Chapter

11
Ischemia-reperfusion
injury
   
     
     
     
     
     
     
     
     
     
   
 Simple phenomenon
Brief history

• 1 ９５５年， Sewell ligated cor

onary artery of dog, restore
blood flow after deligation.
• What happened for this heart?
• １９６０年， Jennings suggest th
e concept of myocardial reperfu
sion injury firstly.
Clinic
：
• Shock , DIC
• Bypass surgery
• Fibrinolytic therapy
• Cardiopulmonary operation
• Organ transplantation
PTCA (percutanerous
transluminal
coronary
angioplasty/stent),
Cardiopulmonary
resuscitation
Features of IRI ：
1. reversible  irreversible
2. Massive in organs
3.participating factors
oxygen paradox
calcium paradox
pH paradox
 perfusion perfusion

oxygen Without O2
Normal O2
supply
paradox
Deteriorate
calcium without with
injury
Ca2+ Ca2+
paradox
Correcting
pH acidosis acidosis
paradox
Concept of Ischemia-Reperfusion
Injury

The restoration of blood flow after

transient ischemia may induce
further reversible or irreversible
cellular injury
 Section 1 etiology of IRI

1. Duration of ischemia
2. Dependency on O2 supply
3. The condition of reperfusion:
reperfusion pressure, speed, T
,
Na+, Ca2+, K+, Mg2+
 Effect of Ischemic time on perfusion
arrhythmia of rat
100
90
80
70
60
incidence
发生率（%） rate 50 RVA
40 RVT
30 RVF
20
10
0
5min 10min 30min
Ischemic time
缺血时间（min)
 Section 2
mechanism of IRI
Part 1. Injury of free
radicals
 concept and types of FR

Free radicals are atoms or molecule

s with unpaired electrons in their
outer orbital.

1. Non-lipid free radicals

2. Lipid free radicals
The Nobel Prize in Chemistry

• 1971： Gerhard Herzberg

• for his contributions to electronic structure and
the geometry of molecules, particularly free
radicals

CELLS
Classification
(1) Oxygen free radical （ OFR)
• Induced by O2
O·-2
types OH·
1
O2
OFR
Active H 2O 2
oxygen ONOO-
                                        
In a nutshell, this is how you could summarize his theory:
(2) Lipid radicals
types ： L·
LO·
LOO·

(3) Cl· 、 CH3 · 、 NO ·

 1. generation of free radical
1) Initiation
2) Propagation
3) Degradation
(1)Production and scavenging of
OFR
1) Origin of O·-2 ：
①Mt
②natural oxidation of some substance
s
③enzyme catalysis
④toxin acting on cell 毒物作用于细胞
2 ） production process of OFR

O2 + e O2 
O2+ 2e + 2H+ H2O2
SOD
Cytaa3
O2 + 3 e + 3H+ HO + H2O
H2O2 nse
O2 + 4 e + 4H+ 2 H2O

Single electron
Single electron reductio
reduction of O2
Dismutation reaction
Single electron reduction
of O2
SOD
2O2  + 2H+ H2O2 + O2

H2O2 nse
 Haber-Weiss reaction (without
Fe
2
)


O2 － + H2O2 O2 + OH +OH
SLOW
 Fenton type of Haber-Wei
ssreaction( with ) Fe
3

2
Fe
O2 
－ + H2O2 O2 + OH +OH
Fast

What significance ？？？

 .
OH 化学效应
 3 ） Scavenging of OFR
*low molecule ~

 hydrofacies of intra- or extracell: Cytosol ： NADPH

Cysteine 、 Vit C 、
Glutathione

Cellular lipid ：
Vit E 、 Vit A
 *enzymatic ~

Glutathione peroxidase Catalase (CAT)

(GSH-Px)

Superoxide dismutase
SOD
GSH-Px : containing selenium
scavenging large biological molecule p
eroxide

LOOH + 2GSH GSSG + LOH + H2O

GSH-Px

GSH reductase

2GSH + NADP+ GSSG + NADPH + H+

(2) Mechanism of OFR ↑during IRI
 1) mitochondria pathway
Single electron
Ca2+ enter Mt reduction of O2
↑

hypoxia MnSOD  O -
2 ·↑
2) Xanthine oxidase(XO) pathway↑

xanthine oxidase (XO )10%

Ca 2 + sensitive enzyme

xanthine dehydrogenase(XD) 90%

 ischemia ATP degradation Hypoxathine↑↑
:
O2
reperfusion (1)Ca2+→protease
:
xanthine + O·-2+ H2O2
XD XO

（ 2 ） restore O2 O2
O·-2+ H2O2 +uric aci
d
XO role in formation of OFR
OH ·
3)Neutrophil pathway

Activates NP  hexose bypass

C3,LTB4
activation
Respiratory
burst

NADH oxidase
NADH(I) H+ + O- ·+H O
NADPH(II) + O2
2 2 2

NADPH oxidase
4) Catecholamine autooxidat
ion pathway
Methyl transferaseVanillylmandelic
Adr monoamine oxidase acid (VMA)

80% during stress

Renal
O2 - ·  adrenochrome excretion
(3) the detrimental effects of
OFR to tissue
1 ） lipid membrane
2 ） protein: channel, pump,
3 ） enzyme
4 ） nuclear acid : DNA
Membrane lipid peroxidation
Biomacromolecle linkage

Protein ~
Lipid –pro ~
Two sulfur ~
Protein
break
-S-S-

OH OH
HO HO

CH3-S-
O Lipid-lipid ~
Amino acid fatty acid
oxidation MDA released by oxidated
oxidation fatty acid

Malondialdehyde(MDA)
 DNA disruption and
chromosome aberration

induced by OH
about 80% damage
Part 2 Calcium overload
 1. Calcium transportation and
distribution

Ca 2+

Ca 2+
Ca2+
binding Pr Ca2+pump

SR
Ca 2+ Channel
Na + -Ca 2+ cotr
ansportor
Mt
2. Mechanism of ~
① Na+ - Ca2+ exchange↑
②ATP ↓: mitochondria,
precursor ↓
③Membrane permeability ↑
④catecholamine ↑
 NE H+ Ca2+

α1 P1
Gq PLC
Na+
DG
IP3 PKC
Ca2+ Ca2+
SR
filament

PKC activating Na+/Ca2+ exchanger indirectly

3. the detrimental effects of Ca
2+ overload to tissue

(1) Activating Ca2+-activated protease

(2) Defects in membrane permeability
activating phospholipase A2
OFR
(3) Hypercontracture and reperfusion a
rrhythmia
cellular electrical action
(4)mitochondria damage
Part 3. The endothelial injury an
d neutrophil activation
1.The role of neutrophil activated
①Swelling
②Adhesion
③Infiltration
④Release: arachidonic acid, PAF, lysosomal e
nzyme
⑤Respiratory burst
⑥Cell adhesion molecules(CAM):
selectins, integrins, immunoglobulin superf
amily
2.mechanism of no-reflow phen
omenon
• Vaso-endothelial damage
• Vaso-endothelial edema
• Occlusion of microvascular lu
man
 Rulo:

肉膜
3.NO and ONOO production
-
（ 1 ） NO
• NO in VEC, little, physiological
• NO in inflammatory cell, rich, cytotoxic (Mt
respiration, aconitase activity, DNA synth
esis) and OONO-
Brief summary Change of metabolism
& energy

Ca2+ ？
OFR

VEC -NP

Ca2+ overload results in cellular death

Section 3 Body change duri
ng IRI
 1. Heart
（ 1 ） reperfusion arrhythmia
ATP–sensitive K+ channel open , hype
rpolarization
long chain acylcarnitines and lysoph
ospholipids released reduced conduction ve
locity
 Heart’s Electrical System

Bundle of His

Sinus (SA) LA
node
AV node Mitral Valve
RA
Purkinje fibers
Tricuspid
Valve LV
RV
AP shortening + conduction slowing
= re-entrant arrhythmia

OFR, AP duration
NE, Ca2+,
phosphoinositide, KATP channel
Na+, K+
（ 2 ） myocardial stunning
Myocardial contractile function is
temporarily but reversibly impaired for a
period of hours to days
5 min ischemia , reperfusion , 40min later
restoring
1 hr ischemia , reperfusion , a month later
restoring
 Mechanism of myocardial
stunning
• OFR
• Ca2+ overload
• No-reflow

• ATP + sensitivity for Ca2+

（ 3 ） myocardial metaboli
sm
ATP depletion
ATP substrate catabolized, rus
hed out
 Processes Involving Energy Production and
Utilization by the Myocardium
Ca++
Ca++

Ca++
O2
TCA cycle ATPase
C
Fatty Acids ATP Ca ++

Lactate (Aerobic) O
Pyruvate N
ATP PC ADP CA++T T T
R
Glycolysis ATP C
A
(Anaerobic) CPK
ATPm + A MA + ADP
C
Myokinase T
Glucose
Glucose-1-PO4 I
O
Glycogen
N
Energy Sources Energy Pool Energy Use

tricarboxylic acid cycle phosphocreatine

（ 4 ） myocardial ultrastr
ucture
2. Cerebral ischemia-reperfusion
injury
3.Hepatic Ischemia-Reperfusion
Injury
(4) Renal ischemia-reperfusion
injury
 Section 4 principle of
prevent and treatment
1. Controlling reperfusion condition
2. Antioxidant and OFR scavenging agents
3. Inhibition of neutrophil activation
4. Ca2+ antagonists or Ca2+ channel blocker
 How prevent and treat IRI

(1) Restore normal perfusion of tissue in

time
(2) Pharmacologic agents
Ca2+ antagonist, Ca2+ channel blocker
OFR scavenging agents
glutathione peroxidase(GP)
GSH + H2O2 GSSG + H2O
GP
Acute preconditioning:
(classical preconditioning)
• within ~2 h
• protein synthesis-independent

Delayed preconditioning:
(ischemic tolerance)
• 24 h - 72 h after the initial insult
• altered gene expression→synthesis of
proteins (antioxidant enzymes, NO
synthase, etc.).