Linkage between inflammation and coagulation: an update on the molecular basis of the crosstalk

Inflammation and coagulation cannot be considered as two separate processes, since there are several connecting points making them part of unique, defensive host response. The endothelium can be considered as the first link between inflammation and coagulation, since damaged endothelium during inflammation represents a surface where proteins involved in both coagulation and the development of inflammation are expressed. During inflammation, cytokines modulate the coagulation system by downregulating the expression of thrombomodulin and the activation of protein C pattern but, at the same time, they induce the expression of tissue factor, modifying, in this way, the balance between procoagulant and anticoagulant activities. At the same time, at the site of tissue injury, platelets become activated and release several mediators that modify tissue integrity. Thrombin, formed following activation of the coagulation cascade, is essential to promote haemostasis but also stimulates several cell functions, including chemotaxis and mitogenesis, which are responsible for the spreading of the lesion and the tissue repair process. Therefore, in the study of inflammation the involvement of the coagulation pathway has to be taken into account, since the interaction between coagulation and inflammation pathways is a critical issue.     

Structure and functions of the endothelium

The vascular endothelium is a dynamic interface between blood and tissues, which releases vasoconstrictors or vasodilators regulating the vascular tone. The endothelium modulates the balance between thrombosis and haemorrhage. Activated endothelium may produce tissue factor which triggers the coagulation cascade. In different tissues, the endothelial cells become specialised and may participate to the immune response and inflammation. Various metabolic or immune stimuli may alter endothelial cell functions, induce leukocyte adhesion through expression of specialised molecules and modify the release of fibrinolytic agents, cytokines, and growth factors.     

Joint inflammation and cartilage destruction may occur uncoupled

Chronic arthritis is characterized by a persistent joint inflammation and concomitant joint destruction. Although the joint swelling is a major clinical problem, destruction of bone and cartilage may occur uncoupled to inflammation and it is of utmost importance to fully understand the elements of the destructive process. TNF and IL-1 are considered master cytokines in the process of human RA, with a claimed cascade of TNF inducing most of the IL-1 production. Studies in experimental models revealed that TNF is indeed a pivotal cytokine in joint swelling, yet IL-1 is the dominant cartilage destructive cytokine and its production may occur independent of TNF. This was found with anti-TNF/IL-1 neutralizing antibodies and the observations were recently backed up with similar data in arthritis models in TNF and IL-1 knockout mice. Apart from the absolute level of IL-1, the destructive potential of an arthritis is determined by the balance with regulatory cytokines and anabolic growth factors. IL-4, IL-6, and IL-10 can promote inflammation and tissue fibrosis, yet cartilage destruction is found to be greatly reduced by these cytokines, linked to a range of pathways which can reduce the IL-1 impact on the articular cartilage. Finally, the presence of anabolic growth factors in the inflamed synovium may have a major impact on net destruction. Endogenous transforming growth factor-beta (TGF-beta) is found in inflamed synovia, but local coadministration of TGF-beta further enhanced the degree of synovitis, yet almost fully prevented cartilage damage, providing another example of a major lack of correlation between inflammatory mass and destructive potential. It is suggested that novel therapy in RA patients should not only focus on reduction of outer signs of joint inflammation, but should also include attempts at reduction of cartilage destruction.     

Cytokine involvement in viral permissiveness and the progression of HIV disease

Many viruses have evolved novel means of exploiting host defense mechanisms for their own survival. This exploitation may be best exemplified by the interrelationships between certain viruses and the host cytokine networks. Many viruses, including the human immunodeficiency virus type-1 (HIV-1), rely on the liberation and cellular action of host immune cytokines to expand their host cell range, to regulate their cellular expression, and to maintain their dormant state until the proper extracellular conditions arise. As again exemplified by HIV-1, viruses may also take an active role regulating cytokine expression and cell surface cytokine receptors. Because the viral life cycle, and in particular the HIV-1 life cycle, is so intertwined with cytokine regulatory networks, these networks represent potential points for therapeutic intervention. As our understanding of cellular cytokine pathways involved in viral infection and replication continues to expand, so too will our ability to design rational anti-viral therapies to alter multiple steps along the viral life cycle.     

Polyester arterial prostheses. Recent developments from the Czech Republic and Poland

Immune and inflammatory responses must be rightly regulated to maintain a homoeostatic balance between an effective immune response and tissue damage to the host. NO is a principal mediator of many of the cytokine-inducible macrophage activities during a normal cell-mediated immune response. STK, the murine homologue of the human RON receptor tyrosine kinase, is expressed on murine resident peritoneal macrophages. The ligand for STK, macrophage-stimulating protein (MSP), is a serum protein that is activated by members of the coagulation cascade in response to tissue damage. In addition to its potential to induce chemotaxis and phagocytosis of C3bi-coated erythrocytes, MSP has an inhibitory effect on the production of NO by activated peritoneal macrophages in vitro. Here we demonstrate that peritoneal macrophages from mice lacking STK produce elevated levels of NO in response to interferon (IFN)-gamma in a dose-dependent manner, without the need for a co-stimulus. However, production of pro-inflammatory cytokines by activated macrophages from stk -/- mice is unaltered. In vivo, stk -/- mice exhibit increased inflammation in an IFN-gamma-mediated delayed-type hypersensitivity reaction and increased susceptibility to lipopolysaccharide (LPS)-induced endotoxic shock. Furthermore, the levels of NO in the serum of mice injected with LPS are significantly higher than those in control littermates. Nevertheless, the serum levels of IFN-gamma and the intermediate cytokines generated by the inflammatory response, which have previously been shown to play a role in septicaemic shock, do not differ significantly from controls. These data suggest that the STK receptor suppresses NO production, therefore ameliorating the potentially tissue-damaging effects of a cell-mediated immune response, through negative regulation of the IFN-gamma signalling pathway.     

Lipocortin 1 and chemokine modulation of granulocyte and monocyte accumulation in experimental inflammation

1. Migration of blood-derived leukocytes to tissue sites of inflammation is a hallmark of the response that the host organizes to counteract an insult or a trauma or an infection. A cascade of events is then activated to allow interaction between the leukocyte and the endothelium of postcapillary venule, and this cascade is finely regulated such that mechanisms of negative control are operating side by side with pathways that promote and sustain the extravasation process. Examples of both these positive and negative regulatory systems are discussed here. 2. In vivo accumulation of specific subtypes of leukocytes in response to application of selective chemokines operates through an indirect mechanism that includes the perivenular mast cell and, in particular, the mast cell-derived amines, such as histamine and serotonin. In fact, treatments of animals with (1) histamine H1 or serotonin antagonists or with (2) the mast cell stabilizer cromolyn or with (3) prior depletion of intact mast cells are maneuvers that successfully reduce eosinophil, neutrophil and monocyte extravasation in response to eotaxin, interleukin-8 or monocyte chemoattractant protein-1, respectively. A model in which histamine provides a P-selectin-dependent rolling phenomenon is then postulated. 3. The discovery that neutrophil-derived lipocortin 1 acts as an autocrine mediator with an inhibitory action on the emigration (diapedesis) process confirms the growing body of experimental data that showed that exogenously administered lipocortin 1 and lipocortin 1 mimetics (peptide Ac2-26) potently inhibit neutrophil extravasation in response to different stimuli. Externalization of lipocortin 1 on the plasma membrane of adherent neutrophils reduces their rate of passage through the endothelial gaps. Because cell-associated lipocortin 1 levels are under the partial control of corticosterone (endogenous circulating glucocorticoid hormone in rodents) and dexamethasone (a synthetic glucocorticoid hormone with a potent anti-inflammatory profile), a model is proposed in which a balance between anti-inflammatory (lipocortin 1, etc.) and pro-inflammatory (adhesion molecules, cytokines and chemokines) mediators explains the difference in the rate of leukocyte accumulation during the different stages of the host inflammatory response. 4. In conclusion, this review emphasizes the importance of in vivo experimental systems as a valid way of obtaining pertinent observations and reiterates the importance of negative regulatory mechanisms on the leukocyte extravasation process operating within the host.     

Intraoperative maintenance of tissue perfusion prevents ARDS. Adult Respiratory Distress Syndrome

Patients undergoing prolonged, complex oncological surgery are at increased risk of developing the adult respiratory distress syndrome (ARDS) and other organ failures. Our hypothesis is that maintaining adequate tissue perfusion and oxygenation may prevent tissue hypoxia and acidosis in pulmonary, peripheral, and splanchnic microcirculations. Experimental evidence suggests that the hypoxic, acidotic endothelium stimulates the release of cytokines, kinins, and other mediators. We developed and tested an intraoperative protocol for surgical patients likely to develop ARDS and organ dysfunction; the protocol focuses on the intraoperative period but is not limited to this time. Nitroglycerin and fluids were used to maintain tissue perfusion and prevent tissue hypoxia as reflected by transcutaneous oxygen tension values. In 155 high-risk patients, none developed ARDS. We conclude that maintenance of tissue perfusion and oxygenation in high-risk surgical patients decreases the incidence of ARDS.     

Cytokine patterns in patients after major vascular surgery, hemorrhagic shock, and severe blunt trauma. Relation with subsequent adult respiratory distress syndrome and multiple organ failure

OBJECTIVE: This study investigates the course of serum cytokine levels in patients with multiple trauma, patients with a ruptured abdominal aortic aneurysm (AAA), and patients undergoing elective AAA repair and the relationship of these cytokines to the development of adult respiratory distress syndrome (ARDS) and multiple organ failure (MOF). SUMMARY BACKGROUND DATA: Severe tissue trauma, hemorrhagic shock, and ischemia-reperfusion injury are pathophysiologic mechanisms that may result in an excessive uncontrolled activation of inflammatory cells and mediators. This inflammatory response is thought to play a key role in the development of (remote) cell and organ dysfunction, which is the basis of ARDS and MOF. METHODS: The study concerns 28 patients with multiple trauma, 20 patients admitted in shock because of a ruptured AAA, and 18 patients undergoing elective AAA repair. Arterial blood was serially sampled from admission (or at the start of elective operation) to day 13 in the intensive care unit, and the serum concentrations of tumor necrosis factor-alpha (TNF-alpha), interleukin (IL)-1 beta, and IL-6 were determined. RESULTS: Twenty-two patients died, 15 within 48 hours and 7 after several weeks, as a result of ARDS/MOF. At hospital admission and after 6 hours, these nonsurvivors had significantly higher plasma TNF-alpha and IL-1 beta levels than did the survivors. At the same measuring points, TNF-alpha and IL-1 beta were significantly more elevated in patients with ruptured AAA than in traumatized patients. However, IL-6 was significantly higher in the traumatized patients. In 10 patients, ARDS/MOF developed, and 41 had an uncomplicated course in this respect. Those with ARDS/MOF exhibited significantly different cytokine patterns in the early postinjury phase. TNF-alpha and IL-1 beta levels were higher mainly on the first day of admission; IL-6 concentrations were significantly elevated in patients with ARDS/MOF from the second day onward. The latter cytokine showed a good correlation with the daily MOF score during the whole 2-week observation period. CONCLUSIONS: In the early postinjury phase, higher concentrations of these cytokines are associated, not only with an increased mortality rate, but also with an increased risk for subsequent ARDS and MOF. These data therefore support the concept that these syndromes are caused by an overwhelming autodestructive inflammatory response.     

Ovine cytokines and their role in the immune response

Using a variety of expression systems the number of available recombinant ovine cytokines has increased steadily. This has led to the use of ovine cytokines as adjuvants to modulate the immune responses to vaccine antigens, both quantitatively and qualitatively. In addition DNA immunization, now common in mice, is being increasingly used in sheep. This may provide a unique avenue for the use of cytokines as immunomodulators, as it avoids preparing large quantities of biologically active recombinant protein and allows a slow, prolonged release of the cytokine at the same site as the antigen. As detection systems are developed their usefulness and shortcomings become apparent. The combination of cytokine detection, lymphatic cannulation and the in vivo neutralization of cytokines has allowed a greater understanding of the immune response during vaccination and of the interaction between pathogens and the immune system.     

Cytokines and the microcirculation in ischemia and reperfusion

The intense inflammatory reaction following reperfusion of the infarcted myocardium has been implicated as a factor in extension of injury. However, this inflammatory reaction is also critical to tissue repair. The cellular responses that mediate these functions are orchestrated by sequential induction and/or release of cytokines resulting in a closely regulated cytokine cascade. This paper reviews research on these cytokine cascades, their cellular origin, and factors which control the cellular response to their presence. Factors examined include leukotaxis, phenotypic transition of leukocytes, adhesion molecule induction and the role of cytokines in tissue repair and scar formation.     

The immune response to trauma

The response to trauma begins in the immune system at the moment of injury. The loci are the wound, with activation of macrophages and production of proinflammatory mediators, and the microcirculation with activation of endothelial cells, blood elements, and a capillary leak. These processes are potentiated by ischemia and impaired oxygen delivery and by the presence of necrotic tissue, each exacerbating the inflammatory response. Hemorrhage alone may be a sufficient stimulus. Inflammation once was considered to be a host reaction to bacteria or other irritants. This concept was expanded by the discovery of autoimmune diseases, and we are now aware that some illnesses are the result of the body's response to an invader rather than the direct effect of the invader itself. The discoveries about the response to trauma described here add another dimension, showing inflammation to be a fundamental life process that begins at the molecular level at the moment of injury and that, depending on the severity of the stimulus and the effectiveness of initial treatment, may spread to include every cell, tissue, and organ in the body, for good or ill. An important part of these expanding concepts is the notion that all noxious stimuli activate the cytokine system as a final common pathway. Sepsis, hemorrhage, ischemia, ischemia-reperfusion, and soft tissue trauma all share an ability to activate macrophages and produce proinflammatory cytokines that may initiate the SIRS. Second-message compounds and effector molecules mediate the observed clinical phenomena.(ABSTRACT TRUNCATED AT 250 WORDS)     

Cytokine and nitric oxide production in the acute phase of bacterial cell wall-induced arthritis

We have investigated the temporal relationship among proinflammatory cytokine expression, nitric oxide (NO) production and joint inflammation in the acute phase of bacterial cell wall-derived peptidoglycan polysaccharide (PG/PS)-induced arthritis. Acute joint inflammation was induced in female LEW/N rats by a single intraperitoneal injection of PG/PS. Arthritis index and paw volume were quantified and joint histopathology was evaluated during acute joint inflammation (0-10 days). Tumor necrosis factor (TNF), interleukin-1 (IL-1) and interleukin-6 (IL-6) were determined by bioassay whereas nitric oxide (NO) was quantified by measuring serum nitrate/nitrite levels via the Griess procedure. We found that serum levels of TNF and serum IL-1 preceded the increase in IL-6 and NO production. Furthermore, the production of these proinflammatory cytokines and NO preceded bone erosion and osteoclast activity. Erosion of subchondral bone preceded pannus formation and cellular synovitis in the acute phase of PG/PS-induced arthritis. The temporal expression of TNF, IL-1, IL-6 and NO suggest a cascade of inflammatory mediators in which monocytes and macrophages respond to PG/PS with enhanced synthesis of TNF and IL-1, which may in turn promote the synthesis of IL-6 and NO. We postulate that one or more of these inflammatory events are responsible for initiating the subchondral bone erosion observed in acute joint inflammation.     

Regulation of iron metabolism in the acute-phase response: interferon gamma and tumour necrosis factor alpha induce hypoferraemia, ferritin production and a decrease in circulating transferrin receptors in cancer patients

BACKGROUND: The acute-phase response and anaemia of chronic disease are characterized by hypoferraemia associated with an increased ferritin synthesis, which might be mediated by the activated cytokine cascade. METHODS: We examined the prolonged effects of isolated limb perfusion (ILP) with recombinant human tumour necrosis factor alpha (rTNF), recombinant human interferon gamma (rIFN-gamma) and melphalan on interleukin (IL) 6 and acute-phase protein levels, iron status and serum transferrin receptor (sTfR) levels in 12 patients with melanoma or sarcoma. Patients were treated with ILP during 90 min after pretreatment with rIFN-gamma during 2 days. RESULTS: After ILP, leakage of TNF resulted in systemic peak levels at 3 min followed by an increase in IL-6 with maximum levels at 4h. C-reactive protein (CRP) rose at 4 h to peak levels at day 2, whereas alpha 1-antitrypsin and alpha 1-acid glycoprotein increased to maximum levels at day 3. Albumin and transferrin levels decreased after ILP and recovered after day 2. Serum iron and sTfR levels decreased during pretreatment and after ILP to minimum levels at 8 h and day 1 respectively. This was associated with an increase in serum ferritin levels, which paralleled CRP values. CONCLUSIONS: Our data point to a central role for the cytokine network in the modulation of iron metabolism in the acute-phase response and anaemia of chronic disease. TNF, possibly via induction of IL-6, and IFN-gamma induce hypoferraemia, which may in part result from a decrease in tissue iron release based on a primary stimulation of ferritin synthesis. The fall in sTfR levels may reflect an impaired erythroid growth and/or TfR expression mediated by TNF and IFN-gamma.     

Cytokines induce airway smooth muscle cell hyperresponsiveness to contractile agonists

Inflammatory cytokines have been shown to play an important role in the pathogenesis of various inflammatory processes. In throat infections, intracellular inflammatory cytokines have been detected from the sites of inflammation. The present study aimed to evaluate serum cytokine levels of patients with throat infections and correlate them to the inflammatory parameters and type of inflammation. Significantly higher inflammatory cytokine levels (interleukin [IL]-6 > 7 pg/mL, IL-1 > 1 beta pg/mL, tumor necrosis factor alpha > 1 pg/mL) were detected in most of the patients as opposed to healthy controls. Clinical parameters of infection (fever > 38 degrees C, leukocytosis > 11,000 white blood cells per cubic millimeter, polymorphonuclear neutrophils > 75%) were significantly correlated with high levels of inflammatory cytokines: mainly IL-6 and tumor necrosis factor alpha, and to a lesser degree with IL-1 beta. No correlation, however, was found between the type of inflammation and cytokine levels. The present study indicates a role of inflammatory cytokines in the pathogenesis of throat infections and the need for an anti-inflammatory and anticytokine therapeutic approach.     

Basic fibroblast growth factor (b-FGF) in the perimatrix of cholesteatoma

The growth of a cholesteatoma requires angioneogenesis in the connective tissue of the perimatrix. Angioneogenesis is also needed for wound healing as a host response to tissue injury. Normal wound repair is conducted through a wide number of growth factors. Basic fibroblast growth factor (b-FGF) plays a pivotal role in wound repair. This cytokine exerts its effects through stimulation of a wide range of target cells. B-FGF is chemotactic and mitogenic for fibroblasts, endothelial cells and keratinocytes. In addition, b-FGF can stimulate the production of collagenase and plasminogen activators to enhance fibroblast proliferation and angioneogenesis. Its necessity for normal wound repair has been confirmed by several workers. METHOD: In order to demonstrate angioneogenesis in the cholesteatoma perimatrix the distribution of b-FGF as the pivotal cytokine of the process was investigated in the perimatrix of 18 cholesteatoma specimens. RESULTS: B-FGF could be observed in 12 of 18 specimens (66%) in close approximation to histological signs of inflammation and wound healing. Areas with b-FGF also exhibited proliferation of the covering squamous epithelium. Cholesteatoma matrix tissue without inflammation or any sign of wound healing did not express b-FGF (6 of 18). CONCLUSION: Histological changes and distribution pattern of b-FGF in the perimatrix of cholesteatoma in the present study indicate that the perimatrix cells and substances of the wound healing cascade may play an important role in cholesteatoma development, angiogenesis and growth.     

Local cytokine response in Helicobacter pylori-infected subjects

The host immune response to Helicobacter pylori infection might be of importance with regard to the outcome of infection by this organism, e.g., to explain why only a proportion of infected subjects develop peptic ulcers. In this study we have analyzed the local response of different cytokines-i.e., the proinflammatory interleukin-1beta, (IL-1beta), IL-6, tumor necrosis factor alpha, and IL-8; the immunoregulatory gamma interferon (IFN-gamma); and IL-4; and the anti-inflammatory transforming growth factor beta (TGF-beta)-in antral biopsy specimens from H. pylori-infected duodenal ulcer (DU) patients and asymptomatic (AS) carriers (i.e., with chronic gastritis only). For comparison, biopsy specimens from uninfected healthy individuals were also analyzed. An immunohistochemical technique was used to allow quantification of the cytokine responses as well as identification of the cell types associated with the cytokine expression. We found that the levels of all of the studied cytokines except IL-4 were increased in the H. pylori-infected subjects compared to the levels in the healthy individuals. Our results indicate that the antral cytokine response is of the Th1 type since IFN-gamma, but not IL-4, was up-regulated both in H. pylori-infected DU patients and in AS carriers. However, there were no significant differences in either proinflammatory or immunoregulatory cytokine levels when H. pylori-infected subjects with and without peptic ulcers were compared. Some of the cytokines, particularly IL-1beta and TGF-beta, were also found in the gastric mucosae of healthy, uninfected subjects. We also showed that the gastric epithelium contributes substantially to the antral cytokine response of the proinflammatory cytokines IL-1beta and IL-6 in addition to IL-8.     

Glucocorticoid-induced type 1/type 2 cytokine alterations in humans: a model for stress-related immune dysfunction

Increased psychologic and physiologic stressors can have profound effects on the immune system. Previously believed to be immunosuppressive, there is mounting evidence that stress may actually induce a shift in the type 1/type 2 cytokine balance toward a type 2 cytokine response. Cortisol is elevated in response to stress and has been reported to alter cytokine production in murine and human peripheral blood mononuclear cells (PBMC). The current investigation examined the effects of dexamethasone (DEX) mimicking basal, stress, and supraphysiologic levels of cortisol on production of interferon-gamma (IFN-gamma) (type-1), interleukin (IL)-12p40 (type 1), IL-10 (type 2), and IL-4 (type 2) by human PBMC. Both supraphysiologic and stress levels of DEX decreased production of type 1 cytokines and either increased or maintained production of type 2 cytokines PBMC stimulated with phytohemagglutinin (PHA), immobilized anti-CD3, lipopolysaccharide (LPS) or tetanus. Although preincubation with DEX was sufficient to induce a type 2 switch in short-term mitogen cultures, PBMC cultures for extended periods of time required DEX at the initiation and throughout the duration of culture. Mifepristone, a glucocorticoid receptor antagonist, blocked the DEX-induced shift in the type 1/type 2 cytokine balance. These data demonstrated the ability of the glucocorticoid dexamethasone, to induce a shift in the type 1/type 2 cytokine balance toward a type 2 cytokine response and simulate the type 1/type 2 cytokine alterations observed in in vivo stress models. This model will allow detailed investigation of the cellular and molecular mechanisms of stress-induced immune alterations in humans.