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Orta ve şiddetli kronik hipoksi sırasında sıçan akciğer dokusunda inflamatuvar yanıtta adenozinerjik sinyal yolunun hedeflenmesi

Year 2025, Volume: 50 Issue: 1, 22 - 37, 31.03.2025
https://doi.org/10.17826/cumj.1525573

Abstract

Amaç: Hipoksi, dokulardaki inflamatuar hastalıklardan sonra ortaya çıkar ve proinflamatuar yanıtların indüklenmesiyle ilişkilidir. Adenozin reseptörleri bu yanıtın başlatılması ve düzenlenmesinde kritik öneme sahiptir. Bu tür inflamatuar hastalıklarda haricen uygulanan adenozin reseptör agonistlerinin/antagonistlerinin etkinliği dikkat çekicidir. Bu çalışmada hipoksi, adenozin ve inflamasyon arasındaki ilişkinin yanı sıra adenozin agonist ve antagonistlerinin bu süreçteki rolünü araştırmayı amaçladık.
Gereç ve Yöntem: Bu amaçla, orta ve şiddetli olmak üzere iki farklı hipoksi modeli kullanıldı. Her iki model için toplam 80 erkek Sprague-Dawley sıçanı kullanılarak 4 alt grup tasarlandı: kontrol (CON), dimetil sülfoksit (DMSO), agonist (AGO; CGS-21680) ve antagonist (ANT; MSX-3). Sıçanlar 7 gün boyunca ince ayarlı normobarik hipoksi odalarında orta gruplarda %13 O2 ve ağır gruplarda %10 O2'ye maruz bırakıldı. 7. günün sonunda ventilasyon ölçümleri yapıldı ve hipoksi modeli doğrulandı. Deneysel aşamalardan sonra akciğer dokularından dondurulmuş kesitler alınarak immünofloresan boyama yöntemi ile A2AR, CD11c, COX2, NFKB ve VEGF antikor ekspresyonları değerlendirildi.
Bulgular: Bu çalışma, deneysel hipoksi modellerinde inflamatuar belirteçlerin ekspresyonunun arttığını gösterdi. Bulgulara göre, her iki modelde de agonist grubunda A2AR ve VEGF düzeyleri diğer gruplara göre daha yüksek iken, inflamasyon belirteçleri CD11c, NFKB ve COX2 düzeyleri anlamlı derecede düşüktü.
Sonuç: Enflamasyonu tedavi etmek için akciğer bozukluklarının tedavisinde yardımcı olabilecek çeşitli doğal ve sentetik ilaçlar mevcuttur. Araştırmacılar hala daha hızlı yanıt verebilecek yeni antiinflamatuar ilaçları araştırıyorlar. Bu bulgular hipoksi kaynaklı akciğer inflamasyonunda kullanılabilecek A2A agonistlerinin potansiyel faydasını vurgulamaktadır.

Ethical Statement

All experimental procedures were approved by the Erciyes University Animal experiments local ethics committee at the meeting dated 05.05.2020, with decision number 20/081 before investigation.

Supporting Institution

With the project code of TKB-2020-10343, support was received from the Erciyes University Scientific Research Project unit.

Project Number

TKB-2020-10343

References

  • Si XA, Xi J. Pulmonary oxygen exchange in a rhythmically expanding-contracting alveolus-capillary model. J Respir. 2022;2:159-73.
  • Araneda OF, Tuesta M. Lung oxidative damage by hypoxia. Oxid Med Cell Longev. 2012;2012:856918.
  • Cowley NJ, Owen A, Bion JF. Interpreting arterial blood gas results. BMJ. 2013;346:f16.
  • Pamenter ME, Powell FL. Time domains of the hypoxic ventilatory response and their molecular basis. Compr Physiol. 2016;6:1345-85.
  • Pavlacky J, Polak J. Technical feasibility and physiological relevance of hypoxic cell culture models. Front Endocrinol (Lausanne). 2020;11:57.
  • Drury AN, Szent-Gyorgyi A. The physiological activity of adenine compounds with especial reference to their action upon the mammalian heart. J Physiol. 1929;68:213–37.
  • Li X, Berg NK, Mills T, Zhang K, Eltzschig HK, Yuan X. Adenosine at the interphase of hypoxia and inflammation in lung injury. Front Immunol. 2021;11:604944.
  • Boussuges A, Bourenne J, Eloufir F, Fromonot J, Mottola G, Risso JJ et al. Contribution of adenosine in the physiological changes and injuries secondary to exposure to extreme oxygen pressure in healthy subjects. Biomedicines. 2022;10:2059.
  • Sheth S, Brito R, Mukherjea D, Rybak LP, Ramkumar V. Adenosine receptors: expression, function and regulation. Int J Mol Sci. 2014;15:2024-52.
  • Vincenzi F, Pasquini S, Borea PA, Varani K. Targeting adenosine receptors: a potential pharmacological avenue for acute and chronic pain. Int J Mol Sci. 2020;21:8710.
  • Halpin-Veszeleiova K, Hatfield SM. Therapeutic targeting of hypoxia-a2adenosinergic pathway in covid-19 patients. Physiology. 2022;37:46-52.
  • Chen PZ, He WJ, Zhu ZR, Guo-Ji E, Xu G, Chen DW et al. Adenosine a2a receptor involves in neuroinflammation-mediated cognitive decline through activating microglia under acute hypobaric hypoxia. Behav Brain Res. 2018;347:99-107.
  • Andres RM, Terencio MC, Arasa J, Paya M, Valcuende-Cavero F, Navalon P et al. Adenosine a2a and a2b receptors differentially modulate keratinocyte proliferation: possible deregulation in psoriatic epidermis. J Invest Dermatol. 2017;137:123–31.
  • Ohta A, Sitkovsky M. Role of G-protein-coupled adenosine receptors in downregulation of inflammation and protection from tissue damage. Nature. 2001;414:916–20.
  • Groneberg DA, Chung KF. Models of chronic obstructive pulmonary disease. Respir Res. 2004;5:18.
  • Shukla SD, Walters EH, Simpson JL, Keely S, Wark PAB, O’Toole RF et al. Hypoxia-inducible factor and bacterial infections in chronic obstructive pulmonary disease. Respirology. 2020;25:53-63.
  • Herrmann J, Mori V, Bates JHT, Suki B. Modeling lung perfusion abnormalities to explain early covid-19 hypoxemia. Nat Commun. 2020;11:4883.
  • Xu Z, Shi L, Wang Y, Zhang J, Huang L, Zhang C et al. Pathological findings of Covid-19 associated with acute respiratory distress syndrome. Lancet Respir Med. 2020;8:420-2.
  • Kashani KB. Hypoxia in Covid-19: sign of severity or cause for poor outcomes. Mayo Clin Proc. 2020;95:1094-6.
  • Puri S, Panza G and Mateika JH. A comprehensive review of respiratory, autonomic and cardiovascular responses to intermittent hypoxia in humans. Exp Neurol. 2021;341:113749.
  • Powell FL, Milsom WK, Mitchell GS. Time domains of the hypoxic ventilatory response. Respir Physiol. 1998;112:123–34.
  • Jacobson KA, Gao ZG. Adenosine receptors as therapeutic targets. Nat Rev Drug Discov. 2006;5:247–64.
  • Ramlackhansingh AF, Bose SK, Ahmed I, Turkheimer FE, Pavese N, Brooks DJ. Adenosine 2a receptor availability in dyskinetic and nondyskinetic patients with parkinson disease. Neurology. 2011;76:1811–6.
  • Mills JH, Thompson LF, Mueller C, Waickman AT, Jalkanen S, Niemela J et al. CD73 is required for efficient entry of lymphocytes into the central nervous system during experimental autoimmune encephalomyelitis. Pro Natl Acad Sci USA. 2008;105:9325–30.
  • Hutchinson AJ, Webb RL, Oei HH, Ghai GR, Zimmerman MB, Williams M. CGS21680, an a2-selective adenosine receptor agonist with preferential hypotensive activity. J Pharmacol Exp Ther. 1989;251:47–55.
  • Dong Z, Huang B, Jiang C, Chen J, Lin H, Lian Q et al. The adenosine a2a receptor activation in nucleus accumbens suppress cue-induced reinstatement of propofol self-administration in rats. Neurochem Res. 2021;46:1081-91.
  • Friedman B, Corciulo C, Castro CM, Cronstein BM. Adenosine a2a receptor signaling promotes foxo associated autophagy in chondrocytes. Sci Rep. 2021;11:968.
  • Johnson SM, Vasdev RMS, Miller MM, Baker TL, Watters JJ. Adenosine A2A receptors modulate trkb receptor-dependent respiratory plasticity in neonatal rats. Respir Physiol Neurobiol. 2021;294:103743.
  • Halpin-Veszeleiova K, Hatfield SM. Therapeutic targeting of hypoxia-a2-adenosinergic pathway in covid-19 patients. Physiology. 2022;37:46-52.
  • Thiel M, Caldwell CC, Sitkovsky MV. The critical role of adenosine a2a receptors in downregulation of inflammation and immunity in the pathogenesis of infectious diseases. Microbes Infect. 2003;5:515–26.
  • Kojima H, Gu H, Nomura S, Caldwell CC, Kobata T, Carmeliet P et al. Abnormal b lymphocyte development and autoimmunity in hypoxia-inducible factor 1 alpha deficient chimeric mice. Proc Natl Acad Sci USA. 2002;99:2170-4.
  • Thiel M, Chouker A, Ohta A, Jackson E, Caldwell C, Smith P et al. Oxygenation inhibits the physiological tissue-protecting mechanism and thereby exacerbates acute inflammatory lung injury. PLoS Biol. 2005;3:e174.
  • Hoffman MS, Golder FJ, Mahamed S, Mitchell GS. Spinal adenosine a2(a) receptor inhibition enhances phrenic long-term facilitation following acute intermittent hypoxia. J Physiol. 2010;588:255-66.
  • Gonzalez-Juarrero M, Shim TS, Kipnis A, Junqueira-Kipnis AP, Orme IM. Dynamics of macrophage cell populations during murine pulmonary tuberculosis. J Immunol. 2003;171:3128–35.
  • Grundy M, Sentman CL. GFP Transgenic mice show dynamics of lung macrophages. Exp Cell Res. 2005;310:409–16.
  • Van Rijt LS, Jung S, Kleinjan A, Vos N, Willart M, Duez C et al. In vivo depletion of lung cd11c+ dendritic cells during allergen challenge abrogates the characteristic features of asthma. J Exp Med. 2005;201:981–91.
  • Draijer C, Florez-Sampedro L, Reker-Smit C, Post E, van Dijk F, Melgert BN. Explaining the polarized macrophage pool during murine allergic lung inflammation. Front Immunol. 2022;13:1056477.
  • Surh YJ, Chun KS, Cha HH, Han SS, Keum YS, Park KK et al. Molecular mechanisms underlying chemopreventive activities of anti-inflammatory phytochemicals: down-regulation of cox-2 and inos through suppression of nf-kappa b activation. Mutat Res. 2001;480-482:243-68.
  • Bulgonda RK, Kumar KA, Gangappa D, Beeda H, Philip HG, Rao DM et al. Mangiferin from pueraria tuberosa reduces inflammation via inactivation of nlrp3 inflammasome. Sci Rep. 2017;7:42683.
  • Lee SY, Cho SS, Li YC, Bae CS, Park KM, Park DH. Anti-inflammatory effect of curcuma longa and allium hookeri co-treatment via nf-κb and cox-2 pathways. Sci Rep. 2020;10:5718.
  • Lim W. and Kang C. Avenanthramide c suppresses hypoxia-induced cyclooxygenase-2 expression through sirtuin1 activation in non-small-cell lung cancer cells. Anim Cells Syst. 2020;24:79-83.
  • Pardeshi CV, Pardeshi SR, Naik JB. Strategies for enhanced drug targeting to inflamed lungs: novel perspectives. In Advanced Drug Delivery Strategies For Targeting Chronic Inflammatory Lung Diseases. (Eds DK Chellappan, K Pabreja, M Faiyazuddin):219-258. Singapore, Springer. 2022.
  • Cai J, Wang YL, Sheng XD, Zhang L, Lv X. Shufeng Jiedu capsule inhibits inflammation and apoptosis by activating a2aar and inhibiting nf-κb to alleviate LPS-induced ALI. J Ethnopharmacol. 2022;298:115661.
  • Laddha AP, Kulkarni YA. VEGF and FGF-2: Promising targets for the treatment of respiratory disorders. Respir Med. 2019;156:33-46.
  • Impellizzeri D, Paola RD, Esposito E, Mazzon E, Paterniti I, Melani A et al CGS 21680, an agonist of the adenosine (a2a) receptor, decreases acute lung inflammation. Rheumatology. 2011;38:2119-29

Targeting the adenosinergic signaling pathway in the inflammatory response in rat lung tissue during moderate and severe chronic hypoxia

Year 2025, Volume: 50 Issue: 1, 22 - 37, 31.03.2025
https://doi.org/10.17826/cumj.1525573

Abstract

Purpose: Hypoxia occurs after inflammatory diseases in tissues and is associated with the induction of proinflammatory responses in addition to the breakdown of barriers. Adenosine receptors are critical in the initiation and regulation of this response. The effectiveness of externally applied adenosine receptor agonists/antagonists in such inflammatory diseases is noteworthy. In this study, we aimed to investigate the relationship between hypoxia, adenosine and inflammation, as well as the role of adenosine agonists and antagonists in this situation.
Materials and Methods: For this purpose, two different hypoxia models, moderate and severe, were used. Using a total of 80 male Sprague-Dawley rats for both models, 4 subgroups were designed: control (CON), dimethyl sulfoxide (DMSO), adenosine agonist (AGO; CGS-21680) and adenosine antagonist (ANT; MSX-3). Rats were exposed to moderate groups 13% O2 and severe groups 10% O2 in fine-tuned normobaric hypoxia chambers for 7 days. At the end of the 7th day, ventilation measurements were made and the hypoxia model was confirmed. A2AR, CD11c, COX2, NFKB and VEGF antibody expressions were evaluated by immunofluorescence staining method by taking frozen sections from the lung tissues after the experimental stages.
Results: This study showed that the expression of inflammation markers increased in experimental hypoxia models. According to the findings, while the levels of A2AR and VEGF were higher in the agonist group compared to the other groups in both models, the levels of inflammatory markers CD11c, NFKB and COX2 were significantly lower.
Conclusion: Various natural and synthetic drugs are available as treating the inflammation which can be helpful in treating lung disorders. Researchers are still searching for new anti-inflammatory drugs which can produced faster response. These findings highlight the potential benefit of A2A agonists, which can be used in hypoxia-induced lung inflammation.

Project Number

TKB-2020-10343

References

  • Si XA, Xi J. Pulmonary oxygen exchange in a rhythmically expanding-contracting alveolus-capillary model. J Respir. 2022;2:159-73.
  • Araneda OF, Tuesta M. Lung oxidative damage by hypoxia. Oxid Med Cell Longev. 2012;2012:856918.
  • Cowley NJ, Owen A, Bion JF. Interpreting arterial blood gas results. BMJ. 2013;346:f16.
  • Pamenter ME, Powell FL. Time domains of the hypoxic ventilatory response and their molecular basis. Compr Physiol. 2016;6:1345-85.
  • Pavlacky J, Polak J. Technical feasibility and physiological relevance of hypoxic cell culture models. Front Endocrinol (Lausanne). 2020;11:57.
  • Drury AN, Szent-Gyorgyi A. The physiological activity of adenine compounds with especial reference to their action upon the mammalian heart. J Physiol. 1929;68:213–37.
  • Li X, Berg NK, Mills T, Zhang K, Eltzschig HK, Yuan X. Adenosine at the interphase of hypoxia and inflammation in lung injury. Front Immunol. 2021;11:604944.
  • Boussuges A, Bourenne J, Eloufir F, Fromonot J, Mottola G, Risso JJ et al. Contribution of adenosine in the physiological changes and injuries secondary to exposure to extreme oxygen pressure in healthy subjects. Biomedicines. 2022;10:2059.
  • Sheth S, Brito R, Mukherjea D, Rybak LP, Ramkumar V. Adenosine receptors: expression, function and regulation. Int J Mol Sci. 2014;15:2024-52.
  • Vincenzi F, Pasquini S, Borea PA, Varani K. Targeting adenosine receptors: a potential pharmacological avenue for acute and chronic pain. Int J Mol Sci. 2020;21:8710.
  • Halpin-Veszeleiova K, Hatfield SM. Therapeutic targeting of hypoxia-a2adenosinergic pathway in covid-19 patients. Physiology. 2022;37:46-52.
  • Chen PZ, He WJ, Zhu ZR, Guo-Ji E, Xu G, Chen DW et al. Adenosine a2a receptor involves in neuroinflammation-mediated cognitive decline through activating microglia under acute hypobaric hypoxia. Behav Brain Res. 2018;347:99-107.
  • Andres RM, Terencio MC, Arasa J, Paya M, Valcuende-Cavero F, Navalon P et al. Adenosine a2a and a2b receptors differentially modulate keratinocyte proliferation: possible deregulation in psoriatic epidermis. J Invest Dermatol. 2017;137:123–31.
  • Ohta A, Sitkovsky M. Role of G-protein-coupled adenosine receptors in downregulation of inflammation and protection from tissue damage. Nature. 2001;414:916–20.
  • Groneberg DA, Chung KF. Models of chronic obstructive pulmonary disease. Respir Res. 2004;5:18.
  • Shukla SD, Walters EH, Simpson JL, Keely S, Wark PAB, O’Toole RF et al. Hypoxia-inducible factor and bacterial infections in chronic obstructive pulmonary disease. Respirology. 2020;25:53-63.
  • Herrmann J, Mori V, Bates JHT, Suki B. Modeling lung perfusion abnormalities to explain early covid-19 hypoxemia. Nat Commun. 2020;11:4883.
  • Xu Z, Shi L, Wang Y, Zhang J, Huang L, Zhang C et al. Pathological findings of Covid-19 associated with acute respiratory distress syndrome. Lancet Respir Med. 2020;8:420-2.
  • Kashani KB. Hypoxia in Covid-19: sign of severity or cause for poor outcomes. Mayo Clin Proc. 2020;95:1094-6.
  • Puri S, Panza G and Mateika JH. A comprehensive review of respiratory, autonomic and cardiovascular responses to intermittent hypoxia in humans. Exp Neurol. 2021;341:113749.
  • Powell FL, Milsom WK, Mitchell GS. Time domains of the hypoxic ventilatory response. Respir Physiol. 1998;112:123–34.
  • Jacobson KA, Gao ZG. Adenosine receptors as therapeutic targets. Nat Rev Drug Discov. 2006;5:247–64.
  • Ramlackhansingh AF, Bose SK, Ahmed I, Turkheimer FE, Pavese N, Brooks DJ. Adenosine 2a receptor availability in dyskinetic and nondyskinetic patients with parkinson disease. Neurology. 2011;76:1811–6.
  • Mills JH, Thompson LF, Mueller C, Waickman AT, Jalkanen S, Niemela J et al. CD73 is required for efficient entry of lymphocytes into the central nervous system during experimental autoimmune encephalomyelitis. Pro Natl Acad Sci USA. 2008;105:9325–30.
  • Hutchinson AJ, Webb RL, Oei HH, Ghai GR, Zimmerman MB, Williams M. CGS21680, an a2-selective adenosine receptor agonist with preferential hypotensive activity. J Pharmacol Exp Ther. 1989;251:47–55.
  • Dong Z, Huang B, Jiang C, Chen J, Lin H, Lian Q et al. The adenosine a2a receptor activation in nucleus accumbens suppress cue-induced reinstatement of propofol self-administration in rats. Neurochem Res. 2021;46:1081-91.
  • Friedman B, Corciulo C, Castro CM, Cronstein BM. Adenosine a2a receptor signaling promotes foxo associated autophagy in chondrocytes. Sci Rep. 2021;11:968.
  • Johnson SM, Vasdev RMS, Miller MM, Baker TL, Watters JJ. Adenosine A2A receptors modulate trkb receptor-dependent respiratory plasticity in neonatal rats. Respir Physiol Neurobiol. 2021;294:103743.
  • Halpin-Veszeleiova K, Hatfield SM. Therapeutic targeting of hypoxia-a2-adenosinergic pathway in covid-19 patients. Physiology. 2022;37:46-52.
  • Thiel M, Caldwell CC, Sitkovsky MV. The critical role of adenosine a2a receptors in downregulation of inflammation and immunity in the pathogenesis of infectious diseases. Microbes Infect. 2003;5:515–26.
  • Kojima H, Gu H, Nomura S, Caldwell CC, Kobata T, Carmeliet P et al. Abnormal b lymphocyte development and autoimmunity in hypoxia-inducible factor 1 alpha deficient chimeric mice. Proc Natl Acad Sci USA. 2002;99:2170-4.
  • Thiel M, Chouker A, Ohta A, Jackson E, Caldwell C, Smith P et al. Oxygenation inhibits the physiological tissue-protecting mechanism and thereby exacerbates acute inflammatory lung injury. PLoS Biol. 2005;3:e174.
  • Hoffman MS, Golder FJ, Mahamed S, Mitchell GS. Spinal adenosine a2(a) receptor inhibition enhances phrenic long-term facilitation following acute intermittent hypoxia. J Physiol. 2010;588:255-66.
  • Gonzalez-Juarrero M, Shim TS, Kipnis A, Junqueira-Kipnis AP, Orme IM. Dynamics of macrophage cell populations during murine pulmonary tuberculosis. J Immunol. 2003;171:3128–35.
  • Grundy M, Sentman CL. GFP Transgenic mice show dynamics of lung macrophages. Exp Cell Res. 2005;310:409–16.
  • Van Rijt LS, Jung S, Kleinjan A, Vos N, Willart M, Duez C et al. In vivo depletion of lung cd11c+ dendritic cells during allergen challenge abrogates the characteristic features of asthma. J Exp Med. 2005;201:981–91.
  • Draijer C, Florez-Sampedro L, Reker-Smit C, Post E, van Dijk F, Melgert BN. Explaining the polarized macrophage pool during murine allergic lung inflammation. Front Immunol. 2022;13:1056477.
  • Surh YJ, Chun KS, Cha HH, Han SS, Keum YS, Park KK et al. Molecular mechanisms underlying chemopreventive activities of anti-inflammatory phytochemicals: down-regulation of cox-2 and inos through suppression of nf-kappa b activation. Mutat Res. 2001;480-482:243-68.
  • Bulgonda RK, Kumar KA, Gangappa D, Beeda H, Philip HG, Rao DM et al. Mangiferin from pueraria tuberosa reduces inflammation via inactivation of nlrp3 inflammasome. Sci Rep. 2017;7:42683.
  • Lee SY, Cho SS, Li YC, Bae CS, Park KM, Park DH. Anti-inflammatory effect of curcuma longa and allium hookeri co-treatment via nf-κb and cox-2 pathways. Sci Rep. 2020;10:5718.
  • Lim W. and Kang C. Avenanthramide c suppresses hypoxia-induced cyclooxygenase-2 expression through sirtuin1 activation in non-small-cell lung cancer cells. Anim Cells Syst. 2020;24:79-83.
  • Pardeshi CV, Pardeshi SR, Naik JB. Strategies for enhanced drug targeting to inflamed lungs: novel perspectives. In Advanced Drug Delivery Strategies For Targeting Chronic Inflammatory Lung Diseases. (Eds DK Chellappan, K Pabreja, M Faiyazuddin):219-258. Singapore, Springer. 2022.
  • Cai J, Wang YL, Sheng XD, Zhang L, Lv X. Shufeng Jiedu capsule inhibits inflammation and apoptosis by activating a2aar and inhibiting nf-κb to alleviate LPS-induced ALI. J Ethnopharmacol. 2022;298:115661.
  • Laddha AP, Kulkarni YA. VEGF and FGF-2: Promising targets for the treatment of respiratory disorders. Respir Med. 2019;156:33-46.
  • Impellizzeri D, Paola RD, Esposito E, Mazzon E, Paterniti I, Melani A et al CGS 21680, an agonist of the adenosine (a2a) receptor, decreases acute lung inflammation. Rheumatology. 2011;38:2119-29
There are 45 citations in total.

Details

Primary Language English
Subjects Chest Diseases
Journal Section Research
Authors

Özge Göktepe 0000-0002-8205-2132

Kemal Erdem Başaran 0000-0001-6035-9398

Pınar Alişan Suna 0000-0002-6861-416X

Demet Bolat 0000-0002-3496-1630

Arzu Yay 0000-0002-0541-8372

Project Number TKB-2020-10343
Publication Date March 31, 2025
Submission Date August 1, 2024
Acceptance Date February 13, 2025
Published in Issue Year 2025 Volume: 50 Issue: 1

Cite

MLA Göktepe, Özge et al. “Targeting the Adenosinergic Signaling Pathway in the Inflammatory Response in Rat Lung Tissue During Moderate and Severe Chronic Hypoxia”. Cukurova Medical Journal, vol. 50, no. 1, 2025, pp. 22-37, doi:10.17826/cumj.1525573.