Re: 만성염증의 호전 과정 2018 네이처

[문형철]

아래 영상대로

염증을 일으키는 글루텐, 유당, 과당, 설탕을 끊고

비타민, 미네랄 결핍 불균형을 개선하고

16시간 공복으로 자가포식학

미생성 운동을 하면 만성염증은

2주면 50% 이상

1개월이면 70-80%%

3개월이면 90%이상 치료가능하다.

네이처조차도 헛다리를 짚고 있는 것이 아닌가 싶다!!

https://www.youtube.com/watch?v=GNxZ8VRmhnc

1. nature  
2. nature communications  
3. review articles  
4. article

Resolution of chronic inflammatory disease: universal and tissue-specific concepts

• Review Article
• Open access
• Published: 15 August 2018

Resolution of chronic inflammatory disease: universal and tissue-specific concepts

• Georg Schett & 
• Markus F. Neurath 

Nature Communications volume 9, Article number: 3261 (2018) Cite this article

• 29k Accesses

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Abstract

Inflammation and its resolution is under-studied in medicine despite being essential for understanding the development of chronic inflammatory disease. In this review article, we discuss the resolution of inflammation in both a biological and translational context. We introduce the concept of impaired resolution leading to diseases like rheumatoid arthritis, Crohn's disease, and asthma, as well as the cellular and molecular components that contribute to resolution of joint, gut, and lung inflammation, respectively. Finally, we discuss potential intervention strategies for fostering the resolution process, and their implications for the therapy of inflammatory diseases.

초록

염증과 그 해결 과정은

만성 염증성 질환의 발병 메커니즘을 이해하는 데 필수적임에도 불구하고

의학 분야에서 충분히 연구되지 않았습니다.

본 리뷰 논문에서는

생물학적 및 번역 의학적 맥락에서 염증의 해결 과정을 논의합니다.

류마티스 관절염, 크론병, 천식 등 질환으로 이어지는 염증 해결 장애의 개념을 소개하며,

관절, 장, 폐 염증의 해결에 기여하는 세포 및 분자적 구성 요소를 각각 설명합니다.

마지막으로,

해결 과정을 촉진하기 위한 잠재적 개입 전략과

염증성 질환 치료에 대한 함의를 논의합니다.

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Introduction

Inflammation is characterized by a sequence of events comprising an induction phase, which leads to the peak of inflammation and is gradually followed by a resolution phase. The induction phase of inflammation is designed to allow fast and robust immune activation that is required for effective host defense. It is initiated by the sensing of exogenous and endogenous danger signals resulting from mechanically, chemically, or biologically induced tissue damage followed by the recruitment of effector cells, which orchestrate an inflammatory response characterized by the release of lipid and protein mediators of inflammation1.

The resolution phase of inflammation is essential to curtail inflammation and restore tissue homeostasis once the danger signal has been eliminated2. It is therefore self-evident that the resolution process is tightly controlled2. Failure to resolve inflammation leads to chronic inflammatory diseases at the inner surfaces of the body, such as arthritis, colitis, or asthma, which are associated with irreversible tissue damage and increased risk for development of cardiovascular disease, cancer, and osteoporosis3,4,5. Factors that can overcome effective resolution processes are (i) genetic factors that encode for exaggerated immune responses (e.g., HLA-B27 in arthritis, NOD2, and IL-10R mutations in colitis) or modulate the gut microflora, (ii) mechanisms that promote the development of autoimmunity (e.g., citrullinated protein antibodies in arthritis), and (iii) processes leading to impairment of the barrier function of epithelial surfaces leading to prolonged microbial exposure (e.g., defensin and mucin reduction in inflammatory bowel diseases) (Fig. 1).

서론

염증은

유도 단계,

염증의 정점을 초래하는 단계, 그리고

점차적으로 해결 단계로 이어지는 일련의 사건으로 특징지어집니다.

염증의 유도 단계는

효과적인 호스트 방어를 위해 빠르고

강력한 면역 활성화를 허용하도록 설계되었습니다.

이는 기계적, 화학적, 생물학적 요인으로 인한 조직 손상으로 인한

외인성 및 내인성 위험 신호의 감지로 시작되며,

효과 세포의 모집을 통해 염증 반응을 조율합니다.

이 반응은

염증 매개체인 지질 및 단백질의 방출로 특징지어집니다1.

염증의 해결 단계는

위험 신호가 제거된 후 염증을 억제하고 조직의 균형을 회복하는 데 필수적입니다2.

따라서

해결 과정이 엄격히 조절된다는 것은 자명합니다2.

염증이 해결되지 않으면

관절염, 대장염, 천식 등 신체 내 표면에서 발생하는 만성 염증성 질환이 발생하며,

이는 조직 손상의 영구화와 심혈관 질환, 암, 골다공증 발병 위험 증가와 연관됩니다3,4,5.

해결 과정을 방해하는 요인에는

(i) 과도한 면역 반응을 암호화하는 유전적 요인(예: 관절염의 HLA-B27, 대장염의 NOD2 및 IL-10R 돌연변이)

  또는 장 미생물군을 조절하는 요인,

(ii) 자가면역 질환의 발병을 촉진하는 메커니즘(예: 관절염에서의 시트룰린화 단백질 항체), 및

(iii) 상피 표면의 장벽 기능 저하로 미생물 노출이 장기화되는 과정(예: 염증성 장 질환에서의 디펜신과 뮤신 감소)(그림 1).

Fig. 1

Activation, resolution, and the process leading to chronicity of inflammation. Time course of the inflammatory response with activation phase, peak phase, and resolution phase. Failure of resolution leads to chronic inflammatory diseases. Key cells of the activation and resolution phase are shown in the gray squares. ILC innate lymphoid cells, TH17 T helper cells 17, MΦ macrophages

그림 1

염증의 활성화, 해결, 및 만성화로 이어지는 과정.

염증 반응의 시간 경과: 활성화 단계, 피크 단계, 및 해결 단계.

해결 실패는 만성 염증성 질환으로 이어집니다.

활성화 및 해결 단계의 주요 세포는 회색 사각형에 표시되었습니다.

ILC 선천성 림프구, TH17 T 보조 세포 17, MΦ 대식세포

Our current concept on the nature of resolution of inflammation is dominated by specific pro-resolving lipid mediators that orchestrate the resolution process. These mediators have been extensively reviewed elsewhere6. However, like the induction phase of inflammation depends on both lipid (e.g., prostaglandin E2) and protein (e.g., tumor necrosis factor) mediators, also the resolution of inflammation is likely to be based on a network of lipid and protein mediators rather than being exclusively controlled by lipids. Furthermore, in addition to universal principles underlying resolution of inflammation, disease-specific, and tissue-specific processes may exist that guide resolution in specific inflammatory conditions. This article will first summarize the universal principles of the resolution process before addressing tissue-specific and disease-specific mechanisms functional in arthritis, colitis, and asthma, as paradigm examples for chronic inflammatory diseases3.

현재 염증 해결의 본질에 대한 우리의 개념은

염증 해결 과정을 조율하는 특정 프로-해결 지질 매개체에 의해 지배되고 있습니다.

이 매개체들은 다른 곳에서 광범위하게 검토되었습니다6.

그러나 염증의 유도 단계가

지질(예: 프로스타글란딘 E2)과 단백질(예: 종양 괴사 인자) 매개체에 의존하는 것처럼,

염증의 해결도 지질과 단백질 매개체의 네트워크에 기반을 두고 있을 가능성이 높으며,

지질에 의해 단독으로 조절되는 것은 아닙니다.

또한 염증 해결의 보편적 원리 외에도

특정 염증 조건에서 해결을 안내하는 질환 특이적 및 조직 특이적 과정이 존재할 수 있습니다.

이 논문은 먼저 염증 해결 과정의 보편적 원리를 요약한 후,

관절염, 대장염, 천식 등 만성 염증 질환의 대표적 예시로

조직 특이적 및 질환 특이적 메커니즘을 논의할 것입니다.

Key aspects of resolution of inflammation

Successful resolution of inflammation is based on a number of key events. At the molecular level, pro-inflammatory mediators need to be effectively antagonized and catabolized. At the cellular level, immune cell numbers at inflammatory sites need to decline, and at the macroscopic level tissue integrity has to be restored by the activation of tissue-resident cells that induce repair7. To some extent, resolution of inflammation represents a “clean-up” process, which follows the “concert” of inflammation. As such, resolution is a highly robust process, which is difficult to overwrite. In consequence, the vast majority of inflammatory responses occurring in humans are self-limited. Furthermore, at the experimental level it is still challenging to mimic chronic inflammation in animal models as many inflammatory models such as dextran sodium sulfate-induced colitis, antigen-induced arthritis, imiquimod-induced psoriasis, or thioglycolate-induced peritonitis are spurious and spontaneously resolve after several days or weeks of active inflammation8,9.

염증 해결의 핵심 측면

염증의 성공적인 해결은 여러 핵심 사건에 기반합니다.

분자 수준에서는

염증 유발 매개체가 효과적으로 억제되고 분해되어야 합니다.

세포 수준에서는

염증 부위의 면역 세포 수가 감소해야 하며,

거시적 수준에서는 조직 내 거주 세포의 활성화로 조직 무결성이 복원되어야 합니다7.

일정程度上, 염증의 해결은 염증의 ‘합주'에 이어지는 '청소’ 과정입니다.

따라서 해결은 매우 견고한 과정으로, 쉽게 덮어쓰기 어렵습니다.

결과적으로 인간에서 발생하는 염증 반응의 대부분은 자체적으로 제한됩니다. 또한 실험 수준에서 동물 모델에서 만성 염증을 모방하는 것은 여전히 도전적입니다. 데크스트란 나트륨 설페이트로 유발된 대장염, 항원 유발 관절염, 이미퀴모드로 유발된 건선, 티오글리콜레이트로 유발된 복막염과 같은 많은 염증 모델은 허위적이며, 활성 염증 후 몇 일 또는 몇 주 후에 자연적으로 해소됩니다.8,9.

Universal mechanisms of resolution of inflammation

Three key processes have been identified, which are intrinsic to resolution of inflammation and represent an over-reaching principle of the resolution process, which is functional across different tissues and diseases. These processes are discussed in the following chapter.

염증 해결의 보편적 메커니즘

염증 해결에 내재된 세 가지 핵심 과정이 식별되었으며, 이는 다양한 조직과 질환에서 기능하는 염증 해결 과정의 기본 원리를 대표합니다. 이 과정들은 다음 장에서 논의됩니다.

중성구 유입의 중단

손상 부위로의 중성구 집결은

염증의 초기 단계입니다10.

염증 해결은

염증 부위에서 가장 풍부한 백혈구 인구인 중성구 모집을 중단하는 것에 달려 있습니다.

이 과정은

부분적으로 염증 해결을 촉진하는 지질 매개체(resolvins)에 의해 조절되며,

이는 다른 곳에서 검토되었습니다7 (표 1도 참조).

간략히 말해, 해결은

염증성 지질 매개체(예: PGE2 및 LTB4)에서

염증 해결을 촉진하는 지질 매개체(예: 프로스타글란딘 D2, 15deoxy-delta-(12-14)-프로스타글란딘 J2, 리포신 A4(LXA4), 레졸빈 E1(RvE1), 프로텍틴 D1, 마레신-111과 같은 프로-해결 지질 매개체로의 클래스 스위치와 함께 진행되는 것으로 보입니다.

이러한 매개체는 중성구 모집을 차단하며,

이는 중성구 활성화 물질(예: leukotriene B4, KC, 보체 인자 5)에 대한 반응을 억제하는

중성구 화학유인물질 수용체(예: CXCR2)의 발현을 감소시키는 방식으로 부분적으로 이루어집니다.

Cessation of neutrophil influx

Neutrophil swarming to sites of damage is the initial step in inflammation10. Resolution of inflammation depends on stopping neutrophil recruitment, which is the most abundant leukocyte population at inflammatory sites. This process is in part controlled by pro-resolving lipid mediators (resolvins), reviewed elsewhere7 (see also Table 1). Briefly, resolution seems to go along with a class-switch from the production of pro-inflammatory (such as PGE2 and LTB4) to pro-resolving lipid mediators such as prostaglandin D2, 15deoxy-delta-(12-14)-prostaglandin J2, lipoxin A4 (LXA4), resolvin E1 (RvE1), protectin D1, and maresin-111. These mediators can block neutrophil recruitment, partially by downregulating their chemokine receptors such as CXCR2 rendering them unresponsive to neutrophil-activating substances such as leukotriene B4, KC, and complement factor 512.

Table 1 Overview of key mediators and processes triggering the resolution of inflammation

Pro-resolving lipid mediators are produced by a concerted action of arachidonate lipoxygenases (ALOX), which catalyze the production of pro-resolving lipid mediators and are highly expressed in eosinophils, alternatively activated macrophages and certain tissue-resident macrophages, cell types that predominate during the resolution process and contribute to tissue homeostasis13,14. Another important feature of pro-resolving lipoxygenases seems to be the oxidation and modification of membrane phospholipids in eosinophils and macrophages, a process that changes biophysical properties of cell membranes and contributes to the non-immunogenic clearance of apoptotic cells and the maintenance of immune tolerance during the resolution process, as well as to cessation of bleeding after injury14.

Neutrophil death and removal

Resolution processes require the removal of tissue neutrophils (Fig. 2), a process that has been recognized more than 100 years ago15. Neutrophils are terminally differentiated cells with a short half-life. Hence, the journey of neutrophils from the bone marrow to the sites of inflammation is, for the most part, unidirectional with cells dying in the target tissue. Neutrophil apoptosis can be induced by expression‎ of death ligands such as TRAIL or FasL, produced by macrophages16,17, or by transforming growth factor beta (TGFβ), produced by regulatory T cells during the resolution phase of inflammation18. Apoptotic neutrophils are rapidly engulfed by macrophages—a process known as efferocytosis. This uptake essentially depends on the expression‎ of “eat-me” and “find-me” signals on apoptotic neutrophils such as phosphatidylserine19, which are recognized by specific receptors such as TIM1 and TIM4 on the surface of resident macrophages20. Neutrophil death and engulfment by macrophages represents an essentially anti-inflammatory and pro-resolving signal21.

Fig. 2

Functional resolution map. Map of resolution with key mechanisms (bright gray squares), cells (blue squares), and molecules (dark gray squares). AAM alternatively activated macrophage, AMPK adenosine monophosphate-activated protein kinase, ILC innate lymphoid cells, IL interleukin, LPX lipoxin, MΦ macrophages, PMN polymorphonuclear neutrophils, TGF transforming growth factor, TRAIL tumor necrosis factor-related apoptosis inducing ligand, FASL Fas ligand, ROS reactive oxygen species

Full size image

Changes in macrophage function

Monocyte-derived macrophages are key players of the innate immune response, where they contribute to cytokine production and pathogen clearance. Consistently, genome-wide association studies recently identified key driver genes of macrophages for inflammatory disorders22. During the course of inflammation, however, monocyte-derived macrophages seem to acquire essential anti-inflammatory and pro-resolving functions23. They clear apoptotic cells, start to release pro-resolving lipids13, express anti-inflammatory receptors such as TGF-R2 and FPR2, and synthesize increased concentrations of immune regulatory intracellular messengers such as cAMP24. These changes appear to be based on both intrinsic and extrinsic mechanisms.

Intrinsic mechanisms triggering the switch in macrophage function: Recent insights into the metabolic control of macrophage function may open new concepts in understanding the switch in macrophage function during resolution. Notably, macrophage function has been associated with different patterns of energy production, which guide the cells functional state. A well-characterized effect of macrophage activation by lipopolysaccharide is the shift from oxidative phosphorylation to aerobic glycolysis, which is also known as the Warburg effect25. Cells involved in the activation phase of inflammation, such as inflammatory M1-like macrophages, must provide energy rapidly to fuel inflammation, which is essentially accomplished by glycolysis26. At the same time, energy production by oxidative phosphorylation through the Krebs cycle is defective in inflammatory M1 macrophages. This phenomenon has also been described as a “broken” Krebs cycle by O’Neill and colleagues27, which is characterized by the accumulation of the metabolites citrate and succinate. Increase of citrate and succinate is the consequence of suppression of the conversion of citrate to a-ketoglutarate as well as oxidation of succinate, respectively. Citrate has proinflammatory functions by facilitating prostaglandin generation28. Succinate, on the other hand, acts in proinflammatory manner as well by fostering the release of TNFa and IL-1β, stabilizing hypoxia inducible factor 1-alpha (HIF1α) and supporting the production of reactive oxygen species (ROS)29,30,31.

On the other hand, M2-like macrophages, which are involved in immune regulation and resolution of inflammation, preferentially use fatty acid oxidation through Krebs cycle as a main source for energy production. In the context of metabolic control of resolution of inflammation, the Krebs cycle metabolite itaconate appears to be an attractive mediator. Manipulation of IRG1, the enzyme responsible for itaconate production, has shown to affect the pro-inflammatory function of macrophages, supporting the concept that itaconate induces a regulatory pro-resolving macrophage phenotype32. Itaconate thereby acts by modifying proteins via alkylation of cysteine residues. One of the targets, which is modified and inactivated by itaconate, is Kelch-like ECH-associated protein-1, which functions as key repressor of the anti-inflammatory transcription factor Nrf2 in macrophages33. Macrophages treated with itaconate show impaired production of key pro-inflammatory cytokines like IL-1β, IL-12, and IL-634. In part, this effect seems to be based on itaconate-mediated suppression of succinate oxidation35, which—as described previously—is an central proinflammatory immune metabolic in macrophages. Altogether, these effects render itaconate as crucial anti-inflammatory metabolite that limits inflammation and potentially also fosters resolution of inflammation.

Extrinsic mechanisms triggering the switch in macrophage function: This switch in macrophage function during resolution may be additionally supported by eosinophils36 as well as tissue-resident group 2 innate lymphoid cells (ILC2s) that produce IL-4 and IL-13 and trigger a regulatory “M2-like” macrophage phenotype through activation of STAT637,38. Regulatory T cells, producing TGF-β and IL-10, as well as other soluble mediators expressed during the resolution process, such as adenosine, annexin 1, and netrin-1, may further add to this phenotype39,40. Newer findings, however, also challenge the concept of a simple switch of monocyte-derived macrophages into a pro-resolving “M2-like” phenotype as the only mechanism involved the resolution of inflammation. Tissue-resident macrophages, that are of embryonic origin and populate virtually all tissues in steady-state conditions, may play a so far underappreciated role in the resolution process41. Although phenotypically distinct, many tissue-resident macrophages such as microglia, resident peritoneal macrophages, or alveolar macrophages display an regulatory phenotype that is characterized by the constant production of anti-inflammatory cytokines and lipid mediators, as well as by an increased capacity to clear dying cells in a non-inflammatory fashion13.

Tissue-specific mechanisms of resolution of inflammation

Tissue-specific resolution processes complement the aforementioned universal mechanisms in resolution of inflammation. Since the pathways involved in the initiation of arthritis, inflammatory bowel disease, or asthma differ considerably from each other with respect to cytokine involvement, composition of the resident tissue, and microbial load, it is not surprising that customized resolution processes exist for specific tissues, which are guided by the local microenvironment3. This is particularly relevant for tissues that represent inner surfaces of the body that are characterized by specific environmental settings. In the following chapter, we will therefore put a focus on the specific mechanisms of resolution of inflammation in diseases such as arthritis, colitis, and asthma.

Resolution of arthritis

Rheumatoid arthritis is the most severe inflammatory joint disease exhibiting a remarkable level of chronicity. While pro-inflammatory mediators, like TNFα and IL-6, are well defined in arthritis4, pro-resolving cytokines have not been defined until recently. In fact, IL-9 appears to be a key resolution cytokine in arthritis42. Antigen-induced arthritis, which represents a self-limited arthritis model, becomes highly chronic in the absence of IL-9, while IL-9 overexpression‎ effectively induces the resolution of arthritis in chronic models. Mechanistically, IL-9 serves as an autocrine growth factor for ILC2s. These cells have pro-resolving properties by activating the suppressive function of regulatory T cells in a cell–cell contact GITRL and ICOSL-dependent fashion. Notably, in the gut and lungs, where IL-9 is preferentially synthesized by T cells, this cytokine fuels rather than resolves inflammation supporting the concept of disease-specific resolution processes43,44.

ILC2s appear to be central components of the resolution phase of several forms of arthritis42,45. Apart from engaging regulatory T cells, ILC2s control eosinophil homeostasis through production of IL-538,46 and support the differentiation of regulatory macrophages36,37,38. Their pro-resolving and immune regulatory function is also illustrated by the decline of ILC2 numbers in inflammation during obesity, which is associated with resistance to resolution of inflammation and higher chronicity of rheumatoid arthritis47. The role of ILC2s in resolution of inflammation in arthritis also sheds light on the function of eosinophils. While in allergic asthma, eosinophils are essentially pro-inflammatory cells, which are targeted by IL-5 neutralization48, the same cells play a role in the resolution of inflammation in arthritis36. Already, Paul Ehrlich described eosinophilia as the “aurora” of resolution at the dawn of the inflammation process more than 100 years ago49. In accordance, lack of eosinophils has been shown to prolong peritonitis50, colitis51, and arthritis36 in mouse models, whereas increasing eosinophil numbers by overexpression‎ of IL-5 strongly inhibits experimental arthritis36.

Another important tissue-specific resolution process in arthritis is the formation of aggregated neutrophil extracellular traps (aggNETs). This mechanism is based on neutrophil death by NET formation, where the dying cell expels their DNA into the extracellular space52. In case of very high neutrophil densities, like those found in gouty arthritis, NETosis can lead to the formation of aggNETs, large agglomerates of dead neutrophils, which macroscopically appear as tophi. These structures are highly potent to trap and degrade cytokines by released neutrophil proteases cleaving essential pro-inflammatory cytokines and chemokines, like TNF, IL-1, IL-6, and CCL253. AggNET formation thereby removes the “fuel” of inflammation leading to the collapse of the inflammatory process and explaining the rapid cessation of the gout attack. ROS, such as superoxide anions and peroxide, are centrally involved in this aggNET-based resolution process. If ROS production is impaired, e.g., by induced mutation of NOX enzymes in mice or by mutation of the enzyme in human chronic granulomatous disease, NET formation is severely impaired and no proper resolution of inflammation is possible52.

Finally, in arthritis, the functional state of resident mesenchymal cells appears to decide upon resolution and chronicity of arthritis. Metabolic changes in synovial fibroblast-like cells, such as the induction glycolysis54, as well as expression‎ of molecules, such as FAP, involved in tissue invasiveness of these cells, have been associated with the failure of resolution and the development of chronic arthritis55.

Resolution of colitis

Chronic inflammatory bowel diseases, like Crohn's disease and ulcerative colitis, are severe inflammatory conditions that preferentially affect the distal small intestine or colon with little signs of spontaneous resolution5. Resolution of colitis appears to essentially depend on regulatory T cells. It has been shown that during the process of resolution, T cells change their transcriptional profile and acquire regulatory properties with induction of the canonical TGF-beta pathway18. Furthermore, IL-10 and IL-35 production by Treg cells supports the resolution process56,57. In this context it is particularly remarkable that some of these regulatory T cells originate from the trans-differentiation of TH17 cells21. Regulatory T cells have shown to effectively suppress pro-inflammatory immune responses in experimental colitis58. For instance, in the adoptive T cell transfer model of colitis, transfer of naturally occurring regulatory T cells and ex vivo TGFβ-induced regulatory T cells permit resolution of colitis59. Interestingly, a pilot study in Crohn's disease used ex vivo generated ovalbumin-specific regulatory T cells from the peripheral blood for clinical treatment60. The administration of such antigen-specific Treg cells was well tolerated and resulted in dose-dependent efficacy, indicating that Treg-based immunotherapeutic approaches hold promise for resolution of inflammation.

With respect to resolution of colitis, also the newly discovered regulatory lymphoid cells (ILCreg) seem to be of pivotal importance61. These cells reside in the lamina propria of the murine and human intestine and expand during colitis. ILCreg, once activated, are a potent source of IL-10 and TGF-beta. In contrast to T cells, ILCreg effectively block IFNγ and IL-17 production, while not affecting IL-22, which is important for maintaining intestinal barrier function62.

IL-22 is an important cytokine for the resolution of colitis, since continuous microbial challenge in the context of impaired barrier function may inhibit resolution in colitis63,64. IL-22, which is produced by ILC3 activates epithelial stem cells, induces mucosal repair and thereby prevents the invasion of gut microbiota62 and the colonization with pathogenic bacteria such as segmented filamentous bacteria in colitis62. In the same line, IL-28 and IL-36 have shown to promote resolution of colitis by healing of epithelial damage and closing mucosal wounds. Activation of these cytokines also exerts permissive effects of IL-22 fostering repair responses and promoting the resolution of inflammation65,66. Modulation of the microbiota has been recently studied as novel approach for achieving resolution of colitis. Indeed, a pilot study using multi-donor stool transplantation led to promising clinical results in ulcerative colitis, suggesting that modulation of the microbiota may be targeted for resolution of inflammation67. Notably, in other organs such as the joints, which are not exposed to microbial load, ILC3 have a different role and act in a pro-inflammatory rather than resolving mode45.

Another, recently identified key resolution process in colitis is the activation of Tet methylcytosine dioxygenase 2 (TET2), which catalyzes the conversion of methylcytosine to 5-hydroxymethylcytosine68. Deficiency of Tet2 leads to long-lasting colitis without signs of resolution. Tet2 induces the resolution of arthritis by interaction with HDAC2 and repression of proinflammatory IL-6 gene locus by deacetylation.

Resolution of lung inflammation

The lungs are designed for effective clearance of infectious agents and other danger signals equipped with a high capacity for resolution of inflammation. Resolution of acute lung injury has shown to depend on the death and clearance of neutrophils69, IL-4/IL-13-mediated macrophage reprogramming70 and ILC2-mediated repair of lung tissue by amphiregulin, a member of the epithelial growth factor protein family that initiates epithelial repair after inflammatory damage71. Notably, some bacteria affecting the lungs, such as Pseudomonas aeruginosa, can disrupt resolution pathways and promote chronicity of inflammation, e.g., by expressing the hydrolase Cif, which cleaves and degrades pro-resolving lipids72. Also, during resolution of bacterial lung injury, a prolonged state of local immunosuppression can remain, which is based on TGF-beta-induced regulatory T cell accumulation73.

In contrast to acute lung injury and many other forms of inflammatory diseases, the process leading to chronicity of allergic airway disease depends on FoxO1-IRF4-mediated alternative macrophages activation74 and activation of ILC2s75. Hence, cells and their dependent cytokines, such as IL4, IL-5, and IL-13, which are normally act as pro-resolving mediators are hijacked in asthma to trigger inflammation. On the other hand, IL-10 is considered being important in the resolution of chronic lung inflammation. Hence, cardiolipin, a damage-associated molecular pattern, can inhibit the resolution of lung inflammation by repressing the IL-10 promoter through histone deacetylation by HDAC376. Resolution of inflammation in the lung also requires the replacement of damaged type I alveolar cells, which is mediated by HIF-1a-induced proliferation and differentiation of type II alveolar cells. This process depends on activation of the beta-catenin pathway—an essential pathway for epithelial regeneration77,78,79. Asthma has a high potential to recur after resolution of inflammation, which can happen in conjunction with exogenous triggers or spontaneously. This recurrence of inflammation after resolution can be at least in part explained by allergen-experienced ILC2, which maintain memory-like properties and allow them to quickly respond after the resolution of inflammation80.

Natural killer (NK) cell have also been proposed to play a role in the resolution of allergic airway disease81. NK cells are diminished in their numbers in asthma and have lost essential cytotoxic properties, which may explain the increased number of leukocytes in the airways of asthma patients82.

Taken together, these data suggest that resolution of inflammation is orchestrated in a tissue-specific and disease-specific manner. The mechanisms that guide resolution in inflammatory processes do not seem to be uniform. In contrast, they appear to be tailored to effectively switch off the dominant cellular and molecular immune process that is also responsible for the activation of inflammation in the respective disease. This concept bears great advantages for the organism, as it can effectively stop inflammation and instigate tissue repair without the need to create a state of systemic immune suppression. It also demonstrates that resolution of inflammation should be perceived as a local process that aims to contain the immuno-inflammatory pathways operating in the affected tissues and organs, while not triggering a systemic change of the immune status of the individual. Furthermore, these findings suggest that the best strategies to therapeutically foster resolution of inflammation may vary from disease to disease and rather depend on effectively influencing the local inflammatory micro-milieu than inducing a state of systemic immune suppression. In the following chapter, potential therapeutic approaches that have the potential to strengthen resolution of inflammation will be discussed.

Fostering resolution as a treatment option

Therapeutic induction of resolution is an attractive concept, but still in its infancy. To date, chronic inflammatory diseases, which are based on the failure of physiological resolution, are targeted via the suppression of effector pathways rather than stimulating resolution processes3. Current therapeutic approaches in arthritis, colitis, psoriasis, and asthma are directed against proinflammatory effector cytokines such as TNF-α, IL-6, IL-1, IL17, IL-12/IL-23, IL-5, or IL-4/13 using monoclonal antibodies or drugs against proinflammatory cytokine signaling pathways like Janus kinases3,4,83. Such approaches, although effective, bear the risk to blunt physiological immune responses and are therefore sometimes complicated by increased infection risk. Furthermore, such treatments usually have to be given life-long as they do not directly tackle the impaired resolution process.

Some newer treatment options, which relate to the regulation of immune cell influx, like the targeting the alpha4/beta7 integrin, or stimulate immune cell efflux, like inhibition of S1P1, may be closer to influencing resolution of inflammation than those tackling effector cytokines84,85. Fostering resolution may move treatments closer to cure by shutting down the pathological process rather than suppressing the inflammatory response86. Furthermore, such approach may also promote tissue repair. In consequence, pro-resolving therapies may also be rather safe and not complicated by higher infection risk. Whether such concept, however, is true in the clinic has not been determined to date.

Surprisingly, in some of the existing anti-inflammatory treatments pro-resolving functions appear to be embedded. For instance, glucocorticoids inhibit 5-ALOX, the key enzyme of leukotriene production, which may shift lipid synthesis to a more pro-resolving pattern87. Furthermore, glucocorticoids stimulate annexin 1 expression‎, in part through the glucocorticoid-induced leucine zipper, and thus induce efferocytosis88. Also, treatments such methotrexate inducing adenosine, as well as phosphodiesterase inhibitors like apremilast inducing cAMP levels and IL-10 production may at least in part act as inducers of resolution. However, such approaches do not specifically induce resolution.

More specific approaches to directly strengthen resolution may arise from the new insights in the metabolic control of macrophage function. Shifting macrophage metabolism from glycolysis to oxidative phosphorylation and changing the balance between citrate/succinate and itaconate in favor of the latter metabolite may not only effectively stop inflammation but also enhance resolution89. The principle, that targeting macrophage metabolism can entail anti-inflammatory effects, is supported by the anti-inflammatory function of the established anti-diabetic drug metformin: metformin inhibits ROS production from the electron transport chain and downregulates IL‐1β production, while boosting IL‐10 production90. In accordance, anti-inflammatory effects have been described for metformin in humans, which are independent from its function to control blood sugar concentrations91.

A number of additional therapeutic targets can be envisioned that modulate macrophage metabolism and may therefore support the induction of resolution of inflammation. For instance, molecules that activate AMP-activated protein kinase (AMPK), which is a key sensor of energy status of the cell and essential for the induction of oxidative phosphorylation, have shown to foster resolution of inflammation92. Itaconate itself may represent a pro-resolving agent as well and cell-permeable modifications of itaconate have been synthesized that are potential tools for inducing resolution of inflammation. Moreover, concepts mimicking the down-stream effects of itaconate, as an inducer of Nrf2 transcription factor expression‎, have already been developed. Among them, oleanane triterpenoid compounds, such as bardoxolone, are the most advanced drugs, which activate Nrf2, but have so far only been tested in diabetes mellitus and chronic kidney disease93. Anti-inflammatory effects in experimental arthritis have also been documented for compounds that block the succinate receptor GPR9194 as well as those blocking glycolysis, such as 3PO95, which fit well in the concept that the proinflammatory state of macrophages is associated with glycolysis (Warburg effect) and the accumulation of succinate. Furthermore, other approaches interfering with glycolysis, such as targeting pyruvate kinase M2, which is critical checkpoint for the Warburg effect, have been undertaken and have shown effective regulation of the expression‎ of pro-inflammatory cytokines, such as IL-1β, in macrophages96.

Apart from modulating immune metabolic pathways and macrophage function, an interesting approach to enhance resolution of inflammation is of course the use pro-resolving lipid mediators, which preferentially target neutrophil influx. Such approaches have been reviewed elsewhere6. For instance, therapeutic use of resolvin E2 in mice has shown to promote resolution of inflammation, including shortening inflammation in experimental colitis97. Finally, a non-pharmacological approach to therapeutically affect resolution of inflammation is to make use of the efferent vagal nerve control of inflammatory responses98. This efferent branch of the neuro-immune reflex arch acts through acetylcholine and the engagement of a7 receptors on macrophages blocking their production of pro-inflammatory cytokines. In accordance, vagal stimulation blocks inflammatory cytokine production and promotes the resolution of arthritis, while vagotomy prolongs the resolution of inflammation99. First studies that used vagal stimulation by an implanted “pacemaker” to control inflammation have been accomplished with promising results in diseases such as arthritis100.

Conclusions

In summary, resolution of inflammation is a tightly regulated process that restores tissue homeostasis and prevents the development of chronic inflammatory disease. Like the induction of inflammation, resolution is based on a network of cells as well as on lipid and protein mediators that cooperate for a common goal, which is to reconstruct the original state of the affected tissue. Apart from universal mechanisms tissue and disease-specific mechanisms have been identified that guide resolution of inflammation in arthritis, colitis, and asthma. Such pathways are of particular therapeutic value as their induction may provide new possibilities to reverse chronicity in distinct inflammatory diseases without curtailing the overall inflammatory response.

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