Advances in molecular mechanism of lung injury induced by paraquat poisoning

Qi Li, Jin Qian, Qi-Feng Huang, Tang Deng, Li-Hua Li, Hang-Fei Wang, Shuang-Qin Xu, Xin-Xin Wu, Xiao-Ran Liu,,3✉

1. T1. Emergency and Trauma College of Hainan Medical University, Haikou 571199, China

2. Emergency Department of the First Affiliated Hospital of Hainan Medical University, Haikou 570102, China

3. Key Laboratory of Hainan Trauma and Disaster Rescue, Haikou 570000, China

Keywords:Paraquat poisoning Lung injury Signaling transduction pathway

ABSTRACT Paraquat (PQ) is a bipyridine dichloride non-selective herbicide, which was widely used in the world in the last century. It is banned in most countries because of the extremely high death rate and the lack of specific detoxification drugs, but the death cases of poisoning still occur frequently, so it is of great clinical significance to study the molecular mechanism of poisoning and detoxification drugs. Its poisoning causes dysfunction of lung, liver, kidney, myocardium,brain and other organs with complex molecular mechanism. There are excessive inflammatory reaction theory, REDOX reaction imbalance, oxidative stress free radical damage, calcium overload, NO molecular damage, apoptosis, etc. For the treatment of poisoning, PQ antibody,pathway target blocker and related factor antibody have been newly developed in recent years.Although certain effects have been achieved, the treatment efficiency has not been significantly improved. This paper summarized the mechanism of signal transduction pathways involved in lung injury caused by PQ poisoning in order to provide a theoretical basis for further research.

Paraquat: 1, 1-dimethyl-4, 4-dipyridine cationic salt, colorless powder, a non-selective and highly effective herbicide, easily soluble in water, non-volatile, stable in acidic and neutral solutions,often dissociated when PH is greater than 7 [1]. It is less absorbed in the gastrointestinal tract, and the blood concentration reaches a peak 2 to 4 hours after absorption and drops 24 hours later. It is rarely degraded in the liver and is mostly excreted in prototype form through the intestine and a small amount through the kidney.Human oral lethal dose 30-40mg/kg, 20% paraquat solution 5-15ml.In recent years, the study of paraquat poisoning has made a deeper understanding, but because of its poisoning after involve multiple organs (lung, liver, heart, kidney, brain, stomach, etc.), excessive inflammation, oxidative stress, free radical damage [2], multiple pathways in complex control network, the poisoning mortality remains high, there is still no specific drug detoxification. In this paper, the main related pathways and target blockers involved after poisoning were summarized to provide a theoretical basis for the study of antidotes.

1. Mechanism of poisoning

1.1 Excessive inflammation

Paraquat is absorbed into the blood circulation through the digestive tract, activates neutrophils, CD4+T, lymphocytes,mononuclear macrophages, vascular endothelial cells, etc., and releases vasoactive substances, such as IL-1, which promote proliferation and secretion of T and B lymphocytes. IL-6 and IL-8 promote the activation of B lymphocytes and promote the formation of immune complexes [3]. IL-17 is involved in immune injury and promotes acute inflammatory response. TNF- activates neutrophils,which produce free radicals and trigger an inflammatory chain reaction. PQ can also activate platelet-derived growth factor, IGF- 1, NK-b, CTGF [4] (connective tissue growth factor: promoting extracellular matrix formation), thromboxane A2and collagenase,histamine, leukotriene, prostaglandin, etc. These active substances and enzymes can damage the structure of pulmonary microvascular endothelial cells and basement membrane barrier, and increase the permeability. Inflammatory substances exude in large quantities,leading to tissue degeneration, necrosis, and fibrosis. The relative deficiency of IL-4, IL-10 and other anti-inflammatory factors is also one of the reasons for the serious injury.

PQ is absorbed into the blood, allowing a large amount of PQ to infiltrate into the stroma from the pulmonary microcirculation through monolayer vascular endothelial cells and/or basement membrane under gradient pressure. There are polyamine transporters in the membrane of alveolar epithelial cells. Due to the similar structure of PQ and endogenous polyamine, PQ is actively transported by alveolar epithelial cell transporters (PQ is also dispersed at high concentration) into the cells, and its intracellular concentration is dozens of times higher than that of plasma [5]. Under the action of reductase systems in organelles such as mitochondria and endoplasmic reticulum, oxidative stress occurs and free radicals are generated, resulting in membrane structure damage and metabolic disorders [6]. Damaged cells accelerate chemotaxis, aggregation,release and phagocytosis of inflammatory cells, further aggravating inflammatory damage. At the same time, the formation of surface active substances in the alveolar cavity is obstructed, which leads to the increase of centriolar force, which causes the Plasma or blood cells to penetrate into the alveolar cavity, and affects the exchange of gas and blood [7], resulting in alveolar collapse, and even atopic lung, secondary by ARDS[8]. The relevant molecular mechanisms of inflammation mainly involve the following pathways:

1.1.1 NF-κB Signaling pathways

NF-κB [9] is a nuclear transcription factor that binds to the inactivated state of inhibitory protein (IκB) in normal state,is easily activated by multiple pathogenic components, and is sensitive to REDOX reactions. NF-κB is the common hub of multiple regulatory pathways, such as P38, TRAF-IKK, PI3K,and P65. Gene expression induced by PQ poisoning is regulated by binding to corresponding gene loci. It has regulatory effects on reactive proteins, cytokines and cell adhesion molecules in the acute phase [10]. Participate in immunity, inflammatory response,proliferation, fibrosis, apoptosis and other biological processes. PQ have stronger immune pathogenic, the activation of inflammatory cells, through multi-channel kappa B phosphorylation, predominate ubiquitin degradation, dissociative NF - κB/Rel complex, further modification after translation activation, into the nucleus, promoting TNF-α, IL-1, chemokine gene transcription, caused by a variety of downstream of the inflammatory cytokines expression and release, make more the activation of inflammatory cells, Form positive feedback cascade amplification effect; And promote the generation of free radicals; Aggravated tissue inflammatory injury and pulmonary fibrosis. Yang et al., knockdown of Angptl2(angiogeninin-like protein 2) attenuated NF-κB expression and reduced inflammation. Relevant experiments have confirmed that NF-κB signaling pathway up-regulates inflammatory response in paraquat poisoning [11].

1.1.2 p38 MAPK Signaling pathways

Mitogen-activated protein kinase (MAPK) can be activated by physicochemical, biological and other factors.MAPKKK phosphorylation activates MKK3/6, which activates p38MAPK,while the latter regulates the expression levels of HSP27, Mapkapk-2(MK2), Mapkapk-3, transcription factor Stat1, Max/Myc complex,MEF-2, ELK-1 and ATF-2, and jointly regulates cell proliferation,differentiation, stress adaptation to the environment, inflammatory response and other important cellular physiological or pathological processes [12]. In lung injury caused by PQ, p38MAPK signaling pathway is involved in various processes such as cellular stress response, inflammatory response and death. Experiments have shown that the expression of protein p38MAPK in this pathway is significantly increased in PQ toxic lung injury, and the expression of the above factors is decreased after the application of inhibitors[13].ERK/MAPK pathway induced by PQ poisoning also resulted in increased tissue vascular permeability, inflammatory cell infiltration and apoptosis [14]. JNK belongs to the downstream molecules of the p38MAPK signaling pathway, which mainly regulates apoptosis in the nucleus and also participates in the stress response of PQ poisoning and the occurrence and development of apoptosis.

1.1.3 W nt / β-catenin Signaling pathwaysWnt exists in a variety of eukaryotic cells and has been proved to play an important role in the formation of pulmonary fibrosis caused by PQ poisoning. Wnt binds to membrane receptors to activate downstream protein -catenin[15], and integrates into nuclear regulatory gene expression to increase the generation of MMP,TGF-β, etc., which leads to interstitial transformation of lung epithelial cells and promotes the formation of fibrosis. Blocking Wnt / -catenin signaling pathway can partially inhibit PQ-induced epithelial-mesenchymal transformation, which also proves that it plays an important regulatory role in the occurrence and development of PQ-induced pulmonary fibrosis. However, other factors, such as hypoxia-inducing factor (HIF-1) and connective tissue growth factor (CTGF), still participate in the fibrosis process jointly. Huang jing etal. demonstrated that the expression levels of cytokines such as IL-1, -catenin, TGF-βand MMP-2 (matrix metalloproteinase)were significantly increased in the formation of PQ toxic fibrosis.It was preliminarily confirmed that the Wnt signaling pathway was activated and involved in the pulmonary fibrosis process after paraquat poisoning [16].

1.1.4 JAK-Stat Signaling pathways

JAK is a family of non-receptor tyrosine kinases found to have four members, and the substrate of JAK is Stat. In PQ poisoning,inflammatory factor, interferon, interleukin family colony stimulating factor (CSF) and the receptor, the latter for a single transmembrane protein, itself does not have enzymes, and the ligand binding occurs after polymerization and activation, two connections and activate intracellular tyrosine protein kinase, which make the Stat phosphorylated modification, and form dimers, activate the downstream genes, platelet derived growth factor (PDGF) exposure in nuclear signal; Stat can be directly inserted into the nucleus to regulate the expression of corresponding genes [17]. This pathway is mainly involved in many important biological processes such as cell proliferation, differentiation, apoptosis and immune regulation,and can cause a variety of cytokines such as PI3K, Ras widespread activation and increased expression of related genes, leading to inflammation and late fibrosis repair. This pathway plays a key role in the mechanism of PQ toxic lung injury. When the JAKS specific blocker AG490 was used to block the JAK/Stat signal transduction, the expression of downstream genes PDGF and Stat1 was decreased, and the degree of lung injury was also significantly reduced, suggesting that the JAK/Stat signal transduction pathway was involved in PQ-induced lung injury [18]. The research of these blockers has become a hot spot in the treatment of PQ poisoning.

1.1.5 Toll-like receptors TLRs Signaling pathways

TLRs are conserved pattern receptors (PRRs), transmembrane proteins found initially in drosophila and later on the surface of mammalian cells, which are partially responsible for embryonic development and formation and are mostly associated with innate immunity. These membrane molecules can recognize pathogenic microorganisms or PQ invading the body, and activate JNK, P38 MAPK and NF-κB [19] through ligand binding to downstream connector protein MyD88 and phosphorylation of IRAK and IKK signal complexes [19], causing a chain reaction that up-regulates the expression of immune response molecules and leads to inflammation. In addition, oxidative stress and free radical damage caused by PQ indirectly activate TLR-4 of pulmonary epithelial cell membrane and downstream IRAK-4 and TRAF-6, aggravating pulmonary inflammatory response. Increased expression of TLR-4 has also been confirmed in PQ rat experiments [20].

1.1.6 TGF-β1/ Smad Signaling pathways

TGF-β1 is synthesized in most cells and is involved in many regulatory processes such as embryonic differentiation, maturation,and apoptosis, and plays an important role in maintaining the dynamic balance between these processes. When PQ is poisoned,a large number of inflammatory factors, including TGF-β1and Wnt, bind to the receptor, recruit and phosphorylate downstream molecules, regulate Smad protein family or TAK- MKK-JNK, CBP/-catenin, etc. The former binds to coSamdSamd4, forming R-SAMD/coSamd complex as transcription factor aggregation in the nucleus,causing downstream chain reaction, myofibroblast activation,excessive deposition of extracellular matrix (ECM), EMT(epithelialmesenchymal transformation), and pulmonary fibrosis and respiratory failure [21]. In addition, Notch1 also participates in epithelial- mesenchymal transformation through the TGF-β1 /Smad3 pathway, leading to fibroblast differentiation and accelerating pulmonary fibrosis progression. Losartan is an angiotensin receptor antagonist, which can alleviate the acute pulmonary exudation and fibrosis caused by paraquat [22].

1.1.7 cAMP /PKA Signaling pathways

In PQ poisoning, the cAMP/PKA signaling pathway is also involved in cellular stress, inflammatory damage and metabolic disorders. It as A classic in the cell signal pathways, by the G protein coupled receptor would transmit the signal first to adenylate cyclase (AC), which controls the content of cAMP, the activity of protein kinase A is determined by cAMP, which make the most of the protein phosphorylation, such as receptors, ion channel proteins,transcription factors, such as the biological activity of regulating cell reaction and balance [23]. Protein kinase (PK) is an enzyme that catalyzes protein phosphorylation and has a variety of functions in cells, including regulating the metabolism of glycogen, sugar, and lipids. PQ toxicity can reduce the content of cAMP in cells, increase the permeability of cells, and cause cell metabolism disorders.PQ toxicity down-regulated the expression of cAMP in this pathway, promoting the occurrence and development of pulmonary inflammation [24].

1.1.8 PI3K-Akt Signaling pathways

This pathway can be activated by hormones, growth factors,and extracellular matrix (ECM) components. The Akt pathway is activated by PI3K, which in turn activates the mTOR pathway[25].Akt, a serine/threonine kinase, is involved in cell proliferation,glucose metabolism, cell survival, cell cycle, protein synthesis, and plays a regulatory role in angiogenesis by regulating downstream molecules. It also participates in cell proliferation by interacting with many proteins involved in the cell cycle. Activation of this pathway increases the expression of IL-1 and TNF-α, and is involved in PQ poisoning leading to pulmonary fibrosis and the reduction of SOD content. The specific mechanism still needs further study [26,27].

1.1.9 HMGB1-TLR4-IL-23-IL-17A Signaling pathways

HMGB1is chromatin binding protein, synthesized from necrotic cells and inflammatory cells release, acting on the helper T cells,gamma delta T cells and NKT cells, neutrophils, CD4+T cells,and membrane Toll-like receptors TLR2and TLR4, TLR9 and RAGE (advanced glycosylation end product receptors), activate IL-23, prompt production of IL-17 a, resulting in neutrophils and other immune cells to the infected parts of the gathering. HMGB1expression is often significantly increased after the peak of acute inflammatory cells (neutrophils), which aggravates the inflammatory response of tissues [28]. In addition to PQ toxic lung injury, this pathway is also common in lung injury caused by other factors.

1.1.10 Keap1-p65-Nrf2 Signaling pathwaysPQ poisoning causes intracellular oxidative stress and the increase of reactive oxygen radicals, leading to the conformational change of Keap1 and Nrf2complex and phosphorylation activation of the latter, which leads to the dissociation of Nrf2into the nucleus and its binding with ARE to initiate the transcription of antioxidant factor genes or the expression of anti-apoptotic proteins [29]. PI3K-akt can also be activated through other pathways. Experiments show that low concentration of PQ poisoning increases the concentration of Nrf2and P65. High concentration of PQ poisoning reduces the formation of both and promotes damage and fibrosis.

1.1.11 MiR-141-3p-Notch-Nrf2 Signaling pathways

MiRNA is a segment of non-coding RNA that regulates transcription, reduces the expression of downstream proteins HMGB1and Notch1, and reduces inflammation. Notch receptor is a transmembrane protein, which regulates the expression of some genes Myc and P21after activation, and is related to the development of angiogenesis, differentiation and development. Nrf2is the main factor to reduce oxidative stress, and Notch-Hesr-NRf2is the antioxidant regulatory pathway [30]. It has been confirmed by gene knockout or RNA interference experiments. PQ poisoning can increase Mir-141-3p and inhibit the expression of Notch1-NRFT2,thus reducing its protection against lung injury and aggravating lung injury [31].

1.1.12 PI3K/Akt/mTOR Signaling pathwaysRapamycin target protein (mTOR) belongs to serine or threonine kinase, which regulates growth proliferation. It binds to the corresponding growth factor, TP enzyme complex and so on to phosphorylate the substrate to regulate metabolism and regulate cell proliferation. The upstream of PI3K/Akt、Ras、P53and other proteins are regulated through different pathways. PQ poisoning can inhibit the regulation of this signaling pathway, increase oxidative stress, and enhance the formation of pulmonary fibrosis. Sirolimus is an mTOR inhibitor that reduces inflammation, inhibits proliferation,and inhibits angiogenesis, reduces inflammation associated with PQ poisoning;inhibits the NF-κB, Wnt/ -catenin signaling pathways,and activates the Nrf2signaling pathway to reduce inflammation and pulmonary fibrosis. Nidanib is a tyrosine kinase inhibitor that targets growth factor receptor, fibroblast growth factor receptor and vascular endothelial growth factor receptor to block downstream signals and reduce pulmonary fibrosis [32].

1.1.13 NLRP3-ASC-caspase-1 Signaling pathways

NLRP3is an inflammatory corome composed of NLRP and articular protein, the latter is apoptosis-related speck protein containing caspase-1 activation domain, which increases expression in PQinduced lung injury and leads to increased secretion of IL-1 and IL-18, activation of TLR4 or TNFR, NF-κB, leading to inflammatory amplification response [33]. Glibenclamide, an inflammasome blocker, can reduce alveolar exudation.

1.1.14 TLR9/MyD88/JNK Signaling pathways

Pathogen-related molecules (such as LPS, mtDNA, etc.) are recognized by the TLR9 receptor of alveolar capillary endothelial cell membrane and activate the downstream protein myeloid molecules (MyD88), phosphorylating IL related kinases IRAK,IκB, JNK, leading to activation of transcription factors and synthesis of a large number of inflammatory mediators, leading to alveolar edema [34]. In PQ poisoning, it has been experimentally demonstrated that the JNK pathway molecular inhibitors (such as SP600125), TLR9 inhibitors (ODN2088), gene silencing (siRNA transfection), or gene knockout in model animals [35] mediated PQinduced alveolar inflammatory damage.

1.1.15 Rho /ROCK Signaling pathways

Rho is a guanosine binding protein with GTP activity. It is a member of Ras subfamily and plays an important role in cell migration, proliferation and transcription. ROCK is a serinethreonine kinase whose structural changes activate phosphorylated substrates that are involved in inflammation and autoimmune diseases and are associated with NF-κB activation. CTGF is a connective tissue growth factor, expressed in small amounts in normal tissue, mainly acting on mesenchymal cells, promoting tissue fibrosis, and also involved in the TGF-β1 pathway regulation. In the case of PQ poisoning, Rho/ROCK signal transduction pathway is involved in the process of tissue fibrosis caused by CTGF [36]. The selective blocker Fasudil can block the degree of fibrosis caused by CTGF.

1.2 The complement system appears

Complement is a kind of serum protein with enzyme activity, which exists in human and vertebrate serum and tissue fluid and is not heatresistant. It is activated through three pathways and can mediate the immune response and inflammatory response [37]. PQ poisoning activates inflammatory cells, releases inflammatory factors, then activates the complement system, and positively responds to activate and release inflammatory cells. Such as playing opsonophagocytosis,cell lysis, mediating inflammation, clearing immune complex and other biological effects; It includes activating neutrophils and enhancing phagocytosis and chemotaxis. Increased vascular permeability; Neutralize the virus; Cytolysis; Immunomodulatory.The complement system activated in the early stage of PQ poisoning also promotes the activation of inflammatory cells, and enhances the excessive release of inflammatory factors such as interleukin-interferon, tumor necrosis factor, collaginase, hydrolase,metalloproteinase, histamine and coagulation factors, causing inflammatory factors such as storm and DIC, and aggravating tissue damage [38]. The use of C3inhibitors or C5aantibodies can effectively reduce the pulmonary inflammatory reaction caused by PQ poisoning [39]. The study of targeted blocking of these key factors is a new direction to reduce the damage of pneumonia.

1.3 Imbalance of REDOX enzyme system and free radical damage

Free radical is "free radical", compound or molecule under photothermal, ultraviolet and other conditions, covalent bond breaks and is generated. Atoms or groups with unpaired electrons have strong oxidability, such as hydrogen atom (H·), hydroxyl radical (·OH) and reactive oxygen species ROS[40]. Paraquat is actively transported by poly (amine) transporters in lung epithelial cells to produce PQ2+under the action of reduced coenzyme II(NADPH), which reacts with O2to produce PQ+and O2-(superoxide anion). When reactive oxygen species (O2-) is activated, hydrogen peroxide (H2O2) is generated under the action of SUPERoxide dismutase (SOD), cytochrome P450monooxygenase, xanthine oxidase, mitochondrial electron transfer enzyme, reduced glutathione and nitric oxide synthase, and the latter is generated under the action of Fe reducing agent .OH, Eventually, more toxic hydroxyl radicals are generated [41], which have stronger oxidation ability. PQ+then reacts with reduced coenzyme II to generate PQ2+,which repeats in a cycle, leading to the generation of more free radicals [42], reduction of reductase system, and REDOX equilibrium disorder [43]. These free radicals can be cross-linked with peripheral one-electron histochemical groups such as unsaturated fatty acids, phospholipids and DNA by covalent or ionic bonds (please delete: Generate malondialdehyde,), damage membrane structure and function, produce lipid peroxidation, generate malondialdehyde,and cause mitochondrial swelling, membrane rupture, reduced ATP synthesis, intracellular reductase consumption, material metabolic system disorders, and even affect DNA replication, transcription and protein expression. Ultimately, it leads to cell edema, aggravating inflammatory response, cell apoptosis, nuclear fragmentation and death [44]. Antioxidants such as N-acetylcysteine, VitD, edaravone,VitE, superoxide dismutase and amifostine can reduce free radicals and resist lipid peroxidation [45].

1.4 Calcium overload

PQ entry into cells leads to inflammatory reactions, lipid peroxidation, imbalance of REDOX reactions, and free radicals production, which damages the structure of tissue membranes,resulting in edema of endoplasmic reticulum, mitochondria and other membranes, increased permeability, intracellular calcium flow, calcium reservoir release, and increased intracellular calcium concentration [46]. It affects membrane functions of various metabolic processes of cells. In addition to aggravating the above injury process, ATP synthesis is reduced, which further aggravates the barrier of ion and material exchange in cell membrane, affects the activity and function of intracellular enzymes, cell electrical activity, skeletal structure and microtubule structure, and organelles such as mitochondrial respiratory chain, Golgi complex structure and DNA structure and function. It also affects arginine metabolism,promotes the formation of NO and peroxynitrite, oxidizes amino acids, nucleotides and polypeptides, and aggravates irreversible cell damage [47]. It has been proved that the use of chelating agent ethylenediamine teacetic acid can reduce intracellular calcium and reduce the damage.

2. Progress in treatment

Traditional treatment is still one of the keys to successful resuscitation, and comprehensive treatment is emphasized for severe patients. Promote the excretion of poisons, and wash the stomach thoroughly many times as early as possible until the gastric juice is tested negative a few days before it is continued; Complete defecation as soon as possible to relieve intestinal paralysis, then adsorbent (medicinal charcoal) plus laxative (rhubarb) with high osmotic pressure laxative (20% mannitol) for whole digestive tract cleaning, and make the rinse solution continuously test PQ negative.At the same time, intravenous nutritional support. In digestive tract cleaning, paraquat decomposition should be promoted with weakly alkaline solution [48]. The absorbed paraquat should be removed as soon as possible by hemoperfusion plus dialysis or plasmapheresis.PEEP and extracorporeal membrane oxygenation as early as possible for respiratory failure [49]. The use of some pathway target antibodies or blockers (Propranolol, Fasudil, Sirolimus, etc.) and the use of reductants can reduce cell damage. Psychotherapy should not be ignored.

3. Problems and Prospects

The damage mechanism of PQ poisoning is complex and involves multiple systems and pathways. Firstly, after PQ enters the circulation, it causes excessive release of a large number of inflammatory cells and inflammatory factors, complement activation,positive feedback amplification effect of multi-pathway network,inflammatory factor storm, and multi-organ acute inflammatory response injury. After PQ enters the cell, it causes REDOX imbalance, free radical damage, lipid peroxidation membrane system damage, metabolic disorder, DNA damage, calcium overload and so on to form a vicious cycle. Nitric oxide (NO) injury is also involved;Apoptosis; The activation of concave protein caused damage. Notch1pathway leads to epithelial-mesenchymal transformation in the lung and pulmonary fibrosis formation. MTOR protein activation, etc.These mechanisms interact to cause serious damage to multiple organs after poisoning, resulting in a high mortality [50].

In the early stage of our research group, anthrahydroquinone-2,6-Disulfonate, a strong reducing agent AH2QDS, can combine with paraquat to generate precipitation in vitro experiments, which significantly reduces the concentration of paraquat in the reaction system, and can improve the survival rate of rats. However, the specific mechanism needs further study, which is expected to significantly improve the survival rate of patients with paraquat poisoning. However, with the development and mutual application of molecular biology, biomarker technology, nanotechnology,proteomics, organic chemistry and other disciplines, the research on these toxic mechanisms and pathway functions has gradually become clear, and the development of pathway target blockers has opened up a new field of detoxification drugs. Research on the structure of membrane polyamine transporters and their blockers is also a new direction. For example, propranolol competes with PQ in polyamine transporters, which is the key to reduce lung injury[51]. Now found no specific antidote, but for some important factor related to inflammation (C3, C5a, TGF -β, Akt, JNK, p38MAPK)inhibitors or antagonists, antibody (PQ antibody, etc.) or interference RNA, knockout research as well as reducing agent application become a new breakthrough [52] PQ poisoning treatment research,strengthen the multidisciplinary cooperation in related research,expect to improve the survival rate of patients.