1. Eiseman B, Beart R, Norton L. Multiple organ failure. Surg Gynecol Obstet Mar;144(3):323-6.

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1 Proteomic Analysis of Human Mesenteric Lymph Max Wohlauer Dr. Eiseman Award Competition 5/2/11

2 BACKGROUND Despite intensive investigation, the supportive care initially proposed by Eiseman nearly 35 years ago remains the standard treatment for MOF. Initially, data from animal studies made gut bacterial translocation an attractive explanation for the pathogenesis of MOF. No endotoxin in the portal circulation of trauma patients despite a 30% incidence of MOF in this population, suggesting an alternative ti inflammatory source. 1. Eiseman B, Beart R, Norton L. Multiple organ failure. Surg Gynecol Obstet Mar;144(3): Carrico CJ, Meakins JL, Marshall JC, Fry D, Maier RV. Multiple-organ-failure syndrome. The gastrointestinal tract: the "motor" of MOF. Arch Surg. 1986;121: Moore FA, Moore EE, Poggetti R, McAnena OJ, Peterson VM, Abernathy CM, ParsonsPE. Gut bacterial translocation via the portal vein: a clinical perspective with major torso trauma. J Trauma May;31(5):629-36; discussion

3 BACKGROUND The lymphatic system was first documented during ancient times, but its significance remained obscure until the Renaissance period. The protein composition of lymph is nearly identical to that of interstitial fluid, and similar, although less concentrated, t than that tof plasma. An important exception is mesenteric lymph which contains a large amount of fat and other molecules resorbed from the intestine, giving it a unique descriptor: chyle. Human Lacteals Joannis Vesling, Padua.

4 Koch s 3 rd Postulate: Postshock Lymph is Sufficient to Provoke ALI. Shock / Trauma Cross-Transfusion Mesenteric Lymph Jugular Vein Lymph to Lung Acute Lung Injury Gut Ischemia / Reperfusion Activating lipids / proteins in lymph Wohlauer M, Moore EE, et al. Journal of Surgical Research. In Press.

5 HYPOTHESIS Characterization of the human mesenteric lymph proteome will advance the understanding of systemic inflammation and multiple organ failure.

6 METHODS Inclusion Criteria Injured patients admitted to the SICU at Denver Health Medical Center. Patients undergoing brain-dead organ donation at various hospitals in the Denver metro area.

7 Surgical Approach

8 Proteomic Analysis Lymph Sample Depletion Column 14 most abundant proteins Tryptic digestioni

9 Image from Sanger Institute LC/MS/MS

10 Human Lymph Bioactivity

11 Patient Profiles.

12 Representative Proteins Found in Lymph

13 Products of red blood cell hemolysis correlate strongly with human lymph bioactivity. A student s t-test test was used to determine significance between high and medium vs. low priming samples: * P < 0.1, ** < 0.05, *** < 0.01.

14 Examples of human lymph proteins with strong correlation with bioactivity.

15 Examples of human lymph proteins with strong negative correlation with bioactivity.

16 Immunoglobulins have a negative correlation with the pro-inflammatory lymph. Parametric analysis of immunoglobulin entries.

17 Conclusion These data substantiate the current body of research implicating post shock mesenteric lymph in the development of systemic inflammation and multiple organ failure. Further studies are underway to determine their role in the pathogenesis of MOF and as biomarkers.

18 References 1. Eiseman B, Beart R, Norton L. Multiple organ failure. Surg Gynecol Obstet 1977;144: Moore FA, Moore EE, Poggetti R, et. al. Gut bacterial translocation via the portal vein: a clinical perspective with major torso trauma. J Trauma 1991;31: Carrico CJ, Meakins JL, Marshall JC, Fry D, Maier RV. Multiple-organ organ-failure syndrome. The gastrointestinal tract: the "motor" of MOF. Arch Surg. 1986;121: Zallen G, Moore EE, Johnson JL, et. al. Posthemorrhagic shock mesenteric lymph primes circulating neutrophils and provokes lung injury. J Surg Res 1999;83: Peltz ED, Moore EE, Zurawel AA, et.al.. Proteome and system ontology of hemorrhagic shock:exploring early constitutive changes in postshock mesenteric lymph. Surgery 2009;146: Carrico CJ, Meakins JL, Marshall JC, et. al. Multiple-organ l organ-failure syndrome. The gastrointestinal t ti tract: t the "motor" of MOF. Arch Surg 1986;121: Lemaire LC, van Lanschot JB, Stoutenbeek CP, et. al. Thoracic duct in patients with multiple organ failure: no major route of bacterial translocation. Ann Surg 1999;229: Lord RS. The white veins: conceptual difficulties in the history of the lymphatics. Med Hist 1968 Apr;12(2): Kakhniashvili DG, Bulla LA, Goodman SR. The Human Erythrocyte Proteome. Mol Cel Proteomics 3(5): , 509, Oh SK, Pavlotsky N, Tauber AI. Specific binding of haptoglobin to human neutrophils and its functional consequences. J Leukoc Biol 47(2): , 148, Wright SD, Ramos RA, Tobias PS, Ulevitch RJ, Mathison JC. CD14, a receptor for complexes of lipopolysaccharide (LPS) and LPS binding protein. Science 249(4975): , 1433, Vreugdenhil AC, Rousseau CH, Hartung T, Greve JW, van 't Veer C, Buurman WA. Lipopolysaccharide (LPS)-binding protein mediates LPS detoxification by chylomicrons. J Immunol Feb 1;170(3): Lai KN, Leung JCK, Metz CN, Lai FM, Bucala R, Lan HY. Role for macrophage migration inhibitory factor in acute respiratory distress syndrome. J Pathol 199(4): , Zhang Q, Itagaki K, Hauser CJ. Mitochondrial DNA is released by shock and activates neutrophils via p38 map kinase. Shock Jul;34(1):55-9.