Reperfusion Injury In Lung Transplantation Research Articles

(1061) - Human Mesenchymal Cell Derived Exosomes as Preventive Therapy for Ischemia Reperfusion Injury in Lung Transplantation

(1061) - Human Mesenchymal Cell Derived Exosomes as Preventive Therapy for Ischemia Reperfusion Injury in Lung Transplantation

Cell death and ischemia-reperfusion injury in lung transplantation.

Lung transplantation is the most effective therapy for patients with end-stage lung disease. However, concern of donor lung damage and ischemia-reperfusion induced lung injury limits the use of "marginal" donor lungs. Recent transcriptomic studies have demonstrated that the enrichment of gene-clusters related to cell death and inflammation are the most profound signals during ischemia-reperfusion in human lung transplants. Herein, we focus on the relationship between inflammation and programmed cell death, especially necroptosis, mitochondrial permeability transition-initiated regulated necrosis, pyroptosis, ferroptosis, and autophagic cell death. Cell death-related molecules have been tested as potential biomarkers for donor lung assessment. Inhibitors for various types of cell death have been explored as therapeutics for ischemia reperfusion injury in lung transplantation. A deeper understanding of these mechanisms may help to improve donor management, organ preservation, prevention and treatment of primary graft dysfunction during and post transplantation. Moreover, evaluation and treatment of cell death and inflammation during ex vivo lung perfusion may be a game changer in donor organ management, assessment, repair, and reconditioning.

Ischemia-Reperfusion Injury in Lung Transplantation.

Lung transplantation has been established worldwide as the last treatment for end-stage respiratory failure. However, ischemia–reperfusion injury (IRI) inevitably occurs after lung transplantation. The most severe form of IRI leads to primary graft failure, which is an important cause of morbidity and mortality after lung transplantation. IRI may also induce rejection, which is the main cause of mortality in recipients. Despite advances in donor management and graft preservation, most donor grafts are still unsuitable for transplantation. Although the pulmonary endothelium is the primary target site of IRI, the pathophysiology of lung IRI remains incompletely understood. It is essential to understand the mechanism of pulmonary IRI to improve the outcomes of lung transplantation. Therefore, we reviewed the state-of-the-art in the management of pulmonary IRI after lung transplantation. Recently, the ex vivo lung perfusion (EVLP) system has been clinically introduced worldwide. Various promising therapeutic strategies for the protection of the endothelium against IRI, including EVLP, inhalation therapy with therapeutic gases and substances, fibrinolytic treatment, and mesenchymal stromal cell therapy, are awaiting clinical application. We herein review the latest advances in the field of pulmonary IRI in lung transplantation.

Annexin V homodimer protects against ischemia reperfusion–induced acute lung injury in lung transplantation

ObjectiveWe hypothesized that administration of a homodimer of recombinant annexin V, diannexin, could shield phosphatidylserine on the endothelium, and inhibit leukocyte and platelet adhesion, thereby potentially reducing ischemia reperfusion injury (IRI) in lung transplantation. This hypothesis was tested using a rat syngeneic single left-lung transplant model. MethodsRats were randomly assigned to receive diannexin (DN group; n = 10) or normal saline (control group; n = 10). Diannexin (1000 μg/kg) was administered to the donor lung in the pulmonary flush solution, and to the recipient intravenously, 5 minutes after initiation of reperfusion. Grafts were reperfused for 2 hours. ResultsThe transplanted grafts in the DN group performed significantly better in gas exchange with higher partial pressure of oxygen (control group: 179 ± 121 vs DN group: 330 ± 54 mm Hg; P = .007) and lower partial pressure of carbon dioxide (control: 55.1 ± 26 vs DN: 34.2 ± 11 mm Hg; P = .04), as well as lower peak airway pressure (control: 20.5 ± 8.5 vs DN: 12.0 ± 7.9 cm H2O; P = .035) after 2 hours of reperfusion. Wet-to-dry lung weight ratio (P = .054), and alveolar fibrin deposition score (P = .04), were reduced in the DN group. Caspase-cleaved cytokeratin 18 in plasma (a marker of epithelial apoptosis) was significantly reduced in the DN group (P = .013). Furthermore, gene-expression levels of proinflammatory cytokines in the transplanted graft, including interleukin-6 (P = .04) and macrophage inflammatory protein 2 (P = .03) were significantly decreased in the DN group. ConclusionsA homodimer of recombinant annexin V reduced ischemia reperfusion injury in a lung transplant animal model, by reducing cell death and tissue inflammation.

Inhaled Nitric Oxide for Modulation of Ischemia–Reperfusion Injury in Lung Transplantation

The prophylactic administration of inhaled nitric oxide (NO) during reperfusion after lung transplantation has been shown to reduce neutrophil-induced injury in animal models. There remain questions regarding efficacy in the clinical setting and concerns regarding increased free radical injury. We sought to assess the efficacy of NO in reducing neutrophil infiltration and associated injury if administered from the very onset of reperfusion in clinical lung transplantation. Twenty bilateral sequential lung transplant recipients were randomized to receive 20-ppm inhaled NO (NO group) or a standard anesthetic gas mixture (control group) from the onset of ventilation. Bronchoalveolar lavage was performed immediately prior to implantation and after 30 minutes of reperfusion and analyzed for inflammatory cytokine levels and free radical surrogates. Primary graft dysfunction (PGD) scoring was performed prospectively for 72 hours post-transplant. The prophylactic administration of NO during the first 30 minutes of reperfusion had no statistically significant effect on the development of Grade II to III PGD (5 of 10 in NO group and 7 of 10 in control group, p = 0.36) or gas exchange (area under the curve: 429 +/- 296 vs 336 +/- 306; p = 0.64) in the NO and control groups, respectively. Pulmonary neutrophil sequestration, as measured by the transpulmonary arteriovenous neutrophil difference, was not influenced by the administration of NO. Prophylactic NO did not significantly alter the concentration of interleukin-8, myeloperoxidase or nitrotyrosine during transplantation. This study could not demonstrate a significant effect of inhaled NO during the first 30 minutes of reperfusion in the prevention of neutrophil injury and primary graft dysfunction after lung transplantation.

Addition of a neutrophil elastase inhibitor to the organ flushing solution decreases lung reperfusion injury in rat lung transplantation

Neutrophil elastase plays an important role in ischemia-reperfusion injury. We hypothesized that the addition of sivelestat, a specific neutrophil elastase inhibitor, to the organ flushing solution would decrease reperfusion injury in a rat single left-lung transplant model. All donor lungs were flushed with 25 ml low-potassium dextran-glucose solution and stored for 16 h at 4 degrees C. Rats were divided into three experimental groups (n=10) that received donor lungs washed in either normal flushing solution (group 1), or flushing solution containing 20mg sivelestat (group 2) or 40 mg sivelestat (group 3). Graft function was assessed 48 h after reperfusion using five measurements: isolated graft oxygenation, wet/dry ratio, peak airway pressure, tissue myeloperoxidase activity, and serum lipid peroxides level. Histological examination of lung grafts was also performed. Group 3 showed better oxygenation (groups 1, 2, and 3: 133.9+/-113.5, 254.0+/-84.6, and 378.7+/-77.6 mmHg, respectively; p<0.0001 vs group 1, p=0.0052 vs group 2), lower peak airway pressure (groups 1, 2, and 3: 28.7+/-6.1, 26.0+/-5.8, and 21.5+/-5.3 mmHg, respectively; p=0.0385 vs group 1), lower wet/dry ratio (groups 1, 2, and 3: 6.74+/-0.78, 5.77+/-0.52, and 4.90+/-0.16, respectively; p=0.0010 vs group 1), and lower myeloperoxidase activity (groups 1, 2, and 3: 0.304+/-0.081, 0.178+/-0.053, and 0.106+/-0.029 DeltaOD/mg/min, respectively; p<0.0001 vs group 1, p=0.0319 vs group 2). No significant differences in arterial PaCO(2) and serum lipid peroxide levels were observed between the three groups. Addition of sivelestat to the organ flushing solution ameliorated ischemia-reperfusion injury in a lung transplant model.

52: Non-hypoxic ischemia: An accurate cell culture model of ischemia reperfusion injury in lung transplantation

“non-treated” control. Furthermore another control investigating the impact of the vehicle ethyl alcohol was obtained. Results: The maximal contractile response for 1mmol NA was similar between the different concentrations of RAPA and the controls. Comparing the ACh induced relaxation in relation to the NA (1mmol) induced precontraction before versus after incubation in each group, we found a concentration dependent decrease in relaxation, being significant for 1mmol and 10mmol RAPA compared to the control (in %: control: 48.0 4.4; 1mmol :30.2 2.8, p 0.01; 10mmol: 12.9 1.2, p 0.001, ethyl alcohol: 51.2 3.3 n.s.). Conclusions: Our results revealed, that contractility induced by NA revealed no direct effect of RAPA on muscular contractile function. However, relaxation of ITA induced by ACh is concentration-dependently decreased by RAPA indicating impaired endothelial function after only short-term exposure to RAPA.

DNA damage and mismatch repair pathway in lung ischemia and reperfusion injury

Oxidative damage induced by reperfusion is responsible for increased morbidity and mortality following lung transplantation. A stable and deleterious DNA adduct, 8-oxogaunine (8-oxoG) results due to oxidative DNA damage. Mut-Y homologue (MYH) is a DNA repair enzyme promoting DNA reconstruction through the mismatch repair pathway to repair 8-oxoG lesion. We investigated the role of DNA mismatch repair pathway mediated by MYH in the setting of lung ischemia and reperfusion. Left lungs of the adult Sprague Dawley rats were subjected to 1 h ischemia and 2 and 4 h reperfusion. Un-operated animals served as controls. Quantification of 8-oxoG was performed using immunohistochemistry (IHC) and MYH was analyzed by Western blot. Apoptosis was assessed by caspase-3 levels. Indices of inflammation and permeability were raised in both reperfusion groups. There was significant increase in DNA damage as reflected by positive 8-oxoG staining in 2 h (22% increase) and 4 h reperfusion (31% increase) compared to control ( p < 0.01). MYH staining by IHC was significantly reduced in 2 and 4 h reperfusion compared to controls ( p < 0.05). Down regulation of DNA repair enzyme (MYH) was mirrored functionally by decreased protein levels in lung tissues subjected to reperfusion compared to controls. Increasing apoptosis was detected in the reperfusion groups as reflected by caspase-3 IHC and protein estimation by Western blot. Reperfusion leads to increased DNA damage and down regulation of DNA mismatch repair pathway in a model of ischemia and reperfusion in lungs. Gene therapy targeted at this pathway may prove an attractive therapeutic intervention to reduce reperfusion injury in lung transplantation.

Intra-operative use of inhaled vasodilators: are there indications?

The US Food and Drug Administration and European authorities have recently approved inhaled nitric oxide for the treatment of neonates with hypoxic respiratory failure associated with pulmonary hypertension. In addition to this highly specific condition, there is an increasing 'off-label' use of inhaled nitric oxide and other inhaled vasodilators in the perioperative setting. Potential indications include right heart failure as a result of acute pulmonary hypertension in cardiac and non-cardiac surgery, the prevention of reperfusion injury in lung transplantation, the treatment of hypoxaemia during single-lung ventilation, and more recently, the treatment of sickle cell crisis.

Ameliorated reperfusion injury in lung transplantation after reduction of brain death induced inflammatory graft damage in the donor

AMELIORATED REPERFUSION INJURY IN LUNG TRANSPLANTATION AFTER REDUCTION OF BRAIN DEATH INDUCED INFLAMMATORY GRAFT DAMAGE IN THE DONOR C.H. Wigfield, H.D. Golledge, B.K. Shenton, J.A. Kirby, J.H. Dark, Department of Cardiothoracic Surgery and Transplantation, Freeman Hospital, Newcastle upon Tyne, United Kingdom; Comparative Biology Centre, University of Newcastle, Newcastle upon Tyne, United Kingdom; Department of Surgery, University of Newcastle, Newcastle upon Tyne, United Kingdom

Dynamic changes in apoptotic and necrotic cell death correlate with severity of ischemia-reperfusion injury in lung transplantation.

Ischemia-reperfusion (IR) injury is a major cause of organ dysfunction following lung transplantation. We have recently described increased apoptosis in transplanted human lungs after graft reperfusion. However, a direct correlation between ischemic time, cell death, and posttransplant lung function has not yet been demonstrated. We hypothesized that an increased ischemic period would lead to an increase in cell death, and that the degree and type of cell death would correlate with lung function. To investigate this, we preserved rat lungs at 4 degrees C for 20 min and 6, 12, 18, and 24 h, and then transplanted the lungs and reperfused them for 2 h. Cell viability was determined with a triple staining technique combining trypan blue, terminal deoxynucleotidyl transferase-uridine nucleotide end-labeling, and propidium iodide nuclear staining. Percentages of apoptotic and necrotic cells were calculated from total cell numbers. Following 20 min and 6 and 12 h of cold preservation, less than 2% of graft cells were dead, whereas after 18 and 24 h of cold preservation, 11% and 27% of cells were dead (p < 0.05), the majority of which were necrotic. After transplantation and reperfusion, the mode of cell death changed significantly. In the 6- and 12-h groups, approximately 30% of cells were apoptotic and < 2% were necrotic, whereas in the 18- and 24-h groups, 21% and 29% of cells, respectively, were necrotic and less than 1% were apoptotic. Lung function (Pa(O(2))) decreased significantly (p < 0.05) with increasing preservation time. The percentage of necrotic cells was inversely correlated with posttransplant graft function (p < 0.0001). The study demonstrates a significant association among cold preservation time, extent and mode of cell death, and posttransplant lung function, and suggests new potential strategies to prevent and treat IR injury.

The effects of a neutrophil elastase inhibitor (ONO-5046 · Na) and neutrophil depletion using a granulotrap (G-1) column on lung reperfusion injury in dogs

Background: Activated neutrophils are reported to be closely involved in ischemia-reperfusion injury after lung transplantation. We investigated the beneficial effects of a new recombinant specific neutrophil elastase inhibitor, ONO-5046 · Na, and an extracorporeal-type granulotrap (G-1) column on ischemia-reperfusion lung injury, by using an in situ warm lung ischemia model in dogs. Methods Warm ischemia was induced for 3 hours by clamping the pulmonary arteries and veins. The left main bronchus was bisected and reanastomosed prior to reperfusion. The left lung was collapsed for 3 hours. A total of 27 adult mongrel dogs were divided into three groups: the control group ( n = 9) treated with a saline vehicle; the ONO group ( n = 9), in which ONO-5046 · Na was continuously administrated from before induced ischemia and to ending 2 hours after reperfusion; and the G-1 group ( n = 9), in which a G-1 column was applied for 90 minutes starting 30 minutes before reperfusion under passive bypass support. Results Circulating neutrophils in the G-1 group decreased significantly ( p < .05) compared to preischemia, and significantly decreased compared with the other groups after reperfusion. Oxygenation was improved actually and pulmonary vascular resistance was kept lower level after the administration of ONO-5046 · Na. The increase of lung weight was significantly ameliorated in both the G-1 and ONO groups. In the histopathological study, lungs from the control group demonstrated diffuse alveolar edema, neutrophil infiltration, massive alveolar exudate and hemorrhage, and thickening of the interstitium. Lungs from the G-1 group showed mild swelling of the alveolar wall and neutrophil infiltration. Lungs from the ONO group showed virtually no abnormalities. Conclusion This study demonstrated that a neutrophil elastase inhibitor and neutrophil depletion prevented lung reperfusion injury. These treatments may prevent ischemia and reperfusion injury in lung transplantation.

Oxygen free radical scavengers decrease reperfusion injury in lung transplantation

An in vivo canine model was used to assess the ability of an oxygen free radical scavenger to decrease reperfusion injury in lung transplantation. In 12 dogs, the left lungs were transplanted after they had been preserved for 24 hours at 4 °C after pulmonary artery flushing with modified Eurocollins solution. In 6 dogs, dimethylthiourea, a potent oxygen free radical scavenger, was added to the flush solution and was also given to the recipients just before reperfusion. In all animals, the contralateral pulmonary artery and bronchus were ligated and lung function was assessed for 12 hours or until death. Three dogs died prematurely in the control group, whereas only 1 dog died prematurely in the dimethylthiourea group. This resulted in a statistically significant difference in the average length of survival ( p < 0.05). Pulmonary artery and right atrial pressures were significantly lower in the dimethylthiourea group during the first 6 hours ( p < 0.05). Treatment with dimethylthiourea resulted in a significantly higher arterial oxygen tension at 4 hours, and intrapulmonary shunt tended to be lower. Thus, it would appear that dimethylthiourea has a protective effect on lungs preserved for 24 hours before transplantation in dogs.