Secondary Logo

Journal Logo

Institutional members access full text with Ovid®

Myeloid-Derived Suppressor Cells Mediate Immunosuppression After Cardiopulmonary Bypass

Hübner, Max MD1,2; Tomasi, Roland MD1,2; Effinger, David MD1,2; Wu, Tingting MD2; Klein, Gregor1; Bender, Martin MD1; Kilger, Erich MD1; Juchem, Gerd MD3; Schwedhelm, Edzard PhD4; Kreth, Simone MD, PhD1,2

doi: 10.1097/CCM.0000000000003820
Online Laboratory Investigations

Objectives: Cardiopulmonary bypass is associated with severe immune dysfunctions. Particularly, a cardiopulmonary bypass–related long-lasting immunosuppressive state predisposes patients to a higher risk of postoperative complications, such as persistent bacterial infections. This study was conducted to elucidate mechanisms of post-cardiopulmonary bypass immunosuppression.

Design: In vitro studies with human peripheral blood mononuclear cells.

Setting: Cardiosurgical ICU, University Research Laboratory.

Patients: Seventy-one patients undergoing cardiac surgery with cardiopulmonary bypass (enrolled May 2017 to August 2018).

Interventions: Peripheral blood mononuclear cells before and after cardiopulmonary bypass were analyzed for the expression of immunomodulatory cell markers by real-time quantitative reverse transcription polymerase chain reaction. T cell effector functions were determined by enzyme-linked immunosorbent assay, carboxyfluorescein succinimidyl ester staining, and cytotoxicity assays. Expression of cell surface markers was assessed by flow cytometry. CD15+ cells were depleted by microbead separation. Serum arginine was measured by mass spectrometry. Patient peripheral blood mononuclear cells were incubated in different arginine concentrations, and T cell functions were tested.

Measurements and Main Results: After cardiopulmonary bypass, peripheral blood mononuclear cells exhibited significantly reduced levels of costimulatory receptors (inducible T-cell costimulator, interleukin 7 receptor), whereas inhibitory receptors (programmed cell death protein 1 and programmed cell death 1 ligand 1) were induced. T cell effector functions (interferon γ secretion, proliferation, and CD8+-specific cell lysis) were markedly repressed. In 66 of 71 patients, a not yet described cell population was found, which could be characterized as myeloid-derived suppressor cells. Myeloid-derived suppressor cells are known to impair immune cell functions by expression of the arginine-degrading enzyme arginase-1. Accordingly, we found dramatically increased arginase-1 levels in post-cardiopulmonary bypass peripheral blood mononuclear cells, whereas serum arginine levels were significantly reduced. Depletion of myeloid-derived suppressor cells from post-cardiopulmonary bypass peripheral blood mononuclear cells remarkably improved T cell effector function in vitro. Additionally, in vitro supplementation of arginine enhanced T cell immunocompetence.

Conclusions: Cardiopulmonary bypass strongly impairs the adaptive immune system by triggering the accumulation of myeloid-derived suppressor cells. These myeloid-derived suppressor cells induce an immunosuppressive T cell phenotype by increasing serum arginine breakdown. Supplementation with L-arginine may be an effective measure to counteract the onset of immunoparalysis in the setting of cardiopulmonary bypass.

1Department of Anesthesiology, University Hospital, LMU Munich, Munich, Germany.

2Walter-Brendel Center of Experimental Medicine, Faculty of Medicine, LMU Munich, Munich, Germany.

3Department of Cardiac Surgery, University Hospital, LMU Munich, Munich, Germany.

4Institute of Clinical Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.

Drs. Hübner and Tomasi contributed equally to this work.

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 website (

Supported, in part, by institutional grants of the LMU Munich.

The authors have disclosed that they do not have any potential conflicts of interest.

Address requests for reprints to: Simone Kreth, MD, PhD, Department of Anesthesiology, University Hospital, LMU Munich, Marchioninistr 15, 81377 Munich, Germany. E-mail:

Copyright © 2019 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.