Cytokine interleukin-2, tumor necrosis factor-alpha, and interferon-gamma release after ischemia/reperfusion injury in a novel lung autograft animal model

Biomarkers of lung injury in primary graft dysfunction following lung transplantation

Primary graft dysfunction, a form of reperfusion pulmonary edema that occurs early after lung transplantation, shares key clinical and pathological features with acute lung injury and its more severe form, the acute respiratory distress syndrome. However, in contrast to acute lung injury/acute respiratory distress syndrome, in which biomarkers in plasma, urine and lung edema fluid have prognostic and pathogenetic value, the role of biomarkers in primary graft dysfunction has been less thoroughly explored. This review summarizes human and animal studies on biomarkers in primary graft dysfunction, including cytokines and markers of acute inflammation, VEGF, endothelial markers and adhesion molecules, markers of coagulation and fibrinolysis and markers of lung epithelial injury. Similarities to the literature in acute lung injury/acute respiratory distress syndrome are highlighted where appropriate, and future directions for research on the role of biomarkers in primary graft dysfunction are suggested.

Inflammatory response to pulmonary ischemia-reperfusion injury

Lung ischemia-reperfusion (IR) injury is one of the most important complications following lung transplant and cardiopulmonary bypass. The pulmonary dysfunction following lung IR has been well documented. Recent studies have shown that ischemia and reperfusion of the lung may each play significant yet differing roles in inducing lung injury. The mechanisms of injury involving neutrophil activation, and the release of numerous inflammatory mediators and oxygen radicals also contributes to lung cellular injury, pneumocyte necrosis, and apoptosis. We herein review the current understanding of the underlying mechanism involved in lung IR injury. The biomolecular mechanisms and interactions which lead to the inflammatory response, pneumocyte necrosis, and apoptosis following lung IR therefore warrant further investigation.

Immune modulation following immunization with polyvalent vaccines in dogs

A decline in T-cell-mediated immunity and transient state of immunosuppression after immunization has been reported in dogs. Nevertheless, dogs are still routinely vaccinated with polyvalent live vaccines and severe disease does not generally occur. In order to investigate these effects on the canine immune system and to elucidate possible mechanisms we determined the following immune parameters in the blood of 33 clinically sound German shepherd dogs before and after standard vaccination with a polyvalent vaccine against distemper, parvovirus, viral hepatitis, leptospirosis, kennel cough and rabies: white and differential blood cell count, the serum concentrations and/or activities of IL-1, IL-2, IFN-gamma, TNF-alpha, neopterin and IgG, natural killer (NK) cell activity, bactericidal activity and complement hemolytic activity, lymphocyte proliferation test (LPT) and nitroblue tetrazolium test (NBT). Our major findings were that significant postvaccinal decreases in T-cell mitogenic response to PHA and in neutrophil function and neopterin serum concentration were accompanied by simultaneous increase in plasma IgG and hemolytic complement activity. This suggests a transient shift in the balance between cell-mediated and humoral (T(H)1/T(H)2) immunity rather than immunosuppression. These results do not imply that dogs should not receive live vaccines, as the response to vaccines just seems to create a state of altered homeostasis when immunization elicits protection by humoral and cell-mediated immunity. However, these recognized compromises of immune function should be considered and vaccines still be applied only in healthy animals and strictly according to the rules and regulations given by the manufacturer.

Critical care issues in lung and heart transplantation

Although much has been accomplished in HTx and LTx in the past few decades, much remains to be conquered. It is an ever-changing, always fascinating field. Though science and technology know no limits, the primary limitation of HTx and LTx continues to be the availability of donor organs. One can only hope that further advances in educating the public will help close the large gap between the list of those waiting and the organs available for transplantation.

Respiratory failure after lung transplantation

STUDY OBJECTIVES

To characterize patients who acquired postoperative respiratory failure after lung transplantation (LT), and to identify risks associated with postoperative respiratory failure and poor surgical outcome.

STUDY DESIGN

Retrospective clinical analysis in a tertiary care transplantation center.

METHODS

We reviewed the records of 80 consecutive patients who underwent LT from April 1994 to May 1999, analyzing their records for a number of preoperative and perioperative variables and complications.

RESULTS

Forty-four patients (55%) acquired postoperative respiratory failure and had a mortality rate of 45%. No difference was noted between patients with respiratory failure and those without in terms of age (mean +/- SD, 56 +/- 9 years vs 53 +/- 11 years), gender, baseline pretransplant arterial blood gas analysis (PaCO(2), 46 +/- 9 mm Hg vs 44 +/- 10 mm Hg), and cardiopulmonary exercise testing (maximum oxygen uptake, 0.76 +/- 0.44 L/min/m(2) vs 0.82 +/- 0.20 L/min/m(2)). Ischemic reperfusion lung injury (IRLI) [55%] and perioperative cardiovascular/hemorrhagic events (36%) were the major contributors to the development of respiratory failure. Preoperative pulmonary hypertension, right ventricular (RV) dysfunction, ischemic times, and need for bilateral LT and cardiopulmonary bypass (CPB) were higher in patients with respiratory failure (p < 0.05) compared to recipients without respiratory failure. However, the presence of preoperative moderate-to-severe RV dysfunction was the only independent factor (odds ratio, 21.9; 95% confidence interval, 1.6 to 309.0).

CONCLUSION

Respiratory failure after LT is common and is associated with high morbidity and mortality. Respiratory failure often occurred in patients with operative technical complications, cardiovascular events, and postoperative IRLI, which were observed most in patients requiring CPB because of RV dysfunction.

Inflammation in lung transplantation for CF. Immunosuppression and modulation of inflammation

Lung transplantation is an accepted therapy for selected individuals with end-stage lung disease due to cystic fibrosis (CF). Recent data show that CF recipients of lung transplantation have survival as good as those of any other diagnostic group. After transplantation, CF patients confront the major threats to life and health of graft infection and rejection. Inflammation is the common mediator of injury to the lung in both these instances. Graft infection after lung transplantation involves the same micro-organisms as are typical with CF as well as opportunistic agents. Prophylactic strategies and aggressive diagnosis via bronchoscopy are both critical in the effective treatment of post-transplant lung infections. Graft rejection involves the detection and recognition of foreign antigen and the subsequent activation of specific T-lymphocyte clones leading to inflammatory injury to the donor organ. Immunosuppression is used to prevent and/or modulate host response to the donor organ and titrated to serum therapeutic drug monitoring and transbronchial biopsy findings. Precise clinical monitoring and aggressive diagnostic approaches are crucial to minimizing graft injury and enhancing life after transplantation. Although most CF lung transplant recipients experience both graft infection and rejection and the 5-yr survival rate remains at approx 50%, improvement in diagnosis and therapy continue over time. With the introduction of new approaches to antimicrobial therapy, new immunosuppressant agents and promising strategies to promote immune tolerance, survival after lung transplantation is likely to improve in the coming decades.

Ischemic pre-conditioning of 5 minutes but not of 10 minutes improves lung function after warm ischemia in a canine model

BACKGROUND

Protection from reperfusion injury by ischemic pre-conditioning (IPC) before prolonged ischemia has been proven for the heart and the liver. We now assess the efficacy of IPC to protect lungs from reperfusion injury.

METHODS

Eighteen foxhounds (25 to 30 kg) were anesthetized, intubated, and ventilated with a fraction of inspired oxygen of 0.3 at a volume-controlled mode to maintain arterial pCO2 of 30 to 40 mm Hg. After left thoracotomy, we performed warm ischemia for 3 hours by clamping the left hilus, and followed with 8 hours of reperfusion (control, n = 6). In the treated groups, IPC was performed either for 5 minutes followed by 15-minute reperfusion (n = 6, IPC-5), or by 2 successive cycles of 10-minute ischemia, followed by 10-minute reperfusion (n = 6, IPC-10) before prior to the 3-hours warm-ischemia period. Pulmonary compliance and gas exchange were determined separately for each lung, and we recorded pulmonary and systemic hemodynamics. We performed bronchoalveolar lavage (BAL) at the end of the experiment and determined total protein concentration as well as tumor necrosis factor alpha (TNF-alpha) mRNA expression in cell-free supernatant and in BAL cells, respectively. We also assessed the wet/dry ratio of the lung.

RESULTS

In the controls, on reperfusion, we encountered a progressive deterioration of gas exchange, especially of the reperfused left lung, which we could largely avoid using the IPC-5 protocol. Similarly, pulmonary compliance steadily declined but was much better in the ICP-5 group. Parallel to the improvement of gas exchange and lung mechanics, we found less total alveolar protein content and TNF-alpha mRNA expression in BAL cells in the IPC-5 than in the controls. However, we did not find IPC-10 to be paralleled by a significant improvement of lung function. Neither IPC-5 nor IPC-10 influenced the pulmonary vascular resistance index or the fluid accumulation in the lung.

CONCLUSION

The major finding of the present study was that 5 minutes of IPC improved lung function after 3 hours of warm ischemia of the lung.

FR167653 ameliorates pulmonary damage in ischemia-reperfusion injury in a canine lung transplantation model

BACKGROUND

Interleukin (IL)-1 and tumor necrosis factor-alpha (TNF-alpha) are recognized as important factors in ischemia-reperfusion (I/R) injury. FR167653 has been characterized as a potent suppressant of IL-1 and TNF-alpha production. We previously reported that FR167653 suppressed the expression of IL-1 beta mRNA after reperfusion and ameliorated pulmonary I/R injury following 3-hour left lung warm ischemia in dogs. The aim of this study was to investigate the effects of FR167653 on I/R injury in a canine left, single, lung transplantation model.

METHODS

We used 10 pairs of weight-matched dogs. We assigned 5 pairs to the FR group, in which each animal received FR167653 (1 mg/kg/hr) IV from 30 minutes before ischemia until 2 hours after reperfusion; we treated the transplanted lungs with FR167653 after the onset of reperfusion. The others were assigned to the control group. After 8-hour preservation with 4 degrees C Euro-Collins solution, orthotopic left, single, lung transplantation was performed. During a 5-minute clamping test at the right pulmonary artery of each recipient, the left (transplanted) pulmonary arterial pressure (L-PAP), left (transplanted) pulmonary vascular resistance (L-PVR), arterial oxygen pressure (PaO(2)), and alveolar-arterial oxygen pressure difference (A-aDO(2)) were measured. We harvested transplanted lung specimens for histologic study, and we counted polymorphonuclear neutrophils (PMNs), which were identified by staining with naphthol AS-D cholroacetate esterase. Pulmonary perfusion and ventilation scintigraphy (Tc-99m-MAA and Xe-133) were performed. We observed the animals for 3 days after transplantation.

RESULTS

The PAP, L-PVR, PaO(2), and A-aDO(2) revealed significantly (p < 0.05) better function in the FR group than in the control group. Histologically, lung edema was milder, and PMN infiltration was significantly (p < 0.05) lower in the FR group than in the control group. Xe-133 and Tc-99m-MAA were widely distributed throughout the graft lung in the FR group. Three-day survival rates in FR and control groups were 60% and 20%, respectively.

CONCLUSIONS

FR167653 appears to generate a protective effect on I/R injury in lung transplantation in dogs.

Reperfusion lung injury after cold preservation correlates with decreased levels of intrapulmonary high-energy phosphates

BACKGROUND

To evaluate the role of energy state in primary graft dysfunction, which is crucial in lung transplantation, we investigated the relationship between intrapulmonary high-energy phosphate compounds and reperfusion lung injury after cold preservation.

METHODS

Using an isolated rat lung perfusion model with fresh rat blood as perfusate, rat lungs were exposed to various cold preservation periods (0, 6, 9, and 12 hr) and reperfused.

RESULTS

We found that extending the preservation period exacerbated the pulmonary hemodynamics after reperfusion. The levels of intrapulmonary high-energy phosphate compounds did not change during cold preservation, but these levels after reperfusion decreased as the preservation period was prolonged. The pulmonary hemodynamics after reperfusion were inversely correlated with the intrapulmonary high-energy phosphate compound levels after reperfusion. Total adenine nucleotide and ATP were sensitive indicators of reperfusion lung injury after cold preservation. Energy charge was not a sensitive indicator. The decreased levels of intrapulmonary high-energy phosphate compounds after reperfusion following cold preservation period were partially caused by their decreased production.

CONCLUSIONS

These results demonstrated that reperfusion lung injury after cold preservation was closely correlated with decreased levels of intrapulmonary high-energy phosphate compounds after reperfusion, although the levels of the intrapulmonary high-energy phosphate compounds did not change during cold preservation of up to 12 hr.

Alterations of nitric oxide synthase expression and activity during rat lung transplantation

Decreased nitric oxide (NO) production has been reported during lung transplantation in patients. To study the effects of ischemia and reperfusion on endogenous NO synthase (NOS) expression, both an ex vivo and an in vivo lung injury model for transplantation were used. Donor rat lungs were flushed with cold low-potassium dextran solution and subjected to either cold (4 degrees C for 12 h) or warm (21 degrees C for 4 h) ischemic preservation followed by reperfusion with an ex vivo model. A significant increase in inducible NOS and a decrease in endothelial NOS mRNA was found after reperfusion. These results were confirmed in a rat single-lung transplant model after warm preservation. Interestingly, protein contents of both inducible NOS and endothelial NOS increased in the transplanted lung after 2 h of reperfusion. However, the total activity of NOS in the transplanted lungs remained at very low levels. We conclude that ischemic lung preservation and reperfusion result in altered NOS gene and protein expression with inhibited NOS activity, which may contribute to the injury of lung transplants.

Age-associated changes in the immune system of German shepherd dogs

In order to look into the ageing of the canine immune system we investigated age-related changes and associated gender-related differences in parameters of innate and acquired immunity in German Shepherd dogs. We obtained the following findings: white blood cell counts, peripheral blood lymphocytes, lymphocyte proliferative activity and interleukin-2 (IL-2) serum concentrations were significantly lower in the group of old animals, whereas the concentrations of gamma-globulins and the functional activity of the complement system were significantly higher in the elderly. Phagocytic and bactericidal activity of polymorphonuclear cells, as well as their 'killing function,' the serum cytokine-like activities of tumour necrosis factor-alpha and the plasma concentrations of immunoglobulin G, as well as of alpha- and beta-globulins, were not significantly affected by age, whereas natural killer-cell activity and the serum cytokine-like activities of IL-1 were significantly higher only in the group of female old animals. With regard to gender-related differences, lymphocyte proliferative activities as well as plasma concentrations of alpha-globulin were significantly higher in the group of female animals, whereas the absolute numbers of segmented neutrophils were significantly lower. Species analogies with regard to ageing as presumed to exist between man and laboratory rodents also seem to be applicable to the dog. The observed age-related changes in the canine immune system are probably among the main causes for the multimorbidity of old age, affecting life expectancy and mortality in the dog and should be recognized and considered by the attending veterinarian.

The role of inflammatory mediators in the mechanism of the host immune response induced by ischemia-reperfusion injury

Our previous study suggested that inflammatory mediators released due to IRI lead to host's immune response by upregulating MHC II in the host's peripheral T lymphocytes. This study hypothesized the role of platelet-activating factor (PAF) in the mechanism of induced MHC II upregulation due to IRI on peripheral T lymphocytes. The objectives of this study were to investigate the role of PAF in the induction of host immune reactivity and the protective effect of PAF-antagonist TCV-309 in combination with prostaglandin E1 (PGE1) against the host's immune response caused by IRI. Thirty female domestic swine were divided into three groups. Group A (6 donors, 6 recipients) had no pharmacological intervention. Group B (6 donors, 6 recipients) was the experimental group treated with TCV-309 + PGE1. Group C underwent sham operation. The ex vivo preservation time for groups A and B was 4 hr at 4 degrees C. To detect the changes in MHC II expression on T cells due to IRI, blood samples were collected before reperfusion (baseline level), 1, 2, and 3 days post-reperfusion. Two-colour flow cytometry analysis (FACS) was used to study MHC II-DR-beta expression in peripheral T lymphocytes. Swine anti-MHC II and anti-CD3 antibodies were used for this purpose. The FACS analyses demonstrated that in group A, there was a significant increase (p < 0.05) in MHC II intensity on peripheral T lymphocytes on day 2 post-reperfusion. By the third day post-reperfusion, MHC intensity had a tendency to decrease but did not reached the baseline level. In group B and C, however, there was no significant change in the level of MHC II in T lymphocytes at any of the post-reperfusion times. In group A, the number of CD3+MHC+ T lymphocytes significantly decreased (p < 0.05) by one day post-reperfusion and remained at this level until the third day post-reperfusion. In groups B and C, no significant change in the number of CD3+MHC+ T cells was observed. The results of this study suggested that the release of inflammatory mediators (e.g. PAF) due to IRI played a role in the mechanism of IRI-induced host's immune response. The results also suggested that the combination of TCV-309 + PGE1 could reduce this immune response.

Acute pulmonary edema after lung transplantation: the pulmonary reimplantation response

BACKGROUND

Although the development of noncardiogenic pulmonary edema or pulmonary reimplantation response (PRR) after lung transplantation has been well described, the incidence has not been established and the relationship of PRR to clinical risk factors has not been analyzed.

STUDY OBJECTIVES

(1) To describe the incidence of PRR in lung transplant recipients, (2) to identify the predictors of PRR, (3) to examine the correlation of suspected predictors with the severity of PRR, and (4) to evaluate the impact of PRR on morbidity and mortality of lung transplant recipients.

DESIGN

Retrospective review of clinical records and radiographic studies.

SETTING

Tertiary care referral center.

PATIENTS

Ninety-nine consecutive patients with end-stage lung disease undergoing lung transplantation between February 1990 and October 1995.

METHODS

Review of clinical records and postoperative chest radiographs of all lung transplant recipients to identify patients who experienced PRR. Chest radiographs of patients with PRR were graded for severity on a scale of 0 (none) to 5 (very severe). Demographic, pre- and perioperative factors were also evaluated along with short- and long-term survival of patients with PRR.

RESULTS

Fifty-six of 99 lung transplant recipients (57%) experienced PRR. The median ischemia time of patients with and without PRR was 168 and 180 min, respectively (p = 0.62). The incidence of PRR was 51% in patients without preoperative pulmonary hypertension, 78% in mild to moderate pulmonary hypertension, and 58% in patients with severe pulmonary hypertension (p = 0.10). Incidence and severity of PRR was similar in patients receiving right, left, or double-lung transplantation. Similarly, age and sex of the recipients and underlying lung disease did not affect the incidence or severity of PRR. The incidence and severity of PRR was higher in patients undergoing cardiopulmonary bypass during lung transplantation. Patients with PRR had prolonged duration of mechanical ventilation and ICU stay. Overall, PRR did not affect the survival of the patients. However, survival of female lung transplant recipients was significantly better than male recipients (median survival, 60 vs 21 months; p = 0.02).

CONCLUSIONS

Acute pulmonary edema or PRR occurs frequently (57%) after lung transplantation. In this series, PRR was not associated with a prolonged ischemia time, preoperative pulmonary hypertension, the type of lung transplant, underlying lung disease, or age or sex of recipients. However, use of cardiopulmonary bypass during surgery was associated with increased incidence and severity of PRR. Also, the development of PRR resulted in prolonged mechanical ventilation and a longer ICU stay, but did not affect survival. Female lung transplant recipients survived significantly longer than male recipients. The reason for this difference in survival is unclear.

The increase in the steady-state level of major histocompatibility complex mRNA in the host peripheral T lymphocytes due to ischaemia-reperfusion injury

In our previous study, using a swine model of single lung transplantation, a relationship between the level of major histocompatibility complex (MHC II) expression on host T lymphocytes and the extent of the ex vivo preservation time was observed. Furthermore, a model of ischaemia by simple cross-clamping proved MHC II up-regulation to be independent of tissue incompatibility. The mechanism through which ischaemia-reperfusion injury (IRI) induces MHC up-regulation in host peripheral T cells has not been reported. The objective of this study was to determine whether IRI induces MHC II up-regulation in T cells by altering the intracellular steady-state level of MHC II mRNA. Group A (seven donors, seven recipients) was an allotransplantation model of 15 h of cold storage (4 degrees C) while in group B (n = 6) animals underwent 2 h of warm ischaemia. Group C (n = 6) underwent sham operation. For quantification of mRNA extracted from peripheral T lymphocytes isolated before and after surgery, semi-quantitative reverse transcription polymerase chain reaction (RT-PCR) was used to determine the time at which mRNA levels reached its peak. The mRNA at pre-reperfusion and the time, at which mRNA peaked, was used for competitive RT-PCR. The results of RT-PCR analyses demonstrated that IRI induced an increase in the steady-state level of MHC II mRNA (p < 0.02) within 2 h post-reperfusion, irrespective of type of ischaemia and tissue incompatibility. In conclusion, this study suggested that IRI up-regulates the MHC II expression in peripheral T cells by altering the intracellular steady-state level of MHC II-DR-beta.

Bronchoalveolar lavage in lung transplantation. State of the art

Fiberoptic bronchoscopy with bronchoalveolar lavage (BAL) has become a crucial tool in the management of lung transplant recipients. Detection of pulmonary infectious pathogens by culture, cytology, and histology of BAL, protected brush specimens, and transbronchial biopsies (TBB) is highly effective. Morphologic and phenotypological analyses of BAL cells may be suggestive for certain complications after lung transplantation. For interpretation of BAL findings, the natural course of BAL cell morphology and phenotypology after lung transplantation must be considered. During the first 3 months after pulmonary transplantation, elevated total cell count in BAL and neutrophilic alveolitis are common, representing the cellular response to graft injury and interaction of immunocompetent cells of donor and recipient origin. With increasing time after transplantation the CD4/CD8 ratio decreases due to lowered percentages of CD4 cells in BAL. During bacterial pneumonias, the cellular profile of BAL is characterized by a marked granulocytic alveolitis. Lymphocytic alveolitis with a decreased CD4/CD8 ratio is suggestive of acute rejection, but is also found in viral pneumonias and obliterative bronchiolitis. In the case of a combined lymphocytosis and neutrophilia without any evidence of infection, obliterative bronchiolitis should be considered. Functional analyses of BAL cells can give additional information about the immunologic status of the graft, even before histologic changes become evident but have not been established in routine transplant monitoring. However, functional studies suggest an important role of activated, alloreactive and donor-specific T lymphocytes in the pathogenesis of acute and chronic lung rejection. Investigations of soluble components in BAL have given further insight into the immunologic processes after lung transplantation. In this overview, the characteristics of BAL after lung transplantation will be summarized, and its relevance for the detection of pulmonary complications will be discussed.

Sulfation-dependent down-regulation of interferon-gamma-induced major histocompatibility complex class I and II and intercellular adhesion molecule-1 expression on tubular and endothelial cells by glycosaminoglycans

BACKGROUND

Previously, it has been demonstrated that heparin inhibits major histocompatibility complex (MHC) class II and intercellular adhesion molecule-1 (ICAM-1) expression on interferon-gamma (IFN-gamma)-stimulated human umbilical vein endothelial cells (HUVECs). Inasmuch as proximal tubular epithelial cells (PTECs) are prime targets in acute renal allograft rejection, we investigated whether there is a difference in the ability of heparin to influence MHC and ICAM-1 expression on PTECs as compared to HUVECs. We also studied whether the degree of sulfation of heparin is of relevance for the binding to IFN-gamma and inhibition of MHC and ICAM-1 expression after IFN-gamma stimulation.

METHODS

Cultured HUVECs and PTECs were stimulated with IFN-gamma for 72 hr in the presence or absence of various heparinoids. MHC and ICAM-1 expression were thereafter determined by fluorescence-activated cell sorting.

RESULTS

Heparin was able to inhibit the up-regulation of MHC and ICAM-1 in a dose-dependent fashion on both IFN-gamma-stimulated HUVECs and PTECs. In PTEC cultures, higher concentrations of heparin were required for the inhibition of MHC class I. Heparin and supersulfated glycosaminoglycans (GAGs) were able to bind to IFN-gamma, whereas N-desulfated N-acetylated GAGs with a low amount of sulfate were not. Inhibition of cell-bound heparan sulfate proteoglycan sulfation with NaClO3 resulted in an impaired MHC and ICAM-1 expression after IFN-gamma stimulation.

CONCLUSION

We postulate that IFN-gamma binds to cell-bound heparan sulfate proteoglycan in a sulfation-dependent fashion. This binding may facilitate the interaction of IFN-gamma with its receptor. Supersulfated GAGs with low anti-coagulant activity could be used therapeutically to decrease MHC and ICAM-1 expression on organ grafts.

Cytokine mRNA expression in whole blood samples from dogs with natural canine distemper virus infection

Cytokines are soluble polypeptides with many physiological functions and a special role during infection and inflammation. Little is known about cytokine regulation in naturally occurring viral diseases of animals. Especially the role of cytokines in the development and progression of lesions in canine distemper virus (CDV) infection in dogs is largely unknown. Whole blood samples from 14 dogs with CDV infection and three dogs suffering from non-distemper diseases were examined for mRNA of pro-inflammatory cytokines such as interleukin-1beta (IL-1), interleukin-6 (IL-6), interleukin-8 (IL-8), interleukin-12 (IL-12), tumor necrosis factor-alpha (TNF), interferon-gamma (IFN), and the anti-inflammatory transforming growth factor-beta1 (TGF) using reverse transcription polymerase chain reaction (RT-PCR). Blood samples from the three dogs that showed no clinical abnormalities during a pre-vaccination physical examination served as control. CDV infection was confirmed by post-mortem immunohistochemistry for CDV nucleoprotein. The degree of immunoreactivity and the number of virus antigen positive organs were expressed as antigen index. IFN transcripts were not identified in any dog and IL-8 transcripts were present in RNA isolates from all 20 dogs. None of the other cytokines was detected in control animals. IL-1 and IL-6 were each found in one non-distemper dog and TGF transcripts were amplified in two dogs with non-distemper disease. The following transcripts were found in variable numbers in distemper dogs: IL-1 (7/14 dogs), IL-6 (3/14 dogs), IL-12 (3/14 dogs), TNF (8/14 dogs), and TGF (10/14 dogs) with multiple cytokines in ten dogs. No cytokine transcripts were detected in three distemper dogs. There was no obvious correlation between cytokine mRNA expression and respiratory and gastrointestinal tract diseases. In the CNS, demyelination was frequently associated with IL-1, IL-12, TNF and TGF mRNA expression in the blood. IL-6 transcripts were found only in animals with early CNS lesions and TGF was the only detectable cytokine in an animal with chronic demyelination. Lack of detectable cytokine transcripts in whole blood samples was associated with a high antigen index and viremia, indicating that an overwhelming virus infection may suppress cytokine production, possibly due to paralysis of the immune system. Simultaneous occurrence of pro- and anti-inflammatory cytokines in whole blood preparation from most of the dogs with distemper, indicated a complex most likely disease stage dependent orchestrated cytokine expression.

The relationship of ischemia-reperfusion injury of transplanted lung and the up-regulation of major histocompatibility complex II on host peripheral lymphocytes

OBJECTIVES

This study was designed to examine the relationship between ex vivo preservation time of the transplanted lung and the extent of injury and to relate this to the severity of rejection with and without allogenicity.

METHODS

Single lung transplantation was performed on two groups of domestic swine. Group A (n = 7) and group B (n = 6) had ex vivo preservation times of 4 and 15 hours, respectively, at 4 degrees C hypothermia. Group C (n = 6) underwent 2 hours of warm ischemia via dissection and isolation of the left lung with ligation of its bronchial artery and crossclamping of the left pulmonary artery, vein, and bronchus without explantation. Assessment measures included lung function, antioxidant enzyme activities in the plasma and lung tissue, levels of inflammatory mediators in the recipient plasma, and quantification of major histocompatibility complex II HLA-DR-beta on host peripheral lymphocytes.

RESULTS

All groups demonstrated increases in interleukin-10, lung weight, and HLA-DR-1beta expression and decreases in lung-tissue antioxidant enzyme activities, gas exchange, and lung compliance. There was a strong positive correlation between ex vivo preservation time and the expression of HLA-DR-beta and a negative correlation between ischemic time and lung-tissue superoxide dismutase.

CONCLUSIONS

These results suggest that the intensity of the host immunogenic response is related to the severity of ischemia-reperfusion injury and is independent of tissue incompatibility and/or the type of ischemic insult. We conclude that the extension of ex vivo preservation time may predispose the transplanted lung to more severe rejection.

Bronchiolitis obliterans: pathogenesis, prevention, and management

Increasing early success-post lung transplant has been tempered by the long-term development of histologic bronchiolitis obliterans (OB) or of the progressive airway obstruction which is called bronchiolitis obliterans syndrome (BOS). Multiple lines of evidence suggest that OB/BOS is due to an injury directed against the epithelial cells in the airways of the donor lung by the immune system of the recipient. Acute rejection is the strongest risk factor for the subsequent development of this process. Efforts to prevent or minimize acute rejection may reduce the prevalence of OB/BOS. Results of treatment with augmented immunosuppression have been disappointing but the treatment of complicating infections in the allograft can be beneficial. Multicenter studies are needed to assess the efficacy of new immunosuppressive agents in preventing or treating OB/BOS.

PGE1, dexamethasone, U-74389G, or Bt2-cAMP as an additive to promote protection by UW solution in I/R injury

A method to reduce ischemia-reperfusion (I/R) injury can be an important criterion to improve the preservation solution. Although University of Wisconsin solution (UW) works as a lung preservation solution, its attenuation effect on I/R injury has not been investigated. We attempted to determine whether, by adding various protective agents, modified UW solutions will enhance the I/R attenuation by UW. We examined the I/R injury in an isolated rat lung model. Various solutions, e.g., physiological salt solution (PSS), UW, and modified UW solutions containing various protective agents such as prostaglandin E1, dexamethasone, U-74389G, or dibutyryl adenosine 3',5'-cyclic monophosphate were perfused individually to evaluate the I/R injury. Isolated rat lung experiments, with ischemia for 45 min, then reperfusion for 60 min, were conducted in a closed circulating system. Hemodynamic changes, lung weight gain (LWG), capillary filtration coefficient (Kfc), protein content of lavage fluid, concentration of cytokines, and lung histopathology were analyzed. Results showed that the acute I/R lung injury with immediate permeability pulmonary edema was associated with an increase in tumor necrosis factor-alpha (TNF-alpha) production. A significant correlation existed between TNF-alpha and Kfc (r = 0.8, P < 0.0001) and TNF-alpha and LWG (r = 0. 9, P < 0.0001), indicating that TNF-alpha is an important cytokine modulating early I/R injury. Significantly lower levels of Kfc, LWG, TNF-alpha, and protein concentration of lung lavage (P < 0.05) were found in the UW-perfused group than in the control group perfused with PSS. Modified UW promoted the protective effect of UW to further decrease Kfc, LWG, and TNF-alpha (P < 0.05). Histopathological observations also substantiated this evidence. In the UW+U-74389G group, bronchial alveolar lavage fluid contained lowest protein concentration. We conclude that the UW solution attenuates I/R injury of rat lung and that the modified UW solutions further enhance the effect of UW in reducing I/R injury. Among modified solutions, UW+U-74389G is the best. Further investigation of the improved effects of the modified UW solutions would be beneficial in lung transplantation.

Prolonged ischemia is associated with more pronounced rejection in the lung allograft

BACKGROUND

Previously it was found that ischemia-reperfusion injury in a left lung autotransplantation model could be a minor inducer of major histocompatibility complex (MHC) class II antigen expression. Thus, we hypothesized that prolonged ischemic times may result in increased expression of MHC class II antigens and predispose the lungs to the development of acute rejection early after transplantation.

METHODS

Twenty conditioned dogs underwent single left lung allotransplantation. Donor lungs were subjected to 4 or 24 hours (n = 10 each) of cold ischemia. Open lung biopsies, bronchoalveolar lavage fluid, and blood samples were taken preoperatively and at various intervals up to 1 week after transplantation. Lung biopsy specimens were examined histologically for MHC class II expression and graded for acute rejection. Bronchoalveolar lavage fluid and plasma were analyzed for cytokines interleukin-2 and interferon-gamma.

RESULTS

In the 4-hour ischemia group, there was mild diffuse staining of the bronchial epithelium and cellular infiltrate for MHC class II antigens after 1 week with subsequent grade 1-2 rejection. In the 24-hour ischemia group, MHC expression after 1 week revealed strong diffuse staining of bronchial epithelium, vascular endothelium, and cellular infiltrates with a significantly higher grade of rejection. Interleukin-2 and interferon-gamma significantly increased in BAL fluid early after transplantation in both groups.

CONCLUSIONS

Ischemic injury may predispose the lung allograft to the development of acute rejection, in part, through the upregulation of MHC class II antigen expression and the local release of cytokines.