Abstract
Background
Sepsis is an unsolved problem worldwide, with a 30–50 % mortality rate. The recent failures of anti-TLR4, recombinant activated protein C, and anti-TNF in clinical trials indicate a need to rethink our current understanding of sepsis’s pathophysiology. While the initial immune response is crucial for effective clearance of invading pathogens, an overly exuberant host response to infection can cause septic shock, tissue damage, and death. Profuse inflammation in sepsis is frequently followed by global immunosuppression that increases susceptibility to viral and bacterial infections. Despite the dangers of immune over-response, the immune system’s anti-inflammatory activities are likely necessary to reduce the initial over-activation of the immune system.
Purpose
With this review, we want to illuminate the different aspects of immune response to sepsis and provide insight to the ongoing difficulties currently present within sepsis research.
Conclusion
Future treatment strategies for sepsis should focus on maintaining balance between pro- and anti-inflammatory immune actions in a timely manner.
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References
Angus DC, Linde-Zwirble WT, Lidicker J, Clermont G, Carcillo J, Pinsky MR (2001) Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med 29:1303–1310
Coopersmith CM, Wunsch H, Fink MP, Linde-Zwirble WT, Olsen KM, Sommers MS, Anand KJ, Tchorz KM, Angus DC, Deutschman CS (2012) A comparison of critical care research funding and the financial burden of critical illness in the United States. Crit Care Med 40:1072–1079
Angus DC (2011) The search for effective therapy for sepsis: back to the drawing board? JAMA 306:2614–2615
Russell JA (2006) Management of sepsis. N Engl J Med 355:1699–1713
Hotchkiss RS, Coopersmith CM, McDunn JE, Ferguson TA (2009) The sepsis seesaw: tilting toward immunosuppression. Nat Med 15:496–497
Takeuchi O, Akira S (2010) Pattern recognition receptors and inflammation. Cell 140:805–820
Khan KS, Wojdyla D, Say L, Gulmezoglu AM, Van Look PF (2006) WHO analysis of causes of maternal death: a systematic review. Lancet 367:1066–1074
Chalupka AN, Talmor D (2012) The economics of sepsis. Crit Care Clin 28:57–76, vi
Martin GS, Mannino DM, Eaton S, Moss M (2003) The epidemiology of sepsis in the United States from 1979 through 2000. N Engl J Med 348:1546–1554
Wood KA, Angus DC (2004) Pharmacoeconomic implications of new therapies in sepsis. Pharmacoeconomics 22:895–906
Vincent JL, Sakr Y, Sprung CL, Ranieri VM, Reinhart K, Gerlach H, Moreno R, Carlet J, Le Gall JR, Payen D (2006) Sepsis in European intensive care units: results of the SOAP study. Crit Care Med 34:344–353
Hotchkiss RS, Karl IE (2003) The pathophysiology and treatment of sepsis. N Engl J Med 348:138–150
Vincent JL, Opal SM, Marshall JC, Tracey KJ (2013) Sepsis definitions: time for change. Lancet 381:774–775
Medzhitov R, Shevach EM, Trinchieri G, Mellor AL, Munn DH, Gordon S, Libby P, Hansson GK, Shortman K, Dong C, Gabrilovich D, Gabrysova L, Howes A, O’Garra A (2011) Highlights of 10 years of immunology in Nature Reviews Immunology. Nat Rev Immunol 11:693–702
Janeway CAJ, Medzhitov R (2002) Innate immune recognition. Annu Rev Immunol 20:197–216
Medzhitov R (2007) Recognition of microorganisms and activation of the immune response. Nature 449:819–826
Lotze MT, Tracey KJ (2005) High-mobility group box 1 protein (HMGB1): nuclear weapon in the immune arsenal. Nat Rev Immunol 5:331–342
Annane D, Bellissant E, Cavaillon JM (2005) Septic shock. Lancet 365:63–78
Medzhitov R (2001) Toll-like receptors and innate immunity. Nat Rev Immunol 1:135–145
Aksoy E, Taboubi S, Torres D, Delbauve S, Hachani A, Whitehead MA, Pearce WP, Berenjeno-Martin I, Nock G, Filloux A, Beyaert R, Flamand V, Vanhaesebroeck B (2012) The p110delta isoform of the kinase PI(3)K controls the subcellular compartmentalization of TLR4 signaling and protects from endotoxic shock. Nat Immunol 13:1045–1054
Kayagaki N, Warming S, Lamkanfi M, Vande Walle L, Louie S, Dong J, Newton K, Qu Y, Liu J, Heldens S, Zhang J, Lee WP, Roose-Girma M, Dixit VM (2011) Non-canonical inflammasome activation targets caspase-11. Nature 479:117–121
Kayagaki N, Wong MT, Stowe IB, Ramani SR, Gonzalez LC, Akashi-Takamura S, Miyake K, Zhang J, Lee WP, Muszynski A, Forsberg LS, Carlson RW, Dixit VM (2013) Noncanonical inflammasome activation by intracellular LPS independent of TLR4. Science 341:1246–1249
Hagar JA, Powell DA, Aachoui Y, Ernst RK, Miao EA (2013) Cytoplasmic LPS activates caspase-11: implications in TLR4-independent endotoxic shock. Science 341:1250–1253
Opal SM, Laterre PF, Francois B, LaRosa SP, Angus DC, Mira JP, Wittebole X, Dugernier T, Perrotin D, Tidswell M, Jauregui L, Krell K, Pachl J, Takahashi T, Peckelsen C, Cordasco E, Chang CS, Oeyen S, Aikawa N, Maruyama T, Schein R, Kalil AC, Van Nuffelen M, Lynn M, Rossignol DP, Gogate J, Roberts MB, Wheeler JL, Vincent JL (2013) Effect of eritoran, an antagonist of MD2-TLR4, on mortality in patients with severe sepsis: the ACCESS randomized trial. JAMA 309:1154–1162
Kelly-Scumpia KM, Scumpia PO, Weinstein JS, Delano MJ, Cuenca AG, Nacionales DC, Wynn JL, Lee PY, Kumagai Y, Efron PA, Akira S, Wasserfall C, Atkinson MA, Moldawer LL (2011) B cells enhance early innate immune responses during bacterial sepsis. J Exp Med 208:1673–1682
Baumgarth N (2011) The double life of a B-1 cell: self-reactivity selects for protective effector functions. Nat Rev Immunol 11:34–46
Cohen IR, Norins LC (1968) Antibiodies of the IgG, IgM, and IgA classes in newborn and adult sera reactive with gram-negative bacteria. J Clin Invest 47:1053–1062
Ehrenstein MR, Notley CA (2010) The importance of natural IgM: scavenger, protector and regulator. Nat Rev Immunol 10:778–786
Litvack ML, Post M, Palaniyar N (2011) IgM promotes the clearance of small particles and apoptotic microparticles by macrophages. PLoS One 6:e17223
Rauch PJ, Chudnovskiy A, Robbins CS, Weber GF, Etzrodt M, Hilgendorf I, Tiglao E, Figueiredo JL, Iwamoto Y, Theurl I, Gorbatov R, Waring MT, Chicoine AT, Mouded M, Pittet MJ, Nahrendorf M, Weissleder R, Swirski FK (2012) Innate response activator B cells protect against microbial sepsis. Science 335:597–601
Hamilton JA (2008) Colony-stimulating factors in inflammation and autoimmunity. Nat Rev Immunol 8:533–544
Hamilton JA, Achuthan A (2012) Colony stimulating factors and myeloid cell biology in health and disease. Trends Immunol 34(2):81–9
Yousefi S, Gold JA, Andina N, Lee JJ, Kelly AM, Kozlowski E, Schmid I, Straumann A, Reichenbach J, Gleich GJ, Simon HU (2008) Catapult-like release of mitochondrial DNA by eosinophils contributes to antibacterial defense. Nat Med 14:949–953
Linch SN, Danielson ET, Kelly AM, Tamakawa RA, Lee JJ, Gold JA (2012) Interleukin 5 is protective during sepsis in an eosinophil-independent manner. Am J Respir Crit Care Med 186:246–254
Nathan C (2002) Points of control in inflammation. Nature 420:846–852
Nathan C (2006) Neutrophils and immunity: challenges and opportunities. Nat Rev Immunol 6:173–182
Spiller F, Costa C, Souto FO, Vinchi F, Mestriner FL, Laure HJ, Alves-Filho JC, Freitas A, Rosa JC, Ferreira SH, Altruda F, Hirsch E, Greene LJ, Tolosano E, Cunha FQ (2011) Inhibition of neutrophil migration by hemopexin leads to increased mortality due to sepsis in mice. Am J Respir Crit Care Med 183:922–931
Ihle JN, Pepersack L, Rebar L (1981) Regulation of T cell differentiation: in vitro induction of 20 alpha-hydroxysteroid dehydrogenase in splenic lymphocytes from athymic mice by a unique lymphokine. J Immunol 126:2184–2189
Yang YC, Ciarletta AB, Temple PA, Chung MP, Kovacic S, Witek-Giannotti JS, Leary AC, Kriz R, Donahue RE, Wong GG et al (1986) Human IL-3 (multi-CSF): identification by expression cloning of a novel hematopoietic growth factor related to murine IL-3. Cell 47:3–10
Langley RJ, Tsalik EL, Velkinburgh JC, Glickman SW, Rice BJ, Wang C, Chen B, Carin L, Suarez A, Mohney RP, Freeman DH, Wang M, You J, Wulff J, Thompson JW, Moseley MA, Reisinger S, Edmonds BT, Grinnell B, Nelson DR, Dinwiddie DL, Miller NA, Saunders CJ, Soden SS, Rogers AJ, Gazourian L, Fredenburgh LE, Massaro AF, Baron RM, Choi AM, Corey GR, Ginsburg GS, Cairns CB, Otero RM, Fowler VGJ, Rivers EP, Woods CW, Kingsmore SF (2013) An integrated clinico-metabolomic model improves prediction of death in sepsis. Sci Transl Med 5:195ra95
Hoebe K, Janssen E, Beutler B (2004) The interface between innate and adaptive immunity. Nat Immunol 5:971–974
Hotchkiss RS, Opal S (2010) Immunotherapy for sepsis—a new approach against an ancient foe. N Engl J Med 363:87–89
Otto GP, Sossdorf M, Claus RA, Rodel J, Menge K, Reinhart K, Bauer M, Riedemann NC (2011) The late phase of sepsis is characterized by an increased microbiological burden and death rate. Crit Care 15:R183
Ward PA (2012) New approaches to the study of sepsis. EMBO Mol Med 4:1234–1243
Boomer JS, To K, Chang KC, Takasu O, Osborne DF, Walton AH, Bricker TL, Jarman SD, Kreisel D, Krupnick AS, Srivastava A, Swanson PE, Green JM, Hotchkiss RS (2011) Immunosuppression in patients who die of sepsis and multiple organ failure. JAMA 306:2594–2605
Inoue S, Suzuki-Utsunomiya K, Okada Y, Taira T, Iida Y, Miura N, Tsuji T, Yamagiwa T, Morita S, Chiba T, Sato T, Inokuchi S (2013) Reduction of immunocompetent T cells followed by prolonged lymphopenia in severe sepsis in the elderly. Crit Care Med 41:810–819
Lee SY, Lee YS, Choi HM, Ko YS, Lee HY, Jo SK, Cho WY, Kim HK (2012) Distinct pathophysiologic mechanisms of septic acute kidney injury: role of immune suppression and renal tubular cell apoptosis in murine model of septic acute kidney injury. Crit Care Med 40:2997–3006
Teijaro JR, Ng C, Lee AM, Sullivan BM, Sheehan KC, Welch M, Schreiber RD, de la Torre JC, Oldstone MB (2013) Persistent LCMV infection is controlled by blockade of type I interferon signaling. Science 340:207–211
Kelly-Scumpia KM, Scumpia PO, Delano MJ, Weinstein JS, Cuenca AG, Wynn JL, Moldawer LL (2010) Type I interferon signaling in hematopoietic cells is required for survival in mouse polymicrobial sepsis by regulating CXCL10. J Exp Med 207:319–326
Hoetzenecker W, Echtenacher B, Guenova E, Hoetzenecker K, Woelbing F, Bruck J, Teske A, Valtcheva N, Fuchs K, Kneilling M, Park JH, Kim KH, Kim KW, Hoffmann P, Krenn C, Hai T, Ghoreschi K, Biedermann T, Rocken M (2012) ROS-induced ATF3 causes susceptibility to secondary infections during sepsis-associated immunosuppression. Nat Med 18:128–134
Turrel-Davin F, Venet F, Monnin C, Barbalat V, Cerrato E, Pachot A, Lepape A, Alberti-Segui C, Monneret G (2011) mRNA-based approach to monitor recombinant gamma-interferon restoration of LPS-induced endotoxin tolerance. Crit Care 15:R252
Pillay J, Kamp VM, van Hoffen E, Visser T, Tak T, Lammers JW, Ulfman LH, Leenen LP, Pickkers P, Koenderman L (2012) A subset of neutrophils in human systemic inflammation inhibits T cell responses through Mac-1. J Clin Invest 122:327–336
Lukaszewicz AC, Grienay M, Resche-Rigon M, Pirracchio R, Faivre V, Boval B, Payen D (2009) Monocytic HLA-DR expression in intensive care patients: interest for prognosis and secondary infection prediction. Crit Care Med 37:2746–2752
Wu HP, Shih CC, Lin CY, Hua CC, Chuang DY (2011) Serial increase of IL-12 response and human leukocyte antigen-DR expression in severe sepsis survivors. Crit Care 15:R224
Pachot A, Cazalis MA, Venet F, Turrel F, Faudot C, Voirin N, Diasparra J, Bourgoin N, Poitevin F, Mougin B, Lepape A, Monneret G (2008) Decreased expression of the fractalkine receptor CX3CR1 on circulating monocytes as new feature of sepsis-induced immunosuppression. J Immunol 180:6421–6429
Grimaldi D, Louis S, Pene F, Sirgo G, Rousseau C, Claessens YE, Vimeux L, Cariou A, Mira JP, Hosmalin A, Chiche JD (2011) Profound and persistent decrease of circulating dendritic cells is associated with ICU-acquired infection in patients with septic shock. Intensive Care Med 37:1438–1446
Pastille E, Didovic S, Brauckmann D, Rani M, Agrawal H, Schade FU, Zhang Y, Flohe SB (2011) Modulation of dendritic cell differentiation in the bone marrow mediates sustained immunosuppression after polymicrobial sepsis. J Immunol 186:977–986
Zhang Y, Zhou Y, Lou J, Li J, Bo L, Zhu K, Wan X, Deng X, Cai Z (2010) PD-L1 blockade improves survival in experimental sepsis by inhibiting lymphocyte apoptosis and reversing monocyte dysfunction. Crit Care 14:R220
Anderson P, Souza-Moreira L, Morell M, Caro M, O’Valle F, Gonzalez-Rey E, Delgado M (2013) Adipose-derived mesenchymal stromal cells induce immunomodulatory macrophages which protect from experimental colitis and sepsis. Gut 62:1131–1141
Cohen HB, Briggs KT, Marino JP, Ravid K, Robson SC, Mosser DM (2013) TLR stimulation initiates a CD39-based autoregulatory mechanism that limits macrophage inflammatory responses. Blood 122(11):1935–45
Brudecki L, Ferguson DA, McCall CE, El Gazzar M (2012) Adoptive transfer of CD34(+) cells during murine sepsis rebalances macrophage lipopolysaccharide responses. Immunol Cell Biol 90:925–934
Brudecki L, Ferguson DA, Yin D, Lesage GD, McCall CE, El Gazzar M (2012) Hematopoietic stem-progenitor cells restore immunoreactivity and improve survival in late sepsis. Infect Immun 80:602–611
Hoogerwerf JJ, Leendertse M, Wieland CW, de Vos AF, de Boer JD, Florquin S, van der Poll T (2011) Loss of suppression of tumorigenicity 2 (ST2) gene reverses sepsis-induced inhibition of lung host defense in mice. Am J Respir Crit Care Med 183:932–940
Deng JC, Cheng G, Newstead MW, Zeng X, Kobayashi K, Flavell RA, Standiford TJ (2006) Sepsis-induced suppression of lung innate immunity is mediated by IRAK-M. J Clin Invest 116:2532–2542
Wiersinga WJ, van’t Veer C, van den Pangaart PS, Dondorp AM, Day NP, Peacock SJ, van der Poll T (2009) Immunosuppression associated with interleukin-1R-associated-kinase-M upregulation predicts mortality in Gram-negative sepsis (melioidosis). Crit Care Med 37:569–576
Weber GF, Schlautkotter S, Kaiser-Moore S, Altmayr F, Holzmann B, Weighardt H (2007) Inhibition of interleukin-22 attenuates bacterial load and organ failure during acute polymicrobial sepsis. Infect Immun 75:1690–1697
Flierl MA, Rittirsch D, Gao H, Hoesel LM, Nadeau BA, Day DE, Zetoune FS, Sarma JV, Huber-Lang MS, Ferrara JL, Ward PA (2008) Adverse functions of IL-17A in experimental sepsis. FASEB J 22:2198–2205
Bingold TM, Ziesche E, Scheller B, Sadik CD, Franck K, Just L, Sartorius S, Wahrmann M, Wissing H, Zwissler B, Pfeilschifter J, Muhl H (2010) Interleukin-22 detected in patients with abdominal sepsis. Shock 34:337–340
Nakada TA, Russell JA, Boyd JH, Walley KR (2011) IL17A genetic variation is associated with altered susceptibility to Gram-positive infection and mortality of severe sepsis. Crit Care 15:R254
Brunialti MK, Santos MC, Rigato O, Machado FR, Silva E, Salomao R (2012) Increased percentages of T helper cells producing IL-17 and monocytes expressing markers of alternative activation in patients with sepsis. PLoS One 7:e37393
Schuetz P, Castro P, Shapiro NI (2011) Diabetes and sepsis: preclinical findings and clinical relevance. Diabetes Care 34:771–778
Seok J, Warren HS, Cuenca AG, Mindrinos MN, Baker HV, Xu W, Richards DR, McDonald-Smith GP, Gao H, Hennessy L, Finnerty CC, Lopez CM, Honari S, Moore EE, Minei JP, Cuschieri J, Bankey PE, Johnson JL, Sperry J, Nathens AB, Billiar TR, West MA, Jeschke MG, Klein MB, Gamelli RL, Gibran NS, Brownstein BH, Miller-Graziano C, Calvano SE, Mason PH, Cobb JP, Rahme LG, Lowry SF, Maier RV, Moldawer LL, Herndon DN, Davis RW, Xiao W, Tompkins RG (2013) Genomic responses in mouse models poorly mimic human inflammatory diseases. Proc Natl Acad Sci U S A 110:3507–3512
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Weber, G.F., Swirski, F.K. Immunopathogenesis of abdominal sepsis. Langenbecks Arch Surg 399, 1–9 (2014). https://doi.org/10.1007/s00423-013-1129-7
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DOI: https://doi.org/10.1007/s00423-013-1129-7