Summary
The main finding of this study was that sepsis impaired microvascular autoregulation during the initial stages of the septic injury. This was evident in two ways: 1) at the capillary level, we found a three- to fourfold delay in capillary response time within hypoxic capillaries (RBC SO2 < 20 %) and 2) at the RBC level, we detected a significant impairment in the ability of septic RBCs to release ATP in response to hypoxic conditions. Both of these findings are consistent with a loss of microvascular autoregulation. In the context of sepsis, this may be important because impairment of microvascular autoregulation may lie at the center of microvascular dysfunction and be an important factor in multiple organ failure by fundamentally altering local tissue O2 transport properties, as well as delivery of nutrients, antioxidants and elimination of waste products.
The data reported here suggest there is an uncoupling of local O
2 delivery from local O
2 demand leaving some tissue regions vulnerable to hypoxia and unable to rapidly respond to O
2 demand; this is consistent with Lam et al. [
4], who found septic skeletal muscle had a weaker microvascular response to electrical stimulation and increased O
2 demand than control. This impairment of microvascular autoregulation and capillary O
2 delivery may, however, be partially offset by increased NO production [
2] and local vasodilation, as skeletal muscle capillary RBC supply rate was found to correlate with increasing plasma NOx levels in this study. Previously, we detected an upregulation of iNOS within skeletal muscle, increased NO within the RBC, and increased NOx within plasma and septic skeletal muscle, 3–6 hours after septic injury [
2,
22]. As NO levels increase within septic tissue, we suspect one target is smooth muscle cells surrounding the arterial resistance vessels. The resulting vasodilation would increase blood flow in these vessels causing downstream increases in capillary RBC supply rate in capillaries that remained patent. Taken together with the finding that iNOS can inhibit cNOS (where constitutive NOS is associated with microvascular autoregulation) [
32], we hypothesize that a trade off occurs between local autoregulatory control of O
2 delivery at the microvascular level and a more general increase in flow as vascular resistance falls in sepsis. In skeletal muscle there is also evidence of increased capillary fast flow as sepsis progresses out to 24 hours [
3], suggesting fast flow may be a later response to an earlier loss of functional capillary density and microvascular autoregulation, although we found evidence of some fast flow during the onset of sepsis. While no tissue oxygenation data were collected in our model, tissue oxygenation measurements made in the septic heart [
33] and simulations of tissue PO
2 in septic skeletal muscle [
34] have suggested the septic tissue is hypoxic, but not anoxic.
Capillary O2 transport—30-second RBC SR–SO2–qO2 profiles
The imaging technique used in this study acquired high-resolution information on capillary RBC hemodynamics (RBC velocity and lineal density) and RBC hemoglobin O
2 saturation (SO
2). From this dynamic information we calculated RBC supply rate (SR) and O
2 supply rate (qO
2) in a capillary segment. The technology allowed a direct evaluation of capillary O
2 transport parameters at locations in the microcirculation where the majority of O
2 is off-loaded to tissue and RBC hemoglobin O
2 saturations are at their lowest values. Deviations in the linear relationship between RBC SR and qO
2 in sepsis animals (Additional file
6) suggested increased heterogeneity in the underlying factors affecting the SR–qO
2 relationship, including heterogeneous tissue O
2 consumption, maldistribution of capillary flow and impaired microvascular autoregulation.
The observed altered functional capillary density, increased capillary stopped-flow and capillaries with low O2 supply rates in the presence of very fast capillaries with high O2 supply rates were indications of increased microvascular heterogeneity, a maldistribution of capillary blood flow and a loss of microvascular autoregulation. Our findings of increased variability in the O2 supply rates and delayed capillary responses within hypoxic capillaries suggested the mechanism by which the RBC responds to hypoxic tissue and signals the vasculature to increase flow had been compromised during the onset of sepsis. Theoretically, arrested RBCs in stopped-flow capillaries would have the greatest potential to release ATP in response to hypoxic conditions increasing flow into the affected area. Evidence of increased capillary stopped-flow in sepsis is another indication that autoregulatory mechansims were severely impaired.
Microvascular autoregulation
While we found evidence of a delayed capillary response within hypoxic capillaries, our finding of decreased RBC O
2-dependent ATP efflux was initially somewhat surprising given the low RBC SO
2 observed in some capillaries, as increased O
2 off-loading should have induced a conformational change in hemoglobin that triggers increased ATP efflux and endothelial signaling. However, we found the opposite as ATP efflux decreased in hypoxic septic RBCs. Consistent with this inhibition of RBC ATP efflux and decreased plasma ATP levels in septic rats is the finding that plasma ATP levels are decreased in critically ill patients [
35].
The association of impaired RBC O
2-dependent ATP efflux with increased plasma NOx and lactate suggested that multiple mechanisms are involved in modulating microvascular autoregulation. In addition to metabolic factors, since erythrocyte deformation induces ATP release [
36‐
39], the possible inhibitory effect of decreased RBC deformability during sepsis [
22,
40,
41] on impaired RBC ATP efflux [
42] must also be considered. Since we have previously shown that RBC deformability rapidly decreased during the onset of septic injury (by 3–6 hours in this animal model [
22]) and decreased RBC deformability inhibits RBC O
2-dependent ATP release [
42], it is possible that changes in the biophysical properties of the RBC membrane may be a mechanism whereby RBC O
2-dependent ATP efflux was impaired during sepsis. Whether age renders RBCs more susceptible to decreased deformability [
41], or a particular subset of RBCs associated with decreased deformability [
22] leads to impaired RBC O
2-dependent ATP efflux is unknown.
In addition to biophysical changes in RBC deformability, biochemical inhibition of RBC glycolysis may be another factor in impaired RBC O
2-dependent ATP efflux. This is consistent with in vitro experiments reporting that both NO [
24] and lactate [
43] inhibit RBC O
2-dependent ATP efflux and the general principle that inhibiting RBC glycolysis impairs RBC O
2-dependent ATP efflux [
13]. As well, peroxynitrite, a derivative of NO and product of the reaction with superoxide anion, has been reported to both stimulate RBC glycolysis at low concentrations via band3 phosphorylation and irreversibly inhibit RBC glycolysis at higher concentrations [
44].
In addition to impaired RBC O
2-dependent ATP signaling, we recognize that impaired electrical coupling of endothelial cell signaling [
9] and impaired integrated capillary signaling due to increased capillary stopped-flow [
45] at the overall network level of autoregulation may also have been factors in the observed impaired microvascular autoregulation. While it was beyond the scope of this study, we also note that deoxyhemoglobin has been reported to convert nitrite anion to nitric oxide [
46], raising the possibility that RBCs within hypoxic capillaries were able to exert a dual level of control over microvascular autoregulation by 1) inhibiting ATP release [
24] (the hypoxic ATP signal from the RBC) and/or 2) inhibiting endothelial cell communication via NO release [
9] (the relay mechanism by which hypoxic regions communicate with resistance vessels to increase downstream flow).
However, since capillaries are not surrounded by smooth muscle any NO or NO derivatives released from hypoxic RBCs would have no direct vasodilatory effect at the venular ends of skeletal muscle capillary networks, where the lowest RBC O
2 saturations are detected, and thus neither of the reported hemoglobin-mediated vascular modulators, nitrite [
46] nor the more controversial S-nitrosohemoglobin [
47‐
49], were capable of having direct vasodilatory effects in the capillary networks where the lowest RBC hemoglobin O
2 saturations have been detected. The resistance vessels upstream of the capillary network are surrounded by smooth muscle and are NO targets; however, arterial O
2 saturations are unchanged in this sepsis model making release of NO from RBCs (or ATP release) along the arterial tree less likely. However, it is conceivable that feeding arterioles neighboring hypoxic tissue regions could be NO targets. Thus the source and targets of NO within the microvascular system during sepsis become of paramount importance in terms of microvascular autoregulation.
While NO is known to inhibit microvascular autoregulation at multiple points in the system (Fig.
5), and may be acting in a negative feedback loop controlling RBC function, we found that increases in arterial NOx correlated with increased capillary RBC supply rate in septic skeletal muscle, suggesting a shift from local control of capillary perfusion via endothelial NOS/NO to a more uncontrolled, but faster delivery of blood flow, as skeletal muscle iNOS/NO rapidly increased in this model [
2]. Consistent with this observation, iNOS/NO overproduction is considered a factor for increased coronary circulation during sepsis [
50]. Increased NO is also responsible for systemic vasodilation and arteriolar hyporesponsiveness [
29,
30]. Thus the pleotropic effects of NO on the cardiovascular system in general and the microcirculation in particular place NO in a central role in modulating microvascular autoregulation. Of further significance to overall organ function during sepsis is that NO inhibits mitochondrial respiration [
26,
27] dampening O
2 consumption during the onset of sepsis in our experimental model [
2] and seemingly inhibiting O
2 consumption when microvascular O
2 delivery is compromised. Decreasing oxygen consumption in hypoxic regions is possibly an additional protective mechanism [
51] that prevents tissue anoxia and certain cell death by decreasing O
2 consumption and thereby increasing O
2 diffusion distances in septic tissue with decreased capillary density. As well, similar responses in terms of NO upregulation and microvascular derangements are evident in the septic diaphragm and heart. If impairment of microvascular autoregulation does indeed exist in other septic organs, it may help explain altered gene expression in the septic heart [
33], as it responds to local hypoxia. Additional file
7 discusses broader implications of impaired microvascular autoregulation.
Study limitations and considerations
This study was specifically designed to consider skeletal muscle microvascular function at the capillary level and test the null hypothesis that sepsis has no effect on RBC O
2-dependent ATP efflux. Changes in capillary O
2 supply rate are due in part to upstream changes in arteriolar tone distant from sites where RBC O
2 saturation is lowest (the venular ends of capillary networks) indicating that conducted microvascular responses [
16,
25,
45] are integral to microvascular autoregulation. The other important distinctions to be made are: 1) the septic injury in this study does not involve systemic hypoxia, as arterial O
2 saturations were normal; rather, altered functional capillary density and micro-regions within capillary networks with stopped-flow or decreased capillary O
2 supply cause local hypoxia and thus a different mechanism is likely involved than that of hypoxic vasodilation [
23,
46,
52]; 2) the skeletal muscle NO environment in this model is known to be due to an upregulation of iNOS [
2]; 3) microvascular derangements exist in the face of hypotensive [
2], “relatively preserved” [
7] and even normotensive blood pressure [
3,
4] with fluid resuscitation, normal arterial O
2 concentration and cardiac output [
3,
4]. Thus microvascular dysfunction is apparently independent of mean arterial pressure and may be masked by seemingly normal cardiovascular parameters.
Increased arterial and tissue NOx previously reported in this sepsis model [
2] are suspected to result from NO oxidation reactions and the scavenging effects of oxy- and deoxyhemoglobin on NO [
53,
54]; however, previous EPR (Electron paramagnetic resonance) spectroscopy studies in our model have shown an accumulation of hemoglobin-NO [
22] in the septic RBC suggesting that NO could be accumulating within the RBC or regenerated by the RBC itself [
46], although the extent and effect of such a reaction in the context of tissue iNOS/NO upregulation and overproduction [
2] is unclear. While NO generated within the RBC, possibly by an RBC NOS [
55], could inhibit RBC glycolysis [
44] effectively reducing the RBC O
2-dependent ATP efflux [
24] in a negative feedback manner, the mechanism in sepsis is not understood. Any possible effects of NO
2− potentiating ATP efflux [
56] are unknown.