Annexin V homodimer protects against ischemia reperfusion–induced acute lung injury in lung transplantation Kohei Hashimoto, MD, Hyunhee Kim, MSc, Hisashi.

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Annexin V homodimer protects against ischemia reperfusion–induced acute lung injury in lung transplantation Kohei Hashimoto, MD, Hyunhee Kim, MSc, Hisashi Oishi, MD, PhD, Manyin Chen, MD, Ilker Iskender, MD, Jin Sakamoto, MD, Akihiro Ohsumi, MD, Zehong Guan, MSc, David Hwang, MD, PhD, Thomas K. Waddell, MD, PhD, Marcelo Cypel, MD, MSc, Mingyao Liu, MD, MSc, Shaf Keshavjee, MD, MSc The Journal of Thoracic and Cardiovascular Surgery Volume 151, Issue 3, Pages 861-869 (March 2016) DOI: 10.1016/j.jtcvs.2015.10.112 Copyright © 2016 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 Diagram of study protocol. Diannexin or normal saline was added to donor pulmonary flushing solution, and administrated to recipient 5 minutes after reperfusion. The Journal of Thoracic and Cardiovascular Surgery 2016 151, 861-869DOI: (10.1016/j.jtcvs.2015.10.112) Copyright © 2016 The American Association for Thoracic Surgery Terms and Conditions

Figure 2 A homodimer of recombinant annexin V improves physiologic function of the transplanted graft. A, Oxygenation in the pulmonary venous blood was significantly improved (*P = .004). B, Gas exchange was better in the DN group (*P = .04). C, Peak airway pressure was decreased in the treatment group. (†P = .0001 in 2-way repeated analysis of variance; **P < .01 and *P < .05 in a post hoc Bonferroni test. D, The wet/dry ratio was lower in the DN group (P = .054). pO2, Partial pressure of oxygen; pCO2, partial pressure of carbon dioxide; C, control; DN, diannexin. The Journal of Thoracic and Cardiovascular Surgery 2016 151, 861-869DOI: (10.1016/j.jtcvs.2015.10.112) Copyright © 2016 The American Association for Thoracic Surgery Terms and Conditions

Figure 3 Localization of the homodimer of recombinant annexin V in the lung graft, and histologic assessment of lung injury. A, Representative images of the transplanted and native right lungs (in the same animal in the DN group) at 2 hours after reperfusion, stained with DN (green). The homodimer was localized primarily in the transplanted graft and rarely in the native right lung. In the alveolar area of the transplanted graft, DN staining was present along alveolar walls, mainly adjacent to the endothelium of alveolar capillaries (red = CD31 positive); blue = DAPI. B, Alveolar fibrin deposition was significantly improved (*P = .04). C, Representative images (x 200) from the C and DN groups, using H&E and MSB staining, demonstrating intra-alveolar fibrinous exudates (pink staining in MSB stain) in the C-group, which are much less apparent in the DN group. DN, Diannexin; DAPI, 4′, 6-diamidino-2-phenylindole; C, control; H&E, hematoxylin and eosin; MSB, Martius scarlet blue. The Journal of Thoracic and Cardiovascular Surgery 2016 151, 861-869DOI: (10.1016/j.jtcvs.2015.10.112) Copyright © 2016 The American Association for Thoracic Surgery Terms and Conditions

Figure 4 Analyses of cell death in plasma and graft. A, TUNEL-positive cells were lower in the DN group (P = .15). B, Plasma CK18-M30 was significantly higher in the control group, compared with the DN group (*P = .013). C, Western blot analysis in the graft of expression of proapoptotic proteins. The expression of PARP and caspase 3 were probed using respective anti-rat antibodies. The relative density of cleaved/full-length molecules showed that the DN group had a significantly lower ratio in PARP (*P = .01), and lower caspase 3 (P = .89). In the picture of PARP, the upper blots represent full-length PARP; lower blots represent cleaved PARP. TUNEL, Terminal deoxynucleotidyl transferase dUTP nick end labeling; CK18-M30, caspase-cleaved cytokeratin 18; HPF, high-powered field; C, control; DN, Diannexin; PARP, poly (ADP [adenosine diphosphate]-ribose) polymerase-1. The Journal of Thoracic and Cardiovascular Surgery 2016 151, 861-869DOI: (10.1016/j.jtcvs.2015.10.112) Copyright © 2016 The American Association for Thoracic Surgery Terms and Conditions

Figure 5 Intragraft proinflammatory cytokine and adhesion molecule expression patterns. A, Reverse transcriptase-polymerase chain reaction analysis showed that the homodimer of annexin V significantly decreased the expression of mRNA coding for IL-6 (*P = .012) and MIP-2 (†P = .03), but not significantly for GRO (P = .14) or IL-1β (P = .21). B, An enzyme-linked immunosorbent assay showed that the homodimer significantly decreased the protein level of IL-6 (*P = .001) but not MIP-2 (P = .84), GRO (P = .31) or IL-1β (P = .07). C, Western blot analysis for ICAM-1 (n = 6 each group) showed that the homodimer ameliorated the expression of ICAM-1 in the graft (*P = .01). Samples analyzed for the Western blots are the same as for PARP and caspase-3 analysis. IL, Interleukin; MIP, macrophage inflammatory protein; GRO, growth-regulated oncogene; mRNA, messenger ribonucleic acid; C, control; DN, Diannexin; ICAM-1, intercellular adhesion molecule 1; PARP, poly (ADP [adenosine diphosphate]-ribose) polymerase-1. The Journal of Thoracic and Cardiovascular Surgery 2016 151, 861-869DOI: (10.1016/j.jtcvs.2015.10.112) Copyright © 2016 The American Association for Thoracic Surgery Terms and Conditions

Figure 6 Analysis of fibrinolysis and coagulation signals. A, The mRNA of PAI-1 (P = .054) in the graft and plasma protein level of PAI-1 level (*P = .009) was decreased in the DN group. B, The TAT complex level (P = .84) in the graft, and the plasma thrombin level (P = .67) were similar across study groups. PAI-1, Plasminogen activator inhibitor-1; mRNA, messenger RNA; C, control; DN, Diannexin; TAT, thrombin-antithrombin. The Journal of Thoracic and Cardiovascular Surgery 2016 151, 861-869DOI: (10.1016/j.jtcvs.2015.10.112) Copyright © 2016 The American Association for Thoracic Surgery Terms and Conditions

Functional improvement of the rat transplanted lung by diannexin treatment. The Journal of Thoracic and Cardiovascular Surgery 2016 151, 861-869DOI: (10.1016/j.jtcvs.2015.10.112) Copyright © 2016 The American Association for Thoracic Surgery Terms and Conditions