Skip to main content

Chronic Obstructive Pulmonary Disease, inflammation and co-morbidity – a common inflammatory phenotype?


Chronic Obstructive Pulmonary Disease (COPD) is and will remain a major cause of morbidity and mortality worldwide. The severity of airflow obstruction is known to relate to overall health status and mortality. However, even allowing for common aetiological factors, a link has been identified between COPD and other systemic diseases such as cardiovascular disease, diabetes and osteoporosis.

COPD is known to be an inflammatory condition and neutrophil elastase has long been considered a significant mediator of the disease. Pro-inflammatory cytokines, in particular TNF-α (Tumour Necrosis Factor alpha), may be the driving force behind the disease process. However, the roles of inflammation and these pro-inflammatory cytokines may extend beyond the lungs and play a part in the systemic effects of the disease and associated co-morbidities. This article describes the mechanisms involved and proposes a common inflammatory TNF-α phenotype that may, in part, account for the associations.


Chronic Obstructive Pulmonary Disease (COPD) is and will remain a major cause of morbidity and mortality Worldwide [1]. The severity of the airflow obstruction as assessed by the forced expired volume in 1 second (FEV1) is a predictor of overall health status [2] and mortality from both respiratory disease [3] and all causes [4].

Recently interest has arisen because of the association of COPD with other systemic diseases including cardiovascular disease [5], diabetes [6], osteoporosis [7] and peptic ulceration [8]. Whereas these associations may represent common aetiological factors such as cigarette smoking and steroid usage, careful studies allowing for these factors have still identified an unexplained link.

COPD is an inflammatory condition and by-products of the inflammatory process lead to the tissue damage and physiological adaptations that typify the condition. The association with smoking is well known although only a proportion of smokers (typically attributed to about 15%) develop clinically important airflow obstruction suggesting a genetic predisposition. In this respect elastase released from activated neutrophils has long been considered to be a significant mediator of the disease [9]. Recent extensive studies involving the smoking mouse model have confirmed this to be a major mechanism possibly driven by pro-inflammatory cytokines of which tumour necrosis factor-alpha (TNF-α) appears to be central [10].

However, the roles of inflammation and these pro-inflammatory cytokines have been proposed to extend beyond the lung in COPD. In particular, they are thought to play a key role in the muscle wasting related to severe emphysema and possibly other co-morbidities. This article describes the mechanisms involved and proposes a common TNF-α driven physiological process that may, in part, account for the associations.

COPD and systemic inflammation

Initially, it was thought that the establishment of lung inflammation resulted in an "overspill" into the circulation producing a low-grade systemic inflammation. However, soluble tumour necrosis factor receptor (sTNF-R) or Interleukin-8 (IL-8) in sputum and plasma do not correlate [11] suggesting that a simple overspill explanation is not correct.

Patients with COPD have higher baseline levels of several circulating inflammatory markers [12]. The reasons are not clear and it remains unknown whether the systemic inflammation is a primary or secondary phenomenon. Specific subsets of patients with COPD have been identified and those with increased resting energy expenditure and decreased fat-fee mass have more marked elevation of stable state C reactive protein (CRP) and lipopolysaccharide binding protein [13]. Furthermore, those with higher levels of systemic inflammation lack a response to nutritional supplementation [14], raising the possibility that this may be an associated phenomenon rather than cause and effect.

Both COPD and smoking have been shown to have negative effects on markers of oxidative stress. Smoking and acute exacerbations of COPD resulted in a marked imbalance in redox status [15]. Raised levels of lipid peroxidation products confirm the persistence of increased oxidative stress and other markers have also been elevated [16]. The increase in oxidative stress may result in the inactivation of antiproteases, airspace epithelial damage, mucus hypersecretion, increased influx of neutrophils into lung tissue and the expression of pro-inflammatory mediators [17, 18].

Changes have also been noted in various inflammatory cells in peripheral blood, including neutrophils and lymphocytes [19]. Patients with COPD have increased numbers of neutrophils in the lungs, increased activation of neutrophils in peripheral blood and an increase in TNF-α and sTNF-R. It has been suggested that this indicates the importance of a TNF-α/neutrophil axis in maintaining the COPD phenotype [20, 21].

The central role of TNF-α in lung inflammation is not only supported by animal models [10] but has also been implicated in the COPD phenotype with low body mass index [7]. Cytokine production by macrophages is enhanced by hypoxia in vitro [22] and thus the inverse correlation between arterial oxygen tension and circulating TNF-α and sTNF-R may be the result of systemic hypoxia [22]. It is tempting therefore to assume that TNF inhibition would be as beneficial in COPD as it has been in other inflammatory conditions such as rheumatoid arthritis and Crohn's disease [23, 24]. However, this was also hypothesised for congestive heart failure (CHF). TNF-α is believed to play a key role in the pathogenesis of CHF and raised levels are associated with a higher mortality in CHF [25]. However, studies using TNF-α blockade have shown no benefit and possibly an increase in mortality for reasons that are not clear [26], suggesting it is not just a simple cause and effect.

Muscle wasting

Low body mass index (BMI), age, and low arterial oxygen tension have been shown to be significant independent predictors of mortality in COPD [27, 28]. More specifically, loss of fat-free mass (FFM) adversely affects respiratory and peripheral muscle function, exercise capacity and health status. Both weight loss and loss of FFM appear to be the result of a negative energy balance, and are seen more commonly in emphysema [29].

In starvation and nutritional imbalance there is an adaptive reduction in resting energy requirements [30]. In contrast (as in cachexia) increased resting energy expenditure has been noted in many COPD patients, linked to systemic inflammation [13, 31]. Furthermore nutritional intake is also generally adequate (apart from during acute exacerbations). The traditional view that this increased basal metabolic rate is due to an increased oxygen consumption by respiratory muscles has been shown to be only part of the reason [32]. Whilst there is no universally agreed definition of cachexia (derived from the Greek kakos [bad] and hexis [condition]), accelerated loss of skeletal muscle in the context of a chronic inflammatory response is a characteristic feature [33], and not limited to COPD. Patients with cachexia display preferential loss of FFM, enhanced protein degradation [34] and poor responsiveness to nutritional interventions [35, 36]. In addition, cachectic patients exhibit changes in the metabolism of proteins, lipids and carbohydrates that are thought to be related to systemic rather than local inflammation [36, 37]. Thus muscle wasting in COPD displays similarities to the cachexia seen in chronic heart failure, renal failure, acquired immunodeficiency syndrome and cancer (amongst others). The importance of cachexia in these conditions is not only that it is associated with reduced survival [35, 3840], but also that it is related to poor functional status and health-related quality of life [33]. Common findings in all these conditions include increased levels of circulating pro-inflammatory molecules including TNF-α, IL-1, IL-6, IL-8, interferon-γ (INF-γ) and reduced levels of anabolic hormones including insulin-like growth factors and testosterone [33].

TNF-α plays a central role in the muscle wasting and weight loss seen in COPD. It has several direct effects (anorexia, altered levels of circulating hormones and catabolic cytokines, and altered end organ sensitivities to them) which could promote muscle wasting [41] predominantly via the ubiquitin pathway. This process is mediated by nuclear factor-κB (NF-κB), a transcription factor that is inactive when bound to its inhibitor but which can be activated by inflammatory cytokines including TNF-α [42]. In muscle cells NF-κB can interfere with skeletal muscle differentiation and repair via inhibition of MyoD expression [43](Figure 1).

Figure 1

Pathogenic process implicated in muscle wasting in COPD. Circulating TNF-α present in some patients with COPD binds to peripheral muscle cell receptors stimulating the production of ROS and apoptosis. In addition the receptor binding stimulates NF-κB activation, possibly enhanced by ROS. Protein loss is caused directly via increased ubiquitin activity, and indirectly via decreased MyoD expression decreasing myofibril synthesis. Protein loss is amplified by a reduction in muscle use. This is the result of a reduction in IGF-1 production (leading to a decrease in myofibril synthesis), and an increase in ubiquitin activity. TNF-α – tumour necrosis factor alpha TNFR – tumour necrosis factor receptor ROS – reactive oxygen species NF-κB – nuclear factor kappa beta Ubq – ubiquitin IGF – insulin-like growth factor

Oudijk et al [20] proposed three different mechanisms by which TNF-α could induce muscle loss. Firstly, protein loss can be directly stimulated in the skeletal muscle cells. Secondly, apoptosis can be stimulated through various signalling pathways via interaction with the TNF-α receptors on the muscle cells. Thirdly, reactive oxygen species (ROS) can lead to changes in TNF-α/NF-κB signalling, although the implications of such changes in this pathway have yet to be clarified. Nevertheless, it appears that inflammation and ROS have a synergistic action on muscle breakdown [37] and since COPD is associated with increased oxidant stress [44] it is likely that this factor also plays a role.


A common process may explain why patients with COPD have a 1.8 RR of developing type II diabetes [45]. Epidemiological studies have provided evidence that indicators of inflammation can predict the development of diabetes and glucose disorders [6, 46]. Indeed, in the ARIC study fibrinogen, circulating white blood cells count and lower serum albumin predicted the development of type II diabetes [6]. Furthermore patients with non insulin dependant diabetes mellitus have increased circulating levels of TNF-α, IL-6 and CRP [47]. For these reasons the roles of circulating cytokines in the pathogenesis of diabetes and insulin resistance have received increasing interest. Adipose tissue secretes numerous adipokines which markedly influence lipid and glucose/insulin metabolism. These include TNF-α and an antagonist, the "protective", adipose tissue specific, adiponectin.

Sonnenberg and colleagues [48] proposed that TNF-α might be a mediator of the diabetic process. As described above, this cytokine acts via its receptor to activate the nuclear transcription factor NF-κB leading to cytokine production, up regulation of adhesion molecules and increasing oxidative stress. Indeed, this latter effect together with TNF-α may provide a stimulating pathway that interferes with glucose metabolism and insulin sensitivity. This pathway can be antagonised by adiponectin which reduces NF-κB activation [49].

This concept is supported by several clinical and experimental observations. Firstly, it is known that TNF-α expression is increased in patients with weight gain and insulin resistance [50]. Perhaps this represents a modulating effect as TNF-α stimulates lipolysis [51] but TNF-α levels are associated with hyper insulinaemia and insulin resistance [52]. Other studies have also confirmed that an acute phase response (CRP) is increased in obesity and associated with insulin resistance [53]. Furthermore, adiponectin levels are reduced in obesity and associated with insulin resistance and hyper insulinaemia [54]. However, the most direct supporting data for this putative axis comes from the obese, insulin resistant mouse where TNF-α inhibition improves insulin sensitivity [50].

These observations support the concept that inflammation as reflected in acute phase proteins are in some way intimately associated with the development of glucose intolerance and insulin resistance. This concept is summarized in figure 2 which is derived from the proposal of Sonnenberg et al [48].

Figure 2

The roles of TNF-α, adiponectin and NF-κB in the metabolic syndrome. [Adapted from Sonnenberg et al (41)] TNF-α secreted from adipose tissue in conjunction with circulating glucose, FFA and insulin stimulate NF-κB activation. This action is opposed by adiponectin (indicated by the broken line), also secreted from adipose tissue. Activation of the PPARγ pathway (for example by TZDs) has been shown to directly increase expression of adiponectin and reduce TNF-α. Further activation of NF-κB is induced through the resulting increase in inflammatory cytokines, adhesion molecules and oxidative stress, leading to the clinical manifestations of the metabolic syndrome. The metabolic syndrome is a constellation of cardiovascular risk factors that is associated with a trebling of risk of type 2 diabetes and a doubling of risk of cardiovascular disease. Several definitions have been proposed [80-83] leading to some confusion and differences in prevalence rates. The International Diabetes Federation have recently proposed a practical, globally applicable definition of the syndrome using waist circumference plus any two of raised triglycerides, reduced HDL-cholesterol, raised blood pressure and raised fasting plasma glucose [84]. TNF-α – tumour necrosis factor alpha NF-κB – nuclear factor kappa beta FFA – free fatty acid LDL – low-density lipoprotein PPARγ – peroxisome proliferator activated receptor gamma TZD – thiazolidenedione

Whereas these studies still raise the issue of cause and effect there have been attempts at proof of concept. Thiazolidinediones are agonists for peroxisome proliferator-activated receptor gamma (PPARγ) – a ligand-activated transcription factor belonging to the nuclear hormone receptor superfamily. This class of drug not only decreases inflammatory markers including TNF-α, soluble ICAM-1, fibrinogen, MIP1 and CRP but also improves insulin action [5558]. These studies are thus in keeping with a common inflammatory process/pathway linking COPD and type II diabetes. They are also consistent with the predictive role of acute phase proteins in the development of type II diabetes [6].

Fernandez-Real [59] expanded on this process to relate the inflammatory mechanism of insulin resistance to atherosclerosis where similar hypotheses have been proposed.


Ridker et al [60] recently published data indicating that baseline CRP showed a concentration dependant relative risk for future cardiovascular events. Pai et al [61] assessed the risk of coronary heart disease and related this to the circulating levels of several inflammatory markers. The authors found that high levels of CRP and IL-6 were significantly related to an increased risk in both males and females. The relative risk was 1.79 for individuals whose baseline was greater than 3 mg/L.

C-reactive protein is a type I acute phase protein with properties suggesting it is an archaic form of immunity which possesses the ability to bind to bacteria subsequently facilitating the binding of complement necessary for bacterial killing and/or phagocytosis. The protein can increase up to 1000 fold within days of the commencement of an inflammatory process. TNF-α, IL-1 and IL-6 stimulate CRP synthesis by inducing hepatic gene expression [62], implicating TNF-α at the core of the process. CRP is known to bind and cause lattice formation and precipitation leading to passive haemaglutination. Macrophages have receptors for CRP and CRP can increase cytokine production [63, 64]. These features may be central to atheroma production. C-reactive protein may deposit directly on to the arterial wall during atherogenesis, possibly via the Fcgamma (Fcγ) receptor [65] facilitating monocyte adherence through the production of the monocyte chemokine MCP-1. Further activation can result in production of other pro-inflammatory cytokines and differentiation of the monocytes into macrophages (Figure 3).

Figure 3

The inflammatory processes involved in atherosclerotic plaque formation. CRP binds to endothelial cells via the Fcγ receptor and is internalized, facilitating monocyte binding via the production of MCP-1. Further activation leads to further cytokine release and differentiation of the monocytes into macrophages. In the presence of oxidized LDL, CRP aids the production of foam cells – the basis of an atherosclerotic plaque. CRP – C reactive protein TNF-α – tumour necrosis factor alpha IL-6 – interleukin-6 MCP1 – monocyte chemotactic protein 1 LDL – low density lipoprotein ROS – reactive oxygen species

In the presence of oxidised low density lipoproteins, CRP can facilitate the production of foam cells which are the building blocks of atherosclerotic plaques (figure 3).

Recent studies by Smeeth et al [66] have indicated that the risk of having a myocardial infarct or cerebrovascular event are increased greatly within the first 3 days after an "acute systemic respiratory tract infection", defined by the authors as pneumonia, acute bronchitis, "chest infections" or influenza (4.95 RR for myocardial infarct and 3.19 RR for stroke). These events are accompanied by a well recognised acute inflammatory response and cytokine production. Indeed in patients with COPD not only is the baseline CRP over 3 mg/L in almost half of the patients but the further rise during an acute exacerbation [67] is also associated with a rise in fibrinogen [68] increasing the pro thrombotic risk. This may well account for the increased risk of vascular events in COPD and particularly the likelihood of the increased mortality within a few month of hospital admission for an acute exacerbation [69].


The risk of osteoporosis with steroid use is well known, but patients with COPD have an increased risk even in the absence of steroid use. McEvoy and colleagues [70] observed that vertebral fractures were present in up to 50% steroid naive males with COPD. More recently studies by Bolton et al confirmed that osteopoenia was a feature of COPD and associated with an increase in circulating TNF-α [7]. Again, the association suggests a cause and effect.

Post menopausal osteoporosis is related to high serum levels of TNF-α and IL-6 [71]. It is known that macrophages can differentiate into osteoclasts in the presence of marrow mesenchymal cells. These latter cells release the cytokine RANK ligand (RANKL) which is a member of the TNF-α superfamily. TNF-α and IL-1 enhance this process and can induce RANKL expression in marrow stromal cells and synergise with RANKL in osteoclastogenesis [72], although osteoclast formation can also be induced by IL-6, independent of RANKL [73]. However, other inflammatory conditions such as rheumatoid arthritis [74] and periodontal disease [75] have T cells induced to produce RANKL and it is therefore likely that a similar process occurs in COPD.

The role of pro-inflammatory cytokines may therefore be central to the osteoporosis associated with inflammatory disease. In support of this concept is the study reported by Gianni et al [71] who confirmed that Raloxifene was able to decrease TNF-α transcription and serum levels whilst increasing bone density. Again these data support a close association between the pro-inflammatory processes and osteopoenia.

Peptic ulceration

Finally peptic ulceration is known to be more frequent in patients with chronic bronchitis and emphysema [76]. Furthermore, studies in patients with gastric ulcers have found a decrease in FEV1 and vital capacity in smokers and non-smokers [8]. More recently Roussos and colleagues [77] demonstrated that helicobacter sero-positivity is increased in COPD patients to 77.8% (compared to 54% in control subjects). Furthermore they noted that sero-positivity to the greater pro-inflammatory phenotype expressing CaGA was present in 53.9% of patients compared to 29.3% of controls. Once more, although these associations could represent common factors such as smoking and socio-economic status, the authors hypothesised that the chronic activation of inflammatory mediators induced by H pylori could amplify the development of COPD. The increased prevalence of the CaGA positive strain supports this hypothesis as it can stimulate the release of IL-1 and TNF-α [78] that may enhance the endothelial adhesion and migration of inflammatory cells into the lung. Whether such a process enhances the inflammatory response to cigarette smoke in the lungs remains unknown. An alternative suggested by the authors is that overspill inhalation of H pylori or its exotoxins into the lungs may in their own right lead to chronic airway inflammation and hence tissue damage. There is, however, no direct evidence of this in COPD, although the hypothesis is feasible and testable by using eradication therapy and observing the subsequent decline in lung function in COPD.


In summary several disease entities occur more commonly in the presence of each other and are associated with similar inflammatory pathophysiology suggesting that a common process results in the clinical overlap. TNF-α appears to be a central mediator in this process suggesting that factors influencing its production may lead to a cascade of events, making several conditions more likely (Figure 4). COPD may enhance this phenomenon by the associated release of ROS. Alternatively it is possible that the systemic inflammatory response to COPD precipitates disease processes at distant sites in its own right, although this seems less likely. Whatever the relationship, it does suggest that COPD patients may present to other specialties because of the co-morbidity. Furthermore, the diagnosis may be missed because of common symptomatology (dyspnoea as a result of cardiovascular disease or obesity). As effective anti-inflammatory therapy becomes available for COPD it will be of importance not only to monitor the effect on the lungs but also any associated co-morbidities. This may explain why inhaled corticosteroids in COPD are associated with decreased cardiovascular mortality [79] but clearly further studies are warranted to dissect this process in detail.

Figure 4

The central role of TNF-α in co-morbidity associated with COPD. TNF-α appears to play a central role in the pathogenesis of COPD and other conditions that are increasingly being recognised as systemic inflammatory diseases. Certain TNF-α receptor polymorphisms are associated with increased severity of disease [85,86] and this may be due to enhanced TNF-α effects. CRP levels can be increased directly by TNF-α and other cytokines. Elevated CRP levels appear to be particularly crucial in the pathogenesis of cardiovascular disease. ROS released as a result of COPD may enhance the likelihood of developing cardiovascular disease, diabetes and osteoporosis. TNF-α – tumour necrosis factor – alpha CRP – C reactive protein ROS – reactive oxygen species


All abbreviations are expanded in the text


  1. 1.

    Pauwels RA, Buist AS, Calverley PM, Jenkins CR, Hurd SS: Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD) Workshop summary. Am J Respir Crit Care Med 2001, 163:1256–1276.

    CAS  Article  PubMed  Google Scholar 

  2. 2.

    Ferrer M, Alonso J, Morera J, Marrades RM, Khalaf A, Aguar MC, Plaza V, Prieto L, Anto JM: Chronic obstructive pulmonary disease stage and health-related quality of life. The Quality of Life of Chronic Obstructive Pulmonary Disease Study Group. Ann Intern Med 1997, 127:1072–1079.

    CAS  Article  PubMed  Google Scholar 

  3. 3.

    Thomason MJ, Strachan DP: Which spirometric indices best predict subsequent death from chronic obstructive pulmonary disease? Thorax 2000, 55:785–788.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  4. 4.

    Stavem K, Aaser E, Sandvik L, Bjornholt JV, Erikssen G, Thaulow E, Erikssen J: Lung function, smoking and mortality in a 26-year follow-up of healthy middle-aged males. Eur Respir J 2005, 25:618–625.

    CAS  Article  PubMed  Google Scholar 

  5. 5.

    Sin DD, Man SF: Chronic obstructive pulmonary disease as a risk factor for cardiovascular morbidity and mortality. Proc Am Thorac Soc 2005, 2:8–11.

    Article  PubMed  Google Scholar 

  6. 6.

    Schmidt MI, Duncan BB, Sharrett AR, Lindberg G, Savage PJ, Offenbacher S, Azambuja MI, Tracy RP, Heiss G: Markers of inflammation and prediction of diabetes mellitus in adults (Atherosclerosis Risk in Communities study): a cohort study. Lancet 1999, 353:1649–1652.

    CAS  Article  PubMed  Google Scholar 

  7. 7.

    Bolton CE, Ionescu AA, Shiels KM, Pettit RJ, Edwards PH, Stone MD, Nixon LS, Evans WD, Griffiths TL, Shale DJ: Associated loss of fat-free mass and bone mineral density in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2004, 170:1286–1293.

    Article  PubMed  Google Scholar 

  8. 8.

    Kellow JE, Tao Z, Piper DW: Ventilatory function in chronic peptic ulcer. A controlled study of ventilatory function in patients with gastric and duodenal ulcer. Gastroenterology 1986, 91:590–595.

    CAS  Article  PubMed  Google Scholar 

  9. 9.

    Stockley RA: The neutrophil in acute and chronic lung disease. In Acute Lung Injury: from inflammation to repair. Edited by: Bellingan G, Laurent G. Amsterdam: IOS Press; 2000:69–84.

    Google Scholar 

  10. 10.

    Churg A, Wang RD, Tai H, Wang X, Xie C, Wright JL: Tumor necrosis factor-alpha drives 70% of cigarette smoke-induced emphysema in the mouse. Am J Respir Crit Care Med 2004, 170:492–498.

    Article  PubMed  Google Scholar 

  11. 11.

    Vernooy JH, Kucukaycan M, Jacobs JA, Chavannes NH, Buurman WA, Dentener MA, Wouters EF: Local and systemic inflammation in patients with chronic obstructive pulmonary disease: soluble tumor necrosis factor receptors are increased in sputum. Am J Respir Crit Care Med 2002, 166:1218–1224.

    Article  PubMed  Google Scholar 

  12. 12.

    Gan WQ, Man SF, Senthilselvan A, Sin DD: Association between chronic obstructive pulmonary disease and systemic inflammation: a systematic review and a meta-analysis. Thorax 2004, 59:574–580.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  13. 13.

    Schols AM, Buurman WA, Staal van den Brekel AJ, Dentener MA, Wouters EF: Evidence for a relation between metabolic derangements and increased levels of inflammatory mediators in a subgroup of patients with chronic obstructive pulmonary disease. Thorax 1996, 51:819–824.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  14. 14.

    Creutzberg EC, Schols AM, Weling-Scheepers CA, Buurman WA, Wouters EF: Characterization of nonresponse to high caloric oral nutritional therapy in depleted patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2000, 161:745–752.

    CAS  Article  PubMed  Google Scholar 

  15. 15.

    Rahman I, Morrison D, Donaldson K, MacNee W: Systemic oxidative stress in asthma, COPD, and smokers. Am J Respir Crit Care Med 1996, 154:1055–1060.

    CAS  Article  PubMed  Google Scholar 

  16. 16.

    Pratico D, Basili S, Vieri M, Cordova C, Violi F, Fitzgerald GA: Chronic obstructive pulmonary disease is associated with an increase in urinary levels of isoprostane F2alpha-III, an index of oxidant stress. Am J Respir Crit Care Med 1998, 158:1709–1714.

    CAS  Article  PubMed  Google Scholar 

  17. 17.

    Repine JE, Bast A, Lankhorst I: Oxidative stress in chronic obstructive pulmonary disease. Oxidative Stress Study Group. Am J Respir Crit Care Med 1997, 156:341–357.

    CAS  Article  PubMed  Google Scholar 

  18. 18.

    MacNee W, Rahman I: Is oxidative stress central to the pathogenesis of chronic obstructive pulmonary disease? Trends Mol Med 2001, 7:55–62.

    CAS  Article  PubMed  Google Scholar 

  19. 19.

    Sauleda J, Garcia-Palmer FJ, Gonzalez G, Palou A, Agusti AG: The activity of cytochrome oxidase is increased in circulating lymphocytes of patients with chronic obstructive pulmonary disease, asthma, and chronic arthritis. Am J Respir Crit Care Med 2000, 161:32–35.

    CAS  Article  PubMed  Google Scholar 

  20. 20.

    Oudijk EJ, Lammers JW, Koenderman L: Systemic inflammation in chronic obstructive pulmonary disease. Eur Respir J Suppl 2003, 46:5s-13s.

    CAS  Article  PubMed  Google Scholar 

  21. 21.

    Lewis SA, Pavord ID, Stringer JR, Knox AJ, Weiss ST, Britton JR: The relation between peripheral blood leukocyte counts and respiratory symptoms, atopy, lung function, and airway responsiveness in adults. Chest 2001, 119:105–114.

    CAS  Article  PubMed  Google Scholar 

  22. 22.

    Takabatake N, Nakamura H, Abe S, Inoue S, Hino T, Saito H, Yuki H, Kato S, Tomoike H: The relationship between chronic hypoxemia and activation of the tumor necrosis factor-alpha system in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2000, 161:1179–1184.

    CAS  Article  PubMed  Google Scholar 

  23. 23.

    National Institute for Clinical Excellence: Guidance on the use of etanercept and infliximab for the treatment of rheumatoid arthritis. [] 2002.

    Google Scholar 

  24. 24.

    Akobeng AK, Zachos M: Tumor necrosis factor-alpha antibody for induction of remission in Crohn's disease. Cochrane Database Syst Rev 2004, CD003574.

    Google Scholar 

  25. 25.

    Deswal A, Petersen NJ, Feldman AM, Young JB, White BG, Mann DL: Cytokines and cytokine receptors in advanced heart failure: an analysis of the cytokine database from the Vesnarinone trial (VEST). Circulation 2001, 103:2055–2059.

    CAS  Article  PubMed  Google Scholar 

  26. 26.

    Coletta AP, Clark AL, Banarjee P, Cleland JG: Clinical trials update: RENEWAL (RENAISSANCE and RECOVER) and ATTACH. Eur J Heart Fail 2002, 4:559–561.

    CAS  Article  PubMed  Google Scholar 

  27. 27.

    Schols AM, Slangen J, Volovics L, Wouters EF: Weight loss is a reversible factor in the prognosis of chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1998, 157:1791–1797.

    CAS  Article  PubMed  Google Scholar 

  28. 28.

    Celli BR, Cote CG, Marin JM, Casanova C, Montes de Oca M, Mendez RA, Pinto Plata V, Cabral HJ: The Body-Mass Index, Airflow Obstruction, Dyspnea, and Exercise Capacity Index in Chronic Obstructive Pulmonary Disease. N Engl J Med 2004, 350:1005–1012.

    CAS  Article  PubMed  Google Scholar 

  29. 29.

    Engelen MP, Schols AM, Lamers RJ, Wouters EF: Different patterns of chronic tissue wasting among patients with chronic obstructive pulmonary disease. Clin Nutr 1999, 18:275–280.

    CAS  Article  PubMed  Google Scholar 

  30. 30.

    Schols AM: Nutritional and metabolic modulation in chronic obstructive pulmonary disease management. Eur Respir J Suppl 2003, 46:81s-86s.

    CAS  Article  PubMed  Google Scholar 

  31. 31.

    Baarends EM, Schols AM, Westerterp KR, Wouters EF: Total daily energy expenditure relative to resting energy expenditure in clinically stable patients with COPD. Thorax 1997, 52:780–785.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  32. 32.

    Agusti AGN, Noguera A, Sauleda J, Sala E, Pons J, Busquets X: Systemic effects of chronic obstructive pulmonary disease. Eur Respir J 2003, 21:347–360.

    CAS  Article  PubMed  Google Scholar 

  33. 33.

    Kotler DP: Cachexia. Ann Intern Med 2000, 133:622–634.

    CAS  Article  PubMed  Google Scholar 

  34. 34.

    Morrison WL, Gibson JN, Scrimgeour C, Rennie MJ: Muscle wasting in emphysema. Clin Sci (Lond) 1988, 75:415–420.

    CAS  Article  Google Scholar 

  35. 35.

    Tisdale MJ: Biology of cachexia. J Natl Cancer Inst 1997, 89:1763–1773.

    CAS  Article  PubMed  Google Scholar 

  36. 36.

    Schols AM, Soeters PB, Mostert R, Pluymers RJ, Wouters EF: Physiologic effects of nutritional support and anabolic steroids in patients with chronic obstructive pulmonary disease. A placebo-controlled randomized trial. Am J Respir Crit Care Med 1995, 152:1268–1274.

    CAS  Article  PubMed  Google Scholar 

  37. 37.

    Debigare R, Cote CH, Maltais F: Peripheral muscle wasting in chronic obstructive pulmonary disease. Clinical relevance and mechanisms. Am J Respir Crit Care Med 2001, 164:1712–1717.

    CAS  Article  PubMed  Google Scholar 

  38. 38.

    Anker SD, Ponikowski P, Varney S, Chua TP, Clark AL, Webb-Peploe KM, Harrington D, Kox WJ, Poole-Wilson PA, Coats AJ: Wasting as independent risk factor for mortality in chronic heart failure. Lancet 1997, 349:1050–1053.

    CAS  Article  PubMed  Google Scholar 

  39. 39.

    Kopple JD: Pathophysiology of protein-energy wasting in chronic renal failure. J Nutr 1999, 129:247S-251S.

    CAS  PubMed  Google Scholar 

  40. 40.

    Macallan DC: Wasting in HIV infection and AIDS. J Nutr 1999, 129:238S-242S.

    CAS  PubMed  Google Scholar 

  41. 41.

    Stewart CE, Newcomb PV, Holly JM: Multifaceted roles of TNF-alpha in myoblast destruction: a multitude of signal transduction pathways. J Cell Physiol 2004, 198:237–247.

    CAS  Article  PubMed  Google Scholar 

  42. 42.

    Reid MB, Li YP: Tumor necrosis factor-alpha and muscle wasting: a cellular perspective. Respir Res 2001, 2:269–272.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  43. 43.

    Gordon JN, Green SR, Goggin PM: Cancer cachexia. Qjm 2005, 98:779–788.

    CAS  Article  PubMed  Google Scholar 

  44. 44.

    Barreiro E, de la Puente B, Minguella J, Corominas JM, Serrano S, Hussain SN, Gea J: Oxidative stress and respiratory muscle dysfunction in severe chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2005, 171:1116–1124.

    Article  PubMed  Google Scholar 

  45. 45.

    Rana JS, Mittleman MA, Sheikh J, Hu FB, Manson JE, Colditz GA, Speizer FE, Barr RG, Camargo CA Jr: Chronic obstructive pulmonary disease, asthma, and risk of type 2 diabetes in women. Diabetes Care 2004, 27:2478–2484.

    Article  PubMed  Google Scholar 

  46. 46.

    Barzilay JI, Abraham L, Heckbert SR, Cushman M, Kuller LH, Resnick HE, Tracy RP: The relation of markers of inflammation to the development of glucose disorders in the elderly: the Cardiovascular Health Study. Diabetes 2001, 50:2384–2389.

    CAS  Article  PubMed  Google Scholar 

  47. 47.

    Pickup JC, Mattock MB, Chusney GD, Burt D: NIDDM as a disease of the innate immune system: association of acute-phase reactants and interleukin-6 with metabolic syndrome X. Diabetologia 1997, 40:1286–1292.

    CAS  Article  PubMed  Google Scholar 

  48. 48.

    Sonnenberg GE, Krakower GR, Kissebah AH: A novel pathway to the manifestations of metabolic syndrome. Obes Res 2004, 12:180–186.

    CAS  Article  PubMed  Google Scholar 

  49. 49.

    Ouchi N, Kihara S, Arita Y, Okamoto Y, Maeda K, Kuriyama H, Hotta K, Nishida M, Takahashi M, Muraguchi M, Ohmoto Y, Nakamura T, Yamashita S, Funahashi T, Matsuzawa Y: Adiponectin, an adipocyte-derived plasma protein, inhibits endothelial NF-kappaB signaling through a cAMP-dependent pathway. Circulation 2000, 102:1296–1301.

    CAS  Article  PubMed  Google Scholar 

  50. 50.

    Hotamisligil GS, Peraldi P, Budavari A, Ellis R, White MF, Spiegelman BM: IRS-1-mediated inhibition of insulin receptor tyrosine kinase activity in TNF-alpha- and obesity-induced insulin resistance. Science 1996, 271:665–668.

    CAS  Article  PubMed  Google Scholar 

  51. 51.

    Porter MH, Cutchins A, Fine JB, Bai Y, DiGirolamo M: Effects of TNF-alpha on glucose metabolism and lipolysis in adipose tissue and isolated fat-cell preparations. J Lab Clin Med 2002, 139:140–146.

    CAS  Article  PubMed  Google Scholar 

  52. 52.

    Zinman B, Hanley AJ, Harris SB, Kwan J, Fantus IG: Circulating tumor necrosis factor-alpha concentrations in a native Canadian population with high rates of type 2 diabetes mellitus. J Clin Endocrinol Metab 1999, 84:272–278.

    CAS  PubMed  Google Scholar 

  53. 53.

    Tamakoshi K, Yatsuya H, Kondo T, Hori Y, Ishikawa M, Zhang H, Murata C, Otsuka R, Zhu S, Toyoshima H: The metabolic syndrome is associated with elevated circulating C-reactive protein in healthy reference range, a systemic low-grade inflammatory state. Int J Obes Relat Metab Disord 2003, 27:443–449.

    CAS  Article  PubMed  Google Scholar 

  54. 54.

    Weyer C, Funahashi T, Tanaka S, Hotta K, Matsuzawa Y, Pratley RE, Tataranni PA: Hypoadiponectinemia in obesity and type 2 diabetes: close association with insulin resistance and hyperinsulinemia. J Clin Endocrinol Metab 2001, 86:1930–1935.

    CAS  Article  PubMed  Google Scholar 

  55. 55.

    Ghanim H, Garg R, Aljada A, Mohanty P, Kumbkarni Y, Assian E, Hamouda W, Dandona P: Suppression of nuclear factor-kappaB and stimulation of inhibitor kappaB by troglitazone: evidence for an anti-inflammatory effect and a potential antiatherosclerotic effect in the obese. J Clin Endocrinol Metab 2001, 86:1306–1312.

    CAS  PubMed  Google Scholar 

  56. 56.

    Haffner SM, Greenberg AS, Weston WM, Chen H, Williams K, Freed MI: Effect of rosiglitazone treatment on nontraditional markers of cardiovascular disease in patients with type 2 diabetes mellitus. Circulation 2002, 106:679–684.

    CAS  Article  PubMed  Google Scholar 

  57. 57.

    Ishibashi M, Egashira K, Hiasa K, Inoue S, Ni W, Zhao Q, Usui M, Kitamoto S, Ichiki T, Takeshita A: Antiinflammatory and antiarteriosclerotic effects of pioglitazone. Hypertension 2002, 40:687–693.

    CAS  Article  PubMed  Google Scholar 

  58. 58.

    Sidhu JS, Cowan D, Kaski JC: The effects of rosiglitazone, a peroxisome proliferator-activated receptor-gamma agonist, on markers of endothelial cell activation, C-reactive protein, and fibrinogen levels in non-diabetic coronary artery disease patients. J Am Coll Cardiol 2003, 42:1757–1763.

    CAS  Article  PubMed  Google Scholar 

  59. 59.

    Fernandez-Real JM, Ricart W: Insulin resistance and chronic cardiovascular inflammatory syndrome. Endocr Rev 2003, 24:278–301.

    CAS  Article  PubMed  Google Scholar 

  60. 60.

    Ridker PM, Rifai N, Rose L, Buring JE, Cook NR: Comparison of C-reactive protein and low-density lipoprotein cholesterol levels in the prediction of first cardiovascular events. N Engl J Med 2002, 347:1557–1565.

    CAS  Article  PubMed  Google Scholar 

  61. 61.

    Pai JK, Pischon T, Ma J, Manson JE, Hankinson SE, Joshipura K, Curhan GC, Rifai N, Cannuscio CC, Stampfer MJ, Rimm EB: Inflammatory markers and the risk of coronary heart disease in men and women. N Engl J Med 2004, 351:2599–2610.

    CAS  Article  PubMed  Google Scholar 

  62. 62.

    Albert MA: The role of C-reactive protein in cardiovascular disease risk. Curr Cardiol Rep 2000, 2:274–279.

    CAS  Article  PubMed  Google Scholar 

  63. 63.

    Zahedi K, Tebo JM, Siripont J, Klimo GF, Mortensen RF: Binding of human C-reactive protein to mouse macrophages is mediated by distinct receptors. J Immunol 1989, 142:2384–2392.

    CAS  PubMed  Google Scholar 

  64. 64.

    Ballou SP, Lozanski G: Induction of inflammatory cytokine release from cultured human monocytes by C-reactive protein. Cytokine 1992, 4:361–368.

    CAS  Article  PubMed  Google Scholar 

  65. 65.

    Devaraj S, Du Clos TW, Jialal I: Binding and internalization of C-reactive protein by Fcgamma receptors on human aortic endothelial cells mediates biological effects. Arterioscler Thromb Vasc Biol 2005, 25:1359–1363.

    CAS  Article  PubMed  Google Scholar 

  66. 66.

    Smeeth L, Thomas SL, Hall AJ, Hubbard R, Farrington P, Vallance P: Risk of myocardial infarction and stroke after acute infection or vaccination. N Engl J Med 2004, 351:2611–2618.

    CAS  Article  PubMed  Google Scholar 

  67. 67.

    Stockley RA, O'Brien C, Pye A, Hill SL: Relationship of sputum color to nature and outpatient management of acute exacerbations of COPD. Chest 2000, 117:1638–1645.

    CAS  Article  PubMed  Google Scholar 

  68. 68.

    Wedzicha JA, Seemungal TA, MacCallum PK, Paul EA, Donaldson GC, Bhowmik A, Jeffries DJ, Meade TW: Acute exacerbations of chronic obstructive pulmonary disease are accompanied by elevations of plasma fibrinogen and serum IL-6 levels. Thromb Haemost 2000, 84:210–215.

    CAS  PubMed  Google Scholar 

  69. 69.

    Almagro P, Calbo E, Ochoa de Echaguen A, Barreiro B, Quintana S, Heredia JL, Garau J: Mortality after hospitalization for COPD. Chest 2002, 121:1441–1448.

    Article  PubMed  Google Scholar 

  70. 70.

    McEvoy CE, Ensrud KE, Bender E, Genant HK, Yu W, Griffith JM, Niewoehner DE: Association between corticosteroid use and vertebral fractures in older men with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1998, 157:704–709.

    CAS  Article  PubMed  Google Scholar 

  71. 71.

    Gianni W, Ricci A, Gazzaniga P, Brama M, Pietropaolo M, Votano S, Patane F, Agliano AM, Spera G, Marigliano V, Ammendola S, Agnusdei D, Migliaccio S, Scandurra R: Raloxifene modulates interleukin-6 and tumor necrosis factor-alpha synthesis in vivo: results from a pilot clinical study. J Clin Endocrinol Metab 2004, 89:6097–6099.

    CAS  Article  PubMed  Google Scholar 

  72. 72.

    Cenci S, Weitzmann MN, Roggia C, Namba N, Novack D, Woodring J, Pacifici R: Estrogen deficiency induces bone loss by enhancing T-cell production of TNF-alpha. J Clin Invest 2000, 106:1229–1237.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  73. 73.

    Kudo O, Sabokbar A, Pocock A, Itonaga I, Fujikawa Y, Athanasou NA: Interleukin-6 and interleukin-11 support human osteoclast formation by a RANKL-independent mechanism. Bone 2003, 32:1–7.

    CAS  Article  PubMed  Google Scholar 

  74. 74.

    Kong YY, Feige U, Sarosi I, Bolon B, Tafuri A, Morony S, Capparelli C, Li J, Elliott R, McCabe S, Wong T, Campagnuolo G, Moran E, Bogoch ER, Van G, Nguyen LT, Ohashi PS, Lacey DL, Fish E, Boyle WJ, Penninger JM: Activated T cells regulate bone loss and joint destruction in adjuvant arthritis through osteoprotegerin ligand. Nature 1999, 402:304–309.

    CAS  Article  PubMed  Google Scholar 

  75. 75.

    Teng YT, Nguyen H, Gao X, Kong YY, Gorczynski RM, Singh B, Ellen RP, Penninger JM: Functional human T-cell immunity and osteoprotegerin ligand control alveolar bone destruction in periodontal infection. J Clin Invest 2000, 106:R59–67.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  76. 76.

    Arora OP, Kapoor CP, Sobti P: Study of gastroduodenal abnormalities in chronic bronchitis and emphysema. Am J Gastroenterol 1968, 50:289–296.

    CAS  PubMed  Google Scholar 

  77. 77.

    Roussos A, Philippou N, Krietsepi V, Anastasakou E, Alepopoulou D, Koursarakos P, Iliopoulos I, Gourgoulianis K: Helicobacter pylori seroprevalence in patients with chronic obstructive pulmonary disease. Respir Med 2005, 99:279–284.

    Article  PubMed  Google Scholar 

  78. 78.

    Perri F, Clemente R, Festa V, De Ambrosio CC, Quitadamo M, Fusillo M, Grossi E, Andriulli A: Serum tumour necrosis factor-alpha is increased in patients with Helicobacter pylori infection and CagA antibodies. Ital J Gastroenterol Hepatol 1999, 31:290–294.

    CAS  PubMed  Google Scholar 

  79. 79.

    Sin DD, Man SF: Why are patients with chronic obstructive pulmonary disease at increased risk of cardiovascular diseases? The potential role of systemic inflammation in chronic obstructive pulmonary disease. Circulation 2003, 107:1514–1519.

    Article  PubMed  Google Scholar 

  80. 80.

    Alberti KG, Zimmet PZ: Definition, diagnosis and classification of diabetes mellitus and its complications. Part 1: diagnosis and classification of diabetes mellitus provisional report of a WHO consultation. Diabet Med 1998, 15:539–553.

    CAS  Article  PubMed  Google Scholar 

  81. 81.

    Balkau B, Charles MA: Comment on the provisional report from the WHO consultation. European Group for the Study of Insulin Resistance (EGIR). Diabet Med 1999, 16:442–443.

    CAS  Article  PubMed  Google Scholar 

  82. 82.

    Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final reportCirculation 2002, 106:3143–3421.

  83. 83.

    Einhorn D, Reaven GM, Cobin RH, Ford E, Ganda OP, Handelsman Y, Hellman R, Jellinger PS, Kendall D, Krauss RM, Neufeld ND, Petak SM, Rodbard HW, Seibel JA, Smith DA, Wilson PW: American College of Endocrinology position statement on the insulin resistance syndrome. Endocr Pract 2003, 9:237–252.

    PubMed  Google Scholar 

  84. 84.

    Alberti KG, Zimmet P, Shaw J: The metabolic syndrome--a new worldwide definition. Lancet 2005, 366:1059–1062.

    Article  PubMed  Google Scholar 

  85. 85.

    Fernandez-Real JM, Vendrell J, Ricart W, Broch M, Gutierrez C, Casamitjana R, Oriola J, Richart C: Polymorphism of the tumor necrosis factor-alpha receptor 2 gene is associated with obesity, leptin levels, and insulin resistance in young subjects and diet-treated type 2 diabetic patients. Diabetes Care 2000, 23:831–837.

    CAS  Article  PubMed  Google Scholar 

  86. 86.

    Sankar VH, Girisha KM, Gilmour A, Singh VP, Sinha N, Tewari S, Ramesh V, Mastana S, Agrawal S: TNFR2 gene polymorphism in coronary artery disease. Indian J Med Sci 2005, 59:104–108.

    CAS  Article  PubMed  Google Scholar 

Download references


The Antitrypsin Deficiency Assessment and Programme for Treatment (ADAPT) project is supported by a non-commercial grant from Talecris Biotherapeutics.

Dr Anita Pye for proof reading the manuscript and assisting with the figures.

Miss R Lewis for typing the manuscript.

Author information



Corresponding author

Correspondence to Robert A Stockley.

Additional information

Competing interests

The author(s) declare that they have no competing interests.

Authors' contributions

MJS and RAS co-authored the paper

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Sevenoaks, M.J., Stockley, R.A. Chronic Obstructive Pulmonary Disease, inflammation and co-morbidity – a common inflammatory phenotype?. Respir Res 7, 70 (2006).

Download citation


  • Chronic Obstructive Pulmonary Disease
  • Chronic Obstructive Pulmonary Disease Patient
  • Acute Phase Protein
  • Airflow Obstruction
  • Muscle Wasting