Targeting the Proline-Glycine-Proline-Protease Feed-Forward Loop Attenuates Primary Graft Dysfunction after Lung Transplantation

Yasufumi Goda¹Stefi Lee¹Adya Chawda¹XX Xu²Mohd Moin Khan¹Gary Visner Do³Amit Gaggar²Antonio Coppolino¹Gabriel Loor⁴Mudassir Banday¹Nirmal S Sharma^1*

• ¹Brigham and Women's Hospital, Harvard Medical School, Boston, United States
• ²The University of Alabama at Birmingham, Birmingham, United States
• ³Boston Children's Research, Boston, United States
• ⁴Baylor College of Medicine, Houston, United States

Primary graft dysfunction (PGD) is the leading cause of early mortality after lung transplantation, yet no targeted therapy exists. We investigated whether the collagen-derived matrikine proline-glycine-proline (PGP) drives neutrophil-predominant injury in PGD and whether its neutralization confers protection. Human mini-bronchoalveolar lavage (BAL) fluid was collected 72 hours post-transplantation from recipients with grade 3 PGD and non-PGD controls. In parallel, a murine orthotopic lung transplantation model incorporating 18 hours of cold ischemia was used to reproduce PGD; mice received vehicle (PBS) or the PGP-sequestering tripeptide L-arginine–threonine–arginine (RTR) immediately before reperfusion. Histology, immunofluorescence, LC-MS/MS quantification of acetyl-PGP (acPGP), gelatin zymography for active MMP-9, and ELISA for MMP-9 and prolyl endopeptidase (PE) were performed four hours later. Human PGD BAL contained approximately fourfold higher acPGP, along with significantly elevated MMP-9 and PE, compared with PGD 0 controls. Murine PGD allografts similarly demonstrated dense neutrophilic infiltrates and increased acPGP, MMP-9, and PE expression. RTR treatment markedly reduced histologic injury, neutrophil accumulation, and composite PGD scores while improving oxygenation and allograft lung function. RTR also restored acPGP, MMP-9, PE, and active MMP-9 levels to near-baseline compared with vehicle-treated PGD allografts. These findings delineate a feed-forward PGP–protease circuit linking extracellular matrix degradation to neutrophil recruitment and vascular leak. Neutralizing PGP effectively disrupts this circuit, attenuating graft injury. By connecting extracellular matrix–derived signals to innate immune activation, this work broadens the immunopathologic framework of PGD.