pamps, damps and our evolving understanding of sepsis and …...•rr >20, pco2
Post on 21-Jul-2020
1 Views
Preview:
TRANSCRIPT
Carl J. Hauser MD, FACS, FCCM
PAMPs, DAMPs and our evolving understanding
of Sepsis and SIRS
Gulf War Subcommittee
Disclosures / Competing interests
FUNDING• NIH • DoD (CDMRP) • CIMIT • No commercial funding
RAC-GWVI Meeting November 1-2, 2010 Presentation 3 - Hauser
BURNSSURGERY
OTHERSPANCREATITIS
INFECTION SIRS TRAUMA
≥ 2 of the following:
•Temp >38°C, <36°C
•Pulse >90
•RR >20, PCO2 <32
•WBC >12,000, <4000 or >10% bands
Systemic Inflammatory Response Syndrome (SIRS)
Inflammatory response to illness of any source
1/3 of all hospitalized patients – More than half of all ICU patients– Nearly all SICU patients– Morbidity and mortality 2° organ
failure • Lung (ALI / ARDS) > liver/kidney
Burden of SIRS
RAC-GWVI Meeting November 1-2, 2010 Presentation 3 - Hauser
Inflammation can reflectInfection or ‘Sterile SIRS’
Hemoperitoneum vsbacterial peritonitis
Aspiration vs bacterial pneumonia
Clinical concepts of SIRS inadequate
“““STUFFSTUFFSTUFF”””
SIRSSIRS DEATH
Infection
Trauma
Fractures
Shock
CytokinesCytokines
??
??
??
??
ALIALI
‘DANGER’ molecules
Mechanistic understanding of SIRS
WRONG!
RAC-GWVI Meeting November 1-2, 2010 Presentation 3 - Hauser
‘Danger’ molecules
SIRSSIRS DEATH
Infection
TRAUMA activate innate immunity Fractures
Shock
??
??
ALIALIinnate innate immunityimmunity
Redundant cytokine cascade
PRRPRR
PRRPRR
Inflammatory program
Pathogens → PAMPs → PRRInjury → DAMPs → PRR
??
Recognized by Pattern Recognition Receptors (PRR)
In the setting of infections
PAMPsPAMPsTLR / GPCRTLR / GPCR
In non-infective conditions
Ancient (invertebrates, multi-celled)PMN, Mφ, DC, NKC
No clonal expansionPRR on germ-line (TLRs, GPCRs)
multi-functional
Immediate response to danger motifs
Rapid responses in trauma, sepsis
Innate immunity
RAC-GWVI Meeting November 1-2, 2010 Presentation 3 - Hauser
Exogenous infective motifs (LPS, FPs, bacterial sugars, ‘CpG’ DNA, dsRNA, flagellin…)
Bind PRRs immune activationCytokines etc
Symptomatic infective SIRS (“sepsis”)↑ NO· release → vasodilatation↑ PMN-EC interactions → capillary leak
PAMPs
Non-infective motifs ? Endogenous products of tissue injury
? Intracellular motifs released by mechanical injury
? Membrane motifs changed by toxins? New motifs 2’ to metabolic, I/R stress
Bind PRRs immune activationCytokines etc
?? …symptomatic non-infective SIRS
?? DAMPs…
RAC-GWVI Meeting November 1-2, 2010 Presentation 3 - Hauser
Putative DAMP PRRHMGB-1 TLR4S-100 RAGEHSP 30/60 TLR4B7-H3 TREM
Few knownSignal through PRR’s like PAMPs
Intracellular DAMPs
Mitochondria as DAMPs…why are clinical sepsis and SIRS so
often indistinguishable?Mitochondria were saprophytic
bacteriaBecame endo-symbiontsEvolved into organelles
?‘Septic’ response to MT?
RAC-GWVI Meeting November 1-2, 2010 Presentation 3 - Hauser
13 ‘endogenous’ peptides begin with n-formyl-met
? Do they activate FP receptors‘Bacteria-like’ DNA
Unmethylated ‘CpG’ repeats? Do they activate TLR-9
Do mitochondria contain DAMPs?
Does mechanical tissue injury cause
circulation of mitochondrial debris ?
(MTD)
RAC-GWVI Meeting November 1-2, 2010 Presentation 3 - Hauser
Fluo
resc
ence
(nor
m)
1000
100
10
10 10 20 30 40
Cycles
Fluo
resc
ence
(nor
m)
1000
100
10
10 10 20 30 40
Cycles
PatientsVolunteers
Cyt B
Cyt C-III PatientsVolunteers
Fluo
resc
ence
(nor
m)
1000
100
10
10 10 20 30 40
NADH PatientsVolunteers
0
10
20
30
40 PatientsVolunteers
Ct v
alue
s (c
ycle
s)
Cyt B Cyt C-III NADH
* * *
a c
b d Cycles
mtDNA circulates after blunt trauma
Zhang, Hauser , Nature 2010
Do shock / ischemia-reperfusion injury
result in circulation of MTD ?
RAC-GWVI Meeting November 1-2, 2010 Presentation 3 - Hauser
Plasma mtDNA in rat HS
mtD
NA
(µg/
ml)
Naïve 3h 1d 3d 7d
A
0.00
0.05
0.10
0.15
0.20
0.25
*
*
*
*
Zhang, Hauser; Shock 2010
Volunteer Plasma Patient Plasma Reaming Fluid
Ct c
ount
(cyc
les)
0
10
20
30
40Plasma Cyto B in Femur Fx
**
*P<0.01 vs vol plasma (ANOVA)
mtDNA appears in plasma of FFx patients
214 -fold increase
Hauser, J Ortho Trauma 2010
RAC-GWVI Meeting November 1-2, 2010 Presentation 3 - Hauser
Do MTD activate inflammatory cell
signaling ?
mtFPs activate [Ca2+]i (via FPR1)
c d0 50 100 150 200 250
0
40
80
120
Ca2+
[Ca2+
] i(n
M)
Seconds
MTD + Anti-FPR1
MTD
500
0Anti-FPR1
+-
Cal
cium
Influ
x (A
UC
) (nM
·s)MTD
*
No MTD
Zhang, Hauser , Nature 2010
RAC-GWVI Meeting November 1-2, 2010 Presentation 3 - Hauser
0
200
400
600
0 2min 5min 10min
p-p3
8 (A
rbitr
ary
unit)
p-p38p38
**
mtDNA (μg/ml) 5 10ODN - + - + p-p38
p38
mtDNA (μg/ml) 5 10ODN - + - + p-p38
p38
mtDNA activates p38 via TLR9
TLR9 blocked by CQ, ODNsZhang, Hauser , Nature 2010
Does MTD activate inflammatory cell
phenotypes ?
RAC-GWVI Meeting November 1-2, 2010 Presentation 3 - Hauser
0
100
200
300
400
500
MTDLPS
MTD (µg/ml) LPS (µg/ml)0 10 20 40 100 200 400 1 10
*
*4hr
0
1
2
3
4
5
MTDLPS
**
0 10 20 40 100 200 400 1 10MTD (µg/ml) LPS (µg/ml)
24hr
***
***
IL-8
(pg/
ml)
IL-8
(ng/
ml)
MTD activates cytokine production
Zhang, Hauser Nature 2010
mtDNA activates PMN / EC interactions
RAC-GWVI Meeting November 1-2, 2010 Presentation 3 - Hauser
Do mitochondrial DAMPs activate innate
immunity in vivo?
0
500
1000
1500
2000
Lung
MM
P-8
(uni
ts)
*
Naïve Media MTD0
1
2
3
4
5
6
Naïve Media MTD
BA
LF %
PM
N
*
MTD → PMN attack on lung
MMP-8 in lung PMN in BALF
Zhang, Hauser Nature 2010
RAC-GWVI Meeting November 1-2, 2010 Presentation 3 - Hauser
MTD causes ALI
Naïve Media MTDNaïve Media MTD
0
10
20
30
40
50
Sham 3h 6h 24h
BA
LF T
NFα
(pg/
ml) *
0
50
100
150
200
Sham 3h 6h 24h
BA
LF IL
-6 (p
g/m
l)
*
0
50
100
150
BA
LF a
lbum
in (µ
g/m
l)
Naïve Media MTD
*
0.0
0.5
1.0
1.5
2.0
2.5
Lung
wet
/dry
wei
ght R
atio
Naïve Media MTD
*A B
C D
Albumin Wet/Dry
TNF-α IL-6
Zhang, Hauser Nature 2010
Sham i.v. MT (=5% liver injury) at 6h
MTD causes ALI
Zhang, Hauser Nature 2010
RAC-GWVI Meeting November 1-2, 2010 Presentation 3 - Hauser
Media MTD
Airway
Airway
MTD ALI is oxidant-related
4-HNE stainsZhang, Hauser Nature 2010
Nature editorial March 4, 2010
Evolutionary conservation of PAMPs and DAMPs in bacteria and mitochondria cause many similarities between sepsis and SIRS
RAC-GWVI Meeting November 1-2, 2010 Presentation 3 - Hauser
BURNS
OTHERSPANCREATITIS
Innate immune cells
TISSUE TRAUMA
So what is ‘septic’ SIRS?
SURGERY
INFECTION
PAMPs from infection cause SIRS
PAMPs
Bystander Organ Injury
OTHERS
PANCREATITIS
INFECTION
What is non-infectious SIRS?
necrosis
Injury causes SIRS without infectionSIRS then predisposes to infection2° Sepsis perpetuates SIRS →MOF→death
BURNS SURGICAL WOUNDS
FRACTURESCrush injury
DAM
Ps
DAMPs
DA
MPs
DA
MPsInnate
immune cells Bystander
Organinjury
RAC-GWVI Meeting November 1-2, 2010 Presentation 3 - Hauser
1) Remove PAMPs (bio-markers)Antibiotic Tx Drainage, source control
2) Rx SIRS after source controlTarget PRR, signal cascadesSteroids, aPC, anti-cytokine Tx(All dangerous w/o source control)
Treatment of infective SIRS
1) Remove DAMPs (bio-markers)Debride / drain sourcesAvoid antibiotics
2) Prevent / treat SIRS earlyTarget DAMPs and PRRInterrupt inflammatory signalingSafe w/o infection (but ??healing)
Treatment of endogenous SIRS
RAC-GWVI Meeting November 1-2, 2010 Presentation 3 - Hauser
Hauser LabKiyoshi ItagakiQin ZhangMustafa RaoofTolga Sursal
Junger LabYu Chen
Yuka Sumi
LondonKarim Brohi
Acknowledgements
RAC-GWVI Meeting November 1-2, 2010 Presentation 3 - Hauser
top related