Marc S.

Penn and Megan Kamath

Novel Mechanisms for Maintaining Endothelial Barrier Function in Sepsis
Print ISSN: 0009-7322. Online ISSN: 1524-4539
Copyright 2012 American Heart Association, Inc. All rights reserved.
is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Circulation
doi: 10.1161/CIRCULATIONAHA.112.146100
2012;126:2677-2679 Circulation.
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Editorial
Novel Mechanisms for Maintaining Endothelial Barrier
Function in Sepsis
Marc S. Penn, MD, PhD; Megan Kamath, MD
T
he pathophysiology of multiple disease states, including
sepsis,
1,2
hypertension,
1
atherosclerosis,
35
and ischemia-
reperfusion injury,
6
is characterized by loss of the endothelial
barrier function leading to the accumulation of plasma-borne
proteins, tissue edema, and cell death. Importantly therapeutic
strategies that inhibit loss of endothelial barrier function
have been associated with strategies that improve out-
comes.
7
There is growing understanding of the role of
adherens in maintaining the integrity of the endothelial
barrier function
8
and the molecular pathways that regulate
adheren expression.
9
Article see p 2728
Treatment strategies that have been shown to enhance
endothelial barrier function have typically focused on pre-
venting endothelial activation,
10
inhibiting endothelial cell
free radical generation,
6
and targeting intracellular kinases.
11
Many studies demonstrate that upregulation or prevention of
Rac1 inhibition during endothelial cell activation leads to
preserved endothelial barrier function.
11
In addition to edema, sepsis is characterized by endothelial
activation, and the generation of microemboli attributed to the
upregulation of the tissue factormediated clotting cascade
further complicates the clinical course of sepsis.
12
Preclinical
studies have demonstrated that the cytokine cascade induced
by sepsis adversely affects endothelial and intimal barrier
functions.
1
In addition to decreasing endothelial barrier func-
tion, the cytokine cascades have been shown to activate the
clotting cascade through endothelial cell tissue factor expres-
sion.
10
This upregulation of tissue factor can lead activation
of the extrinsic coagulation cascade and, because of the
generation of factors Xa and Va, the generation of thrombin
(Figure). The potential therapeutic benefit of downregulating
endothelial activation and thrombin generation has been
demonstrated through the early use of activated protein C
(Xigris) in patients with evidence of worsening sepsis.
13
In this issue of Circulation, Aman et al
14
further our
understanding of the molecular mechanisms regulating the
Rho family GTPase Rac1 and endothelial barrier function
through their studies on the molecular effects of imatinib
mesylate (Gleevec). Imatinib was first approved in 2001 and
has shown clinical efficacy in the treatment of chronic
myelogenous leukemia and gastrointestinal stromal tumors.
15
It was designed to inhibit tyrosine kinases, including c-abl
kinase, platelet-derived growth factor receptors, c-KIT, and
discoid domain receptors 1 and 2.
16
In an excellent example
of translation medicine, Aman et al
14
initiated their studies on
the effects of imatinib and endothelial barrier function based
on the observations of Overbeek et al,
17
who reported
observing resolution of interstitial edema after the adminis-
tration of imatinib in a patient with suspected pulmonary
veno-occlusive disease.
In their studies, Aman et al
14
investigated through in vitro
and in vivo models the effects of imatinib on microvascular
perfusion, extravasation of fluid, and vascular leakage, con-
cluding that imatinib has a direct protective effect on the
endothelial barrier through its previously unrecognized effect
of imatinib, inhibition of the abl-related gene (Arg) kinase,
and the subsequent preservation of Rac1.
14
In vitro studies
using human umbilical vein endothelial cells demonstrated
that imatinib inhibited of endothelial leakage in response to
vascular endothelial growth factor in a dose-dependent man-
ner attributed to the preservation of cell-cell junctions and
prevention of gap formation. Their studies identified a novel
molecular effect of imatinib on endothelial cells, because the
observed effects were mediated through inhibition of Arg
kinase and preservation of Rac1 activity and endothelial
barrier function. Small-interfering RNA knockdowns of
known tyrosine kinases, platelet-derived growth factor
receptor- and -, c-Abl, and discoid domain receptor 1, did
not mimic the effects of imatinib on thrombin-induced
endothelial barrier dysfunction, whereas knockdown of Arg
did.
Murine models were used to demonstrate the protective
effect of imatinib in vivo. Extravasation of fluid was evalu-
ated with Evan blue. Of note, however, vascular leakage and
pulmonary edema were compared between mice pretreated
with imatinib or saline. Although significant benefits were
noted in these experiments in mice pretreated with imatinib,
the potential clinical relevance of this finding for patients
with ongoing sepsis remained unclear. To address the clinical
relevance, the investigators assessed the effects of imatinib
treatment in animals with ongoing sepsis induced by cecal
ligation and puncture. In this model, imatinib was adminis-
tered 6 and 18 hours after induction of sepsis with assessment
of vascular leakage by Evan blue dye extravasation. The
study results demonstrated a significant attenuation of vascu-
lar leakage in the kidneys and the lungs 24 hours after the
induction of sepsis.
14
The opinions expressed in this article are not necessarily those of the
editors or of the American Heart Association.
From the Department of Integrative Medical Sciences, Northeast Ohio
Medical University, Rootstown, OH (M.S.P.); and Summa Cardiovascu-
lar Institute (M.S.P.) and Department of Medicine (M.K.), Summa Health
System, Akron, OH.
Correspondence to Marc S. Penn, MD, PhD, Northeast Ohio Medical
University, Summa Cardiovascular Institute, Summa Health System, 525
E Market St, Akron, OH 44304. E-mail mpenn2@neomed.edu
(Circulation. 2012;126:2677-2679.)
2012 American Heart Association, Inc.
Circulation is available at http://circ.ahajournals.org
DOI: 10.1161/CIRCULATIONAHA.112.146100
2677 by guest on May 3, 2014 http://circ.ahajournals.org/ Downloaded from
The data from this study further define the molecular
mechanisms associated with loss of endothelial barrier func-
tion in sepsis and the potential for imatinib inhibition of
endothelial dysfunction through preservation of rac1 (Figure).
The data further demonstrate a novel role for Arg kinase in
inducing endothelial barrier dysfunction in sepsis. Beyond the
specific effects of imatinib, these data further define the thera-
peutic potential of inhibiting thrombin in sepsis. The inhibition
can either be through inhibition of thrombin generation (eg,
with activated protein C) or specific downstream effects of
thrombin, such as Arg kinase, as seen in the study by Aman
et al
14
with imatinib (Figure).
The improvements observed in response to imatinib are in
contrast to those obtained with 3-hydroxy-3-methylglutaryl co-
enzyme A reductase inhibitors. 3-Hydroxy-3-methylglutaryl co-
enzyme A reductase inhibitors are known to aid in the
maintenance of endothelial barrier function, yet the inhibition
of 3-hydroxy-3-methylglutaryl coenzyme A reductase blocks
geranylgeranylation and downstream translocation of RhoA
and Rac1 to the cell membrane. Despite the downregulation
of Rac1 activity, 3-hydroxy-3-methylglutaryl coenzyme A
reductase has been shown to inhibit thrombin-mediated de-
creases in endothelial barrier function in vitro
5,18
and in vivo.
5
Whether this implies an as yet to be identified off-target effect
of statin therapy or the inhibition of superoxide through the
parallel inhibition of reduced nicotinamide-adenine dinucle-
otide phosphate oxidase remains to be determined.
On a cellular level, imatinib protects the endothelial barrier
and may prevent edema formation in the setting of thrombin
generation; however, it is interesting to note that periorbital
and pedal edemas are 2 of the most common adverse effects
of chronic imatinib treatment.
19,20
Clearly whether these and
other adverse effects represent confounding or problematic
consequences of off-target effects of imatinib on preservation
of endothelial barrier function awaits further investigation.
The authors hypothesize that duration of treatment and
specific inhibition of Arg and c-abl in individual vascular
beds may account for these findings. Given that treatment of
sepsis with imatinib could be achieved with short-term use, it
may lessen the potential for significant adverse effects attrib-
uted to inhibition of off-target kinases. Given the limited
treatments options and the devastating consequences of sig-
nificant loss of endothelial barrier function in sepsis, it would
appear that further investigation may be warranted to deter-
mine whether this interesting preclinical study has identified
real clinical potential.
Sources of Funding
This work was supported by the generous support of the Skirball
Foundation and the Corbin Foundation.
Disclosures
None.
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KEY WORDS: Editorials

edema

endothelial cells

shock
Penn and Kamath Imatinib Effects on Sepsis 2679
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