PULMONARY HYPERTENSION IN HIGH ALTITUDE NEWBORNS22 mmHg 18 17 17 18 mmHg Ross y cols, 2005....
Transcript of PULMONARY HYPERTENSION IN HIGH ALTITUDE NEWBORNS22 mmHg 18 17 17 18 mmHg Ross y cols, 2005....
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PULMONARY HYPERTENSION IN HIGH ALTITUDE NEWBORNS
ANÍBAL LLANOS M.D.
Laboratorio de Fisiología y Fisiopatología del DesarrolloPrograma de Fisiopatología, ICBM, Facultad de Medicina e INCAS,
UNIVERSIDAD DE CHILE.
ALFA-HAPPOM, DECEMBER 3, 2005-LYON, FRANCE
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ATMOSPHERIC O2 LEVEL VS TIME
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PAP in HIGH ALTITUDE
Moore y cols, 1998
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Abman, 1999
PPHT IN THE NEWBORN
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PULMONARY CIRCULATIONTRANSITION FROM FETUS TO NEONATE
Modificado de Abman, 1999
Hem
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NITRIC OXIDE (NO)
Derived from L-arginina and catalyzed by NOS
Three NOS isoforms : nNOS (I), iNOS(II) y eNOS(III)
eNOS in the blood vessels → vasodilation
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Travali y Patole, 2003
NO is an important pulmonary vasodilator
20 mmHg
22 mmHg
18 17 17 18 mmHg
Ross y cols, 2005
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HYPOTHESIS
Chronic fetal hypoxia determines pulmonary vascular hypereactivity in the neonatal period. This hypereactivity will be associated with a lesser expression/activity of the NO pathway and can be assessed as pulmonary hypertension
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p<0.05 : a, vs RNTB; b, vs basal; *, vs todo (dentro del grupo).
NEWBORN SHEEPPULMONARY CIRCULATION DURING ACUTE HYPOXIA-
0
25
50
PAP
(mm
Hg)
0
150
300
450
B B+I H+I R
GC
(ml.m
in-1
.kg-1
)
*a *
0
0,04
0,08
0,12
B B+I H+I RR
VP (m
mH
g.m
l-1.m
in.k
g)
*a aab
*
HIPOXIA
RNTB
RNTA
0 60 120 180Tiempo (min)
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0
150
300
450
B B+I H+I R
GC
(ml.m
in-1
.kg-
1)
L-NAME
**
a
0,0
0,1
0,2
0,3
B B+I H+I R
RVP
(mm
Hg.
ml-1
.min
.kg)
L-NAME
*
*
a
a
b b
0
20
40
60
B B+I H+I R
PAP
(mm
Hg)
*
*
bb
a
a
a
b
L-NAME
P<0,05: a vs RNTB, b vs basal, * vs todos.
NEWBORN SHEEPPULMONARY CIRCULATION DURING ACUTE HYPOXIA + L-NAME
0
20
40
60
B B+I H+I R
PAP
(mm
Hg)
*a a
a
ab
*
RNTB
RNTANaCl O.9%
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SUMMARY I
THE HIGH ALTITUDE NEWBORN SHEEP PRESENTS:
HIGH PULMONARY ARTERIAL PRESSURE AND RESISTANCE
NITRERGIC TONE IS IMPORTANT IN THE PULMONARY CIRCULATION.
NEVERTHELESS THERE IS PULMONARY HYPERTENSION
CONTRACTILITY OF THE PULMONARY ARTERIES?
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PULMONARY ARTERIES
RESPONSES TO KCl
0 20 40 60 80 100 120
0
1
2
3
0,0
1,0
2,0
pD2
0,0
1,0
2,0
3,0
N/m
Tens
ión,
N/m
KCl, mM
p<0.05 a vs RNTB
RNTB RNTA
a
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RESPONSES TO NPS
p<0.05 † vs LLNB
-10 -9 -8 -7 -6 -5 -4 -3
0
50
100
0,0
2,5
5,0
7,5
pD2
Tens
ión,
% K
MA
X
Log [SNP], M RNTB RNTA
a
p<0.05 a vs RNTB
PULMONARY ARTERIES
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SUMMARY II
THE HIGH ALTITUDE NEWBORN SHEEP PRESENTS:
HIGHER CONTRACTILE CAPACITY
HIGHER SENSITIVITY TO NPS, CONSISTENT WITH A HIGHER NITRERGIC ACTIVITY
eNOS EXPRESSION & NOS ACTIVITY IN THE PULMONARY ARTERIES & LUNG?
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0
15
30
45
60
RNTB RNTA
L-ci
trul
ine
form
atio
n (p
mol
. μg
prot
-1.3
0 m
in-1
)
0
0,25
0,5
0,75
1
RNTB RNTA
eNO
S/β
-act
in
(arb
itrar
y un
its)
0
0,25
0,5
0,75
1
RNTB RNTA
mR
NA
eN
OS/ β
-act
in
(arb
itrar
y un
its)
0
0,25
0,5
RNTB RNTA
sGC
/ β-a
ctin
(a
rbitr
ary
units
)
Significant differences p<0.05 : a, low-altitude vs high-altitude.
a
a
a
mRNA eNOS prot eNOS
actividad eNOS prot sGC
NOS-NO PATHWAY
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SUMMARY III
THE HIGH ALTITUDE NEWBORN SHEEP PRESENTS:
DECREASED eNOS PROTEIN EXPRESSION, HOWEVER ITS ACTIVITY IS AUGMENTED
DECREASED sGC PROTEIN EXPRESSION
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CONCLUSIONS NOS-NO
HIGH ALTITUDE & PULMONARY NO- PAP & PVR ↑ (with ↑ nitrergic tone)- eNOS mRNA =- eNOS protein ↓- eNOS activity ↑- sGC protein ↓
PARTIAL COMPENSATION OF THEHIPOXIC VASOCONSTRICTION
Remodelation? Vasodil/vasoconstriction?
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0
10
20
30
40
PAP
(mm
Hg)
RNTARNTB
0 60 120 180TIEMPO (min)
HIPOXEMIA
0
10
20
30
40
PAP
(mm
Hg)
HIPOXEMIA
0 60 120 180TIEMPO (min)
NEONATAL LLAMA & SHEEPPulmonary circulation during acute hypoxia
LLAMA OVEJA
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Herrera EA et alNEWBORN SHEEP NEWBORN LLAMA
0
10
20
30
40
B B + LNAME
PAP
(mm
Hg)
LASHHASH
0
10
20
30
40
B B + LNAME
PAP
(mm
Hg)
LALLHALL
0
0,1
0,2
0,3
B B + LNAME
PVR
(mm
Hg.
mL-1
.min
.Kg)
0
0,1
0,2
0,3
B B + LNAME
PVR
(mm
Hg.
mL-1
.min
.Kg)
ab
a
bc
b
a
ab
a
bc
aa
c
A. PAP in NB sheep with and without L-NAME, B. PAP in NB llama with and without L-NAME, C. PVR in NB sheep with and without L-NAME, D. PVR in NB llama with and without L-NAME
A. B.
C. D.
Significant differences p<0.05 : a, vs basal; b, low-altitude vs high-altitude; c, sheep vs llama (at same altitude).
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Herrera EA et al
0
15
30
45
60
LASH HASH LALL HALL
L-ci
trul
ine
form
atio
n (p
mol
. μg
prot
-1.3
0 m
in-1
)
0
0,25
0,5
0,75
1
LASH HASH LALL HALL
eNO
S/β
-act
in
(arb
itrar
y un
its)
0
0,25
0,5
0,75
1
LASH HASH LALL HALL
sGC
/ β-a
ctin
(a
rbitr
ary
units
)A. B.
C.
A. Western blot of eNOS, B. NOS total activity, C. Western blot of sGCSignificant differences p<0.05 : b, low-altitude vs high-altitude ; c, sheep vs llama (at same altitude).
b
b
b
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Herrera EA et al
0
0,25
0,5
0,75
1
LASH HASH LALL LASH
HO
-1/ β
-act
in
(arb
itrar
y un
its)
0
0,5
1
1,5
LASH HASH LALL HASH
HO
-2/ β
-act
in
(arb
itrar
y un
its)
A. B.
C.
A. Western blot of HO-1, B. Western blot of HO-2, C. CO lung production. Significant differences p<0.05 : b, low-altitude vs high-altitude; c, sheep vs llama (at same altitude).
0
1
2
3
4
5
LASH HASH LALL HALL
CO
pro
duct
ion
(mm
oles
CO
.min
-1.m
l-1)
b
b,c
b
bb
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0
0.2
0.4
0.6
0.8
1
1.2
OVTB OVTA0
0.2
0.4
0.6
0.8
1
1.2
LLTB LLTA
OVEJA LLAMA
SHEEP & LLAMA NEWBORNPDEV mRNA EXPRESSION IN PULMONARY TISSUE
Uni
dade
s re
latia
vs(P
DEV
/ 18
S)
Uni
dade
s re
latia
vs(P
DEV
/ 18
S)
OVTB: recién nacido de oveja de tierras bajas (n=5), OVTA: recién nacido de oveja de tierras altas (n=5), LLTB: recién nacido de llama de tierras bajas (n=5), LLTA: recién nacido de llama de tierras altas (n=5), p<0.05 (test de Student).
*
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VASODILATADOR NO-CO-cGMP MECHANISMS
Modificado de Carvajal et al. J. Cell. Physiol. , 2000.
K+
(+)
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SUMMARY IV
IN THE HIGH ALTITUDE NEWBORN LLAMA:
HEM OXYGENASE-CO, APPEARS TO BE CENTRAL IN THE REGULATION OF THE PULMONARY CIRCULATION
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Enero 2004
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HIGHLANDERS 2005RAQUEL RIQUELMEEMILIA SANHUEZAEMILIO HERRERA ROBERTO REYES
GERMAN EBENSPERGERBERNARDO KRAUSE
PAULA GÁLVEZANIBAL LLANOS
CARLOS BRITOMARIO MORALESGABINO LLUSCO
RENATO EBENSPERGERNATALIA MENDEZ
IRMA VALENZUELADANIEL PEÑA
EVELYN CRUZ RODRIGO ROJAS
JULIAN PARERENRIQUE VALDEZ
MARK HANSONCARLOS BLANCO
DINO GIUSSANI
FFDD
FINANCIAMIENTOFONDECYT 1010636 & 1050479-CHILE
THE WELLCOME TRUST- CRIG 072256-UK
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0 60 120 1800
10
20
30
40
50
Hipoxemia
45
Indometacina
Tpo (min)
PAP
(mm
Hg)
0 60 120 1800
10
20
30
40
50
H solaH indo
45
Indometacina
Hipoxemia
Tpo (min)
PAP RNOV Stgo (580m)PAP RNOV Putre (3600m)
PULMONARY ARTERIAL PRESSURE (PAP) IN NEWBORN SHEEPH ALONE VS H+INDOMETHACIN
n=5 n=6
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0
0,01
0,02
0,03
0,04
0,05
N H 20 40 80 100
CO (ppm)
PVR
(mm
Hg·
ml-1
·min
·kg-1
)INHALATORY CO & PVR
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HANB LANB
CHRONIC FETAL HYPOXIA FETAL NORMOXIA
PUTRE 3,600 m SANTIAGO 580 m
PDE5
PDE5
NOSsGCNO
NOSsGCNO
O2n
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PayachatasPayachatas 6330 mts6240 mts
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0
50
100
150
SAP
(mm
Hg)
0
100
200
300
400
HR (m
in-1
)
0 60 120 180 Time (min)
0,00
0,20
0,40
Basal Hypoxemia Recovery
SVR
(mm
Hg.
ml-1
.min
.Kg)
†* *
SYSTEMIC CIRCULATION - NEWBORN SHEEP
p<0.05, † vs basal, * vs RNTB.
SLSH
HLSH
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MECANISMO VASODILATADOR NO-CO
Hampl y Herget, 2000
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SYSTEM PHYSIOLOGYNEWBORN SHEEPCHRONIC INSTRUMENTATIONSUPERIMPOSED ACUTEHYPOXIA
L-NAME (20 mg.kg-1 + 0.5 mg.kg-1.min-1)
MEASUREMENT OF CARDIOVASCULAR VARIABLESPAP, PcP, CARDIAC OUTPUT, SAP, HR
- 1h BASAL- 1h HYPOXIA- 1h RECOVERY
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PAP & NO in High Altitude
Pulmonary NO in the chronic hypoxic neonate?
NO is a key mediator in thetransition from fetus ti
neonate
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0
10
20
30
40
PAP
(mm
Hg)
RNTARNTB
0 60 120 180TIEMPO (min)
HIPOXEMIA
0
10
20
30
40
PAP
(mm
Hg)
HIPOXEMIA
0 60 120 180TIEMPO (min)
NEONATAL LLAMA & SHEEPPulmonary Circulation during acute hypoxia
LLAMA OVEJA
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HOW THE OXYGEN IS SENSED?
• THE OXYGEN IS SENSED AS PO2
• CHEMORECEPTORS (e.g. carotid body, by inhibition of a potassium channel, generating an action potential traveling by the sinus nerve)
•In the PULMONARY ARTERY, in the ENDOTHELIUM and/or SMOOTH MUSCLE CELLS by inhibition of a potassium channel
• ADRENAL MEDULLA by inhibition of a potassium channel
• In all cells by means of the PROLYL HYDROXILASES and HIF-1
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EX VIVO STUDIES
ARTERIES 150-400 umMOUNTED ON A WIRE MYOGRAPH Optimal Diameter (KCl, 65 mM K+)
Maximal Contraction (KCl, 4,75-125 mM K+)PHARMACOLOGIC RESPONSE
SNP (10-10-10-3M)
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HIPOTHESIS
THE SMALL RESISTANCE ARTERIES OF THE PULMONARY CIRCULATION IN THE CHRONICALLY HYPOXIC NEWBORN SHEEP AT HIGH ALTITUDE HAVE ENHANCED CONTRACTILE RESPONSES THAN LOWLAND NEWBORN LAMBS
RESPONSES ex vivoPOTASSIUM CHLORIDESNP
AIM
TO DETERMINE THE SMALL RESISTENCE ARTERIES RESPONSES OF THE PULMONARY CIRCULATION IN HA AND LA NB SHEEP
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HYPOTHESIS
THE EXPRESSION & ACTIVITY OF THE NITRERGIC PATHWAY IS INCREASED IN THE LUNG OF HA-NB LAMBS, AS A COMPENSATORY MECHANISM TO COPE WITH THE PULMONARY HYPERTENSION IN HIGHLANDS
AIM
TO DETERMINE THE mRNA & PROTEIN EXPRESSION OF eNOS, sGC, AND NOS ACTIVITY
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BIOCHEMISTRY & MOLECULAR BIOLOGY TISSUE OBTENTION- mRNA EXPRESSION (RT-PCR)
eNOS, PDEV vs β-actin, - PROTEIN EXPRESSION (WB)
eNOS, sGCα vs β-actin- ACTIVITY
NOS
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