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Garantziotis S. Modulation of hyaluronan signaling as a therapeutic target in human disease. Pharmacol Ther 2021; 232:107993. [PMID: 34587477 DOI: 10.1016/j.pharmthera.2021.107993] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 09/08/2021] [Accepted: 09/09/2021] [Indexed: 12/14/2022]
Abstract
The extracellular matrix is an active participant, modulator and mediator of the cell, tissue, organ and organismal response to injury. Recent research has highlighted the role of hyaluronan, an abundant glycosaminoglycan constituent of the extracellular matrix, in many fundamental biological processes underpinning homeostasis and disease development. From this basis, emerging studies have demonstrated the therapeutic potential of strategies which target hyaluronan synthesis, biology and signaling, with significant promise as therapeutics for a variety of inflammatory and immune diseases. This review summarizes the state of the art in this field and discusses challenges and opportunities in what could emerge as a new class of therapeutic agents, that we term "matrix biologics".
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Affiliation(s)
- Stavros Garantziotis
- Division of Intramural Research, National Institute of Environmental Health Sciences, Research Triangle Park, North Carolina, USA.
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Frye CC, Bery AI, Kreisel D, Kulkarni HS. Sterile inflammation in thoracic transplantation. Cell Mol Life Sci 2020; 78:581-601. [PMID: 32803398 DOI: 10.1007/s00018-020-03615-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 07/20/2020] [Accepted: 08/07/2020] [Indexed: 02/08/2023]
Abstract
The life-saving benefits of organ transplantation can be thwarted by allograft dysfunction due to both infectious and sterile inflammation post-surgery. Sterile inflammation can occur after necrotic cell death due to the release of endogenous ligands [such as damage-associated molecular patterns (DAMPs) and alarmins], which perpetuate inflammation and ongoing cellular injury via various signaling cascades. Ischemia-reperfusion injury (IRI) is a significant contributor to sterile inflammation after organ transplantation and is associated with detrimental short- and long-term outcomes. While the vicious cycle of sterile inflammation and cellular injury is remarkably consistent amongst different organs and even species, we have begun understanding its mechanistic basis only over the last few decades. This understanding has resulted in the developments of novel, yet non-specific therapies for mitigating IRI-induced graft damage, albeit with moderate results. Thus, further understanding of the mechanisms underlying sterile inflammation after transplantation is critical for identifying personalized therapies to prevent or interrupt this vicious cycle and mitigating allograft dysfunction. In this review, we identify common and distinct pathways of post-transplant sterile inflammation across both heart and lung transplantation that can potentially be targeted.
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Affiliation(s)
- C Corbin Frye
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, 63110, USA.
| | - Amit I Bery
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, 4523 Clayton Avenue, Campus Box 8052, St. Louis, MO, 63110, USA.
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Hrishikesh S Kulkarni
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, 4523 Clayton Avenue, Campus Box 8052, St. Louis, MO, 63110, USA
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Johnson CG, Stober VP, Cyphert-Daly JM, Trempus CS, Flake GP, Cali V, Ahmad I, Midura RJ, Aronica MA, Matalon S, Garantziotis S. High molecular weight hyaluronan ameliorates allergic inflammation and airway hyperresponsiveness in the mouse. Am J Physiol Lung Cell Mol Physiol 2018; 315:L787-L798. [PMID: 30188746 PMCID: PMC6425518 DOI: 10.1152/ajplung.00009.2018] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 08/27/2018] [Accepted: 08/27/2018] [Indexed: 12/22/2022] Open
Abstract
Allergic asthma is a major cause of morbidity in both pediatric and adult patients. Recent research has highlighted the role of hyaluronan (HA), an extracellular matrix glycosaminoglycan, in asthma pathogenesis. Experimental allergic airway inflammation and clinical asthma are associated with an increase of shorter fragments of HA (sHA), which complex with inter-α-inhibitor heavy chains (HCs) and induce inflammation and airway hyperresponsiveness (AHR). Importantly, the effects of sHA can be antagonized by the physiological counterpart high molecular weight HA (HMWHA). We used a mouse model of house dust mite-induced allergic airway inflammation and demonstrated that instilled HMWHA ameliorated allergic airway inflammation and AHR, even when given after the establishment of allergic sensitization and after challenge exposures. Furthermore, instilled HMWHA reduced the development of HA-HC complexes and the activation of Rho-associated, coiled-coil containing protein kinase 2. We conclude that airway application of HMWHA is a potential treatment for allergic airway inflammation.
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Affiliation(s)
- Collin G Johnson
- Division of Intramural Research, National Institute of Environmental Health Sciences , Research Triangle Park, North Carolina
| | - Vandy P Stober
- Division of Intramural Research, National Institute of Environmental Health Sciences , Research Triangle Park, North Carolina
| | - Jaime M Cyphert-Daly
- Division of Intramural Research, National Institute of Environmental Health Sciences , Research Triangle Park, North Carolina
| | - Carol S Trempus
- Division of Intramural Research, National Institute of Environmental Health Sciences , Research Triangle Park, North Carolina
| | - Gordon P Flake
- Division of Intramural Research, National Institute of Environmental Health Sciences , Research Triangle Park, North Carolina
| | - Valbona Cali
- Department of Pathobiology, Cleveland Clinic Foundation , Cleveland, Ohio
| | - Israr Ahmad
- Division of Molecular and Translational Biomedicine, Department of Anesthesiology and Perioperative Medicine, and Pulmonary Injury and Repair Center, School of Medicine, The University of Alabama at Birmingham , Birmingham, Alabama
| | - Ronald J Midura
- Department of Pathobiology, Cleveland Clinic Foundation , Cleveland, Ohio
| | - Mark A Aronica
- Department of Pathobiology, Cleveland Clinic Foundation , Cleveland, Ohio
| | - Sadis Matalon
- Division of Molecular and Translational Biomedicine, Department of Anesthesiology and Perioperative Medicine, and Pulmonary Injury and Repair Center, School of Medicine, The University of Alabama at Birmingham , Birmingham, Alabama
| | - Stavros Garantziotis
- Division of Intramural Research, National Institute of Environmental Health Sciences , Research Triangle Park, North Carolina
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Hyaluronan interactions with innate immunity in lung biology. Matrix Biol 2018; 78-79:84-99. [PMID: 29410190 DOI: 10.1016/j.matbio.2018.01.027] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 01/30/2018] [Indexed: 12/28/2022]
Abstract
Lung disease is a leading cause of morbidity and mortality worldwide. Innate immune responses in the lung play a central role in the pathogenesis of lung disease and the maintenance of lung health, and thus it is crucial to understand factors that regulate them. Hyaluronan is ubiquitous in the lung, and its expression is increased following lung injury and in disease states. Furthermore, hyaladherins like inter-α-inhibitor, tumor necrosis factor-stimulated gene 6, pentraxin 3 and versican are also induced and help form a dynamic hyaluronan matrix in injured lung. This review synthesizes present knowledge about the interactions of hyaluronan and its associated hyaladherins with the lung immune system, and the implications of these interactions for lung biology and disease.
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Hyaluronan mediates the adhesion of porcine peripheral blood mononuclear cells to poly (I:C)-treated intestinal cells and modulates their cytokine production. Vet Immunol Immunopathol 2016; 184:8-17. [PMID: 28166932 DOI: 10.1016/j.vetimm.2016.12.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 11/18/2016] [Accepted: 12/22/2016] [Indexed: 02/07/2023]
Abstract
Hyaluronan (HA), a major component of the extracellular matrix (ECM), has been increasingly recognized as a regulator of inflammation. Its role is complex since it has pro- and anti-inflammatory actions by modulating the expression of inflammatory genes, the recruitment of inflammatory cells and the production of inflammatory cytokines, but also by attenuating the course of inflammation and providing protection against tissue damage. Certain viruses and other inflammatory stimuli induce organization of HA into cable-like structures, which may be responsible for leukocyte recruitment and, on the other hand, low molecular weight fragments of HA have been shown to activate various inflammatory responses. The aim of the present study was to analyze the effects of a simulated infection with the viral mimetic Poly (I:C) on HA deposition on different porcine intestinal cells (primary colonic muscular smooth muscle cells (SMC), and epithelial IPEC-J2 and IPI-2I cell lines) and on the recruitment of peripheral blood mononuclear cells (PBMC) to intestinal cell layers. We show that Poly (I:C) treatment induces the formation of an HA-based pericellular matrix coat in muscular SMC and in intestinal epithelial cells (IECs) and that, on differentiated IPEC-J2 cells, HA accumulates in the basolateral membrane. Porcine PBMCs bind to Poly (I:C)-treated cells and this binding is dependent on HA, since the increase in adhesion is abolished by hyaluronidase treatment of the cell layers. A second goal was to study the effect of different molecular weight HA forms on the production of pro-inflammatory cytokines and chemokines (TNF-α, IL-1β and IL-8) by porcine PBMCs. Low molecular weight HA fragments (100-150kDa), in contrast to high molecular weight HA (2500kDa), stimulate the release of these pro-inflammatory mediators by porcine PBMCs. Our results suggest that HA is involved in the inflammatory response against pathogenic insults to the porcine gut.
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Prakash YS. Emerging concepts in smooth muscle contributions to airway structure and function: implications for health and disease. Am J Physiol Lung Cell Mol Physiol 2016; 311:L1113-L1140. [PMID: 27742732 DOI: 10.1152/ajplung.00370.2016] [Citation(s) in RCA: 99] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 10/06/2016] [Indexed: 12/15/2022] Open
Abstract
Airway structure and function are key aspects of normal lung development, growth, and aging, as well as of lung responses to the environment and the pathophysiology of important diseases such as asthma, chronic obstructive pulmonary disease, and fibrosis. In this regard, the contributions of airway smooth muscle (ASM) are both functional, in the context of airway contractility and relaxation, as well as synthetic, involving production and modulation of extracellular components, modulation of the local immune environment, cellular contribution to airway structure, and, finally, interactions with other airway cell types such as epithelium, fibroblasts, and nerves. These ASM contributions are now found to be critical in airway hyperresponsiveness and remodeling that occur in lung diseases. This review emphasizes established and recent discoveries that underline the central role of ASM and sets the stage for future research toward understanding how ASM plays a central role by being both upstream and downstream in the many interactive processes that determine airway structure and function in health and disease.
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Affiliation(s)
- Y S Prakash
- Departments of Anesthesiology, and Physiology & Biomedical Engineering, Mayo Clinic, Rochester, Minnesota
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Abstract
PURPOSE OF REVIEW Chronic lung allograft dysfunction (CLAD) was recently introduced as an overarching term covering different phenotypes of chronic allograft dysfunction, including obstructive CLAD (bronchiolitis obliterans syndrome), restrictive CLAD (restrictive allograft syndrome) and graft dysfunction due to causes not related to chronic rejection. In the present review, we will highlight the latest insights and current controversies regarding the new CLAD terminology, underlying pathophysiologic mechanisms, diagnostic approach and possible treatment options. RECENT FINDINGS Different pathophysiological mechanisms are clearly involved in clinically distinct phenotypes of chronic rejection, as is reflected by differences in histology, allograft function and imaging. Therefore, not all CLAD patients may equally benefit from specific therapies. SUMMARY The recent introduction of CLAD importantly changed the clinical practice in lung transplant recipients. Given the relative low accuracy of the current diagnostic tools, future research should focus on specific biomarkers, more sensitive pulmonary function parameters and imaging techniques for timely CLAD diagnosis and phenotyping. Personalized or targeted therapeutic options for adequate prevention and treatment of CLAD are required.
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Liang J, Jiang D, Noble PW. Hyaluronan as a therapeutic target in human diseases. Adv Drug Deliv Rev 2016; 97:186-203. [PMID: 26541745 PMCID: PMC4753080 DOI: 10.1016/j.addr.2015.10.017] [Citation(s) in RCA: 146] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Revised: 10/19/2015] [Accepted: 10/20/2015] [Indexed: 02/07/2023]
Abstract
Accumulation and turnover of extracellular matrix is a hallmark of tissue injury, repair and remodeling in human diseases. Hyaluronan is a major component of the extracellular matrix and plays an important role in regulating tissue injury and repair, and controlling disease outcomes. The function of hyaluronan depends on its size, location, and interactions with binding partners. While fragmented hyaluronan stimulates the expression of an array of genes by a variety of cell types regulating inflammatory responses and tissue repair, cell surface hyaluronan provides protection against tissue damage from the environment and promotes regeneration and repair. The interactions of hyaluronan and its binding proteins participate in the pathogenesis of many human diseases. Thus, targeting hyaluronan and its interactions with cells and proteins may provide new approaches to developing therapeutics for inflammatory and fibrosing diseases. This review focuses on the role of hyaluronan in biological and pathological processes, and as a potential therapeutic target in human diseases.
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Affiliation(s)
- Jiurong Liang
- Department of Medicine and Women's Guild Lung Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Dianhua Jiang
- Department of Medicine and Women's Guild Lung Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Paul W Noble
- Department of Medicine and Women's Guild Lung Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA.
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Garantziotis S, Brezina M, Castelnuovo P, Drago L. The role of hyaluronan in the pathobiology and treatment of respiratory disease. Am J Physiol Lung Cell Mol Physiol 2016; 310:L785-95. [PMID: 26747781 DOI: 10.1152/ajplung.00168.2015] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 01/05/2016] [Indexed: 12/11/2022] Open
Abstract
Hyaluronan, a ubiquitous naturally occurring glycosaminoglycan, is a major component of the extracellular matrix, where it participates in biological processes that include water homeostasis, cell-matrix signaling, tissue healing, inflammation, angiogenesis, and cell proliferation and migration. There are emerging data that hyaluronan and its degradation products have an important role in the pathobiology of the respiratory tract. We review the role of hyaluronan in respiratory diseases and present evidence from published literature and from clinical practice supporting hyaluronan as a novel treatment for respiratory diseases. Preliminary data show that aerosolized exogenous hyaluronan has beneficial activity against airway inflammation, protects against bronchial hyperreactivity and remodeling, and disrupts the biofilm associated with chronic infection. This suggests a role in airway diseases with a predominant inflammatory component such as rhinosinusitis, asthma, chronic obstructive pulmonary disease, cystic fibrosis, and primary ciliary dyskinesia. The potential for hyaluronan to complement conventional therapy will become clearer when data are available from controlled trials in larger patient populations.
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Affiliation(s)
- Stavros Garantziotis
- Clinical Research Program, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, North Carolina;
| | - Martin Brezina
- Clinic of Pediatric Pneumology and Phthisiology, University Hospital Bratislava, Bratislava, Slovakia
| | - Paolo Castelnuovo
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Insubria, Ospedale di Circolo, Fondazione Macchi, Varese, Italy; and
| | - Lorenzo Drago
- Laboratory of Clinical Chemistry and Microbiology, IRCCS Galeazzi Orthopaedic Institute, Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
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Lee-Sayer SSM, Dong Y, Arif AA, Olsson M, Brown KL, Johnson P. The where, when, how, and why of hyaluronan binding by immune cells. Front Immunol 2015; 6:150. [PMID: 25926830 PMCID: PMC4396519 DOI: 10.3389/fimmu.2015.00150] [Citation(s) in RCA: 106] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Accepted: 03/20/2015] [Indexed: 01/04/2023] Open
Abstract
Hyaluronan is made and extruded from cells to form a pericellular or extracellular matrix (ECM) and is present in virtually all tissues in the body. The size and form of hyaluronan present in tissues are indicative of a healthy or inflamed tissue, and the interactions of hyaluronan with immune cells can influence their response. Thus, in order to understand how inflammation is regulated, it is necessary to understand these interactions and their consequences. Although there is a large turnover of hyaluronan in our bodies, the large molecular mass form of hyaluronan predominates in healthy tissues. Upon tissue damage and/or infection, the ECM and hyaluronan are broken down and an inflammatory response ensues. As inflammation is resolved, the ECM is restored, and high molecular mass hyaluronan predominates again. Immune cells encounter hyaluronan in the tissues and lymphoid organs and respond differently to high and low molecular mass forms. Immune cells differ in their ability to bind hyaluronan and this can vary with the cell type and their activation state. For example, peritoneal macrophages do not bind soluble hyaluronan but can be induced to bind after exposure to inflammatory stimuli. Likewise, naïve T cells, which typically express low levels of the hyaluronan receptor, CD44, do not bind hyaluronan until they undergo antigen-stimulated T cell proliferation and upregulate CD44. Despite substantial knowledge of where and when immune cells bind hyaluronan, why immune cells bind hyaluronan remains a major outstanding question. Here, we review what is currently known about the interactions of hyaluronan with immune cells in both healthy and inflamed tissues and discuss how hyaluronan binding by immune cells influences the inflammatory response.
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Affiliation(s)
- Sally S M Lee-Sayer
- Department of Microbiology and Immunology, Life Sciences Institute, University of British Columbia , Vancouver, BC , Canada
| | - Yifei Dong
- Department of Microbiology and Immunology, Life Sciences Institute, University of British Columbia , Vancouver, BC , Canada
| | - Arif A Arif
- Department of Microbiology and Immunology, Life Sciences Institute, University of British Columbia , Vancouver, BC , Canada
| | - Mia Olsson
- Department of Microbiology and Immunology, Life Sciences Institute, University of British Columbia , Vancouver, BC , Canada
| | - Kelly L Brown
- Department of Pediatrics, Child and Family Research Institute, University of British Columbia , Vancouver, BC , Canada
| | - Pauline Johnson
- Department of Microbiology and Immunology, Life Sciences Institute, University of British Columbia , Vancouver, BC , Canada
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Characteristic Patterns in the Fibrotic Lung. Comparing Idiopathic Pulmonary Fibrosis with Chronic Lung Allograft Dysfunction. Ann Am Thorac Soc 2015; 12 Suppl 1:S34-41. [DOI: 10.1513/annalsats.201410-476mg] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
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Raza K, Larsen T, Samaratunga N, Price AP, Meyer C, Matson A, Ehrhardt MJ, Fogas S, Tolar J, Hertz MI, Panoskaltsis-Mortari A. MSC therapy attenuates obliterative bronchiolitis after murine bone marrow transplant. PLoS One 2014; 9:e109034. [PMID: 25272285 PMCID: PMC4182803 DOI: 10.1371/journal.pone.0109034] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Accepted: 09/03/2014] [Indexed: 12/18/2022] Open
Abstract
RATIONALE Obliterative bronchiolitis (OB) is a significant cause of morbidity and mortality after lung transplant and hematopoietic cell transplant. Mesenchymal stromal cells (MSCs) have been shown to possess immunomodulatory properties in chronic inflammatory disease. OBJECTIVE Administration of MSCs was evaluated for the ability to ameliorate OB in mice using our established allogeneic bone marrow transplant (BMT) model. METHODS Mice were lethally conditioned and received allogeneic bone marrow without (BM) or with spleen cells (BMS), as a source of OB-causing T-cells. Cell therapy was started at 2 weeks post-transplant, or delayed to 4 weeks when mice developed airway injury, defined as increased airway resistance measured by pulmonary function test (PFT). BM-derived MSC or control cells [mouse pulmonary vein endothelial cells (PVECs) or lung fibroblasts (LFs)] were administered. Route of administration [intratracheally (IT) and IV] and frequency (every 1, 2 or 3 weeks) were compared. Mice were evaluated at 3 months post-BMT. MEASUREMENTS AND MAIN RESULTS No ectopic tissue formation was identified in any mice. When compared to BMS mice receiving control cells or no cells, those receiving MSCs showed improved resistance, compliance and inspiratory capacity. Interim PFT analysis showed no difference in route of administration. Improvements in PFTs were found regardless of dose frequency; but once per week worked best even when administration began late. Mice given MSC also had decreased peribronchiolar inflammation, lower levels of hydroxyproline (collagen) and higher frequencies of macrophages staining for the alternatively activated macrophage (AAM) marker CD206. CONCLUSIONS These results warrant study of MSCs as a potential management option for OB in lung transplant and BMT recipients.
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Affiliation(s)
- Kashif Raza
- Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Trevor Larsen
- Breck High School, Edina, Minnesota, United States of America
| | | | - Andrew P Price
- Pediatric Blood and Bone Marrow Transplant Program, University of Minnesota Cancer Center, Minneapolis, Minnesota, United States of America
| | - Carolyn Meyer
- Pediatric Blood and Bone Marrow Transplant Program, University of Minnesota Cancer Center, Minneapolis, Minnesota, United States of America
| | - Amy Matson
- Pediatric Blood and Bone Marrow Transplant Program, University of Minnesota Cancer Center, Minneapolis, Minnesota, United States of America
| | - Michael J Ehrhardt
- Pediatric Blood and Bone Marrow Transplant Program, University of Minnesota Cancer Center, Minneapolis, Minnesota, United States of America
| | - Samuel Fogas
- Pediatric Blood and Bone Marrow Transplant Program, University of Minnesota Cancer Center, Minneapolis, Minnesota, United States of America
| | - Jakub Tolar
- Pediatric Blood and Bone Marrow Transplant Program, University of Minnesota Cancer Center, Minneapolis, Minnesota, United States of America
| | - Marshall I Hertz
- Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Angela Panoskaltsis-Mortari
- Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Minnesota, Minneapolis, Minnesota, United States of America; Pediatric Blood and Bone Marrow Transplant Program, University of Minnesota Cancer Center, Minneapolis, Minnesota, United States of America
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