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Murphy DM, Forrest IA, Curran D, Ward C. Macrolide antibiotics and the airway: antibiotic or non-antibiotic effects? Expert Opin Investig Drugs 2010; 19:401-14. [DOI: 10.1517/13543781003636480] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
BACKGROUND Previous studies have shown that findings of computed tomography pulmonary angiography (CTPA) relate to outcome in pulmonary embolus (PE). These include clot burden as quantified using an obstruction index and markers of pressure overload such as right ventricle to left ventricle size ratio (RV/LV ratio). Little data exists correlating these findings with clinical presentation and biomarkers. AIM To explore the link between clinical presentation and biomarkers with CTPA findings. METHODS Retrospective case note analysis of consecutive cases presenting to a large teaching hospital. An independent radiologist reviewed CTPAs and clot burden quantified using an obstruction index. RESULTS One hundred and seventy cases were identified and notes retrieved in 137 cases. (i) CLINICAL PRESENTATION correlation was seen between clot burden and systolic blood pressure (BP) (r = -0.299, P = 0.0006) and heart rate (r = 0.240, P = 0.0056). Median obstruction index was significantly higher in those with a presenting BP <90 mmHg [41.25% (95% CI 30-50) vs. 15% (95% CI 12.5-25), (P = 0.0004)]. Clot burden was significantly higher in patients with temperature of >37.5 degrees C [30% (95% CI 25.0-42.5) vs. 15% (95% CI 12.5-28.3), P = 0.02)] and (ii)Biomarkers: significant correlation between clot burden and D-dimer was seen (r = 0.36, P = 0.0001). Location of thrombus was associated with significant differences in D-dimer level. A subgroup of patients had cardiac biomarkers measured (n = 24). There was a statistically significant correlation between troponin I and clot burden (r = 0.412, P = 0.048) and RV/LV ratio (r = 0.699, P = 0.0013). DISCUSSION These findings suggest that clinical parameters and biomarkers have a role in predicting the radiological severity of PE. These data support the need for further studies of risk stratification in patients presenting with acute PE.
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Affiliation(s)
- V Jeebun
- Department of Respiratory Medicine, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP, UK.
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Robertson AGN, Griffin SM, Murphy DM, Pearson JP, Forrest IA, Dark JH, Corris PA, Ward C. Targeting allograft injury and inflammation in the management of post-lung transplant bronchiolitis obliterans syndrome. Am J Transplant 2009; 9:1272-8. [PMID: 19459806 DOI: 10.1111/j.1600-6143.2009.02648.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Chronic allograft dysfunction, manifesting as bronchiolitis obliterans syndrome (BOS), is the major cause of morbidity and mortality in human lung transplant recipients. While alloimmunity has a definite role, there is increasing interest in overall allograft injury and subsequent inflammation and remodeling. This review deals with nonalloimmune factors that may potentiate alloimmune injury. We discuss infection and reflux/aspiration as examples of allograft injury, which may lead to chronic loss of graft function and BOS. Surgical and nonsurgical treatments aimed at preventing these insults and improving survival are considered. The need for further evidence, including randomized-controlled trials, to evaluate the role of medical and surgical therapies is emphasized by the current literature.
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Affiliation(s)
- A G N Robertson
- Northern Oesophago-Gastric Unit, Royal Victoria Infirmary, Newcastle University, Newcastle, UK
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Robertson AGN, Griffin SM, Murphy DM, Pearson JP, Forrest IA, Dark JH, Corris PA, Ward C. Targeting allograft injury and inflammation in the management of post-lung transplant bronchiolitis obliterans syndrome. Am J Transplant 2009. [PMID: 19459806 DOI: 10.1111/j.1600-7143.2009.02648.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Chronic allograft dysfunction, manifesting as bronchiolitis obliterans syndrome (BOS), is the major cause of morbidity and mortality in human lung transplant recipients. While alloimmunity has a definite role, there is increasing interest in overall allograft injury and subsequent inflammation and remodeling. This review deals with nonalloimmune factors that may potentiate alloimmune injury. We discuss infection and reflux/aspiration as examples of allograft injury, which may lead to chronic loss of graft function and BOS. Surgical and nonsurgical treatments aimed at preventing these insults and improving survival are considered. The need for further evidence, including randomized-controlled trials, to evaluate the role of medical and surgical therapies is emphasized by the current literature.
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Affiliation(s)
- A G N Robertson
- Northern Oesophago-Gastric Unit, Royal Victoria Infirmary, Newcastle University, Newcastle, UK
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Anderson RL, Hiemstra PS, Ward C, Forrest IA, Murphy D, Proud D, Lordan J, Corris PA, Fisher AJ. Antimicrobial peptides in lung transplant recipients with bronchiolitis obliterans syndrome. Eur Respir J 2008; 32:670-7. [DOI: 10.1183/09031936.00110807] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Forrest IA, Murphy DM, Ward C, Jones D, Johnson GE, Archer L, Gould FK, Cawston TE, Lordan JL, Corris PA. Primary airway epithelial cell culture from lung transplant recipients. Eur Respir J 2006; 26:1080-5. [PMID: 16319339 DOI: 10.1183/09031936.05.00141404] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Long-term survival in lung transplantation is limited by the development of obliterative bronchiolitis, a condition characterised by inflammation, epithelial injury, fibroproliferation and obliteration of bronchioles leading to airflow obstruction. To investigate the role of the bronchial epithelium in the pathogenesis of obliterative bronchiolitis the current study aimed to establish primary bronchial epithelial cell cultures (PBEC) from lung allografts. Four to six bronchial brushings were obtained from sub-segmental bronchi of lung allografts. Cells were seeded onto collagen-coated plates and grown to confluence in bronchial epithelial growth medium. Bronchial brushings (n=33) were obtained from 27 patients. PBECs were grown to confluence from 12 out of 33 (39%) brushings. Failure to reach confluence was due to early innate infection. Bacteria were usually isolated from both bronchoalveolar lavage and culture media, but a separate population was identified in culture media only. Primary culture of bronchial epithelial cells from lung transplant recipients is feasible, despite a high rate of early, patient-derived infection. Latent infection of the allograft, identified only by bronchial brushings, may itself be a persistent stimulus for epithelial injury. This technique facilitates future mechanistic studies of airway epithelial responses in the pathogenesis of obliterative bronchiolitis.
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Affiliation(s)
- I A Forrest
- Applied Immunobiology and Transplantation Research Group, University of Newcastle upon Tyne, UK.
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Ward C, Robertson H, Forrest IA, Lordan J, Murphy D, Dark JH, Corris PA, Jones DEJ, Kirby JA. Hypothesis: epithelial-to-mesenchymal transition is a common cause of chronic allograft failure. Transplant Proc 2005; 37:977-80. [PMID: 15848596 DOI: 10.1016/j.transproceed.2004.12.203] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Renal, hepatic, and lung allografts are compromised by aggressively deteriorating function. This chronic process is produced by an overall burden of organ damage, but the pathophysiology remains poorly understood. Rates of chronic rejection in the lung, for example, have not substantially improved over the last decade, despite new immunosuppressive drugs and improvements in surgical procedure. We present a hypothesis that epithelial-to-mesenchymal transition is a common cause of chronic allograft failure. Research in this area may provide insights into chronic rejection of kidney, liver, and lung allografts that impact on future therapeutic strategies.
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Affiliation(s)
- C Ward
- Applied Immunobiology and Transplantation Research Group, Faculty of Medical Sciences, Medical School, University of Newcastle, Newcastle upon Tyne, UK.
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Ward C, Forrest IA, Brownlee IA, Johnson GE, Murphy DM, Pearson JP, Dark JH, Corris PA. Pepsin like activity in bronchoalveolar lavage fluid is suggestive of gastric aspiration in lung allografts. Thorax 2005; 60:872-4. [PMID: 16055614 PMCID: PMC1747219 DOI: 10.1136/thx.2004.036426] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND A biologically plausible link between gastro-oesophageal reflux (GOR), aspiration, and lung allograft dysfunction has been suggested, but there is no systematic evidence indicating the presence of gastric contents in the lung. We have tested the hypothesis that pepsin, as a marker of aspiration, is detectable in bronchoalveolar lavage (BAL) fluid of allograft recipients who had not reported symptoms of GOR. METHODS Standardised 3 x 60 ml surveillance BAL fluid samples from 13 chronologically sequential stable lung allograft recipients without chronic rejection (10 patients treated with a prophylactic proton pump inhibitor) were studied. Lavage supernatants were assayed by an ELISA based on a monospecific goat antibody for pepsin/pepsinogen. Pepsin levels were compared with those from four normal volunteer controls. RESULTS Pepsin levels were measurable in all allograft recipients, in keeping with gastric aspiration (median 109 ng/ml (range 35-1375)). In the control group the pepsin levels were below the limit of detection. Treatment with a proton pump inhibitor was not correlated with pepsin levels. There was no correlation between BAL fluid neutrophils and pepsin levels. CONCLUSION These data demonstrate lung epithelial lining fluid concentrations of pepsin in lung allograft recipients which are much higher than blood reference levels, with no detectable pepsin in controls. This provides direct evidence of gastric aspiration, which is potentially injurious to the allograft.
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Affiliation(s)
- C Ward
- Applied Immunobiology and Transplantation Research Group, Freeman Hospital and University of Newcastle upon Tyne, Newcastle upon Tyne NE7 7DN, UK.
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Ward C, Forrest IA, Brownlee IA, Johnson GE, Murphy DM, Pearson JP, Dark JH, Corris PA. Pepsin like activity in bronchoalveolar lavage fluid is suggestive of gastric aspiration in lung allografts. Thorax 2005. [PMID: 16055614 DOI: 10.1163/thx.2004.036426] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND A biologically plausible link between gastro-oesophageal reflux (GOR), aspiration, and lung allograft dysfunction has been suggested, but there is no systematic evidence indicating the presence of gastric contents in the lung. We have tested the hypothesis that pepsin, as a marker of aspiration, is detectable in bronchoalveolar lavage (BAL) fluid of allograft recipients who had not reported symptoms of GOR. METHODS Standardised 3 x 60 ml surveillance BAL fluid samples from 13 chronologically sequential stable lung allograft recipients without chronic rejection (10 patients treated with a prophylactic proton pump inhibitor) were studied. Lavage supernatants were assayed by an ELISA based on a monospecific goat antibody for pepsin/pepsinogen. Pepsin levels were compared with those from four normal volunteer controls. RESULTS Pepsin levels were measurable in all allograft recipients, in keeping with gastric aspiration (median 109 ng/ml (range 35-1375)). In the control group the pepsin levels were below the limit of detection. Treatment with a proton pump inhibitor was not correlated with pepsin levels. There was no correlation between BAL fluid neutrophils and pepsin levels. CONCLUSION These data demonstrate lung epithelial lining fluid concentrations of pepsin in lung allograft recipients which are much higher than blood reference levels, with no detectable pepsin in controls. This provides direct evidence of gastric aspiration, which is potentially injurious to the allograft.
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Affiliation(s)
- C Ward
- Applied Immunobiology and Transplantation Research Group, Freeman Hospital and University of Newcastle upon Tyne, Newcastle upon Tyne NE7 7DN, UK.
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Ward C, Forrest IA, Murphy DM, Johnson GE, Robertson H, Cawston TE, Fisher AJ, Dark JH, Lordan JL, Kirby JA, Corris PA. Phenotype of airway epithelial cells suggests epithelial to mesenchymal cell transition in clinically stable lung transplant recipients. Thorax 2005; 60:865-71. [PMID: 15972366 PMCID: PMC1747194 DOI: 10.1136/thx.2005.043026] [Citation(s) in RCA: 96] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Obliterative bronchiolitis in chronic rejection of lung allografts is characterised by airway epithelial damage and fibrosis. The process whereby normal epithelium is lost and replaced by fibroblastic scar tissue is poorly understood, but recent findings suggest that epithelial cells can become fibroblasts through epithelial-mesenchymal transition (EMT). It is hypothesised that EMT occurs in lung allografts and plays a potential role in airway remodelling. METHODS Sixteen stable lung transplant recipients underwent bronchoscopy with bronchoalveolar lavage (BAL), endobronchial biopsies, and bronchial brushings. Biopsy sections were stained for the fibroblast marker S100A4. Brushings were cultured on collagen, stained with anti-S100A4, and examined for further EMT markers including matrix metalloproteinase (MMP) zymographic activity and epithelial invasion through collagen coated filters. RESULTS A median 15% (0-48%) of the biopsy epithelium stained for S100A4 in stable lung transplant recipients and MMP-7 co-localisation was observed. In non-stimulated epithelial cultures from lung allografts, S100A4 staining was identified with MMP-2 and MMP-9 production and zymographic activity. MMP total protein and activity was increased following stimulation with transforming growth factor (TGF)-beta1. Non-stimulated transplant epithelial cells were invasive and penetration of collagen coated filters increased following TGF-beta1 stimulation. CONCLUSIONS This study provides evidence of EMT markers in lung allografts of patients without loss of lung function. The EMT process may represent a final common pathway following injury in more common diseases characterised by airway remodelling.
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Affiliation(s)
- C Ward
- Applied Immunobiology and Transplantation Research Group, Faculty of Medical Sciences, Medical School, University of Newcastle, Newcastle upon Tyne NE2 4HH, UK
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Ward C, De Soyza A, Fisher AJ, Pritchard G, Forrest IA, Corris PA. Reticular basement membrane thickening in airways of lung transplant recipients is not affected by inhaled corticosteroids. Clin Exp Allergy 2004; 34:1905-9. [PMID: 15663566 DOI: 10.1111/j.1365-2222.2004.02121.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Chronic rejection is a major problem for all lung transplant programmes, which is functionally manifested by fixed airflow limitation, Bronchiolitis Obliterans Syndrome (BOS). The inclusion of a Pre-BOS category, BOS(0 approximately p), in newly revised guidelines, recognizes the potential importance of early changes. We have previously demonstrated reticular basement membrane (Rbm) thickening in clinically stable lung transplant recipients free from BOS. The present study extends this, testing the hypothesis that inhaled corticosteroid (ICS) therapy will lead to a decrease in Rbm thickness in lung transplant recipients. METHODS A parallel group, bronchoscopic intervention study of clinically stable lung allograft recipients, free from BOS, but with evidence of airway inflammation. Following baseline assessment of Rbm thickening, subjects were randomized to 3 months of either chlorofluorocarbon-driven beclomethasone diproprionate (BDP) 400 microg b.i.d., or a formulation designed to yield at least an equivalent dose, hydrofluoroalkane-driven BDP, 200 microg b.i.d. RESULTS Three months treatment with a moderate dose of ICS, including a formulation designed for preferential small airway deposition, had no effect on Rbm thickening (13+/-3 vs. 14+/-5 microm post-ICS). CONCLUSION Our data would suggest that airway remodelling can occur early in lung allografts and is not affected by moderate dose ICS therapy. Longitudinal studies are required to describe the pathophysiological processes involved in BOS, and specifically to elucidate potential relationships between airway remodelling, airflow obstruction and allograft failure.
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Affiliation(s)
- C Ward
- Applied Immunobiology and Transplantation Group, Freeman Hospital and University of Newcastle-upon-Tyne, Newcastle-upon-Tyne NE7 7DN, UK.
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Forrest IA, Small T, Corris PA. Effect of nebulized epoprostenol (prostacyclin) on exhaled nitric oxide in patients with pulmonary hypertension due to congenital heart disease and in normal controls. Clin Sci (Lond) 1999; 97:99-102. [PMID: 10369800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
Inhaled epoprostenol (prostacyclin) may be used in the treatment of severe pulmonary hypertension, improving oxygenation and reducing pulmonary artery pressures. We have observed symptomatic benefits of epoprostenol in patients with congenital heart disease that extend beyond acute haemodynamic effects of the drug, which has a short biological half-life. The aim of this study was to examine the effects of epoprostenol in patients and normal subjects on exhaled nitric oxide (eNO), based on the hypothesis that the drug may alter the resting vasoconstrictor/vasodilator balance. Nine patients with pulmonary hypertension complicating left-to-right cardiac shunts and nine healthy controls received 100 microgram of nebulized epoprostenol. Exhaled eNO was measured, using a chemiluminescence method, before, immediately after and 18 h after nebulization. There was no significant difference between the two groups in baseline eNO or eNO immediately following nebulized epoprostenol. Epoprostenol produced a delayed elevation in eNO 18 h after nebulization in patients, but not in normal controls. This study supports the concept that epoprostenol, while having no effect on the normal pulmonary circulation, acts on the hypertensive circulation via a mechanism that may result in a delayed alteration of vasoconstrictor/vasodilator balance.
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Affiliation(s)
- I A Forrest
- Department of Respiratory Medicine, Freeman Hospital and University of Newcastle upon Tyne, Freeman Hospital, High Heaton, Newcastle upon Tyne NE7 7DN, U.K
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Forrest IA, Adams SA, Nimmo IA, Saunders DH, Stewart AD. The effect of an acute load of glucose on the rate of clearance of lactate from the blood of adult males after severe exercise. Biochem Soc Trans 1991; 19:132S. [PMID: 1889532 DOI: 10.1042/bst019132s] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- I A Forrest
- Department of Biochemistry, University of Edinburgh Medical School, Scotland, U.K
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