Figure 3 Cascade of events leading from AKI to ALI

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Figure 3 Cascade of events leading from AKI to ALI Figure 3 | Cascade of events leading from AKI to ALI. T cells are recruited to the lung and initiate caspase-3-mediated apoptosis of lung endothelial cells, which results in increased lung capillary permeability and non-cardiogenic pulmonary oedema (1). TNF acts via TNFR1 on lung endothelial cells resulting in endothelial cell apoptosis via caspase-3 activation, which causes increased lung capillary permeability and non-cardiogenic pulmonary oedema (2). TNF also activates NFκB which then increases both inflammation and apoptosis leading to endothelial injury, increased lung capillary permeability, and non-cardiogenic pulmonary oedema. AKI is associated with an increase in serum levels of proinflammatory cytokines such as IL-6, IL-8, and TNF, which is consistent with a SIRS response (3). Proinflammatory cytokines are increased in AKI due to their increased renal production, increased extrarenal production (for example, in the monocytes, liver, and spleen), decreased renal clearance, and decreased renal metabolism. Circulating IL-6 binds to circulating soluble IL-6R to engage gp130 on endothelial cells and increase production of IL-8. IL-8 production causes lung injury by facilitating neutrophil accumulation which leads to endothelial injury, increased lung capillary permeability, and non-cardiogenic pulmonary oedema. HMGB1 leads to TLR4 activation (4). The net effect is inflammation, neutrophil accumulation, endothelial injury, increased lung capillary permeability, and non-cardiogenic oedema. Abbreviations: AKI, acute kidney injury; ALI, acute lung injury; SIRS, systemic inflammatory response syndrome. Faubel, S. & Edelstein, C. L. (2015) Mechanisms and mediators of lung injury after acute kidney injury Nat. Rev. Nephrol. doi:10.1038/nrneph.2015.158