mRNA-based approach to monitor recombinant gamma-interferon restoration of LPS-induced endotoxin tolerance
© Turrel-Davin et al.; licensee BioMed Central Ltd. 2011
Received: 7 July 2011
Accepted: 25 October 2011
Published: 25 October 2011
It is now well accepted that sepsis is associated with the development of a pronounced immunosuppressive state, characterized by severe immune alterations (e.g. reduced proliferative capacity, endotoxin tolerance, apoptosis) participating in increased mortality and susceptibility to nosocomial infections. Efforts are currently aimed at restoring a functional immune response in septic patients. Successful therapy depends on the identification of appropriate immunostimulatory drugs and on the development of suitable biomarkers that could be used to stratify patients and to follow response to treatment.
In this study, we evaluated the ex vivo effect of recombinant interferon gamma (rIFN-γ) in restoring monocyte functionality (endotoxin-induced Tumor Necrosis Factor-α production) in a two-hit model of endotoxin tolerance (ET) with peripheral blood mononuclear cells from healthy volunteers and in whole blood of septic shock patients. Importantly, we used quantitative-reverse transcription polymerase-chain reaction to monitor the effect of rIFN-γ on the expression of seven genes known to participate in ET (TNF-α, IL-10, HLA-DRA, CIITA, IRAK-M, ABIN-3 and LY64).
Expression analysis of those genes confirmed the presence of an immunosuppression state and the ex vivo restoration of immune functions by rIFN-γ. We show for the first time that rIFN-γ is able to bypass, at the mRNA level, the effect of negative regulators of the LPS signalling pathway such as IRAK-M, ABIN-3 and LY 64.
Overall, mRNA expressions of a panel of genes could represent promising candidates for the ex vivo evaluation of rIFN-γ effect on monocyte functionality. This ex vivo translational research study demonstrates the potential of a mRNA-based approach to successfully monitor drug efficacy.
Despite advances in supportive care and a number of clinical trials, sepsis remains the leading cause of death in non-coronary ICUs .
With a better understanding of the pathophysiology of sepsis, it is now evident that the early pro-inflammatory phase of the disease is immediately followed by an anti-inflammatory response that rapidly results in an immunosuppressive state. Immunosuppression is believed to be responsible for the increased risk of nosocomial infections and mortality [1–3] and represents an innovative target for future clinical trials. Current challenges consist of finding appropriate immunostimulant drugs, identifying patients that would benefit from immunomodulatory therapies (tailored immunotherapy) and monitoring successful response to treatment. As suggested by Carlet et al. , the development of biological models representative of the immunosuppressive state of the disease and the use of biomarkers may facilitate testing of immunostimulant drugs and the monitoring of response to treatment.
Among other alterations, sepsis-induced immunosuppression is characterized by dramatic monocyte/macrophage dysfunctions [1–3, 5]. The intensity of such dysfunctions has been correlated with an increased risk of death and nosocomial infections in septic patients. Interestingly, these alterations have been partly reproduced in an ex vivo model of endotoxin tolerance (ET). Indeed, ex vivo prior exposure of innate immune cells to minute amounts of endotoxin causes a temporary insensitivity and renders cells refractory to subsequent lipopolysaccharide (LPS) challenge [6, 7]. As observed in patients, this phenomenon is associated with monocyte/macrophage functional alterations, including a reduction in the production of pro-inflammatory cytokines associated with an increased expression of anti-inflammatory cytokines [6–10] and a decrease in antigen presenting capacity partly due to a reduced HLA-DR expression [11–15]. Moreover, LPS unresponsiveness is associated with the upregulation of numerous mechanisms that negatively regulate toll-like receptor (TLR)-associated signaling pathways [6, 7].
In this study we evaluated in an ex vivo experimental model of ET the potential of an immunostimulating therapy (recombinant Interferon (IFN)-γ) that has been proposed as a potential innovative treatment for sepsis [11–13]. Importantly, and as a proof of concept, we monitored response to treatment through the expression level of genes that have been shown in the literature to be involved in ET (TNF-α, IL-10, HLA-DRA, CIITA, LY64, IRAK-M and ABIN-3). Using gene expression analysis we confirmed the inflammatory properties of rIFN-γ. More importantly, restoration of ET-induced monocyte dysfunction by rIFN-γ was found in clinical samples from septic shock patients.
Materials and methods
Preparation of PBMCs and experimental settings of ET model
Functional testing by ELISA
Detection of TNF-α and IL-10 concentrations in PBMCs culture supernatants was done by using commercially available ELISA kits from R&D System (Minneapolis, MN, USA).
RNA extraction and cDNA synthesis by reverse transcription
Total RNA was extracted from PBMCs using RNeasy Plus Mini kits (Qiagen, Hilden, Germany) or from whole blood using QIAamp RNA Blood Mini Kit (Qiagen, Hilden, Germany). For each RNA extraction, the residual genomic DNA was digested using the gDNA Eliminator spin column (Qiagen, Hilden, Germany). RNA was diluted in 30 μl of elution buffer. RNA quantity was determined for each sample using a Qubit (Invitrogen, Carlsbad, CA, USA) according to the manufacturer's instructions. Then, cDNA was synthesized from 100 ng of total RNA using SuperScript® VILO™ system (Invitrogen, Carlsbad, CA, USA) according to manufacturer's instructions.
Quantitative PCR analysis
Quantitative PCR performance, parameters and primers
Septic shock patients and whole blood model
The study group consisted of eight consecutive septic shock patients according to the diagnostic criteria of the American College of Chest Physicians/Society of Critical Care Medicine . Patients were admitted to the two participating ICUs (one medical, one surgical) of the Lyon-Sud University Hospital (Hospices Civils de Lyon, France). Septic shock was defined by an identifiable site of infection, evidence of a systemic inflammatory response manifested by at least two of the following criteria: a) temperature more than 38°C or less than 36°C; b) heart rate above 90 beats per minute; c) respiratory rate above 20 breaths per minute; d) white blood cell count above 12,000 cells/mm3 or less than 4,000 cells/mm3 and hypotension persisting despite fluid resuscitation and requiring vasopressor therapy. The onset of septic shock was defined by the beginning of vasopressive therapy. The only exclusion criteria were patients younger than 18 years old and the absence of circulating leukocytes. Patients were treated according to the standardized recommendations of our ICUs. Severity at the onset of shock was assessed by the Simplified Acute Physiology Score II (SAPS II, range: 0 to 194) . Development of organ dysfunctions was assessed by the Sequential Organ Failure Assessment score (SOFA, range: 0 to 24) measured after 24 hours of ICU stay .
EDTA whole blood was collected from eight patients within three days after the onset of shock and from eight healthy volunteers. After centrifugation and removal of plasma, 3 ml of blood was diluted 1:1 with 3 ml of RPMI 1640 medium (Eurobio, Courtaboeuf, France) and then cultured in presence or absence (control group) of 100 ng/ml LPS +/- 100 ng/ml rIFN-γ1b (Imukin, Boehringer, Ingelheim, Austria) overnight at 37°C and 5% CO2 (15 hours). For each condition, supernatants and cell pellets were recovered and stored at -80°C for TNF-α measurement by ELISA and at -20°C for RNA extraction and quantification by qRT-PCR, respectively, as described previously in this manuscript.
Flow cytometry on peripheral blood from patients
Flow cytometric (FC500, Beckman-Coulter, Hialeah, FL, USA) expressions of cell surface markers was assessed on EDTA-anticoagulated peripheral blood from patients. Monoclonal antibodies and their respective isotype controls were used according to manufacturer's recommendation: PE-labeled anti-HLA-DR (Becton Dickinson-Pharmingen, San Jose, CA, USA), FITC-labeled anti-CD14, ECD-labeled anti-CD4, PE-labeled anti-CD127, PECy5-labeled anti-CD25 (Immunotech, Marseille, France). Red blood cells were lysed using the automated TQ-Prep lysing system (Beckman-Coulter, Miami, FL, USA) in the case of Treg measurement or using FACS lysing solution (Becton Dickinson-Pharmingen, San Jose, CA, USA) for HLA-DR. Results are expressed as percentages of CD4+CD25+CD127- cells out of the total CD4+ lymphocytes and as percentages of cells expressing HLA-DR among total monocyte population. This work belongs to a global study on ICU-induced immune dysfunctions. It has been approved by our Institutional Review Board for ethics which waived the need for informed consent because biomarkers expression was measured on residual blood after completing routine follow-up. This study is registered at French Ministry of Research and Enseignement (#DC-2008-509). It is also recorded at the Comission Nationale de l'Informatique et des Libertés.
Results were expressed as mean ± standard deviation. Statistical analysis was performed using the non-parametric Wilcoxon paired test for comparison between culture conditions or using the Mann Whitney U-test for comparison between septic patients and healthy volunteers. A P value less than 0.05 was considered significant with correction by the number of analyses performed.
Description of the model of endotoxin tolerance (ET)
Models of ET have been characterized by a reduction of TNF-α production associated with an increase in IL-10 secretion following a secondary stimulation with LPS. These cytokines were therefore measured in healthy volunteers' PBMCs supernatant after two challenges with LPS (primed cells) in comparison with cells that were only stimulated with LPS at 100 μg/ml (unprimed cells - Figure 1a). As expected, in response to a second LPS challenge, LPS-primed cells released less TNF-α (58.5 ± 68.3 pg/mL) than unprimed cells (1208 ± 594 pg/mL) and produced more IL-10 (63.2 ± 58.2 vs 8.4 ± 6.9 pg/mL in unprimed cells) (Figure 1b). These results were confirmed at the mRNA level (Figure 1c).
Therefore, this inability to produce TNF-α combined with an increase of IL-10 production in response to a secondary endotoxin challenge in LPS-primed cells confirmed the development of an ET state in our model.
rIFN-γ significantly improves TNF-α production in LPS-deactivated PBMCs
Recombinant IFN-γ has been proposed as a potential immunostimulating therapy in septic shock or trauma patients and preliminary clinical trials have provided encouraging results [11–13]. Therefore, we tested the effect of this drug in our model of ET.
In addition, we monitored by qRT-PCR the expression of five genes described in the literature to be involved in the ET refractory state or sepsis-induced immunosuppression (HLA-DRA, CIITA, IRAK-M, ABIN-3, and LY64) . Our results showed that, in LPS-primed cells, rIFN-γ induced a significant up-regulation of HLA-DRA and CIITA mRNA expressions (Figures 4c and 4d) associated with a significant decrease in the expression level of IRAK-M, ABIN-3 and LY64 (Figures 4e to 4g).
rIFN-γ effect on septic shock patient's whole blood
Demographic and clinical data for septic shock patients
Patients (n= 8)
Age at admission (years)
SAPS II score
% HLA-DR + monocytes
% of regulatory T cells (among CD4+ lymphocytes)
Number of lymphocytes (103/μl)
Sampling time (Days after shock)
It is now largely accepted that sepsis is characterized by the development of profound immune dysfunctions [1, 2, 23]. Such alterations could explain patients' inability to fight the primary bacterial infection and their decreased resistance to secondary nosocomial infections. As a consequence, sepsis-induced immune dysfunctions may contribute largely to mortality. Among mechanisms responsible for this immunosuppression, monocyte dysfunction, generically called ET, is believed to play a pivotal role [2, 6, 7, 24]. Clinically, the state of ET is associated with functional and phenotypic alterations of circulating monocytes. It has been demonstrated that patients with the most severe monocyte dysfunctions are those who have a greater risk of developing nosocomial infections and a greater risk of dying [14, 15, 25]. Overall, these observations provide a rational for the development of novel therapies aimed at boosting the immune functions in septic patients.
ET can be partly mimicked ex vivo when cells from healthy volunteers are activated by sequential LPS challenges [24, 26, 27]. Here, we took advantage of this model to investigate the effects of a pro-inflammatory drug, rIFN-γ, which previously provided interesting preliminary results in small clinical studies [11–13]. We assessed ex vivo drug effect through the monitoring of the expression level of a panel of seven genes (i.e. TNF-α, IL-10, HLA-DRA, CIITA, IRAK-M, ABIN-3 and LY64).
In the present experiments, we observed that rIFN-γ restored ex vivo the production of the pro-inflammatory cytokine TNF-α, therefore reflecting monocyte function improvement. We observed an increase in the expressions of TNF-α, HLA-DRA and CIITA mRNA following rIFN-γ treatment in our model of ET. Importantly, a similar increase in the expression of those genes was also observed in the whole blood of septic shock patients upon ex vivo rIFN-γ challenge. Our data are in agreement with previous literature [9, 11]. The positive effect of rIFN-γ could be explained, in part, by the ability of IFN-γ to enhance NF-κB nuclear translocation in response to LPS  and to induce recruitment of transcription factors. Restoration of the accessibility to endogenous promoters, in part by facilitating TLR-induced chromatin remodeling , may also explain the positive effect of rIFN-γ on monocyte functionality.
Regarding the negative regulators of LPS signaling pathway, we observed, in our model of ET, an increase in the mRNA expression level of IRAK-M and ABIN-3. It is important to note that these results are in agreement with previous reports [29, 30]. However, to our knowledge, we show for the first time that rIFN-γ induced ex vivo a restoration of the TLR signaling pathway, by decreasing both IRAK-M and ABIN-3 mRNA expression levels. Such variation in gene expression induced by rIFN-γ might add to the understanding of cell function recovery. In this model of ET, LY64 gene expression, which is also a TLR4 signaling pathway regulator, was decreased as well in the presence of rIFN-γ. The exact role of LY64 on TLR signaling pathways is not yet clearly established [25, 31] and additional experiments are needed to further address this point.
Regarding the effect of rIFN-γ on IL-10 expression, we observed discrepant results between the ET model on healthy PBMCs and the ex vivo stimulation in whole blood of septic patients. Indeed, at the protein and mRNA levels, rIFN-γ did not result in a decrease of IL-10 in LPS-deactivated PBMCs. In a similar experimental model, Randow et al. showed an increase in the IL-10 production in refractory cells exposed to IFN-γ . In contrast we found that the IL-10 gene was down-regulated by rIFN-γ in whole blood cells from septic shock patients. These results are in agreement with Nakos et al. who observed that the administration of inhaled IFN-γ in immunoparalyzed patients resulted in an increase of pro-inflammatory markers and a decrease of anti-inflammatory molecules like IL-10 .
Importantly, this study highlights the potential of using gene expression analysis to identify novel biomarkers that could contribute to a more personalized medicine. It is now well established that biomarkers will be useful (i) to identify patients eligible for immunomodulatory therapies, (ii) to monitor response to treatment, and (iii) to evaluate benefit/risk ratio. So far, flow cytometric measurement of HLA-DR expression on circulating monocytes has appeared as a reliable biomarker for the prediction of death and nosocomial infections in septic patients [14, 15, 32]. Small clinical trials have used this parameter to stratify ICU patients before administration of rIFN-γ [11, 13]. However, pre-analytical and analytical issues inherent to HLA-DR measurement by flow cytometry limit its use in large multicentered clinical studies and on a routine basis . Based on the results of the current study and on previous investigations showing the correlation between mRNA and protein expression levels for this parameter [32, 34], HLA-DR and CIITA mRNA measurements appear as promising gene candidates for the monitoring of response to immunomodulatory therapies. This is all the more because the availability in routine labs of molecular biology platforms will enable standardized and routine use of such biomarkers.
In total, given that gene expression profiling is now recognized to offer meaningful data, it provides a new perspective in the prognosis and monitoring of septic patients and offers the foundation for possible automated tests with standardized methodologies. As an example, based on microarray data, Pachot et al. identified the loss of CX3CR1 as a new feature of sepsis-induced immunosuppression [25, 35]. Wolk et al. observed that a reduction of CD86 mRNA expression level coupled with a low HLA-DR level is associated with an unfavorable prognosis in ICU patients with post-inflammatory immunodeficiency . Recently, Hinrichs et al. followed the expression level of 23 mRNAs related to inflammation in patients after surgery . They showed that TNF, IL1-β, CD3D and PRF1 gene expressions were significantly different in patients who developed postoperative sepsis in comparison with patients who recovered uneventfully. In addition, their results demonstrate that the combination of TNF, IL1-β and CD3D mRNA expression levels is able to predict secondary infections with an extremely good area under the curve of 0.92.
Our study has some limitations. First, as mentioned previously, seminal studies of immunostimulatory therapy in sepsis have shown that patients'stratification by their relative immunoparalysis, as evidenced by low circulating HLA-DR monocytes could improve treatment efficacy [11, 13]. As this preliminary study was designed as a proof of concept to monitor response to ex vivo rIFN-γ through the expression level of genes, this parameter, although included in the analysis, was not a criterion for patients' inclusion. Nevertheless, at the time of sampling, mHLA-DR expression in patients was decreased in comparison with normal values (Table 2). In further studies investigating this aspect, stratification based on mHLA-DR expression should be performed and it should be investigated whether ex vivo rIFN-γ effect is more important in patients with low mHLA-DR expression. Second, the comparison between results in whole blood and in the model of ET shows some discrepancies. Without mentioning the difference in cell subpopulations, it is obvious that the mechanisms involved in monocyte dysfunctions partly differ between the two models. Indeed, ex vivo model of endotoxin tolerance uses only LPS to induce monocyte alterations whereas, in septic patients, many more parameters (IL-10, cortisol, treatments...) have been shown to impact monocyte functionality. This could explain differences between results obtained in ET model and in whole blood experiments. With that said, overall our results remain consistent between the two models.
As sepsis-acquired immunosuppression appears associated with increased risk of death and of nosocomial infection, immunostimulatory approaches able to restore cell dysfunctions represent innovative and promising therapeutic strategies. In this study, we propose to follow the expression levels of a panel of genes to assess ex vivo monocyte-stimulating drug efficacy. The value of such biomarker panel deserves now to be evaluated in a large cohort of patients.
Recombinant human IFN-γ increases TNF-α, HLA-DRA and CIITA mRNA expression levels in an ex vivo model of ET and in cells from septic shock patients.
Recombinant human IFN-γ decreases IRAK-M and ABIN-3 mRNA expression levels in an ex vivo model of ET.
This ex vivo translational research study demonstrates the potential of a mRNA-based approach to successfully monitor drug efficacy.
enzyme-linked immunosorbent assay
peripheral blood mononuclear cells
peptidylpropyl isomerase B
quantitative reverse-transcription polymerase chain reaction
- SAPS II:
simplified acute physiology score II
Sequential Organ Failure Assessment
tumor necrosis factor.
This work conducted thanks to the logistical support (H. Vallin) of the Centre d'Investigation Clinique (Clinical Research Center) of Inserm and Hospices Civils de Lyon. We would like to thank A. Portier and A. Villars-Mechin for their technical support. This project is part of Advanced Diagnostics for New Therapeutic Approaches, a program dedicated to personalized medicine, coordinated by Mérieux Alliance and supported by the French public agency, OSEO. GM, FV and AL are supported by the Hospices Civils de Lyon. GM is also supported by French ministry of health (PHRC interregional 2008) and DGOS-INSERM (Recherche clinique translationnelle 2009).
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