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Avtaar Singh SS, Das De S, Al-Adhami A, Singh R, Hopkins PMA, Curry PA. Primary graft dysfunction following lung transplantation: From pathogenesis to future frontiers. World J Transplant 2023; 13:58-85. [PMID: 36968136 PMCID: PMC10037231 DOI: 10.5500/wjt.v13.i3.58] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 11/11/2022] [Accepted: 02/17/2023] [Indexed: 03/16/2023] Open
Abstract
Lung transplantation is the treatment of choice for patients with end-stage lung disease. Currently, just under 5000 lung transplants are performed worldwide annually. However, a major scourge leading to 90-d and 1-year mortality remains primary graft dysfunction. It is a spectrum of lung injury ranging from mild to severe depending on the level of hypoxaemia and lung injury post-transplant. This review aims to provide an in-depth analysis of the epidemiology, pathophysiology, risk factors, outcomes, and future frontiers involved in mitigating primary graft dysfunction. The current diagnostic criteria are examined alongside changes from the previous definition. We also highlight the issues surrounding chronic lung allograft dysfunction and identify the novel therapies available for ex-vivo lung perfusion. Although primary graft dysfunction remains a significant contributor to 90-d and 1-year mortality, ongoing research and development abreast with current technological advancements have shed some light on the issue in pursuit of future diagnostic and therapeutic tools.
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Affiliation(s)
- Sanjeet Singh Avtaar Singh
- Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh EH16 4SA, United Kingdom
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 8QQ, United Kingdom
| | - Sudeep Das De
- Heart and Lung Transplant Unit, Wythenshawe Hospital, Manchester M23 9NJ, United Kingdom
| | - Ahmed Al-Adhami
- Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh EH16 4SA, United Kingdom
- Department of Heart and Lung Transplant, Royal Papworth Hospital, Cambridge CB2 0AY, United Kingdom
| | - Ramesh Singh
- Mechanical Circulatory Support, Inova Health System, Falls Church, VA 22042, United States
| | - Peter MA Hopkins
- Queensland Lung Transplant Service, Prince Charles Hospital, Brisbane, QLD 4032, Australia
| | - Philip Alan Curry
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow G81 4DY, United Kingdom
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2
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Hsu J, Krishnan A, Lee SA, Dodd-O JM, Kim BS, Illei P, Yarnoff K, Hamad AA, Rabb H, Bush EL. CD3 +CD4 -CD8 - Double-negative αβ T cells attenuate lung ischemia-reperfusion injury. J Thorac Cardiovasc Surg 2021; 161:e81-e90. [PMID: 31864698 PMCID: PMC7195225 DOI: 10.1016/j.jtcvs.2019.09.188] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 09/05/2019] [Accepted: 09/09/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Lung ischemia-reperfusion injury (IRI) is a common complication after lung transplantation, and immune cells have been implicated in modulating outcomes. We hypothesized that a newly described subset of αβ T-cell receptor positive cells; that is, CD4-CD8- (double negative [DN]) T cells, are found in lungs and can protect against lung IRI. METHODS Ischemia was induced in C57BL/6 mice by left pulmonary artery and vein occlusion for 30 minutes followed by 180 minutes of reperfusion. These mice were paired with sham hilar dissected surgical controls. In mice undergoing IRI, adoptive transfer of DN T cells or conventional T cells was performed 12 hours before occlusion. Flow cytometry was used to quantify T cells and inflammatory cytokines, and apoptotic signaling pathways were evaluated with immunoblotting. Lung injury was assessed with Evans blue dye extravasation. RESULTS DN T cells were significantly higher (5.29% ± 1% vs 2.21% ± 3%; P < .01) in IRI lungs and secreted higher levels of interleukin-10 (30% ± 5% vs 6% ± 1%; P < .01) compared with surgical sham controls. Immunoblotting, hematoxylin and eosin staining and Evans blue dye demonstrated that adoptive transfer of DN T cells significantly decreased interstitial edema (P < .01) and attenuated apoptosis/cleaved caspase-3 expression in the lungs following lung IRI (P < .01). CONCLUSIONS DN T cells traffic into lungs during IRI, and have tissue protective functions regulating inflammation and apoptosis. We propose a potential novel immunoregulatory function of DN T cells during lung IRI.
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Affiliation(s)
- Joshua Hsu
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Aravind Krishnan
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Sul A Lee
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Jefferey M Dodd-O
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Bo S Kim
- Divisions of Pulmonary and Critical Care, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Peter Illei
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Kristine Yarnoff
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Abdel A Hamad
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Hamid Rabb
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Errol L Bush
- Division of Thoracic Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md.
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3
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Rahulan V, Shah U, Yadav P, Ravipathy S, Jindal A, Suresh S, Sandeepa HS, Kumar P, Mohandas A, Kumar S, Shivanna S, Kori S, Dutta P, Anand P, Mahesh BN, Madhusudana N, Bhaskar BV, Balasubramani G, Attawar S. Challenges, experiences, and postoperative outcomes in setting up first successful lung transplant unit in India. Lung India 2021; 38:216-222. [PMID: 33942744 PMCID: PMC8194446 DOI: 10.4103/lungindia.lungindia_585_20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Lung transplantation (LT) has emerged as a definitive cure for a plethora of end-stage lung diseases (ESLDs). With improvements in immune-suppression protocols, the posttransplantation survival rates have gone up. Aim The study reported the initial experience of the India's single largest lung transplant program on clinicopathological profile, procedures, challenges encountered, and outcomes. Settings and Design A retrospective analysis was done from data available at three centers of Institute of Heart and Lung Transplant, Gleneagles Global Hospitals across Chennai, Bengaluru, and Mumbai. Materials and Methods A total of 132 patients underwent lung (single or bilateral) or combined heart and lung transplant between April 2017 and March 2020. All the participants had 30 days' follow-up. Postoperative complications, graft rejection, and 30-day mortality were reported. Kaplan-Meier survival analysis and logistic regression analysis were performed. Statistical Analysis Used Kaplan-Meier survival and binary logistic regression was performed. Results Interstitial lung diseases, 65.91%, were the most common diagnosis. Bilateral LT (81.3%) was the most common type of LT performed. Grade III primary graft dysfunction was observed in 16 (12.1%). Distal airway stenosis (21.97%) was the most common complication followed by anastomotic stenosis (14.30%). Gram-negative bacterial sepsis (52%) was the leading cause of death. Cumulative probability of survival at 1 month was 0.85 (95% confidence interval [CI] 0.80-0.92), and at 1 year, it was 0.78 (95% CI, 0.72-0.86). Conclusion This study establishes the fact that despite multiple challenges, LT is a viable option for selected patients with ESLDs in India and should encourage early referrals to a transplant center.
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Affiliation(s)
- Vijil Rahulan
- Institute of Heart and Lung Transplant, Gleneagles Global Health City, Chennai, Tamil Nadu, India
| | - Unmil Shah
- Institute of Heart and Lung Transplant, Gleneagles Global Health City, Chennai, Tamil Nadu, India
| | - Pavan Yadav
- Institute of Heart and Lung Transplant, Gleneagles Global Health City, Chennai, Tamil Nadu, India
| | - Srinivasa Ravipathy
- Institute of Heart and Lung Transplant, Gleneagles Global Health City, Chennai, Tamil Nadu, India
| | - Apar Jindal
- Institute of Heart and Lung Transplant, Gleneagles Global Health City, Chennai, Tamil Nadu, India
| | - S Suresh
- Institute of Heart and Lung Transplant, Gleneagles Global Health City, Chennai, Tamil Nadu, India
| | - H S Sandeepa
- Department of Pulmonology, BGS Global Hospital, Bengaluru, Karnataka, India
| | - Pradeep Kumar
- Institute of Heart and Lung Transplant, Gleneagles Global Health City, Chennai, Tamil Nadu, India
| | - Anoop Mohandas
- Institute of Heart and Lung Transplant, Gleneagles Global Health City, Chennai, Tamil Nadu, India
| | - Sharanya Kumar
- Institute of Heart and Lung Transplant, Gleneagles Global Health City, Chennai, Tamil Nadu, India
| | - Shivaprakash Shivanna
- Institute of Heart and Lung Transplant, Gleneagles Global Health City, Chennai, Tamil Nadu, India
| | - Santosh Kori
- Department of CTVS, BGS Global Hospital, Bengaluru, Karnataka, India
| | - Prabhat Dutta
- Institute of Heart and Lung Transplant, Gleneagles Global Health City, Chennai, Tamil Nadu, India
| | - Prem Anand
- Institute of Heart and Lung Transplant, Gleneagles Global Health City, Chennai, Tamil Nadu, India
| | - B N Mahesh
- Institute of Heart and Lung Transplant, Gleneagles Global Health City, Chennai, Tamil Nadu, India
| | - N Madhusudana
- Department of CTVS, BGS Global Hospital, Bengaluru, Karnataka, India
| | - B V Bhaskar
- Department of CTVS, BGS Global Hospital, Bengaluru, Karnataka, India
| | - G Balasubramani
- Institute of Heart and Lung Transplant, Gleneagles Global Health City, Chennai, Tamil Nadu, India
| | - Sandeep Attawar
- Institute of Heart and Lung Transplant, Gleneagles Global Health City, Chennai, Tamil Nadu, India
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4
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Zhou Y, Zhou X, Zhou W, Pang Q, Wang Z. The protective effect of dexmedetomidine in a rat ex vivo lung model of ischemia-reperfusion injury. Acta Cir Bras 2018; 33:1-13. [PMID: 29412228 DOI: 10.1590/s0102-865020180010000001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 12/19/2017] [Indexed: 12/20/2022] Open
Abstract
PURPOSE To investigate the effect of dexmedetomidine (Dex) in a rat ex vivo lung model of ischemia-reperfusion injury. METHODS An IL-2 ex vivo lung perfusion system was used to establish a rat ex vivo lung model of ischemia-reperfusion injury. Drugs were added to the perfusion solution for reperfusion. Lung injury was assessed by histopathological changes, airway pressure (Res), lung compliance (Compl), perfusion flow (Flow), pulmonary venous oxygen partial pressure (PaO2), and lung wet/dry (W/D) weight ratio. The levels of superoxide dismutase (SOD), malondialdehyde (MDA), 78 kDa glucose-regulated protein (GRP78) and CCAAT/enhancer-binding protein homologous protein (CHOP) were measured, respectively. RESULTS The introduction of Dex attenuated the post-ischemia-reperfusion lung damage and MDA level, improved lung histology, W/D ratio, lung injury scores and SOD activity. Decreased mRNA and protein levels of GRP78 and CHOP compared with the IR group were observed after Dex treatment. The effect of Dex was dosage-dependence and a high dose of Dex (10 nM) was shown to confer the strongest protective effect against lung damage (P<0.05). Yohimbine, an α2 receptor antagonist, significantly reversed the protective effect of Dex in lung tissues (P<0.05). CONCLUSION Dex reduced ischemia-reperfusion injury in rat ex vivo lungs.
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Affiliation(s)
- Yan Zhou
- MD, Attending physician, Department of Anesthesiology, Affiliated Wuxi People's Hospital, Nanjing Medical University, China. Acquisiton, analysis and interpretaton of data; manuscript preparation
| | - Xinqiao Zhou
- MD, Resident, Department of Anesthesiology, Affiliated Wuxi People's Hospital, Nanjing Medical University, China. Technical procedures, acquisition of data
| | - Wenjuan Zhou
- MD, Resident, Department of Anesthesiology, Affiliated Wuxi People's Hospital, Nanjing Medical University, China. Technical procedures
| | - Qingfeng Pang
- IVPhD, Full Professor, Department of Basic Medicine, Wuxi Medical School, Jiangnan University, China. Technical procedures
| | - Zhiping Wang
- PhD, Full Professor, Department of Anesthesiology, Affiliated Wuxi People's Hospital, Nanjing Medical University, China. Conception and design of the study, manuscript preparation, final approval
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5
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Peng CK, Huang KL, Lan CC, Hsu YJ, Wu GC, Peng CH, Wu CP, Chan KS. Experimental chronic kidney disease attenuates ischemia-reperfusion injury in an ex vivo rat lung model. PLoS One 2017; 12:e0171736. [PMID: 28291795 PMCID: PMC5349449 DOI: 10.1371/journal.pone.0171736] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2016] [Accepted: 01/25/2017] [Indexed: 11/22/2022] Open
Abstract
Lung ischemia reperfusion injury (LIRI) is one of important complications following lung transplant and cardiopulmonary bypass. Although patients on hemodialysis are still excluded as lung transplant donors because of the possible effects of renal failure on the lungs, increased organ demand has led us to evaluate the influence of chronic kidney disease (CKD) on LIRI. A CKD model was induced by feeding Sprague-Dawley rats an adenine-rich (0.75%) diet for 2, 4 and 6 weeks, and an isolated rat lung in situ model was used to evaluate ischemia reperfusion (IR)-induced acute lung injury. The clinicopathological parameters of LIRI, including pulmonary edema, lipid peroxidation, histopathological changes, immunohistochemistry changes, chemokine CXCL1, inducible nitric oxide synthase (iNOS), proinflammatory and anti-inflammatory cytokines, heat shock protein expression, and nuclear factor-κB (NF-κB) activation were determined. Our results indicated that adenine-fed rats developed CKD as characterized by increased blood urea nitrogen and creatinine levels and the deposition of crystals in the renal tubules and interstitium. IR induced a significant increase in the pulmonary arterial pressure, lung edema, lung injury scores, the expression of CXCL1 mRNA, iNOS level, and protein concentration of the bronchial alveolar lavage fluid (BALF). The tumor necrosis factor-α levels in the BALF and perfusate; the interleukin-10 level in the perfusate; and the malondialdehyde levels in the lung tissue and perfusate were also significantly increased by LIRI. Counterintuitively, adenine-induced CKD significantly attenuated the severity of lung injury induced by IR. CKD rats exhibited increased heat shock protein 70 expression and decreased activation of NF-κB signaling. In conclusion, adenine-induced CKD attenuated LIRI by inhibiting the NF-κB pathway.
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Affiliation(s)
- Chung-Kan Peng
- Division of Pulmonary and Critical Care, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Kun-Lun Huang
- Institute of Undersea and Hyperbaric Medicine, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Chou-Chin Lan
- Division of Pulmonary Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taipei, Taiwan, Republic of China
- School of Medicine, Tzu Chi University, Hualien, Taiwan, Republic of China
| | - Yu-Juei Hsu
- Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Geng-Chin Wu
- Division of Pulmonary Medicine, Department of Internal Medicine, Taoyuan Armed Forces General Hospital, Lungtan, Taoyuan, Taiwan, Republic of China
| | - Chia-Hui Peng
- Division of Clinical Nutrition, Taoyuan Armed Forces General Hospital, Lungtan, Taoyuan, Taiwan, Republic of China
| | - Chin-Pyng Wu
- Department of Critical Care Medicine, Li-Shin Hospital, Taoyuan, Taiwan, Republic of China
- * E-mail: (KSC); (CPW)
| | - Khee-Siang Chan
- Department of Critical Care Medicine, Chi-Mei Medical Center, Tainan, Taiwan Republic of China
- * E-mail: (KSC); (CPW)
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6
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Tao JQ, Sorokina EM, Vazquez Medina JP, Mishra MK, Yamada Y, Satalin J, Nieman GF, Nellen JR, Beduhn B, Cantu E, Habashi NM, Jungraithmayr W, Christie JD, Chatterjee S. Onset of Inflammation With Ischemia: Implications for Donor Lung Preservation and Transplant Survival. Am J Transplant 2016; 16:2598-611. [PMID: 26998598 DOI: 10.1111/ajt.13794] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Revised: 02/16/2016] [Accepted: 03/08/2016] [Indexed: 01/25/2023]
Abstract
Lungs stored ahead of transplant surgery experience ischemia. Pulmonary ischemia differs from ischemia in the systemic organs in that stop of blood flow in the lung leads to loss of shear alone because the lung parenchyma does not rely on blood flow for its cellular oxygen requirements. Our earlier studies on the ischemia-induced mechanosignaling cascade showed that the pulmonary endothelium responds to stop of flow by production of reactive oxygen species (ROS). We hypothesized that ROS produced in this way led to induction of proinflammatory mediators. In this study, we used lungs or cells subjected to various periods of storage and evaluated the induction of several proinflammatory mediators. Isolated murine, porcine and human lungs in situ showed increased expression of cellular adhesion molecules; the damage-associated molecular pattern protein high-mobility group box 1 and the corresponding pattern recognition receptor, called the receptor for advanced glycation end products; and induction stabilization and translocation of hypoxia-inducible factor 1α and its downstream effector VEGFA, all of which are participants in inflammation. We concluded that signaling with lung preservation drives expression of inflammatory mediators that potentially predispose the donor lung to an inflammatory response after transplant.
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Affiliation(s)
- J-Q Tao
- Institute for Environmental Medicine and Department of Physiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - E M Sorokina
- Institute for Environmental Medicine and Department of Physiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - J P Vazquez Medina
- Institute for Environmental Medicine and Department of Physiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - M K Mishra
- Department of Physiology, Pennsylvania Muscle Institute, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Y Yamada
- Division of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - J Satalin
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY
| | - G F Nieman
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY
| | - J R Nellen
- Cardiovascular Surgery Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - B Beduhn
- Cardiovascular Surgery Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - E Cantu
- Cardiovascular Surgery Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - N M Habashi
- Surgical Critical Care, University of Maryland Medical Center, Baltimore, MD
| | - W Jungraithmayr
- Division of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - J D Christie
- Cardiovascular Surgery Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Pulmonary Allergy and Critical Care Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - S Chatterjee
- Institute for Environmental Medicine and Department of Physiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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7
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Zhao Y, Gillen JR, Meher AK, Burns JA, Kron IL, Lau CL. Rapamycin prevents bronchiolitis obliterans through increasing infiltration of regulatory B cells in a murine tracheal transplantation model. J Thorac Cardiovasc Surg 2016; 151:487-96.e3. [PMID: 26481278 PMCID: PMC4728002 DOI: 10.1016/j.jtcvs.2015.08.116] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Revised: 07/06/2015] [Accepted: 08/11/2015] [Indexed: 02/05/2023]
Abstract
OBJECTIVE B lymphocytes are generally considered to be activators of the immune response; however, recent findings have shown that a subtype of B lymphocytes, regulatory B lymphocytes, play a role in attenuating the immune response. Bronchiolitis obliterans remains the major limitation to modern-day lung transplantation. The role of regulatory B lymphocytes in bronchiolitis obliterans has not been elucidated. We hypothesized that regulatory B lymphocytes play a role in the attenuation of bronchiolitis obliterans. METHODS We performed a standard heterotopic tracheal transplant model. Tracheas from Balb/c mice were transplanted into C57BL/6 recipients. Rapamycin treatment and dimethyl sulfoxide control groups were each treated for the first 14 days after the transplant. Tracheas were collected on days 7, 14, and 28 post-transplantation. Luminal obliteration was evaluated by hematoxylin-eosin staining and Picrosirius red staining. Immune cell infiltration and characteristics, and secretion of interleukin-10 and transforming growth factor-β1 were accessed by immunohistochemistry. Cytokines and transforming growth factor-β1 were measured using the Luminex assay (Bio-Rad, Hercules, Calif). RESULTS The results revealed that intraperitoneal injection of rapamycin for 14 days after tracheal transplantation significantly reduced luminal obliteration on day 28 when compared with the dimethyl sulfoxide control group (97.78% ± 3.63% vs 3.02% ± 2.14%, P < .001). Rapamycin treatment markedly induced regulatory B lymphocytes (B220(+)IgM(+)IgG(-)IL-10(+)TGF-β1(+)) cells when compared with dimethyl sulfoxide controls. Rapamycin treatment inhibited interleukin-1β, 6, 13, and 17 on days 7 and 14. Rapamycin also greatly increased interleukin-10 and transforming growth factor-β1 production in B cells and regulatory T lymphocytes infiltration on day 28. CONCLUSIONS Mammalian target of rapamycin inhibition decreases the development of bronchiolitis obliterans via inhibition of proinflammatory cytokines and increasing regulatory B lymphocytes cell infiltration, which subsequently produces anti-inflammatory cytokines and upregulates regulatory T lymphocyte cells.
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Affiliation(s)
- Yunge Zhao
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Va
| | - Jacob R Gillen
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Va
| | - Akshaya K Meher
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Va
| | - Jordan A Burns
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Va
| | - Irving L Kron
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Va
| | - Christine L Lau
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Va.
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8
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Stone ML, Sharma AK, Zhao Y, Charles EJ, Huerter ME, Johnston WF, Kron IL, Lynch KR, Laubach VE. Sphingosine-1-phosphate receptor 1 agonism attenuates lung ischemia-reperfusion injury. Am J Physiol Lung Cell Mol Physiol 2015; 308:L1245-52. [PMID: 25910934 DOI: 10.1152/ajplung.00302.2014] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 04/22/2015] [Indexed: 11/22/2022] Open
Abstract
Outcomes for lung transplantation are the worst of any solid organ, and ischemia-reperfusion injury (IRI) limits both short- and long-term outcomes. Presently no therapeutic agents are available to prevent IRI. Sphingosine 1-phosphate (S1P) modulates immune function through binding to a set of G protein-coupled receptors (S1PR1-5). Although S1P has been shown to attenuate lung IRI, the S1P receptors responsible for protection have not been defined. The present study tests the hypothesis that protection from lung IRI is primarily mediated through S1PR1 activation. Mice were treated with either vehicle, FTY720 (a nonselective S1P receptor agonist), or VPC01091 (a selective S1PR1 agonist and S1PR3 antagonist) before left lung IR. Function, vascular permeability, cytokine expression, neutrophil infiltration, and myeloperoxidase levels were measured in lungs. After IR, both FTY720 and VPC01091 significantly improved lung function (reduced pulmonary artery pressure and increased pulmonary compliance) vs. vehicle control. In addition, FTY720 and VPC01091 significantly reduced vascular permeability, expression of proinflammatory cytokines (IL-6, IL-17, IL-12/IL-23 p40, CC chemokine ligand-2, and TNF-α), myeloperoxidase levels, and neutrophil infiltration compared with control. No significant differences were observed between VPC01091 and FTY720 treatment groups. VPC01091 did not significantly affect elevated invariant natural killer T cell infiltration after IR, and administration of an S1PR1 antagonist reversed VPC01091-mediated protection after IR. In conclusion, VPC01091 and FTY720 provide comparable protection from lung injury and dysfunction after IR. These findings suggest that S1P-mediated protection from IRI is mediated by S1PR1 activation, independent of S1PR3, and that selective S1PR1 agonists may provide a novel therapeutic strategy to prevent lung IRI.
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Affiliation(s)
- Matthew L Stone
- Department of Surgery, University of Virginia, Charlottesville, Virginia; and
| | - Ashish K Sharma
- Department of Surgery, University of Virginia, Charlottesville, Virginia; and
| | - Yunge Zhao
- Department of Surgery, University of Virginia, Charlottesville, Virginia; and
| | - Eric J Charles
- Department of Surgery, University of Virginia, Charlottesville, Virginia; and
| | - Mary E Huerter
- Department of Surgery, University of Virginia, Charlottesville, Virginia; and
| | - William F Johnston
- Department of Surgery, University of Virginia, Charlottesville, Virginia; and
| | - Irving L Kron
- Department of Surgery, University of Virginia, Charlottesville, Virginia; and
| | - Kevin R Lynch
- Department of Pharmacology, University of Virginia, Charlottesville, Virginia
| | - Victor E Laubach
- Department of Surgery, University of Virginia, Charlottesville, Virginia; and
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9
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[Non-invasive mechanical ventilation in postoperative patients. A clinical review]. ACTA ACUST UNITED AC 2015; 62:512-22. [PMID: 25892605 DOI: 10.1016/j.redar.2015.03.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Revised: 03/03/2015] [Accepted: 03/05/2015] [Indexed: 11/20/2022]
Abstract
Non-invasive ventilation (NIV) is a method of ventilatory support that is increasing in importance day by day in the management of postoperative respiratory failure. Its role in the prevention and treatment of atelectasis is particularly important in the in the period after thoracic and abdominal surgeries. Similarly, in the transplanted patient, NIV can shorten the time of invasive mechanical ventilation, reducing the risk of infectious complications in these high-risk patients. It has been performed A systematic review of the literature has been performed, including examining the technical, clinical experiences and recommendations concerning the application of NIV in the postoperative period.
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10
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Abstract
Acute lung injury (ALI) and its more severe form, acute respiratory distress syndrome (ARDS), can result from both direct and indirect pulmonary damage caused by trauma and shock. In the course of ALI/ARDS, mediators released from resident cells, such as alveolar macrophages, may act as chemoattractants for invading cells and stimulate local cells to build up a proinflammatory micromilieu. Depending on the trauma setting, the role of alveolar macrophages is differentially defined. This review focuses on alveolar macrophage function after blunt chest trauma, ischemia/reperfusion, hemorrhagic shock, and thermal burns.
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12
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Acute respiratory distress syndrome induction by pulmonary ischemia-reperfusion injury in large animal models. J Surg Res 2014; 189:274-84. [PMID: 24768138 DOI: 10.1016/j.jss.2014.02.034] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Revised: 01/17/2014] [Accepted: 02/20/2014] [Indexed: 01/14/2023]
Abstract
Acute respiratory distress syndrome (ARDS) is a common critical pulmonary complication after esophagectomy and other thoracic surgeries (e.g., lung transplantation, pulmonary thromboendarterectomy). Direct pulmonary ischemia-reperfusion injury (PIRI) is known to play the main role in induction of ARDS in these cases. Large animal models are an appropriate choice for ARDS as well as PIRI study because of their physiological and anatomic similarities to the human body. With regard to large animal models, we reviewed different methods of inducing in situ direct PIRI and the commonly applied methods for diagnosing and monitoring ARDS or PIRI in an experimental research setting.
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Sharma AK, Mulloy DP, Le LT, Laubach VE. NADPH oxidase mediates synergistic effects of IL-17 and TNF-α on CXCL1 expression by epithelial cells after lung ischemia-reperfusion. Am J Physiol Lung Cell Mol Physiol 2013; 306:L69-79. [PMID: 24186876 DOI: 10.1152/ajplung.00205.2013] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Ischemia-reperfusion (I/R) injury leads to increased mortality and morbidity in lung transplant patients. Lung I/R injury involves inflammation contributed by innate immune responses. IL-17 and TNF-α, from iNKT cells and alveolar macrophages, respectively, contribute importantly to lung I/R injury. This study tests the hypothesis that IL-17 and TNF-α synergistically mediate CXCL1 (a potent neutrophil chemokine) production by alveolar type II epithelial (ATII) cells via an NADPH oxidase-dependent mechanism during lung I/R. Using a hilar clamp model, wild-type and p47(phox-/-) (NADPH oxidase-deficient) mice underwent left lung I/R, with or without recombinant IL-17 and/or TNF-α treatment. Wild-type mice undergoing I/R treated with combined IL-17 and TNF-α had significantly enhanced lung dysfunction, edema, CXCL1 production, and neutrophil infiltration compared with treatment with IL-17 or TNF-α alone. However, p47(phox-/-) mice had significantly less pulmonary dysfunction, CXCL1 production, and lung injury after I/R that was not enhanced by combined IL-17-TNF-α treatment. Moreover, in an acute in vitro hypoxia-reoxygenation model, murine ATII cells showed a multifold synergistic increase in CXCL1 expression after combined IL-17-TNF-α treatment compared with treatment with either cytokine alone, which was significantly attenuated by an NADPH oxidase inhibitor. Conditioned media transfer from hypoxia-reoxygenation-exposed iNKT cells and macrophages, major sources of IL-17 and TNF-α, respectively, to ATII cells significantly enhanced CXCL1 production, which was blocked by NADPH oxidase inhibitor. These results demonstrate that IL-17 and TNF-α synergistically mediate CXCL1 production by ATII cells after I/R, via an NADPH oxidase-dependent mechanism, to induce neutrophil infiltration and lung I/R injury.
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Affiliation(s)
- Ashish K Sharma
- Dept. of Surgery, Univ. of Virginia, P.O. Box 801359, Charlottesville, VA 22908.
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Zhao Y, Steidle JF, Upchurch GR, Kron IL, Lau CL. Prevention of the second stage of epithelial loss is a potential novel treatment for bronchiolitis obliterans. J Thorac Cardiovasc Surg 2013; 145:940-947.e1. [PMID: 22939854 PMCID: PMC3602313 DOI: 10.1016/j.jtcvs.2012.07.098] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2012] [Revised: 07/09/2012] [Accepted: 07/31/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVES Loss of epithelial cells is one of the key factors that lead to airway fibrosis. Loss of epithelial cells may decrease the barrier to host cell infiltration into the lumen, allowing deposition of extracellular matrix, with subsequent obliteration of the airway. The objective of this study was to determine whether injection of epithelial cells/progenitor cells from the recipient into the lumen of the donor trachea could prevent bronchiolitis obliterans (BO) in a mouse heterotopic tracheal transplantation (HTT) model. METHODS A major histocompatibility complex class I and class II mismatch of mouse HTT model of BO was used. Epithelial cells from recipient mice were isolated and reinjected into the lumen of the allografts on day 3 after transplantation. Rag-1 knock-out and isografts were also performed as controls. The grafts were analyzed by immunohistochemistry and densitometric analysis. RESULTS The results demonstrated that tracheal epithelium was lost by day 3, regenerated between 3 to 7 days, and was lost again in all allografts, but not in the isografts or in Rag-1 knock-out groups by day 12. The reconstituted epithelium was donor originated on day 7 based on green fluorescent protein staining. Furthermore, with the injection of recipient cells into the tracheal lumen, loss of the epithelium was not observed and the luminal obliteration was significantly less in the allografts. CONCLUSIONS Injection of recipient epithelial cells prevents the second phase of epithelial loss and significantly decreases BO development in an HTT model. Clinically, the use of injected recipient epithelial cells could be a novel treatment for BO.
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Affiliation(s)
- Yunge Zhao
- Department of Surgery, University of Virginia Health System, Charlottesville, Va
| | - John F Steidle
- Department of Surgery, University of Virginia Health System, Charlottesville, Va
| | - Gilbert R Upchurch
- Department of Surgery, University of Virginia Health System, Charlottesville, Va
| | - Irving L Kron
- Department of Surgery, University of Virginia Health System, Charlottesville, Va
| | - Christine L Lau
- Department of Surgery, University of Virginia Health System, Charlottesville, Va.
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Lee JC, Diamond JM, Christie JD. Critical care management of the lung transplant recipient. CURRENT RESPIRATORY CARE REPORTS 2012; 1:168-176. [PMID: 32288970 PMCID: PMC7102351 DOI: 10.1007/s13665-012-0018-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Lung transplantation provides the prospect of improved survival and quality of life for patients with end stage lung and pulmonary vascular diseases. Given the severity of illness of such patients at the time of surgery, lung transplant recipients require particular attention in the immediate post-operative period to ensure optimal short-term and long-term outcomes. The management of such patients involves active involvement of a multidisciplinary team versed in common post-operative complications. This review provides an overview of such complications as they pertain to the practitioners caring for post-operative lung transplant recipients. Causes and treatment of conditions affecting early morbidity and mortality in lung transplant recipients will be detailed, including primary graft dysfunction, cardiovascular and surgical complications, and immunologic and infectious issues. Additionally, lung donor management issues and bridging the critically ill potential lung transplant recipient to transplantation will be discussed.
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Affiliation(s)
- James C. Lee
- Penn Lung Transplant Program, Division of Pulmonary, Allergy, and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, 826 West Gates Pavilion, 3400 Spruce Street, Philadelphia, PA 19104 USA
| | - Joshua M. Diamond
- Penn Lung Transplant Program, Division of Pulmonary, Allergy, and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, 826 West Gates Pavilion, 3400 Spruce Street, Philadelphia, PA 19104 USA
| | - Jason D. Christie
- Department of Biostatistics and Epidemiology, Division of Pulmonary, Allergy, and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104 USA
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Feltracco P, Falasco G, Barbieri S, Milevoj M, Serra E, Ori C. Anesthetic considerations for nontransplant procedures in lung transplant patients. J Clin Anesth 2012; 23:508-16. [PMID: 21911200 DOI: 10.1016/j.jclinane.2011.05.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2010] [Revised: 05/03/2011] [Accepted: 05/08/2011] [Indexed: 12/26/2022]
Abstract
Lung transplantation has become an accepted option for many patients with end-stage pulmonary diseases. Anesthesia and surgery following lung transplantation may be required for various diseases that may affect both systemic organs and the transplanted graft. When a patient with a lung transplant undergoes surgery, there is the potential for interference with lung function, depending on the type of intervention and its anatomical site. Accurate preoperative evaluation, an understanding of the physiology of the transplanted lung, proper airway instrumentation, individualized management of intraoperative ventilation, and fluid balance are essential for a positive perioperative outcome.
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Affiliation(s)
- Paolo Feltracco
- Department of Pharmacology and Anesthesiology, University Hospital of Padova, 2-35121 Padua, Italy.
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Zhao Y, LaPar DJ, Steidle J, Emaminia A, Kron IL, Ailawadi G, Linden J, Lau CL. Adenosine signaling via the adenosine 2B receptor is involved in bronchiolitis obliterans development. J Heart Lung Transplant 2011; 29:1405-14. [PMID: 20920842 DOI: 10.1016/j.healun.2010.07.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2010] [Revised: 06/10/2010] [Accepted: 07/02/2010] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Adenosine is produced in response to ischemia or inflammation and protects tissues from injury. Four adenosine receptors are critical in the physiologic negative-feedback mechanism for limitation and termination of tissue-specific and systemic inflammatory responses. Accumulating evidence has focused on the anti-inflammatory and immunosuppressive role of the adenosine 2A receptor (A(2A)R), and we have previously reported on its role in the development of bronchiolitis obliterans (BO) after lung transplantation. Few studies, however, have reported the role of the adenosine 2B receptor (A(2B)R) in BO. Data suggests that the A(2B)R has pro-inflammatory and pro-fibrotic roles. We hypothesized that adenosine signaling through A(2B)R is involved in the development of BO. METHODS A murine heterotopic tracheal model across a total alloantigenic mismatch was used to study A(2B)R signaling in BO. Tracheal transplants consisted of Balb/c donor tracheas transplanted into wild-type or A(2B)R knockout (KO) C57BL/6 recipients. Transplanted tracheas were removed 3, 7, 12, and 21 days after transplantation. The luminal obliteration was evaluated through hematoxylin and eosin staining, and the cellular infiltration (macrophage, neutrophil, CD3+ and Foxp3+ regulatory T cell) was detected by immunohistochemical staining. RESULTS Compared with allografts in wild-type recipients, tracheas transplanted into A(2B)R KO mice displayed less BO development on Day 21. A(2B)R KO mice had an increase in CD3+ T cells and CD4+/CD25+/Foxp3+ regulatory T cells than did wild-type mice on Day 7. By Day 12, more CD3+ T cells were present in the wild-type trachea compared with the A(2B)R KO, but the percentage of CD4+/CD25+/Foxp3+ regulatory T cells remained higher in the tracheas of A(2B)R KO mice. CONCLUSIONS A(2B)R stimulation may promote the development of BO by inhibiting CD4+/CD25+/Foxp3+ regulatory T-cell infiltration.
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Affiliation(s)
- Yunge Zhao
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia 22908-0679, USA
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18
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Sharma AK, LaPar DJ, Zhao Y, Li L, Lau CL, Kron IL, Iwakura Y, Okusa MD, Laubach VE. Natural killer T cell-derived IL-17 mediates lung ischemia-reperfusion injury. Am J Respir Crit Care Med 2011; 183:1539-49. [PMID: 21317314 DOI: 10.1164/rccm.201007-1173oc] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
RATIONALE We recently implicated a role for CD4(+) T cells and demonstrated elevated IL-17A expression in lung ischemia-reperfusion (IR) injury. However, identification of the specific subset of CD4(+) T cells and their mechanistic role in IR injury remains unknown. OBJECTIVES We tested the hypothesis that invariant natural killer T (iNKT) cells mediate lung IR injury via IL-17A signaling. METHODS Mice underwent lung IR via left hilar ligation. Pulmonary function was measured using an isolated lung system. Lung injury was assessed by measuring edema (wet/dry weight) and vascular permeability (Evans blue dye). Inflammation was assessed by measuring proinflammatory cytokines in lungs, and neutrophil infiltration was measured by immunohistochemistry and myeloperoxidase levels. MEASUREMENTS AND MAIN RESULTS Pulmonary dysfunction (increased airway resistance and pulmonary artery pressure and decreased pulmonary compliance), injury (edema, vascular permeability), and inflammation (elevated IL-17A; IL-6; tumor necrosis factor-α; monocyte chemotactic protein-1; keratinocyte-derived chemokine; regulated upon activation, normal T-cell expressed and secreted; and neutrophil infiltration) after IR were attenuated in IL-17A(-/-) and Rag-1(-/-) mice. Anti-IL-17A antibody attenuated lung dysfunction in wild-type mice after IR. Reconstitution of Rag-1(-/-) mice with wild-type, but not IL-17A(-/-), CD4(+) T cells restored lung dysfunction, injury, and inflammation after IR. Lung dysfunction, injury, IL-17A expression, and neutrophil infiltration were attenuated in Jα18(-/-) mice after IR, all of which were restored by reconstitution with wild-type, but not IL-17A(-/-), iNKT cells. Flow cytometry and enzyme-linked immunosorbent spot assay confirmed IL-17A production by iNKT cells after IR. CONCLUSIONS These results demonstrate that CD4(+) iNKT cells play a pivotal role in initiating lung injury, inflammation, and neutrophil recruitment after IR via an IL-17A-dependent mechanism.
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Affiliation(s)
- Ashish K Sharma
- Department of Surgery, University of Virginia Health System, Charlottesville, VA 22908, USA
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19
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Short- and long-term outcomes of 1000 adult lung transplant recipients at a single center. J Thorac Cardiovasc Surg 2011; 141:215-22. [DOI: 10.1016/j.jtcvs.2010.09.009] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2010] [Revised: 08/23/2010] [Accepted: 09/02/2010] [Indexed: 01/08/2023]
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Rama-Maceiras P, Díaz-Allegue M, Pato-López O, Ramos-López L, Rey-Rilo T, Bonome-González C. [Perioperative treatment of a man receiving a left-lung transplant combined with coronary revascularization without use of extracorporeal circulation: with a brief review of pathophysiology and the literature]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2010; 57:425-430. [PMID: 20857638 DOI: 10.1016/s0034-9356(10)70269-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Patients with significant coronary artery disease were once traditionally rejected as candidates for lung transplants because of higher risk of morbidity and mortality. We report the case of a man who received a left lung transplant and coronary revascularization without extracorporeal circulation in a combined surgical procedure after being diagnosed with significant coronary disease during the preoperative study for acceptance as a candidate for lung transplantation. We review the history of such combination procedures, which are changing clinicians' attitudes as to appropriate therapeutic approaches to take for complex patients. We also discuss the possible advantages of performing surgery without extracorporeal circulation. To our knowledge, this is the first report of a combined procedure that took place in a Spanish hospital.
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Affiliation(s)
- P Rama-Maceiras
- Servicio de Anestesiología y Reanimación. Complejo Hospitalario Universitario. A Coruña.
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21
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Laubach VE, Kron IL. Pulmonary inflammation after lung transplantation. Surgery 2009; 146:1-4. [PMID: 19541003 DOI: 10.1016/j.surg.2009.02.011] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2009] [Accepted: 02/22/2009] [Indexed: 11/17/2022]
Affiliation(s)
- Victor E Laubach
- Department of Surgery, University of Virginia Health System, Charlottesville, VA 22908, USA
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22
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Yang Z, Sharma AK, Linden J, Kron IL, Laubach VE. CD4+ T lymphocytes mediate acute pulmonary ischemia-reperfusion injury. J Thorac Cardiovasc Surg 2009; 137:695-702; discussion 702. [PMID: 19258091 DOI: 10.1016/j.jtcvs.2008.10.044] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2008] [Revised: 09/18/2008] [Accepted: 10/13/2008] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Postischemic reperfusion of the lung triggers proinflammatory responses that stimulate injurious neutrophil chemotaxis. We hypothesized that T lymphocytes are recruited and activated during reperfusion and mediate subsequent neutrophil-induced lung ischemia-reperfusion injury. METHODS An in vivo mouse model of lung ischemia-reperfusion injury was used. C57BL/6 mice were assigned to either the sham group (left thoracotomy) or 7 study groups that underwent 1-hour left hilar occlusion followed by 1 to 24 hours of reperfusion. After in vivo reperfusion, the lungs were perfused ex vivo with buffer whereby pulmonary function was assessed. Lung vascular permeability, edema, neutrophil accumulation, and cytokine/chemokine production (tumor necrosis factor alpha, interleukin 17, CCL3, and CXCL1) were assessed based on Evans blue dye leak, wet/dry weight ratio, myeloperoxidase level, and enzyme-linked immunosorbent assay, respectively. RESULTS A preliminary study showed that 2 hours of reperfusion resulted in greater pulmonary dysfunction than 1 or 24 hours of reperfusion. The 2-hour reperfusion period was thus used for the remaining experiments. Comparable and significant protection from ischemia-reperfusion injury-induced lung dysfunction and injury occurred after antibody depletion of neutrophils or CD4(+) T cells but not CD8(+) T cells (P < .05 vs immunoglobulin G control). Lung ischemia-reperfusion injury was proportional to the infiltration of neutrophils but not T cells. Moreover, pulmonary neutrophil infiltration and the production of CXCL1 (KC) were significantly diminished by CD4(+) T-cell depletion but not vice versa. CONCLUSIONS Both CD4(+) T lymphocytes and neutrophils accumulate during reperfusion and contribute sequentially to lung ischemia-reperfusion injury. The data suggest that neutrophils mediate ischemia-reperfusion injury; however, CD4(+) T cells play a critical role in stimulating chemokine production and neutrophil chemotaxis during ischemia-reperfusion injury.
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Affiliation(s)
- Zequan Yang
- Department of Surgery, University of Virginia Health System, Charlottesville, VA 22908, USA
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Long-acting oral phosphodiesterase inhibition preconditions against reperfusion injury in an experimental lung transplantation model. J Thorac Cardiovasc Surg 2009; 137:1249-57. [PMID: 19379999 DOI: 10.1016/j.jtcvs.2008.12.040] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2008] [Revised: 11/25/2008] [Accepted: 12/30/2008] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Ischemia-reperfusion injury remains a devastating complication of lung transplantation. Phosphodiesterase inhibitors have been shown to precondition tissues against ischemia-reperfusion injury. Little is known, however, about the utility of phosphodiesterase inhibition in reperfusion injury after lung transplantation. We evaluated the long-acting phosphodiesterase-5 inhibitor, tadalafil, in an ex vivo lung transplant model. METHODS New Zealand White rabbits (4 kg), were given oral tadalafil (n = 11) 24 hours before lung harvest and compared with rabbits given oral vehicle alone (n = 11). Lungs were recovered with Perfadex solution (Vitrolife, Kungsbacka, Sweden) and cold stored for 18 hours. After storage, lung blocks were reperfused with donor rabbit blood in an ex vivo apparatus. Pulmonary artery pressures were recorded with serial arterial and venous blood gas sampling and animals served as their own controls. Phosphodiesterase-5 and protein kinase G tissue activity assays confirmed drug effects. Luminol chemiluminescence assay was used to measure reactive oxygen species and levels of endothelial and inducible nitric oxide synthase were measured. RESULTS Extended cold storage, followed by reperfusion produced a consistent reproducible decrease in oxygenation and increase in pulmonary pressure. Tadalafil-treated animals exhibited greater Pao(2) throughout the course of reperfusion (P = .001) Mean pulmonary artery pressure was lower in tadalafil-treated animals (22 vs 40 mm Hg; P = .04). Phosphodiesterase-5 activity was decreased (143 +/- 8 vs 205 +/- 32 mP; P < .001) with protein kinase G activity increased (25 +/- 12 vs 12 +/- 2.4 fU/microg; P = .01) in the experimental group confirming that oral pretreatment resulted in active phosphodiesterase inhibition in the lung tissue. Reactive oxygen species (as measured by luminol activity) were decreased in tadalafil-treated animals (7.8 +/- 1.5 vs 10.2 +/- 1.2 relative light units; P = .003). CONCLUSIONS Our experimental model demonstrates that oral donor pretreatment with a long-acting phosphodiesterase inhibitor is an effective strategy for improving pulmonary performance after reperfusion. Importantly, phosphodiesterase enzymes and their downstream effectors may play a critical role in reperfusion injury after lung transplantation.
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Lung. PATHOLOGY OF SOLID ORGAN TRANSPLANTATION 2009. [PMCID: PMC7120462 DOI: 10.1007/978-3-540-79343-4_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Experiments with animals in the 1940 and 1950s demonstrated that lung transplantation was technically possible [33]. In 1963, Dr. James Hardy performed the first human lung transplantation. The recipient survived 18 days, ultimately succumbing to renal failure and malnutrition [58]. From 1963 through 1978, multiple attempts at lung transplantation failed because of rejection and complications at the bronchial anastomosis. In the 1980s, improvements in immunosuppression, especially the introduction of cyclosporin A, and enhanced surgical techniques led to renewed interest in organ transplantation. In 1981, a 45-year-old-woman received the first successful heart–lung transplantation for idiopathic pulmonary arterial hypertension (IPAH) [106]. She survived 5 years after the procedure. Two years later the first successful single lung transplantation for idiopathic pulmonary fibrosis (IPF) [128] was reported, and in 1986 the first double lung transplantation for emphysema [25] was performed.
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Yang Z, Sharma AK, Marshall M, Kron IL, Laubach VE. NADPH oxidase in bone marrow-derived cells mediates pulmonary ischemia-reperfusion injury. Am J Respir Cell Mol Biol 2008; 40:375-81. [PMID: 18787174 DOI: 10.1165/rcmb.2008-0300oc] [Citation(s) in RCA: 116] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Reactive oxygen species (ROS) play a crucial role in ischemia-reperfusion (IR) injury after lung transplantation. We hypothesized that NADPH oxidase derived from bone marrow (BM) cells contributes importantly to lung IR injury. An in vivo mouse model of lung IR injury was employed. Wild-type C57BL/6 (WT) mice, p47(phox) knockout (p47(phox)-/-) mice, or chimeras created by BM transplantation between WT and p47(phox)-/- mice were assigned to either Sham (left thoracotomy) or six study groups that underwent IR (1 h left hilar occlusion and 2 h reperfusion). After reperfusion, pulmonary function was assessed using an isolated, buffer-perfused lung system. Lung injury was assessed by measuring vascular permeability (via Evans blue dye), edema, neutrophil infiltration (via myeloperoxidase [MPO]), lipid peroxidation (via malondialdyhyde [MDA]), and expression of proinflammatory cytokines. Lung IR resulted in significantly increased MDA in WT mice, indicative of oxidative stress. WT mice treated with apocynin (an NADPH oxidase inhibitor) and p47(phox)-/- mice displayed significantly reduced pulmonary dysfunction and injury (vascular permeability, edema, MPO, and MDA). In BM chimeras, significantly reduced pulmonary dysfunction and injury occurred after IR in p47(phox)-/--->WT chimeras (donor-->recipient) but not WT-->p47(phox)-/- chimeras. Induction of TNF-alpha, IL-17, IL-6, RANTES (CCL5), KC (CXCL1), MIP-2 (CXCL2), and MCP-1 (CCL2) was significantly reduced after IR in NADPH oxidase-deficient mice and p47(phox)-/--->WT chimeras but not WT-->p47(phox)-/- chimeras. These results indicate that NADPH oxidase-generated ROS specifically from BM-derived cells contributes importantly to lung IR injury. NADPH oxidase may represent a novel therapeutic target for the treatment of IR injury after lung transplantation.
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Affiliation(s)
- Zequan Yang
- Department of Surgery, University of Virginia Health System, P.O. Box 801359, Charlottesville, VA 22908, USA
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26
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Dreyer N, Mühlfeld C, Fehrenbach A, Pech T, von Berg S, Nagib R, Richter J, Wittwer T, Wahlers T, Ochs M. Exogenous surfactant application in a rat lung ischemia reperfusion injury model: effects on edema formation and alveolar type II cells. Respir Res 2008; 9:5. [PMID: 18205928 PMCID: PMC2265285 DOI: 10.1186/1465-9921-9-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2007] [Accepted: 01/18/2008] [Indexed: 11/23/2022] Open
Abstract
Background Prophylactic exogenous surfactant therapy is a promising way to attenuate the ischemia and reperfusion (I/R) injury associated with lung transplantation and thereby to decrease the clinical occurrence of acute lung injury and acute respiratory distress syndrome. However, there is little information on the mode by which exogenous surfactant attenuates I/R injury of the lung. We hypothesized that exogenous surfactant may act by limiting pulmonary edema formation and by enhancing alveolar type II cell and lamellar body preservation. Therefore, we investigated the effect of exogenous surfactant therapy on the formation of pulmonary edema in different lung compartments and on the ultrastructure of the surfactant producing alveolar epithelial type II cells. Methods Rats were randomly assigned to a control, Celsior (CE) or Celsior + surfactant (CE+S) group (n = 5 each). In both Celsior groups, the lungs were flush-perfused with Celsior and subsequently exposed to 4 h of extracorporeal ischemia at 4°C and 50 min of reperfusion at 37°C. The CE+S group received an intratracheal bolus of a modified natural bovine surfactant at a dosage of 50 mg/kg body weight before flush perfusion. After reperfusion (Celsior groups) or immediately after sacrifice (Control), the lungs were fixed by vascular perfusion and processed for light and electron microscopy. Stereology was used to quantify edematous changes as well as alterations of the alveolar epithelial type II cells. Results Surfactant treatment decreased the intraalveolar edema formation (mean (coefficient of variation): CE: 160 mm3 (0.61) vs. CE+S: 4 mm3 (0.75); p < 0.05) and the development of atelectases (CE: 342 mm3 (0.90) vs. CE+S: 0 mm3; p < 0.05) but led to a higher degree of peribronchovascular edema (CE: 89 mm3 (0.39) vs. CE+S: 268 mm3 (0.43); p < 0.05). Alveolar type II cells were similarly swollen in CE (423 μm3(0.10)) and CE+S (481 μm3(0.10)) compared with controls (323 μm3(0.07); p < 0.05 vs. CE and CE+S). The number of lamellar bodies was increased and the mean lamellar body volume was decreased in both CE groups compared with the control group (p < 0.05). Conclusion Intratracheal surfactant application before I/R significantly reduces the intraalveolar edema formation and development of atelectases but leads to an increased development of peribronchovascular edema. Morphological changes of alveolar type II cells due to I/R are not affected by surfactant treatment. The beneficial effects of exogenous surfactant therapy are related to the intraalveolar activity of the exogenous surfactant.
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Affiliation(s)
- Niels Dreyer
- Department of Anatomy, Division of Electron Microscopy, University of Göttingen, Kreuzbergring 36, D-37075 Göttingen, Germany.
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Prekker ME, Herrington CS, Hertz MI, Radosevich DM, Dahlberg PS. Early Trends in PaO 2 /Fraction of Inspired Oxygen Ratio Predict Outcome in Lung Transplant Recipients With Severe Primary Graft Dysfunction. Chest 2007; 132:991-7. [PMID: 17550938 DOI: 10.1378/chest.06-2752] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND The development of severe primary graft dysfunction (PGD) is a risk factor for perioperative death following lung transplantation. Our goal is to improve the predictive value of the earliest Pao(2)/fraction of inspired oxygen (P/F) measurements that gauge PGD severity. METHODS We identified 96 patients with severe PGD (P/F < 200) at ICU arrival through a retrospective review of 431 lung transplants performed at our institution from 1992 to 2005. The P/F trend, represented as quartiles of the 12-h percentage change in P/F, was analyzed using multivariate logistic regression. Study outcomes were 90-day death and long-term survival. RESULTS The median percentage change in P/F over 12 h was + 52% (interquartile range, +20 to 90%). We observed the highest early mortality among those in the lowest quartile of the P/F trend (an increase in P/F <or= 20%). Ninety-day death rates decreased across the quartiles (low quartile, 32%; low-mid quartile, 9%; high-mid quartile, 5%; high quartile, 5%; test for trend, p = 0.007). After adjustment for the use of cardiopulmonary bypass, those in the lowest quartile of P/F trend had 6.8 times the odds of early death vs patients with a more favorable trend (odds ratio, 6.80; 95% confidence interval, 1.73 to 0.51; p = 0.007). In the first 5 years after transplant, there were significantly more deaths within the low quartile group vs those with a more rapidly increasing P/F trend (log-rank test, p = 0.01). CONCLUSIONS Among lung recipients with severe PGD at ICU arrival, an improvement in P/F <or= 20% in the first 12 h portends a poor outcome.
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Affiliation(s)
- Matthew E Prekker
- Divisions of Cardiovascular and Thoracic Surgery, University of Minnesota, Minneapolis, MN, USA
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Parambil JG, Myers JL, Aubry MC, Ryu JH. Causes and prognosis of diffuse alveolar damage diagnosed on surgical lung biopsy. Chest 2007; 132:50-7. [PMID: 17475632 DOI: 10.1378/chest.07-0104] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Diffuse alveolar damage (DAD) is a relatively common histopathologic finding at autopsy, particularly in patients dying with ARDS, and can result from a variety of causes. The spectrum of causes and associated prognostic implications for DAD diagnosed by surgical lung biopsy are unclear. METHODS We identified 58 consecutive patients with DAD diagnosed by surgical lung biopsy over a 7-year period, January 1996 through December 2002. The presenting clinicoradiologic features, causes, and clinical course of these patients were studied. RESULTS The median age was 61 years, 48% were women, and 60% were immunocompromised. Ninety percent of patients fulfilled the criteria for ARDS at the time of surgical lung biopsy. Chest radiography demonstrated bilateral parenchymal infiltrates, while CT revealed predominantly ground-glass and consolidative opacities. Infections were the most common cause of DAD (22%). Other causes were noninfectious pulmonary complications of hematopoietic stem-cell or solid-organ transplantation (17%), connective tissue diseases (16%), acute exacerbation of idiopathic pulmonary fibrosis (12%), drugs (10%), and radiation therapy (2%). Twelve patients (21%) had acute interstitial pneumonia (ie, no identifiable cause or predisposing condition for DAD). Overall hospital mortality was 53%, with the highest mortality (86%) occurring among patients for whom DAD represented acute exacerbation of idiopathic pulmonary fibrosis. CONCLUSION Our study showed that infections and acute interstitial pneumonia are the most common causes of DAD diagnosed by surgical lung biopsy. Hospital mortality rate associated with DAD may vary depending on the underlying cause.
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Affiliation(s)
- Joseph G Parambil
- Division of Pulmonary and Critical Care Medicine, Desk East 18, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
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