Role of complement activation in a model of adult respiratory distress syndrome

Complement and COVID-19: Three years on, what we know, what we don't know, and what we ought to know

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus was identified in China in 2019 as the causative agent of COVID-19, and quickly spread throughout the world, causing over 7 million deaths, of which 2 million occurred prior to the introduction of the first vaccine. In the following discussion, while recognising that complement is just one of many players in COVID-19, we focus on the relationship between complement and COVID-19 disease, with limited digression into directly-related areas such as the relationship between complement, kinin release, and coagulation. Prior to the 2019 COVID-19 outbreak, an important role for complement in coronavirus diseases had been established. Subsequently, multiple investigations of patients with COVID-19 confirmed that complement dysregulation is likely to be a major driver of disease pathology, in some, if not all, patients. These data fuelled evaluation of many complement-directed therapeutic agents in small patient cohorts, with claims of significant beneficial effect. As yet, these early results have not been reflected in larger clinical trials, posing questions such as who to treat, appropriate time to treat, duration of treatment, and optimal target for treatment. While significant control of the pandemic has been achieved through a global scientific and medical effort to comprehend the etiology of the disease, through extensive SARS-CoV-2 testing and quarantine measures, through vaccine development, and through improved therapy, possibly aided by attenuation of the dominant strains, it is not yet over. In this review, we summarise complement-relevant literature, emphasise its main conclusions, and formulate a hypothesis for complement involvement in COVID-19. Based on this we make suggestions as to how any future outbreak might be better managed in order to minimise impact on patients.

Complement activation in COVID-19 and targeted therapeutic options: A scoping review

Increasing evidence suggests that activation of the complement system plays a key role in the pathogenesis and disease severity of Coronavirus disease 2019 (COVID-19). We used a systematic approach to create an overview of complement activation in COVID-19 based on histopathological, preclinical, multiomics, observational and clinical interventional studies. A total of 1801 articles from PubMed, EMBASE and Cochrane was screened of which 157 articles were included in this scoping review. Histopathological, preclinical, multiomics and observational studies showed apparent complement activation through all three complement pathways and a correlation with disease severity and mortality. The complement system was targeted at different levels in COVID-19, of which C5 and C5a inhibition seem most promising. Adequately powered, double blind RCTs are necessary in order to further investigate the effect of targeting the complement system in COVID-19.

Mechanisms of SARS-CoV-2-induced lung vascular disease: potential role of complement

The outbreak of COVID-19 disease, caused by SARS-CoV-2 beta-coronovirus, urges a focused search for the underlying mechanisms and treatment options. The lung is the major target organ of COVID-19, wherein the primary cause of mortality is hypoxic respiratory failure, resulting from acute respiratory distress syndrome, with severe hypoxemia, often requiring assisted ventilation. While similar in some ways to acute respiratory distress syndrome secondary to other causes, lungs of some patients dying with COVID-19 exhibit distinct features of vascular involvement, including severe endothelial injury and cell death via apoptosis and/or pyroptosis, widespread capillary inflammation, and thrombosis. Furthermore, the pulmonary pathology of COVID-19 is characterized by focal inflammatory cell infiltration, impeding alveolar gas exchange resulting in areas of local tissue hypoxia, consistent with potential amplification of COVID-19 pathogenicity by hypoxia. Vascular endothelial cells play essential roles in both innate and adaptive immune responses, and are considered to be "conditional innate immune cells" centrally participating in various inflammatory, immune pathologies. Activated endothelial cells produce cytokines/chemokines, dynamically recruit and activate inflammatory cells and platelets, and centrally participate in pro-thrombotic processes (thrombotic microangiopathies). Initial reports presented pathological findings of localized direct infection of vascular endothelial cells with SARS-CoV-2, yet emerging evidence does not support direct infection of endothelial or other vascular wall cell and thus widespread endothelial cell dysfunction and inflammation may be better explained as secondary responses to epithelial cell infection and inflammation. Endothelial cells are also actively engaged in a cross-talk with the complement system, the essential arm of innate immunity. Recent reports present evidence for complement deposition in SARS-CoV-2-damaged lung microcirculation, further strengthening the idea that, in severe cases of COVID-19, complement activation is an essential player, generating destructive hemorrhagic, capillaritis-like tissue damage, clotting, and hyperinflammation. Thus, complement-targeted therapies are actively in development. This review is intended to explore in detail these ideas.

Complement Activation Contributes to Severe Acute Respiratory Syndrome Coronavirus Pathogenesis

The complement system is a critical part of host defense to many bacterial, viral, and fungal infections. It works alongside pattern recognition receptors to stimulate host defense systems in advance of activation of the adaptive immune response. In this study, we directly test the role of complement in SARS-CoV pathogenesis using a mouse model and show that respiratory disease is significantly reduced in the absence of complement even though viral load is unchanged. Complement-deficient mice have reduced neutrophilia in their lungs and reduced systemic inflammation, consistent with the observation that SARS-CoV pathogenesis is an immune-driven disease. These data suggest that inhibition of complement signaling might be an effective treatment option following coronavirus infection.

Acute respiratory distress syndrome (ARDS) is immune-driven pathologies that are observed in severe cases of severe acute respiratory syndrome coronavirus (SARS-CoV) infection. SARS-CoV emerged in 2002 to 2003 and led to a global outbreak of SARS. As with the outcome of human infection, intranasal infection of C57BL/6J mice with mouse-adapted SARS-CoV results in high-titer virus replication within the lung, induction of inflammatory cytokines and chemokines, and immune cell infiltration within the lung. Using this model, we investigated the role of the complement system during SARS-CoV infection. We observed activation of the complement cascade in the lung as early as day 1 following SARS-CoV infection. To test whether this activation contributed to protective or pathologic outcomes, we utilized mice deficient in C3 (C3^–/–), the central component of the complement system. Relative to C57BL/6J control mice, SARS-CoV-infected C3^–/– mice exhibited significantly less weight loss and less respiratory dysfunction despite equivalent viral loads in the lung. Significantly fewer neutrophils and inflammatory monocytes were present in the lungs of C3^–/– mice than in C56BL/6J controls, and subsequent studies revealed reduced lung pathology and lower cytokine and chemokine levels in both the lungs and the sera of C3^–/– mice than in controls. These studies identify the complement system as an important host mediator of SARS-CoV-induced disease and suggest that complement activation regulates a systemic proinflammatory response to SARS-CoV infection. Furthermore, these data suggest that SARS-CoV-mediated disease is largely immune driven and that inhibiting complement signaling after SARS-CoV infection might function as an effective immune therapeutic.

Janus face of complement-driven neutrophil activation during sepsis

During local and systemic inflammation, the complement system and neutrophil granulocytes are activated not only by pathogens, but also by released endogenous danger signals. It is recognized increasingly that complement-mediated neutrophil activation plays an ambivalent role in sepsis pathophysiology. According to the current definition, the onset of organ dysfunction is a hallmark of sepsis. The preceding organ damage can be caused by excessive complement activation and neutrophil actions against the host, resulting in bystander injury of healthy tissue. However, in contrast, persistent and overwhelming inflammation also leads to a reduction in neutrophil responsiveness as well as complement components and thus may render patients at enhanced risk of spreading infection. This review provides an overview on the molecular and cellular processes that link complement with the two-faced functional alterations of neutrophils in sepsis. Finally, we describe novel tools to modulate this interplay beneficially in order to improve outcome.

The role of host and microbial factors in the pathogenesis of pneumococcal bacteraemia arising from a single bacterial cell bottleneck

The pathogenesis of bacteraemia after challenge with one million pneumococci of three isogenic variants was investigated. Sequential analyses of blood samples indicated that most episodes of bacteraemia were monoclonal events providing compelling evidence for a single bacterial cell bottleneck at the origin of invasive disease. With respect to host determinants, results identified novel properties of splenic macrophages and a role for neutrophils in early clearance of pneumococci. Concerning microbial factors, whole genome sequencing provided genetic evidence for the clonal origin of the bacteraemia and identified SNPs in distinct sub-units of F0/F1 ATPase in the majority of the ex vivo isolates. When compared to parental organisms of the inoculum, ex-vivo pneumococci with mutant alleles of the F0/F1 ATPase had acquired the capacity to grow at low pH at the cost of the capacity to grow at high pH. Although founded by a single cell, the genotypes of pneumococci in septicaemic mice indicate strong selective pressure for fitness, emphasising the within-host complexity of the pathogenesis of invasive disease.

Complement activated granulocytes can cause autologous tissue destruction in man

Activation of polymorphonuclear granulocytes (PMNs) by C5a is thought to be important in the pathogenesis of multiple organ failure during sepsis and after trauma. In our experiment exposure of human PMNs to autologous zymosan activated plasma (ZAP) leads to a rapid increase in chemiluminescence. Heating the ZAP at 56^°C for 30 min did not alter the changes, while untreated plasma induced only baseline activity. The respiratory burst could be completely abolished by decomplementation and preincubation with rabbit antihuman C5a antibodies. Observation of human omentum using electron microscopy showed intravascular aggregation of PMNs, with capillary thrombosis and diapedesis of the cells through endothelial junctions 90 s after exposure to ZAP. PMNs caused disruption of connections between the mesothelial cells. After 4 min the mesothelium was completely destroyed, and connective tissue and fat cells exposed. Native plasma and minimum essential medium did not induce any morphological changes. These data support the concept that C5a activated PMNs can cause endothelial and mesothelial damage in man. Even though a causal relationship between anaphylatoxins and organ failure cannot be proved by these experiments C5a seems to be an important mediator in the pathogenesis of changes induced by severe sepsis and trauma in man.

Response of blood cells to hemorrahagic shock in the dog

Response of canine blood cells to hemorrhagic shock was examined using ultrastructural and ultracytochemical techniques. Blood platelets responded to hemorrhagic shock with a decrease of alpha-granules and the simultaneous development of the platelet canalicular system which opened to the extracellular environment, and platelets having no or few granules appeared at the end of the experimental period. Neutrophil leukocytes also responded to shock, with the decrease of both specific and azurophil granules. Eosinophil leukocytes were morphologically unchanged before and after shock but basophils were not found in the present observations. The effects of dexamethasone and phenoxybenzamine on inhibition of blood cell degeneration during hemorrhagic shock were examined. These drugs were considerably effective to inhibit degeneration of blood cells.

Agarose plug instillation causes goblet cell metaplasia by activating EGF receptors in rat airways

We hypothesized that foreign bodies in airways cause inflammation leading to goblet cell metaplasia. Instilled agarose plugs lodged in the bronchi of pathogen-free rats caused a time-dependent increase in Alcian blue-periodic acid-Schiff staining that was detected within 24 h and markedly increased at 72 h. Control bronchi contained no pregoblet or goblet cells, but plugged bronchi contained many pregoblet and goblet cells and a decrease in nongranulated secretory cells. In situ hybridization showed no expression of MUC5AC in control airways, but plugged airways showed a marked expression. Control bronchi showed sparse staining for epidermal growth factor receptor (EGFR) protein, but plugged bronchi showed intense EGFR staining in the epithelium. Pretreatment with an EGFR tyrosine kinase inhibitor (BIBX1522) prevented Alcian blue-periodic acid-Schiff staining and MUC5AC gene expression in plugged bronchi. Pretreatment with tumor necrosis factor-alpha neutralizing antibody or pretreatment with cyclophosphamide abolished plug-induced EGFR protein expression and goblet cell metaplasia. Thus instillation of agarose plugs induces profound goblet cell metaplasia by causing EGFR expression and activation.

The effects of methylprednisolone on complement, immunoglobulins and pulmonary neutrophil sequestration during cardiopulmonary bypass

In this study, the authors administered high dose (30 mg/kg body weight i.v.) methylprednisolone before cardiopulmonary bypass to observe the effects on complement, immunoglobulins and pulmonary neutrophil sequestration. Fifty patients undergoing valve replacements were included in this study. Patients were divided into two groups: group I (20 patients) served as control and did not receive methylprednisolone, group II (30 patients) received methylprednisolone. Blood samples for complements (C3c and C4) were taken, before cardiopulmonary bypass, at 5, 10 and 30 min intervals from the end of cardiopulmonary bypass, after reversal of heparin with protamine infusion, and after skin closure. Blood samples for immunoglobulins were taken before cardiopulmonary bypass, 30 min after onset of cardiopulmonary bypass and after skin closure. After onset of cardiopulmonary bypass, all C3c and C4 levels decreased in both groups. There was a significant decrease in C4 levels at end of cardiopulmonary bypass and after protamine infusion in group I compared with group II (P < 0.05). C3c levels in group I decreased significantly compared with group II after 30 min of cardiopulmonary bypass and after protamine infusion (P < 0.05). All immunoglobulin (IgG, IgM, IgA) levels were decreased in both groups, but the decrease in IgG was statistically significant after skin closure in group I compared with group II (P < 0.05). Pulmonary neutrophil sequestration was higher in the control group compared with the methyl-prednisolone group (P < 0.05). In conclusion, methylprednisolone administration before cardiopulmonary bypass may prevent the harmful effects of complement activation, immunoglobulin denaturation and neutrophil sequestration in the pulmonary capillary system.

Possible involvement of protein kinase c inhibition in the reduction of phorbol ester-induced neutrophil aggregation by magnolol in the rat

The influence of the plant product magnolol on neutrophil aggregation has been investigated in the rat. Magnolol inhibited phorbol 12-myristate 13-acetate (PMA)-activated rat neutrophil aggregation in a concentration-dependent manner with an IC50 (concentration resulting in 50% inhibition) of 24.2 +/- 1.7 microM. Magnolol suppressed the enzyme activity of neutrophil cytosolic and rat brain protein kinase C (PKC) over the same range of concentrations at which it inhibited the aggregation. Magnolol did not affect PMA-induced cytosolic PKC-alpha and -delta membrane translocation or trypsin-treated rat-brain PKC activity, but attenuated [3H]phorbol 12,13-dibutyrate binding to neutrophil cytosolic PKC. These results suggest that the inhibition of PMA-induced rat neutrophil aggregation by magnolol is probably attributable, at least in part, to the direct suppression of PKC activity through blockade of the regulatory region of PKC.

Effect of complement inhibition with soluble complement receptor 1 on pig allotransplant lung function

BACKGROUND

Lung dysfunction after transplantation continues to be a significant clinical problem. Soluble complement receptor 1 (sCR1) is a potent inhibitor of complement activation. We evaluated the inhibitory effect of sCR1 on complement activation and reperfusion injury in pig lung allografts.

METHODS

In a randomized and blinded study, left lung transplantation was performed in 13 pigs. Donor lungs were flushed and then stored for 30 hr at 4 degrees C. Control pigs (n=7) received saline, and the treatment group (n=6) received 15 mg/kg sCR1 1 hr before reperfusion. One hour after reperfusion, the right pulmonary artery was clamped for 10 min to assess the function of the transplanted lung. Pulmonary function was assessed again on day 3.

RESULTS

Complement inhibition was 93% in the sCR1 group and returned to baseline (8% inhibition) after 3 days. There was a trend toward a higher partial pressure of oxygen at 1 hr in the sCR1 group compared with the control group (mean +/- SE: 408+/-42 mmHg vs. 288+/-69 mmHg, P = 0.19). Alveolar ventilation was better in the sCR1 group than in the control group (P = 0.01) at 1 hr. Mixed venous saturation was significantly lower in the control group at both 1 hr (P = 0.02) and 3 days (P = 0.001). The wet/dry weight of the lung tissue was lower in the sCR1 group compared with the control group on day 3 (P < 0.05). Chemiluminescence, an index of phagocyte priming, was lower in the sCR1 group when cells were stimulated with complement opsonized zymosan but not when stimulated with zymosan or phorbol myristate acetate.

CONCLUSION

sCR1 improves ventilation, reduces pulmonary edema, and may be beneficial in improving posttransplant lung oxygenation.

Complement Fragment-Induced Release of Neutrophils From Bone Marrow and Sequestration Within Pulmonary Capillaries in Rabbits

Infusion of complement fragments induces rapid sequestration of neutrophils within the pulmonary capillaries. This study examined the contributions of the bone marrow (BM) and the liver to the accumulation of neutrophils within the lungs. Complement fragments induced the release of neutrophils from the BM within 7 minutes of infusion, and these neutrophils sequestered in the lungs immediately upon reaching the pulmonary capillaries. Neutrophils expressing high levels of L-selectin were preferentially retained within the pulmonary microvasculature. By 30 minutes after the infusion was stopped, the circulating neutrophil counts had increased, primarily because of release from the BM. The number of neutrophils sequestered in the lung had decreased by only 27%, and the number of neutrophils in the liver increased by 223%. These studies indicate that complement fragments induce the release of neutrophils from the BM far more rapidly than previously described. These newly released neutrophils immediately sequester within the lung, increasing the number of neutrophils available to injure the lung many fold beyond the number that were circulating before infusion. The preferential retention of L-selectin–expressing neutrophils likely reflects the requirement for L-selectin–mediated adhesion in maintaining sequestered neutrophils within the pulmonary microvasculature. The number of circulating neutrophils reflects a balance between pulmonary sequestration, rapid release from the BM, and uptake by the liver and other organs.

White blood cell counts and plasma C3a have synergistic predictive value in patients at risk for acute respiratory distress syndrome

OBJECTIVE

To investigate and select nonassociated variables with predictive value for acute respiratory distress syndrome (ARDS) in patients at risk.

DESIGN

Prospective, observational study.

SETTING

A university hospital intensive care unit.

PATIENTS

Twenty-four critically ill patients with different risk factors for ARDS.

INTERVENTIONS

Arterial and mixed venous blood, as well as urine samples, were collected. Invasive hemodynamic measurements were performed.

MEASUREMENTS AND MAIN RESULTS

Fifty-nine variables pertaining to the cardiorespiratory, hepatic, immunologic, and renal systems and including plasma complement activation products C3a and SC5b-9 and polymorphonuclear elastase, were determined every 6 hrs for 3 days in patients at risk for ARDS. Associations among variables were investigated and the predictive value of nonassociated variables for ARDS was determined. Patients who developed ARDS (n=8) had lower white blood cell counts at the time they entered the study (p=.006) and during the first 24 hrs thereafter (p=.032). Also, plasma C3a concentrations were markedly higher during the first 24 hrs in patients who developed ARDS (p=.006). Plasma C3a had better predictive value than did white blood cell counts for cutoff points set by discriminant analysis at 1075 ng/mL (1.075 x 10(-3) g/L) and 5700 cells/mL, respectively. The combination of both variables in a discriminant function improved the predictive value for ARDS.

CONCLUSIONS

The most notable and nonassociated alterations observed in patients who developed ARDS were lower white blood cell counts and higher plasma C3a concentrations compared with counts and concentrations in patients who did not develop ARDS. Plasma C3a concentrations showed better predictive value than white blood cell counts. The combination of white blood cell counts with plasma C3a concentrations synergistically improved the predictive value for ARDS. This combination may prove useful for identifying subpopulations at highest risk for ARDS and may contribute to make treatment at an early stage of the syndrome possible.

Effects of anti-C5a monoclonal antibodies on oxygen use in a porcine model of severe sepsis

METHODS

We analysed the effects of complement depletion and of C5a inhibition on haemodynamic parameters, oxygen delivery (DO2), oxygen consumption (VO2), oxygen extraction ratio (OER) and blood lactate levels after live bacteria infusion in pigs.

RESULTS

In the first series of experiments, animals were decomplemented by cobra venom factor (CVF, 125 micrograms kg-1) and challenged with 1.3 x 10(9) Escherichia coli kg-1. In a second series, animals were treated with neutralizing anti-C5a monoclonal antibodies (mAb) T13/9 before infusion of an increased E. coli dosage (1 x 10(10) E. coli kg-1). Administration of Gram-negative bacteria resulted in hypotension, tachycardia, pulmonary hypertension and decreased cardiac output typical for severe sepsis. These alterations were more pronounced in animals challenged with a higher bacteria concentration (1 x 10(10) E. coli kg-1, n = 5) than with a lower dosage (1.3 x 10(9) E. coli kg-1, n = 4). Complement depletion by CVF injection 24 h before E. coli infusion (n = 4), or anti-C5a mAb T13/9 administration (n = 4) had no effect on the changes in haemodynamic parameters and in DO2 associated with E. coli challenge. Application of either 1.3 x 10(9) or 1 x 10(10) E. coli kg-1 resulted in a marked decrease in VO2 and an increase in blood lactate levels, whereas the OER did not change throughout the experiment. In contrast, pretreatment with CVF 24 h before low-dose E. coli (1.3 x 10(9) kg-1) administration resulted in a significant increase in VO2 (P < 0.05) and in OER (P < 0.05) compared with untreated septic animals (n = 4). No hyperlactaemia occurred in complement-depleted septic animals compared with complement-sufficient animals (P < 0.05). Animals challenged with a high E. coli dose (1 x 10(1) kg-1) and treated with anti-C5a mAbs showed a pronounced increase in VO2 and OER (P < 0.05) accompanied by an attenuated increase in lactate levels (P < 0.05) compared with untreated septic animals.

CONCLUSION

The results demonstrate an improved oxygen use after complement depletion in this model of severe Gram-negative sepsis. Furthermore, a similar effect was seen after specifically neutralizing C5a by mAbs, indicating a role of C5a in the underlying mechanism.

Requirement and role of C5a in acute lung inflammatory injury in rats

The complement activation product, C5a, may play a key role in the acute inflammatory response. Polyclonal antibody to rat C5a was used to define the requirements for C5a in neutrophil-dependent inflammatory lung injury after systemic activation of complement by cobra venom factor (CVF) or after intrapulmonary deposition of IgG immune complexes. In the CVF model, intravenous infusion (but not intratracheal instillation) of anti-C5a produced a dose-dependent reduction in lung permeability and in lung content of myeloperoxidase. In C6-deficient rats, CVF infusion caused the same level of lung injury (measured by leak of 125I-albumin) as found in C6-sufficient rats. In the IgG immune complex model of lung injury, anti-C5a administered intratracheally (but not intravenously) reduced in a dose-dependent manner both the increase in lung vascular permeability as well as the buildup of lung myeloperoxidase. Treatment with anti-C5a greatly suppressed upregulation of lung vascular intercellular adhesion molecule-1 (ICAM-1). This was correlated with a substantial drop in levels of TNFalpha in bronchoalveolar fluids. These data demonstrate the requirement for C5a in the two models of injury. In the IgG immune complex model, C5a is required for the full production of TNFalpha and the corresponding upregulation of lung vascular ICAM-1.

Toxicity of OKT3 increases with dosage: a controlled study in renal transplant recipients

In the present study we prospectively compared side effects occurring in 12 patients after the first administration of low-dose OKT3 (0.5 mg twice daily) induction therapy with those in 10 patients who were treated with a conventional dose of OKT3 (5 mg daily) for acute rejection. We also investigated cytokine release and activation of complement and neutrophils as all of these are held responsible for OKT3-induced side effects. Low-dose OKT3 resulted in a significantly decreased side effects score compared to that after a conventional dose of OKT3 (1.8 vs 5.1, p = 0.0006). Following the first administration of low-dose OKT3, TNF peak levels were significantly lower than after a conventional dose of OKT3. In contrast to our data on conventional dose OKT3 treatment, the first administration of low-dose OKT3 did not induce complement activation as reflected by C3a and C4b/c levels in plasma. Finally, the increase in neutrophil degranulation products lactoferrin and elastase-varies; is directly proportional to 1-antitrypsin was much less following 0.5 mg OKT3 than following 5 mg. We conclude that OKT3-induced toxicity is dose-dependent and is mediated not only by cytokine release but also by activation of complement and neutrophils.

Indium-111-labeled leukocytes for the detection of infection: current status

Several chelates are available for leukocyte labeling. Studies indicate that cells labeled with any of the chelates have a sensitivity for infection of 90% to 95% when imaged at 24 hours postinjection. The sensitivity of 111In-labeled leukocytes at earlier imaging times is more controversial. There has been concern about the utility of labeled leukocytes in musculoskeletal infection. Recent leukocyte studies show a high sensitivity for infected prostheses, even though these infections are often walled off and do not cause systemic symptoms. However, leukocytes frequently miss osteomyelitis of the spine for reasons that are not known. Although some investigators do not recommend the use of 111In-labeled leukocytes in chronic infections, we have found a high sensitivity for infections that are 2 or more weeks old. Autopsy studies from the preantibiotic era indicate that bacterial infections with common organisms have high levels of neutrophil infiltration for months. Labeled lymphocytes from mixed-cell preparations also may play a role in detecting these inflammatory sites. Questions have been raised about the effect of antibiotic therapy on leukocyte sensitivity. Antibiotics do not appear to have a significant effect on scan sensitivity. By reducing the number of bacteria at an inflammatory site, antibiotics reduce the amount of chemotactic inhibitors. In addition, some antibiotics have been shown to directly stimulate leukocyte chemotaxis. Other factors that can theoretically reduce leukocyte function, including hemodialysis, hyperalimentation, hyperglycemia, and steroids, do not appear to reduce labeled leukocyte sensitivity for infection. The specificity of leukocyte uptake is reduced in the gastrointestinal tract and lungs. In these sites, uptake correlates with infection or the true cause of the patients' fever in only 10% to 50% of cases.

Neutrophil dysfunction in end-stage renal failure: reduced response to priming by C5a

We studied the effect of C5a pretreatment on phosphatidyl-inositol-4,5-bisphosphate (PIP2) hydrolysis and on the increase in peak and resting cytosolic calcium levels induced by C5a (0.1 and 10 nM) and/or N-formyl hexapeptide (FLPEP; 10 nM) in neutrophils isolated from patients with end-stage renal failure (ESRF) and those from healthy controls. We also investigated superoxide anion production under the same conditions using the fluorescent para-hydroxyphenylacetic acid assay. The hydrolysis of PIP2 induced by C5a or FLPEP alone was similar in neutrophils from patients with ESRF and in control cells. Likewise, pretreatment of patients' neutrophils with C5a prior to FLPEP did not affect hydrolysis or the increase in cytosolic calcium concentration as shown previously for control neutrophils. Resting calcium levels in both ESRF and control neutrophils, however, were significantly increased after priming with low C5a concentrations. After priming with low C5a, prior to FLPEP, there was also a significant increase in superoxide production. This increase was significantly lower in cells from uremic patients than in those from healthy controls. Our data suggest that priming-induced superoxide production in neutrophils is reduced in patients with ESRF.

Sequestration of labelled granulocytes in the lungs following administration of OKT3 is dose-dependent

In the present study the consequences of administration of low-dose (0.5 mg) OKT3 for respiratory side-effects and pulmonary sequestration of labelled granulocytes are compared with the known effects of 5 mg OKT3. Ten renal transplant patients were studied, of whom five were treated with 0.5 mg OKT3 and five with 5 mg OKT3. None of the patients in the 0.5 mg group and two of the patients in the 5 mg group experienced dyspnoea. Sequestration of labelled granulocytes in the lungs was significantly lower in the patients receiving 0.5 mg OKT3 compared with the patients receiving 5 mg OKT3. The simultaneously occurring peripheral blood granulocytopenia was significantly more severe in the 5 mg group than in the 0.5 mg group. We suppose that this sequestration of circulating granulocytes in the lungs is at least partly mediated by complement activation products. In vitro it is demonstrated that fixation of complement activation products on peripheral blood lymphocytes depends on the concentration of OKT3 present in the culture medium. We conclude that respiratory side-effects shortly following infusion of OKT3 are related to complement-induced pulmonary leucostasis, the degree of which is dependent on the administered dose of OKT3.

Complement activation during OKT3 treatment: a possible explanation for respiratory side effects

Respiratory side effects that sometimes occur during treatment with anti-CD3 MAb OKT3 might result from pulmonary sequestration of activated neutrophils. Therefore, we studied complement activation in relation to activation and pulmonary sequestration of neutrophils during antirejection treatment with OKT3. In each of nine patients studied, plasma C3a-desarg and C4b/c levels increased compared with pretreatment values already in the first sample taken 15 minutes after the first dose of OKT3 (P < 0.05), with peak values at 15 and 30 minutes, respectively. Levels of neutrophil degranulation product elastase (complexed to alpha 1-antitrypsin) also increased already at 15 minutes after the first dose of OKT3 (P < 0.05), which is before elevated levels of the cytokines TNF alpha, IL-6 or IL-8 were detectable. In contrast, upon subsequent OKT3 administrations or in the control group treated with methylprednisolone, neither complement activation, cytokine release nor neutrophil degranulation occurred. In five studied patients treated with OKT3, pulmonary sequestration of radiolabeled granulocytes was observed from 3 until 15 minutes after the first dose of OKT3, together with peripheral blood granulocytopenia, which lasted at least 30 minutes. In conclusion, we demonstrate a simultaneous activation of complement and pulmonary sequestration of activated granulocytes immediately following the first dose of OKT3. These phenomena may be involved in the development of respiratory side effects complicating this therapy.

Inflammatory response to cardiopulmonary bypass

Cardiac operations with cardiopulmonary bypass cause a systemic inflammatory response, which can lead to organ injury and postoperative morbidity. Causative factors include surgical trauma, contact of blood with the extracorporeal circuit, and lung reperfusion injury on discontinuing bypass. Advances in immunological techniques have allowed measurement of both plasma and intracellular components of this multifaceted perioperative response. This includes activation of the complement, coagulation, fibrinolytic, and kallikrein cascades, activation of neutrophils with degranulation and protease enzyme release, oxygen radical production, and the synthesis of various cytokines from mononuclear cells (including tumor necrosis factor, interleukin-1, and interleukin-6). Advances in our understanding of the interactions between these markers of cellular and humoral responses to cardiopulmonary bypass will enable more effective intervention to reduce the deleterious effects and improve the outlook for patients undergoing cardiac operations beyond the 1990s.

Synthetic peptides as antagonists of the anaphylatoxin C3a

Peptide compounds resembling the receptor-binding C-terminal domain of the anaphylatoxic peptide C3a were synthesized to examine two kinds of C3a antagonism: (a) specific desensitization of C3a-sensitive cells and (b) competitive binding to the C3a receptor. We used guinea-pig platelets, which express a C3a receptor and specifically release ATP upon stimulation, to evaluate the actions of the C3a analogues. The ATP liberation can be inhibited by pretreatment (i.e. desensitization) of the guinea-pig platelets with substimulatory concentrations of C3a or its analogues. Compared to C3a, several peptides were found with at least a tenfold greater difference between the required concentrations for C3a-specific half-maximal desensitization (DD50) and half-maximal platelet activation (ED50). The most potent compounds were YAAALKLAR and Fmoc-EAALKLAR (Fmoc: 9-fluorenylmethoxycarbonyl) with an ED50/DD50 of 140 +/- 28 and 80 +/- 17, respectively (mean +/- standard deviation). The ED50/DD50 of human C3a was found to be only 6 +/- 2. Some C3a derivatives were also tested in competitive binding studies for their ability to compete with C3a for receptor sites on guinea-pig platelets. Three of them were considered partial antagonists [YRRGRCGGLCLAR, YRRGRXCGGLCLAR and YRRGRXCGALCLAR (X = 6-aminohexanoyl)] because their Ki were smaller than their ED50 (Ki/ED50 = 0.6 +/- 0.3, 0.5 +/- 0.1 and 0.4 +/- 0.2, respectively). Interestingly, the last two compounds also had ED50/DD50 values greater than 60. Common to all three peptides are N-terminal arginine-rich sequences and intramolecular disulfide bridges which introduce conformational constraint.

Role of neutrophil adherence receptors (CD 18) in lung permeability following lower torso ischemia

Ischemia and reperfusion of the lower torso lead to leukotriene- and neutrophil (PMN)-dependent lung injury characterized by lung PMN sequestration, increased permeability, and noncardiogenic edema. It is thought that PMNs require adhesion to endothelium to alter barrier function. This study tests the role of CD 18, the PMN adherence receptor, in mediating lung permeability after lower torso ischemia and reperfusion. Anesthetized rabbits (n = 9) underwent 3 hours of bilateral hind limb ischemia. Ten minutes after the release of the tourniquets, plasma leukotriene B4 levels increased to 395 +/- 85 pg/ml, higher than 129 +/- 35 pg/ml in controls (n = 9, p less than 0.01). At this time there was a reduction in circulating white blood cells (x 10(3)), 3.56 +/- 0.49/mm3 relative to 6.07 +/- 0.61/mm3 in controls (p less than 0.01). PMNs were sequestered in the hind limbs, indicated by increased myeloperoxidase activity of 1.06 +/- 0.19 units/g compared with 0.56 +/- 0.09 units/g in controls (p less than 0.05). Four hours after tourniquet release, PMNs were sequestered in the lungs, 52 +/- 4 PMNs per 10 high-power fields, a value higher than 31.5 +/- 3 PMNs per 10 high-power fields in controls; bronchoalveolar lavage fluid protein content increased to 554 +/- 90 micrograms/ml relative to 277 +/- 46 micrograms/ml in controls; and there was lung edema, measured by increased wet weight-to-dry weight ratios of 5.19 +/- 0.10, higher than 4.29 +/- 0.21 in controls (all p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Oxidative metabolism of circulating granulocytes in adult respiratory distress syndrome

Among the different mechanisms involved, polymorphonuclear leukocytes (PMNs) may play a central role in the pathogenesis of adult respiratory distress syndrome (ARDS). PMNs were evaluated in 15 patients with ARDS, in 21 at risk of developing ARDS (AR), and in 36 controls (C). Spontaneous and opsonized zymosan (OZ), phorbol myristate acetate (PMA), and F-Met-Leu-Phe (F-M-L-P)-stimulated oxygen radical production was measured by luminol- and lucigenin-enhanced chemiluminescence (CL). Spontaneous CL activity of PMNs from ARDS patients was significantly greater than that from the PMN control (luminol CL, 2.8 +/- 0.6 vs. 0.8 +/- 0.1 mV, p less than 0.001; lucigenin CL, 2.0 +/- 0.6 vs. 0.30 +/- 0.04 mV, p less than 0.001), and the CL value from AR patients (luminol CL, 1.3 +/- 0.2 mV, p less than 0.001 vs. C; lucigenin CL, 0.8 +/- 0.1 mV, p less than 0.001 vs. C) was found to be between the ARDS and C patients. The peak of PMA-stimulated CL occurred earlier and it was significantly higher in ARDS patients than in AR patients (p less than 0.05) and controls (p less than 0.001). When the CL response was elicited with F-M-L-P, no difference among the three groups was found. When stimulated with OZ, the peak CL generated by PMNs from ARDS patients was significantly depressed compared with controls (luminol CL, 26.7 +/- 1.8 vs. 40.9 +/- 2.3 mV, p less than 0.01; lucigenin CL, 5.0 +/- 0.4 vs. 7.4 +/- 0.5 mV, p less than 0.005) with a similar result being obtained from AR patients (luminol CL, 32.1 +/- 2.5 mV, p less than 0.01 vs. C). Plasma from ARDS and AR patients showed a defective opsonizing capacity, suggesting in vivo complement consumption in both patient groups. No correlation between the severity of hypoxemia, the cause of ARDS, the outcome, and the different PMN functions could be established. Our results are in agreement with a determinant role of PMNs in the development of ARDS. The opposite metabolic responses may explain both the pulmonary injury and the increased susceptibility to infections observed in patients at risk of or with ARDS.

Increased PMN CD11b/CD18 expression following post-traumatic ARDS

We investigated the role of polymorphonuclear leukocytes (PMN) in the pathogenesis of post-traumatic adult respiratory distress syndrome (ARDS). Two groups of patients were studied: Group I (n = 29) represents trauma patients studied within 24 hr of admission to the SICU, and Group II (n = 10) represents a subset of Group I patients who subsequently developed ARDS. Circulating pulmonary artery PMN were then assayed for CD11b/CD18 expression, MTT-Formazan production, intracellular H2O2 production, and superoxide anion release. PMN from Group II patients were upregulated with regard to all of the PMN functions assayed within 24 hr of the diagnosis of ARDS being made. Subsequently, longitudinal assays were performed on 17 patients at risk for the development of ARDS. In 6 of 7 patients prior to the clinical recognition of ARDS, CD11b/CD18 expression and MTT-Formazan production increased significantly over baseline. These results suggest that: (i) ARDS coincides with increased CD11b/CD18 expression on PMN cell surfaces, (ii) PMN oxidative metabolism increases at the onset of ARDS, and (iii) changes in circulating pulmonary artery PMN may provide markers for the development of ARDS in the traumatized patient.

Effects of activated polymorphonuclear leukocytes upon pulmonary surfactant in vitro

Current evidence suggests that products of activated inflammatory cells cause or contribute to the acute lung injury of the adult respiratory distress syndrome (ARDS). To assess the possibility that these products may impair surfactant function during ARDS, we exposed surfactant in vitro to polymorphonuclear leukocytes (PMN) activated by phorbol myristate acetate and to the oxidant-producing pair ferric chloride/ascorbate (FeCl3/ASC). After incubation of surfactant with 8 to 32 x 10(6) activated PMN for 1 to 4 h or with FeCl3/ASC for 16 h, its isopycnic density (d), minimum surface tension (gamma min), time course of adsorption, compressibility (SC), and stability index (SI) were determined. We found progressive decreases of d, adsorption, and SI and progressive increases of gamma min and SC after exposure to activated PMN in increasing numbers or for longer time periods. Superoxide dismutase completely inhibited all of these effects except the decreased adsorption, which it did not significantly inhibit. Similar changes in all of these parameters occurred after exposure of surfactant to FeCl3/ASC. Polyacrylamide gel electrophoresis of surfactant after exposure to activated PMN showed a decrease of the major apoprotein that progressed with exposure time and was associated with the appearance of several bands with both lower and higher molecular weights than that of the apoprotein. The data show that activated PMN are capable of impairing surfactant function in vitro and of degrading the major apoprotein. They suggest that the effects upon d, gamma min, SC, and SI are mediated largely if not exclusively by oxidant radicals. While oxidants may contribute to delayed adsorption, proteolysis appears to play the principal role in this effect.

The role of leukocyte depletion by in vivo use of leukocyte filter in lung preservation after warm ischemia

The oxygen metabolites of leukocytes have been implicated as playing the central role in reperfusion injury of preserved lung for transplantation. Furthermore, it is still unknown how leukotrienes take part in this process. Twelve mongrel dogs were used, divided into two groups. In group A, left thoracotomy and hilar stripping of the left lung was performed under anesthesia. During warm ischemia (two hours) and reperfusion (two hours), a filter was used three times between the femoral artery and vein, and quantitative in vivo blood filtration was performed. In group B, warm ischemia and reperfusion was done in the same fashion without filtration. As for tissue free radical assay, lipid peroxidation products were measured by means of thiobarbituric acid. Tissue leukotriene B4 and C4 levels were measured by radio immunoassay. In addition, peripheral blood count and tissue wet/dry ratio were analyzed. Significant leukocyte depletion of peripheral blood with leukocyte efflux from reperfused lung was observed in group A. Significant increase of tissue malondialdehyde (MDA) titers after reperfusion was observed in group B, whereas no significant fluctuation of tissue MDA titers was noted in group A. Concerning leukotriene B4 and C4, no significant increase was observed in either group. Tissue damage estimated by lung wet/dry ratio was considered to be controlled in group A compared with group B. Thus, the authors conclude that in vivo use of a leukocyte filter is efficient in removal of peripheral blood leukocytes and in preservation of reperfused lung after warm ischemia and that oxygen metabolites of leukocytes are considered to play a role in tissue damage in this process.

Complement activation and the prognostic value of C3a in patients at risk of adult respiratory distress syndrome

In vivo and in vitro studies have shown that complement activation plays an important role in the pathogenesis of the adult respiratory distress syndrome (ARDS). In a prospective study of polytrauma patients at risk of ARDS (n = 38) complement parameters were determined over a period of 14 days in serial plasma samples (obtained every 6 h during the first 48 h). Polytrauma induced a rapid and remarkable complement activation. Low levels of the complement proteins C3, C4, C1 inhibitor (C1 INH) factor I and factor H during the first 48 h indicated complement consumption in all patients. Elevated C3a levels in the first few hours after injury were associated with the later development of ARDS. A more sensitive indicator than C3a alone was the calculated C3a:C3 ratio discriminating ARDS and non-ARDS patients. A second rise of C3a levels and C3a:C3 ratio from day 4 on paralleled the course of extravascular lung water. To assess the mode of complement activation, the activation-specific protein complexes C1rC1s-C1 INH and C3b(Bb)P were measured in some of the patients. We demonstrate that in the first 48 h complement activation occurred via the alternative pathway only and was later followed by an additional activation via the classical pathway. Our observations suggest that monitoring of C3a and C3 in plasma can identify polytrauma patients at high risk for ARDS at an early stage of the disease.

Roles of the neutrophil and other mediators in adult respiratory distress syndrome

The adult respiratory distress syndrome (ARDS) and transfusion-related acute lung injury (TRALI) are characterized by diffuse, acute lung injury. Most likely, TRALI is a type of ARDS although it is associated with a much lower morbidity and mortality than found with classic ARDS. For years, the pathogenesis of ARDS has been explained by the complement hypothesis in which pulmonary neutrophilic sequestration and degranulation follow complement-mediated neutrophil chemotaxis. A definitive role for the neutrophil in diffuse, acute lung injury, however, has not been established. Although numerous chemoattractants for neutrophils are generated in the lungs and, through degranulation and formation of toxic oxygen free radicals, the neutrophil is fully capable of causing tissue injury, substantial evidence refutes the requirement for neutrophils in diffuse, acute lung injury. Other potential factors in the pathogenesis of ARDS include primary endothelial cell injury, alveolar macrophage activity, and hemostatic disorders.

Perioperative fluctuation in plasma levels of granulocyte elastase and alpha-1-antitrypsin: the influence of the severity of surgical intervention and their effect on the respiratory index

In order to examine whether granulocyte elastase is related to surgical stress and postoperative respiratory function, the perioperative plasma levels of granulocyte elastase and alpha 1-antitrypsin were periodically measured in 49 patients who underwent various operations and the correlation between these levels and the respiratory index was examined. A strong correlation between elevated plasma levels of granulocyte elastase and the degree of aggressiveness of surgery was quite conspicuous; as the operative intervention became more severe, the plasma levels of granulocyte elastase were higher. The plasma level of alpha 1-antitrypsin was in inverted relation to granulocyte elastase. Moreover, marked and prolonged elevation of plasma granulocyte elastase levels induced postoperative pulmonary complications. A highly significant positive correlation was found between the plasma level of granulocyte elastase and the respiratory index. Elevated granulocyte elastase and/or decreased alpha 1-antitrypsin may therefore be implicated in the etiology of postoperative respiratory dysfunction. Thus, an abnormal elevation of plasma granulocyte elastase may allude the existence of postoperative respiratory dysfunction.

Multiple organ damage caused by tumor necrosis factor and prevented by prior neutrophil depletion

The effect of TNF on nonpulmonary multiple organ damage (MOD) was studied. Since polymorphonuclear leukocytes (PMN) are thought to play an important role in septic or TNF-induced MOD, we investigated both neutrophil sufficient (PMN+) and neutropenic (PMN-) guinea pigs. Sepsis was induced by Escherichia coli administration (2 x 10(9)/kg) or recombinant human TNF (1.4 x 10(6) U/kg) was infused into PMN+ and PMN- guinea pigs. During necropsy, the PMN+/TNF and PMN+/E coli animals exhibited marked damage in the adrenal glands, kidneys and liver as evidenced by hemorrhage, congestion, and PMN sequestration on histopathologic examination. There was also increased tissue albumin accumulation in the adrenal glands, kidneys, spleen, heart, and liver as demonstrated by 125I-labeled albumin determinations. In contrast, the PMN-/TNF group did not reveal histopathologic damage in any organ system and there was no abnormal organ accumulation of 125I-albumin. However, in PMN-/E coli animals, marked histopathologic damage in the adrenal glands and liver was evident. Furthermore, there were marked accumulations of 125I-albumin in the adrenals, heart, kidneys, liver, and spleen. Moreover, the PMN-/E coli guinea pigs had a much greater accumulation (p less than 0.01) of 125I-albumin in the kidneys than any other group including the PMN+/E coli group. Thus, nonpulmonary MOD in guinea pigs is caused by TNF administration and can be prevented by PMN depletion. However, while E coli administration also caused marked nonpulmonary MOD in neutrophil sufficient guinea pigs, equivalent or greater damage was produced in neutropenic animals. This suggests that while TNF-induced MOD may be primarily mediated by PMN, E coli-induced MOD seems to be mediated by more than PMN.

Elevated plasma levels of the anaphylatoxins C3a and C4a are associated with a fatal outcome in sepsis

PURPOSE AND PATIENTS AND METHODS

Both complement and contact system of coagulation have been implicated in the pathophysiology of sepsis. We therefore measured levels of the complement activation products C1-C1-inhibitor complexes and C3a in serial plasma samples (obtained every six hours) from 48 patients with clinically suspected sepsis, and related these levels to the clinical outcome. C4a was also measured in samples obtained on admission.

RESULTS

C3a levels were elevated in 47 patients at least once during the observation period. These levels appeared to be considerably higher in patients who died than in patients who survived. This difference was found for the levels on admission (p = 0.0003), as well as for the highest (p = 0.0010) and the lowest (p less than 0.0001) levels encountered in each patient. The mortality in patients with plasma C3a levels of 13 nmol/liter or less on admission (27 patients) was 33 percent, compared with 86 percent in patients with levels of 14 nmol/liter or more. Patients with septic shock had significantly higher C3a levels than normotensive patients (p values between 0.046 and 0.004). No significant differences in C3a were found between patients who had respiratory distress syndrome and those who did not. C4a levels in plasma samples obtained on admission were elevated in 43 patients. These levels correlated very significantly with C3a levels (p less than 0.0001), and showed similar associations with a fatal outcome. C1-C1-inhibitor complexes were elevated in 23 patients at least once during the observation period. These patients had significantly higher levels of C4a and C3a than patients with normal amounts of C1-C1-inhibitor complexes. Patients who died had higher levels of C1-C1-inhibitor complexes than patients who survived. However, this difference was not significant.

CONCLUSION

On the basis of our results, we propose that activation of the complement system via the classical pathway is involved in the development of fatal complications in sepsis.

Detection of native human complement components C3 and C5 and their primary activation peptides C3a and C5a (anaphylatoxic peptides) by ELISAs with monoclonal antibodies

Monoclonal antibodies (mAbs) were raised against human C3a, C3b, C5a, and C5b after immunization of BALB/c mice with the native components C3 and C5. Using different combinations of these mAbs we have developed four sensitive sandwhich-enzyme-linked immunosorbent assays (ELISAs) for the detection of native C3 or C5 in samples with low concentrations of these proteins, e.g., in cell culture supernatants or synovial fluids and cerebrospinal fluids (CSF) and for the detection of the anaphylatoxic peptides (AT-peptides) C3a or C5a in human EDTA-plasma. The C3- and C5-ELISAs were found to be specific for the uncleaved complement proteins. Two different anti-C3a or anti-C5a mAbs were combined for the C3a- and C5a-ELISA. Before assaying a sample in the C3a- or C5a-ELISA a precipitation step to eliminate uncleaved C3 and C5 was necessary. The sensitivity and specificity of the four ELISAs were tested with purified antigens and EDTA-plasma or Cobra venom factor-activated EGTA-plasma samples as a source of C3a and C5a. The detection limits were 1 ng/ml for C3, 1 ng/ml for C3a, 2 ng/ml for C5, and 100 pg/ml for C5a. Plasma samples from patients undergoing cardiopulmonary bypass (CPB) surgery were used as a source of pathological material.

Allopurinol and lodoxamide in complement-induced hepatic ischemia

Intravascular complement activation with either zymosan or cobra venom factor (CVF) impairs hepatic blood flow. Oxygen radical scavengers given at the time of complement activation attenuate the resulting hepatic ischemia. It is not clear whether complement-stimulated phagocytes or transiently ischemic then reperfused endothelial and parenchymal cells generated the toxic oxygen radicals. In this study, a group of rats were given allopurinol (50 mg/kg/day postoperatively X 3 days plus 100 mg/kg iv at t = 0), a specific inhibitor of xanthine oxidase, prior to complement activation with CVF (20 units/kg iv at t = 30 and 60 min) to determine whether xanthine oxidase-derived oxygen radicals contributed significantly to the hepatic perfusion abnormalities. Additional rats received lodoxamide tromethamine (10 mg/kg iv bolus at t = 0 followed by 20 mg/kg/hr iv infusion), a novel and potent inhibitor of mast cell release and inhibitor of xanthine oxidase, prior to the same CVF challenge to determine whether mast cell mediators were involved in the flow disturbance. Thermodilution cardiac output, mean arterial pressure, heart rate, hematocrit, and effective hepatic blood flow (EHBF) by galactose clearance were determined at t = 2 hr. The percentage change in total hemolytic complement activity (% delta CH50) was determined between serum obtained prior to sacrifice and at t = 0. Systemic hemodynamics and HCT were for the most part unaffected regardless of pretreatment group or challenge with CVF or saline. CVF challenge produced a 25% reduction (P less than 0.05) in EHBF in vehicle-pretreated rats compared to saline challenge. Neither allopurinol nor lodoxamide tromethamine significantly improved EHBF when given prior to CVF challenge.(ABSTRACT TRUNCATED AT 250 WORDS)

Hypoxemia during hemodialysis: a critical review of the facts

The literature describing the fall in PaO2 during dialysis is intensively and critically reviewed. This phenomenon is related to both the type of membrane used (cellulosic v noncellulosic membrane), and to the composition of the dialysate (acetate v bicarbonate). It appears that a ventilation/perfusion mismatch due to pulmonary leukostasis can, in part, explain hypoxemia in patients dialyzed with cellulosic membranes. This phenomenon is especially apparent in patients with preexisting pulmonary abnormalities. However, hypoventilation remains the major cause of hypoxemia. This hypoventilation is mainly due to CO2 consumption during acetate metabolism (acetate dialysis), or alkalinization of the blood (bicarbonate dialysis). The metabolic consequences of acetate metabolism, and of bicarbonate and CO2 losses through the dialyzer are critically analyzed. The cause for the increment in oxygen consumption during acetate dialysis is examined. Finally, the respective role of these combined factors are described and used to explain the changes in VCO2, VO2, respiratory quotient (RQ), and PaO2 reported in the literature during dialysis against acetate and/or bicarbonate.

In vivo effects of C3a on neutrophils and its contribution to inflammatory lung processes in a guinea-pig model

C3a, when injected intravenously in guinea-pigs, caused a rapid drop of circulating neutrophils and platelets. The neutropenia was reversible and followed by a neutrophilia, which reached about 200% of baseline values. Upon challenge with octa- and hexapeptide, mimicking the C-terminal sequence of C3a, neutrophils and platelets reacted in the same manner. The hexapeptide-desArg (pentapeptide without the C-terminal arginine of hexapeptide) induced no neutropenia but a significant neutrophilia. Likewise, when injected in animals with a genetic deficiency or dysfunction of the C3a-receptor, the hexapeptide caused no drop of the neutrophils, but a neutrophilia, indicating that both neutrophil reactions are mediated by different mechanisms. With the octapeptide in vivo dose-response studies were performed. Despite maximal doses of octapeptide about 40% of the neutrophils remained in circulation, indicating that some but not all PMNs are susceptible to C3a. By pretreating the animals with an inhibitor of the serum carboxypeptidase N (SCPN-Inh) the C3a-induced neutropenia could be significantly augmented. But intravenous application of the inhibitor itself caused a 20-40% reduction of neutrophils during the first hour after injection, followed by a neutrophilia. In histological studies the timecourse of neutrophil sequestration in the lung was established, showing that the initial high neutrophil content of the lung lasted for at least 1 h and declined thereafter. Structural derangements could not be detected. These observations stress the importance of C3a besides C5a as an important mediator of inflammatory processes in species, where the C3a-receptor is present on inflammatory cells such as granulocytes.

Anaphylatoxin C3a peptide contracts human pulmonary vasculature

Complement anaphylatoxin C3a C-terminus octapeptide Ala-Ala-Ala-Leu-Gly-Leu-Ala-Arg (C3apep) contracted both pulmonary artery (PA) and pulmonary vein (PV) in a dose-dependent manner over the concentration range of 0.1 micrograms/ml to 100 micrograms/ml with the latter having maximal contractile activity. Removal of the terminal arginine caused complete loss of activity of C3apep. Contractions consisted of an early and a sustained component with the latter component being much greater in PV than PA. The early component was inhibited by pretreatment of tissues with the cyclooxygenase inhibitor indomethacin, or the thromboxane synthase inhibitors dazoxiben or U63,557A. The sustained contractile component was inhibited by the leukotriene antagonist FPL55712 or the 5-lipoxygenase inhibitors U60,257 (Piriprost) or nordihydroguaiiararetic (NDGA). C3apep challenge of both PA and PV resulted in the generation of leukotriene C4. These results suggest that C3apep causes contraction of human pulmonary arteries and veins by the production of thromboxane A2 and leukotrienes.

111In-platelet and 125I-fibrinogen deposition in the lungs in experimental acute pancreatitis

An experimental model of acute pancreatitis in rats has been used to study intrapulmonary 125I-fibrinogen and 111In-platelet deposition. Pancreatitis caused a significant increase in wet lung weight compared to normal, and this could be abolished by heparin or aspirin pretreatment. 125I-fibrinogen was deposited in the lungs of animals to a significantly greater degree than in controls (P less than 0.01). 125I-fibrinogen deposition was reduced to control levels by pretreatment with aspirin or heparin (P less than 0.05). The uptake of radiolabeled platelets was greater in pancreatitis than in controls (P less than 0.001). Pancreatitis appears to be responsible for platelet entrapment in the lungs. Platelet uptake was reduced by heparin treatment but unaffected by aspirin therapy.

Characterization of murine monoclonal antibodies that recognize neutralizing epitopes on human C5a

We generated a panel of 10 murine monoclonal antibodies (MAbs) that recognize human complement fragment C5a. These MAbs were characterized for their ability to immunoprecipitate 125I-labeled C5a, bind C5a in solid-phase enzyme immunoassay, and block 125I-labeled C5a binding to polymorphonuclear leukocytes. Four of these MAbs had affinity constants for C5a in the 1 X 10(9) to 3 X 10(9) M-1 range. These MAbs blocked C5a-induced neutrophil polarization and chemiluminescence. They blocked the ability of passively administered C5a to cause neutropenia in rabbits. These anti-C5a neutralizing MAbs may have potential therapeutic use in states of complement activation.

Differential effects of nylon fibre adherence on the production of superoxide anion by human polymorphonuclear neutrophilic granulocytes stimulated with chemoattractants, ionophore A23187 and phorbol myristate acetate

Human polymorphonuclear neutrophilic granulocytes were made adherent by passing them over protein-coated nylon fibre columns and compared with suspended cells for their production of superoxide anion as measured by cytochrome C reduction. The cells were stimulated with chemotactic factors, the ionophore A 23187, and the tumour promoter phorbol myristate acetate. There was no increased O2-. production by adherent cells in the absence of a stimulus. Adherent cells produced considerably higher amounts of superoxide than suspended cells when stimulated with formyl-methionyl-leucyl-phenylalanine, ionophore A 23187, C5a, C5adesArg, and the platelet activating factor 1-o-alkyl-2-acetyl-sn-glycero-3-phosphorylcholine. In contrast, stimulation with phorbol myristate acetate did not result in higher superoxide release from adherent than from suspended cells, and leukotriene B4 and a mononuclear cell-derived chemotaxin did not stimulate either cell to release significant amounts of superoxide. It is suggested that the augmented production of oxygen radicals with certain stimuli contributes to inflammatory symptoms in situations involving adherent granulocytes.

Biological effects of short-term, high-concentration exposure to methyl isocyanate. VI. In vitro and in vivo complement activation studies

The ability of MIC to induce complement activation in vitro and in vivo was investigated. For the in vitro studies, both human and guinea pig serum or EDTA-plasma samples were exposed to 1167 to 1260 ppm MIC vapor for 15 min at room temperature. The human serum samples exposed to MIC showed significant reductions in Factor B, C2, C4, C3, C5, and total hemolytic complement CH50 activity levels. C6 functional activity was unaffected. The C3, C5, and CH50 functional activities in guinea pig serum (the only functional tests conducted on these samples) were more sensitive to MIC-mediated reduction than the corresponding activity reductions observed in the human serum samples. The human and single guinea pig EDTA-plasma samples exposed to MIC vapor showed no evidence of C3 consumption but did show significant reductions in CH50 levels. Thus, MIC vapor was able to activate, and thereby reduce serum complement C3 activity in vitro by a complement-dependent process. However, the data suggest at least one complement component other than C3 was inactivated in EDTA-plasma by a complement-independent mechanism. For the in vivo studies, five pairs of guinea pigs were exposed to 644 to 702 ppm MIC vapor until one of the pair died (11-15 min). MIC exposure was then discontinued, the surviving guinea pig was sacrificed, and EDTA-plasma was obtained from both animals and analyzed for complement consumption.(ABSTRACT TRUNCATED AT 250 WORDS)

Complement activation and corticosteroid therapy in the development of the adult respiratory distress syndrome

Fifty-nine patients in septic shock were observed for the development of the adult respiratory distress syndrome (ARDS) prior to and after receiving either 30 mg/kg methylprednisolone sodium succinate, 6 mg/kg dexamethasone sodium phosphate or no steroid. Serum levels of C3, C4 and Factor B allowed classification of 42 patients by activation of complement pathways. Despite a trend toward patients with severe septic shock who activate the alternative pathway being protected from the development of ARDS, complement pathway determination did not allow prediction of the development of ARDS and steroid pretreatment did not influence complement levels or prevent ARDS.