THE IMMUNE SYSTEMS ROULETTE WHEEL OF LIFE AND DEATH

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THE IMMUNE SYSTEMS ROULETTE WHEEL OF LIFE AND
DEATH

• Professor Jamie Sleigh2
• Dr Ray Cursons1
• (1) Biological Sciences University of Waikato,
• (2) Intensive Care Unit, Waikato Clinical School,
  University of Auckland, Hamilton, New Zealand

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BACKGROUND Death by Cytokine Storm
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The Hunting of the Snark a Magic Bullet for
Innate System Activation?Randomised Controlled
Trials of Immunotherapy in Sepsis and Septic Shock
Fraud
Mortality No. of Trials Total Patients Pla
cebo Therapy
IL-1-RA 3 1898 35 31 Antibradykinin 2 755 36 3
9 Anti-PAF 2 870 50 45 Anti-TNF 8 4132 41 40
Soluble TNR 2 688 38 40 NSAIDs 3 514 40 37
Steroids 9 1267 35 39 All studies  33 12,034
38 38
PAF platelet-activating factor TNF tumour
necrosis factor NSAIDs nonsteroidalnti-inflamma
tory drugs
Adapted from F. Zeni and colleagues.
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SIRS CARS The battle of Good and Evil?
Fiction
EVIL Pro-inflammation (SIRS) in Tissues
Drug -inhibitor
GOOD Anti-inflammation (CARS) in Blood Stream
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Immunity a War Machine?
The Mechanism of action of TNF
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RCTs Odds RatiosIs outcome from sepsis a
tug-of-war?
Rx..ICU
Co-mobidities
Disease
Immunity
New Rx
Death
Survival
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Cytokinetic Contradictions

• Neutralization of IL-10 increases lethality in
  endotoxemia. Cooperative effects of macrophage
  inflammatory protein-2 and tumor necrosis
  factor.
• Standiford TJ, Strieter RM, Lukacs NW, Kunkel
  SL.J Immunol. 1995 Aug 15155(4)2222-9
  

• Neutralization of IL-10 increases survival in a
  murine model of Klebsiella pneumonia.
  
• Greenberger MJ, Strieter RM, Kunkel SL, Danforth
  JM, Goodman RE, Standiford TJ.J Immunol. 1995
  Jul 15155(2)722-9
  

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Non-machinelike behaviourContext-sensitive
treatment effects
(DeMeester SL, et al. The heat shock paradox
does NF-kB determine cell fate? FASEB J 200115
270.)
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The danger model a renewed sense of self.
Matzinger P. Science 2002 Apr 12296(5566)301-5

• Is the immune systems purpose to detect
• Difference?
• Damage?
• Danger?
• e.g. TLR4 receptor for LPS HSP70 Hyaluron
• Explanation 1 TLR4 evolved to catch LPS
• Explanation 2TLR4 is for Garbage collection
  (i.e. extracellular HSP70) bacteria evolved to
  bind it and induce immunosuppression...

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A Clock or a Web?Simple, clear, explanations are
usually wrong
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Cytokines The web with no spider
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Scale- Free Nets
Random Nets
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How to wreck the Internet (or a terrorist network
)?
Complex systems (unlike machines) maintain their
basic functions even under errors and failures
(cell ? mutations Internet ? router breakdowns)
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Networks Robust to error, Susceptible to attack
1
S
0
1
f
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Obstructing the Sepsis Cascade
Attack Multiple hubs.. WEB ? REDUNDANT PATHS
Drug Companies will have to co-operate!
Anti-TNF Dam
Anti-NFkB
Anti-HMG1
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How to measure the elephant?
GNOMES
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Variability of gene expression increases in sepsis
Individuality and variation in gene expression
patterns in human blood.Whitney AR, Diehn M,
Popper SJ, Alizadeh AA, Boldrick JC, Relman DA,
Brown PO.Proc Natl Acad Sci U S A 2003 Feb
18100(4)1896-901
Cancer
Septic
Healthy
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Molecular Specifics of Host-Pathogen Interaction
(1) Get bacterial DNA (2) Sequence it to find o
ut bacterial species (Sleigh Cursons CCM 2000,
ICM 2002) __________________ (1) Get WBC mRNA
(2) Quantify the amount of transcription for each
cytokine
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There is more to life than plasma levels
Work/Activity METABOLOME/Physiome
Nucleus GENOME
Plasma Cytokine Levels
mRNA TRANSCRIPTOME
Proteins PROTEOME
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Developing an Immune Profile GENES OF INTEREST

• Cytokines ILs, MIF, PDGF, TNFa, INFg
• Intracellular signals transcription COX IkB,
  NOD NFkB, FOS, JUN, Rel-A, B, IRAKM, RIP2
  
• Pattern recognition receptors TREM, TLRs, CD11,
  CD14, C5ar...
  
• Acute Phase Proteins HSP, mtHSP, CRP, PCT
• Microbiocidal -BPI, MPO
• Others - CASP, MMP9, Prot-C, Alpha receptors

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First data single, early samplesPatient 1
Manhattan or Baghdad?

• 25yr male
• Septic arthritis Staphylococcus aureus
• ARDS prone NO,
• ARF - CVVHD,
• Noradrenalin Vasopressin,
• DIC
• Subsequent bacterial endocarditis

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Leukocyte cytokine expression
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PCR - Comparison
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Normal ranges are not always good!Liver abscess,
normal cytokine mRNA expression DIED
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Pneumonia anti-CD14?Both these patients
had pneumoniaBoth survived
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Changes in mRNA expression in sepsis
MMP9
IL6
IL8
INF?
C5ar
The -fold change in genetic expression for each
gene between the septic patients vs the control
group
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Examples of gene expression in different patient
groups.
A peritonitis, B burn, P pneumonia, O
musculo-skeletal
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Longitudinal data Survivor, Meningococcus
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Longitudinal data Died, Staph aureus
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Longitudinal data Survivor, Fusobacterium
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Conclusions and Questions

• What is the best cytokine symphony?
• Mega-variation
• Titration of Rx essential
• Compartmentalisation Does it exist?
• e.g. ARDS. (IL8/MMP9)
• Post-transcription black hole(e.g. NFkB)
• Th2 flavour
• Good /or Bad /or Both
• Directed by the body or the bug?

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Aphorisms

• Postulates
• Immunity Information not Defence
• State of the immune system cannot be diagnosed
  clinically
  
• Immunity is a process of soldification

• Implications
• We are bombing the postal systems/ rubbish
  disposal
  
• Specific tests needed for appropriate targetting
  of treatment
  
• freedom for molecular syndromes
• Expect contradictions /hysteresis

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• To be natures master, you must first learn to be
  natures servant

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MOLECULAR SYNDROMES?
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Treatment 2012 Sepsis diplomacyMicro-ecology
/Biofilms/Net/Rubbish dump

• Identify Micro-ecology (DNA microarrays).
• Identify Micro-proteomics (mRNA expression).
• Identify Host Genomic/Proteomic responses.
• Modify Germ metabolic web (10 antibiotics),
• Feed the germs beneficial competitors
• Modify the pattern of the hosts innate response
  web (10 Inhibitory-RNA targets)
  
• Repress some hubs and enhance genetic expression
  of others

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Cytokinetic Contradictions

• IL10 improves outcome
• Steroids reduce apoptosis by NFkB
• IFN? causes Schwartzmann reaction
• Patients die from too much TNF ?

• Anti-IL10 improves outcome
• Steroids cause lymphoid apoptosis
• Giving IFN ? reduces mortality
• Patients die from too little TNF?