The Effects of Immunostimulation With GM-CSF or IFN-y on Immunoparalysis Following Human Endotoxemia

The Effects of Immunostimulation With GM-CSF or IFN-y on Immunoparalysis Following Human Endotoxemia. A Parallel Randomized Double-blind Placebo-controlled Study

The human body knows a biphasic immunological reaction to sepsis. First, the pro-inflammatory reaction takes place, marked by the release of pro-inflammatory cytokines like TNF-α, as a reaction to the bacterial toxins. Secondly, the counter regulatory anti-inflammatory reaction arises. This phase is acting as negative feedback on the inflammation by inhibition of the pro-inflammatory cytokines. This is called "immunoparalysis", a pronounced immunosuppressive state, which renders patients vulnerable to opportunistic infections. Most of the septic patients survive the initial pro-inflammatory phase, but die during this second stage.Research in the past has shown that immunostimulatory therapy with GM-CSF or IFN-γ has promising effects on the pro-inflammatory reaction during immunoparalysis ex vivo. Both drugs are known for their immunostimulatory effects. Recent pilot studies have showed in septic patients, that long-lasting monocyte deactivation in sepsis ex vivo can be reversed by these two immunostimulants. However, the mechanism and extent of immunoparalysis recovery may be different between the two compounds. Previously it has been shown that human endotoxemia (induced by LPS), leads to marked immunosuppression in healthy individuals, characterized by a transient refractory state to a subsequent LPS challenge (endotoxin tolerance). Consequently, human endotoxemia can serve as a standardized, controlled model for sepsis-induced immunoparalysis. Until now, all studies have focused on the ex vivo tolerance. However, we have recently proved, that the ex vivo condition is not completely representative for the in vivo situation. Ex vivo, leukocyte tolerance to LPS resolves within one day, while the in vivo immunoparalysis persists for two weeks. In this project, we will investigate the effects of both GM-CSF and IFN-γ in a parallel double-blind placebo controlled randomized manner on the immunoparalysis following human endotoxemia, both in-vitro and in vivo. As a result, we hope to get more insight in the pathophysiology of sepsis-induced immunoparalysis and thereby develop new immunostimulatory therapies that improve patient outcome

Study Overview

• Status: Completed
• Conditions: Sepsis; Inflammation; Endotoxemia; Multi Organ Dysfunction Syndrome
• Intervention / Treatment: Other: E.coli endotoxin; Drug: GM-CSF; Drug: IFN-Y

• Study Type: Interventional
• Enrollment (Actual): 18
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Netherlands
  • Gelderland
    • Nijmegen, Gelderland, Netherlands, 6500 HB
      • Radboud University Nijmegen Medical Centre

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 35 years (ADULT)
• Accepts Healthy Volunteers: Yes
• Genders Eligible for Study: Male

Description

Inclusion Criteria:

• Healthy male volunteers

Exclusion Criteria:

• seropositivity for markers of hepatitis B or HIV infection or medical history of any other obvious disease associated with immune deficiency
• Use of any medication or drugs
• a history of adverse reaction or hypersensitivity to GM-CSF/ IFN-γ
• Smoking.
• Previous spontaneous vagal collapse.
• History, signs or symptoms of cardiovascular disease.
• (Family) history of myocardial infarction or stroke under the age of 65 years.
• Cardiac conduction abnormalities on the ECG consisting of a 2nd degree atrioventricular block or a complex bundle branch block.
• Hypertension (defined as RR systolic > 160 or RR diastolic > 90) or hypotension (defined as RR systolic < 100 or RR diastolic < 50).
• Renal impairment (defined as plasma creatinin >120 μmol/l).
• Liver enzyme abnormalities or positive hepatitis serology.
• Febrile illness during the week before the LPS challenge
• Participation in a drug trial or donation of blood 3 months prior to the LPS challenge.
• Chronic hiccups (defined as hiccups longer than 15 minutes in the past 6 months)
• Pre-existent muscle disease (congenital or acquired) or diseases / disorders know to be associated with myopathy including diabetes and auto-immune diseases.
• Pre-existent lung disease
• Upper airway / esophageal pathology
• Recent (< 1 month) nasal bleeding
• Phrenic nerve lesions
• Any metals in body (pacemaker, splinters, metal stitches)

Study Plan

How is the study designed?

Design Details

• Primary Purpose: TREATMENT
• Allocation: RANDOMIZED
• Interventional Model: PARALLEL
• Masking: DOUBLE

Number of Arms

3

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
PLACEBO_COMPARATOR: placebo; LPS will be administered twice on days 1 and 7. In between placebo will be administered on days 2, 4 and 6 subcutaneously.	Other: E.coli endotoxin; 2 ng/kg E.coli reference endotoxin 11:H 10:K negative intravenously
ACTIVE_COMPARATOR: GM-CSF; LPS will be administered twice on days 1 and 7. In between GM-CSF will be administered on days 2, 4 and 6 subcutaneously.	Other: E.coli endotoxin; 2 ng/kg E.coli reference endotoxin 11:H 10:K negative intravenously; Drug: GM-CSF; GM-CSF (4microgram/kg/day subcutaneously) on days 2, 4 and 6.
ACTIVE_COMPARATOR: IFN-y; LPS will be administered twice on days 1 and 7. In between IFN-Y will be administered on days 2, 4 and 6 subcutaneously.	Other: E.coli endotoxin; 2 ng/kg E.coli reference endotoxin 11:H 10:K negative intravenously; Drug: IFN-Y; IFN-Y (100 microgram/day, subcutaneously) on days 2, 4 and 6.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
the effects of GM-CSF/IFN-γ on the development of in vivo immunoparalysis induced by experimental human endotoxemia	This will be determined by measuring plasma levels of various pro and anti-inflammatory cytokines and assessing the difference in the LPS-induced cytokine response between day 1 and 7	1 week (day 1- day 8)

Secondary Outcome Measures

Outcome Measure	Time Frame
The effects of GM-CSF/IFN-γ on the ex-vivo responsiveness of leukocytes to various inflammatory stimuli	1 week (day 1- day 8)
the effects of GM-CSF/IFN-γ on monocyte HLA-DR expression	1 week (day 1- day 8)
the effects of GM-CSF/IFN-γ on transcriptional pathways of leukocytes (qPCR and microarray)	1 week (day 1- day 8)
the effects of GM-CSF/IFN-γ on urine markers of tubular injury	1 week (day 1- day 8)
The effect of LPS on twitch transdiaphragmatic pressure	1 day
the effects of GM-CSF/IFN-γ on clinical symptoms (illness score, mean arterial pressure, heart rate and temperature)	1 week (day 1- day 8)
the effects of GM-CSF/IFN-γ on changes in phenotype and gene expression caused by mechanisms other than changes in the underlying DNA sequence	1 week (day 1- day 8)
Beta 2 Glycoprotein and platelet-monocyte interactions post-LPS	1 day
Macrophage differentiation	1 day
Immunosuppressive neutrophil populations	1 week (day 1- day 8)
Blood viscosity	1 day

Collaborators and Investigators

• Sponsor: Radboud University Medical Center
• Investigators: Principal Investigator: Peter Pickkers, Prof, MD, PhD, Radboud University Nijmegen Medical Centre, The Netherlands

Publications and helpful links

General Publications

• Leentjens J, Kox M, Koch RM, Preijers F, Joosten LA, van der Hoeven JG, Netea MG, Pickkers P. Reversal of immunoparalysis in humans in vivo: a double-blind, placebo-controlled, randomized pilot study. Am J Respir Crit Care Med. 2012 Nov 1;186(9):838-45. doi: 10.1164/rccm.201204-0645OC. Epub 2012 Jul 19.

Study record dates

Study Major Dates

• Study Start: May 1, 2011
• Primary Completion (ACTUAL): November 1, 2011
• Study Completion (ACTUAL): November 1, 2011

Study Registration Dates

• First Submitted: May 19, 2011
• First Submitted That Met QC Criteria: June 15, 2011
• First Posted (ESTIMATE): June 16, 2011

Study Record Updates

• Last Update Posted (ESTIMATE): June 27, 2013
• Last Update Submitted That Met QC Criteria: June 26, 2013
• Last Verified: June 1, 2013

More Information

Terms related to this study

• Keywords: Inflammation; Endotoxin; Sepsis; GM-CSF; IFN-y
• Additional Relevant MeSH Terms: Pathologic Processes; Infections; Systemic Inflammatory Response Syndrome; Sepsis; Bacteremia; Toxemia; Inflammation; Endotoxemia
• Other Study ID Numbers: NL36068.091.11 BI