Regular physical activity and clinical outcomes Inflammation and bacterial defense

1. Regular physical activity and clinical outcomes Inflammation and bacterial defense Pauline van de Weert – van Leeuwen, MD, PhD-student Cystic Fibrosis centre, University medical Centre Utrecht, The Netherlands

2. Exercise programs can have favorable effects in patients with CF, but be aware of possible detrimental effects A real world example

3. Presentation outline • Introduction • Human study • Effect acute exercise • Regular physical activity • Mouse study • Regular physical activity

4. Acute exercise induces a transient pro-inflammatory profile in healthy individuals • Transient pro-inflammatory profile, dominated by: • Neutrophils • Natural killer cells • cytotoxic T cells •  all effector cells  removal apoptotic cells, bacteria, viruses • Cytokine: interleukin 6

5. Regular exercise can dampen inflammation Regular exercise induces: • Induces: Immune tolerance - ↓ production of pro-inflammatory cytokines to a potent stimulus • Caused by: repetitive stimulation of the immune system • Consequence: dampen inflammation in patients suffering from low-grade inflammation • Patients with atherosclerosis, obesitas, etc. • Can regular exercise dampen inflammation in patients with CF as well? Severe chronic inflammation?

6. Relationship between exercise & infections • In healthy controls moderate exercise seems to correlate with a lower infection rate • Viral infections Can regular exercise decrease infection load in patients with CF as well? Bacterial pulmonary infections?

7. Hypothesis • Induces leukocytosis • Increases defense against P. aeruginosa Acute exercise: Regular exercise: • Decreases inflammation • Increases defense against P. aeruginosa

8. HUMAN STUDY

9. Cross-over trial T1 T2 T3 T4 T1 Training period 12 weeks Control period 12 weeks Control period 12 weeks Training period 12 weeks T4 T3 T2

10. 17 patients with CF were included

11. Measurements of bacterial defense mechanisms • Immunoglobulins (IgG) in serum 2. Attachment leukocyte to bacteria 3. Phagocytosis bacteria by leukocyte 4. Killing of bacteria IgG pseudomonas IgG pseudomonas pseudomonas phagocyte IgG pseudomonas

12. Immunological measurements [1] Inflammatory markers leukocyte levels IgG levels [2] Phagocytosis assay phagocytosis of P. aeruginosa by leukocytes

13. EFFECT OF ACUTE EXERCISE T1 T2 T3 T4 Exercise training Control period Control period Exercise training T4 T1 T2 T3 Hypothesis: • Induces leukocytosis • Increases bacterial defense against P. aeruginosa

14. Results 1 - Significant increases in all leukocyte subsets

15. Results 1 - Small changes in IgG levels IgG total IgG1 IgG2 IgG3 IgG4 0.001 0.002 0.005 0.001 0.154 Exercise induced change (%) Relevance?

16. No difference in serum dependent phagocytic capacity Exercise stimulated serum % of leukocytes bound to P. aeruginosa

17. Conclusion • In patients with CF, exercise leads to a leukocytosis dominated by NK cells and cytotoxic T cells, comparable to that seen in healthy controls. • Phagocytosis of P. aeruginosa by leukocytes is dependent of IgG • Exercise induced significant increases in absolute IgG levels, • However it did not change the capacity of serum to mediate phagocytosis of P. aeruginosa by leukocytes. • Leukocytes of healthy controls are used • Maybe exercise induced changes are not serum dependent, but become visible upon use of exercise stimulated leukocytes

18. T1 T2 T3 T4 EFFECT OF REGULAR EXERCISE Exercise training Control Control Exercise training T4 T1 T2 T3 Regular exercise: • Decreases inflammation • Increases bacterial defense against P. aeruginosa

19. No change in exercise capacity and lung function

20. Confounding factors that may have influenced the study results Compliance Disease frequency

21. Discussion • Results of this study: did not meet our expectations • Difficult to develop an appropriate exercise training program in which effect on infection & inflammation can be studied • High compliance required to establish a training induced effect • Heterogeneous group of patients  big sample sizes • Many confounding factors • Disease frequency • Use of antibiotics

22. MOUSE STUDY • In collaboration with the University of Copenhagen & Rigshospitalet, Copenhagen, Denmark • Department of Clinical Microbiology • Copenhagen Muscle Research Centre, Institute of Exercise and Sport Sciences

23. Hypothesis Normal physical active Balb/c mice are less vulnerable for a pulmonary infection with P. aeruginosa compared to sedentary mice

24. Protocol START Running wheel (n = 20) No running wheel (n = 20) 0 - 4 Weekly: running distance 4+1 Intranasalinoculation P. aeruginosa 4+1+8h Symptomseverity score END Wk 4+2 CFUspseudomonaslung

25. Average running distance

26. Sedentary mice had a better clinical score post-infection P = 0.036 Maximum score = 12

27. Sedentary mice had less colony forming units in their lungs p-value = 0.047

28. Conclusion • Sedentary mice: • Less vulnerable for a pulmonary infection with P. aeruginosa • Lower CFU count • Less worse clinical score

29. Summary • Acute exercise induces a leukocytosis, dominated by NK cells and cytotoxic T cells • Exercise stimulated serum could not change phagocytic capacity of leukocytes, although IgG levels were significantly increased • Results suggest that exercise training can • ↑disease frequency – CF patients • ↑disease severity – mice

30. Take home messages The results emphasize the importance of measuring not only absolute values, but functionality of the immune system as well Functional tests show the relevance of changes in absolute values

31. Take home messages Regular exercise can have positive effects on clinical outcome in patients with CF, but be aware of possible detrimental effects

32. University Medical Centre Utrecht, The Netherlands Pediatric Pulmonology: Prof. C.K. Van der Ent MD PhD H.G.M. Arets MD PhD S. Michel, research nurse Pediatric exercise and physical therapy centre: H.J. Hulzebos PT PhD M.W. Werkman PT PhD-student Molecular Immunology Lab: J.M. Beekman MSc, PhD, Postdoc M.A. Van Meegen MD, PhD student L.A.W. Vijftigschild MSc Rigshospitalet Copenhagen & University of Copenhagen, Denmark Department of Clinical Microbiology H.K. Johasen MD PhD O .Ciofu MD PhD Copenhagen Muscle Research Centre, Institute of Exercise and Sport Sciences Prof. J.F.P. Wojtazewski MSc PhD J. Fentz MSc PhD student