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Interface INSERM-SFAR-SRLF
« Predisposition de la réponse à
l’agression »
D Payen, MD, Ph D
[email protected]
Inflammation et métabolisme
sont étroitement intriqués…
Argument phylogénique et
« anatomique »
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.
Therapeutic targets at the interface between
metabolic and inflammatory pathways
Argument génétique
constitutif
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
Gene
Susceptibility and/or Outcome
Mannose Binding Lectin
IL-18
IL-10
IL-6
IL-1 locus
IL-4
Meningococcemia,
Pneumococcemia
Gram
Septic
Severenegative/positive
sepsis
Shock
Legionnaire’s Disease
Septic Shock
Meningococcemia;
Pneumococcemia
Meningococcemia
Septic Shock; Cerebral Malaria
Severe Sepsis
Severe Sepsis, Meningococcemia
Severe sepsis
Severe Sepsis
Viral Pneumonia
PAI-1
FactorV Leiden
Meningococcemia; Severe sepsis
Meningococcemia; Severe sepsis
Toll-Like Receptor 4/2
Toll-Like Receptor 5
CD14
FCgRII Receptor
TNF locus
Limitations of gene by gene approach
Clark et al. Intensive Care Med 2006 32:1706-1712
Hope in development of genome wide association
methods (600 000 variants studied in one shot!)
Argument génomique
• 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
Argument neuro-hormonal
Insulin-receptor signalling interfaces with inflammatory signalling at the level
of insulin-receptor substrates through activation of serine kinases.
Figure 2 - Kaplan Meier Curves for 28
day all-cause mortality in (a) ACTH nonresponders (b) ACTH responders and
(c) all patients
(b) ACTH responders
(a) ACTH non-responders
1.00
1.00
0.75
0.75
0.50
0.50
0.25
steroid
0.25
placebo
0
5
placebo
P value for log rank test: 0.937
0
10
15
20
25
steroid
P value for log rank test: 0.850
0
30
0
5
10
15
20
(c) All patients
1.00
0.75
P value for log rank test: 0.813
0.50
0.25
steroid
placebo
0
0
5
10
15
20
25
30
25
30
Figure 3 - Kaplan Meier Curves for time to reversal
of shock in (a) ACTH nonresponders (b) ACTH
responders and (c) all patients
(b) ACTH responders
1.00
(a) ACTH non-responders
1.00
steroid
placebo
0.75
0.75
0.50
0.50
0.25
0.25
0
P value for log rank test: <0.001
0
5
10
15
20
25
steroid
placebo
30
0
P value for log rank test: 0.038
0
5
10
15
(c) All patients
1.00
steroid
placebo
0.75
P value for log rank test: <0.001
0.50
0.25
0
0
5
10
15
day
20
25
30
20
25
3
0
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 days
1.0
Incidence of shock reversal according to treatment arm
incidence
Cumulative
0.2
0.4
0.6
0.8
Hydrocortisone
Placebo
0.0
P<0.0001
0
1
2
3
4
5
Days after randomization
6
Within the first five days
0.4
0.6
Hydrocortisone
Placebo
0.2
P= 0.28
0.0
Cumulative incidence
0.8
1.0
Incidence of death prior to shock reversal
according to treatment arm
0
1
2
3
Days after randomization
4
5
6
Argument biochimique
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
O2 is used for what type of functions?
Antimycine A
ATP synthase
Respiratoire Chain
H+
ADP+Pi
NADPH oxydase
O2
protein Synthesis
Ouabaïne
ATP
ADN/ARN synthesis
Na+, K+ ATPase
Ca2+ ATPase
DPI
Inhibition
Cycloheximide
Chlorure de
lanthanum
Actinomycine D
Buttgereit, Biochem J, 1995.
Global VO2: the different fractions
% O2
Cellules
100
95
DPI
Cycloheximide
90
Ouabaïne
ActinomycineD
Chlorure de lanthanum
Antimycine A
78 ngatomes O2
85
80
Sec
75
0
500
1000
1500
2000
2500
3000
Effects septic plasma septique on baseline (V0) &
stimulated reponse
Septic plasma  modifications similar to those observed in septic cells
Plasmatic factors +++
Mitochondrial VO2 becomes more decoupled
after incubation in septic plasma.
It cannot result from tissue
hypoxia!!!!
M
Integration of stress-signalling mechanisms.
Le sucre et inflammation…
Exogenous glucose (NUTRITION)
J Appl Physiol 1997
Fed
Fasted
Fasted+iP G
Exogenous glucose (NUTRITION)
J Appl Physiol 1997
In conclusion, glucose metabolism interferes with hemodynamic, metabolic, and
inflammatory responses to LPS.
MAJOR ROLE OF EXOGENOUS GLUCOSE
O2 consumption rate, ngatoms
O2/min/107 cells
16
Vo
Vstim ionomycin
Vstim PMA
p=0.003
12
8
4
0
NG
HG
Delta increase in O2 consumption, %
B
A
200
Delta ionomycin
Delta PMA
p=0.004
150
100
50
0
NG
Fig. 4
HG
Vo,
ngatoms O2/min/107
cells
A
10
HV
sepsis
8
6
4
2
r=0.44
p=0.009
0
0
Delta increase in
O2 consumption,
%
B
10000
20000
30000
40000
50000
HLA-DR, site number
200
150
100
Iono+PMA
r=0.57
p=0.0014
50
HV
sepsis
0
0
Delta increase in
O2 consumption,
%
C
Fig. 5
10000
20000
30000
40000
50000
HLA-DR, site number
225
175
125
ADP
75
r=0.58
p=0.049
25
HV
s eps is
-25
0
10000
20000
30000
HLA-DR, site number
40000
50000
Un example of acute inflammation
aigue in human beings:
hepatic transplantation
Day 4 after OLT
Argument inflammatoire
Immunity triggers inflammation
Pathogen pathway
PAMPs 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
Donc, les facteurs de
prédisposition
Constitutive
Acquired
Polymorphisms?
Epigenetic…
Polymorphisms
SNPs…
Chronic
disease
Pharmacogenomic
Drug induced gene
Expression changes
Chronic
treatment
Poor or good
Quality of feeding
Reversing shock ≠
Improve outcome
Surviving shock increases
the risks of disease
Proteins released
Are changed by
Environment
(nitrosylated…)
Metabolic failure
Not related to perfusion
Need for
Markers
Outcome
D Payen 2010
Shock severity is characterized by scores…
Outcome may then depend on injury but also
on acquired negative factors…
Severity Score
Difficult to reverse but good reserve
INJURY
TISSUE RESERVE
= Co-morbidity
AGE
Co-morbidity
Easy to reverse
 But high co-morbidity in elderly…
Severe Injury + good tissue reserve
Moderate injury + high Co-morbidity
Similar severity score
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?
Viral 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)
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
Attendons les données futures….
ENERGY CONSUMING FUNCTIONS OF IMMUNE CELLS
Specific immune
functions
General housekeeping
functions
Migration
Active
transport of
molecules
and ions
Cytokinesis
Mitochondrial oxygen consumption oxidative phosphorilation (> 90 %).
Phagocytosis
ATP
Antigen
processing
Antigen
presentation
Activation
Synthesis of
macromolecules
(RNA/DNA/protein
synthesis)
Electron transport chain
Saraste M. Science, 1999.
Effector
functions
Buttgereit F. Immunology Today, 2000.
LPS injection: an example of
ACUTE INFLAMMATION …
Calgranulines: an example
of DAMPs molecule
May be a prognostic marker…
alive
dead
Gobal population n = 111
n=61
n=50
25
20
S100A8/A9 pg/ml
18
16
14
12
10
8
20
15
10
5
6
4
0
2
Plasma S100 A8/A9 complex D0
SOFA D0
NS (p<0,09)
p<0,0001
Payen D, Lukazsewicz AC et al. (in review)
(Patented in December 2008)
*
30
*
Plasma S100A8/A9 (g/ml)
28
26
*
24
*
22
20
18
alive
16
(41)
14
dead
(15)
(50)
12
(8)
10
8
6
4
(60)
(59)
(59)
(43)
2
(46)
0
D0
D1
D7
D14
D28
Figure: trend over time of S100A8/A9 complex, according to outcome, in plasma. Results expressed in
g/ml. Effectives in brackets.
*p=<0.0001, test de Mann Whitney
Cinétique des “alive”:
D0-D28, p<0.0001, test de Friedman, n=34
D0-D14, p<0.0001, test de Friedman, n=41
D0-D7, p=0.0005, test de Friedman, n=57
Cinétique des “dead”:
D0-D14,NS, test de Friedman, n=8
D0-D7, p=0.0010, test de Friedman, n=15
S100A8/A9 in patients without shock at D0
N=8 survivors
N=8 non survivors
28
24
p=0.0008
Plasma S100A8/A9 (g/ml)
20
alive
16
dead
12
8
4
0
D0
Mann whitney test, p=0.0008
Metabolic failure and cell recovery
Levine et al. Cell 2008 132:27-42
Signals for
heterophagic removal
of apoptotic cells
Degradation of
misfolded proteins
Removal of surplus
or damage organelles
Genomic stability
Singer et al. Lancet 2004, Belikova et al. CCM 2007
Impairment of capacity of repair?
Exple: autophagy
STRESS
ADAPTATION
Generation of ATP
in stressed cells
Metabolic alterations:
HOMEOSTASIS
Provision of nutrients
during catabolism
– 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
Autophagy in innate and adaptive immunity
Autophagy is impaired in:
degenerative disease, heart
disease, aging, cancer,
dysimmunity…
Levine et al. Cell 2008 132:27-42