Anda di halaman 1dari 59

Inflammation

Cell and Molecular Basic of


Sepsis, SIRS, and MODS
Edi Widjajanto
DR., dr., MS., Sp PK (K)

Bagian Patologi Klinik


FK Unibraw RS Dr Saiful Anwar, Malang
Program Studi Biomedik Pascasarjana, Unibraw

Tema Basic Science in Septicaemia


Pertemuan Ilmiah Berkala XVI, Proyek Trigonum Plus,
Program Studi Ilmu Bedah FK Unibraw, Unair, Unud, Undip, Unhas, Unsrat, UNS, UGM
EdiW_Inflammation
BioMol 2004

Malang (Batu), 9 11 April 2004

Definition

Inflammation is complex reactions


in vascularized tissue (response)
to

injurious agent.

Protective response, however

potentially harmful.
EdiW_Inflammation
BioMol 2004

Cotran RS, et al., (1994). Robins Pathologic Basis of Disease

Injurious agent of inflammation


Inflammation
Bacteriemia
Other

Infection
Fungemia

Sepsis

SIRS
Trauma

Parasitemia

Burn

Viremia
Other
Blood borne infection
EdiW_Inflammation
BioMol 2004

Pancrea
titis

3
Chong D. Sepsis Syndrome. Down load. January, 2003

Interrelationships of terminology used in


defining the continuum of events leading to septic shock

Injury

Infection

Inflammation
SIRS
Organ
failures

MODS

Sepsis
Hypo
tension

Septic shock

SIRS, systemic inflammatory response syndrome; MODS, multiple organ dysfunction syndrome
EdiW_Inflammation
BioMol 2004

4
Baselki VS, et al., (1999). Septic Shock. In (Davis BG., et al. Eds)
Principles of Clinical Laboratory Utilization and Consultation

Clinical aspect of
(acute) Inflammation;

Sepsis
Septic shock
SIRS
MODS

Cell & Molecullar


aspect of Inflammation
EdiW_Inflammation
BioMol 2004

Transcription
factors

EdiW_Inflammation
BioMol 2004

Transcription
Apparatus

EdiW_Inflammation
BioMol 2004

1st messenger
system (ligand):
Hormon, Cytokine
Chemokine, etc

Between cell
communication

2nd messenger system


(Ca, enzyme, etc)

Transcription
factors TF

Within cell
communi
cation

Nucleus

Biologic effectors system


Enzyme, mediators (cytokine,
chemokine), etc

Biologic response

Cell activation, growth,


movement, apoptosis, etc
EdiW_Inflammation
BioMol 2004

EdiW_Inflammation
BioMol 2004

Injurious agent
Mitochondria

Ca2+

Ca2+

Endoplasmic
reticulum
Ca2+

Cytosolic Ca

ATPase
ATP

Phospho
lipase

Protease Endonuclease

Phospho Membrane,
lipid
Cytoskleton
disruption

EdiW_Inflammation
BioMol 2004

Nuclear
Chromatin
damage

Infection
Non-Infection
ROS (Radicals)
[Ca] inbalance
[ATP]
Membrane defect

Cell activation
adaptation

Cell injury
Cell death
Apoptosis
Necrosis 10

Macrophage
Phagocyte
Port of entery,
perivascular
(wide distribution)
Innate immune cells
Inflammatory cells
Antigen Processing
(Presenting) Cells,
APC
[Target septic
inflammation]

EdiW_Inflammation
BioMol 2004

11

Macrophage-Phagocyte
Peri-vascular (sub endothelial)-wide distribution
Spleen 8 %
Bone Marrow
14 %

Kidney 5 %

Lung 3 %
Lymph nodes 3 %

Liver 21 %

Peritoneum 3 %
Gonads 2 %
Peyers patches 1 %

Bowel Intestinal
38 %
EdiW_Inflammation
BioMol 2004

Thymus 1 %
Adrenal 1 %
12
Weinberg 1998. Mononuclear Phagocytes

Mast cell, Macrophage, Endothelial cell,


and cytokines in (allergic) inflammation

Mast
M
Histamin
IL-6 IL-8
ECF,
NCF, BCF

Endothel
permiability

Eo

TNF
IL-1
ICAM-1
P-Selectin

EdiW_Inflammation
BioMol 2004

IL-4

Ly

VCAM
13
Church 1997

EdiW_Inflammation
BioMol 2004

14

EdiW_Inflammation
BioMol 2004

15

EdiW_Inflammation
BioMol 2004

16

EdiW_Inflammation
BioMol 2004

17

Host defense
system

Host Insult

Infectious agent, Trauma, Toxin,

Neoplasia, Autoimmunity

Neutrophil

Macrophage

System Response
Local & Systemic

Haemopoietic: Nonspecific, Immune


Metabolic: Liver
Endocrine: Pituitary, CNS

IL-1, TNF, Cytokine


Limfosit

Regulation:

Energy metabolism
Reduced blood fluidity
Autoaggression

Anorexia, Malaise, Sleep,


Brain switch off

Fever

Acute phase protein


Cell
rising:

Neutrophil,
Platelets

Cell
falling:

RBC, Lymph

Edi Widjajanto
EdiW_Inflammation
Ibister JP,
1990. Host defence failure.
BioMol
In (Oh TE, ed).2004
Intensive care manual.

Sickness Response

Plasma analytes rising:

Fibrinogen, F VIII, Fibronectin,


Complement,Haptoglobin, CRP,
Serum amyloid A, 2-macroglobulin,
1-chymotrypsin, 1-antitrypsin,
ceruloplasmin, Plasminogen

Plasma analytes falling:

Albumin, Iron, transferin, and lipoprotein

Inflammation
18

Healing

Macrophage
activation
Receptor
Activator
Functional
outcome

EdiW_Inflammation
BioMol 2004

19

Macrophage receptors
Seven helical transmembrane
receptors
Cytokine receptors

Toll-like receptor (TLRs)


Fc and complemen receptor
Mannose receptor
Phagocytic receptors

EdiW_Inflammation
BioMol 2004

Luas
spectrum inducer
macrophage

20

Phagocytes

receptors and functional response


Chemokines
N-formylmethionyl
peptides

Microbe
opsonized
with antibody

Microbe
Lipid
mediators LPS
CD14

Recoqnition
of microbes,
and mediators

Fc receptors
Toll-like
receptor

Seven helical
transmembrane
receptors

Increase
Integrin
avidity

Cellular
response

Mannose
receptor

Phagocytic
receptors

Cytosekletal Respiratory
changes
burst

Phagocytosis of
microbe into
phagosome

Reactive Oxygen
Intermediates

(ROIs)

Functional
outcomes

Adhesion to
endothelium

EdiW_Inflammation
BioMol 2004

Migration
into tissue

Killing of
microbes
21

Edi Widjajanto
Abbas AK, et al., (2000). Cellular and Molecular Immunology

Macrophage
activators

N formyl methionyl peptides


Cytokine
Chemokine
Lipid mediators

LPS (Lipopolysacharides)
Opsonin (Ig, Complemen)
Mannose

EdiW_Inflammation
BioMol 2004

22

Activated Macrophage

activation and effector functions


Microbe

IFN

LPS
CD14

IFN-R
Toll-like
receptor

AP-1, NF-B
Transcription factors

Cytokine
receptors
Active STAT-1
Transcription factors

Gene expression
Proteins
produced
Effector
function

Oxidase iNOS
ROIs
NO

Killing of
microbes

EdiW_Inflammation
BioMol 2004

Tissue
factors

Growth factors,
Angiogenic factors,
metaloproteinase

Cytokines
(TNF, IFN)

Thrombosis

Tissue
remodeling

Inflammation,
Adaptive immunity

MHC molecule
costimulators

Antigen
Presentation

Edi Widjajanto
Abbas AK, et al., (2000). Cellular and Molecular Immunology

23

Anti Inflamatory Cytokine:


IL4, IL10, IL13, TGF, IFN

ACTH

Hepato
cyte

* Fever *
Sleep
Anorexia

Adrenals
Gluco
EdiW_Inflammation
corticoid
BioMol 2004

M
Macrophage
IL1, TNF

IL6, IL11,
LIF, TGF

CNS

Triggering Signals
Activating Cytokines:
IFN, IL3, GM-CSF

Acute
Phase
Protein

Target
Cells
Protease, PAF,
Eicosanoids,
Free Radicals

Tissue

Endothel

Catabolism
Degradation
Necrosis
Proteolisis

Pro
coagulant
Permiability
Adherence

IL8, MCP

Inflamation
Edi Widjajanto

Chemo
24
attraction

LPS

Lipopolysaccharide

EdiW_Inflammation
BioMol 2004

25

EdiW_Inflammation
BioMol 2004

Edi Widjajanto
26

EdiW_Inflammation
Edi Widjajanto
BioMol 2004

27

LPS

Beneficial

Harmful

EdiW_Inflammation
BioMol 2004

Edi Widjajanto

28

EdiW_Inflammation
Edi Widjajanto
BioMol 2004

29

Toll-like Receptors
(TLRs)

Cakupan ligand luas


Variasinya luas (10 TLRs)
Distribusi sel luas
Variasi respon biologi luas
Berperan pada sepsis

EdiW_Inflammation
BioMol 2004

30

Toll-like Receptor Pathway


Lipopolysacharides

(BLP,PGN, LAM)

Tak 1

NIK

P IB
NFB

MEK 3
MEK 6

JNK 1

JNK 1

NFB

p 38
AP-1

ELK-1

Proinflammatory cytokines

IL12, IL6, TNF

Adaptive

Immune

EdiW_Inflammation
response
http://www.biocarta.com/
BioMol 2004
(Down load, January 2004)

TAB 1

Nucleus

IB

TAB 2

P MKK 4

MEKK 1

Cytoplasm

IRAK

TRAF 6

ESCIT

Extracellular

MYD88

IRAK

IKK1
IKK1
IKK1

T cells

TLR9

CD14

TLR4

MYD88

IRAK

MEKK1

TLR4

TLR2

TLR2

CD14

MD2

MYD88

Cell mediated
immunity

CpG-DNA

(LPS, LTA)

Mannans

TLR9

Lipoproteins

Apoptosis
of host cells

Bacterial
death

Antimicrobial
response

31
Macrophage, Dendritic,
Intestinal, Endothelial Cells

Toll-like Receptor Pathway

TLR 2: Lipoprotein
Mannans
TLR 3: RNA
TLR 4: Lipopoly
sacharide (LPS)
TLR 5: Bacterial flagelin
TLR 9: bacterial DNA
IRAK : IL-1 Receptor
Associated Kinase.
TRAF-6: TNF Receptor
Associated Factor 6.
TAK-1 : TGF- activating kinase.

EdiW_Inflammation
BioMol 2004

Edi Widjajanto
http://www.biocarta.com/
pathfiles/h_tollPathway.asp 32
(Down load, January 2004)

Biologic response
Cytokine-Chemokine

Pro-inflamatory:
TNF-, IL-1, IL-6, IL-12, IFN
Anti-inflammatory: IL-10, IL-4
Chemokine

Phagocytosis-Bacterial killing
Immune response
Innate-Specific
CMI-HMI

Cell death: Apoptosis

EdiW_Inflammation
BioMol 2004

33

Cytokines &
Chemokine

EdiW_Inflammation
BioMol 2004

34

EdiEdiW_Inflammation
Widjajanto
BioMol 2004

35

EdiW_Inflammation
BioMol 2004

Edi Widjajanto

36

TNF

EdiW_Inflammation
BioMol 2004

IFN

37

Edi EdiW_Inflammation
Widjajanto
BioMol 2004

38

TNFR-I

Edi EdiW_Inflammation
Widjajanto
BioMol 2004

Fas

Death
Domain

39

Apoptosis signaling
by CD95

Proapoptotic and antiapoptotic


signaling by TNFR1 and DR3

TNF

CD95L
CD95/

Fas/

Apo3L
DR3/
Apo3/
WsL1

TNFR1

Apo1

Caspase 8

IKK

Apoptosis

I-kB/NF-kB

EdiW_Inflammation
BioMol 2004 Science 281 (1998)

NF-kB

JNKK
JNK
c-Jun

Edi Widjajanto

DED

MEKK1?

DED

DED

DED

NIK

TRAF2

FADD

DD

TRADD

DD
DD

cIAP1/2

TRADD

DD
DD DED

RIP

DD

TRADD

DD DED
DD

FADD

DD
DD

DD DED

DD

DD DED

FADD

TRADD

RIP

NIK

IKK
Caspase 8

Apoptosis

I-kB/NF-kB
40

NF-kB

EdiW_Inflammation
BioMol 2004 Edi Widjajanto

41

Apoptosis by mitochondria

Cell Death
Triggers

Oxidants
Ceramide

Bax Ca2+

Caspase

Matrix swelling

Channels open

(Outer membrane rupture)

Inactive apaf-1
CED-4-like

(Outer membrane
mostly intact)

CARD

Cyto c

Active apaf-1

+
Other
Caspase
ROS activators

CED-4-like

ATP

Necrosis

Cyto c

L S

Caspase-9
Caspase activated

Apoptosis

EdiW_Inflammation Science 281 (1998)


BioMol 2004
, loss of electrochemical gradient across the inner membrane

42

Edi Widjajanto

Chemokine

EdiW_Inflammation

Edi BioMol
Widjajanto
2004

43

Mast cell, Macrophage, Endothelial cell,


and cytokines in (allergic) inflammation

Mast
M
Histamin
IL-6 IL-8
ECF,
NCF, BCF

Endothel
permiability

Eo

TNF
IL-1
ICAM-1
P-Selectin

EdiW_Inflammation
BioMol 2004

IL-4

Ly

VCAM

Edi Widjajanto

44
Church 1997

Hypothesized role of
cytokine and chemokines in sepsis

IL-10
+TNF
+IL-1

Anti

+MCP-1/JE
? Other
chemokine ?

Pro Anti

Tissue damage
Multi organ
failure
EdiW_Inflammation
BioMol 2004

SEPSIS

+IL-10
TNF
IL-1

Pro Anti

Intact host
defense
Resolution

Edi Widjajanto

Pro

Infection
Steinhauser et al.45(1999).
Animal model of inflammation

EdiW_Inflammation
BioMol 2004

46

EdiW_Inflammation
BioMol 2004

47

Edi Widjajanto

EdiW_Inflammation
Edi BioMol
Widjajanto
2004

48

Cytokines in sepsis
Several classes of cytokines
are induced simultaneously:
Proinflammatory and Th-1 type
cytokines;
TNF, IL-1, IFN,
IL-6, IL-8, IL-12, IL-18

Antiinflammatory cytokines;
IL-10, IL-6, LIF

Cytokines antagonist;
IL-1ra, p68 (sIL-1RII),
p55 (sTNFRI), p75 (sTNFRII)
EdiW_Inflammation
BioMol 2004

Moldawer LL, et al., (2000). Emerging role of more complex role for
Proinflammatory and antiinflammatory cytokines in sepsis response. 49
In (Baue AE, et al., eds) Multiple Organ Failure.

Cytokines in sepsis
These cytokine cause:
initiate innate immune response
IL-10 sustained immunosuppressive
(characterized by Th2-type response)
increased lymphoid apoptosis
the role of TNF family in the
apoptotic injury

EdiW_Inflammation
BioMol 2004

Moldawer LL, et al., (2000). Emerging role of more complex role for
Proinflammatory and antiinflammatory cytokines in sepsis response. 50
In (Baue AE, et al., eds) Multiple Organ Failure.

Cytokines in sepsis
The lack of successful
therapy in patient with sepsis
suggests that knowledge of
the role cytokines play in the
host response to sepsis is
still incomplete.

EdiW_Inflammation
BioMol 2004

Moldawer LL, et al., (2000). Emerging role of more complex role for
Proinflammatory and antiinflammatory cytokines in sepsis response. 51
In (Baue AE, et al., eds) Multiple Organ Failure.

Apoptosis

Untimely Apoptosis in Human


SIRS, Sepsis, and MODS

Delay in neutrophil apoptosis,

Even mild inflammation is sufficient


to retard neutrophil apoptosis.
Induced apoptosis; septic death is
associated with lymphocyte and
intestinal epithelial apoptosis.
Remain unknown, whether
apoptosis are a cause, consequence
or epiphenomenon.

EdiW_Inflammation
BioMol 2004

52
Buchman (2000). Untimely Apoptosis in Human SIRS, Sepsis, and MODS.
In (Baue AE, et al., eds) Multiple Organ Failure.

Potential mechanism of

immune suppression
in patient with sepsis

Shift from inflammatory (Th1) to


antiinflammatory (Th2) response.
Apoptosis induced of CD4 Tcells,
B cells and dendritic cells.
Anergy.
Loss of Macrophage expression of
MHC-II and costimulatory molecule.
Immunosuppressive effect of
apoptotic cells.
EdiW_Inflammation
BioMol 2004

53
Hotchkiss (2003). The Pathophysiology and Treatment of Sepsis.
N Eng J Med 348, p 138 - 150.

Cross talk among


immune cells
Neutrophil

Bacteria

Dendritic
cell

Macrophage

Apoptotic
cells
Necrotic
cells

Inflamatory
products

Anergy

Th-2 anti Inflamatory


Edi EdiW_Inflammation
Widjajanto
BioMol 2004

Necrotic
Apoptotic cells
cells

Lymph
CD4
Th-1 Inflamatory

Anergy
Th-2 anti Inflamatory

54

Immunologic response

In three hypothetical patients with sepsis

*Healthy person with

*Elderly person

meningococcemia

with malnutrition
and diverticulitis

Normal

Immune status

Hyper

Immune activation

Hypo

*Patient with diabetes,

Edi Widjajanto

chronic renal failure,


and pneumonia

Immune
suppression

Death
5

EdiW_Inflammation
Hotchkiss
BioMol
2004(2003). The Pathophysiology and Treatment of Sepsis.N Eng J Med 348, p 138 - 150.

8 Days
55

_
HIV disease in progressor compared with nonprogessor
Primary
infection

1200

_
1100
_
1000

Asymptomatic; immunocompetent course

900
800
700

600

Constitutional
symptom

500
400

Oportunistic
disease

300

Death

200

100
0

6
9
Edi Widjajanto
Weeks
EdiW_Inflammation
BioMol 2004

12

5
6
Years

Fauci et al. (1996), Ann Intern Med 124:654

10 11

56
Years

years

Innate immune cells


(response) hyper activation
and damage.

Acute immune deficiency


EdiW_Inflammation
BioMol 2004

57

Resume & Conclusion


Injurious agent (mostly infection)
induced cell damage.
Macrophage (innate immune cells)
hyper-activation and damage.
Pro-inflammatory mediators storm.
Uncontrolled inflammation.
Acute immune response failure.
Newly promising mediators
approach (chemokine).
Lack of knowledge.
EdiW_Inflammation
BioMol 2004

58

Sekian
Terima Kasih
EdiW_Inflammation
BioMol 2004

59