I.

INJURY ASSOCIATED SYSTEMIC INFLAMMATORY RESPONSE

*Inflammatory response to injury or infection occurs as a
consequencce of local or systemic release of:
"Pathogen-associated" or "damage-mediated" molecules
DETECTION OF CELLULAR INJURY
-mediated by members of DAMPs (damage-associated molecular
pattern)
-clinical features of the injury-mediated systemic inflammatory
response:
Inc. Body temp.
Inc. HR
inc. RR
inc. WBC count
-DAMPs, along with PAMPs (pathogen-asociated molecular pattern),:
Interact with specific receptors
Best characterized of its receptors: TLR family
Best characterized DAMP: HMGB1
-DAMPs, once outside the cell, promote activation of innate immune
cells, as well as the recruitment and activation of APCs
DAMPs and their characteristics:
1. HMGB1 (high mobility group protein B1)
-best characterized DAMP
-rapidly released within 30 minutes following trauma
-participated in a variety of nuclear events: DNA repair and
transcription
-sources:
Cytosol and ECF (at low levels)
Immune-competent cells stimulated by PAMPs (i.e. endotoxin) or
by
inflammatory cytokines (TNF, IL-1)
endothelial cell
Platelet
-upon release, HMGB1 interacts with its receptor, either alone or in
concert
-signaling may lead to the ff pro-inflammatory responses:
Secretion of chemokines and cytokines
Neutrophil activation and chemotaxis
Inc. Permeability of epithelium
Inc. Procoagulant activity on Platelet surface
-when bound to TLR4, leads to pro-inflammatory cytokine release
that mediates "sickness behavior"
Redox state of cytokine residues influence the HMGB1 activity.
Example:
at thiol 106: HMGB1 promote macrophage TNF

disulfide bond between C23 and C45: cytokine release

if all 3 cysteine residues are in reduced form: HMGB1 binds to
CXCL12, which activates CXCR4, resulting to the release of
chemotactic mediator
**excessive HMGB1 may promote self-injurious innate immune
response,
and may produce: fever, weight loss, epithelial barrier
dysfunction
2. Mitochondrial proteins
-act as DAMPs bu triggering an inflammatory response to necrosis &
cellular
stress
-triggered by or in situations such as:
activation of macrophage inflammasome
trauma
patients undergoing femoral fracture repair
-example of mitochondrial protein:
TFAM (mitochondrial transcription factor A)
-highly abundant
-structuraly homologous to HMGB1
-released in high amounts in damaged cells
3. ECM molecules
-sequestered under norma conditions
-can be released in a soluble form with proteolytic digestion of the
ECM
-includes:
proteoglycans
GAGs
glycoproteins (i.e. fibronectin)
biglycan- interacts with TLR2 or TLR4 to generate
inflammatory
response; its effector molecules include TNFalpha and IL-1beta
RECOGNITION RECEPTORS
PRRs (pattern recognition receptors)
-receptors that are important for sensing damaged cells and cell
debris
-its best ligands are the PAMPs
-fall into 4 categories:
TLR (toll-like receptors)
CTLR (calcium-dependent/c-type lectin receptor)
RLRs (retinoic acid-inducible gene/ RIG-I like receptor)
NBD-LRR proteins (nucleotide-binding domain, leucine rich
repeat
containing)

1. TLRs (toll-like receptors)

-best characterized PRRs in mammalian cells
-expresed in both immune and nonimmune cells
-expressed by:
APCs
dendritic cells
macrophages
Nk cells
B cells
Treg cells (can differentiate into T helper cells)
-significantly increased following blunt traumatic injury
-triggers innate imune response to imune homeostasis & therefore
tightly
regulated
2. NBD-LRR
-composed of intracellular PRRs that sense both DAMPs and PAMPs
to trigger innate imune response
-nest characterized: NLRP3
NLRP3- highly expressed in peripheral blod leukocytes
-forms the "key-sensing" component of the INFLAMMASOME
complex which is composed of : NLRP3, ASC, caspase 1
-its inflammasome activation leads to secretion of pro-inflamatory
cytokines (IL-1beta, IL-18)
-inflamasome activity is regulated by:
cell-cell interaction
cellular ion flux
oxidative stress
3. C-type lectin receptors
-found in macrophages and dendritic cells
-includes the selection and the mannose receptor families that
binds
carbohydrates in a calcium-dependent fashion
-best described for their sensing of PAMPs, particularly fungal
antigens
-can promote endocytosis and clearance of cell corpses
SOLUBLE PRM (Pattern recognition molecules): PENTRAXINS
-molecularly diverse group of molecules that share actions defined
by complement activation,agglactivation neutralization and
optimization
-can be synthesized at sites of injury and inflammation by
macrophages & dendritic cells
-stored in neutrophils

Types:
CRP (C-reactive protein)
-plasma level is low under normal circumstances
-synthesize by liver in response to IL-6
-studied as marker for appendicitis, vasculitis, and ulcerative colitis.
-considered part of acute phase response
PENTRAXIN3
-produced by various cells in peripheral tissues, including immune
cells
-plasma concentration increase in response to inflammatory
conditions such as sepsis
PATTERN RECOGNITION RECEPTOR SIGNALING
Sequence:
1. Binding of ligand to receptor
2. Receptor dimerization recruits adaptor proteins through TIR/TIR
interaction
MyD88
- serves as the universal adaptor protein central to the TLR
SIGNALING complex (except for TLR3)
-works through recruitment of of MyD88 adaptor-like protein (Mal),
which serves as a bridge between MyD88 and activated TLRs to
initiate signal
transduction
There are 3 other TIR domain-containing adaptor proteins that are
important to the signaling events:
TRIF (TIR-domain containing adapter inducing INF-beta)
TRAM (TRIF related adaptor molecule
Sterile-alpha and HEAT/armadilo motif-containing protein (SARM)

2 pathways:
1. MyD88 independent
-involves TRIF & TRAM, which are activated by TLR3
2. MyD88 dependent pathway
-results in the activation of numerous cytopladmic protein kinases
including IL-1 receptor-associated kinases (IRAK-1 & IRAK-4), resulting
in interaction with Traf-6. -Traf-6 activates IKK-beta and MAPKs
-phosphorylation of IkB by IKK and NEMO leads to degradation, then
frees NF-kB and allows translocation to the nucleus and transcription
factor NF-kB target genes

II. CENTRAL NERVOUS SYSTEM REGULATION OF INFLAMMATION

IN RESPONSE TO INJURY
CNS receives information with regard to injury-induced inflammation
via:
1. Soluble mediators
- DAMPS and inflammatory molecules convey stimulatory
signals to the CNS via multiple routes
o thru the fenestrated endothelium of the CVO
o leaky blood brain barrier (pathologic brain trauma)
o interaction with receptors located on the brain
endothelial cells
- potent anti-inflammatory signaling, provided by:
o HPA axis
o release of glucocorticoids
2. Direct neural projections
- Via afferent neural fibers, (vagus nerve)
- Interconnect with neurons that project to the hypothalamus to
modulate the HPA axis
- inflammatory reflex
o Formed by the visceromotor component of the vagus
nerve
o Feeds back to the periphery to regulate inflammatory
signaling events
NEUROENDOCRINE RESPONSE TO INJURY
Two principal pathways:
1. HPA axis
2. SNS

THE HYPOTHALAMIC PITUITARY ADRENAL AXIS

Cortisol
- Major glucocorticoid in humans
- Several important anti-inflammatory actions through
glucocorticoid receptor (GR)
- Activated GR complexs net anti-inflammatory effect:
o Interact with transcription factors to inhibit or promote
their degradation
o Affected genes: proinflammatory cytokines, GFs,
adhesion molecules, NO
o Inhibit mechanism by which TLR ligation induces proinflammatory gene transcription
o Promote transcription genes that have antiinflammatory functions
-

MIF (macrophage inhibitory factor)

- Proinflammatory cytokine
- Functions to counteract activity of glucocorticoids
- Eg. Exacerbation of inflammation associated with acute lung
injury
- Upregulate expression of TLR4 in macrophages
- NF-kB translocation and respiratory burst in PMNs
Growth Hormones
- Neurohormone expressed by pituitary gland
- Both metabolic and immune-modulatory effects
o Promotes protein synthesis and insulin resistance
o Enhances fat stores
o Enhances phagoytic activity of immunocytes (inc
lysosomal superoxide prodn)
o Inc. proliferation of T-cell populations
- Upregulated by hypothalamic GHRH
- Downregulated by Somatostatin
- Effects through GH receptors and enhanced hepatic synthesis
of IGF-1
Insulin-like growth factor (IGF-1)
- Anabolic growth factor
- Improve metabolic rate, gut mucosal function and protein loss
- (liver) stimulates protein synthesis and glycogenesis
- (adipose tissue) inc. glucose uptake and lipid utilization
- (Skeletal muscles) mediates glucose uptake and protein
synthesis

Ghrelin
- Natural ligand for GH-secretagogue receptor 1a (GHS-R1a)
- Appetite stimulant; secreted by stomach
- Promotes GH secretion and glucose homeostasis, lipid
metabolism and immune function
- Effect is mediated via the CNS (cholinergic anti-inflammatory
pathway)
The Role of Catecholamines in Postinjury Inflammation
Sympathetic Nervous System
- In response to injury, stimulate secretion of ACH
o From preganglioinc sympathetic fibers innervating the
adrenal medulla (modified postganglionic neuron)
o Tightly regulated by both central and peripheral
mechanisms
- EPI modulated by transcriptional regulation of PNMT
- Has direct immune-modulatory properties via innervations of
lymphoid tissues
Catecholamines
- EPI and NE
- Prepares the body for the fight and flight response
- Effects on CVS, pulmonary systems and metabolism
o Inc. HR
o Inc. myocardial contractility
o Inc. conduction velocity
o Inc. BP
o Redirection of bloodflow to skeletal muscles
o Inc. cellular metabolism
o Inc. mobilization of glucose from liver
o Dec. release of insulin (a-adrenergic pancreatic
receptors)
- Goal: re-establish and maintain the systems homeostasis
- Directly influence inflammatory cytokine production
o EPI
inhibit prodn of TNF-a
Enhance production of anti-inflammatory cytokine
IL-10
(in vitro)
inhibit prodn of IL-12 and TH1
inc. Th2 cytokine prodn
Aldosterone
- Mineralocorticoid released by the zona glomerulosa of adrenal
cortex

Insulin
-

Binds to mineralocorticod receptor (MR) of principal cells in

the collecting duct of the kidney stimulate expression of
genes involved in sodium reabsorption and potassium
excretion
Regulate extracellular volume and BP
Recent studies: interferes with insulin signaling pathways,
reduce expression of the insulin-sensitizing factors
(adiponectin and PPAR-y)
Hormone secreted by pancreas
Mediates an overall host anabolic state, through:
o Hepatic glycogenesis
o Glycolysis
o Peripheral glucose uptake
o Lipogenesis
o Protein synthesis
Insulin receptor (IR)
o widely expressed and consists of 2 isoforms Can
from homo- or heterodimers with insulin binding
o Dimerization receptor autophosphorylation and
activation of tyrosine kinase activity
o Dependent on recruitment of adaptor proteins: IRS-1
and Shc to the IR
o Phosphorylation of IRS-1 systemic insulin resistance
Hyperglycemia (critical illness)
o Inc. mortality
o Modulate inflammatory response by altering leukocyte
functions
Dec phagocytosis, chemotaxis, adhesion and
respiratory burst
Glucose admin Rapid inc in NF-kb activation
and proinflammatory cytokine prodn

III. CELLULAR STRESS RESPONSES

REACTIVE OXYGEN SPECIES AND THE OXIDATIVE STRESS RESPONSE
Oxygen radicals are produced as by product of:
o Oxygen metabolism in mitochondria
o NADPH oxidase (NOX)
Its activation is triggered by inflammatory mediators
o Xanthine oxidase
Production of ROS
o Respiratory chain(mitochondria)
o peroxisomal fatty acid metabolism
o cytochrome P450 reactions

o respiratory burst of phagocytic cells

o protein folding in the endoplasmic reticulum
Potent oxygen radicals
o Oxygen
o Superoxide
o Hydrogen peroxide
o Hydroxyl radicals
Reactive nitrogen species(RNS)
o NO
o Nitrite
Regulation of ROS synthesis
o Ca++ signaling
o Phosphorylation
o GPCR
such regulation of ROS synthesis also:
o influences recruitment of molecules required for NOX
function
o synthesis of ROS in mitochondria
host cell protection from ROS
o upregulation and/or activation of endogenous antioxidant
proteins
o pyruvate kinasenegative feedback for ROS synthesis
o molecules that react nonenzymaticall y with ROS.

THE HEAT SHOCK RESPONSE

Heat shock proteins(HSP)
o Intracellular proteins that increase expression during times
of stress
o Expressed in:
Cytoplasm
Nucleus
ER
Mitochondria
o Function as chaperones to monitor and maintain
appropriate protein folding
HSP appropriates protein folding via:
o Promotion of protein refolding
o Targeting of misfolded proteins for degradation
o Assistance of partially folded proteins to appropriate
membrane compartments
THE UNFOLDED PROTEIN RESPONSE
Cellular stress (eg. Severe inflammation)

decrease

calcium

concentration in ER disruption of normal cellular protein folding

capacity accumulation of misfolded/unfolded proteins sensed by
signaling proteins in ER generation of unfolded protein
response(UPR) nucleus modulates transcription conditions close
to homeostasis
*prolonged UPR irreversible cell damage cell death
*signaling proteins in the ER include:
Inositol requiring enzyme
Protein kinase RNA-like ER kinase
Activating transcription factor
AUTOPHAGY
Hypoxia & low cellular energy autophagy shift from aerobic
respiration to glycolysis cellular components of autophagosome
hyrdrolyzed to energy substrates provision of additional nutrients for
energy production
*increased levels of auutophagy are typical in activated
immune cells and are a mechanism for the disposal of
ROS &
phagocytosed debris
APOPTOSIS
Extrinsic pathway:
Binding of death receptorsrecruitment of FADD
proteinactivation of caspase 3organized breakdown
nuclear DNA

of

Intrinsic pathway

caspase

BCL-2 and associated proteinsincrease membrane

permeability release of cytochrome C activates
3 apoptosis

Regulatory caspases=1, 8, & 10

NECROPTOSIS
Dependent on receptor-interacting protein kinase(RIPK) complex
Occurs in response to SPECIFIC stimuli such as TNF and TLR
mediated signals
Type of necrosis but organized
Its effect on immune response is not yet known
IV. MEDIATORS OF INFLAMMATION

A. Cytokines
A class of protein signaling compounds
Mediators of cellular responses
o Cell migration
o DNA replication
o Cell turnover
o Immunocyte proliferation
o Eradication of invading microorganisms and
promotion of wound healing
Table 1: Cytokines and their sources
Cytokine
Source
TNF

Macrophages/monocytes
Kupffer cells
Neutrophils
NK Cells
Astrocytes
Endothelial cells
T lymphocytes
Adrenal cortical cells
Endothelial cells
T lymphocytes
Adipocytes
Keratinocytes
Osteoblasts
Mast cells
Dendritic cells

Note
Among earliest
responders after injury;
half-life <20 mins;
activates TNF receptors
1&2; induces significant
shock and catabolism

Tumor Necrosis Factor-

Transmembrane TNF
Precursor form
Expressed as a trimer on the surface of activated cells
Acted upon by metalloproteinase TNF- - converting
enzyme (TACE;aka ADAM-17)

TNFR1

Expressed by a wide variety of cells

Sequestered typically in the Golgi complex

TNFR2
Expressed principally to immune cells
Resides in plasma membrane
Other metabolic and immunomodulatory activities:

catabolism
Insulin resistance
Redistribution of AA to hepatic circulation as fuel
substrates
Coagulation activation, cell migration,
macrophage phagocytosis, enhances expression
of adhesion molecules, prostaglandin E2, plateletactivating factor, glucocorticoids, eicosanoids

Cytokine

Source

Note

IL-1

Macrophages/monocytes
B and T lymphocytes
NK Cells
Endothelial cells
Epithelial cells
Keratinocytes
Fibroblasts
Osteoblasts
Dendritic cells
Astrocytes
Adrenal cortical cells
Megakaryocytes
Platelets
Neutrophils
Neuronal cells

Two forms: IL-1

and IL-1 ; similar
physiologic effects
as TNF; induces
fevers through
prostaglandin
activity in anterior
hypothalamus;
promotes endorphin release
from pituitary; halflife<6 mins

IL-1
A family of 11; 3 major forms: IL-1 , IL-1 , IL-R
o IL-1
o Expressed and stored in healthy cells (epithelium,
endothelium, platelets)
o Functions as DAMO which promotes synthesis of
inflammatory mediators
o IL-1
Multifunctional proinflammatory cytokine
Not detectable in healthy cells but in
monocytes, tissue macrophages, dendritic cells
Rate-limiting step: transcription
Synthesized as inactive precursor molecule
Mature IL-1 requires:

Assembly of inflammasome complex by

cell
Activation of caspase 1
Proinflammatory effects largely similar to
those by TNF
2 primary receptor types: IL-R1 and IL-R2
Cytokine

Source

Note

IL-2

Macrophages/monocytes
T lymphocytes

Promotes
lymphoicyte
proliferation,
immunoglobulin
production, gut
barrier integrity; halflife <10 min;
attenuated
production of major
blood loss leads to
immune compromise;
regulates lymphocyte
apoptosis

IL-2

Cytokine

Produced primarily by CD4+ Tcells

Other sources: CD8+, NKT cells, mast cells, activated
dendritic cells
Promotes nave CD4+ T-cell differentiation into TH1 and
TH2
Inhibits TH17 and Tfh cell differentiation
Upregulation requires: Ca2+, protein kinase C signaling
Receptors: IL-2R
o Expressed on leukocytes
o Formed from IL-2R, Il-2R, IL-2R forming low-,
medium-, high-affinity forms
Source

Note

IL-3

T lymphocytes
Macrophages
Eosinophils
Mast cells

IL-4

T-lymphocytes
Mast cells
Basophils
Macrophages
B Lymphocytes
Eosinophils
Stromal cells

Induces -lymphocyte
production of IgG4 and
IgE mediators of
allergic and
antihelminthic
response;
downregulates TNF, IL1, IL-67, IL-8

IL-5

T-lymphocytes
Mast cells
Basophils
Eosinophils

Promotes eosinophil
proliferation and
airway inflammation

IL-6

Macrophages
B Lymphocytes
Neutrophils
Mast cells
Basophils
Fibroblast
Endothelial cells
Astrocytes
Synovial cells
Adipocytes
Osteoblasts
Chromaffin cells
Megakaryocyte
Keratinocytes

Elicited by virtually all

immunogenic cells;
long half-life;
circulating levels
proportional to injury
severity; prolongs
activated neutrophil
survival

IL-6

Pleiotrophic cytokine that plays a central role in

host defense
Detectable by 60 mins, peak between 4-6 hrs,
p[persist for as long as 10 days
Liver
o Induces acute-phase protein CRP and
fibrinogen

o Reduces albumin, cytochrome P450,

transferrin
o Lymphocytes
Induces B-cell maturation
Regulates Th17/Treg balance
Promotes angiogenesis
IL-6 receptor (gp80) expressed on hepatocytes,
monocytes, B cells, neutrophils
Trans signaling: soluble IL-6Rs in serum bind to IL6IL-6/sIL-6R complex bind to gp130
receptorgp130 transduces: (1) JAK-STAT3
pathway and (2) SHP2-Gab-Ras-Erk-MAPK
pathway, regulated by SOCS3
Increased levels associated with mortality during
intra-abdominal sepsis
o
Cytokine

Source

Note

IL-8

Macrophages/Monocyte
T lymphocytes
Basophils
Epithelial cells
Platelets
Mast cells

Chemoattractant for
neutrophils, basophils,
eosinophils,
lymphocytes

IL-10

T lymphocytes
B lymphocytes
Macrophages
Basophils
Mast cells
Keratinocytes

Prominent antiinflammatory cytokines;

reduces mortality in
animal sepsis and ARDS

IL-10
Plays a role in anti-inflammatory response by
regulating duration and magnitude of
inflammation in host
Family of 6 (Il-10, Il-19, Il-20, Il-22, Il-24, Il-26
Increase during stress and systemic
inflammation
Receptors: IL-10 R

Inhibits secretion of proinflammatory cytokines

(TNF, IL-1) through downregulation of NF-KB
Suppresses transcription of 20% LPS-reduced
genes

Cytokine

Source

Note

IL-12

Macrophages/Monocyte
Neutrophils
Keratinocytes
Dendritic cells
B lymphocytes

Promotes TH1
differentiation;
synergistic activity
with Il-2

IL-12

The only heterodimeric cytokine

Family: IL-12, -23, -27, -35

IL-27 and IL-35

o Immunoregulatory
o Inhibits TH17 cells
IL-12 and IL-23
Pro-inflammatory
Stimulates devt of Th1 and Th17

Synthesis and release increase during

endotoxenemia and sepsis

Stimulates lymphocyte to increase IFN

with costimulus of IL-18, NK cell
cytotoxicity, helper T cell differentiation

Inhibited by IL-10

Enhances coagulation and fibrinolysis

Cytokine

Source

Note

IL-13

T lymphocyte

Promotes
lymphocyte function;
similar to IL-4; inhibits
NO and endothelial
activation

IL-15

Macrophage/monocyte

Anti-inflammatory;
promotes lymphocyte
activation; promotes

neutrophil
phagocytosis in fungal
infections
IL-18

Macrophages
Kupffer cells
Keratinocytes
Adrenal cortical cells
Osteoblasts

Similar to IL-12; levels

elevated sepsis
particularly gram(+)
infections; high levels
found in cardiac deaths

IL-18
o A member of IL-1 superfamily
o Ipro-IL-18: Inactive precursor; requires caspase 1
Cytokine

Source

Note

IFN

T lymphocyte
NK cell

Mediates IL-12, IL-18

function; half-life of
days; found in
wounds 5-7 days
after injury;
promotes ARDS

Interferons
Type 1
20 members which include IFN-,-,-
Receptor: IFN- receptor
Produced by nost types And tissues
Influences adaptive response
Induce maturation of dendritic cells
Stimulate class I MHC expression
Inhibit IL-10

Type2
IFN
Secreted by T cells, NK cells, antigenpresenting cells in response to bacterial
antigen, IL-2, -12, -18
Stimulates release of IL-12 and IL-18

 Inhibited by IL-4, -10, glucocorticoids

Activates JAK-STAT pathway
May contribute to acute lung injury after
major surgery or trauma
Promotes Tcell differentiation, B cell
isotype switching to immunoglobulin G
Cytokine

Source

Note

GMCSF

T lymphocyte
Fibroblast
Endothelial cells
Stromal cells

Promotes wound
healing; activation
of leukocytes

Granulocyte- Macrophage Colony-stimulating Factor/ IL-3/

IL-5
Stimulate behavior of myeloid cells by inducing
cytokine expression and antigen presentation
Link innate and acquired immune response
Not essential for constitutive hematopoietic cell
function (except eosinophilic)
High numbers of activated and sensitized cells
required to bolster host defense
Receptors
o Heterodimers of cytokine-specific
subunit and subunit (c)
o Activates JAK2-STAT-, MAPK-, and PI3Kmediated signaling events

Cytokine

Source

Note

IL-21

T lymphocyte

Secreted by TH2
cells; structurally
similar to IL-2 and
IL-15; activates NK
cells, B and T
lymphocyte;
influences adaptive
immunity

HMGB1

Macrophages/lymphocyte

High mobility group

box chromosomal
protein, DNA
transcription factor;
late (downstream)
mediator of
inflammation
(ARDS, gut barrier
disruption), induces
sickness behavior

B. EICOSANOIDS
derived primarily by oxidation of the membrane phospholipid,
arachidonic acid
they are composed of the following:
1) Prostanglandins,
2) Thromboxanes
3) Leukotrienes
-

Prostanoids is composed by the Prostaglandins and

Thromboxanes
The effects of eicosanoids are mediated via specific receptors (Gprotein coupled receptor)
generated rapidly in response to many stimuli which may be the
following:
1) Hypoxic Injury
2) Direct Tissue Injury
3) Endotoxin (Lipopolysaccharide)
4) Norepinephrine
5) Vasopressin
6) Angiotensin II
7) Bradykinin
8) Serotonin
9) Acetylcholine
10) Cytokines
11) Histamine

Function:
1. Neurotransmission
2. Vasomotor Regulation
3. Immune Cell Regulation (by modulating intensity and duration of
inflammatory response)

Arachidonic Acid (AA)

Omega-6 Polyunsaturated Fatty Acid
relatively abundant in the membrane lipids of inflammatory cells
not stored in free in the cell but in an esterified form in
phospholipids and neutral lipids
Lipid droplets are also an important source of AA
Accumulation of LDs in response to TLRs are associated with
an increase in the generation of Eicosanoid metabolites
Mechanism of Release of AA:
(1) Cell senses the proper stimulus (2) enzymatic activation of
Phospholipase A2 (3) Arachidonic Acid is released from
phospholipids or DAG
Production of AA Metabolites:
cell- and stimulus-specific
signalling events that are initiated will depend on the
concentration and type of eicosanoid generated as well as the
unique complement of receptors expressed by their target cells
A. Prostanoid Synthesis
Prostanoids are produced from AA by the Cycloxygenase (COX) enzyme
and terminal synthetases
B. Leukotriene & Lipoxin Synthesis
AA may be oxidized by 5-lipoxygenase to produce leukotrienes and
lipoxins.
Classes of Eicosanoids
1. Prostaglandins
Produced by the action of Cyclooxygenase to form the initial
precursor of the PG series PGG2 and PGH2 (cyclic
endoperoxides)
Composed of PGD2, PGE2, and PGF2,
a) PGE2
suppresses the effector function of macrophages (i.e.
phagocytosis and killing)
modulates chemokine production
enhances local accumulation of regulatory T cells and myeloidderived suppressor cells
inhibit gluconeogenesis
inhibit hormone-stimulated lipolysis

2. Thromboxane
Produced by the action of Cyclooxygenase
Composed of TXA2
3. Prostacyclins
Produced by the action of Cyclooxygenase
a. PGI2
inhibitory effect on Th1- and Th2-mediated immune response
enhancing Th17 differentiation and cytokine production
4 Leukotrienes
Produced by the action of Lipoxygenase
Composed of the LTA4, LTB4, LTC4, LTD4, and LTE4
a.
-

LTB4
synthesized in response to acute Ca2+ signaling induced by
inflammatory mediators

Mechanism of Action:
(1) LTB4 acts on high-affinity leukotriene receptors (BLT1) which are
expressed primarily in leukocytes including granulocytes,
eosinophils, macrophages, and differentiated T cells (2) activation
of BLT1 (3) reduced production of cAMP (4) counteract the
effects of prostaglandin on macrophage function (phagocytosis and
killing)
5 Lipoxins
Produced by the action of Lipoxygenase
anti-inflammatory compound derived from AA
inhibits (1) chemotaxis, and (2) NF-kB activation
*COX Pathway products inhibit -cell release of Insulin
Lipoxygenase pathway product stimulates -cell activity
Inhibitors of Eicosanoid Pathways
block the end products of eicosanoid pathways
composed of the following:
1) Glucocorticoids
2) NSAIDS
3) Leukotriene Inhibitors

while

Table 1: Differences between Omega-3 Polyunsaturated Fat and

Omega-6 Polyunsaturated Fat
Roles

Omega-3 PUFAs
A. Produces Antiinflammatory
mediators which
functions for the (1)
inhibition of NF-kB
activity, (2) TNF
release from
Kuppfer Cells, and
(3) Leukocyte
adhesion and
migration
B. Produces
Resolvins which can
attenuate the
inflammatory
phenotypes of a
number of immune
cells
C. Ameliorate
weight loss
D. Increase smallbowel perfusion
E. Increase gut
barrier protection
F. Decreased
production of TNF,
IL-1, and IL-6 by
endotoxin
stimulated
monocytes

Omega-6 PUFAs
Produces proinflammatory mediators

Dietary Source

1) Derived from
shorter chain -3
fatty acids of plant
origin such as linolenic acid;

1) Meat
2)
Linolenic
Acid
(vegetable oils corn,
sunflower, and soybean;
margarines)

2) Cold water fish

tuna,
salmon,
mackerel,
herring,
sardine
Omega-3 Polyunsaturated Fat Metabolite
-linolenic acid can be converted after ingestion to
Eicosapentaenoic Acid (EPA) and to Docosahexaenoic Acid (DHA)
EPA and DHA are substrates for the COS and LOX enzymes
but the mediators produced have a different structure from
the AA-derived mediators. This causes a change in their
potency.
-3 fatty acids are reported to have specific anti-inflammatory
effects shown in Table 1
These are achieved by:
a) Decreasing production of AA derived pro-inflammatory
mediators (by competition for the same enzymes)
b) Generation of proresolving bioactive lipid mediators
The ratio of dietary -6 to -3 PUFAs is reflected in the
membrane composition of various cells, including cells of
immune system, which has potential implications for
inflammatory response
A diet rich in -6 PUFAs will result in cells whose membranes
are -6 PUFAs rich. When -6 PUFAs are the plasma
membrane lipid abailable for Phospholipase Activity, more
proinflammatory mediators are generated.
Nutritional Supplementation with -3 fatty acid has the
potential to dampen inflammation by shifting the cell
membrane composition in favor of -3 PUFAs
In study of surgical patients, preoperative supplementation
with -3 fatty acid was associated with reduced need for

mechanical ventilation, decreased hospital length of stay, and

decreased mortality with a good safety profile
C. COMPLEMENT SYSTEM
-

Major effector mechanism of the Innate Immune System

Major source: Liver
It may also be produced locally where they have been implicated
in immune cells, including T cells

Functions:
1) First line of defense for the host against pathogens by binding
and clearing them from the circulation
2) Participates in the elimination of immune complexes as well as
damaged and dead cells
3) Mobilization of hematopoietic stem/progenitor cells and lipid
metabolism
Three (3) Pathways for Complement Activation:
1) Classical Pathway
antibody dependent
Mechanism:
Initiation by direct binding of C1q to its common ligands (IgM/IgG)
Series of activation and amplification steps Assembly of C3
convertase Cleavage of C3 into C3a and C3b C3b complexes
with C3 convertase C5 convertase is activated cleavage of C5
into C5a and C5b facilitates Inflammation, Opsonization and
Phagocytosis, and Cell Lysis
*C3a and C5a: Potent Anaphylatoxins
*C3b: opsonin
*C5b: initiates formation of Membrane Attack Complex
**C5b associates with C6 and C7 the complex becomes
inserted into cell membrane an interacts with C8 binding of
several units of C9 to form a lytic pore
2) Alternative Pathway
resembles the mechanism of the Lectin Pathway but involves
Properdin
initiates and propagates the complement response by attracting
fluid-phase C3b to recognized surfaces
The alternative pathway may account for up to 80% to 90% of
total complement activation

3) Lectin Pathway
Mechanism:
Initiation by mannose-binding lectins or ficolins binding with
specific carbohydrate structures that are often present on
pathogens
D. KALLIKREIN KININ SYSTEM
-

group of proteins that contribute inflammation, blood pressure

control, coagulation and pain responses
Prekallikrein is synthesized by the liver and circulates in the
plasma bound to High-molecular weight kininogen (HMWK)

Mechanism of production of Bradykinin

A variety of stimuli lead to the binding of prekallikrein-HMWK complex
to Hageman Factor (Factor XII) Hageman factor is activated and
production of kallikrein kallikrein cleaves HMWK to form Bradykinin
Functions of Bradykinin:
mediates vasodilation
increased capillary permeability
tissue edema
pain pathway activation
inhibition of gluconeogenesis
increased bronchoconstriction
increase renal vasodilation; reduction of renal perfusion pressure
Mechanism of Action of Bradykinin
B1 activation results in increased neutrophil chemotaxis
B2 receptor expression causes activation of arachidonicprostaglandin pathway
-

Bradkinin and Kallikrein levels are increased during gramnegative bacteremia, hypotension, hemorrhage endotoxemia,
and tissue injury
Bradykinin antagonists have shown some benefit in patients with
gram-negative sepsis

E. SEROTONIN
-

a monoamine neurotransmitter derived from tryptophan

synthesized by neurons in the CNS as well as by intestinal

enterochromaffin cells
Once in the plasma, they are taken up rapidly by platelets via the
serotonin transporter (SERT) where it is stored in the dense
granules or targeted for degradation
Receptors for Serotonin are found in the GI tract, cardiovascular
system and some immune cells

Functions of Serotonin:
potent vasoconstrictor
modulates cardiac inotropy and chronotropy through
nonadrenergic CAMP pathways
released at sites of injury for local inflammatory response
important role in neutrophil recruitment to sites of inflammation
and injury
F. HISTAMINE
-

a short-acting endogenous amine

synthesized from histidine by histidine decarboxylase
either rapidly stored or released in neurons, skin, gastric
mucosa, mast cells, basophils, and platelets

Receptors for Histamine

members of the rhodopsin family of G-protein coupled receptors
a. H1R
mediates vasodilation, bronchoconstriction, intestinal motility,
and myocardial contractility
b. H2R
stimulation of gastric parietal acid secretion
modulates mast cell degranulation, and antibody synthesis, Th1
cytokine production, and T cell proliferation
c. H3R
presynaptic autoreceptor in the PNS and CNS
participates in inflammation in the CNS
increased severity of neuroinflammatory diseases, dysregulation
of blood-brain barrier permeability, and increased expression of
macrophage inflammatory protein 2, IFN-inducible protein 10,
and CXCR3 by peripheral T cells
d. H4R
expressed primarily in the bone marrow but has also been
detected in leukocytes including neutrophils, eosinophils, mast
cells, dendritic cells, T cells, and basophils

important modulator of chemoattraction and cytokine production

V. CELLULAR RESPONSE TO INJURY

Cytokine Receptor Families and Their Signaling Pathways
act on their target cells by binding to specific membrane
receptors
receptor families organized by structural motifs:
o type I cytokine receptors
o type II cytokine receptors
o chemokine receptors
o TNF receptors (TNFRs)
o transforming growth factor receptors (TGFRs)
there are cytokine receptors that belong to the immunoglobulin
receptor superfamilies
JAK-STAT Signaling
some cytokines bind to type I/II cytokine receptors, e.g.:
o type I IFNs
o IFN-
o many ILs (e.g., IL-6, IL-10, IL-12, and IL-13)
o hematopoietic growth factors
type I/II cytokine receptors
o selectively associate with the Janus kinases (JAKs)
JAKs
o represent a family of tyrosine kinases that mediate the
signal transduction for these receptors
o constitutively bound to the cytokine receptors
o activated JAKs phosphorylate the receptor to recruit signal
transducer and activator of transcription (STAT) molecules
Activated STAT dimerize goes into the nucleus modulate
transcription of target genes in there
JAKs and STATs
o central players in the regulation of key immune cell
function
proinflammatory cytokines (IL-6 via JAK1 and STAT3)
anti-inflammatory cytokines (IL-10 via STAT3)
integrating signals required for helper and regulatory
T-cell development and differentiation
o inhibited by
action of phosphatase
export of STATs from the nucleus

interaction of antagonistic proteins

Suppressors of Cytokine Signaling

terminates JAK-STAT signaling
can be induced thru activators of JAK-STAT signaling
can positively and negatively influence the activation of
macrophages and dendritic cells and
crucial for T-cell development and differentiation
regulate receptor signaling through the recruitment of
proteasomal degradation components to their target proteins via
proteasome-ubiquitin system
eight family members:
o SOCS1-3
associated with cytokine receptor signaling
o SOCS4-8
associated with growth factor receptor signaling
PRRs (e.g. TLR and C-type lectin receptors)
o activate SOCS
SOCS1 and SOCS3
o Inhibitory effect on JAK-STAT signaling via their N-terminal
kinase inhibitory region (KIR) domain, which acts as a
pseudosubstrate for JAK
o KIR domain binds with high affinity to the JAK kinase
domain to inhibit its activity
SOCS3
o positive regulator of TLR4 responses in macrophages via
inhibition of IL-6 receptormediated STAT3 activation
deficiency of SOCS cell hypersensitive to certain stimuli
Chemokine Receptors Are Members of the G-ProteinCoupled Receptor
Family
all chemokines are mediated by this type of receptor
largest and most diverse of the membrane protein families
ligand binding undergo conformational changes recruitment
of heterotrimeric G proteins to the cytoplasmic surface that is
composed of three subunits
o G, G, and
signal is communicated either by the G subunit or the G
complex
includes receptors for:
o catecholamines
o bradykinins

o leukotrienes
can be classified into four:
o class A rhodopsin-like
o class B secretin like
o class C metabotropic glutamate/pheromone
o class D frizzled receptors
GPCR activation by ligand binding extracellular domain shift
transmitted to cytoplasmic portion of the receptor to facilitate
coupling to its heterotrimeric G proteins
four families of G alpha subunit, example:
Gs
o activation (Gs) of adenylate cyclase to increase cAMP
levels
Gi
o inhibition (Gi) of adenylate cyclase decrease cAMP
levels
Increased intracellular cAMP activate protein kinase
A gene transcription activity
Ga subunits
Gq pathway
o stimulates phospholipase C- to produce the
intracellular messengers inositol trisphosphate and
diacylglycerol
Inositol triphosphate
triggers
the
release
of
calcium
from
intracellular stores
diacylglycerol
recruits protein kinase C to the plasma
membrane for activation
G12/13
o act through Rho- and Ras-mediated signaling

Tumor Necrosis Factor Superfamily

TNFR1 (55 kDa) and TNFR2 (75 kDa)
o occurs by the recruitment of several adapter proteins to
the intracellular receptor complex
o requires receptor trimerization
TNFR1
o initially recruits TNFR associated death domain (TRADD)
o induces apoptosis through the actions of proteolytic
enzymes known as caspases
o induces apoptosis by activating caspase 2

TNFR2
o lacks a DD component
o recruits adapter proteins known as TNFR-associated factors
1 and 2 (TRAF1, TRAF2) that interact with RIP
o TRAF2 also recruits inhibitor of apoptosis proteins (IAPs)

Transforming Growth Factor- Family of Receptors

TGF-beta
o pleiotropic cytokine expressed by immune cells
o has potent immunoregulatory activities
o essential for T-cell homeostasis
o suppresses of IL-2 production by T cells
o inhibits T-cell proliferation
o regulate the maturation of differentiated dendritic cells and
dendritic cellmediated T-cell responses
o can induce alternative activation macrophages, including
IL-10 and arginase-1 (anti-inflammatory and tissue repair)
TGF- superfamily of receptors
o receptors for TGF- ligands
o type I transmembrane proteins that contain intrinsic
serine/threonine kinase activity
two subfamilies
type I and type II receptors
distinguished
by
the
presence
of
a
glycine/serine-rich membrane domain found in
the type I receptors
Mechanism
o TGF- ligand binds to a combination of type I and type II
receptors heterodimerization activates the receptor
directly recruits and activates a receptor-associated Smad
(Smad2 or Smad3) through phosphorylation additional
common Smad is then recruited Smad complex
translocates into the nucleus w/ other nuclear cofactors
regulates the transcription of target genes
VI. TRANSCRIPTIONAL AND TRANSLATIONAL REGULATION OF THE
INJURY RESPONSE
Transcriptional events following BLUNT trauma
-shift in leukocyte transcriptome (collection of RNA molecules) with
>80% of cellular functions and pathways
-demonstration of some alteration in gene expression

-involved responses:
Systemic inflammatory
Innate immune
Compensatory anti-inflammatory
Adaptive immune
occurs rapidly (4-12 hours) but prolonged (days to weeks)
same stress response with burn injury, endotoxemia
Delayed clinical recovery and organ injury are not associated with
distinct pattern of transcriptional response elements
Transcriptional Regulation of Gene expression
-Mainly at the DNA transcription
-which influences on mRNA and other products expression
-Relies on coordinated action of transcription factors and cofactors
binds on the promotor region, the highly specific DNA sequences
upstream of the target gene
Regulation:
A. Enhancer sequences mediate gene expression
B. Repressor sequences non coding regions that inhibit gene
expression
Example:
A. NF-kB
- transcription factor
- central role in regulating gene production after inflammatory
stimuli
- composed of two polypeptides: p50 and p65
-resides in Cytosol in resting state inhibited by kB ((I-kB)
-in inflammation, I- kB is degraded by TNF, IL-1 or endotoxin by
phosphorylation which releases the NF-kB
-on release, it travels to nucleus and promotes gene expression
-also stimulates gene expression for I-kB (negative feedback
regulation)
Epigenetic Regulation of Transcription
Histones proteins help to bind condense DNA into tightly packed
nucleosomes that limits transcription
Transcription activation of many pro-inflammatory genes require
nucleosome remodeling
At least 7 chromatin modifications
o Acetylation
o Methylation
o Phosphorylation
o Ubiquitinylation

o Sumoylation
o ADP ribosylation
o Deamination
o Proline isomerization
The role of histone modification in regulation of gene expression
is called epigenetic control
Addition of acetyl group to lysine residues of histones- epigenetic
mark for regulation
Maintained by:
o Histone acetyltransferases (HATs)
o Histone deacetylase
Acetylation is monitored by:
o Bromodomain
o extraterminal domain
family of proteins (BET)
Process:
TLR4 activation HATs recruited to gene promoters of
proinflammation acetylation of specific histones
phosphorylate of large subunit of RNA polymerase II elongation
of inflammatory gene transcripts
Translation Regulation of Inflammatory Gene Expression
-Regulation of mRNA transcripts:
a. SPLICING- cleave mRNA and remove noncoding regions
b. CAPPING- modifies the 5 ends of mRNA sequence to inhibit
breakdown by exonucleases
c. addition of POLYADENYLATED TAIL- adds a noncoding sequence to
mRNA to regulate the half-life of the transcript
-microRNAs (miRNAs):
are important translational regulators of gene expression
partially bind complementary sequences in the 3 untranslated
region (3UTR) of target mRNA
this usually results in gene SILENCING
endogenous, single stranded RNAs of approx. 22 nucleotides
conserved in eukaryotes
encoded either singly of in polycistronic clusters
Recent data indicate, it is involved in TLR signaling in the innate
immune system
Process:

 primary miRNA transcript is generated by RNA polymerase I or II

processed in the nucleus short hairpin precursor of miRNA
transported to the cytoplasm mature double stranded miRNA is
generated by a protein, Dicer incorporated into the RNA- induced
silencing complex (RISC) in the cytoplasm RISC can silence target
genes by several mechanisms:
a. At level of protein synthesis thru translation inhibition
b. Transcript level thru mRNA degradation
c. Level of the genome itself thru the formation of heterochromatin
or by DNA elimination
VII. CELL-MEDIATED INFLAMMATORY RESPONSE
Platelets
- small (2 m), circulating fragments of a larger cell precursor
(megakaryocyte) that is located chiefly within the bone marrow
- lack a nucleus but contain both mRNA and a large number of
cytoplasmic and surface proteins
- role in hemostasis is well described but may also have some role
in both local and systematic inflammatory responses, particularly
in ischemia reperfusion
- express functional scavenger and TLRs that are important
detectors of both pathogens and damage-assoc molecules
- once activated, adopt an initial proinflammatory phenotype by
expressing and releasing a variety of adhesion molecules,
cytokines, and other immune modulators, including HMGB1, IL1, and CD40 ligand
- however, activated platelets also express large amounts of the
immunosuppressive factor TGF-, which has been implicated in
Treg cell homeostasis
Lymphocytes and T-Cell Immunity
Dendritic Cells
Eosinophils
Mast Cells
Monocyte/Macrophages

Neutrophils
VIII. ENDOTHELIUM-MEDIATED INJURY
Vascular Endothelium
Physiologic conditions,
Overall anticoagulant properties mediated via production and cell surface expression of:
heparin sulfate
dermatan sulphate
tissue factor pathway inhibitor
protein S
thrombomodulin
plasminogen
tissue plasminogen activator
Endothelial cells functions as barriers: regulate tissue migration of circulating cells
Pathologic conditions (e.g. sepsis),
Endothelial cells deferentially modulated overall procoagulant shift via dec.
production of anticoagulant factors microthrombosis & organ injury
Neutrophil-Endothelium Interaction
Regulated inflammatory response to infection facilitates
neutrophil, other immunocyte migration to compromised regions
through actions of:
o increased vascular permeability
o chemoattractants
o increased endothelial adhesion factors (selectins elaborated on
cell surfaces)

Sentinel leukocytes in the tissues release inflammatory

stimuli:
o Chemokines
o Thrombin
o Leukotrienes
o Histamine
o TNF
Response:
o vascular endothelium - activated
o surface protein expression - altered

Within 10 to 20 minutes,
P-selectin expressed on cell surface (mediate neutrophil
recruitment)

After 2 hours,
Endothelial cell transcriptional processes provide additional
surface expression of E-selectin.
E-selectin and P-selectin bind P-selectin glycoprotein ligand-1
(PSGL-1) on the neutrophil
o orchestrate the capture and rolling of these leukocytes
o allow targeted immunocyte extravasation.
Chemokines on the endothelial surface create chemotactic
gradient enhance recruitment.
Secondary leukocyte-leukocyte interactions in which PGSL-1 and
L-selectin binding facilitates further leukocyte tethering.
Effective rolling involves significant degree of functional overlap
among individual selectins in leukocyte rolling.

Chemokines
- family of small proteins (8 to 13 kDa)
- produced at high levels following injury in all tissues (key attractants for immune cell
extravasation)
- more than 50 different chemokines and 20 chemokine receptors that have been
identified.
- released from endothelial cells, mast cells, platelets, macrophages, and lymphocytes.
- soluble proteins which bind to glycosaminoglycans on cell surface or ECM form
fixed chemical gradient that promotes immune cell exit to target areas.
- distinguished (in general) from cytokines by virtue of receptors: members of the Gproteincoupled receptor superfamily

Most chemokine receptors recognize more than one chemokine ligand redundancy in
chemokine signaling
The chemokines are subdivided into families based on their amino acid sequences at their
N-terminus:
CC chemokines
- contain two N-terminus cysteine residues that are immediately
adjacent
CXC chemokines
- N-terminal cysteines separated by a single amino acid.
- important for neutrophil (PMN) proinflammatory function
(IL-8) induce neutrophil migration and secretion of cytotoxic
granular contents and metabolites
C chemokines
CX3C chemokines
Nitric Oxide
- initially known as endothelium-derived relaxing factor due to
effect on vascular smooth muscle.
- maintain normal vascular smooth muscle cell relaxation that is
regulated in the endothelium by both flow- and receptormediated events.
- reduce microthrombosis by:
reducing platelet adhesion and aggregation

interfering with leukocyte adhesion to the endothelium

easily traverses cell membranes, has a short half-life of a few
seconds, and is oxidized into nitrate and nitrite.

Endogenous NO formation
Action of NO synthase (NOS) expressed in endothelial cells
(NOS3).
NOS generates NO by catalyzing the degradation of L-arginine
L-citrulline and NO, in the presence of oxygen and NADPH.
guanylyl cyclise
- mediated vasodilatory effects of NO
enzyme that is found in vascular smooth muscle cells and most
other cells of the body
- activated when NO is formed by endothelium
catalyzes the dephosphorylation of guanosine triphosphate
(GTP) cyclic guanosine monophosphate (cGMP), which serves
as a second messenger (signaling smooth muscle relaxation)
There are two additional isoforms of NOS:
o neuronal NOS (NOS1)
o inducible NOS (iNOS/NOS2)
NO synthesis
Increased in response to:
proinflammatory mediators such as TNF- and IL-1
microbial products, due to the upregulation of iNOS expression
NO as an immunoregulator
- in severe systemic injury and associated hemorrhage early
upregulation of iNOS in the liver, lung, spleen, and vascular
system.
- capable of modulating cytokine production and immune cell
development.
iNOS regulate of T-cell dysfunction in the setting of trauma as evidenced by suppressed
proliferative and Th1 cytokine release
Increased NO
- detectable in septic shock, where it is associated with low
peripheral vascular resistance and hypotension.
- in septic shock:
changes in vascular permeability
inhibition of noradrenergic nerve transmission.
- in sepsis:
largely attributed to greater iNOS activity and expression
- Additional effects

 protein and membrane phospholipid

nitrosylation
inhibition of mitochondrial respiration.

alterations

by

Cytokines are reported to modulate NO release by increasing arginine availability

through:
expression of the cationic amino acid transporter (CAT)
increasing tetrahydrobiopterin levels (cofactor in NO
synthesis)
Inhibition of NO
nonselective NOS inhibitor
- associated with an increase in mortality compared with placebo.
selective iNOS inhibition (peritonitis)
reduced pulmonary artery hypertension and gas exchange
impairment and promoted higher visceral organ blood flow,
coinciding with lower plasma cytokine concentrations
- viable therapeutic option.
Prostacyclin
- best effect cardiovascular system (produced by vascular
endothelial cells)
- potent vasodilator
- inhibits platelet aggregation
- In the pulmonary system, reduces pulmonary blood pressure and
bronchial hyperresponsiveness
- In the kidneys, modulates renal blood flow and glomerular
filtration rate.
- acts through receptor (a G-proteincoupled receptor of the
rhodopsin family) to stimulate the enzyme adenylate cyclise
synthesis of cAMP from adenosine triphosphate (ATP) cAMPmediated decrease in intracellular calcium smooth muscle
relaxation
- During systemic inflammation endothelial prostacyclin
expression impaired procoagulant profile
- Exogenous prostacyclin
improve oxygenation in patients with acute lung injury
improved cardiac index, splanchnic blood flow as measured by
intestinal tonometry, and oxygen delivery in patients with
sepsis
no significant decrease in mean arterial pressure
Endothelins
- potent mediators of vasoconstriction
- composed of three members: ET-1, ET-2, and ET-3

21-amino-acid peptides derived from a 38-amino-acid precursor

molecule.
primarily released to the abluminal side of endothelial cells, and
very little is stored in cells; thus a plasma increase in ET is
associated with a marked increase in production.
half-life of plasma ET4 to 7 minutes, which suggests that ET
release is primarily regulated at the transcriptional level
upregulated release in response to:
hypotension
LPS
Injury
thrombin
TGF-
IL-1
angiotensin II
Vasopressin
Catecholamines
anoxia

o
-

ET-1
synthesized primarily by endothelial cells
most potent endogenous vasoconstrictor
estimated to be 10 times more potent than angiotensin II

Three ET receptors, referred to as ETA, ETB, and ETC, have been

identified and function via the G-proteincoupled receptor
mechanism.

ETB receptors are associated with increased NO and prostacyclin

production, which may serve as a feedback mechanism.
Atrial ETA receptor activation has been associated with increased
inotropy and chronotropy.

ET-1 infusion is associated with increased pulmonary vascular

resistance and pulmonary edema and may contribute to
pulmonary abnormalities during sepsis.

At low levels, in conjunction with NO, ETs regulate vascular tone.

At increased concentrations, ETs can disrupt the normal blood
flow and distributionand may compromise oxygen delivery to the
tissue.

ET expression
in pulmonary vasculature with persistent inflammation
associated with the development of pulmonary hypertension

linked to posttranslational and transcriptional initiation of the

unfolded proteinresponse in the affected cells production of
inflammatory cytokines.

Finally, ET-1 levels correlate with levels of brain natriuretic

peptide and CRP, as well as the Sequential Organ Failure
Assessment score in septic patients

Platelet-Activating Factor
Phosphatidylcholine is a major lipid constituent of the plasma membrane. Its enzymatic
processing by:
cytosolic phospholipase A2 (cPLA2)
calcium-independent phospholipase A2 (iPLA2)
= generates:
powerful small lipid molecules as intracellular second messengers:
1. arachidonic acid, the precursor molecule for eicosanoids
2. platelet-activating factor (PAF)
During acute inflammation,
PAF is released by immune cells following the activation of PLA2.
(PAFR) PAF receptor
- expressed by platelets, leukocytes, and endothelial cells
- G-proteincoupled receptor of the rhodopsin family
- Ligand binding promotes the activation and aggregation of
platelets and leukocytes, leukocyte adherence, motility,
chemotaxis, and invasion, as well as ROS generation
Additionally,
PAF activation of human PMNs extrusion of NETs
Platelet activation IL-1 via a novel posttranscriptional mechanism
PAFR ligation results in the:
upregulation of numerous proinflammatory genes including COX2, iNOS, and IL-6
generation of lipid intermediates such as arachidonic acid and
lysophospholipids through the activation of PLA2
Antagonists to PAF receptors mitigate the effects of ischemia and reperfusion injury. Of
note, human sepsis is associated with a reduction in the levels of PAF-acetylhydrolase,
which inactivates PAF by removing an acetyl group. Indeed, PAF-acetylhydrolase
administration in patients with severe sepsis has yielded some reduction in multiple organ
dysfunction and mortality.
Natriuretic Peptides
Natriuretic peptides

 Atrial natriuretic factor (ANF)

Brain natriuretic peptide (BNP)
- released primarily by atrial tissue
- synthesized by the gut, kidney, brain, adrenal glands, and endothelium.
ANF and BNP
Commonalities:
Functionally active forms of the peptides are C-terminal
fragments of a larger prohormone
N-terminal fragments N-terminal (pro-BNP) and C-terminal
fragments (pro-ANF) detectable in the blood.
Biologic properties: diuretic, natriuretic, vasorelaxant, and
cardiac remodeling properties
Receptor: guanylyl cyclase-A (GC-A) receptor.
Increased in the setting of cardiac disorders
Distinctions:
(setting of inflammation)
Increased plasma N-terminal pro-BNP Endotoxemia (w/o
change in heart rate and blood pressure
Elevated pro-BNP - detected in septic patients (in absence of
myocardial dysfunction)