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James P, Kaushal D, Beaumont Wilson R. NETosis in Surgery: Pathophysiology, Prevention, and Treatment. Ann Surg 2024; 279:765-780. [PMID: 38214150 PMCID: PMC10997183 DOI: 10.1097/sla.0000000000006196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Abstract
OBJECTIVE To provide surgeons with an understanding of the latest research on NETosis, including the pathophysiology and treatment of conditions involving neutrophil extracellular traps (NETs) in the care of surgical patients. BACKGROUND A novel function of neutrophils, the formation of NETs, was described in 2004. Neutrophils form mesh-like structures of extruded decondensed chromatin, comprising DNA and histones decorated with bactericidal proteins. These NETs exert antimicrobial action by trapping microorganisms and preventing their wider dissemination through the body. RESULTS A narrative review of the existing literature describing NETosis was conducted, including NET pathophysiology, conditions related to NET formation, and treatments relevant to surgeons. CONCLUSIONS In addition to its canonical antimicrobial function, NETosis can exacerbate inflammation, resulting in tissue damage and contributing to numerous diseases. NETs promote gallstone formation and acute pancreatitis, impair wound healing in the early postoperative period and in chronic wounds, and facilitate intravascular coagulation, cancer growth, and metastasis. Agents that target NET formation or removal have shown promising efficacy in treating these conditions, although large clinical trials are required to confirm these benefits.
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Affiliation(s)
- Philippa James
- Department of General Surgery, Campbelltown Hospital, Sydney, NSW, Australia
| | - Devesh Kaushal
- Department of General Surgery, Campbelltown Hospital, Sydney, NSW, Australia
| | - Robert Beaumont Wilson
- Faculty of Medicine, University of New South Wales, Liverpool Clinical School, Sydney, NSW, Australia
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2
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Nguyen BA, Alexander MR, Harrison DG. Immune mechanisms in the pathophysiology of hypertension. Nat Rev Nephrol 2024:10.1038/s41581-024-00838-w. [PMID: 38658669 DOI: 10.1038/s41581-024-00838-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2024] [Indexed: 04/26/2024]
Abstract
Hypertension is a leading risk factor for morbidity and mortality worldwide. Despite current anti-hypertensive therapies, most individuals with hypertension fail to achieve adequate blood pressure control. Moreover, even with adequate control, a residual risk of cardiovascular events and associated organ damage remains. These findings suggest that current treatment modalities are not addressing a key element of the underlying pathology. Emerging evidence implicates immune cells as key mediators in the development and progression of hypertension. In this Review, we discuss our current understanding of the diverse roles of innate and adaptive immune cells in hypertension, highlighting key findings from human and rodent studies. We explore mechanisms by which these immune cells promote hypertensive pathophysiology, shedding light on their multifaceted involvement. In addition, we highlight advances in our understanding of autoimmunity, HIV and immune checkpoints that provide valuable insight into mechanisms of chronic and dysregulated inflammation in hypertension.
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Affiliation(s)
- Bianca A Nguyen
- Department of Molecular Physiology and Biophysics, Vanderbilt University, Nashville, TN, USA
| | - Matthew R Alexander
- Department of Molecular Physiology and Biophysics, Vanderbilt University, Nashville, TN, USA
- Department of Medicine, Division of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt Institute for Infection, Immunology and Inflammation, Nashville, TN, USA
| | - David G Harrison
- Department of Molecular Physiology and Biophysics, Vanderbilt University, Nashville, TN, USA.
- Department of Medicine, Division of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA.
- Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
- Vanderbilt Institute for Infection, Immunology and Inflammation, Nashville, TN, USA.
- Department of Pharmacology, Vanderbilt University, Nashville, TN, USA.
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3
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Wu X, Yang Y. Neutrophil extracellular traps (NETs) and fibrotic diseases. Int Immunopharmacol 2024; 133:112085. [PMID: 38626550 DOI: 10.1016/j.intimp.2024.112085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 04/07/2024] [Accepted: 04/10/2024] [Indexed: 04/18/2024]
Abstract
Fibrosis, a common cause and serious outcome of organ failure that can affect any organ, is responsible for up to 45% of all deaths in various clinical settings. Both preclinical models and clinical trials investigating various organ systems have shown that fibrosis is a highly dynamic process. Although many studies have sought to gain understanding of the mechanism of fibrosis progression, their findings have been mixed. In recent years, increasing evidence indicates that neutrophil extracellular traps (NETs) are involved in many inflammatory and autoimmune disorders and participate in the regulation of fibrotic processes in various organs and systems. In this review, we summarize the current understanding of the role of NETs in fibrosis development and progression and their possibility as therapeutic targets.
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Affiliation(s)
- Xiaojiao Wu
- School of Pediatrics, Nanjing Medical University, Nanjing, China
| | - Yang Yang
- Department of Gastroenterology, Sir Run Run Hospital, Nanjing Medical University, Nanjing, China.
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4
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Chen J, Xu Y, Yu F, Ma Z, Yu J, Zhang X. NETs: an extracellular DNA network structure with implication for cardiovascular disease and cancer. Hypertens Res 2024:10.1038/s41440-023-01574-7. [PMID: 38443616 DOI: 10.1038/s41440-023-01574-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 12/19/2023] [Accepted: 12/20/2023] [Indexed: 03/07/2024]
Abstract
Cardiovascular (CV) diseases and tumors are best known for its high morbidity and mortality worldwide. There is a growing recognition of the association between CV diseases and tumorigenesis. In addition to CV damage caused by anti-tumor drugs and tumor-induced organ dysfunction, CV events themselves and their treatment may also have a role in promoting tumorigenesis. Therefore, Therefore, the diagnosis and treatment of the two kinds of diseases have entered the era of clinical convergence. Emerging evidence indicates significant biologic overlap between cancer and CV diseases, with the recognition of shared biologic mechanisms. Neutrophil extracellular traps (NETs) represent an immune mechanism of neutrophils promoting the development of tumors and their metastasis. It has been recently demonstrated that NETs exist in various stages of hypertension and heart failure, exacerbating disease progression. At present, most studies focus on the biological role of NETs in CV diseases and tumor respectively, and there are relatively few studies on the specific regulatory mechanisms and effects of NETs in cardiovascular diseases associated with tumors. In this narrative review, we summarize some recent basic and clinical findings on how NETs are involved in the pathogenesis of cardiovascular diseases associated with tumors. We also highlight that the development of treatments targeting NETs may be one of the effective ways to prevent and treat cardiovascular diseases associated with tumors.
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Affiliation(s)
- Jianshu Chen
- Lanzhou University Second Hospital, Lanzhou, 730030, China
| | - Yuansheng Xu
- Lanzhou University Second Hospital, Lanzhou, 730030, China
| | - Fei Yu
- Lanzhou University Second Hospital, Lanzhou, 730030, China
| | - Zhengke Ma
- Lanzhou University Second Hospital, Lanzhou, 730030, China
| | - Jing Yu
- Lanzhou University Second Hospital, Lanzhou, 730030, China
- Lanzhou University Second College of Clinical Medicine, Lanzhou, 730030, China
| | - Xiaowei Zhang
- Lanzhou University Second Hospital, Lanzhou, 730030, China.
- Lanzhou University Second College of Clinical Medicine, Lanzhou, 730030, China.
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5
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Wang Y, Wang C, Li J. Neutrophil extracellular traps: a catalyst for atherosclerosis. Mol Cell Biochem 2024:10.1007/s11010-024-04931-3. [PMID: 38401035 DOI: 10.1007/s11010-024-04931-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 01/05/2024] [Indexed: 02/26/2024]
Abstract
Neutrophil extracellular traps (NETs) are network-like structures released by activated neutrophils. They consist mainly of double-stranded DNA, histones, and neutrophil granule proteins. Continuous release of NETs in response to external stimuli leads to activation of surrounding platelets and monocytes/macrophages, resulting in damage to endothelial cells (EC) and vascular smooth muscle cells (VSMC). Some clinical trials have demonstrated the association between NETs and the severity and prognosis of atherosclerosis. Furthermore, experimental findings have shed light on the molecular mechanisms by which NETs contribute to atherogenesis. NETs play a significant role in the formation of atherosclerotic plaques. This review focuses on recent advancements in the understanding of the relationship between NETs and atherosclerosis. It explores various aspects, including the formation of NETs in atherosclerosis, clinical trials investigating NET-induced atherosclerosis, the mechanisms by which NETs promote atherogenesis, and the translational implications of NETs. Ultimately, we aim to propose new research directions for the diagnosis and treatment of atherosclerosis.
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Affiliation(s)
- Yinyu Wang
- Department of Cardiology, Affiliated Hospital of Jiangsu University, Zhenjiang, China
| | - Cuiping Wang
- Department of Cardiology, Affiliated Hospital of Jiangsu University, Zhenjiang, China.
| | - Jiayan Li
- Department of Cardiology, Affiliated Hospital of Jiangsu University, Zhenjiang, China
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Regnault V, Lacolley P, Laurent S. Arterial Stiffness: From Basic Primers to Integrative Physiology. Annu Rev Physiol 2024; 86:99-121. [PMID: 38345905 DOI: 10.1146/annurev-physiol-042022-031925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2024]
Abstract
The elastic properties of conductance arteries are one of the most important hemodynamic functions in the body, and data continue to emerge regarding the importance of their dysfunction in vascular aging and a range of cardiovascular diseases. Here, we provide new insight into the integrative physiology of arterial stiffening and its clinical consequence. We also comprehensively review progress made on pathways/molecules that appear today as important basic determinants of arterial stiffness, particularly those mediating the vascular smooth muscle cell (VSMC) contractility, plasticity and stiffness. We focus on membrane and nuclear mechanotransduction, clearance function of the vascular wall, phenotypic switching of VSMCs, immunoinflammatory stimuli and epigenetic mechanisms. Finally, we discuss the most important advances of the latest clinical studies that revisit the classical therapeutic concepts of arterial stiffness and lead to a patient-by-patient strategy according to cardiovascular risk exposure and underlying disease.
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Maïer B, Di Meglio L, Desilles JP, Solo Nomenjanahary M, Delvoye F, Kyheng M, Boursin P, Ollivier V, Dupont S, Rambaud T, Hamdani M, Labreuche J, Blanc R, Piotin M, Halimi JM, Mazighi M, Ho-Tin-Noe B. Neutrophil activation in patients treated with endovascular therapy is associated with unfavorable outcomes and mitigated by intravenous thrombolysis. J Neurointerv Surg 2024; 16:131-137. [PMID: 37068937 DOI: 10.1136/jnis-2022-020020] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 03/25/2023] [Indexed: 04/19/2023]
Abstract
BACKGROUND Accumulating evidence indicates that neutrophil activation (NA) contributes to microvascular thromboinflammation in acute ischemic stroke (AIS) due to a large vessel occlusion. Preclinical data have suggested that intravenous thrombolysis (IVT) before endovascular therapy (EVT) could dampen microvascular thromboinflammation. In this study we investigated the association between NA dynamics and stroke outcome, and the impact of IVT on NA in patients with AIS treated with EVT. METHODS A single-center prospective study was carried out, including patients treated with EVT for whom three blood samples (before, within 1 hour, 24 hours post-EVT) were drawn to measure plasma myeloperoxidase (MPO) concentration as a marker of NA. Unfavorable outcome was defined as a modified Rankin score of 3-6 at 3 months. RESULTS Between 2016 and 2020, 179 patients were included. The plasma MPO concentration peaked significantly 1 hour post-EVT (median increase 21.0 ng/mL (IQR -2.1-150)) and returned to pre-EVT baseline values 24 hours after EVT (median change from baseline -0.8 ng/mL (IQR -7.6-6.7)). This peak was strongly associated with unfavorable outcomes at 3 months (aOR 0.53 (95% CI 0.34 to 0.84), P=0.007). IVT before EVT abolished this 1 hour post-EVT MPO peak. Changes in plasma MPO concentration (baseline to 1 hour post-EVT) were associated with unfavorable outcomes only in patients not treated with IVT before EVT (aOR 0.54 (95% CI 0.33 to 0.88, P=0.013). However, we found no significant heterogeneity in the associations between changes in plasma MPO concentration and outcomes. CONCLUSIONS A peak in plasma MPO concentration occurs early after EVT and is associated with unfavorable outcomes. IVT abolished the post-EVT MPO peak and may modulate the association between NA and outcomes.
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Affiliation(s)
- Benjamin Maïer
- Interventional Neuroradiology Department, Fondation Rothschild Hospital, Paris, France
- UMRS-1144, Optimisation Thérapeutique en Neuropsychopharmacologie, F-75006 Paris, France, Université de Paris Cité, Inserm, Paris, France
- Neurology Department, Hôpital Saint-Joseph, Paris, France
- FHU NeuroVasc, Paris, France
| | - Lucas Di Meglio
- Interventional Neuroradiology Department, Fondation Rothschild Hospital, Paris, France
- UMRS-1144, Optimisation Thérapeutique en Neuropsychopharmacologie, F-75006 Paris, France, Université de Paris Cité, Inserm, Paris, France
| | - Jean-Philippe Desilles
- Interventional Neuroradiology Department, Fondation Rothschild Hospital, Paris, France
- UMRS-1144, Optimisation Thérapeutique en Neuropsychopharmacologie, F-75006 Paris, France, Université de Paris Cité, Inserm, Paris, France
- FHU NeuroVasc, Paris, France
| | - Mialitiana Solo Nomenjanahary
- UMRS-1144, Optimisation Thérapeutique en Neuropsychopharmacologie, F-75006 Paris, France, Université de Paris Cité, Inserm, Paris, France
| | - François Delvoye
- Interventional Neuroradiology Department, Fondation Rothschild Hospital, Paris, France
| | - Maeva Kyheng
- Interventional Neuroradiology Department, Fondation Rothschild Hospital, Paris, France
| | - Perrine Boursin
- Interventional Neuroradiology Department, Fondation Rothschild Hospital, Paris, France
| | - Véronique Ollivier
- UMRS-1144, Optimisation Thérapeutique en Neuropsychopharmacologie, F-75006 Paris, France, Université de Paris Cité, Inserm, Paris, France
| | - Sébastien Dupont
- UMRS-1144, Optimisation Thérapeutique en Neuropsychopharmacologie, F-75006 Paris, France, Université de Paris Cité, Inserm, Paris, France
| | - Thomas Rambaud
- UMRS-1144, Optimisation Thérapeutique en Neuropsychopharmacologie, F-75006 Paris, France, Université de Paris Cité, Inserm, Paris, France
| | - Mylène Hamdani
- Interventional Neuroradiology Department, Fondation Rothschild Hospital, Paris, France
| | | | - Raphaël Blanc
- Interventional Neuroradiology Department, Fondation Rothschild Hospital, Paris, France
| | - Michel Piotin
- Interventional Neuroradiology Department, Fondation Rothschild Hospital, Paris, France
| | - Jean-Michel Halimi
- Nephrology Department, Tours Hospital, Tours, France
- EA4245-Transplantation, Immunology and Inflammation, University of Tours, Tours, France
| | - Mikaël Mazighi
- Interventional Neuroradiology Department, Fondation Rothschild Hospital, Paris, France
- UMRS-1144, Optimisation Thérapeutique en Neuropsychopharmacologie, F-75006 Paris, France, Université de Paris Cité, Inserm, Paris, France
- FHU NeuroVasc, Paris, France
- Department of Neurology, Lariboisiere Hospital, Université Paris Cité, Paris, France
| | - Benoit Ho-Tin-Noe
- UMRS-1144, Optimisation Thérapeutique en Neuropsychopharmacologie, F-75006 Paris, France, Université de Paris Cité, Inserm, Paris, France
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Liu J, Zhang S, Jing Y, Zou W. Neutrophil extracellular traps in intracerebral hemorrhage: implications for pathogenesis and therapeutic targets. Metab Brain Dis 2023; 38:2505-2520. [PMID: 37486436 DOI: 10.1007/s11011-023-01268-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 07/19/2023] [Indexed: 07/25/2023]
Abstract
Intracerebral hemorrhage is a common neurological disease, and its pathological mechanism is complex. As the first recruited leukocyte subtype after intracerebral hemorrhage, neutrophils play an important role in tissue damage. In the past, it was considered that neutrophils performed their functions through phagocytosis, chemotaxis, and degranulation. In recent years, studies have found that neutrophils also have the function of secreting extracellular traps. Extracellular traps are fibrous structure composed of chromatin and granular proteins, which plays an important role in innate immunity. Studies have shown a large number of neutrophil extracellular traps in hematoma samples, plasma samples, and drainage samples after intracerebral hemorrhage. In this paper, we summarized the related mechanisms of neutrophil external traps and injury after intracerebral hemorrhage. Neutrophil extracellular traps are involved in the process of brain injury after intracerebral hemorrhage. The application of related inhibitors to inhibit the formation of neutrophil external traps or promote their dissolution can effectively alleviate the pathological damage caused by intracerebral hemorrhage.
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Affiliation(s)
- Jiawei Liu
- Heilongjiang University of Chinese Medicine, Harbin, Heilongjiang, China
| | - Shuang Zhang
- Heilongjiang University of Chinese Medicine, Harbin, Heilongjiang, China
| | - Yunnan Jing
- Heilongjiang University of Chinese Medicine, Harbin, Heilongjiang, China
| | - Wei Zou
- The First Affiliated Hospital of Heilongjiang University of Chinese Medicine, Harbin, Heilongjiang, China.
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Jones BA, Myakala K, Guha M, Davidson S, Adapa S, Lopez Santiago I, Schaffer I, Yue Y, Allegood JC, Cowart LA, Wang XX, Rosenberg AZ, Levi M. Farnesoid X receptor prevents neutrophil extracellular traps via reduced sphingosine-1-phosphate in chronic kidney disease. Am J Physiol Renal Physiol 2023; 325:F792-F810. [PMID: 37823198 PMCID: PMC10894665 DOI: 10.1152/ajprenal.00292.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 10/10/2023] [Accepted: 10/10/2023] [Indexed: 10/13/2023] Open
Abstract
Farnesoid X receptor (FXR) activation reduces renal inflammation, but the underlying mechanisms remain elusive. Neutrophil extracellular traps (NETs) are webs of DNA formed when neutrophils undergo specialized programmed cell death (NETosis). The signaling lipid sphingosine-1-phosphate (S1P) stimulates NETosis via its receptor on neutrophils. Here, we identify FXR as a negative regulator of NETosis via repressing S1P signaling. We determined the effects of the FXR agonist obeticholic acid (OCA) in mouse models of adenosine phosphoribosyltransferase (APRT) deficiency and Alport syndrome, both genetic disorders that cause chronic kidney disease. Renal FXR activity is greatly reduced in both models, and FXR agonism reduces disease severity. Renal NETosis and sphingosine kinase 1 (Sphk1) expression are increased in diseased mice, and they are reduced by OCA in both models. Genetic deletion of FXR increases Sphk1 expression, and Sphk1 expression correlates with NETosis. Importantly, kidney S1P levels in Alport mice are two-fold higher than controls, and FXR agonism restores them back to baseline. Short-term inhibition of sphingosine synthesis in Alport mice with severe kidney disease reverses NETosis, establishing a causal relationship between S1P signaling and renal NETosis. Finally, extensive NETosis is present in human Alport kidney biopsies (six male, nine female), and NETosis severity correlates with clinical markers of kidney disease. This suggests the potential clinical relevance of the newly identified FXR-S1P-NETosis pathway. In summary, FXR agonism represses kidney Sphk1 expression. This inhibits renal S1P signaling, thereby reducing neutrophilic inflammation and NETosis.NEW & NOTEWORTHY Many preclinical studies have shown that the farnesoid X receptor (FXR) reduces renal inflammation, but the mechanism is poorly understood. This report identifies FXR as a novel regulator of neutrophilic inflammation and NETosis via the inhibition of sphingosine-1-phosphate signaling. Additionally, NETosis severity in human Alport kidney biopsies correlates with clinical markers of kidney disease. A better understanding of this signaling axis may lead to novel treatments that prevent renal inflammation and chronic kidney disease.
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Affiliation(s)
- Bryce A Jones
- Department of Pharmacology and Physiology, Georgetown University, Washington, District of Columbia, United States
| | - Komuraiah Myakala
- Department of Biochemistry and Molecular and Cellular Biology, Georgetown University, Washington, District of Columbia, United States
| | - Mahilan Guha
- Department of Biochemistry and Molecular and Cellular Biology, Georgetown University, Washington, District of Columbia, United States
| | - Shania Davidson
- Department of Biology, Howard University, Washington, District of Columbia, United States
| | - Sharmila Adapa
- Department of Biochemistry and Molecular and Cellular Biology, Georgetown University, Washington, District of Columbia, United States
| | - Isabel Lopez Santiago
- Department of Biochemistry and Molecular and Cellular Biology, Georgetown University, Washington, District of Columbia, United States
| | - Isabel Schaffer
- Department of Biochemistry and Molecular and Cellular Biology, Georgetown University, Washington, District of Columbia, United States
| | - Yang Yue
- Department of Biochemistry and Molecular Biology, Virginia Commonwealth University, Richmond, Virginia, United States
| | - Jeremy C Allegood
- Department of Biochemistry and Molecular Biology, Virginia Commonwealth University, Richmond, Virginia, United States
| | - L Ashley Cowart
- Department of Biochemistry and Molecular Biology, Virginia Commonwealth University, Richmond, Virginia, United States
| | - Xiaoxin X Wang
- Department of Biochemistry and Molecular and Cellular Biology, Georgetown University, Washington, District of Columbia, United States
| | - Avi Z Rosenberg
- Department of Pathology, Johns Hopkins School of Medicine, Baltimore, Maryland, United States
| | - Moshe Levi
- Department of Biochemistry and Molecular and Cellular Biology, Georgetown University, Washington, District of Columbia, United States
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Mengozzi A, de Ciuceis C, Dell'oro R, Georgiopoulos G, Lazaridis A, Nosalski R, Pavlidis G, Tual-Chalot S, Agabiti-Rosei C, Anyfanti P, Camargo LL, Dąbrowska E, Quarti-Trevano F, Hellmann M, Masi S, Mavraganis G, Montezano AC, Rios FJ, Winklewski PJ, Wolf J, Costantino S, Gkaliagkousi E, Grassi G, Guzik TJ, Ikonomidis I, Narkiewicz K, Paneni F, Rizzoni D, Stamatelopoulos K, Stellos K, Taddei S, Touyz RM, Triantafyllou A, Virdis A. The importance of microvascular inflammation in ageing and age-related diseases: a position paper from the ESH working group on small arteries, section of microvascular inflammation. J Hypertens 2023; 41:1521-1543. [PMID: 37382158 DOI: 10.1097/hjh.0000000000003503] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
Microcirculation is pervasive and orchestrates a profound regulatory cross-talk with the surrounding tissue and organs. Similarly, it is one of the earliest biological systems targeted by environmental stressors and consequently involved in the development and progression of ageing and age-related disease. Microvascular dysfunction, if not targeted, leads to a steady derangement of the phenotype, which cumulates comorbidities and eventually results in a nonrescuable, very high-cardiovascular risk. Along the broad spectrum of pathologies, both shared and distinct molecular pathways and pathophysiological alteration are involved in the disruption of microvascular homeostasis, all pointing to microvascular inflammation as the putative primary culprit. This position paper explores the presence and the detrimental contribution of microvascular inflammation across the whole spectrum of chronic age-related diseases, which characterise the 21st-century healthcare landscape. The manuscript aims to strongly affirm the centrality of microvascular inflammation by recapitulating the current evidence and providing a clear synoptic view of the whole cardiometabolic derangement. Indeed, there is an urgent need for further mechanistic exploration to identify clear, very early or disease-specific molecular targets to provide an effective therapeutic strategy against the otherwise unstoppable rising prevalence of age-related diseases.
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Affiliation(s)
- Alessandro Mengozzi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
- Center for Translational and Experimental Cardiology (CTEC), Department of Cardiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa
| | - Carolina de Ciuceis
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia
| | - Raffaella Dell'oro
- Clinica Medica, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Georgios Georgiopoulos
- Angiology and Endothelial Pathophysiology Unit, Department of Clinical Therapeutics, Medical School, National and Kapodistrian University of Athens, Athens
| | - Antonios Lazaridis
- Third Department of Internal Medicine, Aristotle University of Thessaloniki, Papageorgiou Hospital, Thessaloniki, Greece
| | - Ryszard Nosalski
- Centre for Cardiovascular Sciences; Queen's Medical Research Institute; University of Edinburgh, University of Edinburgh, Edinburgh, UK
- Department of Internal Medicine
- Center for Medical Genomics OMICRON, Jagiellonian University Medical College, Krakow, Poland
| | - George Pavlidis
- Preventive Cardiology Laboratory and Clinic of Cardiometabolic Diseases, 2 Cardiology Department, Attikon Hospital, Athens
- Medical School, National and Kapodistrian University of Athens, Greece
| | - Simon Tual-Chalot
- Biosciences Institute, Vascular Biology and Medicine Theme, Faculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, UK
| | | | - Panagiota Anyfanti
- Second Medical Department, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Livia L Camargo
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
- Research Institute of the McGill University Health Centre (RI-MUHC), McGill University, Montreal, Canada
| | - Edyta Dąbrowska
- Department of Hypertension and Diabetology, Center of Translational Medicine
- Center of Translational Medicine
| | - Fosca Quarti-Trevano
- Clinica Medica, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Marcin Hellmann
- Department of Cardiac Diagnostics, Medical University, Gdansk, Poland
| | - Stefano Masi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
- Institute of Cardiovascular Science, University College London, London, UK
| | - Georgios Mavraganis
- Angiology and Endothelial Pathophysiology Unit, Department of Clinical Therapeutics, Medical School, National and Kapodistrian University of Athens, Athens
| | - Augusto C Montezano
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
- Research Institute of the McGill University Health Centre (RI-MUHC), McGill University, Montreal, Canada
| | - Francesco J Rios
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
- Research Institute of the McGill University Health Centre (RI-MUHC), McGill University, Montreal, Canada
| | | | - Jacek Wolf
- Department of Hypertension and Diabetology, Center of Translational Medicine
| | - Sarah Costantino
- Center for Translational and Experimental Cardiology (CTEC), Department of Cardiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- University Heart Center, Cardiology, University Hospital Zurich
| | - Eugenia Gkaliagkousi
- Third Department of Internal Medicine, Aristotle University of Thessaloniki, Papageorgiou Hospital, Thessaloniki, Greece
| | - Guido Grassi
- Clinica Medica, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Tomasz J Guzik
- Centre for Cardiovascular Sciences; Queen's Medical Research Institute; University of Edinburgh, University of Edinburgh, Edinburgh, UK
- Department of Internal Medicine
- Center for Medical Genomics OMICRON, Jagiellonian University Medical College, Krakow, Poland
| | - Ignatios Ikonomidis
- Preventive Cardiology Laboratory and Clinic of Cardiometabolic Diseases, 2 Cardiology Department, Attikon Hospital, Athens
- Medical School, National and Kapodistrian University of Athens, Greece
| | | | - Francesco Paneni
- Center for Translational and Experimental Cardiology (CTEC), Department of Cardiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- University Heart Center, Cardiology, University Hospital Zurich
- Department of Research and Education, University Hospital Zurich, Zurich, Switzerland
| | - Damiano Rizzoni
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia
- Division of Medicine, Spedali Civili di Brescia, Montichiari, Brescia, Italy
| | - Kimon Stamatelopoulos
- Angiology and Endothelial Pathophysiology Unit, Department of Clinical Therapeutics, Medical School, National and Kapodistrian University of Athens, Athens
| | - Konstantinos Stellos
- Biosciences Institute, Vascular Biology and Medicine Theme, Faculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, UK
- Department of Cardiovascular Research, European Center for Angioscience (ECAS), Medical Faculty Mannheim, Heidelberg University
- German Centre for Cardiovascular Research (Deutsches Zentrum für Herz-Kreislauf-Forschung, DZHK), Heidelberg/Mannheim Partner Site
- Department of Cardiology, University Hospital Mannheim, Heidelberg University, Manheim, Germany
| | - Stefano Taddei
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Rhian M Touyz
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
- Research Institute of the McGill University Health Centre (RI-MUHC), McGill University, Montreal, Canada
| | - Areti Triantafyllou
- Third Department of Internal Medicine, Aristotle University of Thessaloniki, Papageorgiou Hospital, Thessaloniki, Greece
| | - Agostino Virdis
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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11
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Jarrahi A, Khodadadi H, Moore NS, Lu Y, Awad ME, Salles EL, Vaibhav K, Baban B, Dhandapani KM. Recombinant human DNase-I improves acute respiratory distress syndrome via neutrophil extracellular trap degradation. J Thromb Haemost 2023; 21:2473-2484. [PMID: 37196848 PMCID: PMC10185489 DOI: 10.1016/j.jtha.2023.04.044] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 04/21/2023] [Accepted: 04/28/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND Respiratory failure is the primary cause of death in patients with COVID-19, whereas coagulopathy is associated with excessive inflammation and multiorgan failure. Neutrophil extracellular traps (NETs) may exacerbate inflammation and provide a scaffold for thrombus formation. OBJECTIVES The goal of this study was to determine whether degradation of NETs by recombinant human DNase-I (rhDNase), a safe, Food and Drug Administration-approved drug, reduces excessive inflammation, reverses aberrant coagulation, and improves pulmonary perfusion after experimental acute respiratory distress syndrome (ARDS). METHODS Intranasal poly(I:C), a synthetic double-stranded RNA, was administered to adult mice for 3 consecutive days to simulate a viral infection, and these subjects were randomized to treatment arms, which received either an intravenous placebo or rhDNase. The effects of rhDNase on immune activation, platelet aggregation, and coagulation were assessed in mice and donor human blood. RESULTS NETs were observed in bronchoalveolar lavage fluid and within regions of hypoxic lung tissue after experimental ARDS. The administration of rhDNase mitigated peribronchiolar, perivascular, and interstitial inflammation induced by poly(I:C). In parallel, rhDNase degraded NETs, attenuated platelet-NET aggregates, reduced platelet activation, and normalized the clotting time to improve regional perfusion, as observed using gross morphology, histology, and microcomputed tomographic imaging in mice. Similarly, rhDNase reduced NETs and attenuated platelet activation in human blood. CONCLUSION NETs exacerbate inflammation and promote aberrant coagulation by providing a scaffold for aggregated platelets after experimental ARDS. Intravenous administration of rhDNase degrades NETs and attenuates coagulopathy in ARDS, providing a promising translational approach to improve pulmonary structure and function after ARDS.
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Affiliation(s)
- Abbas Jarrahi
- Department of Neurosurgery, Medical College of Georgia, Augusta University, Augusta, Georgia, USA
| | - Hesam Khodadadi
- Department of Oral Biology and Diagnostic Sciences, Dental College of Georgia, Augusta University, Augusta, Georgia, USA
| | - Nicholas S Moore
- Department of Neurosurgery, Medical College of Georgia, Augusta University, Augusta, Georgia, USA
| | - Yujiao Lu
- Department of Neurosurgery, Medical College of Georgia, Augusta University, Augusta, Georgia, USA
| | - Mohamed E Awad
- Department of Oral Biology and Diagnostic Sciences, Dental College of Georgia, Augusta University, Augusta, Georgia, USA
| | - Evila L Salles
- Department of Oral Biology and Diagnostic Sciences, Dental College of Georgia, Augusta University, Augusta, Georgia, USA
| | - Kumar Vaibhav
- Department of Neurosurgery, Medical College of Georgia, Augusta University, Augusta, Georgia, USA
| | - Babak Baban
- Department of Oral Biology and Diagnostic Sciences, Dental College of Georgia, Augusta University, Augusta, Georgia, USA; Department of Surgery, Medical College of Georgia, Augusta University, Augusta, Georgia, USA
| | - Krishnan M Dhandapani
- Department of Neurosurgery, Medical College of Georgia, Augusta University, Augusta, Georgia, USA.
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12
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Ntinopoulou M, Cassimos D, Roupakia E, Kolettas E, Panopoulou M, Mantadakis E, Konstantinidis T, Chrysanthopoulou A. Ιnterleukin-17A-Enriched Neutrophil Extracellular Traps Promote Immunofibrotic Aspects of Childhood Asthma Exacerbation. Biomedicines 2023; 11:2104. [PMID: 37626601 PMCID: PMC10452671 DOI: 10.3390/biomedicines11082104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 07/21/2023] [Accepted: 07/24/2023] [Indexed: 08/27/2023] Open
Abstract
Childhood asthma is a chronic inflammatory airway disorder that can drive tissue remodeling. Neutrophils are amongst the most prominent inflammatory cells contributing to disease manifestations and may exert a potent role in the progression of inflammation to fibrosis. However, their role in asthma exacerbation is still understudied. Here, we investigate the association between neutrophil extracellular traps (NETs) and lung fibroblasts in childhood asthma pathophysiology using serum samples from pediatric patients during asthma exacerbation. Cell-based assays and NETs/human fetal lung fibroblast co-cultures were deployed. Increased levels of NETs and interleukin (IL)-17A were detected in the sera of children during asthma exacerbation. The in vitro stimulation of control neutrophils using the sera from pediatric patients during asthma exacerbation resulted in IL-17A-enriched NET formation. The subsequent co-incubation of lung fibroblasts with in vitro-generated IL-17A-enriched NETs led fibroblasts to acquire a pre-fibrotic phenotype, as assessed via enhanced CCN2 expression, migratory/healing capacity, and collagen release. These data uncover the important pathogenic role of the NET/IL-17A axis in asthma exacerbation, linking lung inflammation to fibroblast dysfunction and fibrosis.
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Affiliation(s)
- Maria Ntinopoulou
- Laboratory of Molecular Immunology, Department of Biological Applications and Technology, School of Health Sciences, University of Ioannina, 45110 Ioannina, Greece; (M.N.); (T.K.)
| | - Dimitrios Cassimos
- Department of Pediatrics, University General Hospital of Alexandroupolis, Democritus University of Thrace Medical School, 68100 Thrace, Greece; (D.C.); (E.M.)
| | - Eugenia Roupakia
- Laboratory of Biology, School of Medicine, Faculty of Health Sciences, University of Ioannina, 45110 Ioannina, Greece; (E.R.); (E.K.)
- Biomedical Research Institute, Foundation for Research and Technology-Hellas, 45110 Ioannina, Greece
| | - Evangelos Kolettas
- Laboratory of Biology, School of Medicine, Faculty of Health Sciences, University of Ioannina, 45110 Ioannina, Greece; (E.R.); (E.K.)
- Biomedical Research Institute, Foundation for Research and Technology-Hellas, 45110 Ioannina, Greece
| | - Maria Panopoulou
- Department of Microbiology, University General Hospital of Alexandroupolis, Democritus University of Thrace Medical School, 68100 Thrace, Greece;
| | - Elpis Mantadakis
- Department of Pediatrics, University General Hospital of Alexandroupolis, Democritus University of Thrace Medical School, 68100 Thrace, Greece; (D.C.); (E.M.)
| | - Theocharis Konstantinidis
- Laboratory of Molecular Immunology, Department of Biological Applications and Technology, School of Health Sciences, University of Ioannina, 45110 Ioannina, Greece; (M.N.); (T.K.)
| | - Akrivi Chrysanthopoulou
- Laboratory of Molecular Immunology, Department of Biological Applications and Technology, School of Health Sciences, University of Ioannina, 45110 Ioannina, Greece; (M.N.); (T.K.)
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13
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He L, Liu R, Yue H, Zhang X, Pan X, Sun Y, Shi J, Zhu G, Qin C, Guo Y. Interaction between neutrophil extracellular traps and cardiomyocytes contributes to atrial fibrillation progression. Signal Transduct Target Ther 2023; 8:279. [PMID: 37491321 PMCID: PMC10368710 DOI: 10.1038/s41392-023-01497-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 01/20/2023] [Accepted: 02/18/2023] [Indexed: 07/27/2023] Open
Abstract
Atrial fibrillation (AF) is a frequent arrhythmia associated with cardiovascular morbidity and mortality. Neutrophil extracellular traps (NETs) are DNA fragments with cytoplasm proteins released from neutrophils, which are involved in various cardiovascular diseases. To elucidate the role of NETs in AF, we investigated the effect of NETs on AF progression and the secretion of NETs in AF. Results showed that: NETs induced the autophagic apoptosis of cardiomyocytes, and NETs also led to mitochondrial injury by promoting mitochondrial depolarization and ROS production. Ongoing tachy-pacing led to the structural loss of cardiomyocytes and provided potent stimuli to induce NETs secretion from neutrophils. In the meanwhile, increased Ang II in AF facilitated NETs formation through the upregulation of AKT phosphorylation, while it could not directly initiate NETosis as the autophagy was not induced. In vivo, DNase I was administrated to abrogate NETs formation, and AF-related fibrosis was ameliorated as expected. Correspondingly, the duration of the induced AF was reduced. Our study addresses the formation mechanism of NETs in AF and demonstrates the lethal effects of NETs on cardiomyocytes through the induction of mitochondrial injury and autophagic cell death, which comprehensively describes the positive feedback comprised of NETs and stimuli secreted by cardiomyocytes that sustains the progression of AF and AF related fibrosis.
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Affiliation(s)
- Li He
- Department of Cardiovascular Surgery and Cardiovascular Surgery Research Laboratory, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Ruiqi Liu
- Department of Plastic and Burn Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Honghua Yue
- Department of Cardiovascular Surgery and Cardiovascular Surgery Research Laboratory, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Xiaoxin Zhang
- West China Center of Excellence for Pancreatitis, Institute of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaohui Pan
- Department of Endocrinology & Metabolism, West China Hospital, Sichuan University, Chengdu, China
| | - Yutao Sun
- Department of Cardiovascular Surgery and Cardiovascular Surgery Research Laboratory, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Jun Shi
- Department of Cardiovascular Surgery and Cardiovascular Surgery Research Laboratory, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Guonian Zhu
- Department of Pulmonary and Critical Care Medicine and Institute of Respiratory Health, West China Hospital, Sichuan University, Chengdu, China
| | - Chaoyi Qin
- Department of Cardiovascular Surgery and Cardiovascular Surgery Research Laboratory, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China.
| | - Yingqiang Guo
- Department of Cardiovascular Surgery and Cardiovascular Surgery Research Laboratory, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China.
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14
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Ye S, Huang H, Xiao Y, Han X, Shi F, Luo W, Chen J, Ye Y, Zhao X, Huang W, Wang Y, Lai D, Liang G, Fu G. Macrophage Dectin-1 mediates Ang II renal injury through neutrophil migration and TGF-β1 secretion. Cell Mol Life Sci 2023; 80:184. [PMID: 37340199 DOI: 10.1007/s00018-023-04826-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 05/10/2023] [Accepted: 05/26/2023] [Indexed: 06/22/2023]
Abstract
Macrophage activation has been shown to play an essential role in renal fibrosis and dysfunction in hypertensive chronic kidney disease. Dectin-1 is a pattern recognition receptor that is also involved in chronic noninfectious diseases through immune activation. However, the role of Dectin-1 in Ang II-induced renal failure is still unknown. In this study, we found that Dectin-1 expression on CD68 + macrophages was significantly elevated in the kidney after Ang II infusion. We assessed the effect of Dectin-1 on hypertensive renal injury using Dectin-1-deficient mice infused by Angiotensin II (Ang II) at 1000 ng/kg/min for 4 weeks. Ang II-induced renal dysfunction, interstitial fibrosis, and immune activation were significantly attenuated in Dectin-1-deficient mice. A Dectin-1 neutralizing antibody and Syk inhibitor (R406) were used to examine the effect and mechanism of Dectin-1/Syk signaling axle on cytokine secretion and renal fibrosis in culturing cells. Blocking Dectin-1 or inhibiting Syk significantly reduced the expression and secretion of chemokines in RAW264.7 macrophages. The in vitro data showed that the increase in TGF-β1 in macrophages enhanced the binding of P65 and its target promotor via the Ang II-induced Dectin-1/Syk pathway. Secreted TGF-β1 caused renal fibrosis in kidney cells through Smad3 activation. Thus, macrophage Dectin-1 may be involved in the activation of neutrophil migration and TGF-β1 secretion, thereby promoting kidney fibrosis and dysfunction.
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Affiliation(s)
- Shiju Ye
- Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, 310020, Zhejiang, China
- School of Pharmaceutical Sciences, Hangzhou Medical College, Hangzhou, 311399, Zhejiang, China
- Department of Cardiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325035, Zhejiang, China
| | - He Huang
- Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, 310020, Zhejiang, China
| | - Yun Xiao
- Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, 310020, Zhejiang, China
| | - Xue Han
- School of Pharmaceutical Sciences, Hangzhou Medical College, Hangzhou, 311399, Zhejiang, China
| | - Fengjie Shi
- Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, 310020, Zhejiang, China
| | - Wu Luo
- School of Pharmaceutical Sciences, Hangzhou Medical College, Hangzhou, 311399, Zhejiang, China
- Chemical Biology Research Center, School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou, 325035, Zhejiang, China
| | - Jiawen Chen
- Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, 310020, Zhejiang, China
| | - Yang Ye
- Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, 310020, Zhejiang, China
| | - Xia Zhao
- School of Pharmaceutical Sciences, Hangzhou Medical College, Hangzhou, 311399, Zhejiang, China
| | - Weijian Huang
- Department of Cardiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325035, Zhejiang, China
| | - Yi Wang
- Chemical Biology Research Center, School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou, 325035, Zhejiang, China
| | - Dongwu Lai
- Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, 310020, Zhejiang, China
| | - Guang Liang
- School of Pharmaceutical Sciences, Hangzhou Medical College, Hangzhou, 311399, Zhejiang, China.
- Chemical Biology Research Center, School of Pharmaceutical Sciences, Wenzhou Medical University, Wenzhou, 325035, Zhejiang, China.
| | - Guosheng Fu
- Key Laboratory of Cardiovascular Intervention and Regenerative Medicine of Zhejiang Province, Department of Cardiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, 310020, Zhejiang, China.
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15
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Ząbczyk M, Natorska J, Matusik PT, Mołek P, Wojciechowska W, Rajzer M, Rajtar-Salwa R, Tokarek T, Lenart-Migdalska A, Olszowska M, Undas A. Neutrophil-activating Peptide 2 as a Novel Modulator of Fibrin Clot Properties in Patients with Atrial Fibrillation. Transl Stroke Res 2023:10.1007/s12975-023-01165-1. [PMID: 37294500 DOI: 10.1007/s12975-023-01165-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 05/23/2023] [Accepted: 05/30/2023] [Indexed: 06/10/2023]
Abstract
Neutrophil-activating peptide 2 (NAP-2, CXCL7), a platelet-derived neutrophil chemoattractant, is involved in inflammation. We investigated associations between NAP-2 levels, neutrophil extracellular traps (NETs) formation, and fibrin clot properties in atrial fibrillation (AF). We recruited 237 consecutive patients with AF (mean age, 68 ± 11 years; median CHA2DS2VASc score of 3 [2-4]) and 30 apparently healthy controls. Plasma NAP-2 concentrations were measured, along with plasma fibrin clot permeability (Ks) and clot lysis time (CLT), thrombin generation, citrullinated histone H3 (citH3), as a marker of NETs formation, and 3-nitrotyrosine reflecting oxidative stress. NAP-2 levels were 89% higher in AF patients than in controls (626 [448-796] vs. 331 [226-430] ng/ml; p < 0.0001). NAP-2 levels were not associated with demographics, CHA2DS2-VASc score, or the AF manifestation. Patients with NAP-2 in the top quartile (> 796 ng/ml) were characterized by higher neutrophil count (+ 31.7%), fibrinogen (+ 20.8%), citH3 (+ 86%), and 3-nitrotyrosine (+ 111%) levels, along with 20.2% reduced Ks and 8.4% prolonged CLT as compared to the remaining subjects (all p < 0.05). NAP-2 levels were positively associated with fibrinogen in AF patients (r = 0.41, p = 0.0006) and controls (r = 0.65, p < 0.01), along with citH3 (r = 0.36, p < 0.0001) and 3-nitrotyrosine (r = 0.51, p < 0.0001) in the former group. After adjustment for fibrinogen, higher citH3 (per 1 ng/ml β = -0.046, 95% CI -0.029; -0.064) and NAP-2 (per 100 ng/ml β = -0.21, 95% CI -0.14; -0.28) levels were independently associated with reduced Ks. Elevated NAP-2, associated with increased oxidative stress, has been identified as a novel modulator of prothrombotic plasma fibrin clot properties in patients with AF.
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Affiliation(s)
- Michał Ząbczyk
- Department of Thromboembolic Disorders, Institute of Cardiology, Jagiellonian University Medical College, Pradnicka 80, 31-202, Krakow, Poland
- Krakow Centre for Medical Research and Technologies, the John Paul II Hospital, Pradnicka 80, Krakow, Poland
| | - Joanna Natorska
- Department of Thromboembolic Disorders, Institute of Cardiology, Jagiellonian University Medical College, Pradnicka 80, 31-202, Krakow, Poland
- Krakow Centre for Medical Research and Technologies, the John Paul II Hospital, Pradnicka 80, Krakow, Poland
| | - Paweł T Matusik
- Institute of Cardiology, Faculty of Medicine, Jagiellonian University Medical College, Pradnicka 80, Kraków, Poland
- Department of Electrocardiology, the John Paul II Hospital, Pradnicka 80, Kraków, Poland
| | - Patrycja Mołek
- Krakow Centre for Medical Research and Technologies, the John Paul II Hospital, Pradnicka 80, Krakow, Poland
| | - Wiktoria Wojciechowska
- 1st Department of Cardiology, Interventional Electrocardiology and Arterial Hypertension, Jagiellonian University Medical College, Jakubowskiego 2, Kraków, Poland
| | - Marek Rajzer
- 1st Department of Cardiology, Interventional Electrocardiology and Arterial Hypertension, Jagiellonian University Medical College, Jakubowskiego 2, Kraków, Poland
| | - Renata Rajtar-Salwa
- Department of Cardiology and Cardiovascular Interventions, University Hospital, Jakubowskiego 2, Krakow, Poland
| | - Tomasz Tokarek
- Center for Invasive Cardiology, Electrotherapy and Angiology, Kilinskiego 68, Nowy Sacz, Poland
- Center for Innovative Medical Education, Jagiellonian University Medical College, Medyczna 9, Krakow, Poland
| | - Aleksandra Lenart-Migdalska
- Department of Cardiac and Vascular Diseases, Faculty of Medicine, Institute of Cardiology, Jagiellonian University Medical College, John Paul II Hospital, Pradnicka 80, Kraków, Poland
| | - Maria Olszowska
- Department of Cardiac and Vascular Diseases, Faculty of Medicine, Institute of Cardiology, Jagiellonian University Medical College, John Paul II Hospital, Pradnicka 80, Kraków, Poland
| | - Anetta Undas
- Department of Thromboembolic Disorders, Institute of Cardiology, Jagiellonian University Medical College, Pradnicka 80, 31-202, Krakow, Poland.
- Krakow Centre for Medical Research and Technologies, the John Paul II Hospital, Pradnicka 80, Krakow, Poland.
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16
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Abstract
Arterial and venous thrombosis constitute a major source of morbidity and mortality worldwide. Association between thrombotic complications and cardiovascular and other chronic inflammatory diseases are well described. Inflammation and subsequent initiation of thrombotic events, termed immunothrombosis, also receive growing attention but are still incompletely understood. Nevertheless, the clinical relevance of aberrant immunothrombosis, referred to as thromboinflammation, is evident by an increased risk of thrombosis and cardiovascular events in patients with inflammatory or infectious diseases. Proinflammatory mediators released from platelets, complement activation, and the formation of NETs (neutrophil extracellular traps) initiate and foster immunothrombosis. In this review, we highlight and discuss prominent and emerging interrelationships and functions between NETs and other mediators in immunothrombosis in cardiovascular disease. Also, with patients with chronic kidney disease suffering from increased cardiovascular and thrombotic risk, we summarize current knowledge on neutrophil phenotype, function, and NET formation in chronic kidney disease. In addition, we elaborate on therapeutic targeting of NETs-induced immunothrombosis. A better understanding of the functional relevance of antithrombotic mediators which do not increase bleeding risk may provide opportunities for successful therapeutic interventions to reduce thrombotic risk beyond current treatment options.
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Affiliation(s)
- Manovriti Thakur
- Division of Angiology, Swiss Cardiovascular Center, Inselspital (M.T., S.M.B., M.S., Y.D.), Bern University Hospital, University of Bern, Switzerland
- Department for BioMedical Research (DBMR) (M.T., S.M.B., M.S., Y.D.), Bern University Hospital, University of Bern, Switzerland
| | - Carolina Victoria Cruz Junho
- Institute for Molecular Cardiovascular Research (IMCAR), University Hospital RWTH Aachen, Germany (C.V.C.J., H.N.)
| | - Sarah Maike Bernhard
- Division of Angiology, Swiss Cardiovascular Center, Inselspital (M.T., S.M.B., M.S., Y.D.), Bern University Hospital, University of Bern, Switzerland
- Department for BioMedical Research (DBMR) (M.T., S.M.B., M.S., Y.D.), Bern University Hospital, University of Bern, Switzerland
| | - Marc Schindewolf
- Division of Angiology, Swiss Cardiovascular Center, Inselspital (M.T., S.M.B., M.S., Y.D.), Bern University Hospital, University of Bern, Switzerland
- Department for BioMedical Research (DBMR) (M.T., S.M.B., M.S., Y.D.), Bern University Hospital, University of Bern, Switzerland
| | - Heidi Noels
- Institute for Molecular Cardiovascular Research (IMCAR), University Hospital RWTH Aachen, Germany (C.V.C.J., H.N.)
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, the Netherlands (H.N.)
| | - Yvonne Döring
- Division of Angiology, Swiss Cardiovascular Center, Inselspital (M.T., S.M.B., M.S., Y.D.), Bern University Hospital, University of Bern, Switzerland
- Department for BioMedical Research (DBMR) (M.T., S.M.B., M.S., Y.D.), Bern University Hospital, University of Bern, Switzerland
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany (Y.D.)
- Institute for Cardiovascular Prevention (IPEK), Ludwig-Maximilians-University Munich (LMU), Munich, Germany (Y.D.)
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17
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Chrysanthopoulou A, Antoniadou C, Natsi AM, Gavriilidis E, Papadopoulos V, Xingi E, Didaskalou S, Mikroulis D, Tsironidou V, Kambas K, Koffa M, Skendros P, Ritis K. Down-regulation of KLF2 in lung fibroblasts is linked with COVID-19 immunofibrosis and restored by combined inhibition of NETs, JAK-1/2 and IL-6 signaling. Clin Immunol 2023; 247:109240. [PMID: 36693535 PMCID: PMC9862710 DOI: 10.1016/j.clim.2023.109240] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 01/17/2023] [Accepted: 01/18/2023] [Indexed: 01/22/2023]
Abstract
Kruppel-like factor 2 (KLF2) has been linked with fibrosis and neutrophil-associated thromboinflammation; however, its role in COVID-19 remains elusive. We investigated the effect of disease microenvironment on the fibrotic potential of human lung fibroblasts (LFs) and its association with KLF2 expression. LFs stimulated with plasma from severe COVID-19 patients down-regulated KLF2 expression at mRNA/protein and functional level acquiring a pre-fibrotic phenotype, as indicated by increased CCN2/collagen levels. Pre-incubation with the COMBI-treatment-agents (DNase I and JAKs/IL-6 inhibitors baricitinib/tocilizumab) restored KLF2 levels of LFs to normal abolishing their fibrotic activity. LFs stimulated with plasma from COMBI-treated patients at day-7 expressed lower CCN2 and higher KLF2 levels, compared to plasma prior-to-treatment, an effect not observed in standard-of-care treatment. In line with this, COMBI-treated patients had better outcome than standard-of-care group. These data link fibroblast KLF2 with NETosis and JAK/IL-6 signaling, suggesting the potential of combined therapeutic strategies in immunofibrotic diseases, such as COVID-19.
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Affiliation(s)
- Akrivi Chrysanthopoulou
- Laboratory of Molecular Hematology, Department of Medicine, Democritus University of Thrace, Alexandroupolis, Greece
| | - Christina Antoniadou
- First Department of Internal Medicine, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
| | - Anastasia-Maria Natsi
- Laboratory of Molecular Hematology, Department of Medicine, Democritus University of Thrace, Alexandroupolis, Greece
| | - Efstratios Gavriilidis
- First Department of Internal Medicine, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
| | - Vasileios Papadopoulos
- First Department of Internal Medicine, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
| | - Evangelia Xingi
- Light Microscopy Unit, Hellenic Pasteur Institute, Athens, Greece
| | - Stylianos Didaskalou
- Laboratory of Cell Biology, Proteomics and Cell Cycle, Department of Molecular Biology and Genetics, Democritus University of Thrace, Alexandroupolis, Greece
| | - Dimitrios Mikroulis
- Department of Cardiovascular Surgery, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
| | - Victoria Tsironidou
- Laboratory of Molecular Hematology, Department of Medicine, Democritus University of Thrace, Alexandroupolis, Greece
| | - Konstantinos Kambas
- Laboratory of Molecular Genetics, Department of Immunology, Hellenic Pasteur Institute, Athens, Greece
| | - Maria Koffa
- Laboratory of Cell Biology, Proteomics and Cell Cycle, Department of Molecular Biology and Genetics, Democritus University of Thrace, Alexandroupolis, Greece
| | - Panagiotis Skendros
- Laboratory of Molecular Hematology, Department of Medicine, Democritus University of Thrace, Alexandroupolis, Greece; First Department of Internal Medicine, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece.
| | - Konstantinos Ritis
- Laboratory of Molecular Hematology, Department of Medicine, Democritus University of Thrace, Alexandroupolis, Greece; First Department of Internal Medicine, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece.
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Singh P, Kumar N, Singh M, Kaur M, Singh G, Narang A, Kanwal A, Sharma K, Singh B, Napoli MD, Mastana S. Neutrophil Extracellular Traps and NLRP3 Inflammasome: A Disturbing Duo in Atherosclerosis, Inflammation and Atherothrombosis. Vaccines (Basel) 2023; 11. [PMID: 36851139 DOI: 10.3390/vaccines11020261] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 01/21/2023] [Accepted: 01/23/2023] [Indexed: 01/27/2023] Open
Abstract
Atherosclerosis is the formation of plaque within arteries due to overt assemblage of fats, cholesterol and fibrous material causing a blockage of the free flow of blood leading to ischemia. It is harshly impinging on health statistics worldwide because of being principal cause of high morbidity and mortality for several diseases including rheumatological, heart and brain disorders. Atherosclerosis is perpetuated by pro-inflammatory and exacerbated by pro-coagulatory mediators. Besides several other pathways, the formation of neutrophil extracellular traps (NETs) and the activation of the NOD-like receptor family pyrin domain containing 3 (NLRP3) inflammasome contribute significantly to the initiation and propagation of atherosclerotic plaque for its worst outcomes. The present review highlights the contribution of these two disturbing processes in atherosclerosis, inflammation and atherothrombosis in their individual as well as collaborative manner.
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19
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Zhang Z, Zhao L, Zhou X, Meng X, Zhou X. Role of inflammation, immunity, and oxidative stress in hypertension: New insights and potential therapeutic targets. Front Immunol 2023; 13:1098725. [PMID: 36703963 PMCID: PMC9871625 DOI: 10.3389/fimmu.2022.1098725] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 12/21/2022] [Indexed: 01/12/2023] Open
Abstract
Hypertension is regarded as the most prominent risk factor for cardiovascular diseases, which have become a primary cause of death, and recent research has demonstrated that chronic inflammation is involved in the pathogenesis of hypertension. Both innate and adaptive immunity are now known to promote the elevation of blood pressure by triggering vascular inflammation and microvascular remodeling. For example, as an important part of innate immune system, classically activated macrophages (M1), neutrophils, and dendritic cells contribute to hypertension by secreting inflammatory cy3tokines. In particular, interferon-gamma (IFN-γ) and interleukin-17 (IL-17) produced by activated T lymphocytes contribute to hypertension by inducing oxidative stress injury and endothelial dysfunction. However, the regulatory T cells and alternatively activated macrophages (M2) may have a protective role in hypertension. Although inflammation is related to hypertension, the exact mechanisms are complex and unclear. The present review aims to reveal the roles of inflammation, immunity, and oxidative stress in the initiation and evolution of hypertension. We envisage that the review will strengthen public understanding of the pathophysiological mechanisms of hypertension and may provide new insights and potential therapeutic strategies for hypertension.
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Affiliation(s)
| | | | | | - Xu Meng
- *Correspondence: Xianliang Zhou, ; Xu Meng,
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20
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Cao Y, Li P, Zhang Y, Qiu M, Li J, Ma S, Yan Y, Li Y, Han Y. Association of systemic immune inflammatory index with all-cause and cause-specific mortality in hypertensive individuals: Results from NHANES. Front Immunol 2023; 14:1087345. [PMID: 36817427 PMCID: PMC9932782 DOI: 10.3389/fimmu.2023.1087345] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 01/24/2023] [Indexed: 02/05/2023] Open
Abstract
Background The relationship between the systemic immune inflammatory index (SII) and the prognosis of hypertensive patients is unclear. This study aims to explore the association of SII with all-cause and cause-specific mortality in patients with hypertension. Methods This study included 8524 adults with hypertension from the National Health and Nutritional Examination Surveys (NHANES) 2011-2018, and followed for survival through December 31, 2019. Cox proportional hazards models were used to investigate the associations between SII and mortality from all causes, cardiovascular disease (CVD), and cancer. Restricted cubic spline, piecewise linear regression, subgroup and sensitivity analyses were also used. Results During a median follow-up of 4.58 years, 872 all-cause deaths occurred. After adjusting for covariates, higher SII was significantly associated with an elevated risk of CVD mortality. There was a 102% increased risk of CVD mortality per one-unit increment in natural log-transformed SII (lnSII) (P < 0.001). Consistent results were also observed when SII was examined as categorical variable (quartiles). The associations of SII with all-cause and cancer mortality were detected as U-shaped with threshold values of 5.97 and 6.18 for lnSII respectively. Below thresholds, higher SII was significantly associated with lower all-cause mortality (HR=0.79, 95%CI=0.64-0.97) and cancer mortality (HR=0.73, 95%CI=0.53-1.00). Above thresholds, SII was significantly positive associated with all-cause mortality (HR=1.93, 95%CI=1.55-2.40) and cancer mortality (HR=1.93, 95%CI=1.22-3.05). The results were robust in subgroup and sensitivity analyses. Conclusion Higher SII (either as a continuous or categorical variable) were significantly associated with a higher risk of CVD mortality. The U-shaped associations were observed between SII and all-cause and cancer mortality.
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Affiliation(s)
- Yang Cao
- The Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, Liaoning, China.,The Department of Cardiology, Xijing Hospital, Air Force Medical University, Xi'an, Shanxi, China
| | - Pengxiao Li
- The Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, Liaoning, China.,The Department of Cardiology, Xijing Hospital, Air Force Medical University, Xi'an, Shanxi, China
| | - Yan Zhang
- The Department of Cardiology, Xijing Hospital, Air Force Medical University, Xi'an, Shanxi, China
| | - Miaohan Qiu
- The Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, Liaoning, China
| | - Jing Li
- The Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, Liaoning, China
| | - Sicong Ma
- The Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, Liaoning, China
| | - Yudong Yan
- The Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, Liaoning, China.,The Department of Cardiology, Xijing Hospital, Air Force Medical University, Xi'an, Shanxi, China
| | - Yi Li
- The Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, Liaoning, China
| | - Yaling Han
- The Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, Liaoning, China
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21
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Stoimenou M, Tzoros G, Skendros P, Chrysanthopoulou A. Methods for the Assessment of NET Formation: From Neutrophil Biology to Translational Research. Int J Mol Sci 2022; 23. [PMID: 36555464 DOI: 10.3390/ijms232415823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 11/12/2022] [Accepted: 12/10/2022] [Indexed: 12/15/2022] Open
Abstract
Several studies have indicated that a neutrophil extracellular trap (NET) formation, apart from its role in host defense, can contribute to or drive pathogenesis in a wide range of inflammatory and thrombotic disorders. Therefore, NETs may serve as a therapeutic target or/and a diagnostic tool. Here, we compare the most commonly used techniques for the assessment of NET formation. Furthermore, we review recent data from the literature on the application of basic laboratory tools for detecting NET release and discuss the challenges and the advantages of these strategies in NET evaluation. Taken together, we provide some important insights into the qualitative and quantitative molecular analysis of NETs in translational medicine today.
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22
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Wenzel P. Thromboinflammation in cardiovascular disease: lessons learned for the management of hypertension, heart failure, and aortic valve stenosis. Eur Heart J 2022; 43:4611-4613. [PMID: 35979817 DOI: 10.1093/eurheartj/ehac459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Affiliation(s)
- Philip Wenzel
- Department of Cardiology, University Medical Center Mainz, Langenbeckstraße 1, 55131 Mainz, Germany.,Center for Thrombosis and Hemostasis, University Medical Center Mainz, Mainz, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, University Medical Center Mainz, Mainz, Germany.,Department of Biochemistry, Cardiovascular Research Institute Maastricht, School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands
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23
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Dong Y, Zhang Y, Yang X, Yan C, Feng Y. Recent Insights into Neutrophil Extracellular Traps in Cardiovascular Diseases. J Clin Med 2022; 11. [PMID: 36431139 DOI: 10.3390/jcm11226662] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 11/07/2022] [Accepted: 11/08/2022] [Indexed: 11/13/2022] Open
Abstract
Neutrophils are primary effector cells of the innate immune system. Emerging evidence has consistently shown that activated neutrophils produce and release neutrophil extracellular traps (NETs) that play roles in immunity and non-infectious diseases. NETs are composed of DNA and proteins and serve as a structural platform for pathogen sequestration and degradation. In contrast to their protective role during pathogenic infection, NETs are pathologically involved in cardiovascular disease (CVD). In this review, we introduce the formation, release, and clearance of NETs and the regulatory mechanisms of NETs formation, followed by an overview of the clinical evidence for the involvement of NETs in CVD. Because atherosclerosis is a fundamental part of the pathogenesis of CVD, we chose to focus on the mechanisms by which NETs promote endothelial cell damage and collaborate with macrophages and platelets to accelerate plaque progression and thrombosis. Finally, we present options for clinical intervention to inhibit NETs production and release in the treatment of CVD. In conclusion, this review integrates the latest findings and provides new insights into NETs, which represent a novel biomarker and therapeutic target in clinical practice.
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24
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Ondracek AS, Aszlan A, Schmid M, Lenz M, Mangold A, Artner T, Emich M, Fritzer-Szekeres M, Strametz-Juranek J, Lang IM, Sponder M. Physical Exercise Promotes DNase Activity Enhancing the Capacity to Degrade Neutrophil Extracellular Traps. Biomedicines 2022; 10:2849. [PMID: 36359376 PMCID: PMC9717727 DOI: 10.3390/biomedicines10112849] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 10/24/2022] [Accepted: 10/29/2022] [Indexed: 10/17/2023] Open
Abstract
(1) Background: An unhealthy lifestyle is a significant contributor to the development of chronic diseases. Physical activity can benefit primary and secondary prevention. Higher DNase activity is associated with favourable outcomes after cardiovascular (CV) events. In this study, we aimed to investigate the influence of consequent endurance exercise on DNase activity. (2) Methods: 98 subjects with at least one CV risk factor but the physical ability to perform endurance training were included. Individuals performed a bicycle stress test at the beginning and after 8 months to assess physical performance. In between, all participants were instructed to engage in guideline-directed physical activity. Blood samples were drawn in two-month intervals to assess routine laboratory parameters, cell-free DNA (cfDNA), and DNase activity. (3) Results: Prevailing CV risk factors were overweight (65.9%), a positive family history (44.9%), hypertension (32.7%) and smoking (20.4%). Performance changed by 7.8 ± 9.1% after 8 months. Comparison of baseline to 8 months revealed a decrease in cfDNA and an increase in DNase activity. This effect was driven by participants who achieved a performance gain. (4) Conclusions: Regular physical activity might improve CV health by increasing DNase activity and thereby, the capacity to lower pro-inflammatory signalling, complementing measures of primary and secondary prevention.
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Affiliation(s)
- Anna S. Ondracek
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (A.S.O.); (A.A.); (M.S.); (M.L.); (A.M.); (T.A.); (I.M.L.)
| | - Adrienne Aszlan
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (A.S.O.); (A.A.); (M.S.); (M.L.); (A.M.); (T.A.); (I.M.L.)
| | - Martin Schmid
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (A.S.O.); (A.A.); (M.S.); (M.L.); (A.M.); (T.A.); (I.M.L.)
| | - Max Lenz
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (A.S.O.); (A.A.); (M.S.); (M.L.); (A.M.); (T.A.); (I.M.L.)
| | - Andreas Mangold
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (A.S.O.); (A.A.); (M.S.); (M.L.); (A.M.); (T.A.); (I.M.L.)
| | - Tyler Artner
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (A.S.O.); (A.A.); (M.S.); (M.L.); (A.M.); (T.A.); (I.M.L.)
| | - Michael Emich
- Austrian Federal Ministry of Defence, Austrian Armed Forces, 1090 Vienna, Austria;
| | | | | | - Irene M. Lang
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (A.S.O.); (A.A.); (M.S.); (M.L.); (A.M.); (T.A.); (I.M.L.)
| | - Michael Sponder
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (A.S.O.); (A.A.); (M.S.); (M.L.); (A.M.); (T.A.); (I.M.L.)
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Fang X, Ma L, Wang Y, Ren F, Yu Y, Yuan Z, Wei H, Zhang H, Sun Y. Neutrophil extracellular traps accelerate vascular smooth muscle cell proliferation via Akt/CDKN1b/TK1 accompanying with the occurrence of hypertension. J Hypertens 2022; 40:2045-57. [PMID: 35950975 DOI: 10.1097/HJH.0000000000003231] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Neutrophil extracellular traps (NETs) can trigger pathological changes in vascular cells or vessel wall components, which are vascular pathological changes of hypertension. Therefore, we hypothesized that NETs would be associated with the occurrence of hypertension. METHODS To evaluate the relationship between NETs and hypertension, we evaluated both the NETs formation in spontaneously hypertensive rats (SHRs) and the blood pressure of mice injected phorbol-12-myristate-13-acetate (PMA) via the tail vein to induce NETs formation in arterial wall. Meanwhile, proliferation and cell cycle of vascular smooth muscle cells (VSMCs), which were co-cultured with NETs were assessed. In addition, the role of exosomes from VSMCs co-cultured with NETs on proliferation signaling delivery was assessed. RESULTS Formation of NETs increased in the arteries of SHR. PMA resulted in up-regulation expression of citrullinated Histone H3 (cit Histone H3, a NETs marker) in the arteries of mice accompanied with increasing of blood pressure. NET treatment significantly increased VSMCs count and accelerated G1/S transition in vitro . Cyclin-dependent kinase inhibitor 1b (CDKN1b) was down-regulated and Thymidine kinase 1 (TK1) was up-regulated in VSMCs. Exosomes from VSMCs co-cultured with NETs significantly accelerated the proliferation of VSMCs. TK1 was up-regulated in the exosomes from VSMCs co-cultured with NETs and in both the arterial wall and serum of mice with PMA. CONCLUSION NETs promote VSMCs proliferation via Akt/CDKN1b/TK1 and is related to hypertension development. Exosomes from VSMCs co-cultured with NETs participate in transferring the proliferation signal. These results support the role of NETs in the development of hypertension.
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26
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Gonçalves de Oliveira M, Nadruz W Jr, Zakia Mónica F. Endothelial and Vascular Smooth Muscle Dysfunction in Hypertension. Biochem Pharmacol 2022;:115263. [PMID: 36174768 DOI: 10.1016/j.bcp.2022.115263] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 09/19/2022] [Accepted: 09/20/2022] [Indexed: 12/11/2022]
Abstract
The development of essential hypertension involves several factors. Vascular dysfunction, characterized by endothelial dysfunction, low-grade inflammation and structural remodeling, plays an important role in the initiation and maintenance of essential hypertension. Although the mechanistic pathways by which essential hypertension develops are poorly understood, several pharmacological classes available on the clinical settings improve blood pressure by interfering in the cardiac output and/or vascular function. This review is divided in two major sections. The first section depicts the major molecular pathways as renin angiotensin aldosterone system (RAAS), endothelin, nitric oxide signalling pathway and oxidative stress in the development of vascular dysfunction. The second section describes the role of some pharmacological classes such as i) RAAS inhibitors, ii) dual angiotensin receptor-neprilysin inhibitors, iii) endothelin-1 receptor antagonists, iv) soluble guanylate cyclase modulators, v) phosphodiesterase type 5 inhibitors and vi) sodium-glucose cotransporter 2 inhibitors in the context of hypertension. Some classes are already approved in the treatment of hypertension, but others are not yet approved. However, due to their potential benefits these classes were included.
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27
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Shafqat A, Abdul Rab S, Ammar O, Al Salameh S, Alkhudairi A, Kashir J, Alkattan K, Yaqinuddin A. Emerging role of neutrophil extracellular traps in the complications of diabetes mellitus. Front Med (Lausanne) 2022; 9:995993. [PMID: 36082273 PMCID: PMC9445264 DOI: 10.3389/fmed.2022.995993] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 08/05/2022] [Indexed: 11/13/2022] Open
Abstract
Immune dysfunction is widely regarded as one of the central tenants underpinning the pathophysiology of diabetes mellitus (DM) and its complications. When discussing immunity, the role of neutrophils must be accounted for: neutrophils are the most abundant of the circulating immune cells and are the first to be recruited to sites of inflammation, where they contribute to host defense via phagocytosis, degranulation, and extrusion of neutrophil extracellular traps (NETs). NETs are composed of DNA associated with nuclear and cytosolic neutrophil proteins. Although originally reported as an antimicrobial strategy to prevent microbial dissemination, a growing body of evidence has implicated NETs in the pathophysiology of various autoimmune and metabolic disorders. In these disorders, NETs propagate a pathologic inflammatory response with consequent tissue injury and thrombosis. Many diabetic complications—such as stroke, retinopathy, impaired wound healing, and coronary artery disease—involve these mechanisms. Therefore, in this review, we discuss laboratory and clinical data informing our understanding of the role of NETs in the development of these complications. NET markers, including myeloperoxidase, citrullinated histone H3, neutrophil elastase, and cell-free double-stranded DNA, can easily be measured in serum or be detected via immunohistochemical/immunocytochemical staining of tissue specimens. Therefore, NET constituents potentially constitute reliable biomarkers for use in the management of diabetic patients. However, no NET-targeting drug is currently approved for the treatment of diabetic complications; a candidate drug will require the outcomes of well-designed, robust clinical trials assessing whether NET inhibition can benefit patients in terms of morbidity, quality of life, health expenditures, and mortality. Therefore, much work remains to be done in translating these encouraging pieces of data into clinical trials for NET-targeting medications to be used in the clinic.
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Affiliation(s)
- Areez Shafqat
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
- *Correspondence: Areez Shafqat
| | | | - Osama Ammar
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | | | - Anas Alkhudairi
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Junaid Kashir
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
- Center of Comparative Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Khaled Alkattan
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
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Biswas M, Suvarna R, Krishnan S V, Devasia T, Shenoy Belle V, Prabhu K. The mechanistic role of neutrophil lymphocyte ratio perturbations in the leading non communicable lifestyle diseases. F1000Res 2022; 11:960. [PMID: 36619602 PMCID: PMC9780608 DOI: 10.12688/f1000research.123245.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/08/2022] [Indexed: 01/13/2023] Open
Abstract
Inflammation plays a critical role in the development and progression of chronic diseases like type 2 diabetes mellitus, coronary artery disease, and chronic obstructive pulmonary disease. Inflammatory responses are indispensable for pathogen control and tissue repair, but they also cause collateral damage. A chronically activated immune system and the resultant immune dysregulation mediated inflammatory surge may cause multiple negative effects, requiring tight regulation and dampening of the immune response to minimize host injury. While chronic diseases are characterized by systemic inflammation, the mechanistic relationship of neutrophils and lymphocytes to inflammation and its correlation with the clinical outcomes is yet to be elucidated. The neutrophil to lymphocyte ratio (NLR) is an easy-to-measure laboratory marker used to assess systemic inflammation. Understanding the mechanisms of NLR perturbations in chronic diseases is crucial for risk stratification, early intervention, and finding novel therapeutic targets. We investigated the correlation between NLR and prevalent chronic conditions as a measure of systemic inflammation. In addition to predicting the risk of impending chronic conditions, NLR may also provide insight into their progression. This review summarizes the mechanisms of NLR perturbations at cellular and molecular levels, and the key inflammatory signaling pathways involved in the progression of chronic diseases. We have also explored preclinical studies investigating these pathways and the effect of quelling inflammation in chronic disease as reported by a few in vitro, in vivo studies, and clinical trials.
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Affiliation(s)
- Monalisa Biswas
- Department of Biochemistry, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | - Renuka Suvarna
- Division of Ayurveda, Center for Integrative Medicine and Research, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | - Vimal Krishnan S
- Department of Emergency Medicine, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | - Tom Devasia
- Department of Cardiology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | - Vijetha Shenoy Belle
- Department of Biochemistry, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India,
| | - Krishnananda Prabhu
- Department of Biochemistry, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India,
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Abstract
The multi-ligand receptor for advanced glycation end-products (RAGE) and its ligands are contributing factors in autoimmunity, cancers, and infectious disease. RAGE activation is increased in chronic kidney disease (CKD) and coronavirus disease 2019 (COVID-19). CKD may increase the risk of COVID-19 severity and may also develop in the form of long COVID. RAGE is expressed in essentially all kidney cell types. Increased production of RAGE isoforms and RAGE ligands during CKD and COVID-19 promotes RAGE activity. The downstream effects include cellular dysfunction, tissue injury, fibrosis, and inflammation, which in turn contribute to a decline in kidney function, hypertension, thrombotic disorders, and cognitive impairment. In this review, we discuss the forms and mechanisms of RAGE and RAGE ligands in the kidney and COVID-19. Because various small molecules antagonize RAGE activity in animal models, targeting RAGE, its co-receptors, or its ligands may offer novel therapeutic approaches to slowing or halting progressive kidney disease, for which current therapies are often inadequate.
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Affiliation(s)
- Colleen S. Curran
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, United States
| | - Jeffrey B. Kopp
- Kidney Disease Section, NIDDK (National Institute of Diabetes and Digestive and Kidney Diseases), National Institutes of Health, Bethesda, MD, United States
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30
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Krishnan J, de la Visitación N, Hennen EM, Amarnath V, Harrison DG, Patrick DM. IsoLGs (Isolevuglandins) Drive Neutrophil Migration in Hypertension and Are Essential for the Formation of Neutrophil Extracellular Traps. Hypertension 2022; 79:1644-1655. [PMID: 35686559 PMCID: PMC9308685 DOI: 10.1161/hypertensionaha.122.19305] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND IsoLGs (isolevuglandins) are electrophilic products of lipid peroxidation formed in the presence of reactive oxygen species. IsoLGs contribute to hypertension by an unknown mechanism. Studies have shown that reactive oxygen species production drives the formation of neutrophil extracellular traps (NETs) and that NETs accumulate within the aorta and kidneys of patients with hypertension. The purpose of this study was to determine the role of isoLGs in neutrophil migration and NET formation (NETosis) in hypertension. METHODS Mice were treated with Ang II (angiotensin II) and the specific isoLG scavenger 2-hydroxybenzylamine and examined for tissue neutrophil and NET accumulation by single-cell sequencing and flow cytometry. Isolated human neutrophils were studied to determine the role of isoLGs in NETosis and neutrophil chromatin expansion by immunofluorescence and live cell confocal microscopy. RESULTS Single-cell sequencing performed on sham, Ang II, and Ang II+2-hydroxybenzylamine treated mice revealed neutrophils as a primary target of 2-hydroxybenzylamine. Peripheral neutrophil migration, aortic NET accumulation, and renal NET accumulation is blocked with 2-hydroxybenzylamine treatment. In isolated human neutrophils, isoLGs accumulate during NETosis and scavenging of isoLGs prevents NETosis. IsoLGs drive neutrophil chromatin expansion during NETosis and disrupt nucleosome structure. CONCLUSIONS These observations identified a critical role of isoLGs in neutrophil migration and NETosis in hypertension and provide a potential therapy for NET-associated diseases including hypertension and associated end organ damage.
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Affiliation(s)
- Jaya Krishnan
- Division of Clinical Pharmacology (J.K., N.d.l.V., V.A., D.G.H., D.M.P.), Department of Medicine, Vanderbilt University Medical Center
| | - Néstor de la Visitación
- Division of Clinical Pharmacology (J.K., N.d.l.V., V.A., D.G.H., D.M.P.), Department of Medicine, Vanderbilt University Medical Center
| | | | - Venkataraman Amarnath
- Division of Clinical Pharmacology (J.K., N.d.l.V., V.A., D.G.H., D.M.P.), Department of Medicine, Vanderbilt University Medical Center
| | - David G Harrison
- Division of Clinical Pharmacology (J.K., N.d.l.V., V.A., D.G.H., D.M.P.), Department of Medicine, Vanderbilt University Medical Center.,Division of Cardiovascular Medicine (D.G.H., D.M.P.), Department of Medicine, Vanderbilt University Medical Center
| | - David M Patrick
- Division of Clinical Pharmacology (J.K., N.d.l.V., V.A., D.G.H., D.M.P.), Department of Medicine, Vanderbilt University Medical Center.,Division of Cardiovascular Medicine (D.G.H., D.M.P.), Department of Medicine, Vanderbilt University Medical Center.,Department of Veterans Affairs, Nashville, TN (D.M.P.)
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Shirakawa K, Sano M. Neutrophils and Neutrophil Extracellular Traps in Cardiovascular Disease: An Overview and Potential Therapeutic Approaches. Biomedicines 2022; 10:1850. [PMID: 36009397 PMCID: PMC9405087 DOI: 10.3390/biomedicines10081850] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 07/18/2022] [Accepted: 07/23/2022] [Indexed: 11/17/2022] Open
Abstract
Recent advances in pharmacotherapy have markedly improved the prognosis of cardiovascular disease (CVD) but have not completely conquered it. Therapies targeting the NOD-like receptor family pyrin domain containing 3 inflammasome and its downstream cytokines have proven effective in the secondary prevention of cardiovascular events, suggesting that inflammation is a target for treating residual risk in CVD. Neutrophil-induced inflammation has long been recognized as important in the pathogenesis of CVD. Circadian rhythm-related and disease-specific microenvironment changes give rise to neutrophil diversity. Neutrophils are primed by various stimuli, such as chemokines, cytokines, and damage-related molecular patterns, and the activated neutrophils contribute to the inflammatory response in CVD through degranulation, phagocytosis, reactive oxygen species generation, and the release of neutrophil extracellular traps (NETs). In particular, NETs promote immunothrombosis through the interaction with vascular endothelial cells and platelets and are implicated in the development of various types of CVD, such as acute coronary syndrome, deep vein thrombosis, and heart failure. NETs are promising candidates for anti-inflammatory therapy in CVD, and their efficacy has already been demonstrated in various animal models of the disease; however, they have yet to be clinically applied in humans. This narrative review discusses the diversity and complexity of neutrophils in the trajectory of CVD, the therapeutic potential of targeting NETs, and the related clinical issues.
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Bolkhovitina EL, Vavilova JD, Bogorodskiy AO, Zagryadskaya YA, Okhrimenko IS, Sapozhnikov AM, Borshchevskiy VI, Shevchenko MA. Short-Term Effect of SARS-CoV-2 Spike Protein Receptor-Binding Domain-Specific Antibody Induction on Neutrophil-Mediated Immune Response in Mice. Int J Mol Sci 2022; 23:8234. [PMID: 35897803 DOI: 10.3390/ijms23158234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 07/23/2022] [Accepted: 07/24/2022] [Indexed: 02/04/2023] Open
Abstract
Vaccination protects against COVID-19 via the spike protein receptor-binding domain (RBD)-specific antibody formation, but it also affects the innate immunity. The effects of specific antibody induction on neutrophils that can cause severe respiratory inflammation are important, though not completely investigated. In the present study, using a mouse model mimicking SARS-CoV-2 virus particle inhalation, we investigated neutrophil phenotype and activity alterations in the presence of RBD-specific antibodies. Mice were immunized with RBD and a week after a strong antibody response establishment received 100 nm particles in the RBD solution. Control mice received injections of a phosphate buffer instead of RBD. We show that the application of 100 nm particles in the RBD solution elevates neutrophil recruitment to the blood and the airways of RBD-immunized mice rather than in control mice. Analysis of bone marrow cells of mice with induced RBD-specific antibodies revealed the increased population of CXCR2+CD101+ neutrophils. These neutrophils did not demonstrate an enhanced ability of neutrophil extracellular traps (NETs) formation compared to the neutrophils from control mice. Thus, the induction of RBD-specific antibodies stimulates the activation of mature neutrophils that react to RBD-coated particles without triggering excessive inflammation.
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33
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Navaneethabalakrishnan S, Smith HL, Arenaz CM, Goodlett BL, McDermott JG, Mitchell BM. Update on Immune Mechanisms in Hypertension. Am J Hypertens 2022; 35:842-851. [PMID: 35704473 PMCID: PMC9527774 DOI: 10.1093/ajh/hpac077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 06/09/2022] [Accepted: 06/10/2022] [Indexed: 02/02/2023] Open
Abstract
The contribution of immune cells in the initiation and maintenance of hypertension is undeniable. Several studies have established the association between hypertension, inflammation, and immune cells from the innate and adaptive immune systems. Here, we provide an update to our 2017 American Journal of Hypertension review on the overview of the cellular immune responses involved in hypertension. Further, we discuss the activation of immune cells and their contribution to the pathogenesis of hypertension in different in vivo models. We also highlight existing gaps in the field of hypertension that need attention. The main goal of this review is to provide a knowledge base for translational research to develop therapeutic strategies that can improve cardiovascular health in humans.
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Affiliation(s)
| | | | - Cristina M Arenaz
- Department of Medical Physiology, Texas A&M College of Medicine, Bryan, Texas, USA
| | - Bethany L Goodlett
- Department of Medical Physiology, Texas A&M College of Medicine, Bryan, Texas, USA
| | - Justin G McDermott
- Department of Medical Physiology, Texas A&M College of Medicine, Bryan, Texas, USA
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34
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Romano A, Parrinello NL, Barchitta M, Manuele R, Puglisi F, Maugeri A, Barbato A, Triolo AM, Giallongo C, Tibullo D, La Ferla L, Botta C, Siragusa S, Iacobello C, Montineri A, Volti GL, Agodi A, Palumbo GA, Di Raimondo F. In-vitro NET-osis induced by COVID-19 sera is associated to severe clinical course in not vaccinated patients and immune-dysregulation in breakthrough infection. Sci Rep 2022; 12:7237. [PMID: 35508575 PMCID: PMC9065667 DOI: 10.1038/s41598-022-11157-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 04/18/2022] [Indexed: 11/18/2022] Open
Abstract
Since neutrophil extracellular traps formation (NET-osis) can be assessed indirectly by treating healthy neutrophils with blood-derived fluids from patients and then measuring the NETs response, we designed a pilot study to convey high-dimensional cytometry of peripheral blood immune cells and cytokines, combined with clinical features, to understand if NET-osis assessment could be included in the immune risk profiling to early prediction of clinical patterns, disease severity, and viral clearance at 28 days in COVID-19 patients. Immune cells composition of peripheral blood, cytokines concentration and in-vitro NETosis were detected in peripheral blood of 41 consecutive COVID-19 inpatients, including 21 mild breakthrough infections compared to 20 healthy donors, matched for sex and age. Major immune dysregulation in peripheral blood in not-vaccinated COVID-19 patients compared to healthy subjects included: a significant reduction of percentage of unswitched memory B-cells and transitional B-cells; loss of naïve CD3+CD4+CD45RA+ and CD3+CD8+CD45RA+ cells, increase of IL-1β, IL-17A and IFN-γ. Myeloid compartment was affected as well, due to the increase of classical (CD14++CD16−) and intermediate (CD14++CD16+) monocytes, overexpressing the activation marker CD64, negatively associated to the absolute counts of CD8+ CD45R0+ cells, IFN-γ and IL-6, and expansion of monocytic-like myeloid derived suppressor cells. In not-vaccinated patients who achieved viral clearance by 28 days we found at hospital admission lower absolute counts of effector cells, namely CD8+T cells, CD4+ T-cells and CD4+CD45RO+ T cells. Percentage of in-vitro NET-osis induced by patients’ sera and NET-osis density were progressively higher in moderate and severe COVID-19 patients than in mild disease and controls. The percentage of in-vitro induced NET-osis was positively associated to circulating cytokines IL-1β, IFN-γ and IL-6. In breakthrough COVID-19 infections, characterized by mild clinical course, we observed increased percentage of in-vitro NET-osis, higher CD4+ CD45RO+ and CD8+ CD45RO+ T cells healthy or mild-COVID-19 not-vaccinated patients, reduced by 24 h of treatment with ACE inhibitor ramipril. Taken together our data highlight the role of NETs in orchestrating the complex immune response to SARS-COV-2, that should be considered in a multi-target approach for COVID-19 treatment.
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Affiliation(s)
- Alessandra Romano
- Division of Hematology, Azienda Policlinico-Rodolico San Marco, Catania, Italy. .,Dipartimento di Chirurgia Generale e Specialità Medico Chirurgiche, University of Catania, Catania, Italy.
| | | | - Martina Barchitta
- Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", University of Catania, 95123, Catania, Italy
| | - Rosy Manuele
- U.O.C. di Malattie Infettive, Azienda Policlinico-Rodolico San Marco, Catania, Italy
| | - Fabrizio Puglisi
- Division of Hematology, Azienda Policlinico-Rodolico San Marco, Catania, Italy
| | - Andrea Maugeri
- Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", University of Catania, 95123, Catania, Italy
| | - Alessandro Barbato
- Division of Hematology, Azienda Policlinico-Rodolico San Marco, Catania, Italy
| | - Anna Maria Triolo
- Division of Hematology, Azienda Policlinico-Rodolico San Marco, Catania, Italy
| | - Cesarina Giallongo
- Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", University of Catania, 95123, Catania, Italy
| | - Daniele Tibullo
- Dipartimento di Scienze Biomediche e Biotecnologiche, University of Catania, Catania, Italy
| | - Lucia La Ferla
- U.O.C. di Malattie Infettive, Azienda Cannizzaro, Catania, Italy
| | - Ciro Botta
- Division of Hematology, Università degli Studi di Palermo, Palermo, Italy
| | - Sergio Siragusa
- Division of Hematology, Università degli Studi di Palermo, Palermo, Italy
| | | | - Arturo Montineri
- U.O.C. di Malattie Infettive, Azienda Policlinico-Rodolico San Marco, Catania, Italy
| | - Giovanni Li Volti
- Dipartimento di Scienze Biomediche e Biotecnologiche, University of Catania, Catania, Italy
| | - Antonella Agodi
- Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", University of Catania, 95123, Catania, Italy
| | - Giuseppe Alberto Palumbo
- Division of Hematology, Azienda Policlinico-Rodolico San Marco, Catania, Italy.,Department of Medical and Surgical Sciences and Advanced Technologies "GF Ingrassia", University of Catania, 95123, Catania, Italy
| | - Francesco Di Raimondo
- Division of Hematology, Azienda Policlinico-Rodolico San Marco, Catania, Italy.,Dipartimento di Chirurgia Generale e Specialità Medico Chirurgiche, University of Catania, Catania, Italy
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35
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Gavriilidis E, Antoniadou C, Chrysanthopoulou A, Ntinopoulou M, Smyrlis A, Fotiadou I, Zioga N, Kogias D, Natsi AM, Pelekoudas C, Satiridou E, Bakola SA, Papagoras C, Mitroulis I, Peichamperis P, Mikroulis D, Papadopoulos V, Skendros P, Ritis K. Combined administration of inhaled DNase, baricitinib and tocilizumab as rescue treatment in COVID-19 patients with severe respiratory failure. Clin Immunol 2022; 238:109016. [PMID: 35447311 PMCID: PMC9014660 DOI: 10.1016/j.clim.2022.109016] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 04/09/2022] [Accepted: 04/13/2022] [Indexed: 02/07/2023]
Abstract
Aiming to reduce mortality in COVID-19 with severe respiratory failure we administered a combined rescue treatment (COMBI) on top of standard-of-care (SOC: dexamethasone/heparin) consisted of inhaled DNase to dissolve thrombogenic neutrophil extracellular traps, plus agents against cytokine-mediated hyperinflammation, namely anti-IL-6-receptor tocilizumab and JAK1/2 inhibitor baricitinib. Patients with PaO2/FiO2 < 100 mmHg were analysed. COMBI group (n = 22) was compared with similar groups that had received SOC alone (n = 26) or SOC plus monotherapy with either IL-1-receptor antagonist anakinra (n = 19) or tocilizumab (n = 11). COMBI was significantly associated with lower in-hospital mortality and intubation rate, shorter duration of hospitalization, and prolonged overall survival after a median follow-up of 110 days. In vitro, COVID-19 plasma induced tissue factor/thrombin pathway in primary lung fibroblasts. This effect was inhibited by the immunomodulatory agents of COMBI providing a mechanistic explanation for the clinical observations. These results support the conduct of randomized trials using combined immunomodulation in COVID-19 to target multiple interconnected pathways of immunothrombosis.
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Affiliation(s)
- Efstratios Gavriilidis
- First Department of Internal Medicine, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Christina Antoniadou
- First Department of Internal Medicine, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Akrivi Chrysanthopoulou
- Laboratory of Molecular Hematology, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Maria Ntinopoulou
- Laboratory of Molecular Hematology, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Andreas Smyrlis
- First Department of Internal Medicine, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Iliana Fotiadou
- First Department of Internal Medicine, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Nikoleta Zioga
- First Department of Internal Medicine, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Dionysios Kogias
- First Department of Internal Medicine, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Anastasia-Maria Natsi
- Laboratory of Molecular Hematology, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Christos Pelekoudas
- First Department of Internal Medicine, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Evangelia Satiridou
- First Department of Internal Medicine, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Stefania-Aspasia Bakola
- First Department of Internal Medicine, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Charalampos Papagoras
- First Department of Internal Medicine, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece; Laboratory of Molecular Hematology, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Ioannis Mitroulis
- First Department of Internal Medicine, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece; Laboratory of Molecular Hematology, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Paschalis Peichamperis
- First Department of Internal Medicine, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Dimitrios Mikroulis
- Department of Cardiovascular Surgery, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Vasileios Papadopoulos
- First Department of Internal Medicine, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece; Department of Internal Medicine, Xanthi General Hospital, Xanthi, Greece
| | - Panagiotis Skendros
- First Department of Internal Medicine, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece; Laboratory of Molecular Hematology, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece.
| | - Konstantinos Ritis
- First Department of Internal Medicine, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece; Laboratory of Molecular Hematology, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece.
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36
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Zhang Q, Ling S, Hu K, Liu J, Xu JW. Role of the renin-angiotensin system in NETosis in the coronavirus disease 2019 (COVID-19). Pharmacotherapy 2022; 148:112718. [PMID: 35176710 PMCID: PMC8841219 DOI: 10.1016/j.biopha.2022.112718] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 02/08/2022] [Accepted: 02/10/2022] [Indexed: 12/20/2022]
Abstract
Myocardial infarction and stroke are the leading causes of death in the world. Numerous evidence has confirmed that hypertension promotes thrombosis and induces myocardial infarction and stroke. Recent findings reveal that neutrophil extracellular traps (NETs) are involved in the induction of myocardial infarction and stroke. Meanwhile, patients with severe COVID-19 suffer from complications such as myocardial infarction and stroke with pathological signs of NETs. Due to the extremely low amount of virus detected in the blood and remote organs (e.g., heart, brain and kidney) in a few cases, it is difficult to explain the mechanism by which the virus triggers NETosis, and there may be a different mechanism than in the lung. A large number of studies have found that the renin-angiotensin system regulates the NETosis at multiple levels in patients with COVID-19, such as endocytosis of SARS-COV-2, abnormal angiotensin II levels, neutrophil activation and procoagulant function at multiple levels, which may contribute to the formation of reticular structure and thrombosis. The treatment of angiotensin-converting enzyme inhibitors (ACEI), angiotensin II type 1 receptor blockers (ARBs) and neutrophil recruitment and active antagonists helps to regulate blood pressure and reduce the risk of net and thrombosis. The review will explore the possible role of the angiotensin system in the formation of NETs in severe COVID-19.
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Chang CH, Jung CJ, Huang YM, Chiao L, Chang YL, Hsieh SC, Lin CH, Kuo YM. The first reported case of trastuzumab induced interstitial lung disease associated with anti-neutrophil cytoplasmic antibody vasculitis - A case report and a prospective cohort study on the usefulness of neutrophil derived biomarkers in monitoring vasculitis disease activity during follow-up. Breast 2022; 61:35-42. [PMID: 34894465 PMCID: PMC8669110 DOI: 10.1016/j.breast.2021.11.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 11/15/2021] [Accepted: 11/23/2021] [Indexed: 01/03/2023] Open
Abstract
Targeted therapies against human epidermal growth factor receptor 2 (HER2) are associated with increased interstitial lung disease (ILD). Trastuzumab, lapatinib, pertuzumab, and trastuzumab emtansine have markedly extended HER2 breast cancer survival but current knowledge on how these HER2-targeted agents induce interstitial lung disease is still poorly defined due to limited cases in the literature. Physicians mostly managed this complication by dose interruption, dose de-escalation, or discontinuation with success. In 2019, the FDA had granted accelerated approval on trastuzumab deruxtecan (T-Dxd) in HER2 breast cancer in the late line setting. Severe ILD incidence rate was over ten percent and led to fatal outcomes in 2.2% of patients in the T-Dxd trial. Searching for biomarkers to detect ILD incidence before it becomes clinically fulminant or for treatment response monitoring is of high clinical value. A Case of life-threatening trastuzumab-induced ILD was encountered in our facility. The ILD was confirmed to be antineutrophil cytoplasmic antibody (ANCA) pulmonary capillaritis. The biomarker of neutrophil extracellular traps (NETs), serum MPO-DNA complex, showed a good correlation with the clinical severity. Soon after B cell depleting agent rituximab usage, the serum MPO-DNA outperformed ANCA autoantibody and maintained its correlation with clinical severity. In addition to the trastuzumab-induced ILD case, a prospective cohort in our facility also confirmed the usefulness of MPO-DNA in monitoring vasculitis activity. We postulated that upfront testing with biomarkers of vasculitis during HER2 targeted treatment with high ILD incidence may be beneficial in the future.
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Affiliation(s)
- Chen-Han Chang
- Department of Medical Oncology, National Taiwan University Hospital, Taipei, Taiwan.
| | - Chiau-Jing Jung
- Department of Microbiology and Immunology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yi-Ming Huang
- Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, National Taiwan University Hospital Yunlin Branch, Yunlin, Taiwan
| | - Lo Chiao
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Yih-Leong Chang
- Graduate Institute of Pathology, College of Medicine, National Taiwan University College of Medicine, Taipei, Taiwan; Department of Pathology, National Taiwan University Cancer Center and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Song-Chou Hsieh
- Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Ching-Hung Lin
- Department of Medical Oncology, National Taiwan University Hospital, Taipei, Taiwan; Department of Medical Oncology, National Taiwan University Cancer Center, Taipei, Taiwan
| | - Yu-Min Kuo
- Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.
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38
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Abstract
Low-grade inflammatory processes and related oxidative stress may have a key role in the pathogenesis of hypertension and hypertension-mediated organ damage. Innate immune cells, such as neutrophils, dendritic cells, monocytes/macrophages, as well as unconventional T lymphocytes like γδ T cells contribute to hypertension and may trigger vascular inflammation. Adaptive immunity has been demonstrated to participate in elevation of blood pressure and in vascular and kidney injury. In particular, effector T lymphocytes (Th1, Th2, and Th17) may play a relevant role in promoting hypertension and microvascular remodeling, whereas T-regulatory lymphocytes may have a protective role. Effector cytokines produced by these immune cells lead to increased oxidative stress, endothelial dysfunction and contribute to target organ damage in hypertension. A possible role of immune cell subpopulations in the development and regression of microvascular remodeling has also been proposed in humans with hypertension. The present review summarizes the key immune mechanisms that may participate in the pathophysiology of hypertension-mediated inflammation and vascular remodeling; advances in this field may provide the basis for novel therapeutics for hypertension.
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Affiliation(s)
- Damiano Rizzoni
- Clinica Medica, Department of Clinical and Experimental Sciences, University of Brescia, Italy (D.R., C.D.C.).,Division of Medicine, Spedali Civili di Brescia, Montichiari, Italy (D.R.)
| | - Carolina De Ciuceis
- Clinica Medica, Department of Clinical and Experimental Sciences, University of Brescia, Italy (D.R., C.D.C.)
| | - Piotr Szczepaniak
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (P.S., T.J.G.).,Department of Medicine, Jagiellonian University Medical College, Krakow, Poland (P.S., T.J.G.)
| | - Pierre Paradis
- Hypertension and Vascular Research Unit, Lady Davis Institute for Medical Research, Montreal, Québec, Canada (P.P., E.L.S.)
| | - Ernesto L Schiffrin
- Hypertension and Vascular Research Unit, Lady Davis Institute for Medical Research, Montreal, Québec, Canada (P.P., E.L.S.).,Department of Medicine, Sir Mortimer B. Davis-Jewish General Hospital, McGill University, Montreal, Québec, Canada (E.L.S.)
| | - Tomasz J Guzik
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (P.S., T.J.G.).,Department of Medicine, Jagiellonian University Medical College, Krakow, Poland (P.S., T.J.G.)
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39
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Majumder S, Pushpakumar S, Juin SK, Jala VR, Sen U. Toll-like receptor 4 mutation protects the kidney from Ang-II-induced hypertensive injury. Pharmacol Res 2022; 175:106030. [PMID: 34896544 PMCID: PMC8755630 DOI: 10.1016/j.phrs.2021.106030] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 12/06/2021] [Accepted: 12/07/2021] [Indexed: 01/03/2023]
Abstract
Cellular autophagy is a protective mechanism where cells degrade damaged organelles to maintain intracellular homeostasis. Apoptosis, on the other hand, is considered as programmed cell death. Interestingly, autophagy inhibits apoptosis by degrading apoptosis regulators. In hypertension, an imbalance of autophagy and apoptosis regulators can lead to renal injury and dysfunction. Previously, we have reported that toll-like receptor 4 (TLR4) mutant mice are protective against renal damage, in part, due to reduced oxidative stress and inflammation. However, the detailed mechanism remained elusive. In this study, we tested the hypothesis of whether TLR4 mutation reduces Ang-II-induced renal injury by inciting autophagy and suppressing apoptosis in the hypertensive kidney. Male mice with normal TLR4 expression (TLR4N, C3H/HeOuJ) and mutant TLR4 (TLR4M, C3H/HeJLps-d) aged 10-12 weeks were infused with Ang-II (1000 ng/kg/d) for 4 weeks to create hypertension. Saline infused appropriate control were used. Blood pressure was increased along with increased TLR4 expression in TLR4N mice receiving Ang-II compared to TLR4N control. Autophagy was downregulated, and apoptosis was upregulated in TLR4N mice treated with Ang-II. Also, kidney injury markers plasma lipocalin-2 (LCN2) and kidney injury molecule 1 (KIM-1) were upregulated in TLR4N mice treated with Ang-II. Besides, increased nuclear translocation and activity of NF-kB were measured in Ang-II-treated TLR4N mice. TLR4M mice remained protected against all these insults in hypertension. Together, these results suggest that Ang-II-induced TLR4 activation suppresses autophagy, induces apoptosis and kidney injury through in part by activating NF-kB signaling, and TLR4 mutation protects the kidney from Ang-II-induced hypertensive injury.
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Affiliation(s)
- Suravi Majumder
- Department of Internal Medicine, McGovern Medical School, University of Texas Health Science Center, Houston, TX 77030, USA
| | - Sathnur Pushpakumar
- Department of Physiology, University of Louisville School of Medicine, Louisville, KY 40202, USA
| | - Subir K Juin
- Department of Physiology, University of Louisville School of Medicine, Louisville, KY 40202, USA
| | - Venkatakrishna R Jala
- Department of Microbiology and Immunology, James Graham Brown Cancer Center, University of Louisville, Louisville, KY 40202, USA
| | - Utpal Sen
- Department of Physiology, University of Louisville School of Medicine, Louisville, KY 40202, USA.
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40
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Gavriilaki E, Gkaliagkousi E. Molecular Advances in Hypertension and Blood. Int J Mol Sci 2021; 23:ijms23010278. [PMID: 35008704 PMCID: PMC8745536 DOI: 10.3390/ijms23010278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 12/23/2021] [Indexed: 11/30/2022] Open
Affiliation(s)
- Eleni Gavriilaki
- Bone Marrow Transplantation Unit, Hematology Department, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece
- Correspondence:
| | - Eugenia Gkaliagkousi
- 3rd Department of Internal Medicine, Papageorgiou Hospital, Aristotle University of Thessaloniki, 57010 Thessaloniki, Greece;
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