Role of cytokines as inflammatory mediators, endocrine & immune response to injury

Dr. Amitabha Das PGT Dept. of General Surgery

Introduction

Inflammation is a complex reaction to any injury seen in vascularized connective tissue.

Surgical insult invokes inflammation. Its a double edged sword, can do both healing and auto destruction.

Inflammation
An extremely complex process Involves numerous factors and cell types Manifested by1. color 2. rubor 3. dolor 4. tumor 5. functio laesa

Mediators of inflammation

Chemical mediators: Endogenous- pro & anti-inflammatory. Exogenous.

Cells Neural factors Hormonal factors

Cytokines
Most important endogenous mediators. Acts by paracrine, autocrine and endocrine fashion. Shows pleotropism and redundancy. Structurally 2 types: I (eg, IL-2,3) & II (eg, IFN & IL-10). Funtionally 2 types: TH1 or pro-inflammatory (eg, IFN)and TH2 or anti-inflammatory (eg, IL-4).

Interferons
Key component of innate immunity. 3 types- alpha (a), beta (b), gamma (y). Gamma subtype is pro-inflammatory. Gamma is produced by CD4+TH1, CD8+TH1 & NK cells. IL12 & 18 stimulate production. Acts via JAK-STAT pathway.

Funtions of IFN
Major role in innate immunity. Stimulates macrophages/ monocytes. Induces release of other cytokines. Promotes differentiation of CD4+ T cells to TH1 phenotypes. Inhibits differentiation to TH2 cells.

Tumour necrosis factor

Most important pro-inflammatory mediator. Also called cachectin or TNF-a. Belongs to a large family of related group of ligands- LT-a or TNF-b, FAS-L,CD40L, RANKL & TRAIL. Most of these ligands involved in cell proliferation and apoptosis except TNF-a. Secreted by monocyte/ macrophages, T & B cells, mast cells etc.

List of Stimuli Known to Initiate Release of Tumor Necrosis Factor

Endogenous factors: Cytokines (TNF-, IL-1, IFN-, GM-CSF, IL-2), Platelet-activating factor, Myelin P2 protein, HMGB1, HSP70, HSP60 .
MicrobeDerivedFactors: Lipopolysaccharide, Zymosan, Peptidoglycan, Streptococcal pyrogenic exotoxin A, Streptolysin O, Lipoteichoic acid, Staphylococcal enterotoxin B, Staphylococcal toxic shock syndrome toxin1, Lipoarabinomannan, Bacterial DNA, Flagellin.

Tumour necrosis factor

Activates coagulation cascade along with IL-1. Acts by activation of NF-kB. Acts on 2 types of receptors-TNFR1&2. Extracellular part of TNFR shed into circulation and forms soluble TNFR. Gluco corticoids, pentoxifylline inhibit TNF. Infliximab a monoclonal antibody to TNF Etanercept, a TNF receptor blocker.

Interleukin-1
Family of 3 protiens: IL-1a, IL-1b and IL-1 receptor antagonist. Production triggered by: LPS, TNF, GM-CSF, IL-1& other cytokines. Synthesized in monocyte/ macrophages, neutrophils, endothelium, lymphocytes etc. Acts on 2 types of receptors IL-1RI & II. IL-1RII, IL-1RA and soluble IL-1R are anti inflammatory.

Physiologic effects of IL-1 & TNF

Fever Headache Anorexia Increased plasma adrenocorticotropic hormone Hypercortisolemia Increased plasma nitrite/nitrate levels Systemic arterial hypotension Neutrophilia & transient neutropenia Increased plasma acute phase protein Hypoferremia & hypozincemia Increased plasma level of IL-1RA, TNF-R1& 2, IL-6,8 Activation of coagulation cascades Increased platelet count Pulmonary edema Hepatocellular injury

Chemokines
These are cytokines involved into chemotaxis. Mainly produced by macrophage and endothelial cells. Structurally divided into 4 types: CXC or a- chemokines(IL-8) CC or b- chemokines (MCP1) C CX3C

Anti-inflammatory cytokines
These are IL-4, 10 & 13. Produced by TH2 cells Down regulates pro-inflammatory cytokines & cell mediated immunity. Promotes anti-inflammatory agents like- IL1RA, IL-1RII, 15- lipoxygenase. Induces humoral immunity and class II MHC molecules on b cells.

Other cytokines
IL-6 acts both as pro & anti-inflammatory mediator. It is a primary mediator of hepatic synthesis of acute phase reactants. IL-11 is a potent growth factor for thrombopoiesis. IL-12 & 18 are important stimulators of IFN production.

Arachidonic acid metabolites

Funtions of AA metabolites
PGI-2 causes vasodilatation and inhibits platelet aggregation. TXA-2 causes vasoconstriction and platelet aggregation. PGD2,E2,F2a are involved in development of edema & vasodilatation. LTs cause vasoconstriction, bronchoconstriction & increased capillary permeability.

Other mediators
High mobility group B1 Platelet activating factor Nitric oxide: it enhances vasodilatation, edema formation & inhibits myocardial inotropy. Vasoactive amines: Histamine & serotonincauses vasodilatation & increased permeability.

Contd
Plasma proteases: a. complement system-C3a, C5a, C567 complex. b. coagulation system- factor IIa, Xa, XIIa. c. kinin system- bradykinin. Lysosomal products Neuropeptides

Exogenous mediators
LPS: 3 subunits, stable lipid A, variable oligosaccharide & side chain. Interacts via TLR4 & CD14. Causes profound activation of IL-1 & TNF. Circulates in plasma with LBP. Lipoteichoic acid Lipo-arabinomannan zymosan

Cellular mediators
Neutrophils: kill invading pathogens by oxidative and non-oxidative pathways following phagocytosis. Major cell responsible for end organ damage in SIRS. Monocyte/ Macrophage: professional phagocytes and antigen presenting cells. Endothelial cells: respond to adverse environmental stimuli by releasing cytokines, adhesion molecules & reactive oxygen species.

Neurological mediators
CNS regulates inflammation via autonomic signaling. Afferent signal reaches brain via both circulation and neural pathways. Hypothalamus is primary regulating site of inflammation

Hormonal mediators

Plays an important role ACTH: loss of circadian rhythm seen during injury. Insulin: injury decreases insulin release & produces insulin resistance. Catecholamines: major hormones regulating hypermetabolic state following inury & prevents leukocyte margination. Growth hormone & insulin like growth factors. Aldosterone

Glucocorticoids
Known for its anti-inflammatory effects. Supresses the pro-inflammatory cytokines like TNF, reduces T-cell, NK- cell & neutrophil functions and suppresses chemotaxis and phagocytosis by mononuclear cells. Produces hyperglycemia & insulin resistance. Macrophage inhibitory factor is an endogenous antagonist of glucocorticoids.

Clinical aspects

Inflammation Healing Destruction

Several diseases arise due to unregulated progression of inflammation. eg, inflammatory bowel disease.

SIRS

Most dreaded complication of inflammation in surgical patients. Diagnosed by:

Manifestation of 2 or more of these: temp.>38 or <36 heart rate > 90 resp rate > 20 or PaCO2 < 32 mmhg WBC >12000 or < 4000 with 10% immature cells

Sepsis, a form of SIRS with documented source of infection, associated with very high morbidity and mortality.

Future prospects
Newer anti-inflammatory agents are being prepared and undergoing studies. These will play pivotal role in sepsis management. They are: monoclonal antibodies novel antagonists recombinant anti-inflammatory cytokines.

Summary

Inflammation is a protective response to injury seen in vertebrates. Mediated by numerous cell types and substances in complex way. While it promotes healing, imbalance between its mediators can be devastating.

Conclusion

While all individuals respond to injury by producing inflammation the ultimate outcome varies in different individuals.