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Fitzgerald DB, Polverino E, Waterer GW. Expert Review on Nonsurgical Management of Parapneumonic Effusion: Advances, Controversies, and New Directions. Semin Respir Crit Care Med 2023; 44:468-476. [PMID: 37429296 DOI: 10.1055/s-0043-1769095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2023]
Abstract
Parapneumonic effusion and empyema are rising in incidence worldwide, particularly in association with comorbidities in an aging population. Also driving this change is the widespread uptake of pneumococcal vaccines, leading to the emergence of nonvaccine-type pneumococci and other bacteria. Early treatment with systemic antibiotics is essential but should be guided by local microbial guidelines and antimicrobial resistance patterns due to significant geographical variation. Thoracic ultrasound has emerged as a leading imaging technique in parapneumonic effusion, enabling physicians to characterize effusions, assess the underlying parenchyma, and safely guide pleural procedures. Drainage decisions remain based on longstanding criteria including the size of the effusion and fluid gram stain and biochemistry results. Small-bore chest drains appear to be as effective as large bore and are adequate for the delivery of intrapleural enzyme therapy (IET), which is now supported by a large body of evidence. The IET dosing regimen used in the UK Multicenter Sepsis Trial -2 has the most evidence available but data surrounding alternative dosing, concurrent and once-daily instillations, and novel fibrinolytic agents are promising. Prognostic scores used in pneumonia (e.g., CURB-65) tend to underestimate mortality in parapneumonic effusion/empyema. Scores specifically based on pleural infection have been developed but require validation in prospective cohorts.
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Affiliation(s)
- Deirdre B Fitzgerald
- Department of Respiratory Medicine, Tallaght University Hospital, Dublin, Ireland
- Medical School, University of Western Australia, Australia
| | - Eva Polverino
- Pneumology Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain; CIBER de enfermedades respiratorias
| | - Grant W Waterer
- Medical School, University of Western Australia, Australia
- Royal Perth Hospital, Perth, WA, Australia
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2
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Florova G, De Vera CJ, Emerine RL, Girard RA, Azghani AO, Sarva K, Jacob J, Morris DE, Chamiso M, Idell S, Komissarov AA. Targeting the PAI-1 Mechanism with a Small Peptide Increases the Efficacy of Alteplase in a Rabbit Model of Chronic Empyema. Pharmaceutics 2023; 15:1498. [PMID: 37242740 PMCID: PMC10220965 DOI: 10.3390/pharmaceutics15051498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 05/07/2023] [Accepted: 05/11/2023] [Indexed: 05/28/2023] Open
Abstract
The incidence of empyema is increasing and associated with a mortality rate of 20% in patients older than 65 years. Since 30% of patients with advanced empyema have contraindications to surgical treatment, novel, low-dose, pharmacological treatments are needed. A Streptococcus pneumoniae-induced rabbit model of chronic empyema recapitulates the progression, loculation, fibrotic repair, and pleural thickening of human disease. Treatment with single chain (sc) urokinase (scuPA) or tissue type (sctPA) plasminogen activators in doses 1.0-4.0 mg/kg were only partially effective in this model. Docking Site Peptide (DSP; 8.0 mg/kg), which decreased the dose of sctPA for successful fibrinolytic therapy in acute empyema model did not improve efficacy in combination with 2.0 mg/kg scuPA or sctPA. However, a two-fold increase in either sctPA or DSP (4.0 and 8.0 mg/kg or 2.0 and 16.0 mg/kg sctPA and DSP, respectively) resulted in 100% effective outcome. Thus, DSP-based Plasminogen Activator Inhibitor 1-Targeted Fibrinolytic Therapy (PAI-1-TFT) of chronic infectious pleural injury in rabbits increases the efficacy of alteplase rendering ineffective doses of sctPA effective. PAI-1-TFT represents a novel, well-tolerated treatment of empyema that is amenable to clinical introduction. The chronic empyema model recapitulates increased resistance of advanced human empyema to fibrinolytic therapy, thus allowing for studies of muti-injection treatments.
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Affiliation(s)
- Galina Florova
- The Department of Cellular and Molecular Biology, University of Texas Health Science Center at Tyler (UTHSCT), Tyler, TX 75708, USA; (G.F.); (C.J.D.V.); (R.L.E.); (R.A.G.); (K.S.); (J.J.); (D.E.M.); (M.C.); (S.I.)
| | - Christian J. De Vera
- The Department of Cellular and Molecular Biology, University of Texas Health Science Center at Tyler (UTHSCT), Tyler, TX 75708, USA; (G.F.); (C.J.D.V.); (R.L.E.); (R.A.G.); (K.S.); (J.J.); (D.E.M.); (M.C.); (S.I.)
| | - Rebekah L. Emerine
- The Department of Cellular and Molecular Biology, University of Texas Health Science Center at Tyler (UTHSCT), Tyler, TX 75708, USA; (G.F.); (C.J.D.V.); (R.L.E.); (R.A.G.); (K.S.); (J.J.); (D.E.M.); (M.C.); (S.I.)
| | - René A. Girard
- The Department of Cellular and Molecular Biology, University of Texas Health Science Center at Tyler (UTHSCT), Tyler, TX 75708, USA; (G.F.); (C.J.D.V.); (R.L.E.); (R.A.G.); (K.S.); (J.J.); (D.E.M.); (M.C.); (S.I.)
| | - Ali O. Azghani
- The Department of Biology, University of Texas at Tyler, Tyler, TX 75799, USA;
| | - Krishna Sarva
- The Department of Cellular and Molecular Biology, University of Texas Health Science Center at Tyler (UTHSCT), Tyler, TX 75708, USA; (G.F.); (C.J.D.V.); (R.L.E.); (R.A.G.); (K.S.); (J.J.); (D.E.M.); (M.C.); (S.I.)
| | - Jincy Jacob
- The Department of Cellular and Molecular Biology, University of Texas Health Science Center at Tyler (UTHSCT), Tyler, TX 75708, USA; (G.F.); (C.J.D.V.); (R.L.E.); (R.A.G.); (K.S.); (J.J.); (D.E.M.); (M.C.); (S.I.)
| | - Danna E. Morris
- The Department of Cellular and Molecular Biology, University of Texas Health Science Center at Tyler (UTHSCT), Tyler, TX 75708, USA; (G.F.); (C.J.D.V.); (R.L.E.); (R.A.G.); (K.S.); (J.J.); (D.E.M.); (M.C.); (S.I.)
| | - Mignote Chamiso
- The Department of Cellular and Molecular Biology, University of Texas Health Science Center at Tyler (UTHSCT), Tyler, TX 75708, USA; (G.F.); (C.J.D.V.); (R.L.E.); (R.A.G.); (K.S.); (J.J.); (D.E.M.); (M.C.); (S.I.)
| | - Steven Idell
- The Department of Cellular and Molecular Biology, University of Texas Health Science Center at Tyler (UTHSCT), Tyler, TX 75708, USA; (G.F.); (C.J.D.V.); (R.L.E.); (R.A.G.); (K.S.); (J.J.); (D.E.M.); (M.C.); (S.I.)
| | - Andrey A. Komissarov
- The Department of Cellular and Molecular Biology, University of Texas Health Science Center at Tyler (UTHSCT), Tyler, TX 75708, USA; (G.F.); (C.J.D.V.); (R.L.E.); (R.A.G.); (K.S.); (J.J.); (D.E.M.); (M.C.); (S.I.)
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3
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Komissarov AA, Idell S. PAI-1 Drives Septation and Clinical Outcomes in Pleural Infection. Am J Respir Crit Care Med 2023; 207:653-655. [PMID: 36269762 PMCID: PMC10037477 DOI: 10.1164/rccm.202210-1925ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Andrey A Komissarov
- School of Medicine University of Texas Health Science Center at Tyler Tyler, Texas
| | - Steven Idell
- School of Medicine University of Texas Health Science Center at Tyler Tyler, Texas
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4
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Tucker TA, Idell S. Update on Novel Targeted Therapy for Pleural Organization and Fibrosis. Int J Mol Sci 2022; 23:ijms23031587. [PMID: 35163509 PMCID: PMC8835949 DOI: 10.3390/ijms23031587] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 01/25/2022] [Accepted: 01/28/2022] [Indexed: 11/22/2022] Open
Abstract
Pleural injury and subsequent loculation is characterized by acute injury, sustained inflammation and, when severe, pathologic tissue reorganization. While fibrin deposition is a normal part of the injury response, disordered fibrin turnover can promote pleural loculation and, when unresolved, fibrosis of the affected area. Within this review, we present a brief discussion of the current IPFT therapies, including scuPA, for the treatment of pathologic fibrin deposition and empyema. We also discuss endogenously expressed PAI-1 and how it may affect the efficacy of IPFT therapies. We further delineate the role of pleural mesothelial cells in the progression of pleural injury and subsequent pleural remodeling resulting from matrix deposition. We also describe how pleural mesothelial cells promote pleural fibrosis as myofibroblasts via mesomesenchymal transition. Finally, we discuss novel therapeutic targets which focus on blocking and/or reversing the myofibroblast differentiation of pleural mesothelial cells for the treatment of pleural fibrosis.
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Karandashova S, Florova G, Idell S, Komissarov AA. From Bedside to the Bench—A Call for Novel Approaches to Prognostic Evaluation and Treatment of Empyema. Front Pharmacol 2022; 12:806393. [PMID: 35126140 PMCID: PMC8811368 DOI: 10.3389/fphar.2021.806393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 12/31/2021] [Indexed: 11/13/2022] Open
Abstract
Empyema, a severe complication of pneumonia, trauma, and surgery is characterized by fibrinopurulent effusions and loculations that can result in lung restriction and resistance to drainage. For decades, efforts have been focused on finding a universal treatment that could be applied to all patients with practice recommendations varying between intrapleural fibrinolytic therapy (IPFT) and surgical drainage. However, despite medical advances, the incidence of empyema has increased, suggesting a gap in our understanding of the pathophysiology of this disease and insufficient crosstalk between clinical practice and preclinical research, which slows the development of innovative, personalized therapies. The recent trend towards less invasive treatments in advanced stage empyema opens new opportunities for pharmacological interventions. Its remarkable efficacy in pediatric empyema makes IPFT the first line treatment. Unfortunately, treatment approaches used in pediatrics cannot be extrapolated to empyema in adults, where there is a high level of failure in IPFT when treating advanced stage disease. The risk of bleeding complications and lack of effective low dose IPFT for patients with contraindications to surgery (up to 30%) promote a debate regarding the choice of fibrinolysin, its dosage and schedule. These challenges, which together with a lack of point of care diagnostics to personalize treatment of empyema, contribute to high (up to 20%) mortality in empyema in adults and should be addressed preclinically using validated animal models. Modern preclinical studies are delivering innovative solutions for evaluation and treatment of empyema in clinical practice: low dose, targeted treatments, novel biomarkers to predict IPFT success or failure, novel delivery methods such as encapsulating fibrinolysin in echogenic liposomal carriers to increase the half-life of plasminogen activator. Translational research focused on understanding the pathophysiological mechanisms that control 1) the transition from acute to advanced-stage, chronic empyema, and 2) differences in outcomes of IPFT between pediatric and adult patients, will identify new molecular targets in empyema. We believe that seamless bidirectional communication between those working at the bedside and the bench would result in novel personalized approaches to improve pharmacological treatment outcomes, thus widening the window for use of IPFT in adult patients with advanced stage empyema.
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Affiliation(s)
- Sophia Karandashova
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, United States
| | - Galina Florova
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, TX, United States
| | - Steven Idell
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, TX, United States
| | - Andrey A. Komissarov
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, TX, United States
- *Correspondence: Andrey A. Komissarov,
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TGF-β regulation of the uPA/uPAR axis modulates mesothelial-mesenchymal transition (MesoMT). Sci Rep 2021; 11:21210. [PMID: 34707211 PMCID: PMC8551303 DOI: 10.1038/s41598-021-99520-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 09/28/2021] [Indexed: 12/01/2022] Open
Abstract
Pleural fibrosis (PF) is a chronic and progressive lung disease which affects approximately 30,000 people per year in the United States. Injury and sustained inflammation of the pleural space can result in PF, restricting lung expansion and impairing oxygen exchange. During the progression of pleural injury, normal pleural mesothelial cells (PMCs) undergo a transition, termed mesothelial mesenchymal transition (MesoMT). While multiple components of the fibrinolytic pathway have been investigated in pleural remodeling and PF, the role of the urokinase type plasminogen activator receptor (uPAR) is unknown. We found that uPAR is robustly expressed by pleural mesothelial cells in PF. Downregulation of uPAR by siRNA blocked TGF-β mediated MesoMT. TGF-β was also found to significantly induce uPA expression in PMCs undergoing MesoMT. Like uPAR, uPA downregulation blocked TGF-β mediated MesoMT. Further, uPAR is critical for uPA mediated MesoMT. LRP1 downregulation likewise blunted TGF-β mediated MesoMT. These findings are consistent with in vivo analyses, which showed that uPAR knockout mice were protected from S. pneumoniae-mediated decrements in lung function and restriction. Histological assessments of pleural fibrosis including pleural thickening and α-SMA expression were likewise reduced in uPAR knockout mice compared to WT mice. These studies strongly support the concept that uPAR targeting strategies could be beneficial for the treatment of PF.
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Hassan M, Patel S, Sadaka AS, Bedawi EO, Corcoran JP, Porcel JM. Recent Insights into the Management of Pleural Infection. Int J Gen Med 2021; 14:3415-3429. [PMID: 34290522 PMCID: PMC8286963 DOI: 10.2147/ijgm.s292705] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 06/29/2021] [Indexed: 01/15/2023] Open
Abstract
Pleural infection in adults has considerable morbidity and continues to be a life-threatening condition. The term “pleural infection” encompasses complicated parapneumonic effusions and primary pleural infections, and includes but is not limited to empyema, which refers to collection of pus in the pleural cavity. The incidence of pleural infection in adults has been continuously increasing over the past two decades, particularly in older adults, and most of such patients have comorbidities. Management of pleural infection requires prolonged duration of hospitalization (average 14 days). There are recognized differences in microbial etiology of pleural infection depending on whether the infection was acquired in the community or in a health-care setting. Anaerobic bacteria are acknowledged as a major cause of pleural infection, and thus anaerobic coverage in antibiotic regimens for pleural infection is mandatory. The key components of managing pleural infection are appropriate antimicrobial therapy and chest-tube drainage. In patients who fail medical therapy by manifesting persistent sepsis despite standard measures, surgical intervention to clear the infected space or intrapleural fibrinolytic therapy (in poor surgical candidates) are recommended. Recent studies have explored the role of early intrapleural fibrinolytics or first-line surgery, but due to considerable costs of such interventions and the lack of convincing evidence of improved outcomes with early use, early intervention cannot be recommended, and further evidence is awaited from ongoing studies. Other areas of research include the role of routine molecular testing of infected pleural fluid in improving the rate of identification of causative organisms. Other research topics include the benefit of such interventions as medical thoracoscopy, high-volume pleural irrigation with saline/antiseptic solution, and repeated thoracentesis (as opposed to chest-tube drainage) in reducing morbidity and improving outcomes of pleural infection. This review summarizes current knowledge and practice in managing pleural infection and future research directions.
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Affiliation(s)
- Maged Hassan
- Chest Diseases Department, Alexandria University Faculty of Medicine, Alexandria, Egypt
| | - Shefaly Patel
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals, Oxford, UK
| | - Ahmed S Sadaka
- Chest Diseases Department, Alexandria University Faculty of Medicine, Alexandria, Egypt
| | - Eihab O Bedawi
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals, Oxford, UK
| | - John P Corcoran
- Department of Respiratory Medicine, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - José M Porcel
- Department of Internal Medicine, Arnau de Vilanova University Hospital, Lleida, Spain
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Intrapleural Fibrinolytic Therapy versus Early Medical Thoracoscopy for Treatment of Pleural Infection. Randomized Controlled Clinical Trial. Ann Am Thorac Soc 2021; 17:958-964. [PMID: 32421353 DOI: 10.1513/annalsats.202001-076oc] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Rationale: Pleural infection is frequently encountered in clinical practice and is associated with high morbidity and mortality. Limited evidence exists regarding the optimal treatment. Although both early medical thoracoscopy (MT) and tube thoracostomy with intrapleural instillation of tissue plasminogen activator and human recombinant deoxyribonuclease are acceptable treatments for patients with complicated pleural infection, there is a lack of comparative data for these modes of management.Objectives: The aim of this study was to compare the safety and efficacy of early MT versus intrapleural fibrinolytic therapy (IPFT) in selected patients with multiloculated pleural infection and empyema.Methods: This was a prospective multicenter, randomized controlled trial involving patients who underwent MT or IPFT for pleural infection. The primary outcome was the length of hospital stay after either intervention. Secondary outcomes included the total length of hospital stay, treatment failure, 30-day mortality, and adverse events.Results: Thirty-two patients with pleural infection were included in the study. The median length of stay after an intervention was 4 days in the IPFT arm and 2 days in the MT arm (P = 0.026). The total length of hospital stay was 6 days in the IPFT arm and 3.5 days in MT arm (P = 0.12). There was no difference in treatment failure, mortality, or adverse events between the treatment groups, and no serious complications related to either intervention were recorded.Conclusions: When used early in the course of a complicated parapneumonic effusion or empyema, MT is safe and might shorten hospital stays for selected patients as compared with IPFT therapy. A multicenter trial with a larger sample size is needed to confirm these findings.Clinical trial registered with ClinicalTrials.gov (NCT02973139).
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Florova G, Girard RA, Azghani AO, Sarva K, Buchanan A, Karandashova S, DeVera CJ, Morris D, Chamiso M, Koenig K, Cines DB, Idell S, Komissarov AA. Precision targeting of the plasminogen activator inhibitor-1 mechanism increases efficacy of fibrinolytic therapy in empyema. Physiol Rep 2021; 9:e14861. [PMID: 33991465 PMCID: PMC8123555 DOI: 10.14814/phy2.14861] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 04/11/2021] [Indexed: 01/10/2023] Open
Abstract
Plasminogen activator inhibitor‐1 (PAI‐1) is an endogenous irreversible inhibitor of tissue‐type (tPA) and urokinase (uPA) plasminogen activators. PAI‐1‐targeted fibrinolytic therapy (PAI‐1‐TFT) is designed to decrease the therapeutic dose of tPA and uPA, attenuating the risk of bleeding and other complications. Docking site peptide (DSP) mimics the part of the PAI‐1 reactive center loop that interacts with plasminogen activators, thereby affecting the PAI‐1 mechanism. We used DSP for PAI‐1‐TFT in two rabbit models: chemically induced pleural injury and Streptococcus pneumoniae induced empyema. These models feature different levels of inflammation and PAI‐1 expression. PAI‐1‐TFT with DSP (2.0 mg/kg) converted ineffective doses of single chain (sc) tPA (72.5 µg/kg) and scuPA (62.5 µg/kg) into effective ones in chemically induced pleural injury. DSP (2.0 mg/kg) was ineffective in S. pneumoniae empyema, where the level of PAI‐1 is an order of magnitude higher. DSP dose escalation to 8.0 mg/kg resulted in effective PAI‐1‐TFT with 0.25 mg/kg sctPA (1/8th of the effective dose of sctPA alone) in empyema. There was no increase in the efficacy of scuPA. PAI‐1‐TFT with DSP increases the efficacy of fibrinolytic therapy up to 8‐fold in chemically induced (sctPA and scuPA) and infectious (sctPA) pleural injury in rabbits. PAI‐1 is a valid molecular target in our model of S. pneumoniae empyema in rabbits, which closely recapitulates key characteristics of empyema in humans. Low‐dose PAI‐1‐TFT is a novel interventional strategy that offers the potential to improve fibrinolytic therapy for empyema in clinical practice.
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Affiliation(s)
- Galina Florova
- The Department of Cellular and Molecular Biology of the University of Texas Health Science Center at Tyler (UTHSCT), Tyler, TX, USA
| | - René A Girard
- The Department of Cellular and Molecular Biology of the University of Texas Health Science Center at Tyler (UTHSCT), Tyler, TX, USA
| | | | - Krishna Sarva
- The Department of Cellular and Molecular Biology of the University of Texas Health Science Center at Tyler (UTHSCT), Tyler, TX, USA
| | | | - Sophia Karandashova
- The Department of Cellular and Molecular Biology of the University of Texas Health Science Center at Tyler (UTHSCT), Tyler, TX, USA
| | - Christian J DeVera
- The Department of Cellular and Molecular Biology of the University of Texas Health Science Center at Tyler (UTHSCT), Tyler, TX, USA
| | - Danna Morris
- The Department of Cellular and Molecular Biology of the University of Texas Health Science Center at Tyler (UTHSCT), Tyler, TX, USA
| | - Mignote Chamiso
- The Department of Cellular and Molecular Biology of the University of Texas Health Science Center at Tyler (UTHSCT), Tyler, TX, USA
| | - Kathleen Koenig
- The Department of Cellular and Molecular Biology of the University of Texas Health Science Center at Tyler (UTHSCT), Tyler, TX, USA
| | - Douglas B Cines
- Department of Pathology and Laboratory Medicine, Perelman-University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Steven Idell
- The Department of Cellular and Molecular Biology of the University of Texas Health Science Center at Tyler (UTHSCT), Tyler, TX, USA
| | - Andrey A Komissarov
- The Department of Cellular and Molecular Biology of the University of Texas Health Science Center at Tyler (UTHSCT), Tyler, TX, USA
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Tucker TA, Idell S. The Contribution of the Urokinase Plasminogen Activator and the Urokinase Receptor to Pleural and Parenchymal Lung Injury and Repair: A Narrative Review. Int J Mol Sci 2021; 22:ijms22031437. [PMID: 33535429 PMCID: PMC7867090 DOI: 10.3390/ijms22031437] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 01/26/2021] [Accepted: 01/26/2021] [Indexed: 12/28/2022] Open
Abstract
Pleural and parenchymal lung injury have long been characterized by acute inflammation and pathologic tissue reorganization, when severe. Although transitional matrix deposition is a normal part of the injury response, unresolved fibrin deposition can lead to pleural loculation and scarification of affected areas. Within this review, we present a brief discussion of the fibrinolytic pathway, its components, and their contribution to injury progression. We review how local derangements of fibrinolysis, resulting from increased coagulation and reduced plasminogen activator activity, promote extravascular fibrin deposition. Further, we describe how pleural mesothelial cells contribute to lung scarring via the acquisition of a profibrotic phenotype. We also discuss soluble uPAR, a recently identified biomarker of pleural injury, and its diagnostic value in the grading of pleural effusions. Finally, we provide an in-depth discussion on the clinical importance of single-chain urokinase plasminogen activator (uPA) for the treatment of loculated pleural collections.
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Affiliation(s)
| | - Steven Idell
- Correspondence: ; Tel.: +1-903-877-7556; Fax: +1-903-877-7316
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11
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Zhao R, Ali G, Nie HG, Chang Y, Bhattarai D, Su X, Zhao X, Matthay MA, Ji HL. Plasmin improves blood-gas barrier function in oedematous lungs by cleaving epithelial sodium channels. Br J Pharmacol 2020; 177:3091-3106. [PMID: 32133621 DOI: 10.1111/bph.15038] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 02/11/2020] [Accepted: 02/25/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND AND PURPOSE Lung oedema in association with suppressed fibrinolysis is a hallmark of lung injury. Here, we have tested whether plasmin cleaves epithelial sodium channels (ENaC) to resolve lung oedema fluid. EXPERIMENTAL APPROACH Human lungs and airway acid-instilled mice were used for analysing fluid resolution. In silico prediction, mutagenesis, Xenopus oocytes, immunoblotting, voltage clamp, mass spectrometry, and protein docking were combined for identifying plasmin cleavage sites. KEY RESULTS Plasmin improved lung fluid resolution in both human lungs ex vivo and injured mice. Plasmin activated αβγENaC channels in oocytes in a time-dependent manner. Deletion of four consensus proteolysis tracts (αΔ432-444, γΔ131-138, γΔ178-193, and γΔ410-422) eliminated plasmin-induced activation significantly. Further, immunoblotting assays identified 7 cleavage sites (K126, R135, K136, R153, K168, R178, K179) for plasmin to trim both furin-cleaved C-terminal fragments and full-length human γENaC proteins. In addition, 9 new sites (R122, R137, R138, K150, K170, R172, R180, K181, K189) in synthesized peptides were found to be cleaved by plasmin. These cleavage sites were located in the finger and the thumb, particularly the GRIP domain of human ENaC 3D model composed of two proteolytic centres for plasmin. Novel uncleaved sites beyond the GRIP domain in both α and γ subunits were identified to interrupt the plasmin cleavage-induced conformational change in ENaC channel complexes. Additionally, plasmin could regulate ENaC activity via the G protein signal. CONCLUSION AND IMPLICATIONS Plasmin can cleave ENaC to improve blood-gas exchange by resolving oedema fluid and could be a potent therapy for oedematous lungs.
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Affiliation(s)
- Runzhen Zhao
- Department of Cellular and Molecular Biology, University of Texas Health Science Centre at Tyler, Tyler, Texas
| | - Gibran Ali
- Department of Cellular and Molecular Biology, University of Texas Health Science Centre at Tyler, Tyler, Texas
| | - Hong-Guang Nie
- Department of Cellular and Molecular Biology, University of Texas Health Science Centre at Tyler, Tyler, Texas.,College of Basic Medical Science, China Medical University, Shenyang, Liaoning, China
| | - Yongchang Chang
- Division of Neurobiology, Barrow Neurological Institute, Phoenix, Arizona
| | - Deepa Bhattarai
- Department of Cellular and Molecular Biology, University of Texas Health Science Centre at Tyler, Tyler, Texas
| | - Xuefeng Su
- Department of Cellular and Molecular Biology, University of Texas Health Science Centre at Tyler, Tyler, Texas
| | - Xiaoli Zhao
- Department of Physiological Sciences, Eastern Virginia Medical School, Norfolk, Virginia
| | - Michael A Matthay
- Department of Medicine and Anesthesia, University of California San Francisco, San Francisco, California
| | - Hong-Long Ji
- Department of Cellular and Molecular Biology, University of Texas Health Science Centre at Tyler, Tyler, Texas.,Texas Lung Injury Institute, University of Texas Health Science Centre at Tyler, Tyler, Texas
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Abstract
Hemothorax is a collection of blood in the pleural cavity usually from traumatic injury. Chest X-ray has historically been the imaging modality of choice upon arrival to the hospital. The sensitivity and specificity of point-of-care ultrasound, specifically through the Extended Focal Assessment with Sonography in Trauma (eFAST) protocol has been significant enough to warrant inclusion in most Level 1 trauma centers as an adjunct to radiographs.1,2 If the size or severity of a hemothorax warrants intervention, tube thoracostomy has been and still remains the treatment of choice. Most cases of hemothorax will resolve with tube thoracostomy. If residual blood remains within the pleural cavity after tube thoracostomy, it is then considered to be a retained hemothorax, with significant risks for developing late complications such as empyema and fibrothorax. Once late complications occur, morbidity and mortality increase dramatically and the only definitive treatment is surgery. In order to avoid surgery, research has been focused on removing a retained hemothorax before it progresses pathologically. The most promising therapy consists of fibrinolytics which are infused into the pleural space, disrupting the hemothorax, allowing for further drainage. While significant progress has been made, additional trials are needed to further define the dosing and pharmacokinetics of fibrinolytics in this setting. If medical therapy and early procedures fail to resolve the retained hemothorax, surgery is usually indicated. Surgery historically consisted solely of thoracotomy, but has been largely replaced in non-emergent situations by video-assisted thoracoscopy (VATS), a minimally invasive technique that shows considerable improvement in the patients' recovery and pain post-operatively. Should all prior attempts to resolve the hemothorax fail, then open thoracotomy may be indicated.
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Increased expression of plasminogen activator inhibitor-1 (PAI-1) is associated with depression and depressive phenotype in C57Bl/6J mice. Exp Brain Res 2019; 237:3419-3430. [DOI: 10.1007/s00221-019-05682-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Accepted: 11/07/2019] [Indexed: 02/07/2023]
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14
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Mierzejewski M, Korczynski P, Krenke R, Janssen JP. Chemical pleurodesis - a review of mechanisms involved in pleural space obliteration. Respir Res 2019; 20:247. [PMID: 31699094 PMCID: PMC6836467 DOI: 10.1186/s12931-019-1204-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 10/01/2019] [Indexed: 12/11/2022] Open
Abstract
Chemical pleurodesis is a therapeutic procedure applied to create the symphysis between the parietal and visceral pleura by intrapleural administration of various chemical agents (e.g. talk, tetracycline, iodopovidone, etc.). The two major clinical conditions treated with chemical pleurodesis are recurrent pleural effusion (PE) and recurrent spontaneous pneumothorax. Although the history of chemical pleurodesis began over a century ago, detailed data on the mechanisms of action of sclerosing agents are highly incomplete. The following article aims to present the state of knowledge on this subject.It is believed that mesothelial cells are the main structural axis of pleurodesis. In response to sclerosing agents they secrete a variety of mediators including chemokines such as interleukin 8 (IL-8) and monocyte chemoattractant protein (MCP-1), as well as growth factors - vascular endothelial growth factor (VEGF), platelet-derived growth factor (PDGF), basic fibroblast growth factor (bFGF) and transforming growth factor- β (TGF-β). Numerous data suggest that intact mesothelial cells and the above cytokines play a crucial role in the initiation and maintenance of different pathways of pleural inflammation and pleural space obliteration.It seems that the process of pleurodesis is largely nonspecific to the sclerosant and involves the same ultimate pathways including activation of pleural cells, coagulation cascade, fibrin chain formation, fibroblast proliferation and production of collagen and extracellular matrix components. Of these processes, the coagulation cascade with decreased fibrinolytic activity and increased fibrinogenesis probably plays a pivotal role, at least during the early response to sclerosant administration.A better understanding of various pathways involved in pleurodesis may be a prerequisite for more effective and safe use of various sclerosants and for the development of new, perhaps more personalized therapeutic approaches.
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Affiliation(s)
- Michal Mierzejewski
- Department of Internal Medicine, Pulmonary Diseases & Allergy, Medical University of Warsaw, Warsaw, Poland
| | - Piotr Korczynski
- Department of Internal Medicine, Pulmonary Diseases & Allergy, Medical University of Warsaw, Warsaw, Poland
| | - Rafal Krenke
- Department of Internal Medicine, Pulmonary Diseases & Allergy, Medical University of Warsaw, Warsaw, Poland.
| | - Julius P Janssen
- Department of Pulmonary Diseases, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
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Beckert L, Brockway B, Simpson G, Southcott AM, Lee YG, Rahman N, Light RW, Shoemaker S, Gillies J, Komissarov AA, Florova G, Ochran T, Bradley W, Ndetan H, Singh KP, Sarva K, Idell S. Phase 1 trial of intrapleural LTI-01; single chain urokinase in complicated parapneumonic effusions or empyema. JCI Insight 2019; 5:127470. [PMID: 30998508 PMCID: PMC6542611 DOI: 10.1172/jci.insight.127470] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 04/12/2019] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Current dosing of intrapleural fibrinolytic therapy (IPFT) in adults with complicated parapneumonic effusion (CPE) / empyema is empiric, as dose-escalation trials have not previously been conducted. We hypothesized that LTI-01 (scuPA), which is relatively resistant to PA inhibitor-1 (PAI-1), would be well-tolerated. METHODS This was an open-label, dose-escalation trial of LTI-01 IPFT at 50,000-800,000 IU daily for up to 3 days in adults with loculated CPE/empyema and failed pleural drainage. The primary objective was to evaluate safety and tolerability, and secondary objectives included assessments of processing and bioactivity of scuPA in blood and pleural fluid (PF), and early efficacy. RESULTS LTI-01 was well tolerated with no bleeding, treatment-emergent adverse events or surgical referrals (n=14 subjects). uPA antigen increased in PFs at 3 hours after LTI-01 (p<0.01) but not in plasma. PF saturated active PAI-1, generated PAI-1-resistant bioactive complexes, increased PA and fibrinolytic activities and D-dimers. There was no systemic fibrinogenolysis, nor increments in plasma D-dimer. Decreased pleural opacities occurred in all but one subject. Both subjects receiving 800,000 IU required two doses to relieve pleural sepsis, with two other subjects similarly responding at lower doses. CONCLUSION LTI-01 IPFT was well-tolerated at these doses with no safety concerns. Bioactivity of LTI-01 IPFT was confirmed, limited to PFs where its processing simulated that previously reported in preclinical studies. Preliminary efficacy signals including reduction of pleural opacity were observed.
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Affiliation(s)
| | - Ben Brockway
- University of Otago Dunedin School of Medicine, Dunedin, New Zealand
| | | | | | - Y.C. Gary Lee
- Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Najib Rahman
- Nuffield Department of Medicine, University of Oxford, and Oxford NIHR Biomedical Research Centre, Oxford, United Kingdom
| | - Richard W. Light
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - John Gillies
- Clinical Network Services (CNS), Auckland, New Zealand
| | | | | | | | | | - Harrison Ndetan
- Department of Epidemiology and Biostatistics, School of Community and Rural Health, The University of Texas Health Science Center at Tyler (UTHSCT), Tyler, Texas, USA
| | - Karan P. Singh
- Department of Epidemiology and Biostatistics, School of Community and Rural Health, The University of Texas Health Science Center at Tyler (UTHSCT), Tyler, Texas, USA
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16
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Fukuda S, Enkhbaatar P, Nelson C, Cox RA, Wolfson MR, Shaffer TH, Williams RO, Surasarang SH, Sawittree S, Florova G, Komissarov AA, Koenig K, Sarva K, Ndetan HT, Singh KP, Idell S. Lack of durable protection against cotton smoke-induced acute lung injury in sheep by nebulized single chain urokinase plasminogen activator or tissue plasminogen activator. Clin Transl Med 2018; 7:17. [PMID: 29916009 PMCID: PMC6006005 DOI: 10.1186/s40169-018-0196-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 06/10/2018] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Airway fibrin casts are clinically important complications of severe inhalational smoke-induced acute lung injury (ISIALI) for which reliable evidence-based therapy is lacking. Nebulized anticoagulants or a tissue plasminogen activator; tPA, has been advocated, but airway bleeding is a known and lethal potential complication. We posited that nebulized delivery of single chain urokinase plasminogen activator, scuPA, is well-tolerated and improves physiologic outcomes in ISIALI. To test this hypothesis, we nebulized scuPA or tPA and delivered these agents every 4 h to sheep with cotton smoke induced ISIALI that were ventilated by either adaptive pressure ventilation/controlled mandatory ventilation (APVcmv; Group 1, n = 14) or synchronized controlled mandatory ventilation (SCMV)/limited suctioning; Group 2, n = 32). Physiologic readouts of acute lung injury included arterial blood gas analyses, PaO2/FiO2 ratios, peak and plateau airway pressures, lung resistance and static lung compliance. Lung injury was further assessed by histologic scoring. Biochemical analyses included determination of antigenic and enzymographic uPA and tPA levels, plasminogen activator and plasminogen activator inhibitor-1 activities and D-dimer in bronchoalveolar lavage (BAL). Plasma levels of uPA, tPA antigens, D-dimers and α-macroglobulin-uPA complex levels were also assessed. RESULTS In Group 1, tPA at the 2 mg dose was ineffective, but at 4 mg tPA or scuPA, the PaO2/FiO2 ratios, peak/plateau pressures improved during evolving injury (p < 0.01) without significant differences at 48 h. To improve delivery of the interventions, the experiments were repeated in Group 2 with limited suctioning/SCMV, which generally increased PAs in (BAL). In Group 2, tPA was ineffective, but scuPA (4 or 8 mg) improved physiologic outcomes (p < 0.01) and plateau pressures remained lower at 48 h. Airway bleeding occurred at 8 mg tPA. BAL plasminogen activator (PA) levels positively correlated with physiologic outcomes at 48 h. CONCLUSIONS Physiologic outcomes improved in sheep in which better delivery of the PAs occurred. The benefits of nebulized scuPA were achieved without airway bleeding associated with tPA, but were transient and largely abrogated at 48 h, in part attributable to the progression and severity of ISIALI.
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Affiliation(s)
- Satoshi Fukuda
- Translational Intensive Care Unit, Department of Anesthesiology, The University of Texas Medical Branch, Galveston, TX, USA
| | - Perenlei Enkhbaatar
- Translational Intensive Care Unit, Department of Anesthesiology, The University of Texas Medical Branch, Galveston, TX, USA
| | - Christina Nelson
- Translational Intensive Care Unit, Department of Anesthesiology, The University of Texas Medical Branch, Galveston, TX, USA
| | - Robert A Cox
- Translational Intensive Care Unit, Department of Anesthesiology, The University of Texas Medical Branch, Galveston, TX, USA
| | - Marla R Wolfson
- Department of Physiology, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
- Center for Inflammation, Translational and Clinical Lung Research, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
- CENTRe: Collaborative for Environmental and Neonatal Therapeutics Research, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
- Temple Lung Center, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - Thomas H Shaffer
- Center for Pediatric Lung Research, Alfred I. DuPont Hospital for Children, Wilmington, DE, USA
| | - Robert O Williams
- Molecular Pharmaceutics and Drug Delivery, The University of Texas at Austin, Austin, TX, USA
| | | | - Sahakijpijarn Sawittree
- Molecular Pharmaceutics and Drug Delivery, The University of Texas at Austin, Austin, TX, USA
| | - Galina Florova
- The Department of Cellular and Molecular Biology and the Texas Lung Institute, The University of Texas Health Science Center at Tyler, 11927 US HWY 271, Tyler, TX, 75708, USA
| | - Andrey A Komissarov
- The Department of Cellular and Molecular Biology and the Texas Lung Institute, The University of Texas Health Science Center at Tyler, 11927 US HWY 271, Tyler, TX, 75708, USA
| | - Kathleen Koenig
- The Department of Cellular and Molecular Biology and the Texas Lung Institute, The University of Texas Health Science Center at Tyler, 11927 US HWY 271, Tyler, TX, 75708, USA
| | - Krishna Sarva
- The Department of Cellular and Molecular Biology and the Texas Lung Institute, The University of Texas Health Science Center at Tyler, 11927 US HWY 271, Tyler, TX, 75708, USA
| | - Harrison T Ndetan
- The Department of Epidemiology and Biostatistics, The University of Texas Health Science Center at Tyler, 11927 US HWY 271, Tyler, TX, 75708, USA
| | - Karan P Singh
- The Department of Epidemiology and Biostatistics, The University of Texas Health Science Center at Tyler, 11927 US HWY 271, Tyler, TX, 75708, USA
| | - Steven Idell
- The Department of Cellular and Molecular Biology and the Texas Lung Institute, The University of Texas Health Science Center at Tyler, 11927 US HWY 271, Tyler, TX, 75708, USA.
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17
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Idell S, Rahman NM. Intrapleural Fibrinolytic Therapy for Empyema and Pleural Loculation: Knowns and Unknowns. Ann Am Thorac Soc 2018; 15:515-517. [PMID: 29361235 PMCID: PMC5955053 DOI: 10.1513/annalsats.201711-848ps] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 01/23/2018] [Indexed: 11/20/2022] Open
Affiliation(s)
- Steven Idell
- The Department of Cellular and Molecular Biology and the Texas Lung Injury Institute, the University of Texas Health Science Center at Tyler, Tyler, Texas
| | - Najib M. Rahman
- Oxford Pleural Unit and Oxford Respiratory Trials Unit, University of Oxford, Churchill Hospital, Oxford, United Kingdom; and
- National Institute of Health Research Biomedical Research Centre, Oxford, United Kingdom
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18
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Komissarov AA, Rahman N, Lee YCG, Florova G, Shetty S, Idell R, Ikebe M, Das K, Tucker TA, Idell S. Fibrin turnover and pleural organization: bench to bedside. Am J Physiol Lung Cell Mol Physiol 2018; 314:L757-L768. [PMID: 29345198 DOI: 10.1152/ajplung.00501.2017] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Recent studies have shed new light on the role of the fibrinolytic system in the pathogenesis of pleural organization, including the mechanisms by which the system regulates mesenchymal transition of mesothelial cells and how that process affects outcomes of pleural injury. The key contribution of plasminogen activator inhibitor-1 to the outcomes of pleural injury is now better understood as is its role in the regulation of intrapleural fibrinolytic therapy. In addition, the mechanisms by which fibrinolysins are processed after intrapleural administration have now been elucidated, informing new candidate diagnostics and therapeutics for pleural loculation and failed drainage. The emergence of new potential interventional targets offers the potential for the development of new and more effective therapeutic candidates.
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Affiliation(s)
- Andrey A Komissarov
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler , Tyler, Texas
| | - Najib Rahman
- Oxford Pleural Unit and Oxford Respiratory Trials Unit, University of Oxford, Churchill Hospital; and National Institute of Health Research Biomedical Research Centre , Oxford , United Kingdom
| | - Y C Gary Lee
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital; Pleural Medicine Unit, Institute for Respiratory Health , Perth ; School of Medicine and Pharmacology, University of Western Australia , Perth , Australia
| | - Galina Florova
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler , Tyler, Texas
| | - Sreerama Shetty
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler , Tyler, Texas
| | - Richard Idell
- Department of Behavioral Health, Child and Adolescent Psychiatry, The University of Texas Health Science Center at Tyler , Tyler, Texas
| | - Mitsuo Ikebe
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler , Tyler, Texas
| | - Kumuda Das
- Department of Translational and Vascular Biology, The University of Texas Health Science Center at Tyler , Tyler, Texas
| | - Torry A Tucker
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler , Tyler, Texas
| | - Steven Idell
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler , Tyler, Texas
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19
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Popowicz N, Idell S, Lee YG. Pathogenesis of pleural infection: A complex warfare. Respirology 2017; 23:8-9. [DOI: 10.1111/resp.13171] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Accepted: 08/22/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Natalia Popowicz
- Department of Respiratory Medicine; Sir Charles Gairdner Hospital; Perth WA Australia
- Pleural Medicine Unit; Institute for Respiratory Health; Perth WA Australia
- School of Medicine and Pharmacology; University of Western Australia; Perth WA Australia
| | - Steven Idell
- Department of Cellular and Molecular Biology and Texas Lung Injury Institute; The University of Texas Health Science Center at Tyler; Tyler TX USA
| | - Y.C. Gary Lee
- Department of Respiratory Medicine; Sir Charles Gairdner Hospital; Perth WA Australia
- Pleural Medicine Unit; Institute for Respiratory Health; Perth WA Australia
- School of Medicine and Pharmacology; University of Western Australia; Perth WA Australia
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20
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Florova G, Azghani AO, Karandashova S, Schaefer C, Yarovoi SV, Declerck PJ, Cines DB, Idell S, Komissarov AA. Targeting plasminogen activator inhibitor-1 in tetracycline-induced pleural injury in rabbits. Am J Physiol Lung Cell Mol Physiol 2017; 314:L54-L68. [PMID: 28860148 DOI: 10.1152/ajplung.00579.2016] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Elevated active plasminogen activator inhibitor-1 (PAI-1) has an adverse effect on the outcomes of intrapleural fibrinolytic therapy (IPFT) in tetracycline-induced pleural injury in rabbits. To enhance IPFT with prourokinase (scuPA), two mechanistically distinct approaches to targeting PAI-1 were tested: slowing its reaction with urokinase (uPA) and monoclonal antibody (mAb)-mediated PAI-1 inactivation. Removing positively charged residues at the "PAI-1 docking site" (179RHRGGS184→179AAAAAA184) of uPA results in a 60-fold decrease in the rate of inhibition by PAI-1. Mutant prourokinase (0.0625-0.5 mg/kg; n = 12) showed efficacy comparable to wild-type scuPA and did not change IPFT outcomes ( P > 0.05). Notably, the rate of PAI-1-independent intrapleural inactivation of mutant uPA was 2 times higher ( P < 0.05) than that of the wild-type enzyme. Trapping PAI-1 in a "molecular sandwich"-type complex with catalytically inactive two-chain urokinase with Ser195Ala substitution (S195A-tcuPA; 0.1 and 0.5 mg/kg) did not improve the efficacy of IPFT with scuPA (0.0625-0.5 mg/kg; n = 11). IPFT failed in the presence of MA-56A7C10 (0.5 mg/kg; n = 2), which forms a stable intrapleural molecular sandwich complex, allowing active PAI-1 to accumulate by blocking its transition to a latent form. In contrast, inactivation of PAI-1 by accelerating the active-to-latent transition mediated by mAb MA-33B8 (0.5 mg/kg; n = 2) improved the efficacy of IPFT with scuPA (0.25 mg/kg). Thus, under conditions of slow (4-8 h) fibrinolysis in tetracycline-induced pleural injury in rabbits, only the inactivation of PAI-1, but not a decrease in the rate of its reaction with uPA, enhances IPFT. Therefore the rate of fibrinolysis, which varies in different pathologic states, could affect the selection of PAI-1 inhibitors to enhance fibrinolytic therapy.
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Affiliation(s)
- Galina Florova
- Texas Lung Injury Institute, The University of Texas Health Science Center at Tyler , Tyler, Texas
| | - Ali O Azghani
- Department of Biology, The University of Texas at Tyler, Tyler, Texas
| | - Sophia Karandashova
- Texas Lung Injury Institute, The University of Texas Health Science Center at Tyler , Tyler, Texas
| | - Chris Schaefer
- Texas Lung Injury Institute, The University of Texas Health Science Center at Tyler , Tyler, Texas
| | - Serge V Yarovoi
- Department of Pathology and Laboratory Medicine, Perelman-University of Pennsylvania School of Medicine , Philadelphia, Pennsylvania
| | - Paul J Declerck
- Laboratory for Therapeutic and Diagnostic Antibodies, Faculty of Pharmaceutical Sciences, Katholieke Universiteit Leuven, Leuven , Belgium
| | - Douglas B Cines
- Department of Pathology and Laboratory Medicine, Perelman-University of Pennsylvania School of Medicine , Philadelphia, Pennsylvania
| | - Steven Idell
- Texas Lung Injury Institute, The University of Texas Health Science Center at Tyler , Tyler, Texas
| | - Andrey A Komissarov
- Texas Lung Injury Institute, The University of Texas Health Science Center at Tyler , Tyler, Texas
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21
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Precision-guided, Personalized Intrapleural Fibrinolytic Therapy for Empyema and Complicated Parapneumonic Pleural Effusions: The Case for the Fibrinolytic Potential. ACTA ACUST UNITED AC 2017; 24:163-169. [PMID: 29081644 DOI: 10.1097/cpm.0000000000000216] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Complicated pleural effusions and empyema with loculation and failed drainage are common clinical problems. In adults, intrapleural fibrinolytic therapy is commonly used with variable results and therapy remains empiric. Despite the intrapleural use of various plasminogen activators; fibrinolysins, for about sixty years, there is no clear consensus about which agent is most effective. Emerging evidence demonstrates that intrapleural administration of plasminogen activators is subject to rapid inhibition by plasminogen activator inhibitor-1 and that processing of fibrinolysins is importantly influenced by other factors including the levels and quality of pleural fluid DNA. Current therapy for loculation that accompanies pleural infections also includes surgery, which is invasive and for which patient selection can be problematic. Most of the clinical literature published to date has used flat dosing of intrapleural fibrinolytic therapy in all subjects but little is known about how that strategy influences the processing of the administered fibrinolysin or how this influences outcomes. We developed a new test of pleural fluids ex vivo, which is called the Fibrinolytic Potential or FP, in which a dose of a fibrinolysin is added to pleural fluids ex vivo after which the fibrinolytic activity is measured and normalized to baseline levels. Testing in preclinical and clinical empyema fluids reveals a wide range of responses, indicating that individual patients will likely respond differently to flat dosing of fibrinolysins. The test remains under development but is envisioned as a guide for dosing of these agents, representing a novel candidate approach to personalization of intrapleural fibrinolytic therapy.
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22
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Lee YCG, Idell S, Stathopoulos GT. Translational Research in Pleural Infection and Beyond. Chest 2016; 150:1361-1370. [DOI: 10.1016/j.chest.2016.07.030] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 07/10/2016] [Accepted: 07/30/2016] [Indexed: 12/17/2022] Open
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23
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Komissarov AA, Florova G, Azghani AO, Buchanan A, Boren J, Allen T, Rahman NM, Koenig K, Chamiso M, Karandashova S, Henry J, Idell S. Dose dependency of outcomes of intrapleural fibrinolytic therapy in new rabbit empyema models. Am J Physiol Lung Cell Mol Physiol 2016; 311:L389-99. [PMID: 27343192 DOI: 10.1152/ajplung.00171.2016] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 06/18/2016] [Indexed: 01/22/2023] Open
Abstract
The incidence of empyema (EMP) is increasing worldwide; EMP generally occurs with pleural loculation and impaired drainage is often treated with intrapleural fibrinolytic therapy (IPFT) or surgery. A number of IPFT options are used clinically with empiric dosing and variable outcomes in adults. To evaluate mechanisms governing intrapleural fibrinolysis and disease outcomes, models of Pasteurella multocida and Streptococcus pneumoniae were generated in rabbits and the animals were treated with either human tissue (tPA) plasminogen activator or prourokinase (scuPA). Rabbit EMP was characterized by the development of pleural adhesions detectable by chest ultrasonography and fibrinous coating of the pleura. Similar to human EMP, rabbits with EMP accumulated sizable, 20- to 40-ml fibrinopurulent pleural effusions associated with extensive intrapleural organization, significantly increased pleural thickness, suppression of fibrinolytic and plasminogen-activating activities, and accumulation of high levels of plasminogen activator inhibitor 1, plasminogen, and extracellular DNA. IPFT with tPA (0.145 mg/kg) or scuPA (0.5 mg/kg) was ineffective in rabbit EMP (n = 9 and 3 for P. multocida and S. pneumoniae, respectively); 2 mg/kg tPA or scuPA IPFT (n = 5) effectively cleared S. pneumoniae-induced EMP collections in 24 h with no bleeding observed. Although intrapleural fibrinolytic activity for up to 40 min after IPFT was similar for effective and ineffective doses of fibrinolysin, it was lower for tPA than for scuPA treatments. These results demonstrate similarities between rabbit and human EMP, the importance of pleural fluid PAI-1 activity, and levels of plasminogen in the regulation of intrapleural fibrinolysis and illustrate the dose dependency of IPFT outcomes in EMP.
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Affiliation(s)
- Andrey A Komissarov
- Department of Cellular and Molecular Biology of the University of Texas Health Science Center at Tyler, Tyler, Texas;
| | - Galina Florova
- Department of Cellular and Molecular Biology of the University of Texas Health Science Center at Tyler, Tyler, Texas
| | | | - Ann Buchanan
- Department of Cellular and Molecular Biology of the University of Texas Health Science Center at Tyler, Tyler, Texas
| | - Jake Boren
- Department of Cellular and Molecular Biology of the University of Texas Health Science Center at Tyler, Tyler, Texas
| | - Timothy Allen
- Department of Pathology, The University of Texas Medical Branch, Galveston, Texas; and
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals, National Health Service Trust, Oxford, UK
| | - Kathleen Koenig
- Department of Cellular and Molecular Biology of the University of Texas Health Science Center at Tyler, Tyler, Texas
| | - Mignote Chamiso
- Department of Cellular and Molecular Biology of the University of Texas Health Science Center at Tyler, Tyler, Texas
| | - Sophia Karandashova
- Department of Cellular and Molecular Biology of the University of Texas Health Science Center at Tyler, Tyler, Texas
| | - James Henry
- Department of Cellular and Molecular Biology of the University of Texas Health Science Center at Tyler, Tyler, Texas
| | - Steven Idell
- Department of Cellular and Molecular Biology of the University of Texas Health Science Center at Tyler, Tyler, Texas
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24
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Corcoran JP, Wrightson JM, Belcher E, DeCamp MM, Feller-Kopman D, Rahman NM. Pleural infection: past, present, and future directions. THE LANCET RESPIRATORY MEDICINE 2016; 3:563-77. [PMID: 26170076 DOI: 10.1016/s2213-2600(15)00185-x] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 04/13/2015] [Accepted: 05/05/2015] [Indexed: 02/09/2023]
Abstract
Pleural space infections are increasing in incidence and continue to have high associated morbidity, mortality, and need for invasive treatments such as thoracic surgery. The mechanisms of progression from a non-infected, pneumonia-related effusion to a confirmed pleural infection have been well described in the scientific literature, but the route by which pathogenic organisms access the pleural space is poorly understood. Data suggests that not all pleural infections can be related to lung parenchymal infection. Studies examining the microbiological profile of pleural infection inform antibiotic choice and can help to delineate the source and pathogenesis of infection. The development of radiological methods and use of clinical indices to predict which patients with pleural infection will have a poor outcome, as well as inform patient selection for more invasive treatments, is particularly important. Randomised clinical trial and case series data have shown that the combination of an intrapleural tissue plasminogen activator and deoxyribonuclease therapy can potentially improve outcomes, but the use of this treatment as compared with surgical options has not been precisely defined, particularly in terms of when and in which patients it should be used.
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Affiliation(s)
- John P Corcoran
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK; University of Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, UK
| | - John M Wrightson
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK; University of Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, UK; NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Elizabeth Belcher
- Department of Cardiothoracic Surgery, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Malcolm M DeCamp
- Division of Thoracic Surgery, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - David Feller-Kopman
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK; University of Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, UK; NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK.
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25
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Florova G, Azghani A, Karandashova S, Schaefer C, Koenig K, Stewart-Evans K, Declerck PJ, Idell S, Komissarov AA. Targeting of plasminogen activator inhibitor 1 improves fibrinolytic therapy for tetracycline-induced pleural injury in rabbits. Am J Respir Cell Mol Biol 2016; 52:429-37. [PMID: 25140386 DOI: 10.1165/rcmb.2014-0168oc] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Endogenous active plasminogen activator inhibitor 1 (PAI-1) was targeted in vivo with monoclonal antibodies (mAbs) that redirect its reaction with proteinases to the substrate branch. mAbs were used as an adjunct to prourokinase (single-chain [sc] urokinase [uPA]) intrapleural fibrinolytic therapy (IPFT) of tetracycline-induced pleural injury in rabbits. Outcomes of scuPA IPFT (0.25 or 0.0625 mg/kg) with 0.5 mg/kg of mouse IgG or mAbs (MA-33H1F7 and MA-8H9D4) were assessed at 24 hours. Pleural fluid (PF) was collected at 0, 10, 20, and 40 minutes and 24 hours after IPFT and analyzed for plasminogen activating (PA), uPA, fibrinolytic activities, levels of total plasmin/plasminogen, α-macroglobulin (αM), mAbs/IgG antigens, free active uPA, and αM/uPA complexes. Anti-PAI-1 mAbs, but not mouse IgG, delivered with an eightfold reduction in the minimal effective dose of scuPA (from 0.5 to 0.0625 mg/kg), improved the outcome of IPFT (P < 0.05). mAbs and IgG were detectable in PFs at 24 hours. Compared with identical doses of scuPA alone or with IgG, treatment with scuPA and anti-PAI-1 mAbs generated higher PF uPA amidolytic and PA activities, faster formation of αM/uPA complexes, and slower uPA inactivation. However, PAI-1 targeting did not significantly affect intrapleural fibrinolytic activity or levels of total plasmin/plasminogen and αM antigens. Targeting PAI-1 did not induce bleeding, and rendered otherwise ineffective doses of scuPA able to improve outcomes in tetracycline-induced pleural injury. PAI-1-neutralizing mAbs improved IPFT by increasing the durability of intrapleural PA activity. These results suggest a novel, well-tolerated IPFT strategy that is tractable for clinical development.
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Affiliation(s)
- Galina Florova
- 1 Texas Lung Injury Institute of the University of Texas Health Science Center at Tyler, Tyler, Texas
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26
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Komissarov AA, Florova G, Azghani AO, Buchanan A, Bradley WM, Schaefer C, Koenig K, Idell S. The time course of resolution of adhesions during fibrinolytic therapy in tetracycline-induced pleural injury in rabbits. Am J Physiol Lung Cell Mol Physiol 2015; 309:L562-72. [PMID: 26163512 DOI: 10.1152/ajplung.00136.2015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 07/02/2015] [Indexed: 11/22/2022] Open
Abstract
The time required for the effective clearance of pleural adhesions/organization after intrapleural fibrinolytic therapy (IPFT) is unknown. Chest ultrasonography and computed tomography (CT) were used to assess the efficacy of IPFT in a rabbit model of tetracycline-induced pleural injury, treated with single-chain (sc) urokinase plasminogen activators (scuPAs) or tissue PAs (sctPA). IPFT with sctPA (0.145 mg/kg; n = 10) and scuPA (0.5 mg/kg; n = 12) was monitored by serial ultrasonography alone (n = 12) or alongside CT scanning (n = 10). IPFT efficacy was assessed with gross lung injury scores (GLIS) and ultrasonography scores (USS). Pleural fluids withdrawn at 0-240 min and 24 h after IPFT were assayed for PA and fibrinolytic activities, α-macroglobulin/fibrinolysin complexes, and active PA inhibitor 1 (PAI-1). scuPA and sctPA generated comparable steady-state fibrinolytic activities by 20 min. PA activity in the scuPA group decreased slower than the sctPA group (kobs = 0.016 and 0.042 min(-1)). Significant amounts of bioactive uPA/α-macroglobulin (but not tPA; P < 0.05) complexes accumulated at 0-40 min after IPFT. Despite the differences in intrapleural processing, IPFT with either fibrinolysin was effective (GLIS ≤ 10) in animals imaged with ultrasonography only. USS correlated well with postmortem GLIS (r(2) = 0.85) and confirmed relatively slow intrapleural fibrinolysis after IPFT, which coincided with effective clearance of adhesions/organization at 4-8 h. CT scanning was associated with less effective (GLIS > 10) IPFT and higher levels of active PAI-1 at 24 h following therapy. We concluded that intrapleural fibrinolysis in tetracycline-induced pleural injury in rabbits is relatively slow (4-8 h). In CT-scanned animals, elevated PAI-1 activity (possibly radiation induced) reduced the efficacy of IPFT, buttressing the major impact of active PAI-1 on IPFT outcomes.
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Affiliation(s)
- Andrey A Komissarov
- The Department of Cellular and Molecular Biology and the Texas Lung Injury Institute, The University of Texas Health Science Center at Tyler (UTHSCT), Tyler, Texas;
| | - Galina Florova
- The Department of Cellular and Molecular Biology and the Texas Lung Injury Institute, The University of Texas Health Science Center at Tyler (UTHSCT), Tyler, Texas
| | - Ali O Azghani
- The Department of Biology at the University of Texas at Tyler, Tyler, Texas
| | - Ann Buchanan
- UTHSCT Vivarium, The University of Texas Health Science Center at Tyler, Tyler, Texas
| | - William M Bradley
- The Department of Radiation Oncology, The University of Texas Health Science Center at Tyler, Tyler, Texas
| | - Chris Schaefer
- The Department of Cellular and Molecular Biology and the Texas Lung Injury Institute, The University of Texas Health Science Center at Tyler (UTHSCT), Tyler, Texas
| | - Kathleen Koenig
- The Department of Cellular and Molecular Biology and the Texas Lung Injury Institute, The University of Texas Health Science Center at Tyler (UTHSCT), Tyler, Texas
| | - Steven Idell
- The Department of Cellular and Molecular Biology and the Texas Lung Injury Institute, The University of Texas Health Science Center at Tyler (UTHSCT), Tyler, Texas
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27
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Functional stability of plasminogen activator inhibitor-1. ScientificWorldJournal 2014; 2014:858293. [PMID: 25386620 PMCID: PMC4214104 DOI: 10.1155/2014/858293] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 09/17/2014] [Indexed: 12/23/2022] Open
Abstract
Plasminogen activator inhibitor-1 (PAI-1) is the main inhibitor of plasminogen activators, such as tissue-type plasminogen activator (t-PA) and urokinase-type plasminogen activator (u-PA), and a major regulator of the fibrinolytic system. PAI-1 plays a pivotal role in acute thrombotic events such as deep vein thrombosis (DVT) and myocardial infarction (MI). The biological effects of PAI-1 extend far beyond thrombosis including its critical role in fibrotic disorders, atherosclerosis, renal and pulmonary fibrosis, type-2 diabetes, and cancer. The conversion of PAI-1 from the active to the latent conformation appears to be unique among serpins in that it occurs spontaneously at a relatively rapid rate. Latency transition is believed to represent a regulatory mechanism, reducing the risk of thrombosis from a prolonged antifibrinolytic action of PAI-1. Thus, relying solely on plasma concentrations of PAI-1 without assessing its function may be misleading in interpreting the role of PAI-1 in many complex diseases. Environmental conditions, interaction with other proteins, mutations, and glycosylation are the main factors that have a significant impact on the stability of the PAI-1 structure. This review provides an overview on the current knowledge on PAI-1 especially importance of PAI-1 level and stability and highlights the potential use of PAI-1 inhibitors for treating cardiovascular disease.
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Tucker TA, Jeffers A, Alvarez A, Owens S, Koenig K, Quaid B, Komissarov AA, Florova G, Kothari H, Pendurthi U, Mohan Rao LV, Idell S. Plasminogen activator inhibitor-1 deficiency augments visceral mesothelial organization, intrapleural coagulation, and lung restriction in mice with carbon black/bleomycin-induced pleural injury. Am J Respir Cell Mol Biol 2014; 50:316-27. [PMID: 24024554 DOI: 10.1165/rcmb.2013-0300oc] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Local derangements of fibrin turnover and plasminogen activator inhibitor (PAI)-1 have been implicated in the pathogenesis of pleural injury. However, their role in the control of pleural organization has been unclear. We found that a C57Bl/6j mouse model of carbon black/bleomycin (CBB) injury demonstrates pleural organization resulting in pleural rind formation (14 d). In transgenic mice overexpressing human PAI-1, intrapleural fibrin deposition was increased, but visceral pleural thickness, lung volumes, and compliance were comparable to wild type. CBB injury in PAI-1(-/-) mice significantly increased visceral pleural thickness (P < 0.001), elastance (P < 0.05), and total lung resistance (P < 0.05), while decreasing lung compliance (P < 0.01) and lung volumes (P < 0.05). Collagen, α-smooth muscle actin, and tissue factor were increased in the thickened visceral pleura of PAI-1(-/-) mice. Colocalization of α-smooth muscle actin and calretinin within pleural mesothelial cells was increased in CBB-injured PAI-1(-/-) mice. Thrombin, factor Xa, plasmin, and urokinase induced mesothelial-mesenchymal transition, tissue factor expression, and activity in primary human pleural mesothelial cells. In PAI-1(-/-) mice, D-dimer and thrombin-antithrombin complex concentrations were increased in pleural lavage fluids. The results demonstrate that PAI-1 regulates CBB-induced pleural injury severity via unrestricted fibrinolysis and cross-talk with coagulation proteases. Whereas overexpression of PAI-1 augments intrapleural fibrin deposition, PAI-1 deficiency promotes profibrogenic alterations of the mesothelium that exacerbate pleural organization and lung restriction.
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29
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Komissarov AA, Florova G, Azghani A, Karandashova S, Kurdowska AK, Idell S. Active α-macroglobulin is a reservoir for urokinase after fibrinolytic therapy in rabbits with tetracycline-induced pleural injury and in human pleural fluids. Am J Physiol Lung Cell Mol Physiol 2013; 305:L682-92. [PMID: 23997178 DOI: 10.1152/ajplung.00102.2013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Intrapleural processing of prourokinase (scuPA) in tetracycline (TCN)-induced pleural injury in rabbits was evaluated to better understand the mechanisms governing successful scuPA-based intrapleural fibrinolytic therapy (IPFT), capable of clearing pleural adhesions in this model. Pleural fluid (PF) was withdrawn 0-80 min and 24 h after IPFT with scuPA (0-0.5 mg/kg), and activities of free urokinase (uPA), plasminogen activator inhibitor-1 (PAI-1), and uPA complexed with α-macroglobulin (αM) were assessed. Similar analyses were performed using PFs from patients with empyema, parapneumonic, and malignant pleural effusions. The peak of uPA activity (5-40 min) reciprocally correlated with the dose of intrapleural scuPA. Endogenous active PAI-1 (10-20 nM) decreased the rate of intrapleural scuPA activation. The slow step of intrapleural inactivation of free uPA (t1/2(β) = 40 ± 10 min) was dose independent and 6.7-fold slower than in blood. Up to 260 ± 70 nM of αM/uPA formed in vivo [second order association rate (kass) = 580 ± 60 M(-1)·s(-1)]. αM/uPA and products of its degradation contributed to durable intrapleural plasminogen activation up to 24 h after IPFT. Active PAI-1, active α2M, and α2M/uPA found in empyema, pneumonia, and malignant PFs demonstrate the capacity to support similar mechanisms in humans. Intrapleural scuPA processing differs from that in the bloodstream and includes 1) dose-dependent control of scuPA activation by endogenous active PAI-1; 2) two-step inactivation of free uPA with simultaneous formation of αM/uPA; and 3) slow intrapleural degradation of αM/uPA releasing active free uPA. This mechanism offers potential clinically relevant advantages that may enhance the bioavailability of intrapleural scuPA and may mitigate the risk of bleeding complications.
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Affiliation(s)
- Andrey A Komissarov
- The Univ. of Texas Health Science Center at Tyler, 11937 US Highway 271, Lab C-6, Tyler, TX 75708. or
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30
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Florova G, Karandashova S, Declerck PJ, Idell S, Komissarov AA. Remarkable stabilization of plasminogen activator inhibitor 1 in a "molecular sandwich" complex. Biochemistry 2013; 52:4697-709. [PMID: 23734661 DOI: 10.1021/bi400470s] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Plasminogen activator inhibitor 1 (PAI-1) levels are elevated in a number of life-threatening conditions and often correlate with unfavorable outcomes. Spontaneous inactivation due to active to latent transition limits PAI-1 activity in vivo. While endogenous vitronectin (Vn) stabilizes PAI-1 by 1.5-2.0-fold, further stabilization occurs in a "molecular sandwich" complex (MSC) in which a ligand that restricts the exposed reactive center loop is bound to PAI-1/Vn. The effects of S195A two-chain urokinase (tcuPA) and Vn on inactivation of wild-type (wt) glycosylated (Gl-PAI-1), nonglycosylated (rPAI-1), and nonglycosylated Q123K PAI-1 (lacks Vn binding) forms were studied. S195A tcuPA decreased the rate constant (kL) for spontaneous inactivation at 37 °C for rPAI-1, Q123K, and Gl-PAI-1 by 6.7-, 3.4-, and 7.8-fold, respectively, and both S195A tcuPA and Vn by 66.7-, 5.5-, and 103.3-fold, respectively. Analysis of the temperature dependences of kL revealed a synergistic increase in the Gibbs free activation energy for spontaneous inactivation of wt Gl-PAI-1 and rPAI-1 in MSC from 99.8 and 96.1 to 111.3 and 107.0 kJ/mol, respectively, due to an increase in the activation enthalpy and a decrease in the activation entropy. Anti-PAI-1 monoclonal antibodies (mAbs) competing with proteinase also stabilize PAI-1/Vn. The rate of inhibition of target proteinases by MSCs, with a stoichiometry close to unity, was limited by the dissociation (k = 10(-4) to 10(-3) s(-1)) of S195A tcuPA or mAb. The stabilization of PAI-1 in MSCs in vivo may potentiate uncontrolled thrombosis or extravascular fibrin deposition, suggesting a new paradigm for using PAI-1 inhibitors and novel potential targets for therapy.
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Affiliation(s)
- Galina Florova
- Texas Lung Injury Institute, University of Texas Health Science Center at Tyler , 11937 U.S. Highway 271, Tyler, Texas 75708-3154, United States
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