Transcript Diapositive 1 - DESC Réanimation Médicale

IMMUNODEPRESSION ACQUISE EN REANIMATION
Outils diagnostiques et perspectives thérapeutiques
DESC de Réanimation
2011
Guillaume Monneret
Laboratoire d’Immunologie Cellulaire
Hospices Civils de Lyon
Hôpital E. Herriot
[email protected]
Hôpitaux de Lyon
Sepsis as a starting point :
Septic syndromes an increasing and significant healthcare challenge
- Septic Syndromes : leading cause of death in ICU
- 3rd cause of death after cardiovascular diseases and cancers
- 2005 US figures : 800 000 cases / year
- 2001 F figures : 70 000 cases / year
Constant rise for many years
Sepsis Cases
1,800,000
600,000
Severe Sepsis Cases
1,600,000
500,000
1,400,000
1,200,000
400,000
1,000,000
US Population
800,000
300,000
200,000
600,000
400,000
100,000
200,000
2001
2025
Year
NEJM 2003
Total US Population/1,000
future
2050
- Better care of co-morbidities
- Increased longevity
Hospitalization rate nearly
doubled from 1993 to 2003
Population-based mortality rate
rose by two thirds.
Multiple
Organ
failure
Increased
severity
Definition
Association of an infection and a systemic inflammatory response syndrome (SIRS)
Wenzel 2002 - N Engl J Med
Definition
Association of an infection and a systemic inflammatory response syndrome (SIRS)
=> Sepsis is not caused by the infection itself but by the host response to this infection
Onset :germ(s) + site of infection + local inflammation
organ
systemic
Amplification ?
Lack of modulation ?
Pathophysiology :
uncontrolled inflammatory
response
(“The germ is nothing, the terrain is everything” - Pasteur L. - 1895)
Uncontrolled
Inflammatory
response
Decreased arterial pressure
Shock
Multiple organ failure
Uncontrolled
Inflammatory
response
Emergency symptomatic treatment :
Antibiotherapy
Agressive vascular resuscitation
Vasoactive agents
Decreased arterial pressure
Shock
Multiple organ failure
« Cytokine storm »
=> « Mediator storm » > 300 released mediators (Marshall, Nature Rev. 2003)
Extensive description for many years…..
Cytokines : TNF, IL-1, IL-6, IL-12
Activation, amplification
Chemokines : IL-8, MIP-1, MCP-1
Mobilize and activate leukocytes
Vasoactive hormones, Lipid mediators :
PAF, PG’s, LK, TX, ADM, ANP…
Multiple actions
Oxygen radicals :
superoxide, nitric oxide
Antimicrobial properties
regulation vascular tone
Uncontrolled
inflammatory response
Anti-inflammatory drugs
Failure of clinical trials testing anti-inflammatory therapies
Drug
Anti-endotoxine
Anti-bradykinine
Anti-PAF
Anti-TNF
R solubles TNF
AINS
Stéroïdes
…
Total
Mortality (%)
Placebo
Drug
Number of
studies
Number of
patients
4
2
2
8
2
3
9
…
2010
755
870
4132
688
514
1267
…
35
36
50
41
38
40
35
…
35
39
45
40
40
37
39
…
33
12034
38
38
Zeni et al, Crit Care Med, 1997
Reasons for such a perfect disaster
1. Inappropriate animal models of sepsis
2. Heterogeneity of septic population (germs, virulence factors, co-morbidities, inflammatory
response, site of infection….)
1. Pathophysiology largely unknown
> 70 % total mortality
Simplified description of systemic pro- and anti-inflammatory
immune responses over time after septic shock
1. Inappropriate animal models of sepsis
2. Heterogeneity of septic population
3. Pathophysiology largely unknown
Pro-inflammatory
Response
Onset of
Anti-inflammatory-based RCT
Resultant immune response at the
systemic level = immunosuppression
Time
Anti-inflammatory
Response
Similar mechanisms each time SIRS occurs:
trauma, surgery, pancreatitis, burns……
Summarized view of sepsis-induced immunosuppression
immune functions
IL-10
(and soluble mediators)
Epigenetic
regulation
Endotoxin
tolerance
Apoptosis
(different mechanisms)
PNN chemotaxis and phagocytosis
Monocyte deactivation:
-  antigen presentation capacity
-  pro-inflammatory cytokine production
-  CX3CR1
 dendritic cells nbr
Profound lymphopenia
Th2 shift
Lymphocyte anergy
 apoptosis
 % Treg
Innate Immunity
Adaptive Immunity
Monocyte / DC
anergy
Lymphocyte
anergy
Consequences
- Decreased clearance of initial infection (Togersen 2009)
- Increased nosocomial infections
- Viral reactivation
=> May directly contribute to mortality
Diagnostic?
No clinical sign => biological monitoring
1. Functional testing
2. Soluble mediators
3. Cellular approach
4. Genomics
outcomes:
- mortality
- occurrence of nosocomial infections
1. Functional Testing
- Because this directly measures ex vivo the capacity of a cell population to respond
to an immune challenge, functional testing theoretically represents the method of
reference
- Monocyte capacity to release TNF in response to LPS challenge
- Lymphocyte proliferation in response to recall antigens or mitogens
- Phagocytosis, chemotaxis….
- Time consuming (days of incubation for lymphocyte proliferation)
- Home-made protocols => difficult to standardize
=> Not suitable for routine monitoring
- They remain essential to gain insights in the understanding of pathophysiology and to
assess the validity of surrogate markers
2. Soluble mediators
- In septic shock, > 300 released mediators
- Both pro- and anti-inflammatory mediators are elevated : not informative
- A panel of markers is likely more desirable (or at least a ratio)
=> If a single one : IL-10
- Potent immunosuppressive cytokine
- Many studies have identified it as the most informative
- Standardized measurement
2004
High IL-10 is associated with mortality – not TNF
140
TNF pg/ml
120
200
IL-10 pg/ml
100
**
180
80
160
Non-survivors
60
140
40
120
Non-survivors
20
100
1-2
80
3-4
5-7
8-15
**
60
40
**
20
1-2
3-4
5-7
**
8-15
=> Correlation with mortality but no data on nosocomial infections
3. Cellular phenotyping
- monocytes
- lymphocytes
Monocytes
Gold standard = Decreased mHLA-DR
Why using flow cytometry ? => example of mHLA-DR
100 %
0%
- mHLA-DR expression level = Integrated Σ of the effects of numerous mediators
It is the true reflection of what force dominates at any given time-point
- Decreased mHLA-DR correlates with decreased functional testing (TNF release, Ag presentation)
Ting et al.
Low HLA-DR predicts mortality
(n = 120 septic shock patients)
% HLA-DR + monocytes
(Control values > 90-100 %)
50
p : 0.2
p < 0.001
Survivors
40
30
Non-survivors
0 - 48 h
48 – 96 h
Monneret et al., Intensive Care Med 2006
Survival curves stratified on
mHLA-DR at 30 % at days 3-4
(n = 120 patients)
Multivariate analysis : mHLA-DR is an independent predictor of mortality
(after adjustment for usual clinical confounders)
Odds ratio
95 % CI
p
Sex (F)
-
-
-
Age > 64 years
-
-
-
6.14
1.3 – 28.4
0.02
-
-
-
4.34
1.0 – 18.5
0.05
Type of infection (noso. vs commu.)
-
-
-
Infection site (pulm., abdo., others)
-
-
-
6.58
1.5 – 28.6
0.01
HLA-DR (J1-J2) < 30 %
-
-
-
HLA-DR (J3-J4) < 30 %
8.81
1.9 – 40.4
0.005
IGS II (onset) > 49
Type of admittance (surgery vs med.)
Comorbidity (≥ 1)
SOFA (≠ J1J2 vs J3J4) > 0
9-fold increased risk of death with mHLA-DR < 30 %
- Multivariate analysis (including usual confonding factors):
SOFA, SAPSII, Intubation, catheterization
- Competitive risks
Does mHLA-DR predict nosocomial infections in other ICU contexts ?
HLA-DR expression and soluble HLA-DR levels in septic patients after trauma
Ditschkowski et al. Ann. Surg. 1999
Minor injuries
Severe injuries without
secondary sepsis
Severe injuries + secondary sepsis
Normal
values
AUC : 0.8
Recovery slope
(> 1.2)
Low mHLA-DR predicts nosocomial infections after Day 15
ROC Curves Analysis for the prediction
secondary infections
(AUC = 0.9)
According to
secondary infection
(n = 29 non infected
n = 24 infected)
Dendritic cells
Persisting low circulating myeloid dendritic cells number
is associated with the development of nosocomial infections after septic shock
Days after shock
Pene, Chiche et al. (Société Réanimation Langue Française 2009)
Lymphocytes
Castelino et al.
From lab computer in a university hospital over a 3 month-period
Lymphopenia when Ly < 600 / microL
=> 1042 patients with lymphopenia
Lymphocytes from septic patients do not proliferate upon antigen / mitogen challenge
Controls
Controls
Roth et al.,
Septic
patients
Septic
patients
An increased circulating percentage of Treg is associated
with a decreased cell proliferation in septic shock patients
FOXP3 inhibition restores lymphocyte proliferation
Lymphocytes:
No recent data on correlation with motality and nosocomial infections
Skin testing
Mortality
Nosocomial
infection
9 % (n = 31)
27 % (n = 99)
+/23 %
(n = 272)
25 % (n = 55)
33 % (n = 91)
Negative
47 %
(n = 570)
32 % (n = 184)
(within 24 h after admission)
n = 1211
surgical
ICU patients
Positive
30 %
(n = 369)
*
42 % (n = 237)
* p < 0.005
Skin testing with 5 antigens (positive if  2 reacted, +/- if solely 1 reacted, negative if none reacted)
*
Cook CCM 2009
4. Transcriptomic approach
(microarrays and qRT-PCR)
Genes coding
for pro-inflammatory immune response
are decreased
while genes coding for apoptosis
are increased
Immunol Lett 2006. 106 (1) :63-71
Septic shock patients > 48 h after the onset of shock
31 patients (10 NS) + 7 patients in a prospective control study (3 NS)
HG-U133A oligonucleotide arrays (Affymetrix) – 14 500 genes
A cluster of 28 genes
mostly linked with immunosuppression
differentiated S from NS
Non-survivors
Survivors
Among them, the decreased expression of the
fractalkine receptor CX3CR1 mRNA was the most
interesting because of largest fold change between
S and NS ( 8-fold decreased in survivors)
CX3CR1 is mainly expressed on patroller monocytes
that are the first to reach the site of secondary infections
to initiate immune response.
Due to decreased chemotaxis
(and subsequent decreased inflammatory cytokines release),
the loss of this receptor might have a role in
the development of nosocomial infections
Confirmation cohort (N = 160 septic shock patients) : qRT-PCR in whole blood
Survival distribution fraction
CX3CR1 mRNA > 0.12
Survival curves stratified on CX3CR1
mRNA level at day 1-2 (cut off: 0.12)
p = 0.0002
CX3CR1 mRNA < 0.12
Days after the onset of shock
HLA-DRB mRNA (ratio)
1,2
p < 0.01
1
0,8
S
0,6
0,4
S
NS
NS
0,2
Days 1-3
Days 4-10
Septic shock
Abe R et al.
Cytokines / HLA-DR assessment by qRT-PCR in whole blood (Paxgen tubes)
220 patients
20 infected
20 matched control group
23 genes (PAXGENE) : TNF, IL1, IL10, IL18, SOCS3, CD3, CD69, Perforin, Granulysin, CCR3, KLRK1, IDO1, HLA-DRA, CD74,
IL8, CXCL10, CCL3, CXCL1, HMOX1, S100A8, PF4, IL6
Transcriptomic:
For now, few studies but promising results
Advantages :
- mRNA (all components : intracellular, cell surface, soluble mediators => automated systems)
- Panel of markers
- MIP-Réa (800 patients)
5. Conclusions and perspectives
Representative examples
HLA-DR (% + monocytes)
2 patients with septic shock – community acquired
No comorbidity – first sample < 6 hours after the onset of shock
80
Survivor / non-infected
70
60
50
40
Non-survivor / infected
30
20
10
1
2
3
4
5
6
7
Days post-shock
Representative examples
HLA-DR (% + monocytes)
2 patients with septic shock – community acquired
No comorbidity – first sample < 6 hours after the onset of shock
80
Survivor / non-infected
70
60
50
40
Non-survivor / infected
30
20
10
1
2
3
4
5
6
Therapy ?
7
Days post-shock
Sepsis-induced immune failure
(modified CLP models)
CLP (+ antibiotherapy and volume resuscitation)
Sham
Percent survival (%)
100
80
60
40
20
10
20
days
30
Sepsis-induced immune failure (modified CLP models)
CLP + Infections with germs (Pseudomonas, Legionella, Candida, Aspergillosis)
CLP (+ antibiotherapy and volume resuscitation) + Ø
Sham + Ø
Sham + germs inoculation
Percent survival (%)
100
80
60
40
20
10
20
days
30
Sepsis-induced immune failure (modified CLP models)
Immune stimulation (IL-7, IL-15, FLT3-L, DC, GITR mAbs…)
Infections
with germs
CLP (+ antibiotherapy and volume resuscitation) + Ø
Sham + Ø
Sham + germs inoculation
Nascimento et al., Crit Care Med 2010
Delano et al., J Immunol 2010
Brahmamdam et al, J Leuko Biol 2010
Unsinger et al. J Immunol 2010
Inoue et al., J Immunol 2010
Pene et al., J Immunol 2008
Benjamin et al., Blood 2005
Percent survival (%)
100
80
60
p < 0.05
40
20
10
20
days
30
Perspectives
Most ICU patients present with severe immune alterations after injury
(sepsis, severe burn, trauma, pancreatitis, major surgery)
=>Immune failure should be considered as an important additional organ failure
=> Septic patients who do not recover normal immune functions are those who die
Biomarkers are readily available to monitor pro-/anti-inflammatory responses
(- We now need multicentric clinical studies to validate and reinforce these promising preliminary results
- We need to establish standardized measurement protocols for each potential biomarker)
=> biomarker-based stratification
=> individualized and targeted therapy
THERANOSTIC
And beyond immuno-inflammation…..
Anti-TNF stratified on IL-6 levels.
Panacek EA et al., Crit Care Med. 2004 Nov;32(11):2173-82
Anti-inflammatory drugs
New Strategies:
- Close Monitoring (PCT ?) to detect asap the beginning of infections
- Preventive antibacterial therapy (when possible / risk of resistance)
- Immunotherapy to restore immune functions (pro-inflammatory drugs)
Immunotherapy to restore immune functions ?
Sepsis-induced immune dysfunctions
Innate Immunity
Adaptive Immunity
Monocyte anergy
Lymphocyte anergy
Immunotherapy to restore immune functions ?
Sepsis-induced immune dysfunctions
Innate Immunity
Adaptive Immunity
Monocyte anergy
Lymphocyte anergy
GM-CSF
IFN-g
IL-7
Docke WD et al. Nat Med. 1997;3:678-81
Monocyte deactivation in septic patients:
restoration by IFN-gamma treatment
9 patients sepsis severe
26 patients sepsis severe
HLA-DR < 30 %
(2 jours de suite)
HLA-DR < 30 %
(2 jours de suite)
Non randomisée
Interferon-gamma
Mortalité 33 %
Mortalité 58 %
Nakos G et al., Crit Care Med 2002;30:1488-1494
Immunoparalysis in patients with severe trauma
and the effect of inhaled interferon-gamma
52 trauma patients
HLA-DR at day 3 (BAL)
HLA-DR < 30 % (n = 21)
HLA-DR > 30 % (n = 31)
Usual monitoring
Placebo (n = 10)
Interferon-gamma (n = 11)
Infection II : 5
50 %
Infection II : 1
9%
Infection II : 3
10 %
p < 0.05
Pas d’impact sur mortalité
- No side effects
- Significantly shorter time of ventilation (148 vs 208 h, p=0.04)
- shorter length of intra-hospital stay (59 vs 69 days)
- shorter length of ICU stay (41 vs 52)
- 28-day mortality not different (trial not powered for mortality)
GM-CSF
Stratified on ex vivo TNF release
below 160 pg/mL
All ways may lead to immune suppression
Vincent JL, Crit Care Med 2005
Cavaillon JM & Annane D, J Endotox Res 2007
Effective early treatments
cannot avoid a risk
of immune suppression
Short term beneficial effects
can be hidden by deleterious effects
of immune suppression
when mortality is assessed at 28 days
To be kept in mind
for next years….