Stratifying Patient Immune Endotypes in Sepsis (SPIES Study)

摘要 脓毒症仍然是当今医院死亡的主要原因。1尽管其发病率由于老龄化而增加， 在合并症较多的人群中，住院死亡率在过去十年中显著下降。 在很大程度上是由于早期认识和更好地遵守早期脓毒症管理的最佳实践。 尽管住院死亡率有所改善，但大部分（在某些研究中高达50%）败血症幸存者从未接受过治疗。 完全恢复并发展为慢性危重病（CCI），其特征是持续的免疫抑制， 复发性感染、败血症复发和不良长期结局。然而，有三个关键挑战， 阻碍了在这些脓毒症幸存者中免疫疗法的发展：i）如何对患有 免疫抑制的脓毒症患者; ii）如何量化免疫抑制的程度;以及iii）如何识别 有前途的免疫刺激剂在个体免疫抑制患者？我们认为，目前为 免疫抑制的内源性脓毒症幸存者还没有完全成功，因为他们不能 直接评估免疫功能，而不是使用免疫状态的基因组学或蛋白质组学测量。这里 我们建议：1）评估刺激的T细胞产生IFN-γ和刺激的单核细胞产生IFN-γ是否与刺激的T细胞产生IFN-γ和刺激的单核细胞产生IFN-γ有关。 通过ELISpot定量的TNF-α能更好地预测脓毒症幸存者的感染和长期结局， 基于蛋白质水平、表达和核酸浓度的常见静态测量;以及2） 采用ELISpot评估由脓毒症引起的T细胞产生的IFN-γ和单核细胞产生的TNF-α 存活者，以检查不同免疫刺激剂逆转脓毒症诱导的离体比较功效。 免疫抑制为了实现这些目标，我们提出了一个前瞻性的，观察性试验的270例患者， 脓毒症（使用脓毒症-3标准）与90例无脓毒症的危重病患者（共390例，其中30例 健康受试者进行质量控制和验证）。脓毒症后1、4和7天 诊断后，将获得血液样本和血液T细胞和单核细胞产生的IFN-γ和TNF-γ， 将通过ELISpot测定。此外，还将采集其他生物标志物的样本，包括 血浆蛋白（IL-6和sPD-L1）、HLA-DR的CD 14+细胞表达、总淋巴细胞计数和全血 基因组学继发性感染将是主要的临床指标6，次要指标包括 再入院和180天死亡率。此外，我们将在该ELISpot平台中评估离体 T细胞产生IFN-γ和单核细胞产生TNF-α的反应， 使用随机区组设计，在不同浓度的IL-7、抗PD-1 mAb、GITRL、OX 40 L或4-1BB中，使用不同浓度的IL-7、抗PD-1 mAb、GITRL、OX 40 L或4-1BB对小鼠进行免疫组化。这些 免疫刺激剂目前正被考虑作为脓毒症患者的潜在治疗剂。这 该申请提出了一种新的功能性生物测定法的验证，以确定哪些患者将受益于 免疫疗法，并确定不同的免疫疗法，将有利于个别患者。

ABSTRACT Sepsis remains the leading cause of hospital mortality today.1 Despite its increasing incidence due to an aging population with greater comorbidities, in-hospital mortality has significantly declined over the past decade.2 This is due in large part to earlier recognition and better compliance with best practices in early sepsis management. Despite improved in-hospital mortality, a large proportion (up to 50% in some studies)3-5 of sepsis survivors never fully recover and develop chronic critical illness (CCI), characterized by persistent immune suppression, recurrent infections, sepsis recidivism and poor long-term outcomes. There are three key challenges, however, hindering the development of immunological therapies in these sepsis survivors: i) how to endotype patients with sepsis who are immunosuppressed; ii) how to quantify the degree of immune suppression; and iii) how to identify promising immune stimulants in individual immunosuppressed patients? We believe that current efforts to endotype sepsis survivors as being immunosuppressed have not been fully successful because they fail to directly assess immune function, instead using either genomic or proteomic measures of immune status. Here we propose to: 1) assess whether stimulated T cell production of IFN-γ and stimulated monocyte production of TNF as quantitated by ELISpot, better predicts infectious and long-term outcomes in sepsis survivors than common static measurements based on protein levels, expression and nucleic acid concentrations; and 2) to employ ELISpot assessment of IFN- production by T-cells and TNF production by monocytes from sepsis survivors to examine ex vivo the comparative efficacy of different immune stimulants to reverse sepsis-induced immunosuppression. To achieve these goals, we propose a prospective, observational trial of 270 patients with sepsis (using Sepsis-3 criteria) compared to 90 patients with critical illness without sepsis (total of 390 with 30 healthy subjects for quality control and validation) at 3 academic institutions. At 1, 4 and 7 days post sepsis diagnosis, blood samples will be obtained and blood T-cell and monocyte production of IFN- and TNF, respectively, will be determined by ELISpot. In addition, samples will be obtained for other biomarkers, including plasma proteins (IL-6 and sPD-L1), CD14+ cell expression of HLA-DR, total lymphocyte count and whole blood genomics. Secondary infections will be the primary clinical index of outcome6, with secondary indices including hospital readmission, and 180 day mortality. In addition, we will evaluate in this ELISpot platform the ex vivo response of IFN- production by T-cells and TNF production by monocytes stimulated with varying concentrations of IL-7, anti-PD-1 mAb, GITRL, OX40L or 4-1BB, using a randomized block design. These immune stimulants are currently under consideration as potential therapeutics for sepsis patients. This application proposes the validation of a novel functional bioassay to identify patients who would benefit from immunotherapy, and to identify different immune therapies that would benefit the individual patient.