Controversies surrounding current therapies for sepsis syndrome

Review: Bacterial endotoxin and the human monoclonal antibody HA-IA: specificity, potential mechanisms of action, and limits to its effectiveness

Bacterial endotoxins are lipopolysaccharides present in the outer membrane of all Gram-negative bacteria (GNB). Endotoxins consist of a lipid moiety, lipid A, that is covalently linked to highly variable, serotype O-specific polysaccharide lateral chains. In contrast, the endotoxin core, which includes lipid A, is better conserved and can be recognized by antibodies showing cross-reactivity among various GNB. Such polyclonal and monoclonal antibodies have been developed in an attempt to neutralize the biological and dele. terious effects of endotoxin, thus preventing lipid A from binding to macrophages. In fact, almost all the biological activities of endotoxin are elicited by lipid A, and there is substantial evidence to the effect that the monocyte-macrophage is the principal mediator of endotoxicity. Antiserum against LPS isolated from rough mutants of GNB (expressing virtually only the central core-lipid A), has been shown to counteract the lethal effects of endotoxin in animals and humans. However, such serum or plasma contains antibodies of different specificities and isotypes which represent different effector functions, insofar as LPS is a very complex and highly heterogenous macromolecule. Because of the difficulties encountered in investigating the nature and specificity of the protection afforded by these antisera, and their limited capacity of production for therapeutic use, specific anti-lipid A monoclonal antibodies have been produced in their stead. A variety of mouse and human monoclonal antibodies against LPS have been generated and selected for their ability to cross-react with many GNB species. The most recent clinical trials involving the treatment of septic patients with human HA-IA (Centoxin) or with murine (E5) anti-lipid A monoclonal antibody showed no difference in survival rates, as compared to treatment with a placebo. However, statistical significance was demonstrated in subsets of patients suffering from documented Gram-negative septicemia or Gram-negative sepsis without refractory shock. The usefulness of anti-lipid A antibodies will undoubtedly remain controversial, since they appear to benefit only a minority of all patients treated, and also because no consensus exists regarding their specificity and modes of action. The aim of this review is to describe results which demonstrate the requirements for, difficulties in and limits to, elucidating the ability of certain antibodies to recognize structural elements present in the lipid A domain of LPS. A clear demonstration of antibody cross-reactivity was obtained only when rough LPS bacteria were used, and was markedly enhanced when smooth bacteria had been pretreated with cell wall active antibiotics. Further, new data have recently demonstrated the specific involvement of HA-IA in the immunocytoadherence assay in the presence of human complement and human red blood cells. Such phenomena may form part of the potential role for natural or monoclonal human IgM anti-lipid A antibodies, which will be to remove IgM-lipid A immune complexes through transhepatic clearance via C3b binding to the CR1 present on circulating human erythrocytes. Insofar as immunocytoadherence is a multiparameter phenomenon, various limiting factors probably interfere with its mechanism of clearance. These factors may be absent in various subsets of septic patients under treatment, thus explaining therapeutic failures with HA-IA in humans or preclinical animal studies. Several clinical settings involving defects to CR1 expression, C3b production, LPS recognition and hepatic clearance dysfunction are described. Long term, however, it will impossible to specify the patient subsets suitable for monoclonal therapy without first defining their characteristics. HA-IA may be able to inhibit one of the earliest stages in activation of the cytokine cascade by sequestrating and eliminating biologically active lipid A. The major problem today in terms of using anti-lipid A antibodies is an efficiently early detection of specific pathway defects which detract from or nullify the HA-IA therapeutic effect.

Mechanisms determining phenotypic heterogeneity of hepatocytes

This review summarizes results of biochemical and immunohistochemical studies indicating the existence of functional heterogeneity of hepatocytes depending on their localization in the hepatic acinus; this determines characteristic features of metabolism of carbohydrates, lipids, and xenobiotics. The physiological significance of hepatocyte heterogeneity is discussed. According to the proposed model of intercellular communication, the metabolic specialization of hepatocytes is determined by secretory activity of hepatic resident macrophages (Kupffer cells) localized mainly in the periportal zone of the liver acinus. Macrophages participate in secretion of a wide spectrum of intercellular mediators (cytokines, prostaglandins, growth factors) and also in metabolism of numerous blood metabolites and biologically active substances (hormones, lipoproteins, etc.). In the sinusoid and in the space of Disse (also known as perisinusoidal space) they form a concentration gradient of regulatory factors and metabolites inducing the phenotypic differences between hepatocytes.