Biomarkers of Skin Graft Healing in Venous Leg Ulcers
Keywords:venous leg ulcer, proteinase, cytokine, biomarker, wound healing, keratinocyte
There is a need for biomarkers that predict the success of transplantation of venous leg ulcers (with autologous split-thickness skin grafts). The primary objective of this exploratory study was to investigate the association between split-thickness skin graft healing in venous leg ulcers and candidate wound fluid biomarkers representing inflammatory cell and endogenous proteinase activities, and bioactivity. A secondary objective was to compare biomarker levels of the 17 venous leg ulcers with sterile split-thickness skin graft donor-site wounds in another 10 patients with venous leg ulcers. Wound fluids were collected for 24 h using a validated method. The concentration of preoperative matrix metalloproteinase-9 in wound fluid was higher in venous leg ulcers showing good healing (n = 10) than in venous leg ulcers showing poor healing (n = 7) 12 weeks after transplantation with meshed split-thickness skin grafts. The diagnostic value of matrix metalloproteinase-9 was good according to receiver-operating characteristic curve analysis. Matrix metalloproteinase activity in wound fluids from split-thickness skin graft donor-site wounds increased as a function of time and healing, but was still lower than matrix metalloproteinase activity in venous leg ulcer wound fluids, which showed increased levels of most biomarkers except for matrix metalloproteinase-9 and matrix metalloproteinase-2. In conclusion, wound fluid matrix metalloproteinase-9 concentration is a potential predictive biomarker of split-thickness skin graft healing in venous leg ulcers.
Guest JF, Fuller GW, Vowden P. Venous leg ulcer management in clinical practice in the UK: costs and outcomes. Int Wound J 2018; 15: 29-37.
Melikian R, O'Donnell TF, Jr, Suarez L, Iafrati MD. Risk factors associated with the venous leg ulcer that fails to heal after 1 year of treatment. J Vasc Surg Venous Lymphat Disord 2019; 7: 98-105.
Bitsch M, Saunte DM, Lohmann M, Holstein PE, Jørgensen B, Gottrup F. Standardised method of surgical treatment of chronic leg ulcers. Scand J Plast Reconstr Surg Hand Surg 2005; 39: 162-169.
Høgsberg T, Bjarnsholt T, Thomsen JS, Kirketerp-Møller K. Success rate of split-thickness skin grafting of chronic venous leg ulcers depends on the presence of Pseudomonas aeruginosa: a retrospective study. PLoS One 2011; 6: e20492.
Serra R, Rizzuto A, Rossi A, Perri P, Barbetta A, Abdalla K, et al. Skin grafting for the treatment of chronic leg ulcers - a systematic review in evidence-based medicine. Int Wound J 2017; 14: 149-157.
Patel BJ, Asher CM, Bystrzonowski N, Healy C. Safeguarding skin grafts: an evidence-based summary of fixation techniques. Ann Plast Surg 2021; 87: e180-e188.
Atkin L, King B, Duffus-Grovell D, Meagher H, Chaplin S, Davies S. Highly exuding non-healing leg ulcers: a surmountable challenge. Br J Nurs 2021; 30: S3-S20.
Power G, Moore Z, O'Connor T. Measurement of pH, exudate composition and temperature in wound healing: a systematic review. J Wound Care 2017; 26: 381-397.
Zillmer R, Trøstrup H, Karlsmark T, Ifversen P, Ågren MS. Duration of wound fluid secretion from chronic venous leg ulcers is critical for interleukin-1α, interleukin-1β, interleukin-8 levels and fibroblast activation. Arch Dermatol Res 2011; 303: 601-606.
Katz MH, Alvarez AF, Kirsner RS, Eaglstein WH, Falanga V. Human wound fluid from acute wounds stimulates fibroblast and endothelial cell growth. J Am Acad Dermatol 1991; 25: 1054-1058.
Trengove NJ, Bielefeldt-Ohmann H, Stacey MC. Mitogenic activity and cytokine levels in non-healing and healing chronic leg ulcers. Wound Repair Regen 2000; 8: 13-25.
Toriseva M, Kähäri VM. Proteinases in cutaneous wound healing. Cell Mol Life Sci 2009; 66: 203-224.
Gillard JA, Reed MW, Buttle D, Cross SS, Brown NJ. Matrix metalloproteinase activity and immunohistochemical profile of matrix metalloproteinase-2 and -9 and tissue inhibitor of metalloproteinase-1 during human dermal wound healing. Wound Repair Regen 2004; 12: 295-304.
Ardi VC, Kupriyanova TA, Deryugina EI, Quigley JP. Human neutrophils uniquely release TIMP-free MMP-9 to provide a potent catalytic stimulator of angiogenesis. Proc Natl Acad Sci U S A 2007; 104: 20262-20267.
Tester AM, Cox JH, Connor AR, Starr AE, Dean RA, Puente XS, et al. LPS responsiveness and neutrophil chemotaxis in vivo require PMN MMP-8 activity. PLoS ONE 2007; 2: e312.
Westby MJ, Norman G, Watson REB, Cullum NA, Dumville JC. Protease activity as a prognostic factor for wound healing in complex wounds. Wound Repair Regen 2020; 28: 631-644.
Lammers AM, van de Kerkhof PC, Schalwijk J, Mier PD. Elastase, a marker for neutrophils in skin infiltrates. Br J Dermatol 1986; 115: 181-186.
Izzo V, Meloni M, Vainieri E, Giurato L, Ruotolo V, Uccioli L. High matrix metalloproteinase levels are associated with dermal graft failure in diabetic foot ulcers. Int J Low Extrem Wounds 2014; 13: 191-196.
Trøstrup H, Holstein P, Christophersen L, Jorgensen B, Karlsmark T, Høiby N, et al. S100A8/A9 is an important host defence mediator in neuropathic foot ulcers in patients with type 2 diabetes mellitus. Arch Dermatol Res 2016; 308: 347-355.
Trøstrup H, Holstein P, Karlsmark T, Moser C, Ågren MS. Uncontrolled gelatin degradation in non-healing chronic wounds. J Wound Care 2018; 27: 724-734.
Danielsen P, Jørgensen B, Karlsmark T, Jorgensen LN, Ågren MS. Effect of topical autologous platelet-rich fibrin versus no intervention on epithelialization of donor sites and meshed split-thickness skin autografts: a randomized clinical trial. Plast Reconstr Surg 2008; 122: 1431-1440.
Kirketerp-Møller K, Bjarnsholt T, Jensen PO, Ågren MS. Staphylococcus aureus augments release of matrix metalloproteinase-8 from human polymorphonuclear leukocytes. Acta Derm Venereol 2020; 100: adv00232.
Serena TE. Development of a novel technique to collect proteases from chronic wounds. Adv Wound Care (New Rochelle) 2014; 3: 729-732.
Boukamp P, Petrussevska RT, Breitkreutz D, Hornung J, Markham A, Fusenig NE. Normal keratinization in a spontaneously immortalized aneuploid human keratinocyte cell line. J Cell Biol 1988; 106: 761-771.
Skehan P, Storeng R, Scudiero D, Monks A, McMahon J, Vistica D, et al. New colorimetric cytotoxicity assay for anticancer-drug screening. J Natl Cancer Inst 1990; 82: 1107-1112.
Carter JV, Pan J, Rai SN, Galandiuk S. ROC-ing along: evaluation and interpretation of receiver operating characteristic curves. Surgery 2016; 159: 1638-1645.
Serena TE, Cullen BM, Bayliff SW, Gibson MC, Carter MJ, Chen L, et al. Defining a new diagnostic assessment parameter for wound care: elevated protease activity, an indicator of nonhealing, for targeted protease-modulating treatment. Wound Repair Regen 2016; 24: 589-595.
Hanemaaijer R, Sorsa T, Konttinen YT, Ding Y, Sutinen M, Visser H, et al. Matrix metalloproteinase-8 is expressed in rheumatoid synovial fibroblasts and endothelial cells. Regulation by tumor necrosis factor-alpha and doxycycline. J Biol Chem 1997; 272: 31504-31509.
Lockmann A, Schill T, Hartmann F, Grönemeyer LL, Holzkamp R, Schön MP, et al. Testing elevated protease activity: prospective analysis of 160 wounds. Adv Skin Wound Care 2018; 31: 82-88.
Mirastschijski U, Impola U, Jahkola T, Karlsmark T, Ågren MS, Saarialho-Kere U. Ectopic localization of matrix metalloproteinase-9 in chronic cutaneous wounds. Hum Pathol 2002; 33: 355-364.
Meyer FJ, Burnand KG, Abisi S, TeKoppele JM, van Els B, Smith A. Effect of collagen turnover and matrix metalloproteinase activity on healing of venous leg ulcers. Br J Surg 2008; 95: 319-325.
Ågren MS, Mirastschijski U, Karlsmark T, Saarialho-Kere UK. Topical synthetic inhibitor of matrix metalloproteinases delays epidermal regeneration of human wounds. Exp Dermatol 2001; 10: 337-348.
Kyriakides TR, Wulsin D, Skokos EA, Fleckman P, Pirrone A, Shipley JM, et al. Mice that lack matrix metalloproteinase-9 display delayed wound healing associated with delayed reepithelization and disordered collagen fibrillogenesis. Matrix Biol 2009; 28: 65-73.
Hattori N, Mochizuki S, Kishi K, Nakajima T, Takaishi H, D'Armiento J, et al. MMP-13 plays a role in keratinocyte migration, angiogenesis, and contraction in mouse skin wound healing. Am J Pathol 2009; 175: 533-546.
Weckroth M, Vaheri A, Lauharanta J, Sorsa T, Konttinen YT. Matrix metalloproteinases, gelatinase and collagenase, in chronic leg ulcers. J Invest Dermatol 1996; 106: 1119-1124.
Kim MH, Liu W, Borjesson DL, Curry FR, Miller LS, Cheung AL, et al. Dynamics of neutrophil infiltration during cutaneous wound healing and infection using fluorescence imaging. J Invest Dermatol 2008; 128: 1812-1820.
Vogt PM, Lehnhardt M, Wagner D, Jansen V, Krieg M, Steinau HU. Determination of endogenous growth factors in human wound fluid: temporal presence and profiles of secretion. Plast Reconstr Surg 1998; 102: 117-123.
Han YP, Downey S, Garner WL. Interleukin-1alpha-induced proteolytic activation of metalloproteinase-9 by human skin. Surgery 2005; 138: 932-939.
Mirastschijski U, Bugdahl R, Rollman O, Johansson BR, Ågren MS. Epithelial regeneration from bioengineered skin explants in culture. Br J Dermatol 2006; 154: 42-49.
Buisson AC, Zahm JM, Polette M, Pierrot D, Bellon G, Puchelle E, et al. Gelatinase B is involved in the in vitro wound repair of human respiratory epithelium. J Cell Physiol 1996; 166: 413-426.
Danielsen PL, Holst AV, Maltesen HR, Bassi MR, Holst PJ, Heinemeier KM, et al. Matrix metalloproteinase-8 overexpression prevents proper tissue repair. Surgery 2011; 150: 897-906.
van der Plas MJ, Cai J, Petrlova J, Saleh K, Kjellström S, Schmidtchen A. Method development and characterisation of the low-molecular-weight peptidome of human wound fluids. Elife 2021; 10: e66876.
Sabino F, Hermes O, Egli FE, Kockmann T, Schlage P, Croizat P, et al. In vivo assessment of protease dynamics in cutaneous wound healing by degradomics analysis of porcine wound exudates. Mol Cell Proteomics 2015; 14: 354-370.
Benjamini Y, Hochberg Y. Controlling the false discovery rate: a practical and powerful approach to multiple testing. J R Statist Soc B 1995; 57: 289-300.
How to Cite
Copyright (c) 2022 Klaus Kirketerp-Møller, Petra Doerfler, Nicole Schoefmann, Barbara Wolf-Winiski, Omid Niazi, Vibeke Pless, Tonny Karlsmark, Magnus Ågren
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (https://creativecommons.org/licenses/by-nc/4.0/), allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material for non-commercial purposes, provided proper attribution to the original work.