Plasma resuscitation with adjunctive peritoneal resuscitation reduces ischemic intestinal injury following hemorrhagic shock.J Trauma Acute Care Surg. 2020;89:649-657. [PMID: 32773670 DOI: 10.1097/TA.0000000000002847]

Plasma resuscitation restores glomerular hyaluronic acid and mitigates hemorrhage-induced glomerular dysfunction

BACKGROUND

Acute renal dysfunction following hemorrhagic shock and resuscitation carries significant morbidity and mortality. While shock-induced shedding of the glycocalyx is well described within the pulmonary and splanchnic vasculature, less is known regarding early alterations to the glycocalyx of the renal microcirculation, particularly the glomerulus. We sought to evaluate the impact of hemorrhagic shock and resuscitation modalities on glomerular glycocalyx metabolism and function. We hypothesized that fresh frozen plasma resuscitation would attenuate glomerular glycocalyx shedding and reduce glomerular barrier dysfunction.

METHODS

Male Sprague-Dawley rats were subjected to 60 minutes of hemorrhagic shock to 40% of baseline mean arterial pressure, followed by resuscitation with shed whole blood and either lactated Ringer's or fresh frozen plasma. Experimental groups included the following: (a) baseline, (b) post-hemorrhagic shock, (c) post-lactated Ringer's resuscitation, and (d) post-plasma resuscitation. Enzyme-linked immunosorbent assays and immunohistochemistry were used to evaluate alterations of syndecan-1 and hyaluronic acid within the glomerular glycocalyx. Urine protein concentration was measured as a surrogate for glomerular function, and expression of cubilin and megalin was quantified to evaluate renal tubule protein reabsorptive capacity.

RESULTS

Despite evidence of systemic glycocalyx shedding, hemorrhagic shock and resuscitation did not alter glomerular synedcan-1 expression. However, shock induced shedding of hyaluronic acid from the glomerular glycocalyx. While hyaluronic acid breakdown was exacerbated by crystalloid resuscitation, plasma utilization restored levels back to baseline. Urine protein concentration drastically increased following hemorrhagic shock and resuscitation with lactated Ringer's. By contrast, plasma administration reduced urine protein levels back to normal. Renal cortex cubilin and megalin expression did not differ among the experimental groups, suggesting that alterations in urine protein were driven by changes in glomerular function.

CONCLUSION

Plasma-based resuscitation appears to reverse shock-induced shedding of glomerular hyaluronic acid and attenuates glomerular barrier dysfunction. Differential shedding of the glomerular glycocalyx may represent a novel pathway in acute kidney injury pathophysiology.

Neutrophil extracellular traps drive intestinal microvascular endothelial ferroptosis by impairing Fundc1-dependent mitophagy

Microvascular endothelial damage caused by intestinal ischemia‒reperfusion (II/R) is a primary catalyst for microcirculation dysfunction and enterogenous infection. Previous studies have mainly focused on how neutrophil extracellular traps (NETs) and ferroptosis cause intestinal epithelial injury, and little attention has been given to how NETs, mainly from circulatory neutrophils, affect intestinal endothelial cells during II/R. This study aimed to unravel the mechanisms through which NETs cause intestinal microvascular dysfunction. We first detected heightened local NET infiltration around the intestinal microvasculature, accompanied by increased endothelial cell ferroptosis, resulting in microcirculation dysfunction in both human and animal II/R models. However, the administration of the ferroptosis inhibitor ferrostatin-1 or the inhibition of NETs via neutrophil-specific peptidylarginine deiminase 4 (Pad4) deficiency led to positive outcomes, with reduced intestinal endothelial ferroptosis and microvascular function recovery. Moreover, RNA-seq analysis revealed a significant enrichment of mitophagy- and ferroptosis-related signaling pathways in HUVECs incubated with NETs. Mechanistically, elevated NET formation induced Fundc1 phosphorylation at Tyr18 in intestinal endothelial cells, which led to mitophagy inhibition, mitochondrial quality control imbalance, and excessive mitochondrial ROS generation and lipid peroxidation, resulting in endothelial ferroptosis and microvascular dysfunction. Nevertheless, using the mitophagy activator urolithin A or AAV-Fundc1 transfection could reverse this process and ameliorate microvascular damage. We first demonstrate that increased NETosis could result in intestinal microcirculatory dysfunction and conclude that suppressed NET formation can mitigate intestinal endothelial ferroptosis by improving Fundc1-dependent mitophagy. Targeting NETs could be a promising approach for treating II/R-induced intestinal microcirculatory dysfunction.

Plasma resuscitation improves and restores intestinal microcirculatory physiology following haemorrhagic shock

BACKGROUND AND OBJECTIVES

Intestinal ischaemia-reperfusion injury following resuscitated haemorrhagic shock (HS) leads to endothelial and microcirculatory dysfunction and intestinal barrier breakdown. Although vascular smooth muscle machinery remains intact, microvascular vasoconstriction occurs secondary to endothelial cell dysfunction, resulting in further ischaemia and organ injury. Resuscitation with fresh frozen plasma (FFP) improves blood flow, stabilizes the endothelial glycocalyx and alleviates organ injury. We postulate these improvements correlate with decreased tissue CO2 concentrations, improved microvascular oxygenation and attenuation of intestinal microvascular endothelial dysfunction.

MATERIALS AND METHODS

Male Sprague-Dawley rats were randomly assigned to groups (n = 8/group): (1) sham, (2) HS (40% mean arterial blood pressure [MAP], 60 min) + crystalloid resuscitation (CR) (shed blood saline) and (3) HS + FFP (shed blood + FFP). MAP, heart rate (HR), ileal perfusion, pO2 and pCO2 were measured at intervals until 4 h post-resuscitation (post-RES). At 4 h post-RES, the ileum was rinsed in situ with Krebs solution. Topical acetylcholine and then nitroprusside were applied for 10 min each. Serum was obtained, and after euthanasia, tissues were harvested and snap-frozen in liquid N2 and stored at -80°C.

RESULTS

FFP resuscitation resulted in sustained ileal perfusion as well as rapid sustained return to baseline microvascular pO2 and pCO2 values when compared to CR (p < 0.05). Endothelial function was preserved relative to sham in the FFP group but not in the CR group (p < 0.05).

CONCLUSION

FFP-based resuscitation improves intestinal perfusion immediately following resuscitation, which correlates with improved tissue oxygenation and decreased tissue CO2 levels. CR resulted in significant damage to endothelial vasodilation response to acetylcholine, while FFP preserved this function.

Protective effects of salvianolic acid B on intestinal ischemia/reperfusion injury in rats by regulating the AhR/IL-22/STAT6 axis

PURPOSE

Intestinal ischemia/reperfusion (I/R) injury (IIRI) is associated with high morbidity and mortality. Salvianolic acid B (Sal-B) could exert neuroprotective effects on reperfusion injury after cerebral vascular occlusion, but its effect on IIRI remains unclear. This study set out to investigate the protective effects of Sal-B on IIRI in rats.

METHODS

The rat IIRI model was established by occluding the superior mesenteric artery and reperfusion, and they were pretreated with Sal-B and aryl hydrocarbon receptor (AhR) antagonist CH-223191 before surgery. Pathological changes in rat ileum, IIRI degree, and intestinal cell apoptosis were evaluated through hematoxylin-eosin staining, Chiu's score scale, and TUNEL staining, together with the determination of caspase-3, AhR protein level in the nucleus, and STAT6 phosphorylation by Western blotting. The levels of inflammatory cytokines (IL-1β/IL-6/TNF-α) and IL-22 were determined by ELISA and RT-qPCR. The contents of superoxide dismutase (SOD), glutathione (GSH), and malondialdehyde (MDA) in intestinal tissues were determined by spectrophotometry.

RESULTS

Sal-B alleviated IIRI in rats, evidenced by slight villi shedding and villi edema, reduced Chiu's score, and diminished the number of TUNEL-positive cells and caspase-3 expression. SAL-B alleviated inflammation and oxidative stress (OS) responses induced by IIRI. Sal-B promoted IL-22 secretion by activating AhR in intestinal tissue after IIRI. Inhibition of AhR activation partially reversed the protective effect of Sal-B on IIRI. Sal-B promoted STAT6 phosphorylation by activating the AhR/IL-22 axis.

CONCLUSION

Sal-B plays a protective role against IIRI in rats by activating the AhR/IL-22/STAT6 axis, which may be achieved by reducing the intestinal inflammatory response and OS responses.

ESTROGEN ALLEVIATES POSTHEMORRHAGIC SHOCK MESENTERIC LYMPH-MEDIATED LUNG INJURY THROUGH AUTOPHAGY INHIBITION

ABSTRACT

Background: Hemorrhagic shock-induced acute lung injury (ALI) is commonly associated with the posthemorrhagic shock mesenteric lymph (PHSML) return. Whether excessive autophagy is involved in PHSML-mediated ALI remains unclear. The relationship between estrogen treatment and PHSML or autophagy needs to verify. The current study will clarify the role of estrogen in reducing PHSML-mediated ALI through inhibition of autophagy. Methods: First, a hemorrhagic shock model in conscious rats was used to observe the effects of 17β-estradiol (E2) on intestinal blood flow, pulmonary function, intestinal and pulmonary morphology, and expression of autophagy marker proteins. Meanwhile, the effect of PHSML and autophagy agonist during E2 treatment was also investigated. Secondly, rat primary pulmonary microvascular endothelial cells were used to observe the effect of PHSML, PHSML plus E2, and E2-PHSML (PHSML obtained from rats treated by E2) on the cell viability. Results: Hemorrhagic shock induced intestinal and pulmonary tissue damage and increased wet/dry ratio, reduced intestinal blood flow, along with pulmonary dysfunction characterized by increased functional residual capacity and lung resistance and decreased inspiratory capacity and peak expiratory flow. Hemorrhagic shock also enhanced the autophagy levels in intestinal and pulmonary tissue, which was characterized by increased expressions of LC3 II/I and Beclin-1 and decreased expression of p62. E2 treatment significantly attenuated these adverse changes after hemorrhagic shock, which was reversed by PHSML or rapamycin administration. Importantly, PHSML incubation decreased the viability of pulmonary microvascular endothelial cells, while E2 coincubation or E2-treated lymph counteracted the adverse roles of PHSML. Conclusions: The role of estrogen reducing PHSML-mediated ALI is associated with the inhibition of autophagy.

Direct Peritoneal Resuscitation for Trauma

Direct peritoneal resuscitation (DPR) has been found to be a useful adjunct in the management of critically ill trauma patients. DPR is performed following damage control surgery by leaving a surgical drain in the mesentery, placing a temporary abdominal closure, and postoperatively running peritoneal dialysis solution through the surgical drain with removal through the temporary closure. In the original animal models, the peritoneal dialysate infusion was found to augment visceral microcirculatory blood flow reducing the ischemic insult that occurs following hemorrhagic shock. DPR was also found to minimize the aberrant immune response that occurs secondary to shock and contributes to multisystem organ dysfunction. In the subsequent human trials, performing DPR had significant effects in several key categories. Traumatically injured patients who received DPR had a significantly shorter time to definitive fascial closure, had a higher likelihood of achieving primary fascial closure, and experienced fewer abdominal complications. The use of DPR has been further expanded as a useful adjunct for emergency general surgery patients and in the pretransplant care of human cadaver organ donors.

The role of direct peritoneal resuscitation in the treatment of hemorrhagic shock after trauma and in emergency acute care surgery: a systematic review

PURPOSE

Direct peritoneal resuscitation (DPR) has been used to help preserve microcirculation by reversing vasoconstriction and hypoperfusion associated with the pathophysiological process of shock, which can occur despite appropriate intravenous resuscitation. This approach depends on infusing a hyperosmolar solution intraperitoneally via a percutaneous catheter with the tip ending near the pelvis or the root of the mesentery. The abdomen is usually left open with a negative pressure abdominal dressing to continuously evacuate the infused dialysate. Hypertonicity of the solution triggers visceral vasodilation to help maintain blood flow, even during shock, and is also associated with reduced local inflammatory cytokines and other mediators, preservation of endothelial cell function, and mitigation of organ edema and necrosis. It also has a direct effect on liver perfusion and edema, more rapidly corrects electrolyte abnormalities compared to intravenous resuscitation alone, and may requireless intravenous fluid to stabilize blood pressure, all of which shortens the time required to close patients' abdomen.

METHODS

An online query using the search term "direct peritoneal resuscitation" was carried out in PubMed, MEDLINE and SciELO, limited to publications indexed from January 2014 to June 2020. Of the 20 articles returned, full text was able to be obtained for 19. A manual review of included articles' references was resulted in the addition of 1 article, for a total of 20 included articles.

RESULTS

The 20 articles were comprised of 15 animal studies, 4 clinical studies,and 1 expert opinion. The benefits include both local and possibly systemic effects on perfusion, hypoxia, acidosis, and inflammation, and are associated with improved outcomes and reduced complications.

CONCLUSION

DPR shows promise in patients with hemorrhagic shock, septic shock, and other conditions resulting in an open abdomen after damage control laparotomy.

CD226 deficiency promotes glutaminolysis and alleviates mitochondria damage in vascular endothelial cells under hemorrhagic shock

Hemorrhagic shock (HS) is common in clinical emergencies, leading to millions of deaths each year globally. CD226 is a costimulatory adhesion molecule expressed on both immune cells and endothelial cells (ECs) to regulate their metabolic activity and function. As endothelial dysfunction occurs after HS, the roles CD226 plays in vascular EC metabolism were investigated. CD226^fl/fl Tek^cre mice were adopted to achieve vascular EC-specific knockout of CD226, and subjected to HS modelling. Serum levels of crucial intermediate metabolites were evaluated through liquid chromatography-mass spectrometry analysis. Human umbilical vein ECs (HUVECs) were used to study the effects of CD226 under hypoxia in vitro. Seahorse analysis evaluated the cellular glycolysis and mitochondria bioenergetics. Results showed that CD226 deficiency in vascular ECs alleviated HS-induced intestinal damage and inflammatory response in mice. Animal studies indicated an improved energy metabolism when CD226 was knocked out in ECs after HS, as evidenced by enhanced glutamine-glutamate metabolism and decreased lactic acid levels. Glut-1 was upregulated in mouse vascular ECs after HS and HUVECs under hypoxia, combined with decreased CD226. Moreover, HUVECs with CD226 knockdown exhibited relieved mitochondrial damage and early apoptosis under hypoxia, whereas CD226 overexpression showed opposite effects. Seahorse analysis showed that downregulated CD226 significantly increased mitochondrial ATP production and glucose uptake in HUVECs under hypoxia. Additionally, Erk/PHD2 signaling-mediated HIF-1α/Glut-1 and HIF-2α/ASCT2 pathways were involved in CD226 regulation on HUVEC glutaminolysis after hypoxia. Hence, CD226 deficiency promotes bypass energy supply to vascular ECs under ischemic or hypoxic stress, to ameliorate the stress-mediated metabolic disturbance.

Recombinant angiopoietin-like protein 4 attenuates intestinal barrier structure and function injury after ischemia/reperfusion

BACKGROUND

Intestinal barrier breakdown, a frequent complication of intestinal ischemia-reperfusion (I/R) including dysfunction and the structure changes of the intestine, is characterized by a loss of tight junction and enhanced permeability of the intestinal barrier and increased mortality. To develop effective and novel therapeutics is important for the improvement of outcome of patients with intestinal barrier deterioration. Recombinant human angiopoietin-like protein 4 (rhANGPTL4) is reported to protect the blood-brain barrier when administered exogenously, and endogenous ANGPTL4 deficiency deteriorates radiation-induced intestinal injury.

AIM

To identify whether rhANGPTL4 may protect intestinal barrier breakdown induced by I/R.

METHODS

Intestinal I/R injury was elicited through clamping the superior mesenteric artery for 60 min followed by 240 min reperfusion. Intestinal epithelial (Caco-2) cells and human umbilical vein endothelial cells were challenged by hypoxia/ reoxygenation to mimic I/R in vitro.

RESULTS

Indicators including fluorescein isothiocyanate-conjugated dextran (4 kilodaltons; FD-4) clearance, ratio of phosphorylated myosin light chain/total myosin light chain, myosin light chain kinase and loss of zonula occludens-1, claudin-2 and VE-cadherin were significantly increased after intestinal I/R or cell hypoxia/reoxygenation. rhANGPTL4 treatment significantly reversed these indicators, which were associated with inhibiting the inflammatory and oxidative cascade, excessive activation of cellular autophagy and apoptosis and improvement of survival rate. Similar results were observed in vitro when cells were challenged by hypoxia/reoxygenation, whereas rhANGPTL4 reversed the indicators close to normal level in Caco-2 cells and human umbilical vein endothelial cells significantly.

CONCLUSION

rhANGPTL4 can function as a protective agent against intestinal injury induced by intestinal I/R and improve survival via maintenance of intestinal barrier structure and functions.