Succinate Activation of SUCNR1 Predisposes Severely Injured Patients to Neutrophil-mediated ARDS

Nunns, Geoffrey R. MD^*; Vigneshwar, Navin MD^*; Kelher, Marguerite R. MS^*,†; Stettler, Gregory R. MD^*; Gera, Lajos PhD^‡; Reisz, Julie A. PhD^‡; D’Alessandro, Angelo PhD^‡; Ryon, Joshua BA^*; Hansen, Kirk C. PhD^‡; Gamboni, Fabia PhD^‡; Moore, Ernest E. MD^*,§; Peltz, Erik D. DO^*; Cohen, Mitchell J. MD^*,§; Jones, Kenneth L. PhD^∥; Sauaia, Angela MD, PhD^§,¶; Liang, Xiayuan MD^#; Banerjee, Anirban PhD^*; Ghasabyan, Arsen MPH^*; Chandler, James G. BS^*; Rodawig, Sophia^†,**; Jones, Carter^†,††; Eitel, Andrew MD^*; Hom, Patrick BS^*; Silliman, Christopher C. MD, PhD^*,∥,†

Author Information

^*Department of Surgery, School of Medicine University of Colorado, Aurora, Colorado

^†Department of Biochemistry and Molecular Genetics, School of Medicine University of Colorado, Aurora, Colorado

^‡Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado

^§Department of Pathology, School of Medicine, University of Colorado, Aurora, Colorado

^∥Department of Surgery, Denver Health Medical Center, Denver, Colorado; School of Public Health, University of Colorado, Aurora, Colorado

^#Vitalant Research Institute, Vitalant Denver, Denver, Colorado

^**College of Arts and Letters, University of Notre Dame, Notre Dame, Illinois

^††College of Engineering, Georgia Institute of Technology, Atlanta

[email protected].

Author Contributions: GRN and NV are co-first authors because they both performed identical amounts of scientific experiments and writing. GRN, JR, GRS, AG, and JGC collected clinical data from patients and blindly adjudicated chest x-rays. AD, JR, JAR, KCH performed metabolomics analyses. GRN, MRK, SR, CJ, and CCS performed PMN experiments, FG performed immunofluorescence. CCS, FB, and XL performed histological assessments. GRN, GRS, NV, AE, and MK performed animal experiments. GRN, GRS, PH, and XL performed assays on animal samples. GN, AS, CCS, MK, and KLJ completed the performed statistical analyses. LG synthesized the inhibitor. GRN, CCS, MK, AB, EDP, and EEM were responsible for experimental design and writing the manuscript.

Additional Funding and Support were also provided by Vitalant Research institute, Denver, CO.

This work was supported by grants #P50-GM049222, T32-GM008315, and 1RM1GM131968 from NIGMS, NIH, grant #UM1-HL120877 from NHLBI, NIH, grant #W81XWH-12-2-2008 from the Department of Defense.

CCS and AD serve on the Scientific Advisory Board for Hemanext.

The authors declare no conflict of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.annalsofsurgery.com).

Annals of Surgery276(6):p e944-e954, December 2022. |DOI:10.1097/SLA.0000000000004644

Abstract

Objectives:

Identify the metabolites that are increased in the plasma of severely injured patients that developed ARDS versus severely injured patients that did not, and assay if these increased metabolites prime pulmonary sequestration of neutrophils (PMNs) and induce pulmonary sequestration in an animal model of ARDS. We hypothesize that metabolic derangement due to advanced shock in critically injured patients leads to the PMNs, which serves as the first event in the ARDS.Summary of Background Data: Intracellular metabolites accumulate in the plasma of severely injured patients.

Methods:

Untargeted metabolomics profiling of 67 critically injured patients was completed to establish a metabolic signature associated with ARDS development. Metabolites that significantly increased were assayed for PMN priming activity in vitro. The metabolites that primed PMNs were tested in a 2-event animal model of ARDS to identify a molecular link between circulating metabolites and clinical risk for ARDS.

Results:

After controlling for confounders, 4 metabolites significantly increased: creatine, dehydroascorbate, fumarate, and succinate in trauma patients who developed ARDS (P < 0.05). Succinate alone primed the PMN oxidase in vitro at physiologically relevant levels. Intravenous succinate-induced PMN sequestration in the lung, a first event, and followed by intravenous lipopolysaccharide, a second event, resulted in ARDS in vivo requiring PMNs. SUCNR1 inhibition abrogated PMN priming, PMN sequestration, and ARDS.Conclusion: Significant increases in plasma succinate post-injury may serve as the first event in ARDS. Targeted inhibition of the SUCNR1 may decrease ARDS development from other disease states to prevent ARDS globally.