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Popotas A, Casimir GJ, Corazza F, Lefèvre N. Sex-related immunity: could Toll-like receptors be the answer in acute inflammatory response? Front Immunol 2024; 15:1379754. [PMID: 38835761 PMCID: PMC11148260 DOI: 10.3389/fimmu.2024.1379754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 05/06/2024] [Indexed: 06/06/2024] Open
Abstract
An increasing number of studies have highlighted the existence of a sex-specific immune response, wherein men experience a worse prognosis in cases of acute inflammatory diseases. Initially, this sex-dependent inflammatory response was attributed to the influence of sex hormones. However, a growing body of evidence has shifted the focus toward the influence of chromosomes rather than sex hormones in shaping these inflammatory sex disparities. Notably, certain pattern recognition receptors, such as Toll-like receptors (TLRs), and their associated immune pathways have been implicated in driving the sex-specific immune response. These receptors are encoded by genes located on the X chromosome. TLRs are pivotal components of the innate immune system, playing crucial roles in responding to infectious diseases, including bacterial and viral pathogens, as well as trauma-related conditions. Importantly, the TLR-mediated inflammatory responses, as indicated by the production of specific proteins and cytokines, exhibit discernible sex-dependent patterns. In this review, we delve into the subject of sex bias in TLR activation and explore its clinical implications relatively to both the X chromosome and the hormonal environment. The overarching objective is to enhance our understanding of the fundamental mechanisms underlying these sex differences.
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Affiliation(s)
- Alexandros Popotas
- Laboratory of Pediatrics, Université Libre de Bruxelles, Brussels, Belgium
- Laboratory of Translational Research, Université Libre de Bruxelles, Brussels, Belgium
| | - Georges Jacques Casimir
- Laboratory of Pediatrics, Université Libre de Bruxelles, Brussels, Belgium
- Department of Pulmonology, Allergology and Cystic Fibrosis, Queen Fabiola Childrens University Hospital (Hôpital Universitaire des Enfants Reine Fabiola) – University Hospital of Brussels (Hôpital Universitaire de Bruxelles), Brussels, Belgium
| | - Francis Corazza
- Laboratory of Translational Research, Université Libre de Bruxelles, Brussels, Belgium
- Laboratory of Immunology, Centre Hospitalier Universitaire (CHU) Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Nicolas Lefèvre
- Laboratory of Pediatrics, Université Libre de Bruxelles, Brussels, Belgium
- Department of Pulmonology, Allergology and Cystic Fibrosis, Queen Fabiola Childrens University Hospital (Hôpital Universitaire des Enfants Reine Fabiola) – University Hospital of Brussels (Hôpital Universitaire de Bruxelles), Brussels, Belgium
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2
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Almossawi O, Friend A, Palla L, Feltbower RG, Sardo-Infiri S, O’Brien S, Harron K, Nadel S, Saunders P, De Stavola B. Is there a sex difference in mortality rates in paediatric intensive care units?: a systematic review. Front Pediatr 2023; 11:1225684. [PMID: 37876523 PMCID: PMC10591324 DOI: 10.3389/fped.2023.1225684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 08/30/2023] [Indexed: 10/26/2023] Open
Abstract
Introduction Mortality rates in infancy and childhood are lower in females than males. However, for children admitted to Paediatric Intensive Care Units (PICU), mortality has been reported to be lower in males, although males have higher admission rates. This female mortality excess for the subgroup of children admitted in intensive care is not well understood. To address this, we carried out a systematic literature review to summarise the available evidence. Our review studies the differences in mortality between males and females aged 0 to <18 years, while in a PICU, to examine whether there was a clear difference (in either direction) in PICU mortality between the two sexes, and, if present, to describe the magnitude and direction of this difference. Methods Any studies that directly or indirectly reported the rates of mortality in children admitted to intensive care by sex were eligible for inclusion. The search strings were based on terms related to the population (those admitted into a paediatric intensive care unit), the exposure (sex), and the outcome (mortality). We used the search databases MEDLINE, Embase, and Web of Science as these cover relevant clinical publications. We assessed the reliability of included studies using a modified version of the risk of bias in observational studies of exposures (ROBINS-E) tool. We considered estimating a pooled effect if there were at least three studies with similar populations, periods of follow-up while in PICU, and adjustment variables. Results We identified 124 studies of which 114 reported counts of deaths by males and females which gave a population of 278,274 children for analysis, involving 121,800 (44%) females and 156,474 males (56%). The number of deaths and mortality rate for females were 5,614 (4.61%), and for males 6,828 (4.36%). In the pooled analysis, the odds ratio of female to male mortality was 1.06 [1.01 to 1.11] for the fixed effect model, and 1.10 [1.00 to 1.21] for the random effects model. Discussion Overall, males have a higher admission rate to PCU, and potentially lower overall mortality in PICU than females. Systematic Review Registration www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=203009, identifier (CRD42020203009).
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Affiliation(s)
- Ofran Almossawi
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
- Institute of Child Health, University College London, London, United Kingdom
| | - Amanda Friend
- Department of Paediatric Oncology, Birmingham Children's Hospital, Birmingham, United Kingdom
| | - Luigi Palla
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
- Department of Global Health, Nagasaki University Institute of Tropical Medicine, Nagasaki, Japan
| | - Richard G. Feltbower
- Leeds Institute for Data Analytics, School of Medicine, University of Leeds, Leeds, United Kingdom
| | - Sofia Sardo-Infiri
- Department of Medical Statistics, The Royal Marsden Hospital, London, United Kingdom
| | - Scott O’Brien
- Research Fellow, Imperial Charity (NIHR/BRC), St. Mary's Hospital, London, United Kingdom
| | - Katie Harron
- Institute of Child Health, University College London, London, United Kingdom
| | - Simon Nadel
- Paediatric Intensive Care Unit, St. Mary's Hospital, London, United Kingdom
| | | | - Bianca De Stavola
- Institute of Child Health, University College London, London, United Kingdom
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3
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Collier F, Chau C, Mansell T, Faye-Chauhan K, Vuillermin P, Ponsonby AL, Saffery R, Tang MLK, O'Hely M, Carlin J, Gray LEK, Bekkering S, Burgner D. Innate Immune Activation and Circulating Inflammatory Markers in Preschool Children. Front Immunol 2022; 12:830049. [PMID: 35211111 PMCID: PMC8860896 DOI: 10.3389/fimmu.2021.830049] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 12/28/2021] [Indexed: 12/17/2022] Open
Abstract
Early childhood is characterised by repeated infectious exposures that result in inflammatory responses by the innate immune system. In addition, this inflammatory response to infection is thought to contribute to the epidemiological evidence linking childhood infection and adult non-communicable diseases. Consequently, the relationship between innate immune responses and inflammation during early life may inform prevention of NCDs later in life. In adults, non-genetic host factors such as age, sex, and obesity, strongly impact cytokine production and circulating mediators, but data in children are lacking. Here, we assessed cytokine responses and inflammatory markers in a population of healthy preschool children (mean age 4.2 years). We studied associations between cytokines, plasma inflammatory markers and non-genetic host factors, such as sex, age, adiposity, season, and immune cell composition. Similar to adults, boys had a higher inflammatory response than girls, with IL-12p70 and IL-10 upregulated following TLR stimulation. Adiposity and winter season were associated with increased circulating inflammatory markers but not cytokine production. The inflammatory markers GlycA and hsCRP were positively associated with production of a number of cytokines and may therefore reflect innate immune function and inflammatory potential. This dataset will be informative for future prospective studies relating immune parameters to preclinical childhood NCD phenotypes.
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Affiliation(s)
- Fiona Collier
- School of Medicine, Deakin University, Geelong, VIC, Australia.,Child Health Research Unit, Barwon Health, Geelong, VIC, Australia
| | - Cerys Chau
- Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, VIC, Australia
| | - Toby Mansell
- Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, VIC, Australia
| | | | - Peter Vuillermin
- School of Medicine, Deakin University, Geelong, VIC, Australia.,Child Health Research Unit, Barwon Health, Geelong, VIC, Australia.,Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, VIC, Australia
| | - Anne-Louise Ponsonby
- School of Medicine, Deakin University, Geelong, VIC, Australia.,Department of Neuroepidemiology, The Florey Institute of Neuroscience and Mental Health, Parkville, VIC, Australia
| | - Richard Saffery
- Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, VIC, Australia.,Department of Neuroepidemiology, The Florey Institute of Neuroscience and Mental Health, Parkville, VIC, Australia
| | - Mimi L K Tang
- Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, VIC, Australia.,Department of Paediatrics, Melbourne University, Parkville, VIC, Australia
| | - Martin O'Hely
- School of Medicine, Deakin University, Geelong, VIC, Australia.,Child Health Research Unit, Barwon Health, Geelong, VIC, Australia.,Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, VIC, Australia
| | - John Carlin
- Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, VIC, Australia.,Department of Paediatrics, Melbourne University, Parkville, VIC, Australia
| | | | - Siroon Bekkering
- Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, VIC, Australia.,Department of Internal Medicine and Radboud Institute for Molecular Life Science (RIMLS), Radboud University Medical Center, Nijmegen, Netherlands
| | - David Burgner
- Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, VIC, Australia.,Department of Paediatrics, Melbourne University, Parkville, VIC, Australia.,Department of Paediatrics, Monash University, Clayton, VIC, Australia
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Dzhalilova D, Kosyreva A, Vishnyakova P, Zolotova N, Tsvetkov I, Mkhitarov V, Mikhailova L, Kakturskiy L, Makarova O. Age-related differences in hypoxia-associated genes and cytokine profile in male Wistar rats. Heliyon 2021; 7:e08085. [PMID: 34632150 PMCID: PMC8488852 DOI: 10.1016/j.heliyon.2021.e08085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 08/25/2021] [Accepted: 09/26/2021] [Indexed: 11/29/2022] Open
Abstract
Hypoxia tolerance of the organism depends on many factors, including age. High newborn organisms tolerance and high level of oxidative stress throughout aging were demonstrated by many studies. However, there is lack of investigations reflecting the expression of key hypoxia-inducible factor HIF in different age organisms in correlation to levels of pro-inflammatory and anti-inflammatory cytokines. Liver is a sensitive to hypoxia organ, and is an important organ in providing an acute reaction to infections – it synthesizes acute inflammation phase proteins, in particular, C-reactive protein. The aim of study was to determine relationship between age-related tolerance to hypoxia and HIF-1 and PHD2 (prolyl hydroxylase domain protein) expression levels in the liver and the production of cytokines in the spleen in newborn, prepubertal and adult Wistar rats. Newborn rats are characterized by high mRNA Hif-1α expression level in the liver, accompanied by a low content of HIF-1 protein and high level of PHD2. The growth in HIF-1α protein level throughout age is accompanied by the growth of pro-inflammatory cytokines level. Prepubertal animals are the least hypoxia resistant and their HIF-1α mRNA expression level was higher than in adult animals. The PHD2 activity in prepubertal animals was significantly reduced in comparison to newborn rats, and the HIF-1α protein level did not change. Further studies require the identification of additional mechanisms, determining the regulation of the HIF-1α level in prepubertal animals.
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Affiliation(s)
- Dzhuliia Dzhalilova
- Department of Immunomorphology of Inflammation, Federal State Budgetary Institution Research Institute of Human Morphology, 117418, Tsurupa st., 3, Moscow, Russia
| | - Anna Kosyreva
- Department of Immunomorphology of Inflammation, Federal State Budgetary Institution Research Institute of Human Morphology, 117418, Tsurupa st., 3, Moscow, Russia.,Histology Department, Peoples Friendship University of Russia (RUDN University), 117198, Miklukho-Maklaya st. 6, Moscow, Russia
| | - Polina Vishnyakova
- Histology Department, Peoples Friendship University of Russia (RUDN University), 117198, Miklukho-Maklaya st. 6, Moscow, Russia.,National Medical Research Center for Obstetrics, Gynecology and Perinatology Named After Academician V.I. Kulakov of Ministry of Healthcare of Russian Federation, 117997, Oparina st., 4, Moscow, Russia
| | - Natalia Zolotova
- Department of Immunomorphology of Inflammation, Federal State Budgetary Institution Research Institute of Human Morphology, 117418, Tsurupa st., 3, Moscow, Russia
| | - Ivan Tsvetkov
- Department of Immunomorphology of Inflammation, Federal State Budgetary Institution Research Institute of Human Morphology, 117418, Tsurupa st., 3, Moscow, Russia
| | - Vladimir Mkhitarov
- Department of Immunomorphology of Inflammation, Federal State Budgetary Institution Research Institute of Human Morphology, 117418, Tsurupa st., 3, Moscow, Russia
| | - Liliya Mikhailova
- Department of Immunomorphology of Inflammation, Federal State Budgetary Institution Research Institute of Human Morphology, 117418, Tsurupa st., 3, Moscow, Russia
| | - Lev Kakturskiy
- Department of Immunomorphology of Inflammation, Federal State Budgetary Institution Research Institute of Human Morphology, 117418, Tsurupa st., 3, Moscow, Russia
| | - Olga Makarova
- Department of Immunomorphology of Inflammation, Federal State Budgetary Institution Research Institute of Human Morphology, 117418, Tsurupa st., 3, Moscow, Russia
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5
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Kosyreva AM, Dzhalilova DS, Makarova OV, Tsvetkov IS, Zolotova NA, Diatroptova MA, Ponomarenko EA, Mkhitarov VA, Khochanskiy DN, Mikhailova LP. Sex differences of inflammatory and immune response in pups of Wistar rats with SIRS. Sci Rep 2020; 10:15884. [PMID: 32985516 PMCID: PMC7522713 DOI: 10.1038/s41598-020-72537-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 09/02/2020] [Indexed: 12/13/2022] Open
Abstract
It is a common fact, that the content of sex hormones in humans and animals varies in different age periods. The functional state of the immune system also changes with age. However, sex differences studies of inflammatory and immune responses during puberty prevail in literature. Investigation of immune responses to LPS peculiarities in prepubertal females and males may contribute to the development of more effective immunotherapy and minimize side effects of children vaccination. Therefore, the aim of this work was to investigate the LPS-induced SIRS sex differences in prepubertal Wistar rats. Despite the absence of sex differences in estradiol and testosterone levels, LPS-induced inflammatory changes in liver and lungs are more pronounced among males. Males demonstrate the increasing neopterin, corticosterone levels and alanine aminotransferase (ALT) and aspartate aminotransferase (AST) activity. Not less important is that in females, demonstrating less morphological changes in liver and lungs, endotoxin level is tenfold higher, and corticosterone level decreases. Thus, endotoxin cannot be used as a marker of the severity of multiple organ failure in prepubertal period. The LPS-induced immune reactions in females and males are similar and are characterized by immunosuppression. Both females and males have decreased production of cytokines (IL-2, IL-4, TNF-α, TGF-β) and the absolute number of CD3 + and CD3 + CD8 + lymphocytes in blood. The acute atrophy of thymus and apoptosis of thymic cells are revealed in animals of both sexes. However, the number of CD3 + CD4 + T-helpers and CD4 + CD25 + Foxp3 + T-cells decreases only in females with SIRS, and in males there was a decrease of CD45R + B-cells. The least expressed sex differences in immune responses in the prepubertal period can be determined by the low levels of sex steroids and the absence of their immunomodulatory effect. Further studies require the identification of mechanisms, determining the sex differences in the inflammatory and immune responses in prepubertal animals.
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Affiliation(s)
- Anna M Kosyreva
- Department of Immunomorphology of Inflammation, Research Institute of Human Morphology, Tsyurupi str 3, 117418, Moscow, Russia. .,Medical Institute of Peoples' Friendship, University of Russia (RUDN University), Moscow, Russia.
| | - Dzhuliia Sh Dzhalilova
- Department of Immunomorphology of Inflammation, Research Institute of Human Morphology, Tsyurupi str 3, 117418, Moscow, Russia
| | - Olga V Makarova
- Department of Immunomorphology of Inflammation, Research Institute of Human Morphology, Tsyurupi str 3, 117418, Moscow, Russia
| | - Ivan S Tsvetkov
- Department of Immunomorphology of Inflammation, Research Institute of Human Morphology, Tsyurupi str 3, 117418, Moscow, Russia
| | - Natalia A Zolotova
- Department of Immunomorphology of Inflammation, Research Institute of Human Morphology, Tsyurupi str 3, 117418, Moscow, Russia
| | - Marina A Diatroptova
- Department of Immunomorphology of Inflammation, Research Institute of Human Morphology, Tsyurupi str 3, 117418, Moscow, Russia
| | - Elena A Ponomarenko
- Department of Immunomorphology of Inflammation, Research Institute of Human Morphology, Tsyurupi str 3, 117418, Moscow, Russia
| | - Vladimir A Mkhitarov
- Department of Immunomorphology of Inflammation, Research Institute of Human Morphology, Tsyurupi str 3, 117418, Moscow, Russia
| | - Dmitriy N Khochanskiy
- Department of Immunomorphology of Inflammation, Research Institute of Human Morphology, Tsyurupi str 3, 117418, Moscow, Russia
| | - Liliya P Mikhailova
- Department of Immunomorphology of Inflammation, Research Institute of Human Morphology, Tsyurupi str 3, 117418, Moscow, Russia
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6
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Lefèvre N, Corazza F, Valsamis J, Delbaere A, De Maertelaer V, Duchateau J, Casimir G. The Number of X Chromosomes Influences Inflammatory Cytokine Production Following Toll-Like Receptor Stimulation. Front Immunol 2019; 10:1052. [PMID: 31143188 PMCID: PMC6521177 DOI: 10.3389/fimmu.2019.01052] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 04/24/2019] [Indexed: 02/05/2023] Open
Abstract
Sex differences are observed in the evolution of numerous inflammatory conditions. Women exhibit better clinical courses compared to men in acute inflammatory processes, yet worse prognosis in several chronic inflammatory diseases. Inflammatory markers are significantly different between prepubertal boys and girls, whose sex steroid levels are very low, suggesting genetics play a role. To evaluate the potential influence of the X chromosome, we studied cytokine production and protein phosphorylation following Toll-like receptor (TLR) activation in whole blood and purified neutrophils and monocytes of healthy adults of both sexes as well as subjects with Klinefelter syndrome. We recorded higher levels of inflammatory cytokines in men compared to both women and patients with Klinefelter syndrome following whole blood stimulation. In purified monocytes, production of inflammatory cytokines was also higher in men compared to women, while Klinefelter subjects expressed the same pattern of cytokine production as males, in contrast with whole blood analyses. These differences remained after adjusting for sex steroid levels. Our study revealed higher cytokine inflammatory responses in men than women, yet also compared to subjects with Klinefelter syndrome, who carry two copies of the X chromosome, like women, and thus potentially benefit from the cellular mosaicism of X-linked genes.
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Affiliation(s)
- Nicolas Lefèvre
- Department of Pulmonology, Allergology and Cystic Fibrosis, Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, Brussels, Belgium.,Laboratory of Translational Research, Université Libre de Bruxelles, Brussels, Belgium
| | - Francis Corazza
- Laboratory of Translational Research, Université Libre de Bruxelles, Brussels, Belgium
| | - Joseph Valsamis
- Laboratory of Hormonology, Hôpital Universitaire Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Anne Delbaere
- Fertility Clinic, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Viviane De Maertelaer
- Department of Biostatistics and Medical Computing, Université Libre de Bruxelles, Brussels, Belgium
| | - Jean Duchateau
- Laboratory of Pediatrics, Université Libre de Bruxelles, Brussels, Belgium
| | - Georges Casimir
- Department of Pulmonology, Allergology and Cystic Fibrosis, Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, Brussels, Belgium.,Laboratory of Pediatrics, Université Libre de Bruxelles, Brussels, Belgium
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7
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Casimir GJ, Lefèvre N, Corazza F, Duchateau J, Chamekh M. The Acid-Base Balance and Gender in Inflammation: A Mini-Review. Front Immunol 2018; 9:475. [PMID: 29593728 PMCID: PMC5854649 DOI: 10.3389/fimmu.2018.00475] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Accepted: 02/22/2018] [Indexed: 12/31/2022] Open
Abstract
In humans, acid–base balance is crucial to cell homeostasis. Acidosis is observed in numerous inflammatory processes, primarily acute conditions such as sepsis, trauma, or acute respiratory distress where females tend to exhibit better prognosis compared with males. The mechanisms underlying these gender-dependent differences are multiple, probably involving hormonal and genetic factors, particularly the X chromosome. Although pH influences multiple immunological functions, gender differences in acid–base balance have been poorly investigated. In this review, we provide an update on gender differences in human susceptibility to inflammatory diseases. We additionally discuss the potential impact of acid–base balance on the gender bias of the inflammatory response in view of our recent observation that girls present higher neutrophilic inflammation and lower pH with a trend toward better prognosis in severe sepsis. We also highlight the potent role played by endothelial cells in gender differences of inflammation through activation of proton-sensing G protein-coupled receptors.
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Affiliation(s)
- Georges Jacques Casimir
- Laboratoire académique de Pédiatrie, Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, Brussels, Belgium
| | - Nicolas Lefèvre
- Laboratoire académique de Pédiatrie, Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, Brussels, Belgium.,Laboratoire de Médecine translationnelle, Centre Hospitalier Universitaire Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Francis Corazza
- Laboratoire de Médecine translationnelle, Centre Hospitalier Universitaire Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Jean Duchateau
- Laboratoire académique de Pédiatrie, Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, Brussels, Belgium
| | - Mustapha Chamekh
- Laboratoire académique de Pédiatrie, Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, Brussels, Belgium
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