Post on 14-Dec-2015
transcript
« Predisposition de la réponse à l’agression »
D Payen, MD, Ph Ddpayen1234@orange.fr
Interface INSERM-SFAR-SRLF
the Drosophila fat body
incorporates the mammalian homologues of
the liver and the haematopoietic and immune
Systems.
Function:sensing energy and nutrient
availability,
coordinates the appropriate
metabolic and survival responses
site of coordination of pathogen
responses with metabolic status.
The constitutive view
Topic:Studies on SNP’s associations with
innate immune response.
3 examples of leading pathways:– TNF- promoter variants– TLR4 haplotypes– HLA-DB variants
Strategy: known prot gene SNPs association
Genetic Polymorphisms and Severe Sepsis
Meningococcemia; Severe sepsis
Meningococcemia; Severe sepsis
PAI-1
FactorV Leiden
Severe SepsisViral Pneumonia
IL-1 locusIL-4
MeningococcemiaSeptic Shock; Cerebral MalariaSevere SepsisSevere Sepsis, MeningococcemiaSevere sepsis
TNF locus
IL-18IL-10IL-6
Meningococcemia; Pneumococcemia
FCRII Receptor
Meningococcemia, Pneumococcemia
Severe sepsis
Mannose Binding Lectin
Gene
Gram negative/positive Septic
ShockLegionnaire’s DiseaseSeptic Shock
Toll-Like Receptor 4/2
Toll-Like Receptor 5
CD14
Susceptibility and/or Outcome
Limitations of gene by gene approachLimitations of gene by gene approach
Hope in development of genome wide association methods (600 000 variants studied in one shot!)
Hope in development of genome wide association methods (600 000 variants studied in one shot!)
Clark et al. Intensive Care Med 2006 32:1706-1712
• Gene expression in whole blood leukocytes determined before and at 2, 4, 6, 9 and 24 h after the i.v LPS to 4 HV, compared to 4 additional subjects without LPS.
• Only 3% of the genes modified their expression
• Essentially under-expression human blood leukocyte response to acute systemic inflammation the transient dysregulation of leukocyte bioenergetics &modulation of translational machinery
Insulin-receptor signalling interfaces with inflammatory signalling at the level of insulin-receptor substrates through activation of serine kinases.
(b) ACTH responders
P value for log rank test: 0.9370
0.25
0.50
0.75
1.00
0 5 10 15 20 25 30
placebo
steroid
P value for log rank test: 0.8500
0.25
0.50
0.75
1.00
0 5 10 15 20 25 30
(a) ACTH non-responders
placebo
steroid
P value for log rank test: 0.813
0
0.25
0.50
0.75
1.00
0 5 10 15 20 25 30
day
(c) All patients
placebo
steroid
Figure 2 - Kaplan Meier Curves for 28 day all-cause mortality in (a) ACTH nonresponders (b) ACTH
responders and (c) all patients
Figure 3 - Kaplan Meier Curves for time to reversal of shock in (a) ACTH
nonresponders (b) ACTH responders and (c) all patients
placebo
steroid
P value for log rank test: <0.001
0
0.25
0.50
0.75
1.00
0 5 10 15 20 25 30
day
(c) All patients
P value for log rank test: 0.0380
0.25
0.50
0.75
1.00
0 5 10 15 20 25 30
placebosteroid
(a) ACTH non-responders(b) ACTH responders
P value for log rank test: <0.0010
0.25
0.50
0.75
1.00
0 5 10 15 20 25 30
placebosteroid
Sub-paper from Corticus data base
Our article: shock reversal & outcome
QS: Why success in shock reversal did not improve outcome?
Within the first five daysIncidence of shock reversal according to treatment arm
P<0.0001
0 1 2 3 4 5 6
0.0
0.2
0.4
0.6
0.8
1.0
Days after randomization
Cu
mu
lati
ve i
nci
den
ce
HydrocortisonePlacebo
Within the first five days
Incidence of death prior to shock reversal according to treatment arm
0 1 2 3 4 5 6
0.0
0.2
0.4
0.6
0.8
1.0
Days after randomization
Cu
mu
lativ
e in
cid
en
ce
HydrocortisonePlacebo
P= 0.28
Free energy used by cells respiration or glycolysis
Alternatively, reactions can be centred around ATP.
• ATP-producers include glycolysis & oxidative phosphorylation
• ATP-consumers: transport of cations & synthesis of macromolecules
energy consuming functions of immune cells
• Synthesis of macromolecule & ion transport; O2 is mainly used by mitochondria, non-mitochondrial O2 consumption is negligible
ADN/ARN synthesis
O2 is used for what type of functions?
O2
ADP+Pi
ATP
H+
Actinomycine D
ATP synthase
Respiratoire Chain
NADPH oxydase
protein Synthesis
Na+, K+ ATPase
Ca2+ ATPase
Antimycine A
Cycloheximide
Inhibition
Buttgereit, Biochem J, 1995.
Ouabaïne
DPIChlorure de lanthanum
Global VO2: the different fractions
% O2
75
80
85
90
95
100
0 500 1000 1500 2000 2500 3000
Sec
Cellules
DPI
Cycloheximide
Ouabaïne
ActinomycineDChlorure de lanthanum
Antimycine A
78 ngatomes O2
Septic plasma modifications similar to those observed in septic cellsPlasmatic factors +++
Effects septic plasma septique on baseline (V0) & stimulated reponse
J Appl Physiol 1997
In conclusion, glucose metabolism interferes with hemodynamic, metabolic, and inflammatory responses to LPS. MAJOR ROLE OF EXOGENOUS GLUCOSE
Exogenous glucose (NUTRITION)
Fig. 4
O2 c
on
sum
pti
on
rat
e, n
gat
om
s O
2/m
in/1
07 c
ells
0
4
8
12
16
NG HG
VoVstim ionomycinVstim PMA p=0.003
A
Del
ta i
ncr
ease
in
O2 c
on
sum
pti
on
, %
0
50
100
150
200
NG HG
Delta ionomycinDelta PMA
p=0.004
B
Fig. 5
Vo
, n
gat
om
s O
2/m
in/1
07 ce
lls
HLA-DR, site number
0
2
4
6
8
10
0 10000 20000 30000 40000 50000
sepsis
HV
Del
ta i
ncr
ease
in
O
2 co
nsu
mp
tio
n,
%
HLA-DR, site number
0
50
100
150
200
0 10000 20000 30000 40000 50000
sepsis
HV
Del
ta i
ncr
ease
in
O
2 co
nsu
mp
tio
n,
%
-25
25
75
125
175
225
0 10000 20000 30000 40000 50000
sepsis
HV
HLA-DR, site number
r=0.44p=0.009
r=0.57p=0.0014
r=0.58p=0.049
A
B
C
Iono+PMA
ADP
Immunity triggers inflammation
Pathogen pathwayPAMPs or MAMPs“stranger model”Infection and sepsis
Cell and tissue lesions DAMPs“danger model” infection, trauma,
postop, burns
Kono et coll. Nat Rev Imm 2008
Cell death and inflammation.
- Necrotic cell death DAMPs receptors
on leukocytes + prod of pro-inflam cytokines
(IL‑1).
- Other molecules proteases; hydrolases
act on EC components + mediators
(complement fragments) or DAMPs prod of
pro-inflam cytokines by host cells.
- Pro-inflam mediators local vascular
endothelium ‘leaky’, attracts neutrophils
and monocytes/macrophages soluble
(antibody) and cellular defences in the
tissue
Outcome
ConstitutivePolymorphismsSNPs…
AcquiredPolymorphisms?Epigenetic…
Chronic disease Chronic
treatment
Poor or goodQuality of feeding
PharmacogenomicDrug induced geneExpression changes
Reversing shock ≠Improve outcome
Surviving shock increasesthe risks of disease
Proteins releasedAre changed byEnvironment (nitrosylated…)
Metabolic failureNot related to perfusion
Need forMarkers
D Payen 2010
Difficult to reverse but good reserve
Easy to reverse But high co-morbidity in elderly…
TISSUE RESERVE = Co-morbidity
AGECo-morbidity
Sev
erit
y S
core
INJURY
Severe Injury + good tissue reserveModerate injury + high Co-morbidity Similar severity score
Shock severity is characterized by scores…Outcome may then depend on injury but also
on acquired negative factors…
Survivors of hospitalization for community-acquired pneumonia are at increased risk of cardiovascular events, repeated infections, and death in the following months.
But the cause is unknown…Early and long-lasting mechanisms?But the cause is unknown…Early and long-lasting mechanisms?
Viral co-infections and tissue damageViral co-infections and tissue damage
Crit Care Med 2009; 37:1850-1857
242 ICU patients, 39 CMV infections
ICU mortality: 54% in CMV patients vs 37% in others (p=0.082)
In-hospital mortality: 59% vs 41% (p=0.058)
ICU LOS: 32d vs 12d (p<0.001)
Length of MV: 27d vs 10d
At least one bacterial nosoc inf: 69% vs 33% (p<0.001)
242 ICU patients, 39 CMV infections
ICU mortality: 54% in CMV patients vs 37% in others (p=0.082)
In-hospital mortality: 59% vs 41% (p=0.058)
ICU LOS: 32d vs 12d (p<0.001)
Length of MV: 27d vs 10d
At least one bacterial nosoc inf: 69% vs 33% (p<0.001)
En conclusion
• Métabolisme et inflammation sont intriqués• Les raisons et les preuves sont multiples• Les facteurs enzymatiques, les substrats, les organelles, les facteurs nucléaires interférent pour assurer et moduler la réponse inflammatoire
• Le traitement et les biomarqueurs métaboliques et inflammatoires constituent un espoir diagnostique et thérapeutique
Mitochondrial oxygen consumption - oxidative phosphorilation (> 90 %).
Electron transport chain Saraste M. Science, 1999.
Migration
Cytokinesis
Phagocytosis
Antigen processing
Antigen presentation
Activation
Effector functions
ATP
Active transport of molecules and ions
Synthesis of macromolecules
(RNA/DNA/protein synthesis)
Specific immune functions
General housekeeping functions
ENERGY CONSUMING FUNCTIONS OF IMMUNE CELLS
Buttgereit F. Immunology Today, 2000.
deadalive
p<0,0001
0
5
10
15
20
25
S10
0A8/
A9
pg/m
l
n=61 n=50
Plasma S100 A8/A9 complex D0SOFA D0
2
4
6
8
10
12
14
16
18
20
NS (p<0,09)
Gobal population n = 111
Payen D, Lukazsewicz AC et al. (in review)(Patented in December 2008)
*p=<0.0001, test de Mann WhitneyCinétique des “alive”: D0-D28, p<0.0001, test de Friedman, n=34
D0-D14, p<0.0001, test de Friedman, n=41D0-D7, p=0.0005, test de Friedman, n=57
Cinétique des “dead”: D0-D14,NS, test de Friedman, n=8D0-D7, p=0.0010, test de Friedman, n=15
* *
(41)
0
2
4
6
8
10
12
14
16
18
20
22
24
26
28
30
Pla
sma
S10
0A8/
A9
(g
/ml)
D0 D1 D7 D14 D28
dead
alive
(15)(8)
*
*
(43) (46)(59)
(59)(60)
(50)
Figure: trend over time of S100A8/A9 complex, according to outcome, in plasma. Results expressed in g/ml. Effectives in brackets.
S100A8/A9 in patients without shock at D0N=8 survivorsN=8 non survivors
Mann whitney test, p=0.0008
0
4
8
12
16
20
24
28
D0
dead
alive
Pla
sma
S1
00
A8
/A9
(
g/m
l)
p=0.0008
Metabolic alterations: Singer et al. Lancet 2004, Belikova et al. CCM 2007
Impairment of capacity of repair?
Exple: autophagy – to sustain metabolism during nutrient
deprivation
– to prevent the accumulation of damaged, toxic proteins and organelles during stress
– Implicated in anti-microbial defense
inhibits cell death by necrosis
Metabolic failure and cell recoveryMetabolic failure and cell recovery
HO
ME
OS
TA
SIS
ST
RE
SS
AD
AP
TA
TIO
N
Provision of nutrientsduring catabolism
Generation of ATPin stressed cells
Signals forheterophagic removalof apoptotic cells
Degradation ofmisfolded proteins
Removal of surplusor damage organelles
Genomic stability
Levine et al. Cell 2008 132:27-42