Hiroshi Saito

Background: Sepsis survivors commonly suffer from chronic Post-Sepsis Syndrome (PSS). To understand the mechanisms of PSS, it is critical to utilize appropriate animal models. While cecal ligation and puncture (CLP) is a widely used model of sepsis, a concern exists regarding its suitability for studying long-term outcomes. Alternatively, we previously optimized a highly reproducible murine cecal slurry (CS)-injection model of sepsis. The objective of this study was to compare the suitability of CS and CLP models for investigating PSS. Methods: Male 4-month-old C57BL/6 mice were divided into 7 groups: (1) Naïve control; (2) Sham: laparotomy control; (3) CL: cecal ligation control without puncture; (4) CLP: conventional cecal ligation and puncture (21Gx2); (5) CLP-D: CLP followed by surgical removal (i.e., debridement) of the ligated distal cecum; (6) CS: cecal slurry injection; and (7) vehicle injection control for CS. All mice except for Naïve, received repeated antibiotics and fluid resuscitation starting at 12 h after infection or the control procedure. Blood samples were collected at 6 h and 1-month for IL-6 ELISA. A month later, all mice were euthanized, and qRT-PCR was performed to assess IL-6 gene expression in several tissues including the cecum. Results: Equivalent sepsis severity was confirmed in the sepsis groups (CS, CLP, and CLP-D) by similar survival rates (73–78%) and acute 6 h-plasma IL-6 levels (63.3–159.6 pg./mL). A month later, large abscesses, deformed necrotic tissues, and aberrant adhesions were frequently present in and around the cecum of CL, CLP, and CLP-D mice. Elevated levels of plasma IL-6 (>25 pg./mL) 1-month after sepsis induction were observed in both the CL and CLP groups and also in the CLP-D group to a lesser degree. Strong IL-6 gene expression was found only in the ligated distal cecum from the CLP and CL groups. The cecum abnormality and high levels of plasma IL-6 were completely absent in the CS group. Conclusion: The CLP model is accompanied with abnormal cecum which persistently produces IL-6. The CLP-D model with debridement reduces such problems to some extent but not completely. Because such experimental artifacts are absent in the CS model, this model appears to be better suited for studying PSS.

Background: Sepsis, mainly caused by bacterial infections, is the leading cause of in-patient hospitalizations. After discharge, most sepsis survivors suffer from long-term medical complications, particularly chronic skeletal muscle weakness. To investigate this medical condition in detail, we previously developed a murine severe sepsis-survival model that exhibits long-term post-sepsis skeletal muscle weakness. While mitochondrial abnormalities were present in the skeletal muscle of the sepsis surviving mice, the relationship between abnormal mitochondria and muscle weakness remained unclear. Herein, we aimed to investigate whether mitochondrial abnormalities have a causal role in chronic post-sepsis muscle weakness and could thereby serve as a therapeutic target. Methods: Experimental polymicrobial abdominal sepsis was induced in 16-18 months old male and female mice using cecal slurry injection with subsequent antibiotic and fluid resuscitation. To evaluate the pathological roles of mitochondrial abnormalities in post-sepsis skeletal muscle weakness, we utilized a transgenic mouse strain overexpressing the mitochondria-specific antioxidant enzyme manganese superoxide dismutase (MnSOD). Following sepsis development in C57BL/6 mice, we evaluated the effect of the mitochondria-targeting synthetic tetrapeptide SS-31 in protecting mitochondria from sepsis-induced damage and preventing skeletal muscle weakness development. In vivo and in vitro techniques were leveraged to assess muscle function at multiple timepoints throughout sepsis development and resolution. Histological and biochemical analyses including bulk mRNA sequencing were used to detect molecular changes in the muscle during and after sepsis Results: Our time course study revealed that post sepsis skeletal muscle weakness develops progressively after the resolution of acute sepsis and in parallel with the accumulation of mitochondrial abnormalities and changes in the mitochondria-related gene expression profile. Transgenic mice overexpressing MnSOD were protected from mitochondrial abnormalities and muscle weakness following sepsis. Further, pharmacological protection of mitochondria utilizing SS-31 during sepsis effectively prevented the later development of muscle weakness. Conclusions: Our study revealed that the accumulation of mitochondrial abnormalities is the major cause of post-sepsis skeletal muscle weakness. Pharmacological protection of mitochondria during acute sepsis is a potential clinical treatment strategy to prevent post-sepsis muscle weakness.

BACKGROUND: Mitochondrial transplantation has recently gained prominence as a novel technique primarily focused on addressing ischemiareperfusion injuries and rare mitochondrial mutation diseases. Platelets, abundant in the bloodstream, play a crucial role in immune function. Upon activation, platelets release mitochondria encapsulated within extracellular vesicles, here referred to as “mitlets”. These mitlets exhibit a preference for being internalized by immune cells circulating in the bloodstream, enhancing their cellular energetics. Herein, we hypothesized that the transplantation of mitlets between young animals and aged animals may exert a significant influence on the progression of infectious diseases. STUDY DESIGN AND METHODS: In this study, murine models of Influenza H1N1 infection and sepsis were employed to investigate disease dynamics. Specifically, mitlets isolated from young and healthy mice were transplanted into cohorts of mice of the same age afflicted by H1N1 infection, or into aged mice subjected to polymicrobial infection and sepsis. Survival outcomes and the quantification of cytokine levels were assessed across experimental groups to elucidate the potential therapeutic effects of mitlet transplantation. RESULTS: In the matched-age H1N1 infection model, as predicted, mitlet transplantation did not yield a statistically significant improvement in survival, although it did show a trend towards a reduction in the circulating inflammatory cytokine burden. In the young-to-old sepsis model, the transplantation of mitlets was associated with a significant enhancement in survival rates and a substantial reduction in bacterial loads and circulating cytokine levels. DISCUSSION: Our findings suggest that mitochondrial transplantation may constitute a safe and promising avenue for enhancing the immune system’s capacity to counter infectious threats. This pilot investigation sets the stage for further exploration. It is plausible that in the future, immune senescence resulting from diminished mitochondrial energy production could be ameliorated through such transplantation interventions. As a consequence, this approach holds substantial potential as a novel immunotherapeutic strategy for the management of infectious diseases.

Significance: Both incidence and mortality rates of sepsis significantly increase with advanced age, and the majority of sepsis patients are late middle-aged or older. With the proportion of older adults rapidly increasing in developed countries, age-dependent sepsis vulnerability is an urgent medical issue. Due to an increasing life expectancy, postsepsis complications and health care costs are expected to increase as well. Recent Advances: Older patients suffer from higher sepsis incidence and mortality rates, likely resulting from frequent comorbidities, increased coagulation, dysgylcemia, and altered immune responses. Critical Issues: Despite a large number of ongoing clinical and basic research studies, there is currently no effective therapeutic strategy targeting older patients with severe sepsis. The disparity between clinical and basic studies is a problem, and this is largely due to the use of animal models lacking clinical relevance. Although the majority of sepsis cases occur in older adults, most laboratory animals used for sepsis research are very young. Further, despite the wide use of combination fluid and antibiotic treatment in intensive care unit (ICU) patients, most animal research does not include such treatment. Future Directions: Because sepsis is a systemic disease with multiple organ dysfunction, combined therapy approaches, not those targeting single pathways or single organs, are essential. As for preclinical research, it is critical to confirm new findings using aged animal models with clinically relevant ICU-like medical treatments. Antioxid. Redox Signal. 35, 1358–1375.

Chronic critical illness is a global clinical issue affecting millions of sepsis survivors annually. Survivors report chronic skeletal muscle weakness and development of new functional limitations that persist for years. To delineate mechanisms of sepsis-induced chronic weakness, we first surpassed a critical barrier by establishing a murine model of sepsis with ICU-like interventions that allows for the study of survivors. We show that sepsis survivors have profound weakness for at least 1 month, even after recovery of muscle mass. Abnormal mitochondrial ultrastructure, impaired respiration and electron transport chain activities, and persistent protein oxidative damage were evident in the muscle of survivors. Our data suggest that sustained mitochondrial dysfunction, rather than atrophy alone, underlies chronic sepsis-induced muscle weakness. This study emphasizes that conventional efforts that aim to recover muscle quantity will likely remain ineffective for regaining strength and improving quality of life after sepsis until deficiencies in muscle quality are addressed.

Current animal models of sepsis often incorporate antibiotics to be consistent with clinical standards for treatment of patients in the intensive care unit. However, such experimental intervention is commonly initiated very early after infectious insult, which likely blunts the progression of systemic inflammation and downstream pathology. The objective of this study was to establish an animal model of sepsis with delayed therapeutic intervention, allowing a longer disease course and downstream pathology, but still resulting in a high survival rate. Severe lethal abdominal infection was initiated in young adult (17–18-week-old) C57BL/6 mice by cecal slurry (CS) injection. When initiated early (1- or 6-h post-CS injection), antibiotic treatment (imipenem, 1.5 mg/mouse i.p., twice/day for 5 days) rescued the majority of mice; however, few of these mice showed evidence of bacteremia, cytokinemia, or organ injury. When antibiotic treatment was delayed until late time-points (12- or 24-h post-CS injection) the majority of animals did not survive beyond 48 h. When fluid resuscitation (physiological saline, s.c.) was performed in combination with antibiotic treatment (twice daily) beginning at these late time-points, the majority of mice survived (75%) and showed bacteremia, cytokinemia, organ dysfunction, and prolonged body weight loss (<90% for 4 weeks). We recommend that this new repeated combination treatment with antibiotics and fluids resuscitation be initiated at a late time point after bacteremia becomes evident because this model more closely mimics the downstream pathological characteristics of severe clinical sepsis yet maintains a high survival rate. This model would be advantageous for studies on severe sepsis and postintensive care illness.

Objectives: Visceral adipose tissue is a major site for expression of proinflammatory and procoagulant genes during acute systemic inflammation. In this study, we tested whether the loss of fat mass by dietary restriction would remove the major source of these factors resulting in improved tolerance to sepsis and endotoxemia. Design: Prospective, laboratory controlled experiments. Setting: Aging and critical care research laboratory in a university hospital. Subjects: Middle-aged (12-month old) male C57BL/6 mice. Interventions: Mice were subjected to 40% dietary restriction for 3 weeks followed by induction of abdominal sepsis or endotoxemia by intraperitoneal injection with cecal slurry or lipopolysaccharide, respectively. Measurements and Main Results: Compared with freely fed mice, dietary restricted mice exhibited dramatically improved survival (80% vs 0% after sepsis; p < 0.001 and 86% vs 12% after endotoxemia; p = 0.013) and significantly reduced visceral fat-derived messenger RNA expression of interleukin-6, thrombospondin-1, plasminogen activator inhibitor-1, and tissue factor, which positively correlated with fat mass. Plasma levels of interleukin-6 were significantly reduced by dietary restriction and correlated with adipose interleukin-6 messenger RNA levels and fat mass (p < 0.001; R ² = 0.64 and 0.89). In vitro culture of visceral fat explants from naive dietary restricted mice showed significantly reduced interleukin-6 secretion compared with that from freely fed mice in response to lipopolysaccharide. Analysis of major adipose immune cell populations by flow cytometry demonstrated that macrophages were the only cell population reduced by dietary restriction and that CD11c⁺/CD206⁺ (M2-type) and CD11c^–/CD206^– (double negative) macrophages, in addition to T cells, are the major immune cell populations that produce interleukin-6 in middle-aged mice during systemic inflammation. Conclusions: Short-term dietary restriction drastically improved the survival outcome of middle-aged mice during both polymicrobial sepsis and sterile endotoxemia. Improved survival was accompanied by a significantly attenuated inflammatory response in adipose tissue, which is likely due to alterations of both fat mass quantity and qualitative changes, including a reduction in macrophage populations.

Sepsis is a life-threatening clinical condition that is particularly serious among the elderly who experience considerably higher mortality rates compared with younger patients. Using a sterile endotoxemia model, we previously reported age-dependent mortality in conjunction with enhanced coagulation and insufficient levels of anti-coagulant factor activated protein C (aPC). The purpose of the present study was to further investigate the mechanisms for age-dependent coagulation and aPC insufficiency during experimental sepsis. Intra-abdominal sepsis was induced by cecal ligation and puncture (CLP) using 21 or 16 gauge (G) needles (double-puncture) on young (4 to 6 mo old) and aged (20 to 25 mo old) male C57BL/6 mice. When compared with young mice, aged mice showed significantly increased mortality (92% vs. 28%), systemic inflammation, and coagulation in the lung and kidney after 21G CLP. Young mice with more severe CLP (16G) showed a mortality rate and inflammation equivalent to aged mice with 21G CLP; however, enhanced coagulation and kidney dysfunction were significant only in the aged. In young mice, increased levels of aPC after CLP were coupled with reduced levels of protein C (PC), suggesting the conversion of PC to aPC; however, PC and aPC levels remained unchanged in aged mice, indicating a lack of PC to aPC conversion. Activation of fibrinolysis, determined by plasma d-dimer levels, was similar regardless of age or CLP severity, and plasminogen activator inhibitor-1, an inhibitor of fibrinolysis, showed severity-dependent induction independent of age. These results suggest that enhanced coagulation in aged mice during sepsis is due to dysfunction of the PC activation mechanism.

Sepsis, a life-threatening systemic inflammatory response syndrome induced by infection, is widely studied using laboratory animal models. While cecal-ligation and puncture (CLP) is considered the gold standard model for sepsis research, it may not be preferable for experiments comparing animals of different size or under different dietary regimens. By comparing cecum size, shape, and cecal content characteristics in mice under different experimental conditions (aging, diabetes, pancreatitis), we show that cecum variability could be problematic for some CLP experiments. The cecal slurry (CS) injection model, in which the cecal contents of a laboratory animal are injected intraperitoneally to other animals, is an alternative method for inducing polymicrobial sepsis; however, the CS must be freshly prepared under conventional protocols, which is a major disadvantage with respect to reproducibility and convenience. The objective of this study was to develop an improved CS preparation protocol that allows for long-term storage of CS with reproducible results. Using our new CS preparation protocol we found that bacterial viability is maintained for at least 6 months when the CS is prepared in 15% glycerol-PBS and stored at -80°C. To test sepsis-inducing efficacy of stored CS stocks, various amounts of CS were injected to young (4–6 months old), middle-aged (12–14 months old), and aged (24–26 months old) male C57BL/6 mice. Dose- and age-dependent mortality was observed with high reproducibility. Circulating bacteria levels strongly correlated with mortality suggesting an infection-mediated death. Further, injection with heat-inactivated CS resulted in acute hypothermia without mortality, indicating that CS-mediated death is not due to endotoxic shock. This new CS preparation protocol results in CS stocks which are durable for freezing preservation without loss of bacterial viability, allowing experiments to be performed more conveniently and with higher reproducibility than before.

Expression of interleukin-6 (IL-6) upon acute inflammatory stress is significantly augmented by aging in adipose tissue, a major source of this cytokine. In the present study, we examined the mechanism of age-dependent IL-6 overproduction using visceral white adipose tissue from C57BL/6 mice. Upon treatment with lipopolysaccharide (LPS) in vitro, IL-6 was produced by adipose tissue explants, and secreted levels were significantly higher in cultures from aged (24 months) mice compared to young (4 months). Interleukin 1 beta (IL-1β) and tumor necrosis factor alpha (TNFα), two inducers of IL-6, were mainly produced by the lungs and spleen rather than adipose tissue in mice after LPS injection. Treatment of adipose explants with physiological levels of IL-1β induced significant age-dependent secretion of IL-6, while treatment with TNFα had little effect, demonstrating an augmented response of adipose tissues to IL-1β in the aged. In vitro experiments utilizing a neutralizing antibody against IL-1β and in vivo experiments utilizing IL-1-receptor-1 deficient mice, confirmed that IL-6 overproduction in the aged is regulated by autocrine/paracrine action of IL-1β which specifically occurs in aged adipose tissues. These findings indicate an elevated inflammatory potential of adipose tissue in the aged and a unique IL-1β-mediated mechanism for IL-6 overproduction, which may impact age-associated vulnerability to acute inflammatory diseases such as sepsis.