The impact of the PAI-1 4G/5G polymorphism on the outcome of patients with ALI/ARDS

doi:10.1016/j.thromres.2008.07.018

Thrombosis Research

Volume 123, Issue 6, April 2009, Pages 832-836

https://doi.org/10.1016/j.thromres.2008.07.018 Get rights and content

Abstract

Intoduction

Increased levels of plasminogen activator inhibitor-1 (PAI-1) have been associated with worse outcome in ALI/ARDS. A single guanosine insertion/deletion (4G/5G) polymorphism in the promoter region of the PAI-1 gene, may play an important role in the regulation of PAI-1 expression. The objective of the study was to evaluate the effect of this polymorphism on the outcome of critically ill patients with ALI/ARDS.

Materials and Methods

52 consecutive ventilated patients with ALI/ARDS were studied. Bronchoalveolar lavage was performed within 48 hours from diagnosis. Measurement of plasma and BALF PAI-1 activity and D-dimers levels, and 4G/5G genotyping of PAI-1 were carried out. The primary outcome was 28-day mortality, and secondary outcomes included organ dysfunction and ventilator-free days.

Results

17 patients were homozygotes for the 4G allele. Severity scores were not different between subgroups upon study enrollment. 28-day mortality was 70.6% and 42.9% for the 4G-4G and the non-4G-4G patients, respectively (p = 0.06). PAI-1 activity levels and D-dimer in plasma and BALF were not significantly different between the 4G-4G and the non-4G-4G subgroups. In the multivariate analysis, genotype 4G/4G was the only variable independently associated with 28-day mortality (Odds Ratio = 9.95, 95% CI: 1.79-55.28, p = 0.009). Furthermore, genotype 4G/4G and plasma PAI-1 activity levels were independently negatively associated with ventilator free days (p = 0.033 and p = 0.008, respectively).

Conclusions

ALI/ARDS patients, homozygous for the 4G allele of the PAI-1 gene, experienced higher 28-day mortality. This genotype was associated with a reduction in the number of days of unassisted ventilation and was inversely associated with the number of days without organ failure.

Introduction

Acute lung injury (ALI) and its more severe form, the acute respiratory distress syndrome (ARDS), are life threatening disorders characterized by severe inflammation in the lungs and high incidence of multiple organ failure [1]. They are a consequence of direct (pneumonia, aspiration) or indirect (sepsis, trauma) injury to the lung.

Coagulation and inflammation are interconnected responses to tissue injury in several disease states, including ALI [2]. Activation of the coagulation cascade can lead to inflammatory events [3], while there is clear evidence that inflammation and inflammatory mediators activate coagulation [4]. Sepsis, trauma and aspiration, usual risk factors for ALI, are potent stimuli for both inflammation and coagulation. Coagulation abnormalities have frequently been demonstrated in the early phase of the syndrome, while fibrin deposition is the hallmark of the late stage of ARDS [5], [6]. The disturbance in the alveolar homeostasis has been attributed both to enhanced procoagulant and decreased alveolar fibrinolytic activities [7]. Increased expression of plasminogen activator inhibitor-1 (PAI-1) seems to contribute to the fibrinolytic defect that occurs in the alveolar compartment during evolving ARDS [6], [8]. PAI-1 is increased in ALI/ARDS [9], [10], and alveolar PAI-1 levels have also been found to be a prognostic marker for development of ARDS [11] and associated with higher mortality rates in patients with ALI/ARDS [12], [13]. Although most studies have shown increased alveolar PAI-1 antigen levels in ALI/ARDS patients [6], [12], [14], undetectable or inconsistent with the underlying pathology PAI-1 levels have also been reported [8]. Moreover, abnormalities in fibrin turnover were not restricted to the lungs, and plasma levels of PAI-1 were quite high in patients with ALI/ARDS, identifying those with a poor prognosis [12], [13], although this was not a consistent finding [14].

The differential rise of alveolar PAI-1 antigen levels among ALI/ARDS patients and the variable influence of systemic PAI-1 levels on the outcome of such patients raise the question about the existence of any genetic predisposition for overexpressing PAI-1 following acute insult to the lung. A guanosine insertion/deletion polymorphism in the promoter region of the PAI-1 gene at the -675 bp position, called 4G/5G, has been described [15]. The 4G allele has been linked with moderately higher plasma PAI-1 levels [16], [17]. However, the nature of this polymorphism can be more accurately described as response polymorphism, since PAI-1 is considered a strong acute-phase reactant [18]. Alterations in the levels of PAI-1 have been associated with worse clinical outcomes in patients with ALI in most studies, but it is not clear whether there is any genetic predisposition for overexpressing PAI-1 following acute insult to the lung. This is the first study to evaluate simultaneously the effect of the 4G/5G polymorphism and its gene product in both plasma and bronchoalveolar lavage fluid (BALF), on the clinical outcome of patients with ALI/ARDS.

Section snippets

Methods

The study population consisted of 52 consecutive patients with ALI/ARDS, treated in the general ICU of the “Attikon” University Hospital of Athens during an 18-month period (June 2006 - December 2007). The study was performed in accordance with the Declaration of Helsinki and was approved by the hospital's institutional review board. Informed consent was obtained from the patient's next of kin.

All patients were enrolled within 48 hours of recognition of ALI/ARDS. Diagnosis of ALI and ARDS was

Patients characteristics

Baseline demographic and clinical characteristics for the 52 ALI/ARDS patients classified by PAI-1 genotype are summarized in Table 1. The two groups (4G/4G and non 4G/4G) did not differ in terms of age, gender and severity of illness as well as in terms of plasma and BALF PAI-1 activity levels. There was no difference in the relative proportion of ALI and ARDS between 4G/4G and non 4G/4G patients (ARDS accounting for 11/17, and 22/35 in 4G/4G and non 4G/4G group respectively, p = 0.90). The

Discussion

The contribution of coagulation and fibrinolysis alterations in ALI/ARDS pathogenesis and prognosis remains an open issue. Several studies have demonstrated increased levels of PAI-1 in BALF and plasma obtained from patients with ALI/ARDS and a significant association with worse clinical outcomes has been reported [6], [12], [13]. However, in these studies the 4G/5G polymorphism in the promoter of the PAI-1 gene was not determined.

The circulating plasma PAI-1 level seems to be affected by this

Conflict of interest statement

None.

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Suppression of plasminogen activator inhibitor-1 by inhaled nitric oxide attenuates the adverse effects of hyperoxia in a rat model of acute lung injury
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Citation Excerpt :
A single guanosine insertion/deletion (4G/5G) polymorphism in the promoter region of the PAI-1 gene may play an important role in the regulation of PAI-1 expression. ALI/ARDS patients homozygous for the 4G allele of the PAI-1 gene experience increased 28-day mortality [10]. Accordingly, PAI-1 inhibitors may be used as a new therapeutic intervention for ALI.
Locally increased expression of plasminogen activator inhibitor-1 (PAI-1) in acute lung injury (ALI) is largely responsible for fibrin deposition in the alveolae and lung microvasculature. In vitro, nitric oxide (NO) effectively suppresses the ischemic induction of PAI-1. We aimed to investigate the effects of inhaled NO on PAI-1 expression in ALI in a rat model with and without hyperoxia.
Healthy adult rats were primed with lipopolysaccharide (LPS) via an intraperitoneal challenge followed by a second dose of LPS given intratracheally to induce ALI (LPS group), whereas the control groups were given sterile saline. All groups were allocated to subgroups according to gas exposure: NO (20 parts per million, NO), 95% oxygen (O), both (ONO), or room air (A). At 4 h, 24 h, 48 h (after 4 h or 24 h exposure to the various gases, 24 h gas intervention and then observation until 48 h), the rat lungs were processed and PAI-1 protein and mRNA expression, histopathological lung injury scores and fibrin deposition were evaluated.
At 4 and 24 h, inhaled NO caused the PAI-1 mRNA levels in the LPS-NO and LPS-ONO subgroups to decrease compared with the untreated LPS subgroups. At 48 h, higher PAI-1 mRNA levels than those of the corresponding control subgroup were only observed in the LPS-O subgroup, and these values were lower in the LPS-ONO subgroup than in the LPS-O subgroup. The trends of the PAI-1 protein levels mirrored those of PAI-1 mRNA. At 48 h, PAI-1 protein levels in the LPS-NO and LPS-ONO subgroups were decreased compared with those in the untreated LPS subgroups. The histopathological lung injury scores and fibrin deposition in LPS subgroups that inhaled NO showed a decreasing trend compared with the untreated LPS subgroups.
Inhaled NO can suppress elevated PAI-1 expression in rats with ALI induced by endotoxin. Although exposure to high-concentration oxygen prolongs the duration of PAI-1 mRNA overexpression in ALI, inhaled NO can reduce this effect and alleviate both fibrin deposition and lung injury.
Future clinical applications of genomics for acute respiratory distress syndrome
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Citation Excerpt :
Novel prognostic markers might generate new knowledge about the mechanism underlying lung injury or repair, advancing the pathophysiological understanding of ARDS. Several genetic variants are associated with increased mortality among ARDS populations (panel).35–52,60,64,73,74 The best-replicated associations with ARDS mortality seem to involve genes with a potential role in endothelial function, including SERPINE1, VEGFA, and ACE.
Acute respiratory distress syndrome remains a substantial cause of morbidity and mortality in intensive care units, yet no specific pharmacotherapy has proven useful in reducing the duration of mechanical ventilation or improving survival. One factor that might hamper the development of treatment for acute respiratory distress syndrome is the heterogeneous nature of the population who present with the syndrome. In this Review, the potential of genomic approaches—genetic association, gene expression, metabolomic, proteomic, and systems biology applications—for the identification of molecular endotypes within acute respiratory distress syndrome and potentially for the prediction, diagnosis, prognosis, and treatment of this difficult disorder are discussed.
Critical role of type 1 plasminogen activator inhibitor (PAI-1) in early host defense against nontypeable Haemophilus influenzae (NTHi) infection
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Besides its original/classical role in homeostasis, pleiotropic functions of PAI-1 in biological processes such as wound healing, tumor angiogenesis, bone remodeling, asthma, rheumatoid arthritis, fibrosis, sepsis, and ALI have been reported [10–14]. Clinical reports showed that PAI-1 expression is upregulated in lung tissues of ALI patients, and higher PAI-1 level in these patients is closely associated with poor outcomes in clinic [29,30]. However, growing body of studies reported protective role of PAI-1 in respiratory infections with bacterial pathogens including K. pneumoniae, P. aeruginosa, and S. pneumoniae [15,25,26].
Respiratory systems are constantly being challenged by pathogens. Lung epithelial cells serve as a first line of defense against microbial pathogens by detecting pathogen-associated molecular patterns (PAMPs) and activating downstream signaling pathways, leading to a plethora of biological responses required for shaping both the innate and adaptive arms of the immune response. Acute-phase proteins (APPs), such as type 1 plasminogen activator inhibitor (PAI-1), play important roles in immune/inflammatory responses. PAI-1, a key regulator for fibrinolysis and coagulation, acts as an APP during acute phase response (APR) such as acute lung injury (ALI), inflammation, and sepsis. However, the role of PAI-1 in the pathogenesis of these diseases still remains unclear, especially in bacterial pneumonia. In this study, we showed that PAI-1 expression is upregulated following nontypeable Haemophilus influenzae (NTHi) infection. PAI-1 knockout (KO) mice failed to generate early immune responses against NTHi. Failure of generating early immune responses in PAI-1 KO mice resulted in reduced bacterial clearance and prolonged disease process, which in turn led to enhanced inflammation at late stage of infection. Moreover, we also found that NTHi induces PAI-1 via activation of TLR2–MyD88–MKK3–p38 MAPK signaling pathway. These data suggest that PAI-1 plays critical role in earl host defense response against NTHi infection. Our study thus reveals a novel role of PAI-1 in infection caused by NTHi, one of the most common gram-negative bacterial pathogens in respiratory systems.
Acute lung injury and acute respiratory distress syndrome: A genomic perspective
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Recientemente la genómica ha adquirido una enorme relevancia, permitiendo sustanciales avances en el conocimiento de la etiología y patogenia de entidades complejas como la lesión pulmonar aguda (LPA) y el síndrome de distrés respiratorio agudo (SDRA).
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Uno de los principales desafíos que la comunidad científica debe afrontar es lograr que este conocimiento sea transferido pertinente y rápidamente a la práctica clínica. En caso contrario, es posible que los pacientes sean sometidos a un riesgo innecesario.
En el presente artículo se describen los principales aspectos de la medicina genómica en la LPA/SDRA y cuáles son las aplicaciones clínicas actuales.
Genomics have allowed important advances in the knowledge of the etiology and pathogenesis of complex disease entities such as acute lung injury (ALI) and acute respiratory distress syndrome (ARDS).
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The scientific community must cope with the important challenge of securing rapid transfer of knowledge to clinical practice, in order to prevent patients from becoming exposed to unnecessary risks.
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Citation Excerpt :
Studies on the genetic basis of ALI/ARDS and VILI generally have focused on a few putative mechanistic functions in lung injury and/or inflammation11,30 (Fig 1). This has identified several well-defined candidate genes such as angiotensin converting enzyme (ACE),31,32 extracellular superoxide dismutase (SOD3),33,34 surfactant protein B,35,36 interleukin (IL) 10,37-39 vascular endothelial growth factor (VEGF),40-42 plasminogen activator inhibitor 1 (PAI-1),43 thrombospondin 1 (THBS1),44 transforming growth factor (TGF-β),45 macrophage migration inhibitory factor,46 IL-6,47,48 LPS binding protein,49 myosin light chain kinase,50-53 pre-B-cell colony enhancing factor (PBEF),54,55 and growth arrest and DNA-damage-inducible, alpha.56 The allele frequencies of genetic variants such as those in the form of single nucleotide polymorphisms (SNPs) in these candidate genes as well as their expression patterns were examined between cases and controls (Fig 1).
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¹: Both authors have equal contribution to this work.

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Regular ArticleThe impact of the PAI-1 4G/5G polymorphism on the outcome of patients with ALI/ARDS

Abstract

Intoduction

Materials and Methods

Results

Conclusions

Introduction

Section snippets

Methods

Patients characteristics

Discussion

Conflict of interest statement

J Biol Chem

J Biol Chem

Blood

Thromb Res

Lancet

Lancet

Atherosclerosis

Medical progress: The acute respiratory distress syndrome

N Engl J Med

Genetics of coagulation factors in acute lung injury

Crit Care Med

Thrombin signaling and protease-activated receptors

Nature

Modulation of endothelial cell hemostatic properties by tumor necrosis factor

J Exp Med

Alveolar fibrin formation caused by enhanced procoagulant and depressed fibrinolytic capacities in severe pneumonia. Comparison with the acute respiratory distress syndrome

Am J Respir Crit Care Med

Depressed bronchoalveolar urokinase activity in patients with adult respiratory distress syndrome

N Engl J Med

Procoagulant activity in bronchoalveolar lavage in the adult respiratory distress syndrome. Contribution of tissue factor associated with factor VII

Am Rev Respir Dis

Local abnormalities in coagulation and fibrinolytic pathways predispose to alveolar fibrin deposition in the adult respiratory distress syndrome

J Clin Invest

Endothelium and disordered fibrin turnover in the injured lung: newly recognized pathways

Crit Care Med

Alveolar plasminogen activator inhibitor-1 predicts ARDS in aspiration pneumonitis

Intensive Care Med

Elevated levels of plasminogen activator inhibitor-1 in pulmonary edema fluid are associated with mortality in acute lung injury

Am J Physiol Lung Cell Mol Physiol

Pathogenetic and prognostic significance of altered coagulation and fibrinolysis in acute lung injury/acute respiratory distress syndrome

Crit Care Med

Systemic coagulation and fibrinolysis in patients with or at risk for the adult respiratory distress syndrome

Thromb Haemost

Regular Article
The impact of the PAI-1 4G/5G polymorphism on the outcome of patients with ALI/ARDS