hAAT therapy has long been linked to accelerated wound healing, and so the question of whether it also accelerated wound healing in the presence of an underlying oxidative microenvironment drew interest. Although hAAT is not inherently a potent antioxidant (43), it consistently displays significant benefits in conditions of oxidative stress, as is evident in the impact of hAAT treatment on renal, hepatic, pulmonary and cardiac ischemia-reperfusion injuries, as well as in cerebral stroke (44–50). Feng et al. describe hAAT as preventing the development of preeclampsia in mice through suppression of oxidative stress, observing a dose-dependent impact between hAAT and the expression of superoxide dismutase (SOD), endothelial nitric oxide synthase (eNOS) and glutathione peroxidase (51). Here, in evaluating wound closure in mice, hAAT+/+ mice exhibited accelerated wound healing compared to wild-type mice in wounds inflicted on previously irradiated skin. Despite hAAT not influencing ROS levels or oxidative stress in cultured macrophages, its topical application significantly enhanced wound healing in a model of wound repair in the context of venous insufficiency.
Oxidized clinical-grade hAAT (hAATOX) demonstrated diminished elastase inhibition and impaired in-vitro epithelial gap closure, in correlation to the degree of oxidation. The results of the present study suggest that the degree of oxidation of hAAT influences the functional properties of hAAT. Figure 8 graphically summarizes the differing effects associated with hAAT and hAATOX on tissue response to injury. On the one hand, they playa role in normal wound healing by promoting the resolution of inflammation, on the other hand, under pathologic circumstances such as radiation injury or hemosiderin tissue deposition, they may act as a pro-inflammatory and oxidative agent. The highly oxidized form of hAAT lacks elastase inhibition and contributes to a pro-inflammatory environment, while less oxidized forms of hAAT, though also lacking elastase inhibition, retain some anti-inflammatory properties and still support epithelial gap repair. How does the gradient effect occur at the molecular level? It is suggested that the methionine residue at position 358 in hAAT is sterically exposed and readily oxidized (52). Other methionine residues on the globular surface of the molecule are not as approachable and display unique selectivities to various oxidative agents, most probably due to their physical orientation and neighboring amino acid residues (43, 53). Once these methionine residues do become oxidized, they are likely to cause structural distortion that may result in changes to the properties of hAAT beyond the mere elimination of elastase inhibition, namely, its ability to bind to a plethora of molecular targets (54, 55).
The initial evaluation of hAAT in promoting wound healing in radiation-damaged skin pointed to a complex interaction with oxidative environments. Accordingly, the effect of hAAT on wound repair in radiation-damaged skin differed from its impact on iron-treated skin. In irradiated skin, hAAT initially provided no benefit and possibly exacerbated wound repair in the first seven days, but then led to significantly better wound closure compared to WT irradiated skin. In contrast, on iron-treated skin, topical hAAT treatment showed early benefits in wound healing as soon as three days post-injury. The disparity in response may be explained by the different sources of ROS in both models; radiation-induced ROS result from photochemical reactions causing damage to keratinocytes, fibroblasts and melanocytes, while iron-induced ROS are linked to dysfunction of vascular endothelial cells, local fibroblasts and smooth muscle cells. Future studies should investigate the relationship between ROS-related damage and hAAT treatment, particularly in fibroblasts and endothelial cells, given the intimate protective effects of hAAT on endothelial cell injury (56–60). It is plausible that in iron-treated models, hAAT improves vascular health that is the primary driver of the poor underlying conditions, whereas on irradiated skin, the beneficial effects of hAAT might require a gradual advancement of neovessels, as shown by Bellacen et al. to occur in the presence of hAAT over several days (61).
hAAT has consistently shown improved epithelial cell gap closure outcomes across various studies. Here, gap closure appeared unchanged between hAAT and hAATOX at low oxidative exposure (0.5 mM of H2O2), while at the intermediate degree of oxidation (5 mM of H2O2), hAATOX was far less beneficial per the same concentration of native hAAT. Notably, hAATOX generated in the presence of 25 mM H2O2 significantly stunted gap closure throughout the entire 12-hr follow-up. Cells appeared macroscopically stressed but viable in the presence of hAATOX 25mM, suggesting that the mechanism for the stunting of gap closure has to do with flawed repair pathways rather than epithelial cell death. Interestingly, focusing on progression in gap closure between 6 hours and 12 hours from monolayer disruption, both hAATOX 0.5mM and hAATOX 5mM allowed gap closure advancement, most notable in the hAATOX 5mM setting (closure advanced from 62.12 ± 5.05% gap area at 6 hrs to 23.39 ± 4.28% at 12 hrs, p = 0.0011); nonetheless, these values are still impaired compared to the impact of native hAAT, which had advanced the gap area from 21.36 ± 12.93% at 6 hrs to complete closure at 12 hrs.
In a macrophage stimulation assay, treatment of cells with H2O2 induced IL-1β, IL-1Ra, TNFα, CXCL-1, iNOS and catalase, at all three concentrations of H2O2 exposure (0.5, 5 and 25 mM). However, hAAT that was treated with 0.5 mM H2O2 did not cause this response, and, more importantly, induced IL-1Ra expression as early as 3 hours from treatment. The rise in IL-1Ra at a time when IL-1β expression is low renders the system anti-inflammatory. As expected, 12 hrs from treatment, genes that are downstream to IL-1β/TNFα exhibited more profound responses compared to their 3-hr state of expression. Cytokine concentrations in supernatants were not tested in the current experimental system and may be of interest in future studies. Interestingly, according to transcriptome data generated by Sivaraman et al., hAATOX primarily affects genes related to transcriptional regulation, while native hAAT affects genes involved in inflammatory pathways (62). NF-κB, the key transcription factor for regulating inflammatory responses and oxidative stress (63, 64), is typically inhibited by hAAT, as was recently revisited in a model of hAAT-transgenic Drosophila (65). Taken together, these findings suggest that oxidative modifications of hAAT can impair its anti-inflammatory properties (30, 66).
Despite the clear impairment to anti inflammatory properties, Schuster et al. (27) demonstrated that native hAAT selectively allows for nuclear localization of the p65 (RelA) subunit of NF-κB in favor of inducible IL-1Ra expression. This suggests that hAAT skews NF-κB activity rather than inhibits it altogether, as would occur in the case of, e.g., corticosteroid therapy (27, 67). Janciauskiene et al. (33) and Lechowicz et al. (35) reported that oxidative modifications of hAAT can both exacerbate and ameliorate inflammatory responses, depending on the experimental context. In addition to a possible biological bifurcation, there is variation in laboratory techniques for hAAT oxidation that may account for some of the different experimental outcomes. For instance, in a study by Janciauskiene et al. (68) hAAT was oxidized using N-chlorosuccinimide in a 25 molar excess, while in a study by Alam et al. (69) hAAT was oxidized by exposure to cigarette smoke extract. In some studies, both native and oxidized forms of hAAT were found equally effective (70) whereas in others, addition of native hAAT was required in order to attenuate the inflammatory response induced by hAATOX. hAATOX treatment led to increased expression of iNOS and catalase, as well as increased activation of the Nrf2/ARE pathway, and levels of ROS in macrophage cultures. This indicates that hAATOX induces oxidative stress in an oxidation-dependent manner. Native hAAT did not directly mitigate these oxidative effects, suggesting that its anti-inflammatory properties may be independent of its antioxidant implications. An intriguing exception is observed in the case of Nrf2/ARE pathway activation. At low oxidative conditions, the pathway is suppressed relative to the effect of the oxidative stress itself (Fig. 8 second column from right), yet it is significantly enhanced at intermediate and high oxidative conditions (two left columns). This phenomenon suggests that an environment with mild oxidative stress renders hAAT a putative singular agent distinct from its native form or its highly-oxidized form. In this state, it lacks elastase inhibition capacity thus allowing neutrophil migration through tissues, but allows for inflammatory induction of iNOS and catalase, all while still promoting epithelial gap closure. The close relationship between hAAT and neutrophils is perhaps best represented by the fact that neutrophils actively release hAAT upon degranulation, potentially serving to support adjacent tissue along their destructive path (71). At the other extreme, in conditions of high oxidative stress, such that most probably occur in the presence of an injured tissue laden with activated neutrophils and macrophages (left column), hAATOX exhibits proinflammatory activity. These findings indicate the possibility of using supplementary hAAT treatment in specific circumstances, like as difficult-to-heal wounds, where one's own hAAT may lose its tissue protective attributes and become a pro-inflammatory agent.
Clinical manifestations of hAAT treatment for irradiated skin may include addressing poor wound healing of a surgical resection on skin that underwent radiotherapy in advanced head and neck cancer (72), or potential minimization of severe oral complications after maxillary radiotherapy (73). Clinical manifestations of hAAT treatment for venous insufficiency may include prevention of ulcer development (74). In addition, hAAT oxidation is physiologically reversible, both enzymatically and in the presence of reducing agents (43). This has allowed for an improvement to hAAT activity, through the introduction of antioxidants(33). For example, in baboons, treatment of severe bronchopulmonary dysplasia with antioxidants resulted in the enhancement of the anti-elastase activity of AAT (75). In fact, an oxidation-resistant, recombinant hAAT was developed as early as in 1984 (76) and was recently revisited in a study that showed that it prevents neutrophil elastase-induced cell death (77). It has been proven safe for introducing oxidation-resistant hAAT to patients with genetic AAT deficiency via adenovirus technology (78). It would be interesting to explore the implementation of this technology in pathologies of excessive oxidation, particularly where impaired wound healing is involved and topical hAAT is considered.
Taken together, the present study demonstrates that the oxidation level of hAAT plays a key role in determining its effects on inflammation, oxidative stress and tissue repair. This adaptable and reversible molecular characteristic is readily influenced by local signals, and offers an additional explanation for the remarkable clinical safety record of hAAT augmentation therapy. This is observed in individuals who are not genetically deficient in hAAT and yet receive hAAT treatment for other indications (79–86). Lastly, the study highlights the ability of hAAT to function independent of elastase inhibition, an emerging field which presents opportunities to develop and implement novel recombinant forms of hAAT (24, 87, 88). Additional investigation is required to clarify the processes behind the varying impacts of oxidation on hAAT, with an emphasis on exploring changes in affinity between hAAT and its rich repertoire of binding partners (54, 55). Future research should also explore hAAT’s effect on other medical conditions, particularly in the context of oxidative stress and inadequate tissue repair.