Injury, Int. J.

Care Injured (2007) 38, 13361345

www.elsevier.com/locate/injury

Systemic inammation after trauma

Andreas Lenz a,b, Glen A. Franklin a,b, William G. Cheadle a,b,*
a b

Veterans Affairs Medical Center, Louisville, USA Department of Surgery, University of Louisville, Louisville, KY 40292, USA

Accepted 1 October 2007

KEYWORDS
Multiple trauma; Injury; SIRS; Inammation; Immunology; Neuroendocrine; Cytokines; Alarmins

Summary Trauma is still one of the main reasons for death among the population worldwide. Mortality occurring early after injury is due to rst hits, including severe organ injury, hypoxia, hypovolaemia or head trauma. Massive injury leads to activation of the immune system and the early inammatory immune response after trauma has been dened as systemic inammatory response syndrome (SIRS). Second hits such as infections, ischaemia/reperfusion or operations can further augment the pro-inammatory immune response and have been correlated with the high morbidity and mortality in the latter times after trauma. SIRS can lead to tissue destruction in organs not originally affected by the initial trauma with subsequent development of multi-organ dysfunction (MOD). The initial pro-inammatory response is followed by an anti-inammatory response and can result in immune suppression with high risk of infection and sepsis. Trauma causes activation of nearly all components of the immune system. It activates the neuroendocrine system and local tissue destruction and accumulation of toxic byproducts of metabolic respiration leads to release of mediators. Extensive tissue injury may result in spillover of these mediators into the peripheral bloodstream to further maintain and augment the proinammatory response. Hormones like ACTH, corticosteroids and catecholamines as well as cytokines, chemokines and alarmins play important roles in the initiation and persistence of the pro-inammatory response after severe injury. The purpose of this review is therefore to describe the immunological events after trauma and to introduce important mediators and pathways of the inammatory immune response. # 2007 Elsevier Ltd. All rights reserved.

Introduction
Trauma is the main cause of death in the general public of the United States under the age of
* Corresponding author at: Department of Surgery, University of Louisville, Louisville, KY 40292, USA. Tel.: +1 502 852 1895. E-mail address: wg.cheadle@louisville.edu (W.G. Cheadle).

45.76,47,80 Mortality after major trauma has been divided into three separate time periods after injury. The rst peak of death after injury represents the immediate effects of trauma with death at the scene (5372%) or within the rst hour.76 These deaths are really only affected by prevention measures and are usually due to massive head injury or bleeding. This is followed by a second, smaller peak

00201383/$ see front matter # 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2007.10.003

Systemic inammation after trauma in the rst 24 h normally due to hypoxia, hypovolaemia or severe head trauma.62,7,2,23 Should the seriously injured patient survive over these rst two time peaks, there is a high risk of developing immunological dysfunction and subsequently sepsis or the systemic inammatory response syndrome (SIRS). This can lead to multi organ dysfunction syndrome (MODS) with a high possibility of death.54,57,15,5 MODS is probably a conuence of an uncontrolled systemic inammatory response involving multiple mediators. There is a long recognised vigorous pro-inammatory cytokine response following severe injury that involves increased serum levels of Interleukin-1 (IL-1), IL-2, tumour necrosis factoralpha (TNF), IL-6, IL-12, and Interferon-gamma (IFN).29,67,58,51 These may essentially function as acute phase hormones or danger signals to mount a response to the initial stress, and are produced by a variety of cells including monocyte/macrophages and T helper-1 lymphocytes. Both chemokines and complement have been implicated as important mediators in the pathogenesis of MODS. Complement component C3a and C5a, common to the classical and the alternative pathway, are potent neutrophil chemoattractants and excessive complement activation has been shown to play a role in organ injury. All of these early immune response pathways are simultaneously activated after severe injury, and there is often a correlation between the severity of injury as measured by the injury severity score and the degree of the pro-inammatory immune response. The Moores have described a model of early and late MODS depending on the initial degree of injury severity and extent of shock51 (Fig. 1). Early MODS is associated with severe injury and shock and is accompanied by an early vigorous pro-inammatory response and SIRS. MODS occurring later in the clinical course is often associated with a second, or even multiple stresses, such as additional operations or inter-current infec-

1337 tions. This has also been accompanied by a shift from a Th-1 pro-inammatory response to a Th-2 anti-inammatory response that is compensatory but also may increase the risk of infection through immune suppression. Walter Cannon performed physiological studies of the neuroendocrine response after injury, which demonstrated an adrenocortical response to stress characterised by increased production of adrenocorticosteroids and catecholamines16 This ght or ight reaction has been highly conserved evolutionarily in the animal kingdom, for preservation of vital organ ow and avoidance of further injury (Table 1). Hans Selye further characterised this neuroendocrine response to stress and the hypothalamicpituitaryadrenal axis.68 He pointed out that this was involved in what he termed the general adaptation syndrome essentially a precursor to the systemic inammatory syndrome currently known. This neuroendocrine response is probably caused by stimulation of this axis which then hormonally drives the increase in heart rate, respiratory rate, fever, and leukocytosis seen in these patients after major injury. SIRS can be caused by a variety of insults such as trauma, burns or major surgery and is dened when two or more of the criteria apply as shown in Table 2.11 The denition of sepsis is similar but denotes the presence of a septic focus as a specic cause of SIRS. The immune system has been divided into an early innate and a later adaptive response. The latter is responsible for specic memory in the form of plasma cells and cytotoxic T-cells. The tasks of the immune system include recognition, activation, discrimination, regulation and eradication of intruding exogenous and pathogen derived signals. The rst line of defence against invading microorganisms is the epithelial barrier. This is not only a mechanical obstacle, but also equipped with antimicrobial substances like enzymes and IgA molecules. Colonisation of the skin with normal bacterial ora represents an important mechanism of protection as well, as these often preclude pathogenic microbes from establishment in high concentrations. After penetration through this rst border, invading microorganisms are recognised in minutes by the multiple components of innate immunity. The
Table 1 The hypothalamicpituitaryadrenocortical axis stress response Hypothalamus Pituitary Adrenal Kidney Sympathetics ACTH, endorphins, ADH Corticosteroids, epinephrine Renin (angiotensin I and II) Catecholamines

Figure 1

Post-trauma immune responses.

1338
Table 2 Dened parameters of the systemic inammatory response syndrome (SIRS) Body temperature Heart rate Respiratory rate White blood cell count

A. Lenz et al.

>38 or <36 8C >90 b/min >20 b/min or PaCO2 < 32 mmHg >12,000 or <4000 mm3 or >10% band forms

host defence response leads to activation of immune cells, cytokine secretion, activation of complement and the coagulation cascade, secretion of acute phase proteins and neuroendocrine mediators. In the normal host response to infection these processes are highly controlled and limited to the site of infection.

gut, increased susceptibility to microbiological infections, dysfunction of micro-circulation and disseminated intravascular coagulation and nally lead to tissue damage and MODS.38

Local inammatory mediator production

Local mediators of inammation include histamine, kinins, and arachidonic acid metabolites which cause increased capillary permeability, tissue oedema, and immune cell inltration. Local mediator release is not only triggered by tissue injury in the area neutrophils are usually followed by monocyte/macrophages into the injured interstitial space. Extensive tissue injury may lead to spillover of such mediators into the peripheral bloodstream and amplify the systemic inammatory response. Tissue injury results in breakdown of cellular membranes, which are then subject to the action of phospholipase A. This results in the production of arachidonic acid, which is then degraded by either lipooxygenase to form leukotrienes or cyclooxygenase to form prostaglandins and thromboxanes. Tissue injury also promotes the release of histamine from mast cells as well as bradykinin and kallidin production, and these in turn act directly on vascular endothelium to transport cellular and protein elements of the immune system to the site of injury. Most of these inammatory mediators are formed quickly and locally where their effect is maximum and short lived because of rapid metabolism. These acts in a paracrine fashion, and therefore serum measurements of these mediators may not reect their important activity in local tissues.

Trauma and the early immune response

Trauma also leads to the activation of the local host response with localised activation of immune cells, secretion of various kinds of mediators. This process is necessary for haemostasis, protection against invading microorganism, and for the initiation of tissue repair and wound healing. The process is tightly regulated by anti-inammatory mediators. Depending on the magnitude of tissue damage and on the vulnerability of the host, the local immune response may fail to control the destruction and to restore homeostasis. In patients with more severe injury, release of mediators into the circulation occurs with activation of the immune system and systemic release of both pro-inammatory and, subsequently, anti-inammatory cytokines. The former ultimately leads to activation and migration of immune cells, primarily neutrophils, to the site of damage. Inappropriate neutrophil sequestration has been shown to be associated with pulmonary failure when acute respiratory distress syndrome was rst described. If the systemic immune response is not able to restore the integrity of the host, this process can result in the dysregulation of the immune system and can lead to overwhelming systemic inammation and immune paralysis. Thus, the two (multiple) hit hypothesis of the development of MODS, has been described by the Moores as caused either by the rst hit including organ and soft tissue injuries as well as bone fractures, hypoxia and hypotension or occurs some time after a second or multiple hits such as ischaemia/reperfusion, surgical inventions or bacterial infections affecting the overly sensitive immune status of the patient. These uncontrolled and systemic events in immunity can cause increased endothelial permeability with endothelial damage, accumulation of leukocytes, bacteria and endotoxin translocation from the

Complement
The complement cascade is a series of enzymatic cleavage reactions that are triggered by either antigen-antibody complexes (classical pathway) or bacterial cell wall components (alternate pathway) and must occur in sequential fashion to be effective. The latter pathway does not require prior immunisation for activation and thus represents a mechanism for immediate defence against any foreign antigen. Some of the cleavage products are capable

Systemic inammation after trauma of direct bacterial lysis and activated complement anaphylatoxin components C3a and C5a act with kinins and brin degradation products to increase capillary permeability by causing histamine release. Complement components are capable of recruiting neutrophils by chemotactic action, and facilitate both phagocytosis and bacterial killing through opsonisation of bacteria and stimulation of neutrophil degranulation. Circulating stable complement components (C1, C3-5) have been shown to be decreased following trauma and with multiple organ failure70 and massive complement activation has been associated with septic shock. It has been difcult to predict clinical outcome from complement changes early in the course of illness and many of these changes may be secondary to perpetuation of the inammatory process. Complement, antibodies, bronectin, and probably other proteins all contribute to the opsonic capacity of serum. Complement contributes to the vigorous early innate immune response after injury, not only attracting immune cells to the site of tissue trauma, but also facilitating phagocytosis via opsonisation. Unfortunately, too vigorous a response often occurs which is systemic and results in early inammation involving all organs leading to early organ dysfunction after severe trauma. The complement cascade is a component of innate host defence that rapidly becomes activated in a nonspecic manner after injury and infection. The complement system consists of over 30 proteins that have been conserved phylogenetically. This level of conservation amongst species suggests a vital and basic role in the host response to bacterial pathogens.84,43 Complement activation can occur via three main pathways: classical, alternative, and mannan-binding lectin pathways. Activation of the complement cascade results in the formation of products that act to neutralise foreign substances, opsonise antigens, lyse microbes, activate platelets, stimulate histamine release, and attract leukocytes to the site of infection. The wide-ranging effects of complement activation are stringently regulated by a large number of regulatory complement-control proteins, which prevent over-activation of the whole system. The complement system is generally benecial to the host, and aids in initiating the innate immune response to infection, with mice decient in either complement factors C3 or C4, which are factors involved in the early part of the complement cascade, being more susceptible to experimental sepsis. Whereas local and regulated complement activation is an important part of host defence, systemic activation of complement can result in changes in haemodynamic parameters leading to shock. Persis-

1339 tent elevation of the complement-derived chemotaxins C3a and C4a correlate with increased mortality following sepsis.70 High levels of another complement derived chemoattractant, C5a, have also been associated with increased remote organ damage following surgical peritonitis in both rats and mice. Neutralisation of C5a, using a monoclonal antibody, resulted in improved survival and decreased organ damage in this model.39,21 In a study of patients with SIRS, the platelet count was found to be signicantly lower in septic patients than in those with SIRS. However, no difference in plasma concentrations of CRP and levels of C3 and C4 was noted between the patient groups.74

Alarmins
The presence of systemic inammation without evidence of a bacterial focus suggests the presence of endogenous triggers in immune activation after trauma. These signalling substances are called alarmins in assignment to the term danger signals, including exogenous and endogenous signals. Alarmins are characterised as a group of pathogen associated molecular pattern (PAMPs), which are released either after non-programmed cell death, excluding apoptosis, or produced and released by cells of the immune system.9 To this family of endogenous triggers belongs high mobility group box 1 (HMGB1), heat shock proteins (HSPs), defensins, cathelicidin, eosinophil-derived neurotoxin (EDN) as well as others. These structurally diverse proteins serve as endogenous mediators of innate immunity as chemoattractants and activators of antigen presenting cells (APCs).56 While defensins, cathelicidin and EDN are rapidly released from storage compartments triggered by either PAMP recognition or pro-inammatory cytokines, HMGB1 is released by injured cells.9 HMGB1 is a nuclear protein which not only inuences nuclear transactions, but also plays an important role in signalling after tissue damage.34 The receptor dedicated to the different effects of HMBG1 is the receptor for advanced glycation end product (RAGE). It is released by necrotic but not apoptotic cells as well as secreted by activated immune cells, macrophages, mature myeloid DCs and activated NK cells without using the Golgi apparatus pathway.31,66,78 The active secretion of HMGB1 after LPS stimulation seems to be partially dependent on the TLR4-CD14 complex and TGF-b,19 and is triggered by cytokines like TNF-a, IL-1b and interferon-g.60 It has recently been shown that accumulation of apoptotic cells can stimulate macrophages to secrete HMGB1 which seems to have an role, downstream of apoptosis, in the development of organ

1340 damage in severe sepsis.59 It is also necessary for the up-regulation of CD80, CD83, and CD86 surface markers of human dendritic cells and for the clonal expansion, survival, and functional polarisation of naive Tcells.27 On the other hand HMGB1 can also be released by necrotic or damaged cells. After disposal, HMBG1 is a chemoatractant for macrophages, neutrophils and dendritic cells. Secretion of proinammatory cytokines by monocytes like TNF, IL1a, IL-1b, IL-1RA, IL-6; IL-8, MIP-1a and MIP2b has been shown after activation with HMBG1.4 HMBG1 also is likely to be a mediator of monocyte migration through the endothelium.64 Contrary to these ndings, the application of puried HMGB1 seems to have weak direct pro-inammatory activity.65 It was shown in a murine model after LPS administration, that peak/plateau levels of HMGB1 last from 16 h after LPS administration to 32 h, and that treatment with an anti-HMGB1 antibody had a benecial effect on survival. A study performed by Sunden-Cullberg et al, showed increased levels of HMBG1 over time in patients suffering from sepsis, severe sepsis and septic shock which were still elevated after 144 h.73 They found signicantly lower levels of HMGB1 in the group of patients who died compared to a control group. However, Wang found higher HMGB1 levels in patients who succumbed.77 One explanation could be the use of different experimental methods. However these studies are indicative of an important role of HMBG1 in development of severe sepsis and MODS (29).

A. Lenz et al.

Cytokines
Cytokines are secreted proteins from cells which function as means of communication between cells in both a paracrine and endocrine fashion. Over the last 20 years, cytokines have gained more attention in the understanding of physiological changes after trauma or in inammation. They play an important role in the defence and repair mechanisms following trauma, but this highly controlled system may become over exuberant after severe injury to the host. This has been associated with SIRS and damage to organs not directly involved in the original injury. This has been termed remote organ failure and this response probably also contributes to the immune system paralysis seen in these patients. Cytokines, because of their role in cell to cell communication, are likely to play an important role in the development of SIRS and MODS.82 After polytrauma, elevated levels of cytokines have been observed in patients with SIRS and MODS. Application of recombinant cytokines in animal models can evoke both of these syndromes, and blocking such cytokines can have benecial effects on the circulation. TNF, IL1b, IL-6, IL-8, IL-12, and IFN-gamma (Table 3) are probably the most important and well-studied proinammatory cytokines after trauma.37 One of the best-described pro-inammatory cytokines is TNF, which can produce SIRS when injected into vertebrates in high doses. TNF not only stimulates the activation of many cell types

Table 3 Pro-inammatory cytokines Name TNF-a Source Macrophages/monocytes, T-cells Function Stimulates NK-cells, macrophages/monocytes. induces cytokine secretion, cell survival, apoptosis, synthesis of NO, production of selectins, platelet activation factor, ICAM. Leads to synthesis of thromboxan A2, prostaglandin E2. Induces fever Stimulates T-cells and macrophages. Leads to fever, cytokine secretion, chemokine secretion and to secretion of acute-phase proteins like serumamyloid A. Increases adhesion molecules. Induces neutrophil release from the bone marrow. Stimulates expression of tissue proteases and metalloproteases. Inhibits synthesis of proteoglycans.26 Stimulates monocyte chemotactic peptide (MCP-1) and macrophage inammatory peptide 1-alpha (MIP-1alpha) Regulates growth and differentiation of T- and B-cells. Induces fever. Leads to increased activity of NK-cells and to release of soluble TNFR and IL-1ra. Inhibits apoptosis of neutrophils and mediates the hepatic acute phase response Activation and chemotaxis of immune cells. Activates 5-lopooxygenase which leads to LTB4 release. Induces synthesis of neutrophil derived platlet activating factor

IL-1b

Macrophages/monocytes, endothelial cells

IL-6

T-cells, macrophages/monocytes, endothelial cells

IL-8

Macrophages/monocytes and virtually all somatic cells

Systemic inammation after trauma like NK-cells and macrophages/monocytes, it can although induce cell survival or cell death via apoptosis.22 TNF secretion is stimulated by a number of different physiological stresses such as haemorrhage, hypoxaemia, ischaemia/reperfusion, endotoxins (LPS) and by the complement system. After secretion, TNF leads to multiple effects on the host response. It increases synthesis of nitric oxide (NO), activates the arachidonic acid pathway and induces activation of cyclooxygenase and lipooxygenase. This leads to the production of thromboxane A2 and prostaglandins E2, which have multiple physiological effects. It also induces the production of selectins, platlet activating factor and intracellular adhesion molecules (ICAM), which mediate neutrophil migration into tissues.44 TNF is mainly produced by macrophages and monocytes. It is also produced by T-cells after activation and is among the early cytokines secreted after trauma with a half-life of less than 20 min. Despite the short half-life of TNF, this cytokine can induce secretion of a variety of pro-/ and anti-inammatory cytokines such as IL-6, IL-8, interferon-gamma, and IL-10. TNF also alters the levels of corticosteroids. TNF effects, however, are not only due to the systemic release of TNF. Suter et al. observed local levels of TNF and IL-1beta in bronchoalveolar lavage of patients with adult respiratory distress syndrome while plasma levels were not increased, indicating that end organ failure could be due to local release of these mediators independent of plasma cytokine levels.6 TNF acts via its receptors TNFR1 and TNFR2, which belong to a still growing number of TNF receptors in the TNFR superfamily. Depending on the specic receptor and environmental factors, TNF recognition can lead to divergent results. TNFR1 belongs to the receptors of TNFR superfamily with a death domain at the cytoplasmic tail. Binding of TNF-alpha to TNFR1 can lead to induction of transcription factors such as NF-kB and subsequent transcription of inammatory genes, which seems to protect cells against apoptosis. Binding of TNF to TNFR1 can also lead to induction of apoptosis via the caspase cascade. Activation of TNFR1 only signals for cell death under distinct circumstances e.g. when the protein synthesis is blocked or when NFkB activation is inhibited.53 While TNFR1 is expressed in most tissues and is usually activated by the soluble form of TNF-alpha, TNFR2 is expressed in immune competent cells and on the endothelium and becomes activated by membrane bound TNF-alpha.33 TNFR2 does not contain a death domain. Binding of TNF to TNFR2 leads to activation of signal transduction pathways like NF-kB and Jun N-terminal kinase, p36, extracellular signal related kinase (ERK) and phosphoinositide-3 kinase24 and to

1341 activation and proliferation of immune cells such as neutrophils, NK-cells, B-cells, peripheral T-cells and others.17 Inhibition of TNF by either anti-TNF antibodies or soluble receptors for TNF, has become a strategy in the treatment of patients with chronic inammatory diseases, although this strategy did not work in septic patients. However, it has been shown that increased and elevated concentrations during sepsis are associated with increased mortality.18 Blocking TNF may have benecial effects on the mortality rate in humans from certain specic diseases such as meningococcemia.1 Interleukin-1-beta (IL-1) was rst described as endogenous pyrogen over a half century ago, because it caused fever when injected into rabbits. Despite a different pathway from TNF, IL-1 has similar effects on the immune system after trauma. In fact TNF and IL-1 are often described as synergistically acting mediators, leading to increased permeability and coagulation ability of the endothelium, as well as to increased levels of adhesion molecules on the endothelium leading to PMN activation and transmigration. Secretion of IL-1 is provoked by TNF, C5a a part of the complement cascade, haemorrhage, ischaemia and bacterial endotoxin. It has a half life of only 6 min, and IL-1 has several effects after secretion by monocytes, macrophages or endothelial cells. It is capable of bone marrow stimulation and increases the number of myeloid progenitor cells and the release of neutrophils. It also induces the secretion of many other pro-inammatory cytokines including TNF and can lead to increased levels of chemokines and adhesion molecules.26 IL-1 induces fever, T-cell and macrophage activation, and also induces cyclooxygenase and inducible nitric oxide synthase. IL-1 is not released by typical pathways and the exact process of its secretion is still not fully understood. It is produced as a larger pro-hormone which is subsequently converted by caspase 1 into the biologically active form.79 The effects of IL-1beta and IL-1 alpha are mediated by the type 1 IL-1 receptor (IL-1RI), which is part of the IL-1 receptor superfamily. Another protein which binds to the IL-1RI, but functions like a receptor antagonist, is called IL-1 receptor antagonist (IL-1RA) suggesting a controlling role of this antagonist in IL-1 mediated immune responses. The cytosolic region of the IL-1RI is very similar to the sequence of the Toll-like receptors which gave this region the name Toll-IL-1 receptor (TIR) domain.28 IL-1 binding to this receptor leads to activation of a signalling cascade resulting in the activation of the transcription factor NF-kB, which leads to the transcription of several pro-inammatory cytokines. While IL-1 antagonists are used in the treatment of rheumatoid arthritis,30,25 no study has

1342 shown benecial effects of blocking IL-1 in the SIRS after trauma. Another important cytokine in the early inammatory response to trauma is IL-6. This cytokine has been widely used as a marker of the severity of the inammatory response in many clinical trials. IL-6 is produced and detectable within an hour after trauma, although it appears later than TNF or IL1, and has a longer half-life than these two cytokines. The secretion of IL-6 is induced by TNF and IL-1.69 Il-6 has a wide range of activity, but does not induce SIRS when injected into animals. It regulates growth and differentiation of lymphocytes, and activates NK-cells and neutrophils. Il-6 inhibits apoptosis of neutrophils and mediates the hepatic acute phase response. On the other hand, IL-6 has a regulatory role in the pro-inammatory response by inducing the release of soluble TNFR and IL-I receptor antagonist (IL-1ra).55,75 IL-6 seems therefore to play a dual role in the inammatory response by acting as both a pro-inammatory and anti-inammatory mediator.81,46 After being released, IL-6 binds to the IL-6 receptor. This receptor has no transduction motif in its cytoplasmic chain. Therefore, the IL-6 receptor complex has to recruit two molecules of glycoprotein 130 to induce the activation of the JAK/STAT pathway or the mitogen activated protein kinase (MAPK) cascade35,36 which subsequently leads to the expression of the target genes. It has been shown in murine models that IL-6 is an important mediator of inammation45 and blocking IL-6 increases survival.61 IL-6 belongs to the diagnostic repertoire of research tools used in many intensive care units, and levels have correlated well with clinical outcome. The advantages of serum IL-6 as an indicator for the severity of the inammatory response, is the rapid response to changes in clinical course and the relative independence from bacterial infections. Oda et al., have recently shown that there is a signicant difference in the mean blood IL-6 levels between non survivors and survivors over time, but not on admission to the ICU.

A. Lenz et al. CXCL8 = IL-8) indicates the ligand while R (e.g. CXCR1 = Receptor for IL-8) indicates the receptor.85 Another, more functionally oriented classication is the distinction between constitutively produced homeostatic chemokines. These are pro-inammatory chemokines, which are produced in an inammatory response or as reaction of immunological stimuli, and chemokines with mixed function. The pro-inammatory chemokines can further be divided into angiogenic chemokines which contain an ELR motif (Glu-Leu-Arg) close to the N-terminus (including IL-8) and angiostatic chemokines, without this motif. Overall 18 chemokine receptors and 43 chemokines have been described. The chemokine signalling seems to be redundant, as in most cases one receptor binds several different chemokines and one chemokine can often bind to more than one receptor.48 The chemokine receptors belong to the family of G-protein coupled receptors, and binding to these receptors leads to dose dependent effects including both chemotaxis and activation. IL-8 secretion is induced by IL-1, TNF-alpha, C5a, microbes and their products, hypoxia, hyperoxia and reperfusion. Interferons attenuate the expression of IL-8. It can be produced in an early state of inammation after trauma and can persist over a long time even over weeks. IL-8 forms dimers in solution and is monomeric in lower concentrations. The monomeric form seems to be the active form of IL-8 with the capability for neutrophil activation. IL-8 belongs to the CXC chemokines with the so called ELR motif. Chemokines of these subgroups have the ability to act as potent angiogenic factors and as chemoattractants and activators of immune cells. These include neutrophils initially, followed by lymphocytes, monocytes, endothelial cells and broplasts.42 It is important to understand that it is not the concentration of IL-8 itself but the development of a concentration gradient which directs the cellular recruitment to the site of inammation. Unlike other chemokines like SDF-1 or MDC which appear to be produced constitutively, IL-8 belongs to the inducible chemokines. The processes involved in IL-8 production and secretion are yet not fully understood, although p38 MAP kinase appears to play an important role in IL-8 production. It is also interesting that IL-8 gene expression can be substantially reduced by antioxidants. IL-8 can bind to both the CXCR1 and CXCR2 on human neutrophils, and during inammation, the CXCR2 is down regulated so that the CXCR1 becomes the predominate receptor for IL-8 mediated functions.3,32 These are seven transmembrane receptors, coupled to G-proteins and binding to IL-8 leads to the induction of several pathways. These include activation of MAPK and other pathways which are lead to neutrophil

Chemokines
IL-8 is a chemotactic cytokine, and the most potent endogenous chemoattractant. Therefore it belongs to the chemokine family and is also called CXCL8. Chemokines control the trafc of the immune cells which are the main effectors of the immune system. They are small, structurally related molecules which can be divided into two families, the CC and CXC, depending on the localisation of the two N-terminal cystein residues. An additional L (e.g.

Systemic inammation after trauma granule release, adherence and chemotaxis. IL-8 signalling also induces the shedding of L-selectin from neutrophil cell surface, and together with TNF-alpha and IL-6 are responsible for the regulation of adhesion molecules on endothelial cells.37,52 These effects are chemokine dose dependent. In lower doses, chemokines act mostly as chemoattractants, while in increased concentrations they can lead to cell activation including cytotoxicity and even respiratory burst. There is also evidence that IL-8 can protect neutrophils against apoptosis, which could be one reason for prolongation of the inammatory response at the site of injury or infection. It has also been shown that IL-8 plays an important role not only in the development of the adult respiratory distress syndrome,52 but also in the pathophysiological derangements seen after ischaemia/reperfusion. Reduction in tissue damage after experimental ischaemia reperfusion has been seen with IL-8 blockade. Recently a group of so-called silent chemokine receptors has gained more attention. These receptors can bind chemokines, but do not evoke chemokine related cell responses suggesting a role as decoy or scavenger receptors. One member of this family is the decoy receptor D6. D6 binds most inammatory chemokines, except IL-8, and is now known to be important in limiting the inammatory response in different murine models40,49,50 by allowing degradation of chemokines. This decoy response, however, has not been studied in the trauma setting. Another important member is the Duffy antigen receptor for chemokines (DARC). DARC, rst described as a blood group antigen, is also expressed by red blood cells and endothelial cells. It binds angiogenic chemokines including IL-8. While D6 eliminates the cellular response to chemokines, the DARC receptor seems to act more to differentiate this response and chemokines retain their biological activity after binding to this receptor. DARC on red bloods cells seems to capture chemokines and is therefore supposed to prevent leukocyte activation in the systemic circulation. On the other hand DARC on endothelial cells is required for leukocyte recruitment.63

1343 dent on up to the second or third day.13 Radical oxygen species produced after ischaemia and reperfusion following traumatic injury are one of the most potent activators and chemoattractants for PMN.12 While local PMN migration to the site of tissue damage is important for wound healing and for protection against invading microorganisms, systemic PMN activation can lead to sequestration in organs not primarily effected by the initial trauma. This invasion of activated PMN into such organs is a main source of secondary organ and tissue damage which can lead to development of MOF and ARDS.8,14 PMNs can exist in different activation states. In normal conditions the resting form is predominating. Between the resting state and full activation exists an intermediate state in which neutrophils may be primed by several different substances. Agents which have been shown to be capable of PMN priming include complement C5a, TNF, IL-8, GM-CSF, LPS and others. This priming leads to multiple changes including increased expression of CD11b and CD18, delayed apoptosis, production of IL-8 and the lipid mediator LTB4.20 In this state a second trigger can evoke a more powerful response than in resting PMNs.72 Further activation then leads to PMN migration, which can be divided into at least three different steps. The rst step includes tethering and rolling along the endothelium, which is mediated by leukocyte selectins (L-selectins) and E and P selectins on the endothelium. The second step, the arrest of PMN on the endothelium is mainly mediated by upregulation of integrins like CD11 and CD18 on the leukocyte surface and the interaction of this molecule with ICAM expressed on the surface of activated endothelium.71 The last step, migration into the tissue, is mediated by chemokines and complement anaphylatoxins (C5a and C3a). PMNs then degranulate and release proteolytic enzymes such as elastase and various oxygen radicals. Metalloproteinases or the production of reactive oxygen species (ROS) by PMN are important in host defence against invading microorganism but can also lead to secondary tissue and organ damage.41 It has been shown that patients with a high risk of developing MOF are more resistant to apoptosis10 and that after trauma neutrophils are primed for the release of proinammatory cytokines and elastase.8,83

Cellular immune response Conclusions

The cellular immune response following trauma includes polymorphonuclear granulocyes (PMN), lymphocytes and monocytes/macrophages and natural killer cells. PMN represents 5060% of total circulating leukocytes and are the leading cells in the rst response to severe trauma from the inciTrauma represents the most ancient and greatest stressor to an organism. The initial host defence response is geared towards haemostasis and preservation of vital organ oxygenation. As part of this normal response to injury, there is a surge in the

1344 stress hormone response mediated by the hypothalamicpituitaryadrenal axis, which leads to the typical physiological catecholamine stress response. Danger signals initiate an early innate immune response to injured tissue itself, however an overly vigorous pro-inammatory host defence response may lead to non-specic organ injury as part of this uncontrolled immune activation. Modulation of this response is a major therapeutic goal so as to selectively direct it towards injured tissue and infection, while sparing other vital organ function. Continued research in this area will be required to achieve this lofty goal, and an ability to measure individual organ blood ow and immune activity will be essential throughout the clinical course of these patients.

A. Lenz et al.
16. Cannon WB. The emergency function of the adrenal medulla in pain and the major emotions. Am J Physiol 1914;35672. 17. Carpentier I, Coornaert B, Beyaert R. Function and regulation of tumor necrosis factor type 2. Curr Med Chem 2004;11: 220512. 18. Casey LC, Balk RA, Bone RC. Plasma cytokine and endotoxin levels correlate with survival in patients with the sepsis syndrome. Ann Intern Med 1993;119:7718. 19. Chen G, Li J, Ochani M, et al. Bacterial endotoxin stimulates macrophages to release HMGB1 partly through. J Leukoc Biol 2004;76:9941001. 20. Condliffe AM, Kitchen E, Chilvers ER. Neutrophil priming: pathophysiological consequences and underlying mechanisms. Clin Sci (Lond) 1998;94:46171. 21. Czermak BJ, Sarma V, Pierson CL, et al. Protective effects of C5a blockade in sepsis. Nat Med 1999;5:78892. 22. DeLong Jr WG, Born CT. Cytokines in patients with polytrauma. Clin Orthop Relat Res 2004;5765. 23. Demetriades D, Murray J, Charalambides K, et al. Trauma fatalities: time and location of hospital deaths. J Am Coll Surg 2004;198:206. 24. Dempsey PW, Doyle SE, He JQ, Cheng G. The signaling adaptors and pathways activated by TNF superfamily. Cytokine Growth Factor Rev 2003;14:193209. 25. Dinarello CA. Blocking IL-1 in systemic inammation. J Exp Med 2005;201:13559. 26. Dinarello CA. Interleukin-1beta. Crit Care Med 2005;33: S4602. 27. Dumitriu IE, Baruah P, Valentinis B, et al. Release of high mobility group box 1 by dendritic cells controls T cell activation via the receptor for advanced glycation end products. J Immunol 2005;174:750615. 28. Dunne A, ONeill LA. The interleukin-1 receptor/Toll-like receptor superfamily: signal transduction during inammation and host defense. Sci STKE 2003;2003:re3. 29. Faist E, Wichmann MW. Immunology in the severely injured. Chirurg 1997;68:106670. 30. Furst DE, Breedveld FC, Kalden JR, et al. Updated consensus statement on biological agents, specically tumour necrosis factor {alpha} (TNF{alpha}) blocking agents and interleukin-1 receptor antagonist (IL-1ra), for the treatment of rheumatic diseases, 2005. Ann Rheum Dis 2005;64(Suppl. 4):iv214. 31. Gardella S, Andrei C, Ferrera D, et al. The nuclear protein HMGB1 is secreted by monocytes via a non-classical, vesiclemediated secretory pathway. EMBO Rep 2002;3:9951001. 32. Goodman RB, Pugin J, Lee JS, Matthay MA. Cytokinemediated inammation in acute lung injury. Cytokine Growth Factor Rev 2003;14:52335. 33. Grell M, Becke FM, Wajant H, Mannel DN, Scheurich P. TNF receptor type 2 mediates thymocyte proliferation independently of TNF receptor type 1. Eur J Immunol 1998;28: 25763. 34. Harris HE, Raucci A. Alarmin(g) news about danger: workshop on innate danger signals and HMGB1. EMBO Rep 2006;7: 7748. 35. Heinrich PC, Behrmann I, Haan S, et al. Principles of interleukin (IL)-6-type cytokine signalling and its regulation. Biochem J 2003;374:120. 36. Heinrich PC, Behrmann I, Muller-Newen G, Schaper F, Graeve L. Interleukin-6-type cytokine signalling through the gp130/ Jak/STAT pathway. Biochem J 1998;334(Pt 2):297314. 37. Hildebrand F, Pape HC, Krettek C. The importance of cytokines in the posttraumatic inammatory reaction. Unfallchirurg 2005;108:793803. 38. Hoover L, Bochicchio GV, Napolitano LM, et al. Systemic inammatory response syndrome and nosocomial infection in trauma. J Trauma 2006;61:3106.

References
1. Abraham E. Why immunomodulatory therapies have not worked in sepsis. Intensive Care Med 1999;25:55666. 2. Acosta JA, Yang JC, Winchell RJ, et al. Lethal injuries and time to death in a level I trauma center. J Am Coll Surg 1998;186:52833. 3. Adams JM, Hauser CJ, Livingston DH, et al. Early trauma polymorphonuclear neutrophil responses to chemokines are associated with development of sepsis, pneumonia, and organ failure. J Trauma 2001;51:4526. 4. Andersson U, Wang H, Palmblad K, et al. High mobility group 1 protein (HMG-1) stimulates proinammatory cytokine synthesis in human monocytes. J Exp Med 2000;192:56570. 5. Angus DC, Wax RS. Epidemiology of sepsis: an update. Crit Care Med 2001;29:S10916. 6. Armstrong L, Millar AB. Relative production of tumour necrosis factor alpha and interleukin 10 in adult respiratory distress syndrome. Thorax 1997;52:4426. 7. Baker CC, Oppenheimer L, Stephens B, Lewis FR, Trunkey DD. Epidemiology of trauma deaths. Am J Surg 1980;140: 14450. 8. Bhatia R, Dent C, Topley N, Pallister I. Neutrophil priming for elastase release in adult blunt trauma patients. J Trauma 2006;60:5906. 9. Bianchi ME. DAMPs, PAMPs and alarmins: all we need to know about danger. J Leukoc Biol 2007;81:15. 10. Bif WL, Moore EE, Zallen G, et al. Neutrophils are primed for cytotoxicity and resist apoptosis in injured patients at risk for multiple organ failure. Surgery 1999;126:198202. 11. Bone RC, Balk RA, Cerra FB, et al. Denitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis.In: The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest 1992;101:164455. 12. Botha AJ, Moore FA, Moore EE, et al. Postinjury neutrophil priming and activation states: therapeutic challenges. Shock 1995;3:15766. 13. Botha AJ, Moore FA, Moore EE, et al. Postinjury neutrophil priming and activation: an early vulnerable window. Surgery 1995;118:35864. 14. Botha AJ, Moore FA, Moore EE, et al. Early neutrophil sequestration after injury: a pathogenic mechanism for multiple organ failure. J Trauma 1995;39:4117. 15. Brun-Buisson C. The epidemiology of the systemic inammatory response. Intensive Care Med 2000;26(Suppl. 1):S6474.

Systemic inammation after trauma

39. Huber-Lang M, Sarma VJ, Lu KT, et al. Role of C5a in multiorgan failure during sepsis. J Immunol 2001;166:11939. 40. Jamieson T, Cook DN, Nibbs RJ, et al. The chemokine receptor D6 limits the inammatory response in vivo. Nat Immunol 2005;6:40311. 41. Jochum M, Gippner-Steppert C, Machleidt W, Fritz H. The role of phagocyte proteinases and proteinase inhibitors in multiple organ failure. Am J Respir Crit Care Med 1994;150: S12330. 42. Keane MP, Strieter RM. Chemokine signaling in inammation. Crit Care Med 2000;28:N1326. 43. Krem MM, Di Cera E. Evolution of enzyme cascades from embryonic development to blood coagulation. Trends Biochem Sci 2002;27:6774. 44. Law MM, Cryer HG, Abraham E. Elevated levels of soluble ICAM-1 correlate with the development of multiple organ failure in severely injured trauma patients. J Trauma 1994;37:1009. 45. Leon LR. Invited review: cytokine regulation of fever: studies using gene knockout mice. J Appl Physiol 2002;92:264855. 46. Lin E, Calvano SE, Lowry SF. Inammatory cytokines and cell response in surgery. Surgery 2000;127:11726. 47. MacKenzie EJ. Epidemiology of injuries: current trends and future challenges. Epidemiol Rev 2000;22:1129. 48. Mantovani A, Bonecchi R, Locati M. Tuning inammation and immunity by chemokine sequestration: decoys and more. Nat Rev Immunol 2006;6:90718. 49. Martinez dlT, Buracchi C, Borroni EM, et al. Protection against inammation- and autoantibody-caused fetal loss by the chemokine decoy receptor D6. Proc Natl Acad Sci USA 2007. 50. Martinez dlT, Locati M, Buracchi C, et al. Increased inammation in mice decient for the chemokine decoy receptor D6. Eur J Immunol 2005;35:13426. 51. Moore FA, Moore EE. Evolving concepts in the pathogenesis of postinjury multiple organ failure. Surg Clin North Am 1995;75:25777. 52. Mukaida N. Pathophysiological roles of interleukin-8/CXCL8 in pulmonary diseases. Am J Physiol Lung Cell Mol Physiol 2003;284:L56677. 53. Muppidi JR, Tschopp J, Siegel RM. Life and death decisions: secondary complexes and lipid rafts in TNF receptor family signal transduction. Immunity 2004;21:4615. 54. Nast-Kolb D, Aufmkolk M, Rucholtz S, Obertacke U, Waydhas C. Multiple organ failure still a major cause of morbidity but not mortality in blunt multiple trauma. J Trauma 2001;51:83541. 55. Opal SM, DePalo VA. Anti-inammatory cytokines. Chest 2000;117:116272. 56. Oppenheim JJ, Yang D. Alarmins: chemotactic activators of immune responses. Curr Opin Immunol 2005;17:35965. 57. Osborn TM, Tracy JK, Dunne JR, Pasquale M, Napolitano LM. Epidemiology of sepsis in patients with traumatic injury. Crit Care Med 2004;32:223440. 58. Polk Jr HC, George CD, Wellhausen SR, et al. A systematic study of host defense processes in badly injured patients. Ann Surg 1986;204:28299. 59. Qin S, Wang H, Yuan R, et al. Role of HMGB1 in apoptosismediated sepsis lethality. J Exp Med 2006;203:163742. 60. Rendon-Mitchell B, Ochani M, Li J, et al. IFN-gamma induces high mobility group box 1 protein release partly through a TNF-dependent mechanism. J Immunol 2003;170:38907. 61. Riedemann NC, Neff TA, Guo RF, et al. Protective effects of IL-6 blockade in sepsis are linked to reduced C5a receptor expression. J Immunol 2003;170:5037. 62. Rogers FB, Shackford SR, Hoyt DB, et al. Trauma deaths in a mature urban vs rural trauma system. A comparison. Arch Surg 1997;132:37681.

1345
63. Rot A. Contribution of Duffy antigen to chemokine function. Cytokine Growth Factor Rev 2005;16:68794. 64. Rouhiainen A, Kuja-Panula J, Wilkman E, et al. Regulation of monocyte migration by amphoterin (HMGB1). Blood 2004;104:117482. 65. Rouhiainen A, Tumova S, Valmu L, Kalkkinen N, Rauvala H. Analysis of proinammatory activity of highly puried eukaryotic recombinant HMGB1 (amphoterin). J Leukoc Biol 2007;81:4958. 66. Scafdi P, Misteli T, Bianchi ME. Release of chromatin protein HMGB1 by necrotic cells triggers inammation. Nature 2002;418:1915. 67. Schinkel C, Sendtner R, Zimmer S, Faist E. Functional analysis of monocyte subsets in surgical sepsis. J Trauma 1998;44: 7438. 68. Selye H. The general adaptation syndrome and the diseases of adaptation. Am J Med 1951;10:54955. 69. Shalaby MR, Waage A, Espevik T. Cytokine regulation of interleukin 6 production by human endothelial cells. Cell Immunol 1989;121:37282. 70. Shatney CH, Benner C. Sequential serum complement (C3) and immunoglobulin levels in shock/trauma patients developing acute fulminant systemic sepsis. Circ Shock 1985;16:917. 71. Simon SI, Green CE. Molecular mechanics and dynamics of leukocyte recruitment during inammation. Annu Rev Biomed Eng 2005;7:15185. 72. Smith JA. Neutrophils, host defense, and inammation: a double-edged sword. J Leukoc Biol 1994;56:67286. 73. Sunden-Cullberg J, Norrby-Teglund A, Rouhiainen A, et al. Persistent elevation of high mobility group box-1 protein (HMGB1) in patients with severe sepsis and septic shock. Crit Care Med 2005;33:56473. 74. Sungurtekin H, Sungurtekin U, Balci C. Circulating complement (C3 and C4) for differentiation of SIRS from sepsis. Adv Ther 2006;23:893901. 75. Tilg H, Trehu E, Atkins MB, Dinarello CA, Mier JW. Interleukin6 (IL-6) as an anti-inammatory cytokine: induction of circulating IL-1 receptor antagonist and soluble tumor necrosis factor receptor p55. Blood 1994;83:1138. 76. Trunkey DD. Trauma. Accidental and intentional injuries account for more years of life lost in the U.S. than cancer and heart disease. Among the prescribed remedies are improved preventive efforts, speedier surgery and further research. Sci Am 1983;249:2835. 77. Wang H, Bloom O, Zhang M, et al. HMG-1 as a late mediator of endotoxin lethality in mice. Science 1999;285:24851. 78. Wang H, Vishnubhakat JM, Bloom O, et al. Proinammatory cytokines (tumor necrosis factor and interleukin 1) stimulate release of high mobility group protein-1 by pituicytes. Surgery 1999;126:38992. 79. Wewers MD. IL-1beta: an endosomal exit. Proc Natl Acad Sci USA 2004;101:102412. 80. Wick M, Ekkernkamp A, Muhr G. The epidemiology of multiple trauma. Chirurg 1997;68:10538. 81. Xing Z, Gauldie J, Cox G, et al. IL-6 is an antiinammatory cytokine required for controlling local or systemic acute inammatory responses. J Clin Invest 1998;101:31120. 82. Yao YM, Redl H, Bahrami S, Schlag G. The inammatory basis of trauma/shock-associated multiple organ failure. Inamm Res 1998;47:20110. 83. Zallen G, Moore EE, Johnson JL, et al. Circulating postinjury neutrophils are primed for the release of proinammatory cytokines. J Trauma 1999;46:428. 84. Zarkadis IK, Mastellos D, Lambris JD. Phylogenetic aspects of the complement system. Dev Comp Immunol 2001;25: 74562. 85. Zlotnik A, Yoshie O. Chemokines: a new classication system and their role in immunity. Immunity 2000;12:1217.