Recombinant activated protein C attenuates coagulopathy and inflammation when administered early in murine pneumococcal pneumonia

Summary

Recombinant human activated protein C (APC), which has both anticoagulant and anti-inflammatory properties, improves survival of patients with severe sepsis. This beneficial effect is especially apparent in patients with pneumococcal pneumonia. Earlier treatment with APC in sepsis has been associated with a better therapeutic response as compared to later treatment. In a mouse model it was recently confirmed that recombinant murine (rm-)APC decreases coagulation activation and improves survival in pneumococcal pneumonia; however, APC did not impact on the inflammatory response. The aim of this study was to determine the effect of APC treatment instigated early in infection on activation of coagulation and inflammation after induction of pneumococcal pneumonia. Mice were infected intranasally with viable S. pneumoniae. Mice were treated with rm-APC (125 μg) or vehicle intraperitoneally 12 hours after infection and were sacrificed after 20 hours, after which blood and organs were harvested for determination of bacterial outgrowth, coagulation activation and inflammatory markers. In this early treatment model, rm-APC treatment inhibited pulmonary and systemic activation of coagulation as reflected by lower levels of throm-bin-antithrombin complexes and D-dimer. Moreover, rm-APC reduced the levels of a large number of cytokines and chemokines in the lung. When administered early in pneumococcal pneumonia, rm-APC inhibits systemic and pulmonary activation of coagulation and moreover exerts various anti-inflammatory effects in the lung.

Keywords

Protein C/S pathway - infectious diseases - bacteria - sepsis - animal models

• References

• 1 Laterre PF, Garber G, Levy H. et al. Severe community-acquired pneumonia as a cause of severe sepsis: Data from the PROWESS study. Crit Care Med 2005; 33: 952-961.
• 2 Bartlett JG, Dowell SF, Mandell LA. et al. Practice guidelines for the management of community-acquired pneumonia in adults. Infectious Diseases Society of America. Clin Infect Dis 2000; 31: 347-382.
• 3 Feldman C. Clinical relevance of antimicrobial resistance in the management of pneumococcal community-acquired pneumonia. J Lab Clin Med 2004; 143: 269-283.
• 4 Schouten M, Wiersinga WJ, Levi M. et al. Inflammation, endothelium, and coagulation in sepsis. J Leukoc Biol 2008; 83: 536-545.
• 5 Schultz MJ, Millo J, Levi M. et al. Local activation of coagulation and inhibition of fibrinolysis in the lung during ventilator associated pneumonia. Thorax 2004; 59: 130-135.
• 6 Rijneveld AW, Weijer S, Bresser P. et al. Local activation of the tissue factor-factor VIIa pathway in patients with pneumonia and the effect of inhibition of this pathway in murine pneumococcal pneumonia. Crit Care Med 2006; 34: 1725-1730.
• 7 Choi G, Schultz MJ, Levi M. et al. Protein C in pneumonia. Thorax 2005; 60: 705-706.
• 8 Choi G, Hofstra JJ, Roelofs JJ. et al. Recombinant human activated protein C inhibits local and systemic activation of coagulation without influencing inflammation during Pseudomonas aeruginosa pneumonia in rats. Crit Care Med 2007; 35: 1362-1368.
• 9 Rijneveld AW, Florquin S, Bresser P. et al. Plasminogen activator inhibitor type-1 deficiency does not influence the outcome of murine pneumococcal pneumonia. Blood 2003; 102: 934-939.
• 10 Mosnier LO, Zlokovic BV, Griffin JH. et al. The cytoprotective protein C pathway. Blood 2007; 109: 3161-3172.
• 11 Macias WL, Nelson DR. Severe protein C deficiency predicts early death in severe sepsis. Crit Care Med 2004; 32: S223-228. Suppl
• 12 Vail GM, Xie YJ, Haney DJ. et al. Biomarkers of Thrombosis, Fibrinolysis, and Inflammation in Patients with Severe Sepsis due to Community-Acquired Pneumonia with and without Streptococcus pneumoniae. Infection 2009; 37: 358-364.
• 13 Bernard GR, Vincent JL, Laterre PF. et al. Efficacy and safety of recombinant human activated protein C for severe sepsis. N Engl J Med 2001; 344: 699-709.
• 14 Schouten M, van't Veer C, van den Boogaard FE. et al. Therapeutic recombinant murine activated protein C attenuates pulmonary coagulopathy and improves survival in murine pneumococcal pneumonia. J Infect Dis 2010; 202: 1600-1607.
• 15 Rivers E, Nguyen B, Havstad S. et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001; 345: 1368-1377.
• 16 Vincent JL, Bernard GR, Beale R. et al. Drotrecogin alfa (activated) treatment in severe sepsis from the global open-label trial ENHANCE: further evidence for survival and safety and implications for early treatment. Crit Care Med 2005; 33: 2266-2277.
• 17 Vincent JL, O’Brien Jr J, Wheeler A. et al. Use of an integrated clinical trial database to evaluate the effect of timing of drotrecogin alfa (activated) treatment in severe sepsis. Crit Care 2006; 10: R74
• 18 Schouten M, van 't Veer C, Roelofs JJ. et al. Impact of the factor V Leiden mutation on the outcome of pneumococcal pneumonia: a controlled laboratory study. Crit Care 2010; 14: R145
• 19 Berg DT, Gerlitz B, Shang J. et al. Engineering the proteolytic specificity of activated protein C improves its pharmacological properties. Proc Natl Acad Sci USA 2003; 100: 4423-4428.
• 20 Verheijen JH, Wijngaards G, Kluft C. et al. A Sensitive Spectrophotometric Assay for Extrinsic (Tissue-Type) Plasminogen-Activator - Its Application for Measurements in Plasma. Haemostasis 1982; 12: 62
• 21 Verheijen JH, Chang GT, Kluft C. Evidence for the Occurrence of A Fast-Acting Inhibitor for Tissue-Type Plasminogen-Activator in Human-Plasma. Thromb Haemost 1984; 51: 392-395.
• 22 Rijneveld AW, Levi M, Florquin S. et al. Urokinase receptor is necessary for adequate host defense against pneumococcal pneumonia. J Immunol 2002; 168: 3507-3511.
• 23 Knapp S, Wieland CW, Florquin S. et al. Differential roles of CD14 and Toll-like receptors 4 and 2 in murine Acinetobacter pneumonia. Am J Respir Crit Care Med 2006; 173: 122-129.
• 24 Bajzar L, Nesheim ME, Tracy PB. The profibrinolytic effect of activated protein C in clots formed from plasma is TAFI-dependent. Blood 1996; 88: 2093-2100.
• 25 Taylor FB, Lockhart MS. Whole-Blood Clot Lysis - Invitro Modulation by Activated Protein-C. Thromb Res 1985; 37: 639-649.
• 26 Suzuki K, Gabazza EC, Hayashi T. et al. Protective role of activated protein C in lung and airway remodeling. Crit Care Med 2004; 32: S262-265. Suppl
• 27 Choi G, Hofstra JJ, Roelofs JJ. et al. Antithrombin inhibits bronchoalveolar activation of coagulation and limits lung injury during Streptococcus pneumoniae pneumonia in rats. Crit Care Med 2008; 36: 204-210.
• 28 Van der Poll T, Levi M, Nick JA. et al. Activated protein C inhibits local coagulation after intrapulmonary delivery of endotoxin in humans. Am J Respir Crit Care Med 2005; 171: 1125-1128.
• 29 Schouten M, van der Sluijs KF, Gerlitz B. et al. Activated protein C ameliorates coagulopathy but does not influence outcome in lethal H1N1 influenza: a controlled laboratory study. Crit Care 2010; 14: R65
• 30 Macias WL, Dhainaut JF, Yan SCB. et al. Pharmacokinetic-pharmacodynamic analysis of drotrecogin alfa (activated) in patients with severe sepsis. Clin Pharmacol Ther 2002; 72: 391-402.
• 31 Kerschen EJ, Fernandez JA, Cooley BC. et al. Endotoxemia and sepsis mortality reduction by non-anticoagulant activated protein C. J Exp Med 2007; 204: 2439-2448.
• 32 Mosnier LO, Zampolli A, Kerschen EJ. et al. Hyper-antithrombotic, non-cytoprotective Glu149Ala-activated protein C mutant. Blood 2009; 113: 5970-5978.
• 33 Gupta A, Gerlitz B, Richardson MA. et al. Distinct Functions of Activated Protein C Differentially Attenuate Acute Kidney Injury. J Am Soc Nephrol 2009; 20: 267-277.
• 34 Jian MY, Koizumi T, Tsushima K. et al. Activated protein C attenuates acid-aspiration lung injury in rats. Pulm Pharmacol Ther 2005; 18: 291-296.
• 35 Tanaka A, Minoguchi K, Chen XY. et al. Activated protein C attenuates leukocyte elastase-induced lung injury in mice. Shock 2008; 30: 153-158.
• 36 Richardson MA, Gupta A, O'Brien LA. et al. Treatment of Sepsis-Induced Acquired Protein C Deficiency Reverses ACE-2 Inhibition and Decreases Pulmonary Inflammatory Response. J Pharmacol Exp Ther 2008; 325: 17-26.
• 37 Slofstra SH, Groot AP, Maris NA. et al. Inhalation of activated protein C inhibits endotoxin-induced pulmonary inflammation in mice independent of neutrophil recruitment. Br J Pharmacol 2006; 149: 740-746.
• 38 Franscini N, Bachli EB, Blau N. et al. Gene expression profiling of inflamed human endothelial cells and influence of activated protein C. Circulation 2004; 110: 2903-2909.
• 39 Joyce DE, Gelbert L, Ciaccia A. et al. Gene expression profile of antithrombotic protein c defines new mechanisms modulating inflammation and apoptosis. J Biol Chem 2001; 276: 11199-11203.
• 40 Riewald M, Petrovan RJ, Donner A. et al. Activation of endothelial cell protease activated receptor 1 by the protein C pathway. Science 2002; 296: 1880-1882.
• 41 Yuda H, Adachi Y, Taguchi O. et al. Activated protein C inhibits bronchial hyperresponsiveness and Th2 cytokine expression in mice. Blood 2004; 103: 2196-2204.
• 42 Robriquet L, Collet F, Tournoys A. et al. Intravenous administration of activated protein C in Pseudomonas-induced lung injury in the rat: impact on the lung fluid balance and the inflammatory response. Respir Res 2006; 7: 41