Inhibition of HIF-prolyl hydroxylases improves healing of intestinal anastomoses

Anastomotic leakage (AL) accounts for a major part of in-house mortality in patients undergoing colorectal surgery. Local ischemia and abdominal sepsis are common risk factors contributing to AL and are characterized by upregulation of the hypoxia-inducible factor (HIF) pathway. The HIF pathway is critically regulated by HIF-prolyl hydroxylases (PHDs). Here, we investigated the significance of PHDs and the effects of pharmacologic PHD inhibition (PHI) during anastomotic healing. Ischemic or septic colonic anastomoses were created in mice by ligation of mesenteric vessels or lipopolysaccharide-induced abdominal sepsis, respectively. Genetic PHD deficiency (Phd1–/–, Phd2+/–, and Phd3–/–) or PHI were applied to manipulate PHD activity. Pharmacologic PHI and genetic PHD2 haplodeficiency (Phd2+/–) significantly improved healing of ischemic or septic colonic anastomoses, as indicated by increased bursting pressure and reduced AL rates. Only Phd2+/– (but not PHI or Phd1–/–) protected from sepsis-related mortality. Mechanistically, PHI and Phd2+/– induced immunomodulatory (M2) polarization of macrophages, resulting in increased collagen content and attenuated inflammation-driven immune cell recruitment. We conclude that PHI improves healing of colonic anastomoses in ischemic or septic conditions by Phd2+/–-mediated M2 polarization of macrophages, conferring a favorable microenvironment for anastomotic healing. Patients with critically perfused colorectal anastomosis or abdominal sepsis could benefit from pharmacologic PHI.

[1]  E. Cummins,et al.  Mechanisms and consequences of oxygen- and carbon dioxide-sensing in mammals. , 2020, Physiological reviews.

[2]  F. Lasitschka,et al.  Prolyl Hydroxylase Inhibition Mitigates Pouchitis. , 2019, Inflammatory bowel diseases.

[3]  M. Strowitzki,et al.  Hypoxia-adaptive pathways: A pharmacological target in fibrotic disease? , 2019, Pharmacological research.

[4]  L. Szczech,et al.  Roxadustat Treatment for Anemia in Patients Undergoing Long-Term Dialysis. , 2019, The New England journal of medicine.

[5]  M. Strowitzki,et al.  Protein Hydroxylation by Hypoxia-Inducible Factor (HIF) Hydroxylases: Unique or Ubiquitous? , 2019, Cells.

[6]  S. Fichtner-Feigl,et al.  Recurring Anastomotic Leak-A Prospective Clinicopathological Investigation of a Distinct Disease Pattern. , 2019, The Journal of surgical research.

[7]  M. Strowitzki,et al.  High hepatic expression of PDK4 improves survival upon multimodal treatment of colorectal liver metastases , 2019, British Journal of Cancer.

[8]  S. Ying,et al.  Urokinase Attenuates Pulmonary Thromboembolism in an Animal Model by Inhibition of Inflammatory Response , 2018, Journal of immunology research.

[9]  M. Strowitzki,et al.  Pharmacologic inhibition of hypoxia‐inducible factor (HIF)‐hydroxylases ameliorates allergic contact dermatitis , 2018, Allergy.

[10]  F. Lasitschka,et al.  Loss of Prolyl-Hydroxylase 1 Protects against Biliary Fibrosis via Attenuated Activation of Hepatic Stellate Cells. , 2018, The American journal of pathology.

[11]  U. Keppler,et al.  Pharmacological HIF-inhibition attenuates postoperative adhesion formation , 2017, Scientific Reports.

[12]  C. Taylor,et al.  Regulation of immunity and inflammation by hypoxia in immunological niches , 2017, Nature Reviews Immunology.

[13]  S. Colgan,et al.  Epithelial Barrier Regulation by Hypoxia‐Inducible Factor , 2017, Annals of the American Thoracic Society.

[14]  D. Katschinski,et al.  Loss of PHD3 in myeloid cells dampens the inflammatory response and fibrosis after hind-limb ischemia , 2017, Cell Death & Disease.

[15]  P. Carmeliet,et al.  Haematopoietic prolyl hydroxylase‐1 deficiency promotes M2 macrophage polarization and is both necessary and sufficient to protect against experimental colitis , 2017, The Journal of pathology.

[16]  A. Shah,et al.  PHD2 Is a Regulator for Glycolytic Reprogramming in Macrophages , 2016, Molecular and Cellular Biology.

[17]  R. Flavell,et al.  Fibroblasts and myofibroblasts of the intestinal lamina propria in physiology and disease. , 2016, Differentiation; research in biological diversity.

[18]  P. Krarup,et al.  Therapeutic improvement of colonic anastomotic healing under complicated conditions: A systematic review. , 2016, World journal of gastrointestinal surgery.

[19]  J. Jeekel,et al.  Hyperbaric oxygen therapy improves colorectal anastomotic healing , 2016, International Journal of Colorectal Disease.

[20]  James N. Luo,et al.  Collagen degradation and MMP9 activation by Enterococcus faecalis contribute to intestinal anastomotic leak , 2015, Science Translational Medicine.

[21]  Y. Oike,et al.  Prolyl‐4‐hydroxylase domain 3 (PHD3) is a critical terminator for cell survival of macrophages under stress conditions , 2014, Journal of leukocyte biology.

[22]  M. Longaker,et al.  The Role of Hypoxia-Inducible Factor in Wound Healing. , 2014, Advances in wound care.

[23]  Xin Gao,et al.  The Burden of Gastrointestinal Anastomotic Leaks: an Evaluation of Clinical and Economic Outcomes , 2014, Journal of Gastrointestinal Surgery.

[24]  W. Huttner,et al.  Loss of Epithelial Hypoxia-Inducible Factor Prolyl Hydroxylase 2 Accelerates Skin Wound Healing in Mice , 2013, Molecular and Cellular Biology.

[25]  K. Sunagawa,et al.  Deletion of Phd2 in Myeloid Lineage Attenuates Hypertensive Cardiovascular Remodeling , 2013, Journal of the American Heart Association.

[26]  P. Krarup,et al.  Expression and inhibition of matrix metalloproteinase (MMP)-8, MMP-9 and MMP-12 in early colonic anastomotic repair , 2013, International Journal of Colorectal Disease.

[27]  A. Sica,et al.  Macrophage plasticity and polarization in tissue repair and remodelling , 2013, The Journal of pathology.

[28]  P. Carmeliet,et al.  Loss of the Oxygen Sensor PHD3 Enhances the Innate Immune Response to Abdominal Sepsis , 2012, The Journal of Immunology.

[29]  L. Vallières,et al.  CXCL1 can be regulated by IL-6 and promotes granulocyte adhesion to brain capillaries during bacterial toxin exposure and encephalomyelitis , 2012, Journal of Neuroinflammation.

[30]  K. Alitalo,et al.  Macrophage skewing by Phd2 haplodeficiency prevents ischaemia by inducing arteriogenesis , 2011, Nature.

[31]  E. Cummins,et al.  The Hydroxylase Inhibitor Dimethyloxallyl Glycine Attenuates Endotoxic Shock Via Alternative Activation of Macrophages and IL-10 Production by B1 Cells , 2011, Shock.

[32]  G. Semenza.  Oxygen sensing, homeostasis, and disease. , 2011, The New England journal of medicine.

[33]  Andrew L. Weinstein,et al.  Topical prolyl hydroxylase domain‐2 silencing improves diabetic murine wound closure , 2011, Wound repair and regeneration : official publication of the Wound Healing Society [and] the European Tissue Repair Society.

[34]  P. Carmeliet,et al.  Loss of prolyl hydroxylase-1 protects against colitis through reduced epithelial cell apoptosis and increased barrier function. , 2010, Gastroenterology.

[35]  A. Seluanov,et al.  Establishing primary adult fibroblast cultures from rodents. , 2010, Journal of visualized experiments : JoVE.

[36]  V. Borges,et al.  Epithelial and Mesenchymal Cell Biology Alternatively Activated Macrophages and Collagen Remodeling Characterize the Postpartum Involuting Mammary Gland across Species , 2010 .

[37]  Robert A. Harris,et al.  Loss or silencing of the PHD1 prolyl hydroxylase protects livers of mice against ischemia/reperfusion injury. , 2010, Gastroenterology.

[38]  H. Spiegel,et al.  ATIII attenuates endotoxemia induced healing impairment in the colon. , 2009, The Journal of surgical research.

[39]  F. Cadeddu,et al.  Colonic anastomotic leak: risk factors, diagnosis, and treatment. , 2009, Journal of the American College of Surgeons.

[40]  Petros Koumoutsakos,et al.  TScratch: a novel and simple software tool for automated analysis of monolayer wound healing assays. , 2009, BioTechniques.

[41]  A. Smith,et al.  Arginase-1–Expressing Macrophages Suppress Th2 Cytokine–Driven Inflammation and Fibrosis , 2009, PLoS pathogens.

[42]  Frederik De Smet,et al.  Heterozygous Deficiency of PHD2 Restores Tumor Oxygenation and Inhibits Metastasis via Endothelial Normalization , 2009, Cell.

[43]  C. Fielding,et al.  IL-6 Regulates Neutrophil Trafficking during Acute Inflammation via STAT31 , 2008, The Journal of Immunology.

[44]  P. Carmeliet,et al.  Fibrinogen drives dystrophic muscle fibrosis via a TGFbeta/alternative macrophage activation pathway. , 2008, Genes & development.

[45]  Robert A. Harris,et al.  Deficiency or inhibition of oxygen sensor Phd1 induces hypoxia tolerance by reprogramming basal metabolism , 2008, Nature Genetics.

[46]  R. Mason,et al.  Intraoperative assessment of colonic perfusion using scanning laser Doppler flowmetry during colonic resection. , 2000, Journal of the American College of Surgeons.

[47]  H. L. Young,et al.  Tissue oxygen tension as a predictor of colonic anastomotic healing , 1987, Diseases of the colon and rectum.

[48]  H. L. Young,et al.  Colonic anastomotic healing and oxygen tension , 1985, The British journal of surgery.

[49]  T. Schrock,et al.  Factors Contributing to Leakage of Colonic Anastomoses , 1973, Annals of surgery.

[50]  E. Cummins,et al.  The hydroxylase inhibitor dimethyloxalylglycine is protective in a murine model of colitis. , 2008, Gastroenterology.

[51]  B. Jobe,et al.  Clinical review: Healing in gastrointestinal anastomoses, Part I , 2006, Microsurgery.

[52]  R. Jaenisch,et al.  HIF-1alpha is essential for myeloid cell-mediated inflammation. , 2003, Cell.

[53]  U. Tantry,et al.  Intra-abdominal sepsis impairs colonic reparative collagen synthesis. , 1996, American journal of surgery.