Peritoneal defenses against infection: winning the battle but losing the war?

İntrabdominal Adezyon Oluşum Mekanizmalarına ve Tedavi Stratejilerine Histopatolojik Bakış

Hayat standartlarını olumsuz etkileyen abdominal adezyonlar, postoperatif dönemde görülen önemli bir sağlık sorunudur. Peritoneal kavite ve serozal yüzeylerde oluşan, abdominal travmalara sebep olan kimyasal ve termal faktörler ya da enfeksiyon ve yabancı cisim reaksiyonları adezyon oluşumuna sebep olabilir. Abdominal adezyonların sınıflandırması genellikle adezyon yoğunluğuna ve prognoz ciddiyetine göre yapılsa da henüz dünya çapında kabul görmüş standart bir sınıflandırma sistemi mevcut değildir. Abdominal adezyonlar ağrı, infertilite, cerrahi sonrası hastanede yatış süresinin uzaması ve ekonomik yük gibi olumsuz sonuçlarla klinik yansımalar gösterir. Sonuç olarak, postoperatif süreçte karşılaşılan adezyonlar ciddi bir sorundur ve adezyon oluşumunu engellemek için ileri çalışmaların laboratuvar ortamından klinik araştırma modellerine uyarlanması gerekmektedir. Bu derleme çalışması intraabdominal adezyon oluşumu, histopatolojisi, derecelendirilmesi, önlenmesi ve klinik önemi ile ilgili literatürü gözden geçirmek için hazırlanmıştır.

The Role of Peritoneal Macrophages in Endometriosis

Endometriosis is an estrogen-dependent gynecological disorder, defined as the growth of endometrial stromal cells and glands at extrauterine sites. Endometriotic lesions are more frequently located into the abdominal cavity, although they can also be implanted in distant places. Among its etiological factors, the presence of immune dysregulation occupies a prominent place, pointing out the beneficial and harmful outcomes of macrophages in the pathogenesis of this disease. Macrophages are tissue-resident cells that connect innate and adaptive immunity, playing a key role in maintaining local homeostasis in healthy conditions and being critical in the development and sustainment of many inflammatory diseases. Macrophages accumulate in the peritoneal cavity of women with endometriosis, but their ability to clear migrated endometrial fragments seems to be inefficient. Hence, the characteristics of the peritoneal immune system in endometriosis must be further studied to facilitate the search for new diagnostic and therapeutic tools. In this review, we summarize recent relevant advances obtained in both mouse, as the main animal model used to study endometriosis, and human, focusing on peritoneal macrophages obtained from endometriotic patients and healthy donors, under the perspective of its future clinical translation to the role that these cells play on this pathology.

CD40 Ligand Expression Correlates with Resolution of Peritonitis and Mononuclear Cell Recruitment

Background

CD40 belongs to the tumor necrosis factor receptor family and its ligation is a central event in major inflammatory and immune reactions. We have previously demonstrated that CD40 ligation upregulates the secretion of mononuclear chemokines from peritoneal mesothelial cells (PMC), and that blocking the CD40 ligand (CD154) reduced the mononuclear infiltrate in a model of peritonitis.

Objective

To characterize the kinetics of CD154 expression on peritoneal leukocytes and examine the correlation of this occurrence with the mononuclear transition at the resolution phase of peritonitis.

Methods

Leukocytes were collected from the effluent of 11 patients during episodes of peritonitis while undergoing peritoneal dialysis (PD). The effluent was then analyzed by flow cytometry to characterize CD154 expression.

Results

CD154 expression on peritoneal mononuclear cells gradually increased during the resolution phase of peritonitis, peaking first on T cells (CD4+ and CD8+ cells at 20 – 45 hours) and then on macrophages (CD14+ at 20 – 50 hours). The maximal expression of CD154 on macrophages, CD4+ cells, and CD8+ cells during peak hours reached values of 33% ± 23%, 4% ± 3%, and 24% ± 17%, respectively. The increase in CD154 expression was in negative correlation ( r=–0.44, p = 0.032) with total leukocyte numbers and in positive correlation ( r = 0.52, p = 0.009) with the increase of mononuclear cells. Deterioration of peritonitis was associated with a decrease in CD154 levels, while recurrence of peritonitis was related to high CD154 levels.

Conclusion

Our data, which show a positive correlation between CD154 levels and mononuclear dominance, suggest that CD40–CD154 ligation plays an important role in the transition to mononuclear predominance in the late phase of peritonitis.

The Effects of Peritoneal Dialysis Solutions on Peritoneal Host Defense

Conventional peritoneal dialysis fluid (PDF) is a bioincompatible solution owing to the acidic pH, the high glucose concentrations and the associated hyperosmolarity, the high lactate concentrations, and the presence of glucose degradation products (GDPs). This unphysiologic composition adversely affects peritoneal host defense and may thus contribute to the development of PD-related peritonitis. The viability of polymorphonuclear leukocytes, monocytes, peritoneal macrophages, and mesothelial cells is severely depressed in the presence of conventional PDF. In addition, the production of inflammatory cytokines and chemoattractants by these cells is markedly affected by conventional PDF. Further, conventional PDF hampers the recruitment of circulating leukocytes in response to an infectious stimulus. Finally, phagocytosis, respiratory burst, and bacterial killing are markedly lower when polymorphonuclear leukocytes, monocytes, and peritoneal macrophages are exposed to conventional PDF. Although there are a few discrepant results, all major PDF components have been implicated as causative factors. Generally, novel PDF with alternative osmotic agents or with alternative buffers, neutral pH, and low GDP content have much milder inhibitory effects on peritoneal host defense. Clinical studies, however, still need to demonstrate their superiority with respect to the incidence of PD-related peritonitis.

Expression of Defensin Antimicrobial Peptides in the Peritoneal Cavity of Patients on Peritoneal Dialysis

Objective

To investigate the expression and regulation of defensins in the peritoneal cavity of peritoneal dialysis (PD) patients.

Design

The presence of defensins in the peritoneal cavity was assessed using reverse transcription polymerase chain reaction (RT-PCR). In vivo defensin expression was analyzed in human peritoneal membrane biopsies and in peritoneal cavity leukocytes isolated from spent dialysate. Defensin expression in vitro was assessed in cultured human peritoneal mesothelial cells (HPMC) and confirmed with PCR Southern blot and DNA sequencing. The effect of tumor necrosis factor alpha (TNFa) and epidermal growth factor (EGF) on b2 defensin expression in HPMC was analyzed by Northern blot analysis and RT-PCR respectively.

Results

Both a and b classes of defensins are expressed in the peritoneal cavity of PD patients. Messenger RNA for the a-defensin human neutrophil peptide 3 and for b-defensin-1 (hbD-1) were found in preparations containing predominantly peritoneal leukocytes, whereas b-defensin-2 (hbD-2) is expressed by HPMC. HPMC isolated from different individuals displayed variability in both basal hbD-2 expression and in response to stimulation by TNFa. Conversely, EGF consistently downregulated the level of hbD-2 message in HPMC.

Conclusion

a- and b-defensins are expressed in the peritoneal cavity, and hbD-2 is the main defensin present in the peritoneal membrane. Variable levels of expression of hbD-2 by mesothelial cells were seen, with evidence of regulation by cytokines and growth factors. This provides evidence for a previously unknown mechanism of innate immunity at that site.

Lymphocytes modulate peritoneal leukocyte recruitment in peritonitis

OBJECTIVE AND DESIGN

To investigate the modulating role of lymphocytes in leukocyte recruitment in a murine model of peritonitis.

MATERIALS OR SUBJECTS

RAG-1 knockout (KO) mice, NUDE mice and microMT KO mice were compared to their wild-type controls.

TREATMENT

Mice were administered with 1 ml of Brewer's thioglycollate (BTG) and terminal peritoneal lavages were performed at 8, 24, 72 and 120 h after treatment.

METHODS

Leukocyte numbers recruited at the different time points following a BTG administration were determined. Chemokine and cytokine levels were assessed by either ELISAs or cytometric bead array.

RESULTS

RAG-1 KO mice (absent B and T cells) exhibited increased early neutrophil infiltration and blunted late monocyte/macrophage infiltration. NUDE mice (absent T cells) exhibited both increased neutrophil and monocyte/macrophage infiltration. In contrast, microMT KO mice (absent B cells) demonstrated reduced influx of both neutrophils and monocyte/macrophages. Chemokine analysis revealed various differences in important chemokines.

CONCLUSIONS

These data suggest that T cells act to suppress leukocyte recruitment while B cells promote leukocyte recruitment.

MAKING A VIRTUE OF NECESSITY: MANAGING THE OPEN ABDOMEN

BACKGROUND

The open abdomen, or laparostomy, is becoming increasingly used in the management of critically ill surgical patients.

METHODS

The published work on laparostomy is reviewed, in the light of personal experience, with particular attention to the history and pathophysiology associated with laparostomy.

RESULTS AND CONCLUSION

The combination of an inert plastic sheet in contact with the viscera, and the application of subatmospheric pressure on the wound, is an effective combination to maximize the prospects of delayed primary wound closure while minimizing the chance of fistula and ventral hernia.

CD40 ligand (CD154) takes part in regulation of the transition to mononuclear cell dominance during peritonitis

BACKGROUND

CD40 is a member of the tumor necrosis factor (TNF) family of receptors whose ligand (CD154) is found mainly on membranes of activated mononuclear cells. CD154-CD40 cross-linking is a central event in antigen presentation, B-cell activation, and regulation of cytokine and chemokine secretion from various types of cells. We have previously demonstrated in vitro the presence of CD40 on human peritoneal mesothelial cells (PMC) and have also shown that CD40 ligation synergizes with interferon-gamma (IFN-gamma) to up-regulate CC chemokine secretion from these cells. The aim of the present study was to investigate the role of CD40 ligation in leukocyte recruitment during peritonitis.

METHODS

Peritonitis was induced in mice by bacterial inoculation, CD40 levels were analyzed on PMC by reverse transcription-polymerase chain reaction (RT-PCR) and immunohistochemistry. CD154 levels on leukocytes were analyzed by flow cytometry and RT-PCR. Chemokines mRNA levels were analyzed by RT-PCR. CD154 was blocked in vivo using monoclonal antibodies. Results. In mice inoculated by Staphylococcus epidermidis or Escherichia coli, CD40 in PMC increased twofold at 24 hours and CD154 was induced and reached a peak at 48 hours. In both Gram-positive and Gram-negative-peritonitis, peritoneal macrophages were the main peritoneal leukocyte population to express CD154. Similar results were observed in human subjects during peritonitis. Injection of CD154 blocking monoclonal antibody (MR1) reduced the mononuclear infiltrate by 50% and had no effect on granulocyte recruitment 48 hours after inoculation of S. epidermidis.

CONCLUSION

Our data suggest that CD40 plays a significant role in the process of the mononuclear infiltration during peritonitis.

Regulation of complement C3 and C4 synthesis in human peritoneal mesothelial cells by peritoneal dialysis fluid

Although complement is activated in the peritoneal cavity during chronic peritoneal dialysis (PD), little is known about its role in peritoneal defence and injury related to long-term PD. We examined the impact of glucose and commercial peritoneal dialysis solutions on complement expression in HPMCs obtained by primary culture from omental tissues of consented patients undergoing elective abdominal surgery. Constitutive expression of C3 and C4 mRNA in HPMCs was up-regulated upon exposure to 75 mm glucose in a time-dependent manner. C3 and C4 protein was secreted in both apical and basolateral directions. Glucose doses beyond 100 mm markedly down-regulated C3 and C4 expression, and stimulated LDH release dose-dependently. Such cytotoxic effects were attenuated using equivalent doses of mannitol instead of glucose. Treatment with conventional lactate-buffered dialysis solution gave rise to down-regulation of C3 and C4 expression, and heightened LDH release in HPMCs. These effects correlated with the glucose strength of the solution, persisted despite replacement with a bicarbonate-buffered solution, aggravated by glycated albumin, and were partially abrogated by supplementation with 10% fetal bovine serum in the culture system. Our findings suggest that the artificial conditions imposed by PD lead to alterations in local complement synthesis that have implications for the role of the peritoneal mesothelium in both inflammation and defence.