Didier Payen, MD, Ph D

dpayen1234@orange.fr

Lariboisière Hospital – Université Paris 7 UMR INSERM 1160

20  ans  de  Réanima-on:  le  choc  sep-que  

En  20  ans,  que  s’est-­‐il  passé?  •  Sepsis  defini-on  more  or  less  stable  •  Epidemiology  è    

–  incidence,  age,  comorbidi-eskk – Big  data  èè  large  cohort  

•  BeBer  educa-on,  faster  diagnosis,  reasonable  recomenda-ons  (SSC  x  3)  

•  Huge  technological  progresses:  genotyping;  transcriptomic;  proteomic;  metabolomic…  

•  More  clear  aspects  of  immuno-­‐inflammatory  processes  •  Reasonable  suppor-ve  therapy:  Fluid  amount;  pressors;  ven-la-on;  RRT;  ECorp  Circ…  

En  20  ans,  qu’en  ai-­‐je  -ré?  •  Over  simplis-c  view  leads  to  mistakes:  è  RCTs  always  failed  despite  solid  basic  science  background  

•  Infec-on  does  not  kill  by  itself  but  by  host  response  –  Concept  of  sep-c  phases  –  Inflamma-on  BM;  organ    damage  BM,  etc…      

•  Time  for  infec-on  treatment  is  crucial  (SSC  x  3)  –  Golden  hours;  AB  administra-on;  fluid  is  necessary  but  not  too  much!  Pressors  YES  but  for  what  BP  level?  

•  Huge  technological  progresses:  –   genotyping;  transcriptomic;  proteomic;  metabolomic…  –  More  rapid  detec<on  of  pathogens  

•  Elderly  pa-ents  SHOULD  be  treated.  •  Exp  models  are  not  easily  transposable  to  human  beings  

SEVERE  SEPSIS      

•  Sepsis  +  hypotension  (÷÷APSyst  >  20  mmHg  or  APsyst  <80  mmHg)  or  symptoms  of  hypo-­‐perfusion  or  organ  failure  :    

•  AND  at  least  ONE  among  following  criteria    

 -­‐  hypotension  (systAP<  90  or  ÷÷>  40)  

   -­‐  lac-c  acidosis  

   -­‐  oliguria  

   -­‐  encephalopathy  

   -­‐  hypoxemia  

   -­‐  coagulopathy  

Le  Sepsis:  un  pb    de  Santé  Publique  Mondial…  

Budget  1%  of  US  PIB  

The W-shaped mortality curve seen in the 1918 influenza pandemic curves for incidence of clinical illness vs. fatality rate markedly differ Same age-dependent mortality pattern is seen for TB, pneumococcal infection, trauma, Yellow fever, malaria, streptococcal Toxic shock, etc. èè What accounts for this difference?

Fedson  D.  An-viral  Research  2013;    99,(3),  417-­‐  435  

Sepsis:  a  syndrome  with  mul-ples  facets…  mul-ple  determinants  for  outcome  

Sepsis  Puzzle    

outcome  An-  infl  cytokines  

Physiol  Status  

Type    of    infec-on  

circulatory  &  metabolic    consequences  

Iatrogenic        complica-ons  

Economical        aspects  

Gene-c   Time  course  of    the  Disease  

Pro    infl    cytokines  

Strategy  for  care  

Hormonal  paBerns  

Sepsis:  we  beBer  understand  and  conceptualize  …  

From  the  last  20  years,  concept  have  moved  on  a  lot…  especially  in  immuno-­‐

inflammatory  processes  

Impact of sepsis on innate and adaptive immune cells

PAMPS  èè  mu-ple;  PRR    DAMPS  èè  mul-ple;  DAMP  rec  -­‐  Necro<c  cells  à  DAMPs    -­‐  Criteria  for  DAMPs      

-­‐  Alone  è  biological  response  without  contamina<on  (PAMPs  =  0)    

-­‐  Being  efficient  at  physiological  [  ]  -­‐  Their  blockade  èè  inhibates  their  ac-on  -­‐  Examples:  HMGB1;  Calgranulines…  

 

From  Matzinger  theory  

APC  

•  PAMP:    Proteins  from  pathogens  are  processed  in  the  lysosomes  to  generate  an-genic  pep-des,  which  form  a  complex  with  MHC  class  II  on  the  surface  of  APC,  recognized  by  T  cell  receptors  (TCR)  

APC  =  ANTIGEN  PRESENTING  CELLS  

•   LPS  complex  has  3  components:        CD14,  TLR4,  and  MD-­‐2.      •   TLR4  interacts  with  CD14.  Protein  MD-­‐2  is  required  for  TLR4-­‐mediated  recogni-on  of  LPS    •   TLR4  and  MD-­‐2  are  cons-tu-vely  associated  with  each  other.  (CD14  is  presumably  recruited  aNer  binding  LPS)    •   Limited  informa-on  about  allelic  variants  of  human  toll  genes  and  impact  on  suscep-bility  to  infec-on  

The signalisation

From  Cell  death  to  inflamma-on  and  OF    - Necrotic cell death è DAMPs è receptors

è+ prod of inflam cytokines (IL‑1). - Other molecules proteases; hydrolases act on EC components è + mediators (complement fragments) or DAMPs è prod of inflam cytokines by host cells.

- Pro-inflam mediators è local vascular endothelium lesions è ‘leaky’, attracts neutrophils and monocytes/macrophages è soluble (antibody) and cellular defences in the tissue (cell infiltration) neutralize or contain pathogens

The reaction to the sepsis-induced stress…

Medzhitov  et  al.  Science  2012;  355:936-­‐41  

•  ““Threat”” vs. non-threat

•  Tolerating pathogens

•  Limiting host response

•  Stress hormones •  Anti-inflammatory

actions •  Pro-resolving

actions

Organ-­‐specific    tolerance  capacity  to  pathogen-­‐  or  immune-­‐induced  pathology    

Medzhitov  et  al.  Science  2012;  355:936-­‐41  

Organs  largely  differ  in  term  of  :  -­‐  Suscep-bility  -­‐  Repair  capabili-es  -­‐  Func-onal  autonomy  -­‐  sequela    

Mortality    

-­‐  Is  early  mortality  (1st  Wk)  similar  to  late  mortality?    

-­‐  Is  inflamma-on  moving  along  -me?  -­‐  What  is  sepsis-­‐induced  mortality?  

-­‐  Crude  mortality?  -­‐  ACributable  mortality?  

0 5 10 15 20 25 30

0 0.

1 0.

2 0.

3 0.

4 0.

5 0.

6

0 5 10 15 20 25 30

0 0.

1 0.

2 0.

3 0.

4 0.

5 0.

6

0 5 10 15 20 25 30

0.1

0.2

0.3

0.4

Low  IL  -­‐  10/  Low  comorbidi-es  (n=67)  High  IL  -­‐  10/  Low  comorbidi<es  (n=71)  Low  IL  -­‐  10/High    comorbidi-es  (n=42)  High  IL  -­‐  10/High    comorbidi<es  (n=38)  

Pro

babi

lity o

f deat

h

Days Days

Pro

babi

lity o

f deat

h Low  IL  -­‐  6/  Low  comorbidi-es   (n=64)  High  IL  -­‐  6/  Low  comorbidi<es   (n=75)  Low  IL  -­‐  6/High    comorbidi-es   (n=46)  High  IL  -­‐  6/High    comorbidi<es   (n=34)  

IL-10 IL-6

202 SS Patients (multicentric)

Early death (<7days) relates mainly to inflammation intensity, but not to comorbidity

level but

Late death (>7days), relates mainly comorbidity

This concept obtained from a training cohort (202 pts) was tested in large testing cohort N = 989 SS patients from Prowess data base

N  =  989  pa-ents  in  sep-c  shock  

0 5 10 15 20 25

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0.1

0.2

0.3

0.4

0.5

0.6

Days

Prob

abili

ty o

f dea

th

Low Il6/Low comorbidities n=167 Low IL6/High comorbidities n=297 High Il6/Low comorbidities n=215 High IL6/High comorbidities n=253

P value < 0.001

Theore<cal    crude  mortality  of  40%  in  the  absence  of  therapy.    Since  matched  controls  had  a  crude  mortality  of  20%,    è the  es<mate  of  aBributable  mortality  is  20%  (40%  -­‐20%).  è The  best  Bmt  can  reduce  mortality  about  max  20%  but  cannot  reduce  the  mortality  due  to  the  underlying  diseases.  

ATTRIBUTABLE MORTALITY 20  %  

NEJM  2013;  369:  840  

To  summarize:  The  Host  Response  to  Sepsis  canbe  seen  as  

The  -me  phases  of  sepsis    

Phase  1   Phase  2   Phase  3  

Phase  1  

The host response to sepsis

Days

Pro

-in

flam

mat

ory

re

s po

nse

s A

nti

-in

flam

mat

ory

re

s po

nse

s Excessive inflammation causing collateral damage (tissue injury)

Immune suppression resulting in enhanced susceptibility for nosocomial pathogens

The  Host  Response  to  Sepsis  

The  Host  Response  to  Sepsis  

The  Host  Response  to  Sepsis  

0   1   2   3   4   5   6   7   8   9   10   11   12   13   14   15   16   17   18   19   20   21   22   23   24   25   26   27   28  0.4  

0.5  

0.6  

0.7  

0.8  

0.9  

1.0  

Survival  

Study  Day  

Log-­‐rank  test  P  value:  0.5789  

Hazard  ra-o  (95%  CI):  1.05  (0.88,  1.26)  

Placebo  

Eritoran  

Placebo  Censored  

Eritoran  Censored  

ACCESS trial: TLR4/MD2 inhibition in severe sepsis

28-day mortality

28.1%  

26.9%  

The  Host  Response  to  Sepsis  

Activated Protein C Antithrombin

Tissue factor pathway inhibitor

PROWESS-SHOCK (NEJM 2012)

Ranieri  et  al    NEJM  2012  

Percent in study hospital 28d: DrotAA 305 (49%) Placebo 279 (43%)

 

-­‐  fast  track  process  (short  windows:  hrs…)  

-­‐  mul-  interac-ve  processes  

-­‐  lack  of  validated  BM  to  rapidly  characterize  host  

reponse  

 

Early  phase  is  challenging  because  of:

Why  not  being  inspired  by  cancer    strategies?

cecal  liga<on  and  puncture  (CLP)  mouse  model:  80%  of  C57BL/6  mice  succumbed  within  48  hr    Ø epirubicin i.p. at the time of CLP and again 24 hr later reproducibly and significantly (p < 0.001) increased the survival Ø Independently  from  mouse  strain  Ø “ “ “ “ of sepsis of origins in addition to peritoneal sepsis  

Ø  epirubicin-treated + CLP has similar bacterial load in blood and organs 24 hr post-CLP

Ø  a substantial reduction in the levels of inflammatory mediators TNF, IL-1b, IL-6, and HMGB1

Ø  Epirubicin protection against Sepsis is mediated by ATM, a master regulator of the DDR (DNA damage response)

Ø  ATM-deficient(Atm-/-) mice were not

protected by epirubicin against CLP and died with similar kinetics to wild-type (WT, Atm+/+) animals

Epirubicin  has  a  24  hr  Therapeu-c  Window  to  Protect  against  Sepsis  

The  Host  Response  to  Sepsis  

Urgent need for biomarkers that reflect the predominant type of the host response to sepsis in an individual patient. ü  Aid in identification of patients that might

benefit from a specific intervention. ü  Aid in titrating the intervention and

monitoring the response. ü  Rapid: “point-of-care”.

The kidney: a good example

Pathophysiology: Kidney is perfused by inflamed blood: èè activated Immune

Cells + elevated mediators plasma levels èè infiltration

Systemic  inflamma-on  èè  AKI  via  vascular  compartment    

Is  there  any  difference  between  AKI  groups  for  inflamma-on  ?  

PHASE 2

Phase  1   Phase  2   Phase  3  

Post-­‐Agressive  Immuno-­‐Depression  (PAID)  Syndrome  

q Loss  of  delayed  type  hypersensi-vity  response  to  common  recall  an<gens  

q Apoptosis-­‐induced  deple-on  of  immune  effector  cells,  loss  of  CD4,  CD8,  B,  and  dendri-c  cells  q Reac-va-on  of  latent  viruses  (CMV;  herpes  virus  in  roughly  25–35%  of  pa<ents  with  sepsis)  

q   autopsy  èè  most  pa-ents  admiBed  to  ICUs  for  treatment  of  sepsis  had  unresolved  sep-c  foci  at  post  mortem,  èèpa-ents  unable  to  eradicate  invading  pathogens  and  were  more  suscep-ble  to  nosocomial  organisms,  or  both  q Blood  studies  from  pa<ents  with  and  without  sepsis  show  decreased  produc-on  of  proinflammatory  cytokines,  decreased  monocyte  HLA-­‐DR  expression,  increased  numbers  of  regulatory  T  cells  (Treg  Fox  P3),  increased  produc-on  of  PD-­‐1  or  PD-­‐L1  

Clinical  or  laboratory  evidence  for  sepsis  being  an  immunosuppressive  disorder  

Venet  et  al.  Crit  Care  Med  2013;  41(1):111-­‐119    

T  cell  repertoire  rapidly  decreases  in  sepsis      

Is  this  immunodepression  also  observed  in  -ssue  infiltra-ng  immune  cells?  

q   splenocytes  from  sepsis  pa<ents  had  highly  

significant  func-onal  impairments  as  evidenced  by  major  reduc-ons  in  cytokine  secre-on.  

q   Mul-ple  inhibitory  mechanisms  were  iden-fied,  ü   dominance  of  inhibitory  over  ac-va-ng  receptors,    

ü expansion  of  suppressive  cell  types,    

ü and  induc-on  of  inhibitory  ligands  on  both  APCs  and  

<ssue  parenchymal  cells.  

q   Both  pro-­‐  and  an--­‐inflammatory  cytokines  were  

impaired.  

q   Cytokine  produc-on  at  22  hours  in  sepsis  pa-ents  was  comparable  

with  controls,  è  some  pa-ents,  defec-ve  cytokine  secre-on  

may  be  reversible  if  cells  are  removed  from  the  sepsis  milieu.  

Sepsis  èè    Profound  Loss  of  CD4  and  CD8  Cells    the  loss  of  CD  4  T  cells  mimics  HIV  in  severity  èè  

 in  ineffec-ve  adap-ve  immunity    

Non-­‐  sep-c                    Sep-c      

Boomer,  Chang,    Takasu,  et.  al  Journal  of  the  American  Med.  Associa;on  (JAMA)  306:2594  2011  

(In press)

1

10

100

1000

10000

100000

BLOOD BM

Mon

ocyt

e H

LA-D

R (A

B/C

)

p<0.0001 p=0.0009

A ICU Patients; Non ICU patients; HV

Blood  and  BM  mHLA-­‐DR  expression  in  pa-ents  vs  controls  

1

10

100

1000

10000

100000

BLOOD BM

Mon

ocyt

e H

LA-D

R (A

B/C

)

B Sshock, Septic, non septic; non ICU, HV

p<0.0001

p=0.0006

p<0.0001 p=0.0008

p=0.0412

p=0.0056

PlosOne (In press)

Conclusion

The  downregula-on  of  HLA-­‐DR  in  BM  monocyte  

lineage  is  present  in  ICU  pa-ents  without  major  

changes  in  myeloid  cells.  It  may  result  from  a  

regula-on  mediated  by  soluble  and/or  neuro-­‐

endocrine  factors  present  in  BM  cell  

microenvironment.  

at least 1500 patients

Can  We  treat  this  immunosuppression?  

59 2013

PMN,  Mono  phagocytose  mHLA-­‐DR  TNFαα    

Fct  Mono  Phagocytose    

Prolif.  Tcell  IFNγγ    An--­‐apoptose  êêPD-­‐1,  ãã  molec  adhesion  êêTreg  Diversité  récepteurs  TCR  

TotoR Pseudomonas aeruginosa septic shock – severe ARDS – peritonitis in a 15 months post-LT child

0

5000

10000

15000

20000

25000

J6 J8 J11 J14 J15 J18 J26

mHLA-DR

Leuco

Lympho

Neutro

Severe PAIDsn

Normal

Grey zone

PAIDs

AB/C or 10e6

INFγγ

Norepinephrine

Mechanical ventilation Positive cultures Negative cultures

To conclude •  PAIDs is a fact that concerns all acute situations, particularly severe sepsis is

always present after 1 or 2 days post injury

•  IMMUNOSCOPE –  Blood measurements: WBC (fractions), NCLRatio; semi-quantitative cytokine level

–  Flowcytometry: HLA-DR; Ly sub-populations

•  è IMMUNOSCOPE! èè Personalized therapy

•  HLA-DR is a good candidate and is cheap and fast to be measured with

semi-quantitative IL-6, IL-10.

•  Immuno-stimulation can be proposed on solid criteria

•  RCT are on going testing different targets and molecules (INFγγ, GM-CSF; IL-7…)

interferon  γγ  

0  

5000  

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20000  

25000  

30000  

35000  

Day3   Day6  Day7  

Day9  Day11  

Day12  Day13    

Day15  Day17   discharge  

BAL  pseudomonas  aeru    109   +++    +++                      +                  0  0  

2603  570  

mHLA-­‐DR

 (AB/C)  

Days  awer  ICU  admission  (post  cardiac  arrest)    

Lukaszewicz  et  al.Crit  Care  Med  2009;  37:  2746–2752  

Nl  

Risk  factors  for  severe  sepsis  or  sep-c  shock  

Brun-­‐Buisson  et  al,  JAMA  1995  

 

•  Ageing  •  Male  sex  (63  %)  •  Emergency  admission:  medical  or  surgical  •  Admission  in  a  large  hospital:  >  400  beds  •  immunodepression  or  underlying  pathologies  with  a  short  term  bad  prognosis.  

Le  Sepsis:  Stratégie  de  recherche  basée  sur  l’inflamma-on…  

EXPRESSION OF ADHERENCE MOLECULES ON ENDOTHELIAL CELL CULTURE èè TOO LONG

SERA WHOLE

BLOOD

SURFACE ANTIGEN EXPRESSION (FLOW

CYTOMETRY)

2hrs

CYTOKINE SECRETION Quick semi-quantitative method IMMEDIATE

WHOLE

BLOOD

PATIENTS

Post-agressive Immuno-Depression Syndrome: PAIDs STRATEGY FOR IMMUNOSCOPING!

Blood as « tissue Biopsy » - WBC - Fractional count - PMN/Ly ratio

Phase  1   Phase  2   Phase  3