SYSTEMIC AND INFLAMMATORY RESPONSE TO INJURY

Dr. Michael Martin Baccay

September 7, 2020
SEM 1 MIDTERMS – TRANS 3

OUTLINE  The body responds to both injury and infection with:

o Brain & hormones (neural and hormonal response)
I. Detection of Cellular Injury o Cellular level (cell-mediated response)
A. Systemic Response  Types:
B. DAMPs  Innate – acute inflammation; first responders
C. PAMPs  Adaptive – figure out what exactly do they need to
II. Neuroendocrine response to injury respondproduction of antibody; they have sense of
A. HPA Axis (until ghrelin, aldosterone, insulin) preparedness
B. Sympathetic nervous system (catecholamines) A. Damage Associated Molecular Patterns (DAMPS)
III. Sepsis, severe sepsis, septic shock
 Aka alarmins
IV. Signal Transduction
V. Cell signaling pathways  Produced following tissue and cellular injury.
A. JAK-STAT signaling  Interact with immune and nonimmune receptors to initiate a
B. Suppressors of Cytokine Signaling sterile systemic inflammatory response following severe
C. G-protein coupled receptor family traumatic injury.
D. Tumor necrosis factor family  Released either passively from necrotic/damaged cells or
E. Transforming growth factor actively from physiologically stressed cells.
VI. Endothelial-mediated injury  Once they are outside the cell, DAMPs promote the activation
A. Neutrophil-endothelium interaction of innate immune cells, as well as the recruitment and
B. Chemokines activation of antigen-presenting cells, which are engaged in
C. Nitric Oxide host defense.
D. Prostacyclin A. Damps that Mediate Detection of Injury
E. Endothelin
F. Platelet-activating factor 1. High Mobility Group Protein B1 (HMGB1)
G. Natriuretic peptides  The best characterized DAMP
H. Leukocyte endothelium interaction  Rapidly released into the circulation within 30 minutes
VII. Cell-mediated immune response following trauma
VIII. Cells of the immune system  The diverse proinflammatory biologic responses that result
IX. Leukocyte-Endothelium Interaction from HMGB1 signaling include:
o Release of cytokines and chemokines from
Legends macrophages/monocytes and dendritic cells; o Neutrophil
 from the book activation and chemotaxis;
 take note/ boards/good to know o Alteration in epithelial barrier function, including increased
permeability; and
 General info (from 2022 trans, Doc’s ppt, and additional
o Increased procoagulant activity on platelet surfaces
references other than the book)
 HMGB1 binding to TLR4 triggers the proinflammatory cytokine
I. DETECTION OF CELLULAR INJURY
release that mediates “sickness behavior”
A. Systemic Response
2. Mitochondrial DNA (mtDNA)
 Act as DAMPs by triggering an inflammatory response to
necrosis and cellular stress
 The release of mtDNA and formyl peptides from damaged or
dysfunctional mitochondria has been implicated in activation
of the macrophage inflammasome (a cytosolic signalling
complex that responds to cellular stress)
 With stress and tissue injury mtDNA and peptides are released
from damaged mitochondria where they can contribute to a
sterile inflammatory response
B. DAMPS as Ligands for Pattern Recognition Receptors

1. Soluble Pattern Recognition Molecules (PRM):

The Pentraxins

 PRMs are a molecularly diverse group of molecules that share

Figure 1. Key players of systemic response
a conserved mode of action that is defined by complement
 Two most important provoking factors in surgery:
activation, agglutination and neutralization and opsonization
o Infection/ Sepsis
 The best describe of the PRMs are the pentraxins.
o Injury/ Trauma
 Synthesized at sites of injury and inflammation by
 Maintenance – hardest and most important part; body tries to
macrophages and dendritic cells, while neutrophils can store
return everything to normal (homeostasis)
PRMs and release them rapidly following activation.
 Apoptosis – cell death; normal occurrence because everything
dies eventually but it has to follow the natural course.

TRANSCRIBERS Batinga, Pajinag, Salmorin EDITOR Salmorin 1

 2. C – Reactive Protein (CRP)
 The first PRM to be identified
 Synthesized in the liver in response to IL-6
 Part of the acute-phase protein response
 Marker of the proinflammatory response in many clinical
setting, including appendicitis, vasculitis, and ulcerative colitis.
 F-actin is an evolutionarily conserved DAMPs recognized by
DNGR-1 (receptor for dead cells). The identification of F-actin
as a DNGR-1 ligand suggests that cytoskeletal exposure is a
universal sign of cell damage that can be targeted by the
innate immune system to initiate immunity.
C. Pathogen Associated Molecular Patterns
 Along with DAMPs, interact with specific cell receptors that
are located both on the cell surface and intracellularly.
o Endotoxin
 A toxin produced by certain bacteria and released upon
destruction of bacterial cell.
o Flagellin
 A potent activator of a broad range of cell types involved
in innate and adaptive immunity.
o dsRNA
o Peptidoglycan
II. NEUROENDOCRINE RESPPONSE TO INJURY
 Traumatic injury results in complex neuroendocrine signaling
 Enhance immune defense and rapidly mobilize substrates
necessary to meet essential energy and structural needs
 Two principle neuroendocrine pathways:
o Hypothalamic-pituitary-adrenal (HPA) axis - Results in the
release of glucocorticoid hormones.
o Sympathetic nervous system - Results in release of the
catecholamines (epinephrine and norepinephrine)
A. Hypothalamic-Pituitary-Adrenal (HPA) Axis
 Respond to injury-associated stress
 After injury, corticotropin releasing hormone (CRH) is secreted
from the paraventricular nucleus (PVN) of the hypothalamus
o Mediated by TNF-α, IL-1β, IL-6, and the type I IFNs (IFN-α/β)
as a result of innate immune response to injury.
 Cortisol release
o Mediated by IL-2 and IFN-γ as a result of adaptive immune
response
 Direct neural input via afferent vagal fibers that interconnect
with neurons projecting to the hypothalamus
o Trigger CRH release  stimulate secretion of ACTH by the
APG
 Cytokines that act on the hypothalamus are also capable of
stimulating ACTH release from the anterior pituitary so that
marked elevations in ACTH and in cortisol can occur that are
proportional in magnitude to the injury severity
Figure 2. Neural circuit relaying messages of localized injury to the
SURG – [03] Systemic and Inflammatory Respose to Injury
brain (nucleus tractus solitarius).
A. ACTH
 Acts on the zona fasciculata of the adrenal glands
 Synthesizes and secretes glucocorticoids
B. Cortisol
 Major glucocorticoid which is essential for survival during
significant physiologic stress
 Trauma  increase cortisol  anti-inflammatory actions
 Elicits action thru a cytosolic receptor (glucocorticoid
receptor).
 Lipid soluble - can diffuse through the plasma membrane to
interact with its receptor sequestered in the cytoplasm in a
complex with heat shock proteins
 Ligand binding  activation of GR  modulate
proinflammatory gene transcription and signaling
events“net” anti-inflammatory effect.
 Glucocorticoids can negatively affect the access of the
 transcription factor, NF-κB, to the promoter regions of its
target genes via a mechanism that involves histone
deacetylase 2.
 Glucocorticoids can inhibit a major mechanism by which TLR
ligation induces proinflammatory gene expression.
 Glucocorticoid receptor (GR) complex bind to specific
nucleotide sequences (glucocorticoid response
elements)promote the transcription of genes (IL-10 and IL-1
receptor Antagonist)  anti-inflammatory functions
 GR complex activation can indirectly influence TLR activity via
an interaction with signaling pathways such as the mitogen-
activated protein kinase and transforming growth factor–
activated kinase-1 (TAK1) pathways
 GR complex can target both suppressor of cytokine signaling 1
(SOCS1) and type 1 IFNs to regulate TLR- induced STAT1
activation
C. Adrenal Insufficiency
 Due to inadequate amounts of circulating cortisol and
aldosterone.
 Caused by exogenous steroid administration who undergo a
stressor such as surgery (in patients with atrophic adrenal
glands).
 S/sx: tachycardia, hypotension, weakness, nausea, vomiting,
and fever.
 Relative adrenal insufficiency
o Adrenal gland cannot mount an effective cortisol response
to match the degree of injury
 Critical illness-associated cortisol insufficiency in trauma
patients occurs more frequently.
 Bimodal presentation: patient is at increased risk both early
following the injury associated inflammatoryresponse and in a
delayed fashion, with sepsis being the initiating event.
 Laboratory findings in adrenal insufficiency
o Hypoglycemia from decreased gluconeogenesis
o Hyponatremia from impaired renal tubular sodium
resorption
o Hyperkalemia from diminished kaliuresis
 Diagnosis: monitoring of basal and ACTH-stimulated cortisol
levels = lower than normal
 Treatment: low-dose steroid supplementation.
B. Macrophage Inhibitory Factor
 Modulates cortisol function
 Proinflammatory cytokine expressed by anterior pituitary,
macrophages, and T lymphocytes
2
  Counteracts the anti-inflammatory activity of glucocorticoids
causes exacerbation of inflammation associated with acute
lung injury.
 Upregulate the expression of TLR4 in macrophages
 Early increase in plasma MIF has been detected in severely
injured patients and was found to correlate with NF-κB
translocation and respiratory burst in polymorphonuclear
lymphocytes (PMNs) derived from severely injured patients.
 MIF after injury may be beneficial in preventing early PMN
activation and subsequent organ failure in severely injured
patients.
C. Growth Hormone
 Neurohormone expressed primarily by the pituitary gland that
has both metabolic and immunomodulatory effects
 Promotes protein synthesis and insulin resistance and
enhances the mobilization of fat stores
 Upregulation: by hypothalamic GH-releasing hormone
 Downregulation: by somatostatin
 Exerts its downstream effects through direct interaction with
GH receptors and through the enhanced hepatic synthesis of
insulin-like growth factor (IGF)-1
 Enhances phagocytic activity of immunocytes – inc. lysosomal
superoxide production
 inc. proliferation of T-cell populations
 inc. severe injury  suppression of the GHIGF-IGFBP  dec.
axis IGF levels
 Administration of exogenous recombinant human GH (rhGH) -
associated with increased mortality, prolonged ventilator
dependence, and increased susceptibility to infection
 GH level = independent predictor of mortality, along with the
APACHE II/SAPS II scores
 Severely burned children
o rhGH administration is beneficial
 Improved growth and lean body mass hypermetabolism
was significantly attenuated.
 Significant in serum GH, IGF-1, and IGFBP-3.
D. Insulin-Like Growth Factor (IGF) - 1
 Anabolic growth factor improve the metabolic rate, gut
mucosal function, and protein loss after traumatic injury.
 < 5% = circulates free in the plasma
 Remainder = bound principally to one of six IGF-binding
proteins (IGFBPs), the majority to IGFBP-3.
 Liver – IGF inc. CHON synthesis and glycogenesis
 Adipose tissue - inc. glucose uptake and lipid utilization
 Skeletal muscle – inc. glucose uptake and CHON synthesis.
E. Ghrelin
 Natural ligand for the GH-secretagogue receptor 1a (GHS-R1a)
 GHS-R1a – expressed in immune cells, B and T cells, and
neutrophils
 Appetite stimulant secreted by the stomach promotes GH
secretion and in glucose homeostasis, lipid metabolism, and
immune function.
 In rodent gut ischemia/reperfusion model, ghrelin
administration caused the ff:
o Inhibited proinflammatory cytokine release
o Reduced neutrophil infiltration
o Ameliorated intestinal barrier dysfunction
o Attenuated organ injury
o Improved survival
 Effect of ghrelin is dependent on an intact vagus nerve
 Effect is mediated via the CNS (“cholinergic anti- inflammatory
pathway)
 High ghrelin levels
SURG – [03] Systemic and Inflammatory Respose to Injury
o Seen in critically ill patients
o Positive predictor of intensive care unit survival in septic
patients
F. Catecholamines in Post-Injury Inflammation
 Injury induced activation of SNS secretion of Ach from
preganglionic sympathetic fibers innervating the adrenal
medulla
 Adrenal medulla = considered a modified postganglionic
neuron
 Ach signaling to resident chromaffin cells  surge of
epinephrine (EPI) and norepinephrine (NE) release into the
circulation (regulated by central and peripheral mechanisms)
 release of EPI
o Modulated by transcriptional regulation of
phenylethanolamine N-methyltransferase (PNMT)
o PNMT - catalyzed the last step of catecholamine
biosynthesis pathway methylating NE to form EPI
o PNMT transcription - key step in regulating EPI production
and is activated in response to stress and tissue hypoxia by
hypoxia- inducible factor 1α (HIF1A)
 Catecholamine release:
o Causes increased heart rate, myocardial contractility,
conduction velocity, and blood pressure; redirection of
blood flow to skeletal muscle; increased cellular
metabolism throughout the body; and mobilization of
glucose from the liver via glycogenolysis, gluconeogenesis,
lipolysis, and ketogenesis (“fight or flight” response).
o Insulin release is decreased mainly through the stimulation
of α-adrenergic pancreatic receptors hyperglycemia 
proinflammatory response mitochondrial dysfunction.
o Goal: re-establish and maintain the system’s homeostasis,
including the innate immune system
o It directly influence inflammatory cytokine production
 EPI levels condition the activity and responsiveness of
cytokine-secreting cells
 Epinephrine infusion (higher doses) - inhibit production
of TNF-α in vivo and to enhance the production of the
anti-inflammatory cytokine IL-10
 Stress levels of glucocorticoids and EPI
 Inhibit production of IL-12 (potent stimulator of Th1
responses)
 Decrease Th1 cytokine production and increase Th2
cytokine production
o Adrenal gland: catecholamine (part. EPI) – causes innate
proinflammatory cytokine regulation and adaptive Th
responses; may act in concert with cortisol to modulate
cytokine activity during injuries
 Human immune cells (e.g., mononuclear cells, macrophages,
granulocytes) express adrenergic receptors that are members
of the family of G-protein–coupled receptors that act through
the activation of intracellular second messengers such as cyclic
adenosine monophosphate (cAMP) and calcium ion influx
 Second messengers regulate the release of inflammatory
cytokine and chemokines and other immune cell functions
 SNS has direct immune modulatory properties via its
innervation of lymphoid tissues containing resting and
activated immune cells
 Stimulation of postganglionic nerves  NE release  NE
interacts with β2-adrenergic receptors expressed by CD4+ T
and B lymphocytes
 Human peripheral blood mononuclear cells contain inducible
mRNA for the catecholamine-generating enzymes, tyrosine-
hydroxylase and dopamine-β- hydroxylase, and data suggest
that cells can regulate their own catecholamine synthesis in
response to extracellular cues
3
  Exposure of peripheral blood mononuclear cells to NE 
triggers a distinct genetic profile that indicates a modulation
of Th cell function
G. Aldosterone
 A mineralocorticoid released by the zona glomerulosa of the
adrenal cortex.
 Binds to the mineralocorticoid receptor of principal cells in the
collecting duct of the kidney
 It can stimulate expression of genes involved in sodium
reabsorption and potassium excretion to regulate extracellular
volume and blood pressure.
A. Mononuclear Cells (Monocytes & Lymphocytes)
 Has mineralocorticoid receptor (MR) that binds aldosterone
with high specificity, regulating sodium and potassium flux, as
well as plasminogen activator inhibitor-1 and p22 phox
expression
 Aldosterone also inhibits cytokine-mediated NF-κB activation
in neutrophils, which also possess a functional MR.
H. Insulin
 Hyperglycemia and insulin resistance – hallmarks of injury and
critical illness.
o Due to the catabolic effects of circulating mediators,
including catecholamines, cortisol, glucagon, and GH.
 Proglycemic factors, particularly EPI, induces:
o Glycogenolysis
o Lipolysis
 Aerobic glycolysis – increased lactate production independent
of available oxygen in a process
 Severe stress – associated with insulin resistance, leading to
decreased glucose uptake in the liver and the periphery
contributing to acute hyperglycemia.
 It is a hormone secreted by the pancreas
 Mediates an overall host anabolic state through:
o Hepatic glycogenesis and glycolysis
o Peripheral glucose uptake
o Lipogenesis
o Protein synthesis.
 Insulin Receptor (IR)
o Widely expressed and consists of two isoforms, which can
form homo- or heterodimers with insulin binding.
o Dimerization leads to receptor autophosphorylation and
activation of intrinsic tyrosine kinase activity.
o Downstream signaling events are dependent on the
recruitment of the adaptor proteins, insulin receptor
substrate (IRS-1), and Shc to the IR.
 Systemic insulin resistance likely results from proinflammatory
signals, which modulate the phosphorylation of IRS-1 to affect
its function.
III. SEPSIS, SEVERE SEPSIS, & SEPTIC SHOCK
Figure 3. Criteria for SIRS, sepsis, severe sepsis and septic shock.
 Infection – a host response to the presence of microorganisms
or tissue invasion by microorganisms.
SURG – [03] Systemic and Inflammatory Respose to Injury
 Bacteremia – the presence of viable bacteria in circulating
blood.
 Systemic Inflammatory Response Syndrome (SIRS) – the
systemic inflammatory response to a wide variety of severe
clinical insults, manifested by two or more of the following
conditions:
o Temp above101F (38.3C) or below 96.8F (36C)
o HR >90bpm
o RR >20bpm or PaCO2 <32mmHg
o WBC count >12,000/mm3, <4,000/mm3, or >10% immature
(band) forms
 Sepsis – the systemic inflammatory response to infection and
is defined as the presence of SIRS in addition to documented
or presumed infection. The clinical manifestations would
include two or more of the following conditions* as a result of
documented infection.
 Severe Sepsis/SIRS – Sepsis (SIRS) associated with organ
dysfunction, hypoperfusion, or hypotension. Hypoperfusion
and perfusion abnormalities may include, but are not limited
to, lactic acidosis, oliguria, or an acute alteration in mental
status. Sepsis is usually considered severe when the patient
exhibits at least one of the following signs and symptoms
(which indicate an organ may be failing):
o Significantly decreased urine output
o Abrupt change in mental status
o Decrease in platelet count
o Difficulty breathing
o Abnormal heart pumping function
o Abdominal pain
 Multiple Organ Dysfunction Syndrome (MODS) – presence of
altered organ function in an acutely ill patient such that
homeostasis cannot be maintained without intervention.
IV. SIGNAL TRANSDUCTION
 Signal Transduction – the process of transferring a signal
throughout an organism, especially across or through a cell.
 Receptors – it waits for a chemical, physical or electrical signal.
Chemical signals are ligands, and can be produced by
organisms to control their body or received by the
environment.
 Receptor Proteins – specialized by the type of cell they are
attached to. Each type of cell receives different signals from
the body and environment, so that the body can produce a
specific and coordinated response.
 Second Messenger – carry the message to the nucleus or
other organelles
Figure 4. Sigal transduction pathway
4
 V. CELL SIGNALING PATHWAYS
 Act on their target cells by binding to specific membrane
receptors
 These receptor families have been organized by structural
motifs and include:
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.
 Several of these receptors have characteristic signaling
pathways that are associated with them.
A. JAK-STAT SIGNALING (Receptor Kinase)
Figure 5. JAK-STAT signaling pathway
 A major subgroup of cytokines, comprising roughly 60 factors,
bind to receptors termed type I/II cytokine receptors
 Cytokines that bind these receptors include:
o Type I IFNs
o IFN-γ
o ILs (e.g., IL-6, IL-10, IL-12, and IL-13
o Hematopoietic growth factors
 These cytokines play essential roles in the initiation,
maintenance, and modulation of innate and adaptive
immunity for host defense.
 All type I/II cytokine receptors selectively associate with the
Janus kinases (JAKs).
o Represent a family of tyrosine kinases that mediate the
signal transduction for these receptors.
 JAKs are constitutively bound to the cytokine receptors, and
on ligand binding and receptor dimerization, activated JAKs
phosphorylate the receptor to recruit signal transducer and
activator of transcription (STAT) molecules.
 Activated STAT proteins further dimerize and translocate into
the nucleus where they modulate the transcription of target
genes
 Individual cytokines activate more than one STAT
 STAT-DNA binding can be observed within minutes of cytokine
binding
 STATs: modulate gene transcription via epigenetic
mechanisms
 JAKs and STATs: central players in the regulation of key
immune cell function, by providing a signaling platform for
 Proinflammatory cytokines (IL-6 via JAK1 and STAT3) and anti-
inflammatory cytokines (IL-10 via STAT3) and integrating
signals required for helper and regulatory T-cell development
and differentiation
SURG – [03] Systemic and Inflammatory Respose to Injury
 The JAK/STAT pathway is inhibited by the action of
phosphatase, the export of STATs from the nucleus, and the
interaction of antagonistic proteins
B. Suppressors of Cytokine Signaling
A. Suppressors of Cytokine Signaling Molecules (SOCS)
 Family of proteins that function as a negative feedback loop
for type I and II cytokine receptors by terminating JAK- STAT
signaling
 Eight family members
o SOCS1-3: associated with cytokine receptor signaling
o SOCS4-8: associated with growth factor receptor signaling.
 PRRs, including both TLR and C-type lectin receptors: activate
SOCS by:
o Induction of SOCS proteins is achieved through activators
of JAK-STAT signaling, creating an inhibitory feedback loop
through which cytokines can effectively self-regulate by
extinguishing their own signal.
o SOCS molecules can positively and negatively influence the
activation of macrophages and dendritic cells and are
crucial for T-cell development and differentiation.
o All SOCS proteins are able to regulate receptor signaling
through the recruitment of proteasomal degradation
components to their target proteins, whether the target is
a specific receptor or an associated adaptor molecule.
 Once associated with the SOCS complex, target proteins are
readily ubiquinated and targeted to the proteasome for
degradation
 SOCS1 and SOCS3: also exert an inhibitory effect on JAK- STAT
signaling via their N-terminal kinase inhibitory region (KIR)
domain.
o N-terminal kinase inhibitory region (KIR) domain
 Acts as a pseudo-substrate for JAK
 Binds with high affinity to the JAK kinase domain to
inhibit its activity.
 SOC3: positive regulator of TLR4 responses in macrophages
via inhibition of IL-6 receptor–mediated STAT3 activation.
 Deficiency of SOCS activity → cell hypersensitive to certain
stimuli, such as inflammatory cytokines and GHs
C. G Protein Receptor Family
 Chemokine Receptors that respond to ligands such as
adrenaline and serotonin
 On ligand binding to the receptor (R), the G protein (G)
undergoes a conformational change through guanosine
triphosphate–guanosine diphosphate conversion and in turn
activates the effector (E) component.
 The E component subsequently activates second messengers.
 Three subunits of Heterotrimeric G proteins:
o Gα, Gβ, and Gγ
 G proteins perform functionally as dimers because the signal is
communicated either by the Gα subunit or the Gβγ complex.
Figure 6. G-protein coupled receptor activation pathway
5
  Includes the receptors for catecholamines, bradykinins, and
leukotrienes, in addition to a variety of other ligands important
to the inflammatory response.
 Classification according to their pharmacologic properties (4
Main Families):
o Class A Rhodopsin-Like
o Class B Secretin-like,
o Class C Metabotropic Glutamate/Pheromone
o Class D Frizzled Receptors
 Ligand binding → GPCR activation → extracellular domain
shift: transmitted to cytoplasmic portion of the receptor →
facilitate coupling to its principle effector molecules, the
heterotrimeric G proteins.
A. G
 There are more than 20 known Gα subunits, they have been
divided into 4 families based on sequence similarity, which has
served to define both receptor and effector coupling.
 Gαs: signal through the activation (Gαs) of adenylate cyclase
to ↑ cAMP levels → activate gene transcription through the
activity of intracellular signal transducers such as protein
kinase A.
 Gαi: inhibition (Gαi) of adenylate cyclase to ↓ cAMP levels
 Gq pathway: stimulates phospholipase C-β to produce the
intracellular messengers inositol trisphosphate and
diacylglycerol.
o Inositol triphosphate: triggers the release of calcium from
intracellular stores from the ER
o Diacylglycerol: recruits protein kinase C to the plasma
membrane for activation.
 Gα12/13: act through Rho- and Ras-mediated signaling.
D. Tumor Necrosis Factor Superfamily
 The signaling pathway for TNFR1 (55 kDa) and TNFR2 (75 kDa)
occurs by the recruitment of several adapter proteins to the
intracellular receptor complex.
 Optimal signaling activity requires receptor trimerization
TNFR1: initially recruits TNFR- associated death domain
(TRADD) → induces apoptosis through the actions of
proteolytic enzymes known as caspases.
 CD95 and TNFR1: possess similar intracellular sequences
known as death domains (DDs).
o Both recruit the same adapter proteins: Fas- associated
death domains (FADDs) before activating caspase 8.
o TNFR1: induces apoptosis by activating caspase 2 through
the recruitment of receptor-interacting protein (RIP).
 RIP - has a functional component that can initiate NF-κB
and c-Jun activation, both favoring cell survival and
proinflammatory functions
 TNFR2: lacks a DD component but recruits adapter proteins
known as TNFR-associated factors 1 and 2 (TRAF1, TRAF2) that
interact with RIP to mediate NF-κB and c-Jun activation that
recruits additional proteins that are antiapoptotic, known as
inhibitor of apoptosis proteins (IAPs).
E. Transforming Growth Factor-B Family of Receptors
B. TGF-1
 Pleiotropic cytokine expressed by immune cells that has
potent immunoregulatory activities
 Essential for T-cell homeostasis
 Receptors for TGF-β ligands: TGF-β superfamily of receptors
o Type I transmembrane proteins that contain intrinsic
serine/threonine kinase activity
o Comprise two subfamilies:
SURG – [03] Systemic and Inflammatory Respose to Injury
 Type I receptors: distinguished by the presence of a
glycine/serine-rich membrane domain found
 Type II receptors
 Each TGF-β ligand binds a characteristic combination of type I
and type II receptors, both of which are required for signaling
o Whether the type I or the type II receptor binds first is
ligand-dependent, and the second type I or type II receptor
→ recruited to form a heteromeric signaling complex.
 TGF-β binds to the TGF-β receptor → heterodimerization →
activates the receptor, which then directly recruits and
activates a receptor-associated Smad (Smad2 or Smad3)
through phosphorylation → additional “common” Smad is
then recruited
o Activated Smad complex translocate into the nucleus and,
with other nuclear cofactors, regulates the transcription of
target genes.
 Also induce the rapid activation of the Ras-extracellular signal-
regulated kinase (ERK) signaling pathway in addition to other
MAPK pathways (JNK, p38MAPK)
 Inhibits immune responses by:
o Suppression of IL-2 production by T cells (one of the most
important effects)
o Inhibits T-cell proliferation
o Can regulate the maturation of differentiated dendritic
cells and dendritic cell–mediated T-cell responses.
o Induce “alternative activation” macrophages, designated
M2 macrophages, which express a wide array of anti-
inflammatory molecules, including IL-10 and arginase-1.
Figure 7. Ligand-gated ion channels vs G-coupled receptors
VI. ENDOTHELIAL MEDIATED INJURY
A. Vascular Endothelium
 Normal: VE has overall anticoagulant properties mediated via
the production and cell surface expression of heparin sulfate,
dermatan sulfate, tissue factor pathway inhibitor, protein S,
thrombomodulin, plasminogen, and tissue plasminogen
activator
 Sepsis Injury: VE has overall procoagulant shift via decreased
production of anticoagulant factors, which may lead to
microthrombosis and organ injury
B. Neutrophil-Endothelium Interaction
 Neutrophil facilitation and immunocyte migration: Brought
about by increased vascular permeability, chemoattractants,
and increased endothelial adhesion factors (selectins on cell
surfaces.).
 In response to inflammatory stimuli released from sentinel
leukocytes in the tissues, including chemokines, thrombin,
leukotrienes, histamine, and TNF → activation of vascular
endothelium and alteration of surface protein expression.
 Within 10 to 20 minutes: P-selectins are mobilized to the cell
surface where it can mediate neutrophil recruitment.
6
  After 2 hours: Provision of additional surface expression of E- o CX3C
selectin. D. Nitric Oxide
 E-selectin and P-selectin bind P-selectin glycoprotein ligand-1  Maintains normal vascular smooth muscle cell relaxation
(PSGL-1) on the neutrophils to orchestrate the capture and  Reduces platelet adhesion and aggregation and interferes
rolling of these leukocytes and allow targeted immunocyte with leukocyte adhesion to the endothelium
extravasation.  Easily traverses cell membranes, has a short half-life of a few
 Immobilized chemokines on the endothelial surface create a seconds, and is oxidized into nitrate and nitrite
chemotactic gradient to further enhance immune cell  Endogenous NO formation is largely derived from the action
recruitment. of NO synthase (NOS).
Table 1. Molecules that mediate Leukocyte-endothelial interaction  NOS
Adhesion Action Origin Inducers Target Cells
o Constitutively expressed in endothelial cells (NOS3)
Molecule of o Generates NO by catalyzing the degradation of L-arginine
Expression to L-citrulline and NO, in the presence of oxygen and
Selectins NADPH
L-selectin Fast rolling Leukocytes Native Endothelium, o 2 additional isoforms of NOS: neuronal NOS (NOS1) and
platelets,
inducible NOS (iNOS/ NOS2).
eosinophils
P-selectin Slow rolling Platelets and Thrombin, Neutrophils,  Guanylyl cyclase (GC) mediates the vasodilatory effect of NO
endothelium histamine monocytes o When NO is formed by endothelium, it rapidly diffuses into
adjacent cells where it binds to and activates guanylyl
E-selectin Very slow Endothelium Cytokines Neutrophils,
rolling monocytes, cyclase.
lymphocytes o GC catalyzes the dephosphorylation of guanosine
Immunoglobulins triphosphate (GTP) to cyclic guanosine monophosphate
ICAM-1 Firm adhesion/ Endothelium, Cytokines Leukocytes (cGMP), which serves as a second messenger for signaling
transmigration leukocytes, smooth muscle relaxation.
fibroblasts,  Due to the upregulation of iNOS expression, NO synthesis is
epithelium
ICAM-2 Firm adhesion Endothelium, Native Leukocytes
increased in response to TNF-α and IL-1β, as well as microbial
platelets products.
VCAM-1 Firm adhesion/ Endothelium Cytokines Monocytes, o Severe systemic injury and associated hemorrhage
transmigration lymphocytes produce an early upregulation of iNOS in the liver, lung,
PECAM-1 Adhesion/ Endothelium, Native Endothelium, spleen, and vascular system in which NO acts as an
transmigration platelets, platelets, immunoregulator which modulates cytokine production
leukocytes leukocytes
and immune cell development.
β2-(CD18) Integrins
CD18/11a Firm adhesion/ Leukocytes Leukocyte Endothelium
o Because of greater iNOS activity and expression, NO is
transmigration activation increased in septic shock, where it is associated with low
CD18/11b Firm adhesion/ Neutrophils, Leukocyte Endothelium peripheral vascular resistance and hypotension as well as
(Mac-1) transmigration monocytes, activation with changes in vascular permeability and inhibition of
natural killer noradrenergic nerve transmission.
cells
o Cytokines modulate NO release by increasing arginine
CD18/11c Adhesion Neutrophils, Leukocyte Endothelium
monocytes, activation availability through the expression of the cationic amino
natural killer acid transporter (CAT) or by increasing
cells tetrahydrobiopterin levels, a key cofactor in NO synthesis.
β1-(CD29) Integrins o Protein and membrane phospholipid alterations by
VLA-4 Firm adhesion/ Lymphocytes Leukocyte Monocytes, nitrosylation and the inhibition of mitochondrial
transmigration monocytes activation endothelium,
epthelium
respiration, also happen when NO is increased
E. Prostacyclin (PGI2)
C. Chemokines  Best described effects: Cardiovascular system
 First identified through their chemotactic and activating  A potent vasodilator that also inhibits platelet aggregation
effects on inflammatory cells  Pulmonary system: It reduces pulmonary blood pressure and
 Produced at high levels following nearly all forms of injury in bronchial hyper-responsiveness.
all tissues, where they are key attractants for immune cell  Kidneys: It modulates renal blood flow and glomerular
extravasation. filtration rate.
 Soluble proteins, which when secreted, bind to  Acts through its receptor (a G-protein–coupled receptor of the
glycosaminoglycans on the cell surface or in the ECM. In this rhodopsin family) to → stimulation of adenylate cyclase →
way, the chemokines can form a fixed chemical gradient that synthesis of cAMP from adenosine triphosphate (ATP) →
promotes immune cell exit to target areas. cAMP-mediated decrease in intracellular calcium and
 Chemokines are distinguished (in general) from cytokines by subsequent smooth muscle relaxation
virtue of their receptors, which are members of the G-protein-  During systemic inflammation: endothelial prostacyclin
coupled receptor superfamily. expression is impaired → more pro-coagulant profile of
 4 Major Groups: endothelium
o C-X-C: important for neutrophil (PMN) proinflammatory  Both intravenous and inhaled exogenous prostacyclin
function analogues have been used to improve oxygenation in patients
o C-C: Generally, attract monocytes, eosinophils, basophils with acute lung injury.
and lymphocytes  Infusion of prostacyclin improved cardiac index, splanchnic
o C: Specific for lymphocytes blood flow as measured by intestinal tonometry, and oxygen

SURG – [03] Systemic and Inflammatory Respose to Injury 7

 delivery in patients with sepsis and there was no significant
decrease in mean arterial pressure.
F. Endothelin
 Potent mediators of vasoconstriction
 Release is upregulated in response to hypotension, injury,
thrombin, TGFβ, IL-1, angiotensin II, vasopressin,
catecholamines, and anoxia.
 Primarily released to the abluminal side of endothelial cells,
and very little is stored in cells. Regulation: at the
transcriptional level.
 3 members
o ET-1
 Most potent endogenous vasoconstricton.
 Estimated to be 10 times more potent than angiotensin II.
 Synthesized primarily by endothelial cells.
 Infusion of it is associated with increased pulmonary
vascular resistance and pulmonary edema and may
contribute to pulmonary abnormalities during sepsis.
o ET-2
o ET-3
 3 ET receptors: associated with increased NO and prostacyclin
production, which may serve as a feedback mechanism
o ETA: associated with increased inotropy and chronotropy
o ETB
o ETC
 At low levels, in conjunction with NO, ETs regulate vascular
tone.
 At increased concentrations, ETs can disrupt the normal blood
flow and distribution and may compromise oxygen delivery to
the tissues.
G. Platelet Activating Factor
 Phosphatidylcholine: major lipid constituent of the plasma
membrane. Enzymatic processing by:
o Cytosolic phospholipase A2 (cPLA2)
o Calcium-independent phospholipase A2 (iPLA2)
 Precursor molecule for eicosanoids
o Arachidonic acid
o Platelet-activating factor (PAF)
 Acute inflammation: PAF is released by immune cells following
the activation of PLA2.
o Receptor for PAF (PAFR): constitutively expressed by
platelets, leukocytes, and endothelial cells
o Ligand binding to the PAFR → activation and aggregation
of platelets and leukocytes, leukocyte adherence, motility,
chemotaxis, and invasion, as well as ROS generation
o PAFR ligation results in the:
 Upregulation of numerous proinflammatory genes
including COX-2, iNOS, and IL-6.
 Generation of lipid intermediates such as arachidonic
acid and lysophospholipids through the activation of
PLA2.
H. Natriuretic Peptides
 2 kinds
o Atrial natriuretic factor (ANF)
o Brain natriuretic peptide (BNP)
 Released primarily by atrial tissue but are also synthesized by
the gut, kidney, brain, adrenal glands, and endothelium.
 Functionally active forms
o C-terminal fragments of a larger prohormone
o Both N- and C-terminal fragments are detectable in the
blood (referred to a N- terminal pro-BNP and pro-ANF,
respectively)
 Biologic Properties
o Diuretic
SURG – [03] Systemic and Inflammatory Respose to Injury
o Natriuretic
o Vasorelaxant
o Cardiac remodeling properties that are effected by
signaling through a common receptor: the guanylyl
cyclase-A (GC-A) receptor
 Both are increased in the setting of cardiac disorders.
VII. CELL MEDIATED IMMUNE RESPONSE
 An immune response that does not involve antibodies
 Involves the activation of phagocytes, antigen-specific
cytotoxic T-lymphocytes, and release of cytokines in response
to an antigen
 Role: Detect and eliminate cells that harbor intracellular
pathogens
 Antigen-specific cells
o CD8+ cytotoxic T lymphocytes (CTLs)
o Cytokine-secreting CD4+ TH (T helper cells)
I. Steps
I. Na ve T lymphocytes recognize MHC-associated peptide
antigens displayed on dendritic cells.
II. The T cells are activated to proliferate and to differentiate into
effector and memory cells, which migrate to the site of
infection.
III. CD4+ effector T cells of the TH1 subset recognize the antigens
of microbes ingested by phagocytes, and activate the
phagocytes to kill the microbes. Other subsets of effector cells
enhance leukocyte recruitment and stimulate different
immune responses.
CD8+ cytotoxic T lymphocytes (CTLs) kill infected cells harboring
microbes in the cytoplasm. Some T cells remain in the lymphoid
organs and help B cells to produce antibodies and some will
differentiate into memory cells
VIII. CELL OF THE IMMUNE SYSTEM
 2 Specialized Types of Stem Cells
o Lymphoid progenitor: gives rise to the T and B
lymphocytes.
 T lymphocytes (T for thymus, where they mature)
 B lymphocytes (B for bone marrow, where they originate)
 Natural killer (NK) cells
o Myeloid progenitor: gives rise to different types of
leukocytes, erythrocytes and megakaryocytes.
Figure 8. Cells of the immune system
A. Platelets
 Play a role in both local and systemic inflammatory responses,
particularly following ischemia reperfusion.
 Express functional scavenger and TLRs that are important
detectors of both pathogens and “damage”- associated
molecules.
 At the site of tissue injury, complex interactions between
platelets, endothelial cells, and circulating leukocytes facilitate
8
 cellular activation by the numerous local alarmins and immune
mediators.
B. Dendritic Cells
 Activated in response to damage signals, to stimulate both
the innate and the adaptive immune responses.
 Specialized antigen-presenting cells (APCs).
 “Professional APCs”: Principal function of capturing,
processing, and presenting both endogenous and exogenous
antigens, which, along with their co- stimulatory molecules,
are capable of inducing a primary immune response in resting
na ve T lymphocytes.
 Have the capacity to further regulate the immune response,
both positively and negatively, through the upregulation and
release of immunomodulatory molecules such as the
chemokine CCL5 and the CXC chemokine CXCL5.
 Have been implicated both in the induction and maintenance
of immune tolerance as well as in the acquisition of immune
memory.
C. Eosinophils
 Immunocytes whose primary functions are antihelminthic
 Found mostly in tissues such as the lung and gastrointestinal
tract, which may suggest a role in immune surveillance
 Can be activated by IL-3, IL-5, GM-CSF, chemoattractants, and
platelet-activating factor
 Activation can lead to subsequent release of toxic mediators,
including ROSs, histamine, and peroxidase
D. Mast Cells
 Important in the primary response to injury because they are
located in tissues.
 TNF release from mast cells has been found to be crucial for
neutrophil recruitment and pathogen clearance.
 With a role in the anaphylactic response to allergens.
 On activation from stimuli including allergen binding, infection,
and trauma, mast cells produce histamine, cytokines,
eicosanoids, proteases, and chemokines, which leads to:
o Vasodilation
o Capillary Leakage
o Immunocyte Recruitment
 Important co-signaling effector cells of the immune system via
the release of IL-3, IL-4, IL-5, IL-6, IL-10, IL-13, and IL-14, as well
as macrophage migration– inhibiting factor
E. Monocytes/ Macrophages
 Mononuclear phagocytes that circulate in the bloodstream
and can differentiate into macrophages, osteoclasts, and DCs
on migrating into tissues.
 Macrophages: main effector cells of the immune response to
infection and injury, primarily through mechanisms that
include phagocytosis of microbial pathogens, release of
inflammatory mediators, and clearance of apoptotic cells.
 Fulfill homeostatic roles beyond host defense
o Remodeling of tissues, both during development and in
the adult animal
 In response to various signals, macrophages may undergo:
o Classical M1 activation (stimulated by TLR ligands and IFN-γ).
 M1 phenotype: Characterized by the expression of high
levels of proinflammatory cytokines, like TNF-α, IL-1,
and IL-6, in addition to the synthesis of ROS and RNS;
promote a strong Th1 response
o Alternative M2 activation (stimulated by type II cytokines IL-
4/IL-13).
 M2 phenotype: Considered to be involved in the
promotion of wound repair and the restoration of
immune homeostasis through their expression of
SURG – [03] Systemic and Inflammatory Respose to Injury
arginase-1 and IL-10, in addition to a variety of PRRs
(e.g., scavenging molecules).
F. Neutrophils
 First responders to sites of infection and injury
 Potent mediators of acute inflammation
 Chemotactic mediators from a site of injury induce neutrophil
adherence to the vascular endothelium and promote eventual
cell migration into the injured tissue.
 Once primed and activated by inflammatory stimuli, including
TNF, IL-1, and microbial pathogens, neutrophils are able to
enlist a variety of killing mechanisms to manage invading
pathogens.
 Phagocytosed bacteria are killed using NADPH oxygenase-
dependent generation of ROS or by releasing lytic enzymes
and antibacterial proteins into the phagosome.
 When highly activated, neutrophils can also extrude a
meshwork of chromatin fibers, composed of DNA and
histones that are decorated with granule contents.
 Neutrophil extracellular traps (NETs): Effective mechanism
whereby neutrophils can immobilize bacteria to facilitate their
killing; may also serve to prime T cells, making their threshold
for activation lower.
 Neutrophils facilitate the recruitment of monocytes into
inflamed tissues. These recruited cells are capable of
phagocytosing apoptotic neutrophils to contribute to
resolution of the inflammatory response.
IX. LEUKOCYTE-ENDOTHELIUM INTERACTION
 Process: Leukocytes first roll → become activated and adhere
to the endothelium → transmigrate across the endothelium
and pierce the basement membrane → migrate toward chemo
attractants emanating from the source of injury
 Molecules used in the process
o Selectins: Rolling
o Chemokines: Activation of neutrophils to increase avidity
of integrins
o Integrins: Firm adhesion
o CD31 (PECAM-1): Transmigration/Diapedesis
Figure 8. Leukocyte Edothelium Interaction
X. REFERENCES
 Naregta 2022 Trans
 Brunicardi, F.C. (2019). Schwartz’ Principles of Surgery (11th ed).
USA: McGraw-Hill.
9