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Scaravilli V, Turconi G, Colombo SM, Guzzardella A, Bosone M, Zanella A, Bos L, Grasselli G. Early serum biomarkers to characterise different phenotypes of primary graft dysfunction after lung transplantation: a systematic scoping review. ERJ Open Res 2024; 10:00121-2024. [PMID: 39104958 PMCID: PMC11298996 DOI: 10.1183/23120541.00121-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 03/12/2024] [Indexed: 08/07/2024] Open
Abstract
Background Lung transplantation (LUTX) is often complicated by primary graft dysfunction (PGD). Plasma biomarkers hold potential for PGD phenotyping and targeted therapy. This scoping review aims to collect the available literature in search of serum biomarkers for PGD phenotyping. Methods Following JBI and PRISMA guidelines, we conducted a systematic review searching MEDLINE, Web of Science, EMBASE and The Cochrane Library for papers reporting the association between serum biomarkers measured within 72 h of reperfusion and PGD, following International Society for Heart and Lung Transplantation (ISHLT) guidelines. We extracted study details, patient demographics, PGD definition and timing, biomarker concentration, and their performance in identifying PGD cases. Results Among the 1050 papers screened, 25 prospective observational studies were included, with only nine conducted in the last decade. These papers included 1793 unique adult patients (1195 double LUTX, median study size 100 (IQR 44-119)). Most (n=21) compared PGD grade 3 to less severe PGD, but only four adhered to 2016 PGD definitions. Enzyme-linked immunosorbent assays and the multiplex bead array technique were utilised in 23 and two papers, respectively. In total, 26 candidate biomarkers were identified, comprising 13 inflammatory, three endothelial activation, three epithelial injury, three cellular damage and two coagulation dysregulation markers. Only five biomarkers (sRAGE, ICAM-1, PAI-1, SP-D, FSTL-1) underwent area under the receiver operating characteristic curve analysis, yielding a median value of 0.58 (0.51-0.78) in 406 patients (276 double LUTX). Conclusions Several biomarkers exhibit promise for future studies aimed at PGD phenotyping after LUTX. To uncover the significant existing knowledge gaps, further international prospective studies incorporating updated diagnostic criteria, modern platforms and advanced statistical approaches are essential.
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Affiliation(s)
- Vittorio Scaravilli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca’ Granda – Ospedale Maggiore Policlinico, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Gloria Turconi
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Sebastiano Maria Colombo
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca’ Granda – Ospedale Maggiore Policlinico, Milan, Italy
| | - Amedeo Guzzardella
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Marco Bosone
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Alberto Zanella
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca’ Granda – Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Lieuwe Bos
- Department of Intensive Care, University of Amsterdam, Amsterdam, Netherlands
| | - Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca’ Granda – Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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2
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Diamond JM, Anderson MR, Cantu E, Clausen ES, Shashaty MGS, Kalman L, Oyster M, Crespo MM, Bermudez CA, Benvenuto L, Palmer SM, Snyder LD, Hartwig MG, Wille K, Hage C, McDyer JF, Merlo CA, Shah PD, Orens JB, Dhillon GS, Lama VN, Patel MG, Singer JP, Hachem RR, Michelson AP, Hsu J, Russell Localio A, Christie JD. Development and validation of primary graft dysfunction predictive algorithm for lung transplant candidates. J Heart Lung Transplant 2024; 43:633-641. [PMID: 38065239 PMCID: PMC10947904 DOI: 10.1016/j.healun.2023.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 11/05/2023] [Accepted: 11/30/2023] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND Primary graft dysfunction (PGD) is the leading cause of early morbidity and mortality after lung transplantation. Accurate prediction of PGD risk could inform donor approaches and perioperative care planning. We sought to develop a clinically useful, generalizable PGD prediction model to aid in transplant decision-making. METHODS We derived a predictive model in a prospective cohort study of subjects from 2012 to 2018, followed by a single-center external validation. We used regularized (lasso) logistic regression to evaluate the predictive ability of clinically available PGD predictors and developed a user interface for clinical application. Using decision curve analysis, we quantified the net benefit of the model across a range of PGD risk thresholds and assessed model calibration and discrimination. RESULTS The PGD predictive model included distance from donor hospital to recipient transplant center, recipient age, predicted total lung capacity, lung allocation score (LAS), body mass index, pulmonary artery mean pressure, sex, and indication for transplant; donor age, sex, mechanism of death, and donor smoking status; and interaction terms for LAS and donor distance. The interface allows for real-time assessment of PGD risk for any donor/recipient combination. The model offers decision-making net benefit in the PGD risk range of 10% to 75% in the derivation centers and 2% to 10% in the validation cohort, a range incorporating the incidence in that cohort. CONCLUSION We developed a clinically useful PGD predictive algorithm across a range of PGD risk thresholds to support transplant decision-making, posttransplant care, and enrich samples for PGD treatment trials.
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Affiliation(s)
- Joshua M Diamond
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Michaela R Anderson
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Edward Cantu
- Division of Cardiovascular Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Emily S Clausen
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael G S Shashaty
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Laurel Kalman
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michelle Oyster
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Maria M Crespo
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christian A Bermudez
- Division of Cardiovascular Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Luke Benvenuto
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University School of Medicine, New York, New York
| | - Scott M Palmer
- Division of Pulmonary and Critical Care Medicine, Duke University Medical Center, Durham, North Carolina
| | - Laurie D Snyder
- Division of Pulmonary and Critical Care Medicine, Duke University Medical Center, Durham, North Carolina
| | - Matthew G Hartwig
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Keith Wille
- Division of Pulmonary and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Chadi Hage
- Division of Pulmonary, Allergy, and Critical Care, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - John F McDyer
- Division of Pulmonary, Allergy, and Critical Care, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Christian A Merlo
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University Medical Center, Baltimore, Maryland
| | - Pali D Shah
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University Medical Center, Baltimore, Maryland
| | - Jonathan B Orens
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University Medical Center, Baltimore, Maryland
| | - Ghundeep S Dhillon
- Division of Pulmonary and Critical Care Medicine, Stanford University Medical Center, Palo Alto, California
| | - Vibha N Lama
- Division of Pulmonary and Critical Care Medicine, University of Michigan Medical Center, Ann Arbor, Michigan
| | - Mrunal G Patel
- Division of Pulmonary and Critical Care Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jonathan P Singer
- Division of Pulmonary and Critical Care Allergy and Sleep Medicine, University of California, San Francisco, San Francisco, California
| | - Ramsey R Hachem
- Division of Pulmonary and Critical Care Medicine, Washington University, St. Louis, Missouri
| | - Andrew P Michelson
- Division of Pulmonary and Critical Care Medicine, Washington University, St. Louis, Missouri
| | - Jesse Hsu
- Division of Biostatistics, Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - A Russell Localio
- Division of Biostatistics, Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason D Christie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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3
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Cerier E, Manerikar A, Kandula V, Toyoda T, Thomae B, Yagi Y, Patino DMA, Lung K, Garza-Castillon R, Bharat A, Kurihara C. Postreperfusion Pulmonary Artery Pressure Indicates Primary Graft Dysfunction After Lung Transplant. Ann Thorac Surg 2024; 117:206-212. [PMID: 36521520 PMCID: PMC10258214 DOI: 10.1016/j.athoracsur.2022.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 11/10/2022] [Accepted: 12/06/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Primary graft dysfunction is a risk factor of early mortality after lung transplant. Models identifying patients at high risk for primary graft dysfunction are limited. We hypothesize high postreperfusion systolic pulmonary artery pressure is a clinical marker for primary graft dysfunction. METHODS This is a retrospective review of 158 consecutive lung transplants performed at a single academic center from January 2020 through July 2022. Only bilateral lung transplants were included and patients with pretransplant extracorporeal life support were excluded. RESULTS Primary graft dysfunction occurred in 42.3% (n = 30). Patients with primary graft dysfunction had higher postreperfusion systolic pulmonary artery pressure (41 ± 9.1 mm Hg) than those without (31.5 ± 8.8 mm Hg) (P < .001). Logistic regression showed postreperfusion systolic pulmonary artery pressure is a predictor for primary graft dysfunction (odds ratio 1.14, 95% CI 1.06-1.24, P < .001). Postreperfusion systolic pulmonary artery pressure of 37 mm Hg was optimal for predicting primary graft dysfunction by Youden index. The receiver operating characteristic curve of postreperfusion systolic pulmonary artery pressure at 37 mm Hg (sensitivity 0.77, specificity 0.78, area under the curve 0.81), was superior to the prereperfusion pressure curve at 36 mm Hg (sensitivity 0.77, specificity 0.39, area under the curve 0.57) (P < .01). CONCLUSIONS Elevated postreperfusion systolic pulmonary artery pressure after lung transplant is predictive of primary graft dysfunction. Postreperfusion systolic pulmonary artery pressure is more indicative of primary graft dysfunction than prereperfusion systolic pulmonary artery pressure. Using postreperfusion systolic pulmonary artery pressure as a positive signal of primary graft dysfunction allows earlier intervention, which could improve outcomes.
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Affiliation(s)
- Emily Cerier
- Division of Thoracic Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Adwaiy Manerikar
- Division of Thoracic Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Viswajit Kandula
- Division of Thoracic Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Takahide Toyoda
- Division of Thoracic Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Benjamin Thomae
- Division of Thoracic Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Yuriko Yagi
- Division of Thoracic Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Diego Mauricio Avella Patino
- Division of Thoracic Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Kalvin Lung
- Division of Thoracic Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Rafael Garza-Castillon
- Division of Thoracic Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Ankit Bharat
- Division of Thoracic Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Chitaru Kurihara
- Division of Thoracic Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
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4
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Diamond JM, Cantu E, Calfee CS, Anderson MR, Clausen ES, Shashaty MGS, Courtwright AM, Kalman L, Oyster M, Crespo MM, Bermudez CA, Benvenuto L, Palmer SM, Snyder LD, Hartwig MG, Todd JL, Wille K, Hage C, McDyer JF, Merlo CA, Shah PD, Orens JB, Dhillon GS, Weinacker AB, Lama VN, Patel MG, Singer JP, Hsu J, Localio AR, Christie JD. The Impact of Donor Smoking on Primary Graft Dysfunction and Mortality after Lung Transplantation. Am J Respir Crit Care Med 2024; 209:91-100. [PMID: 37734031 PMCID: PMC10870879 DOI: 10.1164/rccm.202303-0358oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 09/21/2023] [Indexed: 09/23/2023] Open
Abstract
Rationale: Primary graft dysfunction (PGD) is the leading cause of early morbidity and mortality after lung transplantation. Prior studies implicated proxy-defined donor smoking as a risk factor for PGD and mortality. Objectives: We aimed to more accurately assess the impact of donor smoke exposure on PGD and mortality using quantitative smoke exposure biomarkers. Methods: We performed a multicenter prospective cohort study of lung transplant recipients enrolled in the Lung Transplant Outcomes Group cohort between 2012 and 2018. PGD was defined as grade 3 at 48 or 72 hours after lung reperfusion. Donor smoking was defined using accepted thresholds of urinary biomarkers of nicotine exposure (cotinine) and tobacco-specific nitrosamine (4-[methylnitrosamino]-1-[3-pyridyl]-1-butanol [NNAL]) in addition to clinical history. The donor smoking-PGD association was assessed using logistic regression, and survival analysis was performed using inverse probability of exposure weighting according to smoking category. Measurements and Main Results: Active donor smoking prevalence varied by definition, with 34-43% based on urinary cotinine, 28% by urinary NNAL, and 37% by clinical documentation. The standardized risk of PGD associated with active donor smoking was higher across all definitions, with an absolute risk increase of 11.5% (95% confidence interval [CI], 3.8% to 19.2%) by urinary cotinine, 5.7% (95% CI, -3.4% to 14.9%) by urinary NNAL, and 6.5% (95% CI, -2.8% to 15.8%) defined clinically. Donor smoking was not associated with differential post-lung transplant survival using any definition. Conclusions: Donor smoking associates with a modest increase in PGD risk but not with increased recipient mortality. Use of lungs from smokers is likely safe and may increase lung donor availability. Clinical trial registered with www.clinicaltrials.gov (NCT00552357).
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Affiliation(s)
- Joshua M. Diamond
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
| | | | - Carolyn S. Calfee
- Department of Medicine and Anesthesia, University of California, San Francisco, San Francisco, California
| | - Michaela R. Anderson
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
| | - Emily S. Clausen
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
| | | | | | - Laurel Kalman
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
| | - Michelle Oyster
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
| | - Maria M. Crespo
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
| | | | - Luke Benvenuto
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University School of Medicine, New York, New York
| | | | | | - Matthew G. Hartwig
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jamie L. Todd
- Division of Pulmonary and Critical Care Medicine and
| | - Keith Wille
- Division of Pulmonary and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Chadi Hage
- Division of Pulmonary, Allergy, and Critical Care, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - John F. McDyer
- Division of Pulmonary, Allergy, and Critical Care, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Christian A. Merlo
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University Medical Center, Baltimore, Maryland
| | - Pali D. Shah
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University Medical Center, Baltimore, Maryland
| | - Jonathan B. Orens
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University Medical Center, Baltimore, Maryland
| | - Gundeep S. Dhillon
- Division of Pulmonary and Critical Care Medicine, Stanford University Medical Center, Palo Alto, California
| | - Ann B. Weinacker
- Division of Pulmonary and Critical Care Medicine, Stanford University Medical Center, Palo Alto, California
| | - Vibha N. Lama
- Division of Pulmonary and Critical Care Medicine, University of Michigan Medical Center, Ann Arbor, Michigan; and
| | - Mrunal G. Patel
- Division of Pulmonary and Critical Care Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jonathan P. Singer
- Department of Medicine and Anesthesia, University of California, San Francisco, San Francisco, California
| | - Jesse Hsu
- Division of Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - A. Russell Localio
- Division of Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason D. Christie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
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5
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Kim JL, Gouchoe DA, Reader BF, Dumond C, Lee YG, Black SM, Whitson BA. Biometric Profiling to Quantify Lung Injury Through Ex Vivo Lung Perfusion Following Warm Ischemia. ASAIO J 2023; 69:e368-e375. [PMID: 37192317 DOI: 10.1097/mat.0000000000001988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2023] Open
Abstract
Standard physiologic assessment parameters of donor lung grafts may not accurately reflect lung injury or quality. A biometric profile of ischemic injury could be identified as a means to assess the quality of the donor allograft. We sought to identify a biometric profile of lung ischemic injury assessed during ex vivo lung perfusion (EVLP). A rat model of lung donation after circulatory death (DCD) warm ischemic injury with subsequent EVLP evaluation was utilized. We did not observe a significant correlation between the classical physiological assessment parameters and the duration of the ischemic. In the perfusate, solubilized lactate dehydrogenase (LDH) as well as hyaluronic acid (HA) significantly correlated with duration of ischemic injury and length of perfusion ( p < 0.05). Similarly, in perfusates, the endothelin-1 (ET-1) and Big ET-1 correlated ischemic injury ( p < 0.05) and demonstrated a measure of endothelial cell injury. In tissue protein expression, heme oxygenase-1 (HO-1), angiopoietin 1 (Ang-1), and angiopoietin 2 (Ang-2) levels were correlated with the duration of ischemic injury ( p < 0.05). Cleaved caspase-3 levels were significantly elevated at 90 and 120 minutes ( p < 0.05) demonstrating increased apoptosis. A biometric profile of solubilized and tissue protein markers correlated with cell injury is a critical tool to aid in the evaluation of lung transplantation, as accurate evaluation of lung quality is imperative and improved quality leads to better results. http://links.lww.com/ASAIO/B49.
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Affiliation(s)
- Jung-Lye Kim
- From the Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
- The Collaboration for Organ Perfusion, Protection, Engineering and Regeneration (COPPER) Laboratory, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Doug A Gouchoe
- From the Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
- The Collaboration for Organ Perfusion, Protection, Engineering and Regeneration (COPPER) Laboratory, The Ohio State University Wexner Medical Center, Columbus, Ohio
- 88th Surgical Operations Squadron, Wright-Patterson Medical Center, Wright-Patterson AFB, Ohio
| | - Brenda F Reader
- From the Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
- Comprehensive Transplant Center, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Curtis Dumond
- From the Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Yong Gyu Lee
- From the Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
- The Collaboration for Organ Perfusion, Protection, Engineering and Regeneration (COPPER) Laboratory, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Sylvester M Black
- From the Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
- The Collaboration for Organ Perfusion, Protection, Engineering and Regeneration (COPPER) Laboratory, The Ohio State University Wexner Medical Center, Columbus, Ohio
- Comprehensive Transplant Center, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Bryan A Whitson
- From the Division of Cardiac Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
- The Collaboration for Organ Perfusion, Protection, Engineering and Regeneration (COPPER) Laboratory, The Ohio State University Wexner Medical Center, Columbus, Ohio
- Comprehensive Transplant Center, The Ohio State University Wexner Medical Center, Columbus, Ohio
- The Davis Heart and Lung Research Institute at The Ohio State University Wexner Medical, College of Medicine, Columbus, Ohio
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6
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Patel PM, Connolly MR, Coe TM, Calhoun A, Pollok F, Markmann JF, Burdorf L, Azimzadeh A, Madsen JC, Pierson RN. Minimizing Ischemia Reperfusion Injury in Xenotransplantation. Front Immunol 2021; 12:681504. [PMID: 34566955 PMCID: PMC8458821 DOI: 10.3389/fimmu.2021.681504] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 08/12/2021] [Indexed: 12/21/2022] Open
Abstract
The recent dramatic advances in preventing "initial xenograft dysfunction" in pig-to-non-human primate heart transplantation achieved by minimizing ischemia suggests that ischemia reperfusion injury (IRI) plays an important role in cardiac xenotransplantation. Here we review the molecular, cellular, and immune mechanisms that characterize IRI and associated "primary graft dysfunction" in allotransplantation and consider how they correspond with "xeno-associated" injury mechanisms. Based on this analysis, we describe potential genetic modifications as well as novel technical strategies that may minimize IRI for heart and other organ xenografts and which could facilitate safe and effective clinical xenotransplantation.
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Affiliation(s)
- Parth M. Patel
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Margaret R. Connolly
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Taylor M. Coe
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Anthony Calhoun
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Department of Surgery, Division of Cardiac Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Franziska Pollok
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Department of Anesthesiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - James F. Markmann
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Department of Surgery, Division of Transplantation, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Lars Burdorf
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Department of Surgery, Division of Cardiac Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Agnes Azimzadeh
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Department of Surgery, Division of Cardiac Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Joren C. Madsen
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Department of Surgery, Division of Cardiac Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Richard N. Pierson
- Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Department of Surgery, Division of Cardiac Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
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7
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Natalini JG, Diamond JM. Primary Graft Dysfunction. Semin Respir Crit Care Med 2021; 42:368-379. [PMID: 34030200 DOI: 10.1055/s-0041-1728794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2022]
Abstract
Primary graft dysfunction (PGD) is a form of acute lung injury after transplantation characterized by hypoxemia and the development of alveolar infiltrates on chest radiograph that occurs within 72 hours of reperfusion. PGD is among the most common early complications following lung transplantation and significantly contributes to increased short-term morbidity and mortality. In addition, severe PGD has been associated with higher 90-day and 1-year mortality rates compared with absent or less severe PGD and is a significant risk factor for the subsequent development of chronic lung allograft dysfunction. The International Society for Heart and Lung Transplantation released updated consensus guidelines in 2017, defining grade 3 PGD, the most severe form, by the presence of alveolar infiltrates and a ratio of PaO2:FiO2 less than 200. Multiple donor-related, recipient-related, and perioperative risk factors for PGD have been identified, many of which are potentially modifiable. Consistently identified risk factors include donor tobacco and alcohol use; increased recipient body mass index; recipient history of pulmonary hypertension, sarcoidosis, or pulmonary fibrosis; single lung transplantation; and use of cardiopulmonary bypass, among others. Several cellular pathways have been implicated in the pathogenesis of PGD, thus presenting several possible therapeutic targets for preventing and treating PGD. Notably, use of ex vivo lung perfusion (EVLP) has become more widespread and offers a potential platform to safely investigate novel PGD treatments while expanding the lung donor pool. Even in the presence of significantly prolonged ischemic times, EVLP has not been associated with an increased risk for PGD.
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Affiliation(s)
- Jake G Natalini
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joshua M Diamond
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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8
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Endothelial Glycocalyx Shedding Predicts Donor Organ Acceptability and Is Associated With Primary Graft Dysfunction in Lung Transplant Recipients. Transplantation 2019; 103:1277-1285. [DOI: 10.1097/tp.0000000000002539] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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9
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Young KA, Dilling DF. The Future of Lung Transplantation. Chest 2018; 155:465-473. [PMID: 30171860 DOI: 10.1016/j.chest.2018.08.1036] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Revised: 08/10/2018] [Accepted: 08/15/2018] [Indexed: 12/17/2022] Open
Abstract
The field of lung transplant has made significant advances over the last several decades. Despite these advances, morbidity and mortality remain high when compared with other solid organ transplants. As the field moves forward, the speed by which progress can be made will in part be determined by our ability to overcome several stumbling blocks, including donor shortage, proper selection of candidates, primary graft dysfunction, and chronic lung allograft dysfunction. The advances and developments surrounding these factors will have a significant impact on shaping the field within the coming years. In this review, we look at the current climate (ripe for expanding the donor pool), new technology (ex vivo lung perfusion and bioengineered lungs), cutting-edge innovation (novel biomarkers and new ways to treat infected donors), and evidence-based medicine to discuss current trends and predict future developments for what we hope is a bright future for the field of lung transplantation.
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Affiliation(s)
- Katherine A Young
- Department of Pulmonary and Critical Care, Loyola University Medical Center, Maywood, IL
| | - Daniel F Dilling
- Department of Pulmonary and Critical Care, Loyola University Medical Center, Maywood, IL.
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Shaver CM, Wickersham N, McNeil JB, Nagata H, Miller A, Landstreet SR, Kuck JL, Diamond JM, Lederer DJ, Kawut SM, Palmer SM, Wille KM, Weinacker A, Lama VN, Crespo MM, Orens JB, Shah PD, Hage CA, Cantu E, Porteous MK, Dhillon G, McDyer J, Bastarache JA, Christie JD, Ware LB. Cell-free hemoglobin promotes primary graft dysfunction through oxidative lung endothelial injury. JCI Insight 2018; 3:98546. [PMID: 29367464 DOI: 10.1172/jci.insight.98546] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 12/19/2017] [Indexed: 12/31/2022] Open
Abstract
Primary graft dysfunction (PGD) is acute lung injury within 72 hours of lung transplantation. We hypothesized that cell-free hemoglobin (CFH) contributes to PGD by increasing lung microvascular permeability and tested this in patients, ex vivo human lungs, and cultured human lung microvascular endothelial cells. In a nested case control study of 40 patients with severe PGD at 72 hours and 80 matched controls without PGD, elevated preoperative CFH was independently associated with increased PGD risk (odds ratio [OR] 2.75, 95%CI, 1.23-6.16, P = 0.014). The effect of CFH on PGD was magnified by reperfusion fraction of inspired oxygen (FiO2) ≥ 0.40 (OR 3.41, P = 0.031). Isolated perfused human lungs exposed to intravascular CFH (100 mg/dl) developed increased vascular permeability as measured by lung weight (CFH 14.4% vs. control 0.65%, P = 0.047) and extravasation of Evans blue-labeled albumin dye (EBD) into the airspace (P = 0.027). CFH (1 mg/dl) also increased paracellular permeability of human pulmonary microvascular endothelial cell monolayers (hPMVECs). Hyperoxia (FiO2 = 0.95) increased human lung and hPMVEC permeability compared with normoxia (FiO2 = 0.21). Treatment with acetaminophen (15 μg/ml), a specific hemoprotein reductant, prevented CFH-dependent permeability in human lungs (P = 0.046) and hPMVECs (P = 0.037). In summary, CFH may mediate PGD through oxidative effects on microvascular permeability, which are augmented by hyperoxia and abrogated by acetaminophen.
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Affiliation(s)
- Ciara M Shaver
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Nancy Wickersham
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - J Brennan McNeil
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Hiromasa Nagata
- Department of Anesthesiology, Keio University School of Medicine, Tokyo, Japan
| | - Adam Miller
- Tennessee Donor Services, Nashville, Tennessee, USA
| | - Stuart R Landstreet
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jamie L Kuck
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Joshua M Diamond
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David J Lederer
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University School of Medicine, New York, New York, USA
| | - Steven M Kawut
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Scott M Palmer
- Division of Pulmonary and Critical Care Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Keith M Wille
- Division of Pulmonary and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Ann Weinacker
- Division of Pulmonary and Critical Care Medicine, Stanford University Medical Center, Palo Alto, California, USA
| | - Vibha N Lama
- Division of Pulmonary and Critical Care Medicine, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Maria M Crespo
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jonathan B Orens
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University Medical Center, Baltimore, Maryland, USA
| | - Pali D Shah
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University Medical Center, Baltimore, Maryland, USA
| | - Chadi A Hage
- Division of Pulmonary, Allergy, Critical Care, and Occupational Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Edward Cantu
- Division of Cardiovascular Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mary K Porteous
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gundeep Dhillon
- Division of Pulmonary and Critical Care Medicine, Stanford University Medical Center, Palo Alto, California, USA
| | - John McDyer
- Division of Pulmonary, Allergy, and Critical Care, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Julie A Bastarache
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jason D Christie
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lorraine B Ware
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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11
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Affiliation(s)
- Robert Jeen-Chen Chen
- 1 Cardiothoracic Surgery Taipei Tzuchi Hospital Buddhist Tzuchi Medical Foundation New Taipei City, Taiwan.,2 Tzuchi University College of Medicine Buddhist Tzuchi Medical Foundation Hualian, Taiwan and
| | - Wei-Hsuan Yu
- 3 Biochemistry & Molecular Biology National Taiwan University College of Medicine Taipei, Taiwan
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Abstract
Primary graft dysfunction is a form of acute injury after lung transplantation that is associated with significant short- and long-term morbidity and mortality. Multiple mechanisms contribute to the pathogenesis of primary graft dysfunction, including ischemia reperfusion injury, epithelial cell death, endothelial cell dysfunction, innate immune activation, oxidative stress, and release of inflammatory cytokines and chemokines. This article reviews the epidemiology, pathogenesis, risk factors, prevention, and treatment of primary graft dysfunction.
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Affiliation(s)
- Mary K Porteous
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA 19104, USA.
| | - James C Lee
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
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Morrison MI, Pither TL, Fisher AJ. Pathophysiology and classification of primary graft dysfunction after lung transplantation. J Thorac Dis 2017; 9:4084-4097. [PMID: 29268419 DOI: 10.21037/jtd.2017.09.09] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The term primary graft dysfunction (PGD) incorporates a continuum of disease severity from moderate to severe acute lung injury (ALI) within 72 h of lung transplantation. It represents the most significant obstacle to achieving good early post-transplant outcomes, but is also associated with increased incidence of bronchiolitis obliterans syndrome (BOS) subsequently. PGD is characterised histologically by diffuse alveolar damage, but is graded on clinical grounds with a combination of PaO2/FiO2 (P/F) and the presence of radiographic infiltrates, with 0 being absence of disease and 3 being severe PGD. The aetiology is multifactorial but commonly results from severe ischaemia-reperfusion injury (IRI), with tissue-resident macrophages largely responsible for stimulating a secondary 'wave' of neutrophils and lymphocytes that produce severe and widespread tissue damage. Donor history, recipient health and operative factors may all potentially contribute to the likelihood of PGD development. Work that aims to minimise the incidence of PGD in ongoing, with techniques such as ex vivo perfusion of donor lungs showing promise both in research and in clinical studies. This review will summarise the current clinical status of PGD before going on to discuss its pathophysiology, current therapies available and future directions for clinical management of PGD.
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Affiliation(s)
- Morvern Isabel Morrison
- Institute of Transplantation, Freeman Hospital, Newcastle Upon Tyne, UK.,Institute of Cellular Medicine, Faculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, UK
| | - Thomas Leonard Pither
- Institute of Transplantation, Freeman Hospital, Newcastle Upon Tyne, UK.,Institute of Cellular Medicine, Faculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, UK
| | - Andrew John Fisher
- Institute of Transplantation, Freeman Hospital, Newcastle Upon Tyne, UK.,Institute of Cellular Medicine, Faculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, UK
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Alqudah M, Qandeel H, Al-Zoubi N, Alqudah A, Bani-Ahmad M, Alzoubi A. Changes of serum growth factors profiles in patients with venous thromboembolism. Scandinavian Journal of Clinical and Laboratory Investigation 2017; 77:595-600. [DOI: 10.1080/00365513.2017.1379607] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Mohammad Alqudah
- Department of Pathology, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Haitham Qandeel
- Department of General Surgery, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Nabil Al-Zoubi
- Department of General Surgery, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | | | - Mohammad Bani-Ahmad
- Department of Medical Laboratory Sciences, Faculty of Applied Medical Sciences, Jordan University of Science and Technology, Irbid, Jordan
| | - Abdallah Alzoubi
- Department of Pharmacology, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
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Abstract
Complement is a major contributor to inflammation and graft injury. This system is especially important in ischemia-reperfusion injury/delayed graft function as well as in acute and chronic antibody-mediated rejection (AMR). The latter is increasingly recognized as a major cause of late graft loss, for which we have few effective therapies. C1 inhibitor (C1-INH) regulates several pathways which contribute to both acute and chronic graft injuries. However, C1-INH spares the alternative pathway and the membrane attack complex (C5–9) so innate antibacterial defenses remain intact. Plasma-derived C1-INH has been used to treat hereditary angioedema for more than 30 years with excellent safety. Studies with C1-INH in transplant recipients are limited, but have not revealed any unique toxicity or serious adverse events attributed to the protein. Extensive data from animal and ex vivo models suggest that C1-INH ameliorates ischemia-reperfusion injury. Initial clinical studies suggest this effect may allow transplantation of donor organs which are now discarded because the risk of primary graft dysfunction is considered too great. Although the incidence of severe early AMR is declining, accumulating evidence strongly suggests that complement is an important mediator of chronic AMR, a major cause of late graft loss. Thus, C1-INH may also be helpful in preserving function of established grafts. Early clinical studies in transplantation suggest significant beneficial effects of C1-INH with minimal toxicity. Recent results encourage continued investigation of this already-available therapeutic agent.
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Komarova YA, Kruse K, Mehta D, Malik AB. Protein Interactions at Endothelial Junctions and Signaling Mechanisms Regulating Endothelial Permeability. Circ Res 2017; 120:179-206. [PMID: 28057793 DOI: 10.1161/circresaha.116.306534] [Citation(s) in RCA: 300] [Impact Index Per Article: 42.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Revised: 10/04/2016] [Accepted: 10/06/2016] [Indexed: 12/31/2022]
Abstract
The monolayer of endothelial cells lining the vessel wall forms a semipermeable barrier (in all tissue except the relatively impermeable blood-brain and inner retinal barriers) that regulates tissue-fluid homeostasis, transport of nutrients, and migration of blood cells across the barrier. Permeability of the endothelial barrier is primarily regulated by a protein complex called adherens junctions. Adherens junctions are not static structures; they are continuously remodeled in response to mechanical and chemical cues in both physiological and pathological settings. Here, we discuss recent insights into the post-translational modifications of junctional proteins and signaling pathways regulating plasticity of adherens junctions and endothelial permeability. We also discuss in the context of what is already known and newly defined signaling pathways that mediate endothelial barrier leakiness (hyperpermeability) that are important in the pathogenesis of cardiovascular and lung diseases and vascular inflammation.
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Affiliation(s)
- Yulia A Komarova
- From the Department of Pharmacology and the Center for Lung and Vascular Biology, University of Illinois College of Medicine, Chicago
| | - Kevin Kruse
- From the Department of Pharmacology and the Center for Lung and Vascular Biology, University of Illinois College of Medicine, Chicago
| | - Dolly Mehta
- From the Department of Pharmacology and the Center for Lung and Vascular Biology, University of Illinois College of Medicine, Chicago
| | - Asrar B Malik
- From the Department of Pharmacology and the Center for Lung and Vascular Biology, University of Illinois College of Medicine, Chicago.
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Hamilton BCS, Kukreja J, Ware LB, Matthay MA. Protein biomarkers associated with primary graft dysfunction following lung transplantation. Am J Physiol Lung Cell Mol Physiol 2017; 312:L531-L541. [PMID: 28130262 DOI: 10.1152/ajplung.00454.2016] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 01/23/2017] [Accepted: 01/23/2017] [Indexed: 12/13/2022] Open
Abstract
Severe primary graft dysfunction affects 15-20% of lung transplant recipients and carries a high mortality risk. In addition to known donor, recipient, and perioperative clinical risk factors, numerous biologic factors are thought to contribute to primary graft dysfunction. Our current understanding of the pathogenesis of lung injury and primary graft dysfunction emphasizes multiple pathways leading to lung endothelial and epithelial injury. Protein biomarkers specific to these pathways can be measured in the plasma, bronchoalveolar lavage fluid, and lung tissue. Clarification of the pathophysiology and timing of primary graft dysfunction could illuminate predictors of dysfunction, allowing for better risk stratification, earlier identification of susceptible recipients, and development of targeted therapies. Here, we review much of what has been learned about the association of protein biomarkers with primary graft dysfunction and evaluate this association at different measurement time points.
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Affiliation(s)
- B C S Hamilton
- Department of Surgery, University of California San Francisco, San Francisco, California;
| | - J Kukreja
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - L B Ware
- Department of Medicine and Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - M A Matthay
- Department of Medicine, Anesthesia, and the Cardiovascular Research Institute, University of California San Francisco, San Francisco, California; and
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Hashimoto K, Besla R, Zamel R, Juvet S, Kim H, Azad S, Waddell TK, Cypel M, Liu M, Keshavjee S. Circulating Cell Death Biomarkers May Predict Survival in Human Lung Transplantation. Am J Respir Crit Care Med 2016; 194:97-105. [DOI: 10.1164/rccm.201510-2115oc] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
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Hilbert T, Duerr GD, Hamiko M, Frede S, Rogers L, Baumgarten G, Hoeft A, Velten M. Endothelial permeability following coronary artery bypass grafting: an observational study on the possible role of angiopoietin imbalance. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:51. [PMID: 26951111 PMCID: PMC4782352 DOI: 10.1186/s13054-016-1238-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 02/15/2016] [Indexed: 12/26/2022]
Abstract
BACKGROUND Unresolved inflammation resulting in capillary leakage with endothelial barrier dysfunction is a major contributor to postoperative morbidity and mortality after coronary artery bypass graft (CABG). Angiopoietins (ANGs) are vascular growth factors, also mediating inflammation and disruption of the endothelium, thus inducing capillary leakage. We hypothesized that changes in the relative serum levels of ANG1 and ANG2 influence endothelial barrier function and perioperative morbidity after CABG. METHODS After approval and informed consent, serum samples (n = 28) were collected pre CABG surgery, 1, 6, and 24 h after aortic de-clamping. ANG1, ANG2, soluble ANG receptor TIE2 (sTIE2), and IL-6 serum concentrations were analyzed by ELISA. Human pulmonary microvascular endothelial cells (HPMECs) were incubated with patient serum and FITC-dextran permeability was assessed. Furthermore, ANG2 secretion of HPMECs was analyzed after incubation with IL-6-containing patient serum. RESULTS CABG induced an early and sustained increase of ANG2/ANG1 ratio (5-fold after 24 h compared to pre-surgery). These changes correlated with elevated serum lactate levels, fluid balance, as well as the duration of mechanical ventilation. Permeability of HPMECs significantly increased after incubation with post-surgery serum showing a marked shift of ANG2/ANG1 balance (18-fold) compared to serum with a less pronounced increase (6-fold). Furthermore, CABG resulted in increased IL-6 serum content. Pre-incubation with serum containing high levels of IL-6 amplified the ANG2 secretion by HPMECs; however, this was not influenced by blocking IL-6. CONCLUSIONS CABG affects the balance between ANG1 and ANG2 towards a dominance of the barrier-disruptive ANG2. Our data suggest that this ANG2/ANG1 imbalance contributes to an increased postoperative endothelial permeability, likewise being reflected by the clinical course. The results strongly suggest a biological effect of altered angiopoietin balance during cardiac surgery on endothelial permeability.
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Affiliation(s)
- Tobias Hilbert
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Rheinische Friedrich-Wilhelms-University Bonn, Bonn, Germany.
| | - Georg Daniel Duerr
- Department of Cardiovascular Surgery, University Medical Center Rheinische Friedrich-Wilhelms-University Bonn, Bonn, Germany.
| | - Marwan Hamiko
- Department of Cardiovascular Surgery, University Medical Center Rheinische Friedrich-Wilhelms-University Bonn, Bonn, Germany.
| | - Stilla Frede
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Rheinische Friedrich-Wilhelms-University Bonn, Bonn, Germany.
| | - Lynette Rogers
- Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA.
| | - Georg Baumgarten
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Rheinische Friedrich-Wilhelms-University Bonn, Bonn, Germany.
| | - Andreas Hoeft
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Rheinische Friedrich-Wilhelms-University Bonn, Bonn, Germany.
| | - Markus Velten
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Rheinische Friedrich-Wilhelms-University Bonn, Bonn, Germany.
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Rajput C, Tauseef M, Farazuddin M, Yazbeck P, Amin MR, Avin Br V, Sharma T, Mehta D. MicroRNA-150 Suppression of Angiopoetin-2 Generation and Signaling Is Crucial for Resolving Vascular Injury. Arterioscler Thromb Vasc Biol 2016; 36:380-8. [PMID: 26743170 DOI: 10.1161/atvbaha.115.306997] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 12/17/2015] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Increased vascular permeability is a hallmark of sepsis and acute respiratory distress syndrome. Angiopoietin (Ang2) induces vascular leak, and excess Ang2 generation is associated with patient mortality from these diseases. However, mechanisms dampening Ang2 generation during injury remain unclear. Interestingly, microRNA (miR)-150 levels were decreased in septic patients. miR regulate signaling networks by silencing mRNAs containing complementary sequences. Thus, we hypothesized that miR-150 suppresses Ang2 generation and thereby resolves vascular injury. APPROACH AND RESULTS Wild-type or miR-150(-/-) mice or endothelial cells were exposed to lipopolysaccharide or sepsis, and Ang2 levels, adherens junction reannealing, endothelial barrier function, and mortality were determined. Although Ang2 transiently increased during lipopolysaccharide-induced injury in wild-type endothelial cells and lungs, miR-150 expression was elevated only during recovery from injury. Deletion of miR-150 caused a persistent increase in Ang2 levels and impaired adherens junctions reannealing after injury, resulting thereby in an irreversible increase in vascular permeability. Also, miR-150(-/-) mice died rapidly after sepsis. Rescuing miR-150 expression in endothelial cells prevented Ang2 generation, thereby restoring vascular barrier function in miR-150(-/-) mice. miR-150 terminated Ang2 generation by targeting the transcription factor, early growth response 2. Thus, early growth response 2 or Ang2 depletion in miR-150(-/-) endothelial cells restored junctional reannealing and reinstated barrier function. Importantly, upregulating miR-150 expression by injecting a chemically synthesized miR-150 mimic into wild-type mice vasculature decreased early growth response 2 and Ang2 levels and hence mortality from sepsis. CONCLUSIONS miR-150 is a novel suppressor of Ang2 generation with a key role in resolving vascular injury and reducing mortality resulting from sepsis.
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Affiliation(s)
- Charu Rajput
- From the Department of Pharmacology and Center for Lung and Vascular Biology, University of Illinois at Chicago
| | - Mohammad Tauseef
- From the Department of Pharmacology and Center for Lung and Vascular Biology, University of Illinois at Chicago
| | - Mohammad Farazuddin
- From the Department of Pharmacology and Center for Lung and Vascular Biology, University of Illinois at Chicago
| | - Pascal Yazbeck
- From the Department of Pharmacology and Center for Lung and Vascular Biology, University of Illinois at Chicago
| | - Md-Ruhul Amin
- From the Department of Pharmacology and Center for Lung and Vascular Biology, University of Illinois at Chicago
| | - Vijay Avin Br
- From the Department of Pharmacology and Center for Lung and Vascular Biology, University of Illinois at Chicago
| | - Tiffany Sharma
- From the Department of Pharmacology and Center for Lung and Vascular Biology, University of Illinois at Chicago
| | - Dolly Mehta
- From the Department of Pharmacology and Center for Lung and Vascular Biology, University of Illinois at Chicago.
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Porteous MK, Diamond JM, Christie JD. Primary graft dysfunction: lessons learned about the first 72 h after lung transplantation. Curr Opin Organ Transplant 2015; 20:506-14. [PMID: 26262465 PMCID: PMC4624097 DOI: 10.1097/mot.0000000000000232] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW In 2005, the International Society for Heart and Lung Transplantation published a standardized definition of primary graft dysfunction (PGD), facilitating new knowledge on this form of acute lung injury that occurs within 72 h of lung transplantation. PGD continues to be associated with significant morbidity and mortality. This article will summarize the current literature on the epidemiology of PGD, pathogenesis, risk factors, and preventive and treatment strategies. RECENT FINDINGS Since 2011, several manuscripts have been published that provide insight into the clinical risk factors and pathogenesis of PGD. In addition, several transplant centers have explored preventive and treatment strategies for PGD, including the use of extracorporeal strategies. More recently, results from several trials assessing the role of extracorporeal lung perfusion may allow for much-needed expansion of the donor pool, without raising PGD rates. SUMMARY This article will highlight the current state of the science regarding PGD, focusing on recent advances, and set a framework for future preventive and treatment strategies.
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Affiliation(s)
- Mary K Porteous
- aDepartment of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA bCenter for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Role of innate immunity in primary graft dysfunction after lung transplantation. Curr Opin Organ Transplant 2015; 18:518-23. [PMID: 23995372 DOI: 10.1097/mot.0b013e3283651994] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Primary graft dysfunction (PGD), a form of acute lung injury after lung transplantation, has a significant impact on clinical outcomes after lung transplantation. This potentially reversible graft impairment occurs after ischemia-reperfusion injury. This review describes the expanding body of literature evaluating the central role of innate immune activation, nonadaptive responses and dysregulation in the development of PGD after lung transplant. RECENT FINDINGS The innate immune system, highlighted by Toll-like receptor pathways and neutrophil migration and influx, plays an important role in the initiation and propagation of ischemia-reperfusion injury. Recent plasma biomarker and gene association studies have identified several genes and proteins composing innate immune pathways to be associated with PGDs. Long pentraxin-3 and Toll-like receptors, as well as inflammasomes and Toll-interacting protein, are associated with the development of PGD after lung transplantation. SUMMARY Innate immune pathways are involved in the development of PGD and may provide attractive targets for therapies. It may be possible to prevent or treat PGD, as well as to allow pre-transplant PGD risk stratification. To improve understanding of the mechanisms behind clinical risk factors for PGD will require further in-depth correlation of donor-specific and recipient-related triggers of nonadaptive immune responses.
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Uchida T, Ito H, Yamamoto H, Ohno N, Asahara M, Yamada Y, Yamaguchi O, Tomita M, Makita K. Elevated levels of angiopoietin-2 as a biomarker for respiratory failure after cardiac surgery. J Cardiothorac Vasc Anesth 2014; 28:1293-301. [PMID: 25027103 DOI: 10.1053/j.jvca.2014.03.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2013] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Angiopoietin-1 and angiopoietin-2 are important factors in regulating endothelial vascular permeability. This study evaluated perioperative changes in serum levels of angiopoietin-1 and -2 in patients undergoing cardiac surgery. DESIGN Measurement of serum levels of angiopoietin-1 and angiopoietin-2 in samples collected during a previously conducted prospective, multicenter, observational study. SETTING Three university hospitals. PARTICIPANTS Eighty-four adult patients undergoing cardiac surgery. INTERVENTION Serum levels of angiopoietins were measured at baseline, immediately after surgery, and the day after surgery (POD-1). MEASUREMENTS AND MAIN RESULTS Serum levels of angiopoietin-2 were elevated by POD-1 (median 3.3 ng/mL, interquartile range [IQR] 2.5-4.6 ng/mL) compared with baseline (median 1.6 ng/mL, IQR 1.3-2.1 ng/mL, p < 0.0001), and angiopoietin-1 levels were decreased immediately after surgery (baseline median 23.2 ng/mL, IQR 10.2-32.8 ng/mL; postoperative median 8.0 ng/mL, IQR 1.5-13.2 ng/mL, p<0.0001). Angiopoietin-2 levels on POD-1 in patients undergoing off-pump coronary artery bypass grafting were significantly lower than those in patients undergoing aortic surgery (p = 0.0009) and valve surgery (p = 0.008). Angiopoietin-2 levels on POD-1 had a predictive performance of the area under the curve (AUC) of the receiver operating characteristic curve 0.74 for mechanical ventilation>3 days. Angiopoietin-1 levels and the angiopoietin-2/angiopoietin-1 ratio showed lower predictive performance (AUC values 0.58 and 0.68, respectively). CONCLUSIONS Angiopoietin-2 serum levels were elevated after cardiac surgery. Elevated angiopoietin-2 had a good predictive performance for respiratory failure after cardiac surgery, perhaps reflecting the severity of lung dysfunction related to postoperative increases in vascular permeability.
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Affiliation(s)
- Tokujiro Uchida
- Department of Anesthesiology, Tokyo Medical and Dental University, Graduate School of Medical and Dental Sciences, Tokyo, Japan.
| | - Hiroyuki Ito
- Department of Anesthesiology, Tokyo Medical and Dental University, Graduate School of Medical and Dental Sciences, Tokyo, Japan
| | - Hiroto Yamamoto
- Department of Anesthesiology, Tokyo Medical and Dental University, Graduate School of Medical and Dental Sciences, Tokyo, Japan
| | - Nagara Ohno
- Department of Anesthesiology, University of Tokyo, Graduate School of Medicine, Tokyo, Japan
| | - Miho Asahara
- Department of Anesthesiology, University of Tokyo, Graduate School of Medicine, Tokyo, Japan
| | - Yoshitsugu Yamada
- Department of Anesthesiology, University of Tokyo, Graduate School of Medicine, Tokyo, Japan
| | - Osamu Yamaguchi
- Department of Critical Care Medicine, Yokohama City University Medical Center, Kanagawa, Tokyo, Japan
| | - Makoto Tomita
- Clinical Research Center, Tokyo Medical and Dental University Hospital of Medicine, Tokyo, Japan
| | - Koshi Makita
- Department of Anesthesiology, Tokyo Medical and Dental University, Graduate School of Medical and Dental Sciences, Tokyo, Japan
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Mammoto T, Jiang E, Jiang A, Lu Y, Juan AM, Chen J, Mammoto A. Twist1 controls lung vascular permeability and endotoxin-induced pulmonary edema by altering Tie2 expression. PLoS One 2013; 8:e73407. [PMID: 24023872 PMCID: PMC3759405 DOI: 10.1371/journal.pone.0073407] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2013] [Accepted: 07/20/2013] [Indexed: 11/19/2022] Open
Abstract
Tight regulation of vascular permeability is necessary for normal development and deregulated vascular barrier function contributes to the pathogenesis of various diseases, including acute respiratory distress syndrome, cancer and inflammation. The angiopoietin (Ang)-Tie2 pathway is known to control vascular permeability. However, the mechanism by which the expression of Tie2 is regulated to control vascular permeability has not been fully elucidated. Here we show that transcription factor Twist1 modulates pulmonary vascular leakage by altering the expression of Tie2 in a context-dependent way. Twist1 knockdown in cultured human lung microvascular endothelial cells decreases Tie2 expression and phosphorylation and increases RhoA activity, which disrupts cell-cell junctional integrity and increases vascular permeability in vitro. In physiological conditions, where Ang1 is dominant, pulmonary vascular permeability is elevated in the Tie2-specific Twist1 knockout mice. However, depletion of Twist1 and resultant suppression of Tie2 expression prevent increase in vascular permeability in an endotoxin-induced lung injury model, where the balance of Angs shifts toward Ang2. These results suggest that Twist1-Tie2-Angs signaling is important for controlling vascular permeability and modulation of this mechanism may lead to the development of new therapeutic approaches for pulmonary edema and other diseases caused by abnormal vascular permeability.
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Affiliation(s)
- Tadanori Mammoto
- 1 Vascular Biology Program, Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Elisabeth Jiang
- 1 Vascular Biology Program, Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Amanda Jiang
- 1 Vascular Biology Program, Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Yongbo Lu
- 2 Department of Biomedical Sciences, Baylor College of Dentistry, Texas A&M Health Science Center, Dallas, Texas, United States of America
| | - Aimee M. Juan
- 3 Department of Ophthalmology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Jing Chen
- 3 Department of Ophthalmology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Akiko Mammoto
- 1 Vascular Biology Program, Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
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26
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Abstract
Primary graft dysfunction (PGD) is a syndrome encompassing a spectrum of mild to severe lung injury that occurs within the first 72 hours after lung transplantation. PGD is characterized by pulmonary edema with diffuse alveolar damage that manifests clinically as progressive hypoxemia with radiographic pulmonary infiltrates. In recent years, new knowledge has been generated on risks and mechanisms of PGD. Following ischemia and reperfusion, inflammatory and immunological injury-repair responses appear to be key controlling mechanisms. In addition, PGD has a significant impact on short- and long-term outcomes; therefore, the choice of donor organ is impacted by this potential adverse consequence. Improved methods of reducing PGD risk and efforts to safely expand the pool are being developed. Ex vivo lung perfusion is a strategy that may improve risk assessment and become a promising platform to implement treatment interventions to prevent PGD. This review details recent updates in the epidemiology, pathophysiology, molecular and genetic biomarkers, and state-of-the-art technical developments affecting PGD.
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Affiliation(s)
- Yoshikazu Suzuki
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Edward Cantu
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Jason D Christie
- Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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27
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Abstract
Dynamic changes in microvascular endothelial structure and function are pivotal in the acute inflammatory response, the body's rapid, coordinated effort to localize, sequester, and eliminate microbial invaders at their portal of entry. To achieve this, the endothelium becomes leaky and inflamed, providing innate immune cells and humoral effector molecules access to the site of infection. During sepsis this locally adaptive response becomes manifest throughout the body, leading to dangerous host consequences. Increased leakiness in the pulmonary circulation contributes to acute respiratory distress syndrome (ARDS), a complication of sepsis associated with 40% mortality. Understanding the molecular governance of vascular leak and inflammation has major diagnostic, prognostic, and potentially therapeutic implications for this common and pernicious disease. This review summarizes results from cell-based experiments, animal models, and observational human studies; together, these studies suggest that an endothelial receptor called Tie2 and its ligands, called angiopoietins, form a signaling axis key to the vascular dyshomeostasis that underlies sepsis.
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