Liver-lung interactions following Escherichia coli bacteremic sepsis and secondary hepatic ischemia/reperfusion injury

Prognostic, Immunological, and Mutational Analysis of MTA2 in Pan-Cancer and Drug Screening for Hepatocellular Carcinoma

BACKGROUND

Metastasis-associated protein 2 (MTA2) is a member of the metastasis-associated transcriptional regulator family and is a core component of the nucleosome remodeling and histone deacetylation complex. Despite growing evidence that MTA2 plays a crucial role in the tumorigenesis of certain cancers, no systematic pan-cancer analysis of MTA2 is available to date. Therefore, the aim of our study is to explore the prognostic value of MTA2 in 33 cancer types and to investigate its potential immune function.

METHODS

by comprehensive use of databases from TCGA, GTEx, GEO, UCSC xena, cBioPortal, comPPI, GeneMANIA, TCIA, MSigDB, and PDB, we applied various bioinformatics approaches to investigate the potential role of MTA2, including analyzing the association of MTA2 with MSI, prognosis, gene mutation, and immune cell infiltration in different tumors. We constructed a nomogram in TCGA-LIHC, performed single-cell sequencing (scRNA-seq) analysis of MTA2 in hepatocellular carcinoma (HCC), and screened drugs for the treatment of HCC. Finally, immunohistochemical experiments were performed to verify the expression and prognostic value of MTA2 in HCC. In vitro experiments were employed to observe the growth inhibition effects of MK-886 on the HCC cell line HepG2.

RESULTS

The results suggested that MTA2 was highly expressed in most cancers, and MTA2 expression was associated with the prognosis of different cancers. In addition, MTA2 expression was associated with Tumor Mutation Burden (TMB) in 12 cancer types and MSI in 8 cancer types. Immunoassays indicated that MTA2 positively correlated with activated memory CD4 T cells and M0 macrophage infiltration levels in HCC. ScRNA-seq analysis based on the GEO dataset discovered that MTA2 was significantly expressed in T cells in HCC. Finally, the eXtreme Sum (Xsum) algorithm was used to screen the antitumor drug MK-886, and the molecular docking technique was utilized to reveal the binding capacity between MK-886 and the MTA2 protein. The results demonstrated excellent binding sites between them, which bind to each other through Π-alkyl and alkyl interaction forces. An immunohistochemistry experiment showed that MTA2 protein was highly expressed in HCC, and high MTA2 expression was associated with poor survival in HCC patients. MK-886 significantly inhibited the proliferation and induced cell death of HepG2 cells in a dose-dependent manner.

CONCLUSIONS

Our study demonstrated that MTA2 plays crucial roles in tumor progression and tumor immunity, and it could be used as a prognostic marker for various malignancies. MK-886 might be a powerful drug for HCC.

New progress in understanding roles of nitric oxide during hepatic ischemia-reperfusion injury

Hepatic ischemia-reperfusion injury (HIRI) is a major clinical cause of morbidity and mortality in liver surgery and transplantation. Many studies have found that nitric oxide (NO) plays an important role in the HIRI and its increase or decrease can affect the progression and outcome of HIRI. However, the role of NO in HIRI is controversial and complicated. NO derived by endothelial NO synthase (eNOS) shows a protective role in HIRI, while excessive NO derived by inducible NO synthase (iNOS) accelerates inflammation and increases oxidative stress, further aggravating HIRI. Nevertheless, the overexpression of eNOS may exacerbate HIRI and iNOS-derived NO in some cases reduces HIRI. Here we review the new progress in the understanding of the roles of NO during HIRI: (1) NO possesses different roles in HIRI by increasing NO bioavailability, down-regulating leukotriene C4 synthase, inhibiting the activation of the nuclear factorκB (NFκB) pathway, enhancing cell autophagy, and reducing inflammatory cytokines and reactive oxygen species (ROS). And NO has both protective and deleterious effects by regulating apoptotic factors; (2) eNOS promotes NO production and suppresses its own overexpression, exerting a hepatoprotective effect reversely. Its activation is regulated by the PI3K/Akt and KLF2/AMPK pathways; and (3) iNOS derived NO mainly has deteriorating effects on HIRI, while it may have a protective function under some conditions. Their expression should reach a balance to reduce the adverse side and make NO protective in the treatment of HIRI. Thus, it can be inferred that NO modulating drugs may be a new direction in the treatment of HIRI or may be used as an adjunct to mitigate HIRI for the purpose of protecting the liver.

Modulatory effect of Prosopis juliflora leaves on hepatic fibrogenic and fibrolytic alterations induced in rats by thioacetamide

This study investigated the antifibrotic effect of Prosopis juliflora leaves crude methanolic extract (PJEL) against thioacetamide (TAA)-induced liver fibrosis. The phytochemical analysis of PJEL was performed via HPLC/MS in association with evaluating its free radical scavenging and cytotoxic activities. The antifibrotic activity of PJEL was assessed by dividing Wistar rats into 8 groups: normal control, PJEL1-administered rats (2 mg/ Kg b.w.), PJEL2-administered rats (4 mg/ Kg b.w.), PJEL3-administered rats (8 mg/Kg b.w.), TAA-induced hepatic fibrosis, TTA + PJEL1, TAA + PJEL2, and TAA + PJEL3. Results indicated that PJEL crude methanolic extract is rich in polyphenolic compounds and alkaloids. PJEL exerted free radical scavenging activity with IC₅₀ of 123.5 μg/mL and cytotoxic activity against a well-differentiated hepatocellular cell line (IC₅₀ = 11.1 μg/mL). PJEL at a dose of 4 mg/Kg b.w. ameliorated serum ALT activity and improved serum albumin level and hepatic hydroxyproline content in association with a reduction in the fibrosis stage. PJEL elevated hepatic tumor necrosis factor-α and interleukin-6 contents with less necrosis grade. PJEL post-therapy ameliorated the relative expression of Bcl-2, Col1A1, Mmp-9, and Mmp-2 genes in liver. CONCLUSION: PJEL possesses a good therapeutic activity against TAA-induced liver fibrosis via enhancing extracellular matrix removal and stimulating hepatic regeneration to decrease hepatic necrosis.

A portable and reconfigurable multi-organ platform for drug development with onboard microfluidic flow control

The drug development pipeline is severely limited by a lack of reliable tools for prediction of human clinical safety and efficacy profiles for compounds at the pre-clinical stage. Here we present the design and implementation of a platform technology comprising multiple human cell-based tissue models in a portable and reconfigurable format that supports individual organ function and crosstalk for periods of up to several weeks. Organ perfusion and crosstalk are enabled by a precision flow control technology based on electromagnetic actuators embedded in an arrayed format on a microfluidic platform. We demonstrate two parallel circuits of connected airway and liver modules on a platform containing 62 electromagnetic microactuators, with precise and controlled flow rates as well as functional biological metrics over a two week time course. Technical advancements enabled by this platform include the use of non-sorptive construction materials, enhanced scalability, portability, flow control, and usability relative to conventional flow control modes (such as capillary action, pressure heads, or pneumatic air lines), and a reconfigurable and modular organ model format with common fluidic port architecture. We demonstrate stable biological function for multiple pairs of airway-liver models for periods of 2 weeks in the platform, with precise control over fluid levels, temperature, flow rate and oxygenation in order to support relevant use cases involving drug toxicity, efficacy testing, and organ-organ interaction.

Effects of Ecballium Elaterium on Proinflammatory Cytokines in a Rat Model of Sepsis

OBJECTIVE

Ecballium elaterium (EE) is a plant from Cucurbitaceae family. Its anti-inflammatory role in sepsis is not well understood. We investigated the effects of EE on serum levels of proinflammatory cytokines and further explored the mechanisms underlying histological changes in liver and ileum following EE administration in a polymicrobial sepsis model.

METHODS

Thirty rats were divided into three groups of 10 rats each. Rats were subjected to sham laparotomy plus normal saline administration (control group, CG), laparotomy with cecal ligation and puncture (CLP) (sepsis group, SG), and laparotomy with CLP plus 2.5 mg/kg EE administration (experimental group, EG). Twenty-four hours after laparotomy, animals underwent cardiac puncture, and blood was collected for interleukin 1 (IL-1), interleukin 6 (IL-6), and tumor necrosis factor alpha (TNF-α) assessment. Whole sections of liver and ileum tissues were collected for histologic examination.

RESULTS

The serum level of IL-6 was significantly lower in EG as compared to SG. Although IL-6 levels were shown a statistically significant (p < 0.0001) decline to near control values, no significant changes were observed in serum levels of IL-1 and TNF-α after EE treatment. Histologic examination revealed statistically significant reduction in collagen formation (p = 0.001) on serosal surface of ileum and hepatic venous congestion (p = 0.040) in EG as compared to SG.

CONCLUSION

EE might play a protective role in sepsis prevention and treatment by decreasing IL-6 production and reducing liver damage and may influence bacterial translocation by reinforcing intestinal barrier function.

Early Hepatic Dysfunction Is Associated with a Worse Outcome in Patients Presenting with Acute Respiratory Distress Syndrome: A Post-Hoc Analysis of the ACURASYS and PROSEVA Studies

Introduction

Bilirubin is well-recognized marker of hepatic dysfunction in intensive care unit (ICU) patients. Multiple organ failure often complicates acute respiratory distress syndrome (ARDS) evolution and is associated with high mortality. The effect of early hepatic dysfunction on ARDS mortality has been poorly investigated. We evaluated the incidence and the prognostic significance of increased serum bilirubin levels in the initial phase of ARDS.

Methods

The data of 805 patients with ARDS were retrospectively analysed. This population was extracted from two recent multicenter, prospective and randomised trials. Patients presenting with ARDS with a ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen < 150 mmHg measured with a PEEP ≥ 5 cm of water were included. The total serum bilirubin was measured at inclusion and at days 2, 4, 7 and 14. The primary objective was to analyse the bilirubin at inclusion according to the 90-day mortality rate.

Results

The 90-day mortality rate was 33.8% (n = 272). The non-survivors were older, had higher Sepsis-related Organ Failure Assessment (SOFA) score and were more likely to have a medical diagnosis on admission than the survivors. At inclusion, the SOFA score without the liver score (10.3±2.9 vs. 9.0±3.0, p<0.0001) and the serum bilirubin levels (36.1±57.0 vs. 20.5±31.5 μmol/L, p<0.0001) were significantly higher in the non-survivors than in the survivors. Age, the hepatic SOFA score, the coagulation SOFA score, the arterial pH level, and the plateau pressure were independently associated with 90-day mortality in patients with ARDS.

Conclusion

Bilirubin used as a surrogate marker of hepatic dysfunction and measured early in the course of ARDS was associated with the 90-day mortality rate.

Risk factor analysis of postoperative acute respiratory distress syndrome in valvular heart surgery

PURPOSE

The aim of this study is to investigate the incidence, severity, and outcome of postoperative acute respiratory distress syndrome (ARDS), according to the Berlin definition, in isolated valvular heart surgery. The preoperative and perioperative predisposing factors of this complication were also identified.

METHODS

A retrospective chart review was conducted on 457 patients who underwent isolated valvular heart surgery between January 2010 and December 2012. Clinical characteristics and outcomes were collected. The primary outcome was postoperative ARDS, according to the 2012 Berlin definition for ARDS.

RESULTS

A total of 37 patients (8.1%) developed postoperative ARDS, with a mortality rate of 29.7%. The multivariate analysis identified that age (odds ratios [ORs], 1.067, P ≤ .001), liver cirrhosis (OR, 7.159; P = .001), massive blood transfusion (OR, 2.980; P = .005), and tricuspid valve replacement (OR, 5.197; P = .012) were independent risk factors of postoperative ARDS. Furthermore, we have determined that the increased severity stages of ARDS were associated with decreased postoperative survival.

CONCLUSIONS

In conclusion, postoperative ARDS, according to Berlin definition, in valvular surgery, was associated with high in-hospital mortality. The severity of ARDS was associated with patient midterm mortality. In multivariate analysis, age, liver cirrhosis, massive blood transfusion, and tricuspid valve replacement were identified as independent risk factors of ARDS.

Predicting risk of postoperative lung injury in high-risk surgical patients: a multicenter cohort study

BACKGROUND

Acute respiratory distress syndrome (ARDS) remains a serious postoperative complication. Although ARDS prevention is a priority, the inability to identify patients at risk for ARDS remains a barrier to progress. The authors tested and refined the previously reported surgical lung injury prediction (SLIP) model in a multicenter cohort of at-risk surgical patients.

METHODS

This is a secondary analysis of a multicenter, prospective cohort investigation evaluating high-risk patients undergoing surgery. Preoperative ARDS risk factors and risk modifiers were evaluated for inclusion in a parsimonious risk-prediction model. Multiple imputation and domain analysis were used to facilitate development of a refined model, designated SLIP-2. Area under the receiver operating characteristic curve and the Hosmer-Lemeshow goodness-of-fit test were used to assess model performance.

RESULTS

Among 1,562 at-risk patients, ARDS developed in 117 (7.5%). Nine independent predictors of ARDS were identified: sepsis, high-risk aortic vascular surgery, high-risk cardiac surgery, emergency surgery, cirrhosis, admission location other than home, increased respiratory rate (20 to 29 and ≥30 breaths/min), FIO2 greater than 35%, and SpO2 less than 95%. The original SLIP score performed poorly in this heterogeneous cohort with baseline risk factors for ARDS (area under the receiver operating characteristic curve [95% CI], 0.56 [0.50 to 0.62]). In contrast, SLIP-2 score performed well (area under the receiver operating characteristic curve [95% CI], 0.84 [0.81 to 0.88]). Internal validation indicated similar discrimination, with an area under the receiver operating characteristic curve of 0.84.

CONCLUSIONS

In this multicenter cohort of patients at risk for ARDS, the SLIP-2 score outperformed the original SLIP score. If validated in an independent sample, this tool may help identify surgical patients at high risk for ARDS.

Global consequences of liver ischemia/reperfusion injury

Liver ischemia/reperfusion injury has been extensively studied during the last decades and has been implicated in the pathophysiology of many clinical entities following hepatic surgery and transplantation. Apart from its pivotal role in the pathogenesis of the organ's post reperfusion injury, it has also been proposed as an underlying mechanism responsible for the dysfunction and injury of other organs as well. It seems that liver ischemia and reperfusion represent an event with “global” consequences that influence the function of many remote organs including the lung, kidney, intestine, pancreas, adrenals, and myocardium among others. The molecular and clinical manifestation of these remote organs injury may lead to the multiple organ dysfunction syndrome, frequently encountered in these patients. Remote organ injury seems to be in part the result of the oxidative burst and the inflammatory response following reperfusion. The present paper aims to review the existing literature regarding the proposed mechanisms of remote organ injury after liver ischemia and reperfusion.

The role of the liver in sepsis

Despite the progress made in the clinical management of sepsis, sepsis morbidity and mortality rates remain high. The inflammatory pathogenesis and organ injury leading to death from sepsis are not fully understood for vital organs, especially the liver. Only recently has the role of the liver in sepsis begun to be revealed. Pre-existing liver dysfunction is a risk factor for the progression of infection to sepsis. Liver dysfunction after sepsis is an independent risk factor for multiple organ dysfunction and sepsis-induced death. The liver works as a lymphoid organ in response to sepsis. Acting as a double-edged sword in sepsis, the liver-mediated immune response is responsible for clearing bacteria and toxins but also causes inflammation, immunosuppression, and organ damage. Attenuating liver injury and restoring liver function lowers morbidity and mortality rates in patients with sepsis. This review summarizes the central role of liver in the host immune response to sepsis and in clinical outcomes.

Expression of caspase activation recruitment and pyrin domain levels of apoptosis-associated speck-like protein complex in the pancreas of rats subjected to experimental pancreatitis: influence of rutin administration

The present study investigated the effect of rutin, a natural flavonoid, on the expression of caspase activation recruitment domain (CARD) and pyrin domain (PYD) of apoptosis-associated speck-like protein (ASC), a mediator of inflammation, in the pancreas of rats administered with ethanol (EtOH) and high-fat diet (HFD). Pancreatitis was induced in male albino Wistar rats by administering EtOH (8-12 g/kg/day) and HFD (22% fat) for 90 days. In addition, rats also received 100 mg rutin/kg body weight orally from 31st day till the experimental period. Serum levels of cytokines, interleukin 18 (IL-18) and IL-6; activity levels of caspase-1 and myeloperoxidase (MPO); messenger RNA (mRNA) expression of tumor necrosis factor α (TNF-α), caspase-1, CARD and PYD of ASC; and histological changes in pancreas were assessed. We observed a significant elevation in serum IL-18, IL-6, caspase-1 and MPO activities, mRNA expression of PYD, TNF-α and caspase-1 in the pancreas of rats administered with EtOH and HFD. Rutin administration along with EtOH and HFD significantly upregulated the mRNA expression of CARD and downregulated PYD, caspase-1, and TNF-α expressions. Rutin supplementation was also found to reduce IL-18 and IL-6 levels; and inflammatory changes in tissue architecture were evidenced by histological observations. The anti-inflammatory activity of rutin might be due to its effect on modulating the expression of ASC complex that mediates inflammation.

PD-L1 blockade attenuated sepsis-induced liver injury in a mouse cecal ligation and puncture model

Liver plays a major role in hypermetabolism and produces acute phase proteins during systemic inflammatory response syndrome and it is of vital importance in host defense and bacteria clearance. Our previous studies indicated that programmed death-1 (PD-1) and its ligand programmed death ligand-1 (PD-L1) are crucial modulators of host immune responses during sepsis. Our current study was designed to investigate the role of PD-L1 in sepsis-induced liver injury by a mouse cecal ligation and puncture (CLP) model. Our results indicated that there was a significant increase of PD-L1 expression in liver after CLP challenge compared to sham-operated controls, in terms of levels of mRNA transcription and immunohistochemistry. Anti-PD-L1 antibody significantly alleviated the morphology of liver injury in CLP mice. Anti-PD-L1 antibody administration decreased ALT and AST release in CLP mice, decreased the levels of tumor necrosis factor (TNF)-α, interleukin (IL)-6, and IL-10 mRNA in liver after sepsis challenge. Thus, anti-PD-L1 antibody might have a therapeutic potential in attenuating liver injury in sepsis.

Protective effects of nicotinamide against acetaminophen-induced acute liver injury

Nicotinamide (NAM), the amide form of vitamin B3, is involved in a wide range of biological processes. Recent evidence revealed the anti-inflammatory and anti-oxidant properties of NAM and suggests it may be used as a novel strategy in the prevention of acute liver injury. In the present study, we investigated the potential protective effects of NAM on acetaminophen (APAP)-induced acute liver injury in mice. Mice were treated with NAM at 400mg/kg 30 min before or after administration of APAP at a hepatotoxic dose of 400mg/kg body weight via intraperitoneal injection. Liver injury and the expression of inflammation-related molecules were determined by histological examination and biochemical analysis, respectively. In addition, the survival rate of mice was assessed after APAP administration. Pretreatment with NAM for 30 min significantly decreased plasma levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST) and malondialdehyde (MDA), and diminished histopathologic evidence of hepatic toxicity in mice following APAP administration. Similarly, posttreatment with NAM also decreased plasma ALT and AST levels in APAP-administrated mice. Furthermore, both pretreatment and posttreatment with NAM prolonged the survival rate of acute liver injury mice, accompanied by a significant reduction in the plasma levels of pro-inflammatory cytokines tumor necrosis factor-α (TNF-α), interferon-γ (INF-γ), and interleukin-6 (IL-6). Together, these findings suggest that NAM possesses protective effects on APAP-induced liver injury, which may involve the anti-inflammatory action.

Intraoperative vital and haemodynamic monitoring using an integrated multiple-channel monitor in rats

The aim of this study is to give a hands-on description of the successful monitoring procedure established for extended liver resections and liver transplantations in rats and to provide the typical range of data as obtained before and after a hepatobiliary surgical procedure (right median hepatic vein [RMHV] ligation) in healthy male Lewis rats. All manipulations were performed in anaesthetized (3% isoflurane in O2 1 L/min) healthy male Lewis rats (250–350 g) with an integrated multiple-channel intraoperative monitor (Powerlab® system) using a series of sensors for data acquisition. Vital parameters (body temperature, electrocardiogram, respiratory rate and heart rate), haemodynamic parameters (mean arterial blood pressure [MAP] and central venous pressure) and liver perfusion parameters (inferior hepatic venous pressure, portal vein pressure [PVP], blood flow of portal vein and inferior hepatic cava) were monitored. Catheters were placed in microsurgical technique after careful exposure guided by anatomical landmarks. Vascular incisions were closed with interrupted sutures. Complete instrumentation of animals was performed within 1 h. No specific complications occurred. Vital and haemodynamic parameters such as MAP (94 ± 16.2 mmHg) or portal pressure (9.6 ± 1.34 mmHg) were in the same range as known for humans (MAP = 100 mmHg, portal pressure = 5–10 mmHg), whereas parameters dependent on the size of the body or organ such as flow rates (portal blood flow = 16.2 ± 6 mL/min) were obviously different compared with those of humans (portal blood flow = 800 mL/min). In conclusion, the normal range for vital, haemodynamic and liver perfusion parameters was reported as reference values to allow quality control for future surgical hepatobiliary research projects. As the procedure can be easily learned, the extensive intraoperative monitoring can be used routinely.

[High PEEP vs. conventional PEEP in the acute respiratory distress syndrome: a systematic review and meta-analysis]

OBJECTIVE

To perform a systematic review and meta-analysis of the literature to evaluate the effects of high PEEP versus conventional PEEP on mortality and on the risk of barotrauma in patients with the acute respiratory distress syndrome (ARDS).

SOURCE OF DATA

Computer search of Medline, Embase, CINAHL, CANCERLIT, Pascal-Biomed, ACP Journal Club, Cochrane library (CDSR, DARE, CCTR), ISI Proceedings, Current Contents, and Web of Science, as well as manual search of selected references.

SELECTION OF STUDIES

Controlled random clinical trials published after NAECC (1994) that evaluated the effect of two levels of PEEP and that reported the mortality and incidence of barotrauma in the series.

DATA EXTRACTION

By two investigators working independently, with discrepancies resolved by group consensus. Contingency tables were elaborated and the RRs with corresponding confidence intervals were obtained for each study.

RESULTS

Four articles were selected for the meta-analysis of mortality and three for the meta-analysis of barotrauma. No effects of PEEP level on mortality were found (RR 0.73, 95% CI: 0.49 to 1.10) or on the incidence of barotrauma (RR 0.50, 95% CI: 0.14 to 1.73). However, an analysis of the studies in which PEEP was individualized in function of Pflex showed a significant decrease in mortality (RR 0.59, 95% CI: 0.43 to 0.82) (p=0.001)

CONCLUSIONS

The use of high or conventional PEEP in function of oxygenation does not affect mortality or the incidence of barotrauma in patients with ARDS. However, there might be a decrease in mortality associated to high PEEP individualized in function of the pulmonary mechanics of each patient.

[Mechanical ventilation induced lung injury]

Mechanical ventilation is associated with important complications, among which production or perpetuation of acute lung injury and product of distant organ injuries of the lung basically through the release of inflammatory mediators to the systemic circulation. There is increasingly greater evidence in both in vitro and in vivo experimental models that show the reality of this lesional mechanism. The main lesional mechanisms are both stretching and rupture of the lung structures (volutrauma) and cyclical opening and closure of the closed alveolar zones (atelectrauma). Studies on the use of protective lung ventilation strategies have shown a beneficial effect in patients with ARDS of the use of open lung ventilation strategies, use of circulating volumes less than 10 ml/kg and of maintaining alveolar pressure under 30 cm of H2O. It should be investigated if these same strategies would be useful in preventing the appearance of ARDS in mechanically ventilated patients for another reason, basically in those with risk factors for the development of this condition.

Sodium nitroprusside regulates mRNA expressions of LTC4 synthesis enzymes in hepatic ischemia/reperfusion injury rats via NF-kappaB signaling pathway

Leukotriene (LT) C4 (LTC4) synthesis enzymes including LTC4 synthase (LTC4S), microsomal glutathione S-transferase (MGST) 2 and MGST3 can all conjugate LTA4 and reduced glutathione (GSH) to form LTC4, which is related to hepatic ischemia/reperfusion (I/R) injury. The relationship between nitric oxide (NO) and cysteinyl LTs has been shown in previous studies. However, the mechanisms of NO action on gene expression of LTC4 synthesis enzymes are still largely unclear during hepatic I/R. Adult male Sprague-Dawley rats were divided into 5 groups: a sham group (control), an I/R group, and sodium nitroprusside (SNP, 2.5, 5 and 10 microg/kg/min)+I/R groups. Livers were subjected to 60 min of partial hepatic ischemia followed by 5 h of reperfusion, saline or SNP (2.5, 5 and 10 microg/kg/min) administered intravenously. The mRNA levels of LTC4 synthesis enzymes, inducible NO synthase (iNOS) and endothelial No synthase (eNOS) in rat liver tissue were examined by RT-PCR; the protein expressions of NF-kappaB p65, p50 and IkappaBalpha in liver cell lysates and nuclear extracts were detected by Western blot analysis, and serum NO2. levels were also evaluated. Serum NO2. levels, the protein expressions of NF-kappaB p65 and p50 in the nucleus extract, and hepatic mRNA expressions of LTC4S and iNOS were decreased while hepatic mRNA of eNOS was increased in the SNP (5 and 10 microg/kg/min)+I/R groups when compared with those in the I/R group. SNP (2.5 microg/kg/min) promoted the mRNA expressions of both MGST2 and MGST3, whereas SNP (10 microg/kg/min) increased MGST2 mRNA but decreased MGST3 mRNA compared to those in I/R group. Compared with control, the mRNA expression of MGST2 and MGST3 were elevated in SNP (2.5 microg/kg/min)+I/R group, MGST3 mRNA was significantly declined in the SNP (5 and 10 microg/kg/min)+I/R groups. Immunohistochemistry staining revealed that I/R liver exhibited strong cytoplasmic and nuclear staining for NF-kappaB p65, but the livers of the SNP (2.5 microg/kg/min)+I/R group presented slight cytoplasmic and nuclear staining. But IkappaBalpha protein in all groups remains unchanged. It was concluded that SNP downregulated LTC4S mRNA expression by inhibiting NF-kappaB activation independent of IkappaBalpha, but appeared to have a dual influence on the mRNA expressions of MGST2 and MGST3 by other signaling pathways during hepatic I/R injury.

Increased leukotriene c4 synthesis accompanied enhanced leukotriene c4 synthase expression and activities of ischemia-reperfusion-injured liver in rats

BACKGROUND

Hepatic ischemia-reperfusion (I/R) injury is an important clinical issue and relates to cysteinyl leukotrienes (LTs), the first committed synthesis step of which is that LTC4 synthesis enzymes including leukotriene C4 synthase (LTC4S), microsomal glutathione-S-transferase (mGST)2, and mGST3-catalyzed LTA4 and reduced glutathione (GSH), to generate LTC4. However, the mechanisms of LTC4 generation during hepatic I/R are far from being elucidated.

MATERIALS AND METHODS

Adult male Sprague Dawley rats were divided into two groups: sham group (control) and I/R group. Liver was subjected to 60 min of partial hepatic ischemia followed by 5 h of reperfusion; saline was administered intravenously. LTC4 content, the activities, and expressions of LTC4 synthesis enzymes were examined with reversed phase high-performance liquid chromatography, reverse transcriptase-polymerase chain reaction, immunoblot, and immunohistochemistry, respectively. Liver damage was assessed by serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) measurements and histological observation. The superoxide dismutase (SOD) activity and malondialdehyde (MDA) level in liver tissue were used to evaluate lipid peroxidation, and oxidative stress was estimated by the reduced GSH level in liver tissue in the pathological process.

RESULTS

Compared with control, LTC4 content, the LTC4 synthesis enzymes' activities, and the mRNA and protein expressions of LTC4S were significantly increased, while the mRNA expressions of mGST2 and mGST3 were declined obviously in rat liver during I/R (P < 0.05); most hepatocytes and sinusoidal endothelial cells expressed intensively LTC4S in an I/R-sensitive manner. This was accompanied by the increase in serum ALT and AST levels together with liver tissue MDA content (P < 0.05), the decrease in liver tissue GSH level, and SOD activity (P < 0.05), as well as histological damage. There were no differences in the protein expression of mGST3 between control and I/R groups.

CONCLUSIONS

These results demonstrated that hepatic I/R injury up-regulated the mRNA and protein expressions of LTC4S in hepatocytes and sinusoidal endothelial cells and enhanced the activities of the LTC4 synthesis enzymes. It suggests that LTC4 accumulation after hepatic I/R can be caused partially by LTC4S expression up-regulation and the LTC4 synthesis enzymes' activities augment to which LTC4S rather than mGST2 or mGST3 may mainly contribute.

High tidal volume ventilation induces lung injury after hepatic ischemia-reperfusion

Ischemia-reperfusion not only damages the affected organ but also leads to remote organ injuries. Hepatic inflow interruption usually occurs during hepatic surgery. To investigate the influence of liver ischemia-reperfusion on lung injury and to determine the contribution of tidal volume settings on liver ischemia-reperfusion-induced lung injury, we studied anesthetized and mechanically ventilated rats in which the hepatic inflow was transiently interrupted twice for 15 min. Two tidal volumes, 6 ml/kg as a low tidal volume (IR-LT) and 24 ml/kg as a high tidal volume (IR-HT), were assessed after liver ischemia-reperfusion, as well as after a sham operation, 6 ml/kg (NC-LT) and 24 ml/kg (NC-HT). Both the IR-HT and IR-LT groups had a gradual decline in the systemic blood pressure and a significant increase in plasma TNF-α concentrations. Of the four groups, only the IR-HT group developed lung injury, as assessed by an increase in the lung wet-to-dry weight ratio, the presence of significant histopathological changes, such as perivascular edema and intravascular leukocyte aggregation, and an increase in the bronchoalveolar lavage fluid TNF-α concentration. Furthermore, only in the IR-HT group was airway pressure increased significantly during the 6-h reperfusion period. These findings suggest that liver ischemia-reperfusion caused systemic inflammation and that lung injury is triggered when high tidal volume ventilation follows liver ischemia-reperfusion.

Early noncardiogenic pulmonary edema and the use of PEEP and prone ventilation after emergency liver transplantation

Noncardiogenic pulmonary edema in liver transplant recipients is usually secondary to TRALI (transfusion related acute lung injury) or liver ischemic-reperfusion injury. If persistent, the resultant hypoxemia is associated with increased ventilator days, prolonged length of stay (intensive care and hospital) and increased 28-day mortality. Ventilation strategies for the management of hypoxemia in acute lung injury include moderate to high levels of PEEP (positive and expiratory pressure) and prone ventilation (PV). Such strategies have theoretical adverse effects on graft perfusion. Evidence does however exist to demonstrate that maintenance of cardiac output and correct positioning of the prone patient to allow abdominal excursion can negate the deleterious effects of PEEP and PV. A liver transplant recipient became profoundly hypoxemic on our intensive care unit following the onset of noncardiogenic pulmonary edema. A risk-benefit assessment performed at the time deemed that the potential adverse effects of PEEP and PV were outweighed by the life-threatening nature of hypoxemia. The patient's condition improved following prone positioning and application of PEEP (10-15 cm H(2)O). We conclude that such ventilation strategies are appropriate in hypoxemic liver transplant recipients if an appropriate risk-benefit assessment is performed.

Prostacyclin in sepsis: A systematic review

According to current literature, infective processes greatly modify both vascular hemodynamics and anti-oxidant properties of affected tissues, causing a change in homeostasis that regulates the correct functioning of all cells responsible for the physiological and metabolic balance of various organs. As a consequence, the response to the infection that has caused the change is also likely to be weaker and, in the case of septic shock, ineffective. In this review, we will take into consideration these mechanisms and then focus on a group of vasodilator drugs (prostacyclin and its analogs) which, though have been used for over 20 years mainly to treat obstructive vascular diseases, have such hemodynamic and anti-inflammatory properties which prevent homeostatic changes. It is obvious that prostacyclin does not definitively have anti-infective characteristics; however, in association with anti-infective drugs (antibiotics, etc.), the effectiveness of the latter appears improved, at least in some circumstances. Similarly, the fact that prostacyclin and its analogs have a cytoprotective effect on the liver and reduce the ischemia-reperfusion damage following liver transplant is not a novelty and evidence that they improve hepatic hemodynamics suggests their use in those pathologies characterized by possible reduced perfusion or ascertained ischemia of the liver.

Sodium nitroprusside decreased leukotriene C4 generation by inhibiting leukotriene C4 synthase expression and activity in hepatic ischemia-reperfusion injured rats

The effects of NO on LTC4 generation during hepatic ischemia-reperfusion (I/R) are largely unclear. Sprague-Dawley rats were divided into control, I/R and sodium nitroprusside (SNP, 2.5, 5 and 10 microg/kg/min)+I/R groups. Liver was subjected to I/R injury, saline or SNP administered intravenously. The protein expressions of LTC4 synthesis enzymes including LTC4 synthase (LTC4S), microsomal glutathione-S-transferase (mGST)2 and mGST3 were detected with immunoblotting, the LTC4 synthesis enzymes' activities and LTC4 content were measured by RP-HPLC, the mRNA expressions of inducible nitric oxide synthase (iNOS) and endogenous nitric oxide synthase (eNOS) in liver were measured by RT-PCR. Tissue injuries were assessed by serum ALT and AST and histological changes. Serum NO(2)(-) and liver tissue GSH were also examined. Compared with I/R group, SNP markedly decreased LTC4 content, LTC4S protein and iNOS mRNA levels, and the LTC4 synthesis enzymes' activities (P<0.05), but significantly enhanced eNOS mRNA expression in liver (P<0.05). The decline in serum ALT, AST and NO(2)(-) levels (P<0.05) together with hepatic GSH elevation (P<0.05) in SNP+I/R groups were also observed. LTC4S expression in hepatocytes and sinusoidal endothelial cells in SNP+I/R groups was lower than that in I/R group. But no significant differences in the protein expressions of mGST3 and mGST2 existed between control, I/R and SNP+I/R groups (P>0.05). These results demonstrated that the decline in LTC4 production by SNP treatment during hepatic I/R could be partially resulted from SNP down-regulating the protein expression of LTC4S rather than mGST2 or mGST3 and its inhibiting the LTC4 synthesis enzymes' activities.

Early perioperative death associated with reexpansion pulmonary edema during liver transplantation

Hydrothorax is a frequent finding in patients with end-stage liver disease. During the hepatectomy phase of liver transplantation, it is often needed to evacuate large pleural effusions. The acute expansion of the collapsed lung can cause reexpansion pulmonary edema with variable clinical significance. However, this complication has rarely been reported after liver transplantation. In conclusion, we report on an overwhelming reexpansion pulmonary edema during a liver transplantation that rapidly led to the patient's demise and speculate if this condition has not been under recognized in the transplantation setting.

Endotoxin-induced acute lung injury requires interaction with the liver

Clinical and laboratory data indicate that the liver plays an important role in the incidence, pathogenesis, and outcome of acute lung injury/acute respiratory distress syndrome. To distinguish direct effects of endotoxin on the lungs from liver-dependent effects during the early phase of the response to endotoxemia, we used an in situ perfused piglet preparation in which only the ventilated lung or both the lung and liver could be included in a blood perfused circuit. We monitored pulmonary vascular resistance, oxygenation, neutrophil count, lung edema as reflected by wet-dry weights of lung tissue, perfusate concentrations of TNF-alpha, IL-6, and 8-isoprostane (a marker of oxidative stress), and activation of the transcription factor (NF-kappaB) in lung tissue before and for 2 h after endotoxin. When only the lung was perfused, endotoxin caused pulmonary hypertension and neutropenia; but oxygenation was maintained; TNF-alpha, IL-6, and 8-isoprostane levels were minimally elevated; and there was no lung edema. When both the liver and lung were perfused, endotoxin caused marked hypoxemia, large increases in perfusate TNF-alpha, IL-6, and 8-isoprostane concentrations, and severe lung edema. NF-kappaB activation in the lung was greatest when the liver was in the perfusion circuit. We conclude that the direct effects of endotoxemia on the lungs include vasoconstriction and leukocyte sequestration, but not lung injury. Intense activation of the inflammatory response and oxidative injury that results in pulmonary edema and hypoxemia (acute lung injury) requires interaction of the lungs with the liver.

THE DEVELOPMENT OF ACUTE RESPIRATORY DISTRESS SYNDROME AFTER GUT ISCHEMIA/REPERFUSION INJURY FOLLOWED BY FECAL PERITONITIS IN PIGS: A CLINICALLY RELEVANT MODEL

Numerous clinical trials using anti-inflammatory agents for patients with acute respiratory distress syndrome (ARDS) have failed despite efficacy in acute animal models. This underscores the necessity of developing a clinically relevant model of ARDS. Initially, we attempted to induce lung injury in pigs by fecal peritonitis only. When this was unsuccessful, we designed a two-hit model of ischemia/reperfusion (I/R) injury followed by fecal peritonitis to create a clinically applicable model of ARDS. The initial study consisted of Yorkshire swine [group 1, fecal clot (FC), n = 4] that were followed clinically after intraperitoneal placement of a fecal (0.5 mL/kg) blood (2 mL/kg) clot. Blood was sampled daily for cultures, a complete blood count, a lactate level, and various cytokine expression determined by enzyme-linked immunosorbent assay (ELISA). Pigs were treated with antibiotics and fluids, placed on a ventilator before sacrifice to obtain hemodynamic and pulmonary parameters, and underwent histologic lung assessment. Additionally, bronchoalveolar lavage fluid was obtained for protein concentration and cytokine levels. Once it was evident that no lung injury had occurred, we designed a more severe model. A second group of Yorkshire swine [group 2, superior mesenteric artery (SMA) + FC, n = 4] underwent SMA occlusion for 30 min (I/R) followed by intraperitoneal placement of a FC as in the initial group. These pigs were monitored more invasively and continuously in an intensive care setting for 48 h and followed, treated, and assessed in a similar fashion to group 1. Group 1 (FC) pigs survived 9 days and showed signs of sepsis (bacteremia with polymicrobial organisms), an inflammatory response in the form of elevated cytokines, yet no physiologic or histologic evidence of lung injury. Group 2 (SMA + FC) pigs demonstrated more severe sepsis, a significantly increased cytokine response compared with animals in the FC group, and physiologic signs of progressive pulmonary injury. Pigs in the SMA + FC group were sacrificed at 48 h after clinical deterioration (significant decline in oxygenation) and demonstrated pathologic evidence of lung injury indicated by increased bronchoalveolar lavage fluid protein, diffuse and thickened alveolar septae, hyaline membrane formation, and pulmonary edema. The addition of a second "hit" (SMA occlusion, I/R) to a FC sepsis model resulted in severe lung injury that developed within a 3-day period. To our knowledge, this is the first large animal experiment that definitively and consistently causes insidious onset ARDS in pigs. By closely paralleling the clinical development of pulmonary injury, this model should prove invaluable in the study of human ARDS.

Cholestatic interleukin-6-deficient mice succumb to endotoxin-induced liver injury and pulmonary inflammation

Circulating and hepatic interleukin (IL)-6 levels are strongly increased during clinical and experimental cholestasis. Cholestatic liver injury is associated with increased susceptibility to endotoxin-induced toxicity. To determine the role of IL-6 herein, extrahepatic cholestasis was induced by bile duct ligation (BDL) in IL-6-gene deficient (IL-6(-/-)) and normal (IL-6(+/+)) mice. BDL elicited increased levels of hepatic IL-6 mRNA and protein in normal mice. Hepatocellular injury 2 weeks after BDL was similar in IL-6(-/-) and IL-6(+/+) mice as demonstrated by clinical chemistry and histopathology. Administration of endotoxin to cholestatic mice 2 weeks after BDL was associated with enhanced cytokine release, severe liver damage, and death when compared with sham-operated mice. Effects of endotoxin were largely similar in sham-operated IL-6(-/-) and IL-6(+/+) mice, but cholestatic IL-6(-/-) mice were more susceptible to the toxic effects of endotoxin, as reflected by increased cytokine release, more profound liver injury and lung inflammation, and higher mortality. Although endogenous IL-6 is not important in the development of liver injury after experimentally induced obstructive jaundice, this cytokine plays an important role in decreasing hypersensitivity to endotoxin in cholestatic mice.

Clinical relevance of time of onset, duration, and type of pulmonary edema after liver transplantation

We investigated the clinical significance of time of onset, duration, and type of pulmonary edema after orthotopic liver transplantation by retrospectively reviewing 93 consecutive recipients. Pulmonary edema was diagnosed by means of radiographic criteria and Pao(2)/Fio(2) ratio <300. Type was identified by pulmonary artery wedge pressure (hydrostatic, >18 mm Hg; permeability, < or =18 mm Hg). Of 91 evaluable patients, 44 (48%) had no pulmonary edema, 23 (25%) had immediate pulmonary edema resolving within 24 hours, 8 (9%) had late pulmonary edema (developing de novo in the first 16 to 24 hours), and 16 (18%) had persistent pulmonary edema (developing immediately and persisting for at least 16 hours). At 16 to 24 hours, mean arterial pressure was lower with persistent permeability-type edema than without pulmonary edema (75 versus 87 mm Hg, P <.01). Patients with persistent permeability-type edema had higher mean pulmonary arterial pressure (23 versus 16 mm Hg, P <.01) and higher pulmonary vascular resistance (103 versus 53 dyn. second. m(-5), P <.05), consistent with a resistance-dependent mechanism. Patients with persistent hydrostatic-type edema did not differ from those without edema in mean arterial pressure (84 versus 87 mm Hg, P >.05) or pulmonary vascular resistance (67 versus 53 dyn. second. m(-5), P >.05), but had increased mean pulmonary arterial pressure (27 versus 16, P <.01), suggesting a flow volume-dependent mechanism. Duration of mechanical ventilation, intensive care, and hospital stay were prolonged in patients with late or persistent permeability-type edema but not in patients with immediate pulmonary edema of any type. In conclusion, immediate pulmonary edema resolving within 24 hours after liver transplantation had little clinical consequence; persistent permeability-type pulmonary edema portended a worse outcome.

Cytokines and related receptor-mediated signaling pathways

Cytokines represent a multi-diverse family of polypeptide regulators; they are of relatively low molecular weight, pharmacologically active proteins that are secreted by one cell for the purpose of altering either its own functions (autocrine effect) or those of adjacent cells (paracrine effect). Cytokines are small, non-enzymatic glycoproteins whose actions are both diverse and overlapping (specificity/redundancy) and may affect diverse and overlapping target cell populations. In many instances, individual cytokines have multiple biological activities. Different cytokines can also have the same activity, which provides for functional redundancy within the inflammatory and immune systems. As biological cofactors that are released by specific cells, cytokines have specific effects on cell-cell interaction, communication, and behavior of other cells. As a result, it is infrequent that loss or neutralization of one cytokine will markedly interfere with either of these systems. The biological effect of one cytokine is often modified or augmented by another. Because an inter-digitating, redundant network of cytokines is involved in the production of most biological effects, both under physiologic and pathologic conditions, it usually requires more than a single defect in the network to alter drastically the outcome of the process. This fact therefore may have crucial significance in the development of therapeutic strategies for bio-pharmacologic intervention in cytokine-mediated inflammatory processes and infections.

Redox- and oxidant-mediated regulation of interleukin-10: an anti-inflammatory, antioxidant cytokine?

Reduction-oxidation (redox) state constitutes such a potential signaling mechanism for the regulation of an inflammatory signal associated with oxidative stress. Interleukin (IL)-10 has recently emerged as an anti-inflammatory cytokine with antioxidant properties. Interestingly, redox- and oxidant-mediated pathways positively and/or negatively regulate the expression, distribution, and functional properties of IL-10, thus, allowing the evolution of what is known as an anti-inflammatory redox-oxidant revolving axis. This axis is directly involved in regulating phosphorylation mechanisms, which eventually control gene expression and the biosynthesis of oxidative stress-related cofactors, such as reactive species and inflammatory cytokines. The association between IL-10, an anti-inflammatory antioxidant, with redox- and oxidant-related pathways governing the regulation of inflammatory and closely dependent processes is thereafter discussed.