age & gender related septic complications in trauma patients:
DESCRIPTION
LBI Trauma. Age & gender related septic complications in trauma patients: individually tailored treatment during posttraumatic phase. M. Osuchowski/S. Bahrami. Ludwig Boltzmann Institute for Experimental and Clinical Traumatology AUVA Trauma Research Center Vienna, Austria. - PowerPoint PPT PresentationTRANSCRIPT
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Age & gender related septic complications in trauma patients: individually tailored treatment during posttraumatic phase
M. Osuchowski/S. Bahrami
LBI Trauma
Ludwig Boltzmann Institute for Experimental and Clinical Traumatology
AUVA Trauma Research CenterVienna, Austria
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Ludwig Boltzmann Institute for Experimental und Clinical Traumatology Head:
Heinz Redl
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http://www.my-ibook.net/browser/piclins/piclins_publick/gallery.html
One Disease, Many Faces...>>Differential Host Response<<LBI Trauma AUVA
SIRS
Systemic Inflammatory Response Syndrome
MARS
Mixed Anti-inflammatory Response Syndrome
CARS
Compensatory Anti-inflammatory Response Syndrome
Pulmonary
Gastro-intestinal
Genito-urinary
Blood
skin
CNS
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Risk factors in Sepsis
Gender
Age
LBI Trauma AUVA
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Humanimmuno-
inflammatory system
Age-relateddifferences
Gender-relateddifferences
Our Starting PointLBI Trauma AUVA
plasminogen activator inhibitor 1 gene (PAI-1)
Interferon gamma-induced protein 10 gene (CXCL10/IP-10)
Olfactomedin 4 gene (OLFM4)
Secretory phospholipase A2 gene (PLA2G2A)
Characterization and Targeted Therapyagainst Sepsis
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Incidence and mortality rate of sepsis increase with age
Martin et al. Crit Care Med, 2006
LBI Trauma AUVA
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Schroeder et al. Arch Surg, 1998
Unclear Gender Benefits
ICU Mortality
Sepsis subgroup
LBI Trauma AUVA
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LBI Trauma AUVA
Human Physiology
?Far from ideal…
Mouse Physiology
lymphocyte rich blood neutrophil rich blood LPS-induced NO release by macrophages - yes
LPS-induced NO release by macrophages - no
BALT presence - strong BALT presence - absent
different IgG and IgA isotypes/subtypes
caspase 10 - no caspase 10 - yes MHC II on T cells - no MHC II on T cells - yes
≠
Mestas & Hughes. J Immunol. 2004
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AUVAEstablishing a Relevant Mouse ModelLBI Trauma
Vincent JL et al., Crit Care Med, 2006
Tien H et al., Cur Orthopedics, 2004
ICU
35% developing secondary Sepsis
27% mortality in septic patients
Trauma + Hemorrhagic Shock
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• 2nd hit – Sepsis – Semilethal Cecal ligation and puncture (CLP)
• Outbred mice, 3 age groups (3, 15, 20M), analgesia, fluid resuscitation, antibiotics
• 1st hit – Trauma/Hemorrhagic Shock (TH)– Femur fracture with local tissue damage– Sublethal hemorrhage
-48 -24 0 24 48 72 96
TH CLP
Pre-CLP Post-CLP
blood sampling
Hours6-48 -24 0 24 48 72 96
TH CLP
Pre-CLP Post-CLP
blood sampling
Hours6
Establishing a Relevant Mouse ModelLBI Trauma AUVAEstablishing a Relevant Mouse ModelLBI Trauma AUVAEstablishing a Relevant Mouse ModelLBI Trauma
Drechsler et al. J Biomed Biotechnol 2011
Serious glitch:AUP only after 12 months!
Wichmann et al., J. Surg 1996;Gentile et al., CCM 2013
Immunosuppression
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– Inflammatory Cytokines• KC (CXCL-1), MIP-1α, TNFα, MCP-1, IFNγ, IL-1β,IL-5, IL-6, IL-10
– Complete Blood Count• Red blood cells (RBC), hemoglobin (Hb), platelets (PLT), white blood
cells (WBC), neutrophils (NEU), lymphocytes (LYM)
– Circulating Organ Function Parameters• ALT, AST, LDH, Glucose, Urea
Repetitive daily low-volume blood sampling
Weixelbaumer et al. Shock 2010
20µl20
parametersIn total
Establishing a Relevant Mouse ModelLBI Trauma AUVA
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Survival post TH-CLP: young&females have advantage
0
20
40
60
80
10015fem3fem
20fem
Hours
CLP
-24-48 72 96 Day 160 24 48
% s
urvi
val
0
20
40
60
80
10015male3male
20male
CLP
-48 -24 0 24 48 72 96 Day 16Hours
% s
urvi
val
A BFemales Males
A steady approx. 20-30% inter-gender survival difference
Drechsler et al. Plos One 2012
LBI Trauma AUVA
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pre-CLP
A D
B E
C F
0.0
0.5
1.0345
24 3125 25
-48h (baseline)
28 283m 3m 15m 15m 20m 20m
infla
mm
ator
y sc
ore
0.0
0.5
1.0345
12 12 22314 11 7 18
-48h (baseline)
208 269
3m 3m 15m 15m 20m 20m
infla
mm
ator
y sc
ore
0
1
2
3
4
5
51 4925 25
-24h
*
27 28
3m 3m 15m 15m 20m 20m
femalemale
infla
mm
ator
y sc
ore
0
1
2
3
4
5
24 27 9 4014 11 7 18
*-24h
0.05
8 19 2 26
3m 3m 15m 15m 20m 20m
SURDIE
infla
mm
ator
y sc
ore
0
1
2
3
4
5
54 5125 25
0h
0.06
29 26
*
3m 3m 15m 15m 20m 20m
infla
mm
ator
y sc
ore
0
1
2
3
4
5
28 25 9 4214 11 7 18
0h
8 21 2 24
3m 3m 15m 15m 20m 20m
infla
mm
ator
y sc
ore
Inflammatory score Organ function score
0
1
2
3
4 -48h (baseline)
80 5233 25 32 293m 3m 15m 15m 20m 20m
orga
n fu
nctio
n sc
ore
0
1
2
3
4
12 12 22314 11 7 18
-48h (baseline)
208 269
3m 3m 15m 15m 20m 20m
orga
n fu
nctio
n sc
ore
0
1
2
3
4
79 5043 25
-24h
31 29
*
3m 3m 15m 15m 20m 20m
femalemale
orga
n fu
nctio
n sc
ore
0
1
2
3
4
24 27 9 4014 11 7 18
-24h
8 19 2 26
3m 3m 15m 15m 20m 20m
SURDIE
orga
n fu
nctio
n sc
ore
0
1
2
3
4
80 5225 25
0h
31 293m 3m 15m 15m 20m 20m
orga
n fu
nctio
n sc
ore
0
1
2
3
4
28 25 9 42 14 11 7 18
0h
8 21 2 24
3m 3m 15m 15m 20m 20m
orga
n fu
nctio
n sc
ore
A
B
C
D
E
F
DIE vs. SUR DIE vs. SUR
Only marginal age/gender differences after TH
Drechsler et al. Plos One 2012
LBI Trauma AUVA
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Pre-CLP: Individual cytokines in 15m♂
0
200400
600800
1000 MIP-1a* *
-24h 0h
pg/m
l0
500
1000
1500 IL-5*
-24h 0h
SURDIE
pg/m
l
0
2000
4000
6000
8000 IFN-g*
-24h 0h
pg/m
l
SUR vs. DIESeptic outcomes can be hardly
predicted based on the TH response
Drechsler et al. Plos One 2012
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Post-CLP: Gender/age did not greatly affect magnitude of pre-lethal cytokine responses
Drechsler et al., PlosONE, 2012
0
2
4
6
8
10
314224 24
24h
*
*
19 22
femalemale
3m 3m 15m 15m 20m 20m
infla
mm
ator
y sc
ore
0
2
4
6
8
10
18 13 6 3614 10 8 11
24h
* * *
** *
202816
3m 3m 15m 15m 20m 20m
DIESUR
LBI Trauma
AUVA
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0
1
2
3
4
508242 23
6h
31 273m 3m 15m 15m 20m 20m
femalemale
orga
n fu
nctio
n sc
ore
0
1
2
3
4
23 19 7 16 31 51 11 39
6h
8 23 2 25
3m 3m 15m 15m 20m 20m
SURDIE
orga
n fu
nctio
n sc
ore
0
1
2
3
4
466941 25
24h
21 223m 3m 15m 15m 20m 20m
orga
n fu
nctio
n sc
ore
0
1
2
3
4
24 17 7 18 29 40 11 13
24h
202835
**
3m 3m 15m 15m 20m 20mor
gan
func
tion
scor
e
0
1
2
3
4
335437 21
48h
16 123m 3m 15m 15m 20m 20m
orga
n fu
nctio
n sc
ore
0
1
2
3
4 48h**
* * * *
24 13 7 14 25 29 11 8 102822
3m 3m 15m 15m 20m 20m
orga
n fu
nctio
n sc
ore
A
B
C
D
E
F
Post-CLP: Gender/age did not affect magnitude of pre-lethal organ function responses
0
1
2
3
4
24 13 7 14 25 29 11 8
48h
102822
*** * * *
3m 3m 15m 15m 20m 20m
orga
n fu
nctio
n sc
ore
DIESUR
AUVA
LBI Trauma
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Summary of Findings:
Drechsler et al. Plos One 2012
LBI Trauma AUVA
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n=32 n=20 n=24 n=363 n=168 n=242
No „menopause“ in CD-1 mice
Weixelbaumer et al. almost (??) accepted in SHOCK
LBI Trauma AUVA
R. Palme & A. Tichy
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Vaginal cytology did not reflect concentration of systemic fecal estrogens
No correlation between cycle phases & fecal estrogen:
r=-0.117 in 3M; r=0.026 in 15M r=0.112 in 20M
LBI Trauma AUVA
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On 15.09.2011, the breeder pulled the plug…
EUR 53/15M old mouse EUR 160/mouse
LBI Trauma AUVA
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-24h 0h 24h
CLP
48h
Acute sepsis (days 1-5)
Anti-PAI-1siRNA(0.1 & 10uM/mouse)
I.P.I.V.
PAI-1In blood
PAI-1in blood
&lavage
fluid
proteinexpression
Liver, kidneys, lungs, heartgene
expression
VEH SCRsiRNA 10siRNA0
200
400
600
800
1000
1200 PAI-1 48h post-CLPPilot 1 and 2
P=0.06
n=10 n=10n=8
downregulation of PAI-1 in the heart/liver at 48h
LBI Trauma AUVAsiRNA drama unfolding...
4 transfection reagents tested:• Invivofectamine• DOTAP• Virus Like Particle (VLP)• jetPEI• PEI-25-LMW
in heatlhy and CLP mice:• anti-PAI-1• anti-VEGF
-48h-72h
• extended treatments,• different doses,• different N/P ratios
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Never a reproducible k/o effect achieved
4 transfection reagents tested:• Invivofectamine• DOTAP• Virus Like Particle (VLP)• jetPEI• PEI-25-LMW
in heatlhy and CLP mice:• anti-PAI-1• anti-VEGF
• extended treatments,• different doses,• different N/P ratios
hemorrhagic necrosis
ischemic necrosis
liver intestine
effective PEI-mediated systemic AF680 siRNA delivery
LBI Trauma AUVALarge Biodystribution Study:
Achim Aigner Heiko ManingaRichard Hotchkiss
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LBI Trauma AUVAScramblin’ to stay afloat…
got scooped up… ouch!
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PAI-1 is increased in septic non-survivors
Shapiro et al. Crit Care 2010
dying
survivors
PAI-1 (ng/ml)
Septic patientsLBI Trauma AUVA
CLP mice
Raeven et al. PLoS ONE 2013
dying
survivors
**
0 24 48 720
1000
2000
3000
6Hours post CLP
ng/m
l
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Effects of anti-PAI-1 Co-Treatment in CLP Sepsis
PAI-1 ELISA
healthy MA-Control MA-MP6H60
100
200
300
400
CLP - + +
*
activ
e PA
I-1 (n
g/m
l)
Partial Neutralization of Plasma PAI-1
-73%
0 10 20 30 400
3
6
9
12
2 4
**
plasma dilution (fold)di
amet
er (m
m)
Fibrin Plate Assay
CLP + MA-MP6H6
healthyCLP + MA-Control
Full Restoration of early Fibrinolysis
Raeven et al. Crit Care 2012
LBI Trauma AUVA
Paul Declerk
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Inhibition of Mouse PAI-1: no benefit in all-inclusive population
0 1 2 3 4 5 6 70
20
40
60
80
100
7 14 21 28
MA-MP6H6 (n=15)MA-Control (n=14)
p = 0.51
co-treatment Days post CLP
Perc
ent s
urvi
val
0 1 2 3 4 5 6 70
20
40
60
80
100
7 14 21 28
MA-MP6H6 (n=10)MA-Control (n=10)
18hpost-treatment
Days post CLP
Perc
ent s
urvi
val
0 1 2 3 4 5 6 70
20
40
60
80
100
7 14 21 28
MA-MP6H6 (n=23)MA-Control (n=23)
p = 0.34
30hpost-treatment
Days post CLP
Perc
ent s
urvi
val
Co-treatment
18h post-treatment 30h post-treatment
17%
14%
Raeven et al. Crit Care 2012
LBI Trauma AUVA
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CLP
24h 30h 48h 72h 96h 28day
IL-6 as predictor
predicted to DIE
predicted to LIVE
Stratification (IL-6 cut-off 14 ng/ml)
Treatment:Anti-PAI-1 ab
(i.p., 10 mg/kg b.w.)
50% treated (T)
50%Treated (T)
50% not-treated (NT)
50%not-treated (NT)
Treatment
Targeted anti-PAI-1 treatment CLP sepsis
Raeven et al. J Throm Homeastasis 2013 - submitted
LBI Trauma AUVA
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Detrimental effect of PAI-1 inhibition
29%
0
20
40
60
80
100
0 1 2 3 4 5 6 7 7 14 21 28
P-DIE + MA-MP6H6 (n=9)P-DIE + MA-Control (n=10)
P-SUR + MA-MP6H (n=14)P-SUR + MA-Control (n=13)
p = 0.02
p = 0.04
30hpost-treatment
Days post CLP
Perc
ent s
urvi
val
Two-tailed test
Retrospective stratification (3.3 ng/ml IL-6 cut-off)
Raeven et al. Crit Care 2012
LBI Trauma AUVA
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P=0.15
Only a neg. trend after prospective stratification
Low 3.3 ng/ml cut-offMA-Control-treatedP-SUR started dying!
LBI Trauma AUVA
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pLIVE plasmid DNA (Mirus Bio Co.)
Wooddell et al. J Gene Med, 2008
+ full-length mouse PAI-1 cDNA
Trying the other end: Overexpressing PAI-1 in the liver
M.-C. Alessi/D. Bastellica
LBI Trauma AUVA
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-72h
MICE ( , CD-1, 3 months ♀old)
Overexpressing PAI-1: the design
Hydrodynamic i.v. delivery
pLIVE.PAI-150µg
pLIVE empty50µg
-48h
-24h
0h
17G cecal ligation & puncture (CLP)
24h
d28
daily observation
facial vein20-30µl
1:10 dilution
Complete blood count
Active PAI-1 (ELISA) plasma
pellet
Organ function parameters
LBI Trauma AUVA
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Gene over-expression increases plasma PAI-1…
p=0.02
2-fold
*
n=10N=22
mean ± s.e.m.
LBI Trauma AUVA
n=12
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… but does not affect CLP survival
p = 0.73
0 7 14 21 280
20
40
60
80
100
LBI Trauma AUVA
pLIVE Empty (n=10)pLIVE PAI-1 (n=22)Restoration of fibrinolysis in early sepsis
does not help and appears to harm
Liver specific PAI-1 over-expression priorto the onset of sepsis has no effect
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WWTF Grant Summary:Major Obstacles/Mistakes
• Overloaded grant plan: almost no slack for “s..t happens”
• Overconfidence on (untested) siRNA: total failure of the in vitro to in vivo translation (a grant on its own!)
Our Bad Judgement:
• Delayed AUP: 12 month of burning time/resources
Bad Luck:
• The price hike on aged mice: implosion of the budget
LBI Trauma AUVA
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LBI Trauma AUVA
10 direct papers (+1 review) published/under review/ in writing
WWTF Grant Summary:Output/Visibility
16 conference contributions (published)
11 Travel Awards and/or Invited Oral Talks to the team
Qualified twice to New Invest. Award C. at 2011/13 ESS
Best Abstract Award at 2012 Intrl Sepsis Forum
Pierre won the 2012 ASS 5k Presidential Run!
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WWTF Grant Summary:Other Positives
LBI Trauma AUVA
we pulled through & stayed afloat – Hail to the team!
strong international network – 7 partners
all students graduated with distinction,major career advances to participants
Paul Declerk
R. Palme & P. Schmidt
M.-C. Alessi/D. Bastellica
Achim Aigner
Heiko Maninga
Richard Hotchkiss
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LBI Trauma AUVA
The heck of an experience, no doubt!
2008
2013
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Special thanks to M001, M002, M003, M004,
M005, M006, M007, M008 M009…, …M749, M750, M751, M752, M753, M754, M755, M756, M757, M758 M759, M760, M761, M762, M763, M764, M765, M786, M787, M788, M789, M790, M791, M792, M793, M794, M795, M796, M797, M798, M799, M800, M801, M802, M803, M804, M805, M806, M807, M808, M809, M810, M811, Ect...
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Soheyl Bahrami-IC Dept. Head and co-PI
Heinz Redl –LBI Head
Thank you! – questions?
Paul
Christina
Anna
Pierre
Kathrin
PiaTony
…and manyotherLBI
employeeswho helped!
Georg
Martijn
Michaela
Mohammad
Suzy
Ewa