Hypoxia regulates gene expression of alveolar epithelial transport proteins

Exploration on anti-hypoxia properties of peptides: a review

Peptides are important components of human nutrition and health, and considered as safe, nontoxic, and easily absorbed potential drugs. Anti-hypoxia peptides are a kind of peptides that can prevent hypoxia or hypoxia damage. In this paper, the sources, preparations, and molecular mechanisms of anti-hypoxia peptides were systemically reviewed. The combination of bioinformatics, chemical synthesis, enzymatic hydrolysis, and microbial fermentation are recommended for efficient productions of anti-hypoxic peptides. The mechanisms of anti-hypoxic peptides include interference with glycolytic process and HIF-1α pathway, mitochondrial apoptosis, and inflammatory response. In addition, bioinformatics analysis, including virtual screening and molecular docking, provides an alternative or auxiliary method for exploring the potential anti-hypoxic activities and mechanisms of peptides. The potential challenges and prospects of anti-hypoxic peptides are also discussed. This paper can provide references for researchers in this field and promote further research and clinical applications of anti-hypoxic peptides in the future.

Maturation of the Na,K-ATPase in the Endoplasmic Reticulum in Health and Disease

Abstract

The Na,K-ATPase establishes the electrochemical gradient of cells by driving an active exchange of Na⁺ and K⁺ ions while consuming ATP. The minimal functional transporter consists of a catalytic α-subunit and a β-subunit with chaperon activity. The Na,K-ATPase also functions as a cell adhesion molecule and participates in various intracellular signaling pathways. The maturation and trafficking of the Na,K-ATPase include co- and post-translational processing of the enzyme in the endoplasmic reticulum (ER) and the Golgi apparatus and subsequent delivery to the plasma membrane (PM). The ER folding of the enzyme is considered as the rate-limiting step in the membrane delivery of the protein. It has been demonstrated that only assembled Na,K-ATPase α:β-complexes may exit the organelle, whereas unassembled, misfolded or unfolded subunits are retained in the ER and are subsequently degraded. Loss of function of the Na,K-ATPase has been associated with lung, heart, kidney and neurological disorders. Recently, it has been shown that ER dysfunction, in particular, alterations in the homeostasis of the organelle, as well as impaired ER-resident chaperone activity may impede folding of Na,K-ATPase subunits, thus decreasing the abundance and function of the enzyme at the PM. Here, we summarize our current understanding on maturation and subsequent processing of the Na,K-ATPase in the ER under physiological and pathophysiological conditions.

Graphic Abstract

Positive association between moderate altitude and chronic lower respiratory disease mortality in United States counties

For patients with chronic lower respiratory disease, hypobaric hypoxia at a high altitude is considered a risk factor for mortality. However, the effects of residing at moderately high altitudes remain unclear. We investigated the association between moderate altitude and chronic lower respiratory disease mortality. In particular, we examined the lower 48 United States counties for age-adjusted chronic lower respiratory disease mortality rates, altitude, and socioeconomic factors, including tobacco use, per capita income, population density, sex ratio, unemployment, poverty, and education between 1979 and 1998. The socioeconomic factors were incorporated into the correlation analysis as potential covariates. Considerable positive (R = 0.235; P <0.001) and partial (R = 0.260; P <0.001) correlations were observed between altitude and chronic lower respiratory disease mortality rate. In the subgroup with high COPD prevalence subgroup, even stronger positive (R = 0.346; P <0.001) and partial (R = 0.423, P <0.001) correlations were observed. Multivariate regression analysis of all available socioeconomic factors revealed that additional knowledge on altitude improved the adjusted R2 values from 0.128 to 0.186 for all counties and from 0.301 to 0.421 for counties with high COPD prevalence. We concluded that in the lower 48 United States counties, even a moderate altitude may pose considerable risks in patients with chronic lower respiratory disease.

Cystic fibrosis transmembrane conductance regulator-emerging regulator of cancer

Mutations of cystic fibrosis transmembrane conductance regulator (CFTR) cause cystic fibrosis, the most common life-limiting recessive genetic disease among Caucasians. CFTR mutations have also been linked to increased risk of various cancers but remained controversial for a long time. Recent studies have begun to reveal that CFTR is not merely an ion channel but also an important regulator of cancer development and progression with multiple signaling pathways identified. In this review, we will first present clinical findings showing the correlation of genetic mutations or aberrant expression of CFTR with cancer incidence in multiple cancers. We will then focus on the roles of CFTR in fundamental cellular processes including transformation, survival, proliferation, migration, invasion and epithelial-mesenchymal transition in cancer cells, highlighting the signaling pathways involved. Finally, the association of CFTR expression levels with patient prognosis, and the potential of CFTR as a cancer prognosis indicator in human malignancies will be discussed.

The role of declining adaptive homeostasis in ageing

Adaptive homeostasis is "the transient expansion or contraction of the homeostatic range for any given physiological parameter in response to exposure to sub-toxic, non-damaging, signalling molecules or events, or the removal or cessation of such molecules or events" (Davies, 2016). Adaptive homeostasis enables biological systems to make continuous short-term adjustments for optimal functioning despite ever-changing internal and external environments. Initiation of adaptation in response to an appropriate signal allows organisms to successfully cope with much greater, normally toxic, stresses. These short-term responses are initiated following effective signals, including hypoxia, cold shock, heat shock, oxidative stress, exercise-induced adaptation, caloric restriction, osmotic stress, mechanical stress, immune response, and even emotional stress. There is now substantial literature detailing a decline in adaptive homeostasis that, unfortunately, appears to manifest with ageing, especially in the last third of the lifespan. In this review, we present the hypothesis that one hallmark of the ageing process is a significant decline in adaptive homeostasis capacity. We discuss the mechanistic importance of diminished capacity for short-term (reversible) adaptive responses (both biochemical and signal transduction/gene expression-based) to changing internal and external conditions, for short-term survival and for lifespan and healthspan. Studies of cultured mammalian cells, worms, flies, rodents, simians, apes, and even humans, all indicate declining adaptive homeostasis as a potential contributor to age-dependent senescence, increased risk of disease, and even mortality. Emerging work points to Nrf2-Keap1 signal transduction pathway inhibitors, including Bach1 and c-Myc, both of whose tissue concentrations increase with age, as possible major causes for age-dependent loss of adaptive homeostasis.

Hydrogen sulfide contributes to hypoxic inhibition of airway transepithelial sodium absorption

In lung epithelial cells, hypoxia decreases the expression and activity of sodium-transporting molecules, thereby reducing the rate of transepithelial sodium absorption. The mechanisms underlying the sensing of hypoxia and subsequent coupling to sodium-transporting molecules remain unclear. Hydrogen sulfide (H2S) has recently been recognized as a cellular signaling molecule whose intracellular concentrations critically depend on oxygen levels. Therefore, it was questioned whether endogenously produced H2S contributes to hypoxic inhibition of sodium transport. In electrophysiological Ussing chamber experiments, hypoxia was established by decreasing oxygen concentrations in the chambers. Hypoxia concentration dependently and reversibly decreased amiloride-sensitive sodium absorption by cultured H441 monolayers and freshly dissected porcine tracheal epithelia due to inhibition of basolateral Na+/K+-ATPase. Exogenous application of H2S by the sulfur salt Na2S mimicked the effect of hypoxia and inhibited amiloride-sensitive sodium absorption by both tissues in an oxygen-dependent manner. Hypoxia increased intracellular concentrations of H2S and decreased the concentration of polysulfides. Pretreatment with the cystathionine-γ-lyase inhibitor d/l-propargylglycine (PAG) decreased hypoxic inhibition of sodium transport by H441 monolayers, whereas inhibition of cystathionine-β-synthase (with aminooxy-acetic acid; AOAA) or 3-mercaptopyruvate sulfurtransferase (with aspartate) had no effect. Inhibition of all of these H2S-generating enzymes with a combination of AOAA, PAG, and aspartate decreased the hypoxic inhibition of sodium transport by H441 cells and pig tracheae and decreased H2S production by tracheae. These data suggest that airway epithelial cells endogenously produce H2S during hypoxia, and this contributes to hypoxic inhibition of transepithelial sodium absorption.

FXYD5: Na(+)/K(+)-ATPase Regulator in Health and Disease

FXYD5 (Dysadherin, RIC) is a single span type I membrane protein that plays multiple roles in regulation of cellular functions. It is expressed in a variety of epithelial tissues and acts as an auxiliary subunit of the Na⁺/K⁺-ATPase. During the past decade, a correlation between enhanced expression of FXYD5 and tumor progression has been established for various tumor types. In this review, current knowledge on FXYD5 is discussed, including experimental data on the functional effects of FXYD5 on the Na⁺/K⁺-ATPase. FXYD5 modulates cellular junctions, influences chemokine production, and affects cell adhesion. The accumulated data may provide a basis for understanding the molecular mechanisms underlying FXYD5 mediated phenotypes.

Biphasic modulation of α-ENaC expression by lipopolysaccharide in vitro and in vivo

Acute lung injury (ALI) is characterized by pulmonary edema, in which the epithelial sodium channel (ENaC) has a critical role in the clearance of edema fluid from the alveolar space. Lipopolysaccharide (LPS), frequently employed to induce ALI in experimental animal models, has been reported to regulate ENaC expression and alveolar fluid clearance. The role of LPS in regulating ENaC expression is currently controversial, with increases and decreases reported in ENaC expression in response to LPS treatment, as well as reports that ENaC expression is not affected by LPS induction. The present study aimed to systematically analyze the regulation of α‑ENaC expression in LPS models of ALI at different pathological stages in vitro and in vivo. ENaC expression was observed to increase ≤8 h after LPS treatment, and to decrease thereafter. This finding may explain the contradictory data regarding α‑ENaC expression in response to LPS in the lung. The results of the present study, in combination with those of previous studies, indicate that the modulation of α-ENaC expression may not be a direct genetic response to LPS exposure, but a general response of the lung to the pathological changes associated with inflammation, hypoxia and endothelial and epithelial damage involved in the development of ALI. The findings of this study may have potential clinical significance for understanding the pathogenesis of ALI and improving patient outcome.

Conditioned media from mesenchymal stromal cells restore sodium transport and preserve epithelial permeability in an in vitro model of acute alveolar injury

Mesenchymal stromal cells (MSCs) or their media (MSC-M) were reported to reverse acute lung injury (ALI)-induced decrease of alveolar fluid clearance. To determine the mechanisms by which MSC-M exert their beneficial effects, an in vitro model of alveolar epithelial injury was created by exposing primary rat alveolar epithelial cells (AECs) to hypoxia (3% O2) plus cytomix, a combination of IL-1β, TNF-α, and IFN-γ. MSC-M were collected from human MSCs exposed for 12 h to either normoxia (MSC-M) or to hypoxia plus cytomix (HCYT-MSC-M). This latter condition was used to model the effect of alveolar inflammation and hypoxia on paracrine secretion of MSCs in the injured lung. Comparison of paracrine soluble factors in MSC media showed that the IL-1 receptor antagonist and prostaglandin E2 were markedly increased while keratinocyte growth factor (KGF) was twofold lower in HCYT-MSC-M compared with MSC-M. In AECs, hypoxia plus cytomix increased protein permeability, reduced amiloride-sensitive short-circuit current (AS-Isc), and also decreased the number of α-epithelial sodium channel (α-ENaC) subunits in the apical membrane. To test the effects of MSC media, MSC-M and HCYT-MSC-M were added for an additional 12 h to AECs exposed to hypoxia plus cytomix. MSC-M and HCYT-MSC-M completely restored epithelial permeability to normal. MSC-M, but not HCYT-MSC-M, significantly prevented the hypoxia plus cytomix-induced decrease of ENaC activity and restored apical α-ENaC channels. Interestingly, KGF-deprived MSC-M were unable to restore amiloride-sensitive sodium transport, indicating a possible role for KGF in the beneficial effect of MSC-M. These results indicate that MSC-M may be a preferable therapeutic option for ALI.

Effect of hypoxia and dexamethasone on inflammation and ion transporter function in pulmonary cells

Dexamethasone has been found to reduce the incidence of high-altitude pulmonary oedema. Mechanisms explaining this effect still remain unclear. We assessed the effect of dexamethasone using established cell lines, including rat alveolar epithelial cells (AEC), pulmonary artery endothelial cells (RPAEC) and alveolar macrophages (MAC), in an environment of low oxygen, simulating a condition of alveolar hypoxia as found at high altitude. Inflammatory mediators and ion transporter expression were quantified. Based on earlier results, we hypothesized that hypoxic conditions trigger inflammation. AEC, RPAEC and MAC, pre-incubated for 1 h with or without dexamethasone (10(-7) mol/l), were subsequently exposed to mild hypoxia (5% O(2), or normoxia as control) for 24 h. mRNA and protein levels of cytokine-induced neutrophil chemoattractant-1, monocyte chemoattractant protein-1 and interleukin-6 were analysed. mRNA expression and functional activity of the apical epithelial sodium channel and basolateral Na(+)/K(+)-ATPase were determined using radioactive marker ions. In all three types of pulmonary cells hypoxic conditions led to an attenuated secretion of inflammatory mediators, which was even more pronounced in dexamethasone pretreated samples. Function of Na(+)/K(+)-ATPase was not significantly influenced by hypoxia or dexamethasone, while activity of epithelial sodium channels was decreased under hypoxic conditions. When pre-incubated with dexamethasone, however, transporter activity was partially maintained. These findings illustrate that long-term hypoxia does not trigger an inflammatory response. The ion transport across apical epithelial sodium channels under hypoxic conditions is ameliorated in cells treated with dexamethasone.

Ion transport by pulmonary epithelia

The lung surface of air-breathing vertebrates is formed by a continuous epithelium that is covered by a fluid layer. In the airways, this epithelium is largely pseudostratified consisting of diverse cell types such as ciliated cells, goblet cells, and undifferentiated basal cells, whereas the alveolar epithelium consists of alveolar type I and alveolar type II cells. Regulation and maintenance of the volume and viscosity of the fluid layer covering the epithelium is one of the most important functions of the epithelial barrier that forms the outer surface area of the lungs. Therefore, the epithelial cells are equipped with a wide variety of ion transport proteins, among which Na⁺, Cl⁻, and K⁺ channels have been identified to play a role in the regulation of the fluid layer. Malfunctions of pulmonary epithelial ion transport processes and, thus, impairment of the liquid balance in our lungs is associated with severe diseases, such as cystic fibrosis and pulmonary oedema. Due to the important role of pulmonary epithelial ion transport processes for proper lung function, the present paper summarizes the recent findings about composition, function, and ion transport properties of the airway epithelium as well as of the alveolar epithelium.

Hypoxia-inducible factor regulates expression of surfactant protein in alveolar type II cells in vitro

Alveolar type II (ATII) cells cultured at an air-liquid (A/L) interface maintain differentiation, but they lose these properties when they are submerged. Others showed that an oxygen tension gradient develops in the culture medium as ATII cells consume oxygen. Therefore, we wondered whether hypoxia inducible factor (HIF) signaling could explain differences in the phenotypes of ATII cells cultured under A/L interface or submerged conditions. ATII cells were isolated from male Sprague-Dawley rats and cultured on inserts coated with a mixture of rat-tail collagen and Matrigel, in medium including 5% rat serum and 10 ng/ml keratinocyte growth factor, with their apical surfaces either exposed to air or submerged. The A/L interface condition maintained the expression of surfactant proteins, whereas that expression was down-regulated under the submerged condition, and the effect was rapid and reversible. Under submerged conditions, there was an increase in HIF1α and HIF2α in nuclear extracts, mRNA levels of HIF inducible genes, vascular endothelial growth factor, glucose transporter-1 (GLUT1), and the protein level of pyruvate dehydrogenase kinase isozyme-1. The expression of surfactant proteins was suppressed and GLUT1 mRNA levels were induced when cells were cultured with 1 mM dimethyloxalyl glycine. The expression of surfactant proteins was restored under submerged conditions with supplemented 60% oxygen. HIF signaling and oxygen tension at the surface of cells appears to be important in regulating the phenotype of rat ATII cells.

Amiloride-sensitive sodium channels and pulmonary edema

The development of pulmonary edema can be considered as a combination of alveolar flooding via increased fluid filtration, impaired alveolar-capillary barrier integrity, and disturbed resolution due to decreased alveolar fluid clearance. An important mechanism regulating alveolar fluid clearance is sodium transport across the alveolar epithelium. Transepithelial sodium transport is largely dependent on the activity of sodium channels in alveolar epithelial cells. This paper describes how sodium channels contribute to alveolar fluid clearance under physiological conditions and how deregulation of sodium channel activity might contribute to the pathogenesis of lung diseases associated with pulmonary edema. Furthermore, sodium channels as putative molecular targets for the treatment of pulmonary edema are discussed.

Role of endothelin-1 in acute lung injury

The alveolar-capillary membrane serves as a barrier that prevents the accumulation of fluid in the alveolar space and restricts the diffusion of large solutes while facilitating an efficient gas exchange. When this barrier becomes dysfunctional, patients develop acute lung injury (ALI), which is characterized by pulmonary edema and increased lung inflammation that leads to a life-threatening impairment of gas exchange. In addition to the increase of inflammatory cytokines, plasma levels of endothelin-1 (ET-1), which is a primarily endothelium-derived vasoconstrictor, are increased in patients with ALI. As patients recover, ET-1 levels decrease, which suggests that ET-1 may not only be a marker of endothelial dysfunction but may have a role in the pathogenesis of ALI. While pulmonary edema accumulates, alveolar fluid clearance (AFC) is of critical importance, as failure to return to normal clearance is associated with poor prognosis in patients with pulmonary edema. AFC involves active transport mechanisms where sodium (Na(+)) is actively transported from the alveolar airspaces, across the alveolar epithelium, and into the pulmonary circulation, which creates an osmotic gradient that is responsible for the clearance of lung edema. In this article, we review the relevance of ET-1 in the development of ALI, not only as a vasoconstrictor molecule but also by inhibiting AFC via the activation of endothelial ET-B receptors and generation. Furthermore, this review highlights the therapeutic role of drugs such as beta-adrenergic agonists and, in particular, of endothelin receptor antagonists in patients with ALI.

Glycemic control in the ICU

Glycemic control clearly improves outcome in critically ill patients. Remaining questions are how tight the control must be to obtain the most benefit without increasing the risk for severe hypoglycemia, and whether an acuity level exists in which this benefit is not clearly visualized. In other words, is this benefit only seen in severely ill patients? The authors believe that clinical trials with ICU lengths of stay of 3 days or less make showing a clinical benefit difficult. Rather, they believe that clinical benefit is seen in higher acuity patients whose ICU length of stay is directly related to the reversal of the inflammatory systemic response rather than the disease or injury alone. Finally, the issue remains of how to obtain a TGC in the 80 to 110 mg/dL range without achieving a less-than-acceptable incidence of hypoglycemia. The answer may well lie with the introduction of continuous glucose monitors that will allow measurements to be obtained every 15 to 30 minutes without introducing an increased workload to the nursing staff. Many of these devices, such as the Optiscanner, which measures plasma glucose continuously, are on the horizon and should be approved by the FDA in 2008.

Glycaemic control and perioperative organ protection

The concept of stress hyperglycaemia as an adaptive, beneficial response in critical illness has recently been challenged. Two large prospective randomized controlled trials in the Leuven University Hospital surgical and medical ICUs demonstrated that maintenance of normoglycaemia with intensive insulin therapy substantially prevents morbidity and reduces mortality. Strict normoglycaemia is required to gain most clinical benefit. With this therapy the risk of hypoglycaemia increased, but without inducing obvious clinical sequellae. Other studies have been used to advocate against implementation of intensive insulin therapy by showing lack of benefit or questioning safety. However, these studies are inconclusive on this subject, due to problems of not reaching normal glucose levels clearly separated from the standard glycaemic group or lack of statistical power. Clearly, future studies should be adequately powered and comply with the study protocol in order to confirm the survival and other clinical benefits of intensive insulin therapy.

Role of oxygen availability in CFTR expression and function

The cystic fibrosis transmembrane conductance regulator (CFTR) serves a pivotal role in normal epithelial homeostasis; its absence leads to destruction of exocrine tissues, including those of the gastrointestinal tract and lung. Acute regulation of CFTR protein in response to environmental stimuli occurs at several levels (e.g., ion channel phosphorylation, ATP hydrolysis, apical membrane recycling). However, less information is available concerning the regulatory pathways that control levels of CFTR mRNA. In the present study, we investigated regulation of CFTR mRNA during oxygen restriction, examined effects of hypoxic signaling on chloride transport across cell monolayers, and related these findings to a possible role in the pathogenesis of chronic hypoxic lung disease. CFTR mRNA, protein, and function were robustly and reversibly altered in human cells in relation to hypoxia. In mice subjected to low oxygen in vivo, CFTR mRNA expression in airways, gastrointestinal tissues, and liver was repressed. CFTR mRNA expression was also diminished in pulmonary tissues taken from hypoxemic subjects at the time of lung transplantation. Environmental factors that induce hypoxic signaling regulate CFTR mRNA and epithelial Cl(-) transport in vitro and in vivo.

Effect of hypoxic "dose" on physiological responses and sea-level performance

Live high-train low (LH+TL) altitude training was developed in the early 1990s in response to potential training limitations imposed on endurance athletes by traditional live high-train high (LH+TH) altitude training. The essence of LH+TL is that it allows athletes to "live high" for the purpose of facilitating altitude acclimatization, as manifest by a profound and sustained increase in endogenous erythropoietin (EPO) and ultimately an augmented erythrocyte volume, while simultaneously allowing athletes to "train low" for the purpose of replicating sea-level training intensity and oxygen flux, thereby inducing beneficial metabolic and neuromuscular adaptations. In addition to "natural/terrestrial" LH+TL, several simulated LH+TL devices have been developed to conveniently bring the mountain to the athlete, including nitrogen apartments, hypoxic tents, and hypoxicator devices. One of the key questions regarding the practical application of LH+TL is, what is the optimal hypoxic dose needed to facilitate altitude acclimatization and produce the expected beneficial physiological responses and sea-level performance effects? The purpose of this paper is to objectively answer that question, on the basis of an extensive body of research by our group in LH+TL altitude training. We will address three key questions: 1) What is the optimal altitude at which to live? 2) How many days are required at altitude? and 3) How many hours per day are required? On the basis of consistent findings from our research group, we recommend that for athletes to derive the physiological benefits of LH+TL, they need to live at a natural elevation of 2000-2500 m for >or=4 wk for >or=22 h.d(-1).

Intensive insulin therapy in the intensive care unit: update on clinical impact and mechanisms of action

OBJECTIVE

Hyperglycemia is a common feature of the critically ill and has been associated with increased mortality. In this review, we give an overview of studies associating critical illness-induced hyperglycemia with adverse outcome and describe how mortality and morbidity are affected when blood glucose levels are strictly controlled to normoglycemia with intensive insulin therapy.

RESULTS

Maintaining normoglycemia with intensive insulin therapy improves survival rates and reduces morbidity in prolonged critically ill patients in both surgical and medical intensive care units (ICUs), as shown by 2 large randomized controlled studies. Prevention of cellular glucose toxicity by strict glycemic control appears to play a predominant role, but other metabolic and nonmetabolic effects of insulin also seem to contribute to the clinical benefits of this therapy.

CONCLUSION

These data support the generalized implementation of a strict blood glucose control management with intensive insulin therapy in adult surgical as well as medical ICU patients.

Chronic continuous hypoxia decreases the expression of SLC4A7 (NBCn1) and SLC4A10 (NCBE) in mouse brain

In the mammalian CNS, hypoxia causes a wide range of physiological effects, and these effects often depend on the stage of development. Among the effects are alterations in pH homeostasis. Na+-coupled HCO3(-) transporters can play critical roles in intracellular pH regulation and several, such as NCBE and NBCn1, are expressed abundantly in the central nervous system. In the present study, we examined the effect of chronic continuous hypoxia on the expression of two electroneutral Na-coupled HCO3(-) transporters, SLC4a7 (NBCn1) and SLC4a10 (NCBE), in mouse brain, the first such study on any acid-base transporter. We placed the mice in normobaric chambers and either maintained normoxia (21% inspired O2) or imposed continuous chronic hypoxia (11% O2) for a duration of either 14 days or 28 days, starting from ages of either postnatal age 2 days (P2) or P90. We assessed protein abundance by Western blot analysis, loading equal amounts of total protein for each condition. In most cases, hypoxia reduced NBCn1 levels by 20-50%, and NCBE levels by 15-40% in cerebral cortex, subcortex, cerebellum, and hippocampus, both after 14 and 28 days, and in both pups and adults. We hypothesize that these decreases, which are out of proportion to the expected overall decreases in brain protein levels, may especially be important for reducing energy consumption.

FDG-PET/CT finding of high uptake in pulmonary alveolar microlithiasis

Pulmonary alveolar microlithiasis (PAM) is a rare lung disease characterized by progressive intra-alveolar calcification. We present a case of PAM with abnormal accumulation of 18F-fluorodeoxyglucose (FDG) in both lungs. A 55-year-old man was referred to our hospital for progressive dyspnea. He had been diagnosed with PAM 25 years earlier by transbronchial lung biopsy. High-resolution computed tomography revealed multiple dense calcifications with little aerated lung. Combined positron emission tomography and computed tomography using 18F-FDG (FDG-PET/CT) showed the abnormal accumulation of FDG in both lungs with a maximal standardized uptake value of 7.3. High FDG uptake was observed mainly in the lung regions showing sparing calcification. The patient died of respiratory failure a month later and an autopsy revealed no significant inflammatory changes in either lung. We suspect that the markedly enhanced pulmonary FDG uptake may have some relation to the pathophysiology of PAM.

Dexamethasone prevents transport inhibition by hypoxia in rat lung and alveolar epithelial cells by stimulating activity and expression of Na+-K+-ATPase and epithelial Na+ channels

Hypoxia inhibits Na and lung fluid reabsorption, which contributes to the formation of pulmonary edema. We tested whether dexamethasone prevents hypoxia-induced inhibition of reabsorption by stimulation of alveolar Na transport. Fluid reabsorption, transport activity, and expression of Na transporters were measured in hypoxia-exposed rats and in primary alveolar type II (ATII) cells. Rats were treated with dexamethasone (DEX; 2 mg/kg) on 3 consecutive days and exposed to 10% O(2) on the 2nd and 3rd day of treatment to measure hypoxia effects on reabsorption of fluid instilled into lungs. ATII cells were treated with DEX (1 muM) for 3 days before exposure to hypoxia (1.5% O(2)). In normoxic rats, DEX induced a twofold increase in alveolar fluid clearance. Hypoxia decreased reabsorption (-30%) by decreasing its amiloride-sensitive component; pretreatment with DEX prevented the hypoxia-induced inhibition. DEX increased short-circuit currents (ISC) of ATII monolayers in normoxia and blunted hypoxic transport inhibition by increasing the capacity of Na(+)-K(+)-ATPase and epithelial Na(+) channels (ENaC) and amiloride-sensitive ISC. DEX slightly increased the mRNA of alpha- and gamma-ENaC in whole rat lung. In ATII cells from DEX-treated rats, mRNA of alpha(1)-Na(+)-K(+)-ATPase and alpha-ENaC increased in normoxia and hypoxia, and gamma-ENaC was increased in normoxia only. DEX stimulated the mRNA expression of alpha(1)-Na(+)-K(+)-ATPase and alpha-, beta-, and gamma-ENaC of A549 cells in normoxia and hypoxia (1.5% O(2)) when DEX treatment was begun before or during hypoxic exposure. These results indicate that DEX prevents inhibition of alveolar reabsorption by hypoxia and stimulates the expression of Na transporters even when it is applied in hypoxia.

Is there a role for intensive insulin therapy in patients with kidney disease?

There is increasing evidence for the benefit of intensive insulin therapy in maintaining near-normoglycemia in patients without diabetes with severe acute illness. Morbidity and mortality have both improved, with decreased episodes of sepsis, acute kidney injury, transfusion requirements, and post-intensive care complications. The metabolic mayhem of severe acute illness has many parallels with those induced by kidney failure itself, and patients with kidney failure are at increased risk from many of the complications potentially improved by insulin therapy. We reviewed the potential benefits of intensive insulin therapy and examined the published trials for data directly applicable to patients with kidney failure. There are no trials directly answering the question and no specific analysis of patients with kidney disease in published studies. We extracted pertinent data regarding patients with impaired renal function from the reported trials, identified parallels between patients with kidney injury and other severe illnesses, and suggest possible future studies. We hypothesize that intensive insulin therapy has a role outside the intensive care setting and, in particular, a role for patients with severe acute illness and kidney failure, whether acute or chronic.

Hypoxia-induced changes in the expression of rat hepatobiliary transporter genes

Cholestatic disorders may arise from liver ischemia (e.g., in liver transplantation) through various mechanisms. We have examined the potential of hypoxia to induce changes in the expression of hepatobiliary transporter genes. In a model of arterial liver ischemia subsequent to complete arterial deprivation of the rat liver, the mRNA levels of VEGF, a hypoxia-inducible gene, were increased fivefold after 24 h. The pattern of VEGF-induced expression and ultrastructural changes, including swelling of the endoplasmic reticulum, indicated that hypoxia affected primarily cholangiocytes, but also hepatocytes, predominantly in the periportal area. Serum and bile analyses demonstrated liver dysfunction of cholestatic type with reduced bile acid biliary excretion. Fluorescence-labeled ursodeoxycholic acid used as a tracer displayed no regurgitation, eliminating bile leakage as a significant mechanism of cholestasis in this model. In liver tissue, a marked reduction in the mRNA levels of Na(+)-taurocholate-cotransporting polypeptide (Ntcp), bile salt export protein (Bsep), and multidrug resistance-associated protein 2 (Mrp2) and an increase in those of Cftr were detected before bile duct proliferation occurred. In cultured hepatocytes, a nontoxic hypoxic treatment caused a decrease in the mRNA and protein expression of Ntcp, Bsep, and Mrp2 and in the mRNA levels of nuclear factors involved in the transactivation of these genes, i.e., HNF4alpha, RXRalpha, and FXR. In bile duct preparations, hypoxic treatment elicited an increase in Cftr transcripts, along with a rise in cAMP, a major regulator of Cftr expression and function. In conclusion, hypoxia triggers a downregulation of hepatocellular transporters, which may contribute to cholestasis, whereas Cftr, which drives secretion in cholangiocytes, is upregulated.

Role of the small GTPase RhoA in the hypoxia-induced decrease of plasma membrane Na,K-ATPase in A549 cells

Hypoxia impairs alveolar fluid reabsorption by promoting Na,K-ATPase endocytosis, from the plasma membrane of alveolar epithelial cells. The present study was designed to determine whether hypoxia induces Na,K-ATPase endocytosis via reactive oxygen species (ROS)-mediated RhoA activation. In A549 cells, RhoA activation occurred within 15 minutes of cells exposure to hypoxia. This activation was inhibited in cells infected with adenovirus coding for gluthatione peroxidase (an H2O2 scavenger), in mitochondria depleted (rho0) cells or cells expressing decreased levels of the Rieske iron-sulfur protein (inhibitor of mitochondrial complex III), which suggests a role for mitochondrial ROS. Moreover, exogenous H2O2 treatment during normoxia mimicked the effects of hypoxia on RhoA, further supporting a role for ROS. Cells expressing dominant negative RhoA failed to endocytose the Na,K-ATPase during hypoxia or after H2O2 treatment. Na,K-ATPase endocytosis was also prevented in cells treated with Y-27632, a Rho-associated kinase (ROCK) inhibitor, and in cells expressing dominant negative ROCK. In summary, we provide evidence that in human alveolar epithelial cells exposed to hypoxia, RhoA/ROCK activation is necessary for Na,K-ATPase endocytosis via a mechanism that requires mitochondrial ROS.

Alveolar edema fluid clearance and acute lung injury

Although lung-protective ventilation strategies have substantially reduced mortality of acute lung injury patients there is still a need for new therapies that can further decrease mortality in patients with acute lung injury. Studies of epithelial ion and fluid transport across the distal pulmonary epithelia have provided important new concepts regarding potential new therapies for acute lung injury. Overall, there is convincing evidence that the alveolar epithelium is not only a tight epithelial barrier that resists the movement of edema fluid into the alveoli, but it is also actively involved in the transport of ions and solutes, a process that is essential for edema fluid clearance and the resolution of acute lung injury. The objective of this article is to consider some areas of recent progress in the field of alveolar fluid transport under normal and pathologic conditions. Vectorial ion transport across the alveolar and distal airway epithelia is the primary determinant of alveolar fluid clearance. The general paradigm is that active Na(+) and Cl(-) transport drives net alveolar fluid clearance, as demonstrated in several different species, including the human lung. Although these transport processes can be impaired in severe lung injury, multiple experimental studies suggest that upregulation of Na(+) and Cl(-) transport might be an effective therapy in acute lung injury. We will review mechanisms involved in pharmacological modulation of ion transport in lung injury with a special focus on the use of beta-adrenergic agonists which has generated considerable interest and is a promising therapy for clinical acute lung injury.

Therapy insight: the effect of tight glycemic control in acute illness

Hyperglycemia commonly occurs in patients who are acutely ill, in a variety of clinical situations. Generally, moderate hyperglycemia in critically ill patients was thought to be beneficial; however, the degree of hyperglycemia on admission and the duration of hyperglycemia during critical illness are now recognized markers of adverse outcome. The use of insulin therapy to maintain normoglycemia for at least a few days improves survival and reduces morbidity in patients who are in a surgical intensive care unit (ICU), as shown by a large, randomized, controlled study. These results were recently confirmed by two studies--a randomized, controlled study of patients in a medical ICU, and a prospective, observational study of a heterogeneous patient population admitted to a mixed medical and surgical ICU. Results of multicenter trials that investigated tight blood-glucose control in critically ill patients are, however, still lacking. While we await those multicenter results, the current evidence favors the control of blood glucose levels in the ICU. Indeed, the studies showed that many lives are saved with this intervention, despite an increased incidence of hypoglycemia. Prevention of glucose toxicity by strict glycemic control (but also other metabolic and nonmetabolic effects of insulin) contribute to these clinical benefits.

Diabetes of injury: novel insights

Critically ill patients usually develop hyperglycemia, a condition referred to as "diabetes of injury." More and more evidence argues against the concept that this is an adaptive beneficial response. Indeed, the development of hyperglycemia seems to be detrimental for the outcome of critically ill patients, because maintenance of normoglycemia with intensive insulin therapy prevents morbidity and reduces mortality of critically ill patients to a large extent. The mechanisms underlying these clinical benefits are being studied further.

Diabetes and hyperglycemia: strict glycemic control

OBJECTIVE

To critically review recent evidence on pathophysiology, diagnosis, and control of acute and chronic hyperglycemia in medical and surgical intensive care unit (ICU) patients.

DATA SOURCE AND STUDY SELECTION

A MEDLINE/PubMed search (1966 through February 2006) with manual cross-referencing was conducted, including all relevant articles published on blood glucose control in intensive care patients. An emphasis was placed on more recent clinical trials investigating the effects of tight glycemic control in ICU patients and on basic science studies investigating the pathophysiology and systemic effects of transient hyperglycemia in nondiabetic patients.

DATA EXTRACTION AND SYNTHESIS

Original articles, selected reviews, letters to the editor, and chapters of selected textbooks were extracted. The reviewed information was then analyzed with respect to the prevalence of hyperglycemia in ICU patients, the pathophysiology of hyperglycemia in nondiabetics, and evidence on glycemic control in various subgroups of ICU patients. The risk of iatrogenic hypoglycemia in the ICU and potential future research directions are discussed at the end of the review.

CONCLUSIONS

Recent evidence shows direct improvements in patient mortality and in-hospital morbidity with strict control of even short-term elevations of glucose levels in certain subgroups of ICU patients. However, precisely defined target glucose levels, subgroup analyses of different patient populations and treatment interventions, and the avoidance of hypoglycemic episodes during insulin therapy remain incompletely resolved and warrant future investigation.

The metabolic effects of fasting and surgery

This review discusses the metabolic changes that occur during fasting, especially in relation to surgical stress. Currently available evidence on the relevance of different aspects of perioperative nutritional support are presented. Attenuation of surgical stress and insulin treatment in insulin-resistant patients after surgery and trauma have been shown to markedly affect stress metabolism as well as patient morbidity and mortality. Avoiding preoperative fasting has been shown to be related to a substantial reduction in postoperative stress and insulin resistance. Implementation of a standardized programme with a multimodal approach using evidence-based perioperative routines has been shown to further reduce surgical stress and to markedly enhance functional recovery also after major surgical procedures.

Beta-adrenergic receptor stimulation and adenoviral overexpression of superoxide dismutase prevent the hypoxia-mediated decrease in Na,K-ATPase and alveolar fluid reabsorption

Hypoxia has been shown to cause lung edema and impair lung edema clearance. In the present study, we exposed isolated rat lungs to pO(2) = 40 mm Hg for 60 min or rats to 8% O(2) for up to 24 h and then measured changes in alveolar fluid reabsorption (AFR) and Na,K-ATPase function. Low levels of oxygen severely impaired AFR in both ex vivo and in vivo models. The decrease in AFR was associated with a decrease in Na,K-ATPase activity and protein abundance in the basolateral membranes from peripheral lung tissue of hypoxic rats. Beta-adrenergic agonists restored AFR in rats exposed to 8% O(2) (from 0.02 +/- 0.07 ml/h to 0.59 +/- 0.03 ml/h), which was associated with parallel increases in Na,K-ATPase protein abundance in the basolateral membrane. Hypoxia is associated with increased production of reactive oxygen species. Therefore, we examined whether overexpression of SOD2, manganese superoxide dismutase, would prevent the hypoxia-mediated decrease in AFR. Spontaneously breathing rats were infected with a replication-deficient human type 5 adenovirus containing cDNA for SOD2. An otherwise identical virus that contained no cDNA was used as a control (Adnull). Hypoxic Adnull rats had decreased rates of AFR (0.12 +/- 0.1 ml/h) as compared with hypoxic AdSOD2 and normoxic control rats (0.47 +/- 0.04 ml/h and 0.49 +/- 0.02 ml/h, respectively), with parallel changes in Na,K-ATPase.

Inhibition of hypoxia inducible factor-1α (HIF-1α) decreases vascular endothelial growth factor (VEGF) secretion and tumor growth in malignant gliomas

INTRODUCTION

Hypoxia inducible factor-1alpha (HIF-1alpha) regulates vascular endothelial growth factor (VEGF), the presumed principal mediator of angiogenesis in malignant gliomas, under normal physiologic conditions. We examined the effect of HIF-1alpha on VEGF secretion, tumor growth, and angiogenesis in malignant gliomas.

METHODS

We examined 175 human gliomas for expression of HIF-1alpha and its downstream-regulated proteins. HIF-1alpha expression and VEGF secretion in glioma cell lines under normoxia and hypoxia were examined using ELISA and Western blot. Malignant glioma cell lines were transfected with dominant-negative HIF-1alpha (DN-HIF-1alpha) expression vector or siRNA constructs against the HIF-1alpha gene. Growth studies were conducted on cells with the highest VEGF/HIF-1alpha inhibition isolated from stable transfected cell lines. MIB-1-labeling index and microvascular density (MVD) measurements were performed on the in vivo tumors.

RESULTS

HIF-1 expression correlates with malignant glioma phenotype and was not confined to perinecrotic, pseudopalisading cells. VEGF and HIF-1 expression was high in glioma cell lines even under normoxia, and increased after exposure to hypoxia or growth factor stimulation. Cells transfected with DN-HIF-1alpha or HIF-1alpha siRNA demonstrated decreased HIF-1alpha and VEGF secretion. In vivo but not in vitro growth decreased in response to VEGF and HIF-1 inhibition. HIF-1 siRNA studies showed decreased VEGF secretion and in vitro and in vivo growth of glioma cell lines. MVD was unchanged but MIB-1 proliferation index decreased for both types of HIF-1 inhibition.

CONCLUSIONS

VEGF and HIF-1alpha are elevated in malignant gliomas. HIF-1alpha inhibition results in VEGF secretion inhibition. HIF-1alpha expression affects glioma tumor growth, suggesting clinical applications for malignant glioma treatment.

Hypoxia-mediated degradation of Na,K-ATPase via mitochondrial reactive oxygen species and the ubiquitin-conjugating system

We set out to determine whether cellular hypoxia, via mitochondrial reactive oxygen species, promotes Na,K-ATPase degradation via the ubiquitin-conjugating system. Cells exposed to 1.5% O2 had a decrease in Na,K-ATPase activity and oxygen consumption. The total cell pool of alpha1 Na,K-ATPase protein decreased on exposure to 1.5% O2 for 30 hours, whereas the plasma membrane Na,K-ATPase was 50% degraded after 2 hours of hypoxia, which was prevented by lysosome and proteasome inhibitors. When Chinese hamster ovary cells that exhibit a temperature-sensitive defect in E1 ubiquitin conjugation enzyme were incubated at 40 degrees C and 1.5% O2, the degradation of the alpha1 Na,K-ATPase was prevented. Exogenous reactive oxygen species increased the plasma membrane Na,K-ATPase degradation, whereas, in mitochondrial DNA deficient rho(0) cells and in cells transfected with small interfering RNA against Rieske iron sulfur protein, the hypoxia-mediated Na,K-ATPase degradation was prevented. The catalase/superoxide dismutase (SOD) mimetic (EUK-134) and glutathione peroxidase overexpression prevented the hypoxia-mediated Na,K-ATPase degradation and overexpression of SOD1, but not SOD2, partially inhibited the Na+ pump degradation. Accordingly, we provide evidence that during hypoxia, mitochondrial reactive oxygen species are necessary to degrade the plasma membrane Na,K-ATPase via the ubiquitin-conjugating system.

Glucose metabolism and insulin therapy

Hyperglycemia is a common feature of the critically ill patient and has been associated with increased mortality. Maintaining normoglycemia with insulin therapy improves survival and reduces morbidity in surgical ICU patients, as shown by a large randomized controlled study. Prevention of glucose toxicity by strict glycemic control but also other metabolic and non-metabolic effects of insulin contribute to these clinical benefits.

Mechanisms of pulmonary edema clearance

The mechanisms of pulmonary edema resolution are different from those regulating edema formation. Absorption of excess alveolar fluid is an active process that involves vectorial transport of Na+out of alveolar air spaces with water following the Na+osmotic gradient. Active Na+transport across the alveolar epithelium is regulated via apical Na+and chloride channels and basolateral Na-K-ATPase in normal and injured lungs. During lung injury, mechanisms regulating alveolar fluid reabsorption are inhibited by yet unclear pathways and can be upregulated by pharmacological means. Better understanding of the mechanisms that regulate edema clearance may lead to therapeutic interventions to improve the ability of lungs to clear fluid, which is of clinical significance.

The Lung, an Organ for Absorption?

This review summarizes information concerning the mechanisms of absorption of substances across the pulmonary epithelium. Inhalation is now increasingly used as a route of administration, although the scientific understanding of these mechanisms is rather limited. The aim of this study is to draw attention to these questions.

Glycemic and nonglycemic effects of insulin: how do they contribute to a better outcome of critical illness?

PURPOSE OF REVIEW

This review gives an overview of the clinical outcome benefits associated with intensive insulin therapy administered to critically ill patients and of the progress in the unraveling of the mechanisms underlying these positive effects.

RECENT FINDINGS

In a large, prospective, randomized, controlled study, strict blood glucose control with intensive insulin therapy strongly reduced mortality and morbidity of surgical intensive care patients. These results were recently confirmed in a more heterogeneous patient population admitted to a mixed medical-surgical intensive care unit. Most of the clinical benefits of intensive insulin therapy appear to be related to prevention of hyperglycemia, which has been demonstrated to adversely affect outcome. Part of the improvement is related to protection of the mitochondrial compartment and innate immunity from glucose toxicity. Also, direct insulin effects contribute to the improved outcome. The beneficial nonglycemic metabolic actions of insulin include a partial correction of the abnormal serum lipid profile and counteraction of the catabolic state evoked by critical illness. The prevention of excessive inflammation and myocardial protection illustrate other nonmetabolic direct anti-inflammatory and anti-apoptotic properties of insulin, although lowering of glucose levels may have played a role in these events as well.

SUMMARY

Substantial progress has been made in the understanding of the mechanisms underlying the improved survival and reduced morbidity with intensive insulin therapy in critical illness. More studies, however, are needed to further elucidate the exact pathways involved and the relative contribution of prevention of glucose toxicity and direct nonglycemic effects of insulin.

Metabolic perioperative management: novel concepts

PURPOSE OF REVIEW

This review summarizes novel information regarding the role of metabolic control in the perioperative period.

RECENT FINDINGS

Managing perioperative metabolism has recently been shown to be an important way to improve outcomes in surgical care. In particular, postoperative insulin resistance and hyperglycemia have been linked to many common complications. Recent studies have explored the toxicity of hyperglycemia and suggest a causal relation between insulin resistance and complications in the postoperative state. Controlling glucose concentrations with insulin has been shown to also improve protein balance and fat metabolism. In addition, insulin may affect other hormones including insulinlike growth factor-I during surgical stress. Lastly, recent data suggest that hyperglycemia plays an important role in aggravating the inflammatory response, in that overflow of substrates in the mitochondria causes the formation of excess free oxygen radicals and may also alter gene expression to enhance cytokine production. Although overcoming insulin resistance by insulin infusion is one way of combating hyperglycemia, prevention of its development can also be achieved by using epidural blockade to reduce the release of adrenal stress hormones and to control pain, by preoperative carbohydrates instead of overnight fasting, and by minimal invasive surgical techniques.

SUMMARY

Minimizing the effects of insulin resistance has been shown to substantially improve outcome after surgical stress.

Bcl-XL disrupts death-inducing signal complex formation in plasma membrane induced by hypoxia/reoxygenation

Hypoxia/reoxygenation (H/R) causes cellular injury and death. The cell death pathways induced by H/R remain incompletely understood. H/R can induce Bid and Bax mitochondrial translocation and cytochrome c release. Using mouse lung endothelial cells (MLEC), we examined the role of Bcl-X(L), an anti-apoptotic Bcl-2-related protein, in H/R-induced cell death. The expression of Bcl-X(L) protected MLEC against H/R-induced cell death by blocking Bax and Bid translocation and inhibiting mitochondrial cytochrome c release. Bcl-X(L) expression inhibited caspase-8 cleavage and death-inducing signal complex (DISC) formation in plasma membrane. By isolating mitochondrial, nuclear, and Golgi fractions, we found that H/R induced DISC formation in these organelles. Bcl-X(L) expression inhibited DISC formation in the nuclear and Golgi fractions relative to LacZ-infected controls. In contrast, DISC formation was elevated in the mitochondrial fraction of Bcl-X(L)-infected cells. GRASP65, a Golgi-associated protein, physically associated with Fas and caspase-8; Bcl-X(L) expression decreased these associations. Bcl-X(L) expression also up-regulated FLIP, a caspase-8 inhibitor. In conclusion, Bcl-X(L) may inactivate caspase-8 by decreasing DISC formation in the plasma membrane, nucleus, and Golgi complex while diverting DISC formation to the mitochondria. The inhibitory effects of Bcl-X(L) on DISC formation may play significant roles in protecting endothelial cells from H/R-induced cell death.

Endocrine interventions in the ICU

Patients with critical illness, particularly those who depend on intensive care for a prolonged period of time, have a high morbidity and mortality. The acute and chronic phases of critical illness are associated with distinct endocrine alterations. Acute endocrine adaptations to the severe stress of critical illness, comprising an activated anterior pituitary function, have been selected by nature and can, as such, be considered as beneficial for surviving. These adaptations disappear or wane during the prolonged phase of critical illness. In this phase there is a reduced pulsatile secretion of different anterior pituitary hormones and the so-called "wasting syndrome" occurs. This prolonged endocrine/metabolic stress response is quite different from the acute response and may, to some extent, no longer be adaptive. Intervention within the endocrine system, however, remains highly controversial, as it is difficult to differentiate between beneficial adaptations and harmful abnormalities and to outline strategies for therapy. Insulin infusion titrated to maintain normoglycemia may be a notable exception, as this intervention has been proven to increase survival and reduce morbidity of surgical intensive care patients. Treatment of "relative adrenal failure" with hydrocortisone also appears to improve the outcome of patients with septic shock, but diagnostic and dosing issues still remain unresolved. Although extensive research has shown that infusion of hypothalamic-releasing peptides is able to restore physiological hormonal patterns within the somatotropic, thyrotropic, and gonadal axes and, thereby, to generate a controlled anabolic response, further research is needed to investigate whether such interventions actually improve the outcome of critical illness.

How does blood glucose control with insulin save lives in intensive care?

Patients requiring prolonged intensive care are at high risk for multiple organ failure and death. Insulin resistance and hyperglycemia accompany critical illness, and the severity of this "diabetes of stress" reflects the risk of death. Recently it was shown that preventing hyperglycemia with insulin substantially improves outcome of critical illness. This article examines some potential mechanisms underlying prevention of glucose toxicity as well as the effects of insulin independent of glucose control. Unraveling the molecular mechanisms will provide new insights into the pathogenesis of multiple organ failure and open avenues for novel therapeutic strategies.

Bench-to-bedside review: the role of the alveolar epithelium in the resolution of pulmonary edema in acute lung injury

Clearance of pulmonary edema fluid is accomplished by active ion transport, predominantly by the alveolar epithelium. Various ion pumps and channels on the surface of the alveolar epithelial cell generate an osmotic gradient across the epithelium, which in turn drives the movement of water out of the airspaces. Here, the mechanisms of alveolar ion and fluid clearance are reviewed. In addition, many factors that regulate the rate of edema clearance, such as catecholamines, steroids, cytokines, and growth factors, are discussed. Finally, we address the changes to the alveolar epithelium and its transport processes during acute lung injury (ALI). Since relevant clinical outcomes correlate with rates of edema clearance in ALI, therapies based on our understanding of the mechanisms and regulation of fluid transport may be developed.

How does blood glucose control with insulin save lives in intensive care?

Patients requiring prolonged intensive care are at high risk for multiple organ failure and death. Insulin resistance and hyperglycemia accompany critical illness, and the severity of this "diabetes of stress" reflects the risk of death. Recently it was shown that preventing hyperglycemia with insulin substantially improves outcome of critical illness. This article examines some potential mechanisms underlying prevention of glucose toxicity as well as the effects of insulin independent of glucose control. Unraveling the molecular mechanisms will provide new insights into the pathogenesis of multiple organ failure and open avenues for novel therapeutic strategies.