin Chen
- Department of Burns, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, PR China
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Xu J, Yang J, Chen J, Luo Q, Zhang Q, Zhang H. Vitamin D alleviates lipopolysaccharide‑induced acute lung injury via regulation of the renin‑angiotensin system. Mol Med Rep 2017; 16:7432-7438. [PMID: 28944831 PMCID: PMC5865875 DOI: 10.3892/mmr.2017.7546] [Citation(s) in RCA: 245] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Accepted: 06/29/2017] [Indexed: 12/30/2022] Open
Abstract
Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are the clinical manifestations of severe lung damage and respiratory failure. ALI and ARDS result are associated with high mortality in patients. At present, no effective treatments for ALI and ARDS exist. It is established that vitamin D exhibits anti-inflammatory effects, however, the specific effect of vitamin D on ALI remains largely unknown. The aim of the present study was to investigate whether, and by which mechanism, vitamin D alleviates lipopolysaccharide (LPS)-induced ALI. The results demonstrated that a vitamin D agonist, calcitriol, exhibited a beneficial effect on LPS-induced ALI in rats; calcitriol pretreatment significantly improved LPS-induced lung permeability, as determined using Evans blue dye. Results from reverse transcription-quantitative polymerase chain reaction, western blotting and ELISA analysis demonstrated that calcitriol also modulated the expression of members of the renin-angiotensin system (RAS), including angiotensin (Ang) I-converting enzymes (ACE and ACE2), renin and Ang II, which indicates that calcitriol may exert protective effects on LPS-induced lung injury, at least partially, by regulating the balance between the expression of members of the RAS. The results of the present study may provide novel targets for the future treatment of ALI.
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Affiliation(s)
- Jun Xu
- Department of Endocrinology, First Affiliated Hospital of Anhui Medical University, Hefei, Anhui 230022, P.R. China
| | - Jialai Yang
- Emergency Department, First Affiliated Hospital of Anhui Medical University, Hefei, Anhui 230022, P.R. China
| | - Jian Chen
- Intensive Care Unit, Southside of Anhui Provincial Hospital Affiliated to Anhui Medical University, Hefei, Anhui 230001, P.R. China
| | - Qingli Luo
- Anhui Provincial Laboratory of Pathogen Biology, Anhui Medical University, Hefei, Anhui 230022, P.R. China
| | - Qiu Zhang
- Department of Endocrinology, First Affiliated Hospital of Anhui Medical University, Hefei, Anhui 230022, P.R. China
| | - Hong Zhang
- Emergency Department, First Affiliated Hospital of Anhui Medical University, Hefei, Anhui 230022, P.R. China
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Baudiß K, de Paula Vieira R, Cicko S, Ayata K, Hossfeld M, Ehrat N, Gómez-Muñoz A, Eltzschig HK, Idzko M. C1P Attenuates Lipopolysaccharide-Induced Acute Lung Injury by Preventing NF-κB Activation in Neutrophils. THE JOURNAL OF IMMUNOLOGY 2016; 196:2319-26. [PMID: 26800872 DOI: 10.4049/jimmunol.1402681] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 12/14/2015] [Indexed: 12/14/2022]
Abstract
Recently, ceramide-1-phosphate (C1P) has been shown to modulate acute inflammatory events. Acute lung injury (Arnalich et al. 2000. Infect. Immun. 68: 1942-1945) is characterized by rapid alveolar injury, lung inflammation, induced cytokine production, neutrophil accumulation, and vascular leakage leading to lung edema. The aim of this study was to investigate the role of C1P during LPS-induced acute lung injury in mice. To evaluate the effect of C1P, we used a prophylactic and therapeutic LPS-induced ALI model in C57BL/6 male mice. Our studies revealed that intrapulmonary application of C1P before (prophylactic) or 24 h after (therapeutic) LPS instillation decreased neutrophil trafficking to the lung, proinflammatory cytokine levels in bronchoalveolar lavage, and alveolar capillary leakage. Mechanistically, C1P inhibited the LPS-triggered NF-κB levels in lung tissue in vivo. In addition, ex vivo experiments revealed that C1P also attenuates LPS-induced NF-κB phosphorylation and IL-8 production in human neutrophils. These results indicate C1P playing a role in dampening LPS-induced acute lung inflammation and suggest that C1P could be a valuable candidate for treatment of ALI.
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Affiliation(s)
- Kristin Baudiß
- Department of Pneumology, COPD and Asthma Research Group, University Hospital Freiburg, 79106 Freiburg, Germany
| | - Rodolfo de Paula Vieira
- Department of Pneumology, COPD and Asthma Research Group, University Hospital Freiburg, 79106 Freiburg, Germany
| | - Sanja Cicko
- Department of Pneumology, COPD and Asthma Research Group, University Hospital Freiburg, 79106 Freiburg, Germany
| | - Korcan Ayata
- Department of Pneumology, COPD and Asthma Research Group, University Hospital Freiburg, 79106 Freiburg, Germany
| | - Madelon Hossfeld
- Department of Pneumology, COPD and Asthma Research Group, University Hospital Freiburg, 79106 Freiburg, Germany
| | - Nicolas Ehrat
- Department of Pneumology, COPD and Asthma Research Group, University Hospital Freiburg, 79106 Freiburg, Germany
| | - Antonio Gómez-Muñoz
- Department of Biochemistry and Molecular Biology, University of the Basque Country, 48080 Bilbao, Spain; and
| | - Holger K Eltzschig
- Organ Protection Program, Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO 80045
| | - Marco Idzko
- Department of Pneumology, COPD and Asthma Research Group, University Hospital Freiburg, 79106 Freiburg, Germany;
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Chronic Activation of the Renin-Angiotensin System Induces Lung Fibrosis. Sci Rep 2015; 5:15561. [PMID: 26494430 PMCID: PMC4616037 DOI: 10.1038/srep15561] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Accepted: 09/29/2015] [Indexed: 11/28/2022] Open
Abstract
Pulmonary fibrosis is a serious lung disorder that can lead to respiratory failure. Here we show that transgenic mice expressing active renin from the liver (RenTgMK) developed progressive pulmonary fibrosis leading to impaired pulmonary function. Histological analyses revealed a marked increase in extracellular matrix (ECM) deposition and decrease in alveolar size in the lungs of RenTgMK mice compared to wild-type (WT) littermates, accompanied with increased expression of ECM proteins and fibrogenic factors. The increase in lung fibrosis led to a substantial decrease in respiratory system compliance. Two-week treatment with aliskiren (renin inhibitor) or losartan (AT1 antagonist) ameliorated pulmonary ECM deposition, blocked the induction of ECM proteins and fibrogenic factors and improved respiratory compliance in RenTgMK mice, confirming a critical role of the renin-Ang II-AT1 cascade in promoting pulmonary fibrogenesis. However, when RenTgMK mice were treated with hydralazine (a smooth muscle relaxant), the blood pressure was normalized but the lung fibrotic abnormalities, fibrogenic gene induction and pulmonary elasticity were not corrected. Moreover, intratracheal instillation of lipopolysaccharide induced more severe lung injury in RenTgMK mice compared to WT littermates. These observations demonstrate that the renin-angiotensin system is a key mediator of lung fibrosis, and its pro-fibrotic effect is independent of blood pressure.
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Hillman NH, Gisslen T, Polglase GR, Kallapur SG, Jobe AH. Ventilation-induced increases in EGFR ligand mRNA are not altered by intra-amniotic LPS or ureaplasma in preterm lambs. PLoS One 2014; 9:e96087. [PMID: 24788984 PMCID: PMC4005755 DOI: 10.1371/journal.pone.0096087] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Accepted: 04/02/2014] [Indexed: 11/18/2022] Open
Abstract
Chorioamnionitis and mechanical ventilation are associated with bronchopulmonary dysplasia (BPD) in preterm infants. Mechanical ventilation at birth activates both inflammatory and acute phase responses. These responses can be partially modulated by previous exposure to intra-amniotic (IA) LPS or Ureaplasma parvum (UP). Epidermal growth factor receptor (EGFR) ligands participate in lung development, and angiotensin converting enzyme (ACE) 1 and ACE2 contribute to lung inflammation. We asked whether brief mechanical ventilation at birth altered EGFR and ACE pathways and if antenatal exposure to IA LPS or UP could modulate these effects. Ewes were exposed to IA injections of UP, LPS or saline multiple days prior to preterm delivery at 85% gestation. Lambs were either immediately euthanized or mechanically ventilated for 2 to 3 hr. IA UP and LPS cause modest changes in the EGFR ligands amphiregulin (AREG), epiregulin (EREG), heparin binding epidermal growth factor (HB-EGF), and betacellulin (BTC) mRNA expression. Mechanical ventilation greatly increased mRNA expression of AREG, EREG, and HB-EGF, with no additional increases resulting from IA LPS or UP. With ventilation AREG and EREG mRNA localized to cells in terminal airspace. EGFR mRNA also increased with mechanical ventilation. IA UP and LPS decreased ACE1 mRNA and increased ACE2 mRNA, resulting in a 4 fold change in the ACE1/ACE2 ratio. Mechanical ventilation with large tidal volumes increased both ACE1 and ACE2 expression. The alterations seen in ACE with IA exposures and EGFR pathways with mechanical ventilation may contribute to the development of BPD in preterm infants.
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Affiliation(s)
- Noah H. Hillman
- Division of Neonatology, Saint Louis University, Saint Louis, Missouri, United States of America
- Division of Pulmonary Biology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, United States of America
- * E-mail:
| | - Tate Gisslen
- Division of Neonatology, Saint Louis University, Saint Louis, Missouri, United States of America
| | - Graeme R. Polglase
- School of Women and Infants' Health, University of Western Australia Perth, WA, Australia
- The Ritchie Centre, Monash Institute of Medical Research, Monash University, Melbourne, VIC, Australia
| | - Suhas G. Kallapur
- Division of Pulmonary Biology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, United States of America
- School of Women and Infants' Health, University of Western Australia Perth, WA, Australia
| | - Alan H. Jobe
- Division of Pulmonary Biology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, United States of America
- School of Women and Infants' Health, University of Western Australia Perth, WA, Australia
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Kong J, Zhu X, Shi Y, Liu T, Chen Y, Bhan I, Zhao Q, Thadhani R, Li YC. VDR attenuates acute lung injury by blocking Ang-2-Tie-2 pathway and renin-angiotensin system. Mol Endocrinol 2013; 27:2116-25. [PMID: 24196349 DOI: 10.1210/me.2013-1146] [Citation(s) in RCA: 109] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Acute lung injury (ALI) is a hallmark of systemic inflammation associated with high mortality. Although the vitamin D receptor (VDR) is highly expressed in the lung, its role in lung physiology remains unclear. We investigated the effect of VDR deletion on ALI using a lipopolysaccharide (LPS)-induced sepsis model. After LPS challenge VDR-null mice exhibited more severe ALI and higher mortality compared with wild-type (WT) counterparts, manifested by increased pulmonary vascular leakiness, pulmonary edema, apoptosis, neutrophil infiltration, and pulmonary inflammation, which was accompanied by excessive induction of angiopoietin (Ang)-2 and myosin light chain (MLC) phosphorylation in the lung. 1,25-Dihydroxyvitamin D blocked LPS-induced Ang-2 expression by blocking nuclear factor-κB activation in human pulmonary artery endothelial cells. The severity of lung injury seen in VDR-null mice was ameliorated by pretreatment with L1-10, an antagonist of Ang-2, suggesting that VDR signaling protects the pulmonary vascular barrier by targeting the Ang-2-Tie-2-MLC kinase cascade. Severe ALI in VDR-null mice was also accompanied by an increase in pulmonary renin and angiotensin II levels, and pretreatment of VDR-null mice with angiotensin II type 1 receptor blocker losartan partially ameliorated the severity of LPS-induced lung injury. Taken together, these observations provide evidence that the vitamin D-VDR signaling prevents lung injury by blocking the Ang-2-Tie-2-MLC kinase cascade and the renin-angiotensin system.
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Affiliation(s)
- Juan Kong
- Laboratory of Metabolic Disease Research and Drug Development and Shengjing Hospital, China Medical University, Shenyang, 110000, China; ; Ravi Thadhani, M.P.H., Renal Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114. E-mail: ; and Yan Chun Li, Department of Medicine, The University of Chicago, 900 East 57th Street, KCBD 9110, Chicago, Illinois 60637. E-mail:
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Mineralocorticoid receptor antagonists attenuate pulmonary inflammation and bleomycin-evoked fibrosis in rodent models. Eur J Pharmacol 2013; 718:290-8. [DOI: 10.1016/j.ejphar.2013.08.019] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Revised: 07/25/2013] [Accepted: 08/26/2013] [Indexed: 01/14/2023]
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The effect of endogenous angiotensin II on alveolar fluid clearance in rats with acute lung injury. Can Respir J 2013; 19:311-8. [PMID: 23061076 DOI: 10.1155/2012/951025] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND In acute lung injury (ALI), angiotensin II (Ang II) plays a vital role in the stimulation of pulmonary permeability edema formation through the angiotensin type 1 (AT1) receptor. The effect of Ang II on alveolar fluid clearance (AFC) in ALI remains unknown. METHODS Sprague Dawley rats were anesthetized and intratracheally injected with 1 mg⁄kg lipopolysaccharide (LPS), while control rats received saline. The AT1 receptor antagonist ZD7155 was injected intraperitoneally (10 mg⁄kg) 30 min before LPS administration. The lungs were isolated for AFC measurement, and alpha-epithelial sodium channel (ENaC) messenger RNA and protein expression were detected by reverse-transcription polymerase chain reaction and Western blot. RESULTS LPS-induced ALI caused an increase in Ang II levels in plasma and lung tissue but a decrease in AFC. The time course of Ang II levels paralleled that of AFC. Pretreatment with ZD7155 prevented ALI-induced reduction of AFC. ZD7155 also reversed the ALI-induced reduction of beta-ENaC and gamma-ENaC levels, and further decreased alpha-ENaC levels. CONCLUSIONS These findings suggest that endogenous Ang II inhibits AFC and dysregulates ENaC expression via AT1 receptors, which contribute to alveolar filling and pulmonary edema in LPS-induced ALI.
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Dhande I, Ali Q, Hussain T. Proximal tubule angiotensin AT2 receptors mediate an anti-inflammatory response via interleukin-10: role in renoprotection in obese rats. Hypertension 2013; 61:1218-26. [PMID: 23547236 DOI: 10.1161/hypertensionaha.111.00422] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
The angiotensin type 2 receptor (AT2R) has been shown to lower inflammation in the kidney. However, the role of the anti-inflammatory cytokine interleukin (IL)-10 in AT2R-mediated attenuation of inflammation has not been elucidated. We hypothesized that AT2R activation is renoprotective by directly increasing the levels of anti-inflammatory cytokine IL-10 in the kidney via nitric oxide (NO) signaling. For in vitro studies, the human proximal tubule epithelial cell-line (human kidney-2 [HK-2]) was activated with lipopolysaccharide (10 μg/mL) and AT2R agonist C21 (1 μmol/L) for 24 hours, and media cytokine levels were assessed. Lipopolysaccharide modestly downregulated AT2R expression. Treatment with C21 lowered lipopolysaccharide-induced levels of both tumor necrosis factor-α and IL-6, but increased IL-10 levels. Treatment with neutralizing IL-10 antibody (1 μg/mL) or NO synthase inhibitor L-NAME (1 mmol/L) abolished this effect. For in vivo studies, prehypertensive obese Zucker rats and age-matched lean Zucker rats were treated for 2 weeks with C21 (300 μg/kg per day, IP) and AT2R antagonist (PD123319; 50 μg/kg per minute, SC infusion). Compared with lean Zucker rats, obese Zucker rats had higher levels of renal AT2R expression, tumor necrosis factor-α, and IL-6. C21 treatment decreased levels of tumor necrosis factor-α by 75% and IL-6 by 60%. Conversely, PD treatment lowered the renal IL-10 levels in obese Zucker rats by ≈60%. Renal morphometry revealed increased mesangial matrix expansion and glomerular macrophage infiltration, which was improved by C21 treatment in obese Zucker rats. Our findings suggest that proximal tubule AT2R activation is anti-inflammatory by increasing IL-10 production, which is largely NO dependent and thus offers renoprotection by preventing early inflammation-induced renal injury in obesity.
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Affiliation(s)
- Isha Dhande
- Department of Pharmacological and Pharmaceutical Sciences, Rm 521 Science and Research Bldg 2, University of Houston, Houston, TX 77004, USA
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Shi Y, Zhang B, Chen XJ, Xu DQ, Wang YX, Dong HY, Ma SR, Sun RH, Hui YP, Li ZC. Osthole protects lipopolysaccharide-induced acute lung injury in mice by preventing down-regulation of angiotensin-converting enzyme 2. Eur J Pharm Sci 2013; 48:819-24. [DOI: 10.1016/j.ejps.2012.12.031] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2012] [Revised: 12/14/2012] [Accepted: 12/30/2012] [Indexed: 12/14/2022]
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Yang Z, Deng Y, Su D, Tian J, Gao Y, He Z, Wang X. TLR4 as receptor for HMGB1-mediated acute lung injury after liver ischemia/reperfusion injury. J Transl Med 2013; 93:792-800. [PMID: 23628899 PMCID: PMC7101938 DOI: 10.1038/labinvest.2013.66] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Acute lung injury (ALI) frequently occurs after liver transplantation and major liver surgery. Proinflammatory mediators released by damaged liver after liver ischemia/reperfusion (I/R) injury might contribute to this form of ALI, but the underlying mechanisms have not been well characterized. High-mobility group box protein 1 (HMGB1), a recently identified proinflammatory cytokine, was found to be significantly higher in the serum after liver I/R injury. This study investigated whether HMGB1 was involved as a stimulating factor, and whether its downstream Toll-like receptor 4 (TLR4), p38 mitogen-activated protein kinase (p38MAPK), and activator protein-1 (AP-1) signaling pathways act as mediators in the development of liver I/R injury-induced ALI. Extensive ALI and lung inflammation was induced in a rat model of liver I/R injury. Serum HMGB1 was significantly higher after liver I/R injury, and more importantly, expression of HMGB1 mRNA and protein in the lung tissue was also significantly increased. We further found that liver I/R injury enhanced the expression of TLR4 mRNA and protein, and the activity of p38MAPK and AP-1 in the lung tissue. Inhibition of TLR4 expression in the lung tissue by infection with pGCSIL-GFP-lentivirus-expressing small hairpin RNAs targeting the TLR4 gene (TLR4-shRNA lentivirus) significantly attenuated ALI, lung inflammation, and activity of p38MAPK and AP-1 in the lung tissue. These findings indicate that HMGB1 might contribute to the underlying mechanism for liver I/R injury-induced ALI and that its downstream TLR4, p38MAPK, and AP-1 signaling pathways are potentially important mediators in the development of ALI.
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Affiliation(s)
- Zhongwei Yang
- grid.16821.3c0000 0004 0368 8293Department of Anesthesiology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yuxiao Deng
- grid.16821.3c0000 0004 0368 8293Department of Anesthesiology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Diansan Su
- grid.16821.3c0000 0004 0368 8293Department of Anesthesiology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jie Tian
- grid.16821.3c0000 0004 0368 8293Department of Anesthesiology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yuan Gao
- grid.16821.3c0000 0004 0368 8293Department of Anesthesiology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zhengyu He
- grid.16821.3c0000 0004 0368 8293Department of Anesthesiology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xiangrui Wang
- grid.16821.3c0000 0004 0368 8293Department of Anesthesiology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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Cao S, Wu R. Expression of Angiotensin II and Aldosterone in Radiation-induced Lung Injury. Cancer Biol Med 2012; 9:254-60. [PMID: 23691486 PMCID: PMC3643675 DOI: 10.7497/j.issn.2095-3941.2012.04.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Accepted: 12/04/2012] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE Radiation-induced lung injury (RILI) is the most common, dose-limiting complication in thoracic malignancy radiotherapy. Considering its negative impact on patients and restrictions to efficacy, the mechanism of RILI was studied. METHODS Wistar rats were locally irradiated with a single dose of 0, 16, and 20 Gy to the right half of the lung to establish a lung injury model. Two and six months after irradiation, the right half of the rat lung tissue was removed, and the concentrations of TGF-β1, angiotensin II, and aldosterone were determined via enzyme-linked immunosorbent assay. RESULTS Statistical differences were observed in the expression levels of angiotensin II and aldosterone between the non-irradiation and irradiation groups. Moreover, the expression level of the angiotensin II-aldosterone system increased with increasing doses, and the difference was still observed as time progressed. CONCLUSIONS Angiotensin II-aldosterone system has an important pathophysiological function in the progression of RILI.
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Affiliation(s)
- Shuo Cao
- Department of Oncology, Shengjing Hospital of China Medical University, Shenyang 110022, China
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Koh GCKW, Vlaar APJ, Hofstra JJ, de Jong HK, van Nierop S, Peacock SJ, Wiersinga WJ, Schultz MJ, Juffermans NP. In the critically ill patient, diabetes predicts mortality independent of statin therapy but is not associated with acute lung injury: a cohort study. Crit Care Med 2012; 40:1835-43. [PMID: 22488007 PMCID: PMC3379571 DOI: 10.1097/ccm.0b013e31824e1696] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Patients with diabetes mellitus form 23%-30% of published cohorts of critically ill patients. Conflicting published evidence links diabetes mellitus to both higher and lower mortality. Other cohort studies suggest that diabetes mellitus protects against acute lung injury. We hypothesized that diabetes mellitus is an independent risk factor for mortality. We further hypothesized that diabetes mellitus is a risk factor for cardiac overload and not for acute lung injury. DESIGN Retrospective cohort study. SETTING The intensive care unit of a tertiary referral hospital. PATIENTS From November 1, 2004, to October 1, 2007, a cohort of patients admitted ≥48 hrs to the intensive care unit. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 2,013 patients, 317 had diabetes mellitus. Ninety-day mortality was higher in the diabetes mellitus patients compared to patients without diabetes mellitus (hazard ratio 1.53, 95% confidence interval 1.29-1.80). This association strengthened after adjusting for confounders and for medication (hazard ratio 1.53, 95% confidence interval 1.07-2.17).We found no association between diabetes mellitus and acute lung injury (relative risk ratio 1.01, 95% confidence interval 0.78-1.32; adjusted relative risk ratio 0.99, 95% confidence interval 0.75-1.31), but diabetes mellitus was a risk factor for cardiac overload (relative risk ratio 1.91, 95% confidence interval 1.30-2.81; adjusted relative risk ratio 1.45, 95% confidence interval 0.97-2.18). Statins were associated with both a reduced risk of mortality (hazard ratio 0.74, 95% confidence interval 0.63-0.87; adjusted hazard ratio 0.53, 95% confidence interval 0.44-0.64) and a decreased risk of developing acute lung injury (relative risk ratio 0.71, 95% confidence interval 0.56-0.89; adjusted relative risk ratio 0.61, 95% confidence interval 0.47-0.79). CONCLUSIONS Diabetes mellitus is an independent risk factor for mortality in critically ill patients and failure to adjust for statins underestimates the size of this association. Diabetes mellitus is not associated with acute lung injury but is associated with cardiac overload. A diagnosis of cardiac overload excludes a diagnosis of acute lung injury. Investigators who do not account for cardiac overload as a competing alternative outcome may therefore falsely conclude that diabetes mellitus protects from acute lung injury.
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Abstract
The renin-angiotensin system (RAS) is a powerful biological system that plays an important role in regulation of systemic blood pressure through the maintenance of fluid and salt homeostasis. It is a multifactorial system since it includes different components (Fig. 1): The first, renin, was discovered in 1898 [1], whereas the discovery of the last component, angiotensin-converting enzyme 2 (ACE 2), is relatively recent, from 2000 [2, 3]. Three kinds of RAS are known: A) circulating, B) local, and C) intracellular.
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Wong MH, Chapin OC, Johnson MD. LPS-stimulated cytokine production in type I cells is modulated by the renin-angiotensin system. Am J Respir Cell Mol Biol 2011; 46:641-50. [PMID: 22205632 DOI: 10.1165/rcmb.2011-0289oc] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
The alveolar epithelium serves as a barrier to the entry of potential respiratory pathogens. Alveolar Type II (TII) cells have immunomodulatory functions, but whether Type I (TI) cells, which comprise approximately 95% of the alveolar epithelium, also play a role in immunity is unknown. Because the renin-angiotensin system (RAS) is emerging as an important mediator of inflammation, and angiotensin-converting enzyme 2 (ACE2), an element of the RAS, has been implicated in lung injury, we hypothesize that TI cells can produce cytokines in response to LPS stimulation, and that this inflammation can be modulated by the RAS. Alveolar TI cells were isolated from adult Sprague-Dawley rat lungs that had been injured with an intratracheal instillation of LPS. PCR was performed to determine whether TI cells expressed transcripts for TNF-α, IL-6, or IL-1β at baseline and after lung injury. Immunocytochemical and protein analysis detected angiotensin II (Ang II) and ACE2, as well as angiotensin Type 1 receptor (AT1R) and Type 2 receptor (AT2R), in TI cells. To separate cell-specific responses, primary TI cells were isolated, cultured, and exposed to LPS, Ang II, or specific inhibitors of AT1R or AT2R. Cytokine production was assayed by ELISA. LPS stimulated the production of all cytokines, whereas ACE2 and losartan, an AT1R inhibitor, blocked elements of the LPS-induced cytokine response. Primary TI cells produce cytokines when treated with LPS, contain important components of the RAS, and can modulate LPS-induced cytokine production via the RAS, suggesting a role for TI cells in the innate immune response of the lung.
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Affiliation(s)
- Mandi H Wong
- San Francisco VA Medical Center, 4150 Clement St., San Francisco, CA 94121, USA
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Yang J, Tan Y, Zhao F, Ma Z, Wang Y, Zheng S, Epstein PN, Yu J, Yin X, Zheng Y, Li X, Miao L, Cai L. Angiotensin II plays a critical role in diabetic pulmonary fibrosis most likely via activation of NADPH oxidase-mediated nitrosative damage. Am J Physiol Endocrinol Metab 2011; 301:E132-44. [PMID: 21487074 DOI: 10.1152/ajpendo.00629.2010] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Diabetic patients have a high risk of pulmonary disorders that are usually associated with restrictive impairment of lung function, suggesting a fibrotic process (van den Borst B, Gosker HR, Zeegers MP, Schols AM. Chest 138: 393-406, 2010; Ehrlich SF, Quesenberry CP Jr, Van Den Eeden SK, Shan J, Ferrara A. Diabetes Care 33: 55-60, 2010). The present study was undertaken to define whether and how diabetes causes lung fibrosis. Lung samples from streptozotocin-induced type 1 diabetic mice, spontaneously developed type 1 diabetic OVE26 mice, and their age-matched controls were investigated with histopathological and biochemical analysis. Signaling mechanism was investigated with cultured normal human lung fibroblasts in vitro. In both diabetes models, histological examination with Sirius red and hemotoxylin and eosin stains showed fibrosis along with massive inflammatory cell infiltration. The fibrotic and inflammatory processes were confirmed by real-time PCR and Western blotting assays for the increased fibronectin, CTGF, PAI-1, and TNFα mRNA and protein expressions. Diabetes also significantly increased NADPH oxidase (NOX) expression and protein nitration along with upregulation of angiotensin II (Ang II) and its receptor expression. In cell culture, exposure of lung fibroblasts to Ang II increased CTGF expression in a dose- and time-dependent manner, which could be abolished by inhibition of superoxide, NO, and peroxynitrite accumulation. Furthermore, chronic infusion of Ang II to normal mice at a subpressor dose induced diabetes-like lung fibrosis, and Ang II receptor AT1 blocker (losartan) abolished the lung fibrotic and inflammatory responses in diabetic mice. These results suggest that Ang II plays a critical role in diabetic lung fibrosis, which is most likely caused by NOX activation-mediated nitrosative damage.
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Affiliation(s)
- Junling Yang
- Department of Pulmonary Medicine, Second Hospital of Jilin University, Changchun, China
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Wösten-van Asperen RM, Lutter R, Specht PAC, van Woensel JB, van der Loos CM, Florquin S, Lachmann B, Bos AP. Ventilator-induced inflammatory response in lipopolysaccharide-exposed rat lung is mediated by angiotensin-converting enzyme. THE AMERICAN JOURNAL OF PATHOLOGY 2010; 176:2219-27. [PMID: 20304959 DOI: 10.2353/ajpath.2010.090565] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Angiotensin-converting enzyme (ACE) mediates the ventilator-induced inflammatory response in healthy lungs via angiotensin II (Ang II). A rat model was used to examine the role of ACE and Ang II in the inflammatory response during mechanical ventilation of preinjured (ie, lipopolysaccharide [LPS]-exposed) lungs. When indicated, rats were pretreated with the ACE inhibitor captopril and/or intratracheal administration of LPS. The animals were ventilated for 4 hours with moderate pressure amplitudes. Nonventilated animals served as controls. ACE activity and levels of Ang II and inflammatory mediators (interleukin-6, Cytokine-induced Neutrophil Chemoattractant (CINC)-3, interleukin-1beta, and interleukin-10) were determined in bronchoalveolar lavage fluid (BALF). The localization of ACE and Ang II type 1 receptor in lung tissue was determined by immunohistochemistry. The role of the Ang II pathway was assessed by using its receptor antagonist Losartan. Mechanical ventilation of LPS-exposed animals increased ACE activity and levels of inflammatory mediators in BALF compared with ventilated nonexposed and LPS-exposed nonventilated animals. Blocking ACE by captopril attenuated the lung inflammatory response. Furthermore, increased ACE activity in BALF was accompanied by increased levels of Ang II and enhanced expression of its receptor on alveolar cells. Blocking the Ang II receptor attenuated the inflammatory mediator response to a larger extent than by blocking ACE. In conclusion, during mechanical ventilation ACE, via Ang II, mediates the inflammatory response of both healthy and preinjured lungs.
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Affiliation(s)
- Roelie M Wösten-van Asperen
- Department of Pediatric Intensive Care, Emma Children's Hospital/Academic Medical Center, Amsterdam, The Netherlands.
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