Molecular hydrogen attenuates sepsis-induced neuroinflammation through regulation of microglia polarization through an mTOR-autophagy-dependent pathway

International Immunopharmacology 81 (2020) 106287

Contents lists available at ScienceDirect

International Immunopharmacology journal homepage: www.elsevier.com/locate/intimp

Molecular hydrogen attenuates sepsis-induced neuroinflammation through regulation of microglia polarization through an mTOR-autophagydependent pathway☆

T

⁎

Xinqi Zhuanga, Yang Yub, , Yi Jiangb, Sen Zhaoa, Yuzun Wangb, Lin Sub, Keliang Xieb, ⁎ Yonghao Yub, , Yuechun Lua, Guoyi Lva a b

Department of Anesthesiology, The Second Hospital of Tianjin Medical University, Tianjin 300211, China Department of Anesthesiology, Tianjin Medical University General Hospital, Tianjin 300052, China

A R T I C LE I N FO

A B S T R A C T

Keywords: Hydrogen Sepsis Neuroinflammation Microglia polarization Autophagy

Sepsis-associated encephalopathy (SAE) is the cognitive impairment resulting from sepsis and is associated with increased morbidity and mortality. Hydrogen has emerged as a promising therapeutic agent to alleviate SAE. The mechanism, however, remains unclear. This research aimed to determine whether hydrogen alleviates SAE by regulating microglia polarization and whether it is mediated by the mammalian target of rapamycin (mTOR)autophagy pathway. Septic models were established by cecal ligation and puncture (CLP) performed on mice. The Morris Water Maze was used to evaluate cognitive function. M1/M2 microglia polarization was assessed by immunofluorescence. Inflammatory cytokines were determined by ELISA. Septic cell models were established using BV-2 cells incubated with 1 μg/ml lipopolysaccharide (LPS). M1/M2 microglia polarization was assessed by flow cytometry. Inflammatory cytokines from culture medium supernatant were determined by ELISA, and associated protein expression levels of mTOR-autophagy pathway were assessed by Western blot. Hydrogen inhalation attenuated sepsis-induced cognitive impairment with improved escape latency, time spent in the target platform quadrant and number of times crossing the target platform. In both animal and cell research, hydrogen reduced TNF-α, IL-6 and HMGB1 levels and M1 polarization, but increased IL-10 and TGF-β levels and M2 polarization. Hydrogen treatment decreased the ratio of p-mTOR/mTOR and the expression of p62 and increased the ratio of p-AMPK/AMPK, LC3II/LC3I and the expression of TREM-2 and Beclin-1 in LPS-treated BV2 cells. MHY1485, an mTOR activator, abolished the protective effects of hydrogen in vitro. Taken together, these results demonstrated that hydrogen attenuated sepsis-induced neuroinflammation by modulating microglia polarization, which was mediated by the mTOR-autophagy signaling pathway.

1. Introduction Sepsis is a kind of systematic inflammatory syndrome that is a main reason for intensive care unit admission and a leading cause of death [1,2]. Many sepsis patients exhibit cognitive impairment, which is called sepsis-associated encephalopathy (SAE) [3]. It occurs secondary to sepsis and manifests as diffused cerebral dysfunction. SAE has high morbidity in septic patients and is always associated with high mortality [4]. Even for the survivors of SAE, altered mental status and longterm cognitive impairment can persist for several years [5,6].

Molecular hydrogen has emerged as a promising therapeutic agent that can be effectively used for the treatment of more than 70 types of disease [7]. Our previous studies indicated that hydrogen gas inhalation or hydrogen-rich saline injection could protect against sepsis or septic organ damage, including in the lung, liver, intestines and brain [8–11]. In addition, our previous research also showed that 2% hydrogen gas inhalation could alleviate sepsis-induced cognitive dysfunction in rodent models [11,12]. However, the underlying mechanism remains uncertain. Although the pathophysiology of SAE has not been fully elucidated,

☆ This study was supported by the National Natural Science Foundation of China (grant no. 81772043, 81,671,888 and 81971879), Natural Science Foundation of Tianjin (grant no. 17JCYBJC24800), and Science and Technology Support Key Program Affiliated with the Key Research and Development Plan of Tianjin Science and Technology Project (grant no. 18YFZCSY00560). ⁎ Corresponding authors at: Department of Anesthesiology, Tianjin Medical University General Hospital, No. 154 Anshan Rd, Heping District, Tianjin 300052, China. E-mail addresses: [email protected] (Y. Yu), [email protected] (Y. Yu).

https://doi.org/10.1016/j.intimp.2020.106287 Received 25 September 2019; Received in revised form 20 January 2020; Accepted 2 February 2020 1567-5769/ © 2020 Elsevier B.V. All rights reserved.

International Immunopharmacology 81 (2020) 106287

X. Zhuang, et al.

sterile saline) was given via subcutaneous injection immediately after the operation. Any mouse that died within 8 days after sham or CLP operation was excluded.

several investigations have revealed its potential mechanism, such as blood brain barrier compromise, inflammatory cytokine involvement and neuroinflammation [13–15]. Recent studies have shown that cognitive impairment is associated with inflammatory cytokines release and cerebral inflammation, which might be due to microglia activation and polarization [16]. Microglia are the immune cells in the CNS and can be activated in a pathological state. Microglia are thought to play a dual role in cerebral inflammation according their polarization. One detrimental polarization (M1) mainly secretes pro-inflammatory factors, mediates inflammation and aggravates neurologic deficits. A beneficial form of polarization (M2) mainly secretes anti-inflammatory factors, inhibits inflammation and promotes tissue recovery [17]. It is reported that in animal models of sepsis, activated microglia mainly present with M1 polarization and have destructive effects [18]. A therapeutic approach to modulating their polarization could alleviate cerebral inflammation and attenuate cognitive impairment [18]. Several researchers have revealed the relationship between microglia polarization and the mammalian target of rapamycin (mTOR)-autophagy signaling pathway [19,20]. mTOR, which is regulated by upstream kinases of adenosine 5′-monophosphate-activated protein kinase (AMPK), is an important regulator of basic cellular activity. mTOR takes 2 forms as mTORC1 and mTORC2. mTORC1 regulates cellular activities including autophagy. Inhibition of mTOR could promote autophagy, which affects immune response and cytokine secretion processes [21,22]. Recently, it has been reported that regulating mTOR and autophagy could modulate microglia polarization and alleviate cerebral inflammation in neurodegenerative diseases, spinal injury, ischemicreperfusion injury and septic encephalopathy [23–25]. Furthermore, as an immunoglobin superfamily receptor present on microglia, triggering receptor expressed on myeloid cells-2 (TREM-2) participated in microglia regulation [26]. As little is known regarding what exact role TREM-2 plays and how it affects SAE progression, investigations are needed to reveal its function. Therefore, our current study hypothesized that hydrogen gas could alleviate SAE by switching the microglia polarization that is mediated by the mTOR-autophagy signaling pathway. We performed both in vivo and in vitro studies to test our hypothesis and the expression of TREM-2 was also observed.

2.3. Establishment of cell models The mouse BV-2 microglia cell lines (cat. no. ZQ0397) from Zhongqiao Biological Technology Co., Ltd. (Shanghai, China) were used for in vitro experiments. Cells were cultured in minimum Eagle’s medium (MEM) with 10% fetal bovine serum (FBS) and 1% streptomycin and penicillin (all Invitrogen; Thermo Fisher Scientific, Inc., Waltham, MA, USA) and cultivated in a Forma 3 incubator (Thermo Fisher Scientific, Inc.) at 37℃ and 5% CO2. The second and third passages were selected for the subsequent experiments. 2.4. Experimental design For animal research, all mice were randomly divided into 4 groups using a random number table: Sham group, Sham + H2 group, CLP group and CLP + H2 group. The sepsis model was reproduced by performing the cecal ligation and puncture (CLP) operation in the CLP and CLP + H2 groups. The Sham and Sham + H2 group underwent the same process except for cecal ligation and puncture. Hydrogen gas (2%) was inhaled for 60 min in the Sham + H2 and CLP + H2 groups at 1 h and 6 h after the operation, whereas the Sham and CLP groups inhaled air only. At 24 h after sham or CLP operation, mice were sacrificed and perfused for brain tissue (hippocampus) harvest. Different groups of mice (n = 10 mice per group) were used for the Morris Water Maze (MWM) test from D4 to D8 after sham or CLP operation. The hippocampi (n = 6 mice per group) of each group were used for TNF-α, IL-6, HMGB1, TGF-β and IL-10 detection by ELISA. Brain slices (n = 4 per group) of each group were used for Iba-1, CD86 and CD206 analysis by immunofluorescence (as shown in Fig. 1A). For cell experiments, the BV-2 cells were randomly divided into 4 groups using a random number table: Control group, lipopolysaccharide (LPS) group, LPS + H2 group and LPS + H2 + MHY1485 group. In the Control group, cells were cultured in FBS-free DMEM for 24 h. In the LPS group, LPS (cat. no. L8880, Solarbio, Beijing, China) was added at a final concentration of 1 μg/ml, and cells were incubated in FBS-free DMEM for 24 h. In the LPS + H2 group, LPS was added at a final concentration of 1 μg/ml, the medium was replaced with a

2. Materials and methods 2.1. Animals Male C57BL/6J mice, aged 6–8 weeks and weighing 20–25 g, were purchased from the Experimental Animal Center of the Institute of Sanitation and Environmental Medicine, Academy of Military Medical Sciences (license number, SCXK 2014-0001; Tianjin, China). All mice were raised in cages (5 mice per cage) in a standard controlled environment (temperature 21–23 °C, humidity 50–60%, 12:12 h lightdark cycle). The animal protocol was approved by the Institutional Animal Care and Use Committee of Tianjin Medical University General Hospital (Tianjin, China). Efforts were made to minimize the number of animals used in the studies. 2.2. Cecal ligation and puncture (CLP) models Sepsis was established by cecal ligation and puncture (CLP) as previously described [10]. After a week acclimating to the lab environment, the mice were anesthetized with sevoflurane and sterilized in a prone position. Ophthalmic scissors were used to open the skin and peritoneum to expose the cecum. The cecum was ligated with surgical sutures in the 1/4 distance to the end below the ileocecal flap and then punctured with a 20G sterilized needle. The intestinal content was pushed out for approximately 0.3 ml and returned to the abdominal cavity; then, the peritoneum and skin were closed by stitching. In addition, a single dose of antibiotics (Primaxin, 0.5 mg/mouse in 200 μL

Fig. 1. Experimental design. (A) Male C57BL/6J mice, aged 6–8 weeks and weighing 20–25 g, were subjected to sham or CLP operation. Then, 2% hydrogen gas or fresh air was inhaled for 1 h starting from 1 and 6 h after CLP or sham surgery, respectively. The hippocampi of different groups were collected for tests 24 h after the sham or CLP operation. The Morris Water Maze task was carried out from the 4th to 8th days after the sham or CLP operation. (B) The mouse BV-2 microglia cell lines were incubated with Control medium, LPS medium, LPS + H2 medium and LPS + H2 + MHY1485 medium. The cells and culture medium supernatants were collected for testing on 24 h after incubation. CLP, cecal ligation and puncture; LPS, lipopolysaccharide. 2

International Immunopharmacology 81 (2020) 106287

X. Zhuang, et al.

hydrogen-rich medium at a final concentration of 0.6 mM and cells were incubated for 24 h. In the LPS + H2 + MHY1485 group, MHY1485 (the specific activator of mTOR, cat. no. SML0810, SigmaAldrich, USA) was added at a final concentration of 10 mM, and the subsequent treatment was the same as the LPS + H2 group. After 24 h of treatment in the different groups, cell samples were harvested. Samples were used for TNF-α, IL-6, HBMG1, TGF-β and IL-10 detection by ELISA (n = 6 samples per group), for Iba-1, CD86 and CD206 measurements by flow cytometry (n = 4 samples per group), and for pAMPK, AMPK, p-mTOR, mTOR, TREM-2, LC3I, LC3II, Beclin-1 and p62 expression measurements with Western blot (n = 6 samples per group) (as shown in Fig. 1B).

2.8. Enzyme-linked immunosorbent assay (ELISA) For the animal experiment, the hippocampal tissue was stripped and homogenized. After centrifugation at 15,000 g for 10 min, the supernatants were collected. For the cytology experiment, the supernatants were collected from the culture medium. Cytokines were detected by mouse ELISA assay kits that detect tumor necrosis factor (TNF)-α (cat. no. E-EL-M0049c), IL-6 (cat. no. E-EL-M0044c), IL-10 (cat. no. E-ELM0046c) and transforming growth factor (TGF)-β (cat. no. E-EL-0162c) from Elabscience Biological Technology Co., Ltd. (Wuhan, China) and HMGB1 (cat. no. BOS-14703) from BOSK Co., Ltd. (Wuhan, China). All experiments were conducted in accordance with the manufacturer’s instructions as previously described [8].

2.5. Hydrogen gas treatment 2.9. Immunofluorescence

As described previously [10], the animals in the Sham + H2 and CLP + H2 groups were put into a sealed plastic box with inflow and outflow outlets. Hydrogen gas (mixed with air) was supplied by a TF-1 gas flowmeter (YUTAKA Engineering Corp, Tokyo, Japan) and delivered through a tube at a rate of 4 l/min. The concentration of H2 in the box was continuously monitored by a HY-ALERTA handheld detector (Model 500; H2 Scan, Valencia, CA) and maintained at 2% during the treatment period (2% H2 was inhaled for 60 min each time, at both 1 h and 6 h after CLP or sham operations). The animals in the Sham and CLP groups were put into another box (same as the box used in the Sham + H2 and CLP + H2 groups) and breathed air instead of H2.

Twenty-four hours after the sham or CLP operation, the mice were deeply anesthetized by sevoflurane and transcardially perfused using phosphate buffered saline (PBS) to obtain the brain without blood. The brain was fixed with 4% paraformaldehyde for 24 h and then frozen and cut into 10 mm sections. After returning to room temperature, the slides were permeabilized with 0.3% Triton for 5 min and blocked using 5% bovine serum albumin for 30 min. After washing three times with PBS, the slides were incubated with rabbit anti-ionized calcium binding adapter molecule-1 (Iba-1, 1:500; cat. no. ab178846) and rat anti-CD86 (1:500; cat. no. ab119857) or CD206 (1:500; cat. no. ab8918) primary antibodies from Abcam (Cambridge, UK) at 4℃ overnight. After washing three times with PBS the next day, the sections were incubated with P-phycoerythrin (PE) labeled donkey anti-rabbit IgG (1:1000; cat. no. ab2340599) or fluorescein isothiocyanate (FITC)-labeled donkey anti-rat IgG (1:1000; cat. no. ab2340655) secondary antibodies from Jackson ImmunoResearch Laboratories Inc.(West Grove, PA, USA) for 1 h. Nuclei were stained by 4,6-diamidino-2-phenylindole (1:2000; cat no. C1002) from Beyotime Institute of Biotechnology (Shanghai, China) for 10 min. The slides were mounted with cover glasses and observed using a BX35F fluorescence microscope from Olympus Corporation (Tokyo, Japan). Sections from the dentate gyrus in the hippocampus from four mice were viewed and photographed. Iba-1+ was regarded as activated microglia, Iba-1+CD86+ was regarded as M1 microglia polarization and Iba-1+CD206+ was regarded as M2 polarization. The number of activated, M1 polarized and M2 polarized microglia was counted under a microscope, and the percentage of M1 and M2 polarized microglia was calculated.

2.6. Hydrogen-rich medium preparation The hydrogen-rich medium was prepared as previously described [27]. Briefly, H2 (1 l/min) mixed with air (1 l/min) was dissolved in FBS-free DMEM at a pressure of 0.5 MPa for 4 h so that it was completely dissolved and attained saturation (0.6 mM of hydrogen). H2 was produced by a GCH-300 high-purity hydrogen generator (Tianjin Tongpu Analytic Instrument Technology Co., Tianjin, China). A special sealed aluminum bag (no dead volume left) was used to store the saturated HM under atmospheric conditions at 4 °C. To ensure the saturated concentration of hydrogen, the hydrogen-rich medium was freshly prepared every week. 2.7. Morris Water Maze task The Morris Water Maze task consisted of a plastic black circular pool 100 cm in diameter and 50 cm in height and surrounded by dark curtains. Water mixed with food-grade silicon dioxide was poured into the pool to a height of 35 cm to hide the platform under the water. The temperature of the water was maintained at 22 ± 1℃. A digital camera was placed above the pool, which was divided it into 4 quadrants. A platform 6 cm in diameter was place 1 cm below the water surface in one of the quadrants. Different plastic symbol shapes were hung on the inner shelf to help with positional recognition. All these instruments were purchased from Xinruan Information Technology Co., Ltd. (Shanghai, China). From the 4th to 8th day after the operation, a hidden platform exploration test was performed by the mice in each group. A mouse was placed on the platform for 10 s and then placed into each of the three other quadrants to search for the platform. The escape latency was recorded by digital camera to indicate learning, and swimming speed was also obtained. If the mouse could not reach the platform within 60 s, it was recorded as 60 s for escape latency and placed on the platform for 10 more seconds. Two hours after the experiment on the 8th day, the platform was removed and a probe trial was performed. Each mouse was allowed to swim for 60 s in the pool, the time spent in the target quadrant and the number of times crossing the platform was captured by a digital camera and indicated as memory abilities.

2.10. Flow cytometry The cells were harvested by trypsin, collected and suspended in PBS and adjusted to 1 × 106 cells/ml. The cells were incubated with rabbit anti-Iba-1(1:200; cat. no. ab178846, Abcam), rat anti-CD86(1:200; cat. no. ab119857, Abcam) and goat anti-CD206(1:200, cat. no. PA5-46994, Thermo Fisher Scientific, Inc.) primary antibodies at 4℃ for 30 min. After washing three times with PBS, the cells were incubated with FITClabeled donkey anti-rabbit IgG (1:500, cat. no. ab2315776), R-PE-labeled donkey anti-rat IgG (1:500, cat. no. ab2340656) and peridininchlorophyll-protein (PerCP)-labeled donkey anti-goat IgG (1:500, cat. no. ab2340406) secondary antibodies (Jackson ImmunoResearch Laboratories Inc.) for 30 min at room temperature. Flow cytometry was performed on a FACScalibur Flow Cytometer operated with CellQuest software for data collection (all BD Biosciences, Franklin Lakes, NJ, USA). Iba-1+ was regarded as activated microglia, Iba-1+CD86+ was regarded as M1 microglia polarization and Iba-1+CD206+ was regarded as M2 polarization. The percentage of activated, M1 and M2 polarization microglia was calculated.

3

International Immunopharmacology 81 (2020) 106287

X. Zhuang, et al.

in the CLP + H2 group compared with the CLP group (P < 0.05 vs. CLP group; Fig. 2C). No differences in swimming speed were detected among groups (P > 0.05 vs. Sham group or P > 0.05 vs. CLP group; Fig. 2D). For the probe trail, the time spent on the target platform quadrant and the number of times they crossed the platform decreased significantly in the CLP group compared to the Sham group (P < 0.05 vs. Sham group; Fig. 2E and F). Hydrogen gas inhalation increased the time spent in the target platform quadrant and the number of time crossing the platform in the CLP + H2 group compared with the CLP group (P < 0.05 vs. CLP group; Fig. 2E and F). There was no cognitive improvement in the Sham + H2 group compared with the Sham group (P > 0.05 vs. Sham group; Fig. 2A, E and F). These results indicated that hydrogen gas inhalation could alleviate learning and memory impairment induced by sepsis.

2.11. Western blot assay For cell experiments, the cells were harvested by trypsin and homogenized by lysis buffer with phosphatase and protease inhibitors (cat. no. P0013; Beyotime Institute of Biotechnology). A Protein Assay Kit (cat. no. P0011; Beyotime Institute of Biotechnology) was used to assess protein concentration, and 20 mg protein was loaded for each lane. The protein was separated by 10% SDS-PAGE electrophoresis and transferred to a polyvinylidene fluoride membrane. The membrane was blocked with 5% skim milk and incubated with primary antibody at 4℃ overnight. The membrane was then washed 3 times with PBS and incubated with secondary antibody at room temperature for 2 h. The membrane was finally treated with an electrochemiluminescence (ECL) assay kit (cat. no. P0018FS; Beyotime Institute of Biotechnology). The density of the bolt was captured by a ChemiDoc XRS imaging system and analyzed by Image Lab software (all Bio-Rad Laboratories, Inc., Hercules, CA, USA). The levels of p-AMPK, p-mTOR and LC3II were calculated as the ratio of band density to that of AMPK, mTOR and LC3I, respectively. The levels of TREM-2, p62 and Beclin-1 were calculated as the ratio of band density to that of β-actin. The primary antibodies including rabbit anti-microtubule-associated protein 1 light chain 3I (LC3I, 1:2000; cat. no. ab48394), rabbit anti-Beclin-1 (1:1000; cat. no. ab62557), rabbit anti-p62 (1:2000; cat. no. ab91526), rabbit anti-AMPK (1:2000; cat. no. ab207442), rabbit anti-p-AMPK (phospho Thr183 & Thr172, 1:2000; cat. no. ab133448), rabbit anti-mTOR (1:2000; cat. no. ab2732), rabbit anti-p-mTOR (phospho Ser2448, 1:2000; cat. no. ab109268) and rabbit anti-β-actin (1:2000, cat. no. ab8227) from Abcam. The primary antibody of sheet anti-TREM-2 (1:1000; cat. no. AF1729) was purchased from R&D systems. (Minneapolis, MN, USA). The secondary antibody was horseradish peroxide-labeled goat anti-rabbit IgG (1:4000, cat. no. ab6721) and donkey anti-sheet IgG (1:4000, cat. no. ab6900) from Abcam.

3.2. Hydrogen gas inhalation attenuated sepsis-induced neuroinflammation and modulated microglia polarization in mice To investigate the inflammatory microenvironment during sepsis in hippocampus, inflammatory cytokines were detected by ELISA assay kits. We detected pro-inflammatory cytokines of TNF-α, IL-6, HMGB1 and anti-inflammatory cytokines of IL-10 and TGF-β. CLP treatment significantly increased the level of TNF-α, IL-6, HMGB1, IL-10 and TGFβ in CLP group compared with the Sham group (P < 0.05 vs. Sham group; Fig. 3A- 3E), demonstrated that sepsis-induced inflammatory factors infiltration in the hippocampus. Hydrogen gas inhalation significantly decreased the levels of TNF-α, IL-6 and HMGB1 levels and increased the levels of IL-10 and TGF-β in the CLP + H2 group compared to the CLP group (P < 0.05 vs. CLP group; Fig. 3A–E), indicating that hydrogen inhalation changed the inflammatory microenvironment by reducing pro-inflammatory cytokines and promoting anti-inflammatory cytokines. To explore changes in microglia polarization in the hippocampus from each group, microglia were stained by double immunofluorescence of Iba-1 and CD86 (Fig. 4A) or Iba-1 and CD206 (Fig. 4D). Iba-1 is the indicator of activated microglia, CD86 is an M1 microglia polarization-associated protein marker, and CD206 is an M2 marker. Through observation of the dentate gyrus from the hippocampus, the number and percentage of Iba-1+CD86+ and Iba1+CD206+ microglia significantly increased in the CLP group compared with the Sham group (P < 0.05 vs. Sham group; Fig. 4B, 4C, 4E and 4F). Hydrogen gas inhalation significantly reduced the number and percentage of Iba-1+CD86+ microglia and increased Iba-1+CD206+ in the CLP + H2 group compared to the CLP group (P < 0.05 vs. CLP group; Fig. 4B, C, E and F), illustrating that hydrogen gas inhalation alleviated neuroinflammation by switching microglia from M1 to M2 polarization.

2.12. Statistical analysis The escape latency, swimming speed and time spent in the target quadrant of the MWM in different groups are shown as the means ± standard deviation (SD), the numbers of the platform crossings of the MWM are presented as median with interquartile range and other data are reported as the means ± standard deviation (SD). Two-way ANOVAs with repeated measurements were used to determine the interaction between time and group (based on escape latency and swimming speed) between two groups in the MWM, and post-hoc Bonferroni tests were used to compare the differences in escape latency and swimming speed between the two groups on each day of the MWM test. Mann-Whitney U-tests were used to determine the differences among all groups for the number of times crossing the platform. There were no missing data for the MWM variables during data analysis. Finally, unpaired t-tests (if the values followed a Gaussian distribution) or Mann-Whitney U-tests (if values did not follow a Gaussian distribution) were used to analyze the differences between two groups in other biochemistry data. P < 0.05 was considered statistically significant, and the significance testing was two-tailed. Statistical analysis was conducted using GraphPad Prism software (version 5.0) and SPSS statistic software (version 21.0).

3.3. Hydrogen-rich medium treatment mitigated LPS-induced neuroinflammation and microglia polarization in BV-2 cells BV-2 cell lines were cultured and used to further investigate the underlying mechanism of hydrogen’s therapeutic effect. LPS incubation is a classic method to induce microglia activation, and it can simulate activation and an inflammatory state of microglia during sepsis in vitro. ELISA analysis using the supernatant showed increased TNF-α, IL-6, HMGB1, IL-10 and TGF-β in the LPS group compared with the Control group (P < 0.05 vs. Control group; Fig. 5A–E). Hydrogen-rich medium treatment decreased the levels of TNF-α, IL-6 and HMGB1 and increased the levels of IL-10 and TGF-β in the LPS + H2 group compared with the LPS group (P < 0.05 vs. LPS group; Fig. 5A–E). The polarization of microglia was detected by flow cytometry (Fig. 6A). LPS treatment increased the percentage of Iba-1+CD86+ and Iba1+CD206+ in the LPS group compared with the Control group (P < 0.05 vs. Control group; Fig. 6B and C). Hydrogen-rich medium incubation increased the percentage of Iba-1+CD206+ staining and decreased the percentage of Iba-1+CD86+ staining in the LPS + H2

3. Results 3.1. Hydrogen gas inhalation alleviated cognitive dysfunction in septic mice. To assess the therapeutic effect of hydrogen inhalation, we created an SAE mouse model using CLP and detected spatial learning and memory abilities with the Morris Water Maze from day 4 to day 8 after CLP or sham operation. The escape latency of mice in the CLP group was significantly longer than that of mice in the Sham group (P < 0.05 vs. Sham group; Fig. 2B). Hydrogen inhalation decreased escape latency 4

International Immunopharmacology 81 (2020) 106287

X. Zhuang, et al.

Fig. 2. Hydrogen gas inhalation attenuated sepsis-induced cognitive impairment in mice. (A–C) Escape latency, (D) swimming speed, (E) platform crossing time and (F) time spent in the target quadrant were measured in each group (n = 10 mice per group). *P < 0.05 vs Sham group; #P < 0.05 vs CLP group. CLP, cecal ligation and puncture.

group compared with the LPS group (P < 0.05 vs. LPS group; Fig. 6B and C). These data were consistent with the results from vivo research.

3.4. Hydrogen-rich medium regulated microglia polarization by mTOR inhibition and autophagy promotion Western blot was used to detect the mTOR autophagy signaling pathway (Fig. 7A). The results showed that LPS incubation significantly

Fig. 3. Hydrogen gas inhalation adjusted the inflammatory cytokines of the hippocampi in septic mice. The pro-inflammatory cytokines of (A) TNF-α, (B) IL-6 and (C) HMGB1 and the anti-inflammatory cytokines of (D) TGF-β and (E) IL-10 were measured in the mouse hippocampi by ELISA in each group (n = 6 mice per group). *P < 0.05 vs Sham group; #P < 0.05 vs CLP group. CLP, cecal ligation and puncture. 5

International Immunopharmacology 81 (2020) 106287

X. Zhuang, et al.

Fig. 4. Hydrogen gas inhalation regulated microglia polarization in the hippocampi of septic mice. (A) Double immunofluorescence staining of activated microglia (Iba-1+) and M1 polarization (Iba-1+CD86+) in hippocampal sections. (D) Double immunofluorescence staining of activated microglia (Iba-1+) and M2 polarization (Iba-1+CD206+) in hippocampal sections. Quantitative analysis of (B) the number of Iba-1+CD86+ microglia and (C) the percentage of Iba-1+CD86+ over Iba-1+ microglia (n = 4 mice pre group). Quantitative analysis of (E) the number of Iba-1+CD206+ microglia and (F) the percentage of Iba-1+CD206+ over Iba-1+ microglia (n = 4 mice per group. *P < 0.05 vs Sham group; #P < 0.05 vs CLP group. CLP, cecal ligation and puncture; Iba-1, ionized calcium binding adapter molecule-1.

mTOR and p62 expression increased and the ratio of LC3II/LC3I and the expression of Beclin-1 decreased in the LPS + H2 + MHY1485 group compared with the LPS + H2 group (P < 0.05 vs. LPS + H2 group; Fig. 7D–G). No differences in the ratio of p-AMPK/AMPK and TREM-2 expression were detected in the LPS + H2 + MHY1485 group compared with the LPS + H2 group (P > 0.05 vs. LPS + H2 group; Fig. 7B and C). These results indicated that molecular hydrogen regulated microglia polarization through AMPK mediated mTOR inhibition and autophagy promotion.

increased the ratio of p-mTOR/mTOR and p62 expression and decreased the ratio of p-AMPK/AMPK, LC3II/LC3I and the expression of TREM-2 and Beclin-1 in the LPS group compared with the Control group (P < 0.05 vs. Control group; Fig. 7B–G). Hydrogen-rich medium treatment increased the ratio of p-AMPK/AMPK, LC3II/LC3I and the expression of TREM-2 and Beclin-1 and decreased the ratio of p-mTOR/ mTOR and p62 expression in the LPS + H2 group compared with the LPS group (P < 0.05 vs. LPS group; Fig. 7B–G). These results revealed that the therapeutic effect of molecular hydrogen was accompanied by inhibiting mTOR and promoting autophagy. As an activator of mTOR, MHY1485 incubation abolished the protective effect of molecular hydrogen. The levels of TNF-α, IL-6 and HMGB1 increased and the levels of IL-10 and TGF-β decreased in the LPS + H2 + MHY1485 group compared with the LPS + H2 group (P < 0.05 vs. LPS + H2 group; Fig. 5A–E). Flow cytometry revealed that the percentage of Iba-1+CD86+ cells increased and the percentage of Iba-1+CD206+ cells decreased in the LPS + H2 + MHY1485 group compared with the LPS + H2 group (P < 0.05 vs. LPS + H2 group; Fig. 6B and C). MHY1485 treatment also reversed the adjustment of mTOR and autophagy from molecular hydrogen. The ratio of p-mTOR/

4. Discussion Sepsis is a systemic inflammatory syndrome caused by various infectious factors [28]. It is believed that sepsis could lead to neurological impairment, such as neuroinflammation and behavioral deficits [5,11]. In the current study, these detrimental effects were alleviated by molecular hydrogen using in vivo and in vitro research. In the animal model, we revealed that hydrogen gas inhalation attenuated SAE through improving cognitive function, transforming microglia polarization and reconditioning the inflammatory microenvironment. In the 6

International Immunopharmacology 81 (2020) 106287

X. Zhuang, et al.

Fig. 5. MHY1485 reversed the regulation of inflammatory cytokines with hydrogen-rich medium treatment. The pro-inflammatory cytokines of (A) TNF-α and (B) IL6 and (C) HMGB1 and the anti-inflammatory cytokines of (D) TGF-β and (E) IL-10 were measured in the supernatant using ELISA in each group (n = 6 samples per group). *P < 0.05 vs Control group; #P < 0.05 vs LPS group; &P < 0.05 vs LPS + H2 group. LPS, lipopolysaccharide, MHY1485, a kind of mTOR activator.

[23–25,29], this study was the first research to show that the above mechanisms existed in the therapeutic effect of hydrogen against SAE. Sepsis is the result of imbalanced anti-inflammatory and pro-inflammatory interaction [30]. Activation and infiltration of macrophages constitutes the main characteristics of sepsis [31]. It is well-

cell model, we discovered that the protective mechanism of the hydrogen-rich medium was associated with mTOR inhibition and autophagy promotion. Although it had been reported that the mTOR-autophagy signaling pathway modulates microglia polarization and alleviates neuroinflammation in the pathological process of cerebral impairment

Fig. 6. MHY1485 reversed the modulation of BV-2 cell polarization with hydrogen-rich medium treatment. (A) Flow cytometry detecting activated microglia (Iba1+), M1 polarization (Iba-1+CD86+) and M2 polarization (Iba-1+CD206+) in vitro. Quantitative analysis of (B) the percentage of Iba-1+CD86+ microglia and (C) the percentage of Iba-1+CD206+ microglia (n = 4 samples per group). *P < 0.05 vs Control group; #P < 0.05 vs LPS group; &P < 0.05 vs LPS + H2 group. Iba-1, ionized calcium binding adapter molecule-1; LPS, lipopolysaccharide; MHY1485, a kind of mTOR activator. 7

International Immunopharmacology 81 (2020) 106287

X. Zhuang, et al.

Fig. 7. Hydrogen-rich medium inhibited mTOR and promoted autophagy, which were reversed by MHY1485 in BV-2 cells. (A) The expressions of TREM-2, p-AMPK, AMPK, p-mTOR, mTOR, Beclin-1, p62, LC3I and LC3II in BV-2 cells were detected by Western blot. Quantitative analysis of (B) TREM-2, (C) p-AMPK and (D) p-mTOR is shown as the ratio of band density to that of β-actin, AMPK and mTOR respectively. Quantitative analysis of (E) Beclin-1, (F) p62 and (G) LC3II shown as the ratio of band density to that of β-actin and LC3I, respectively. *P < 0.05 vs Control group; #P < 0.05 vs LPS group; &P < 0.05 vs LPS + H2 group. TREM-2, triggering receptor expressed on myeloid cells-2; AMPK, adenosine 5′-monophosphate-activated protein kinase; mTOR, mammalian target of rapamycin; LC3, microtubuleassociated protein 1 light chain 3; LPS, lipopolysaccharide; MHY1485, a kind of mTOR activator.

astrocytes and represented an inflammatory cerebral microenvironment. However, the secretion of inflammatory cytokines from astrocytes required microglia regulation and was consistent with their polarization [34]. Therefore, the detection of inflammatory cytokines in vivo reflected the microenvironment and, to some extent, the polarization of microglia. For cognitive assessment, hydrogen inhalation decreased escape latency and increased the time spent in the target platform quadrant and the number of times crossing the platform. All these results indicated that the therapeutic effect of hydrogen was mediated, partially at least, by transforming microglia polarization and alleviating inflammation to finally help improve cognitive dysfunction. In this study, we did not record the survival rate from the different groups because our previous research showed that 2% hydrogen inhalation markedly increased survival rate compared with CLP alone [8–11]. Therefore, any mice who died within 8 days of sham or CLP operation were excluded from groups. As microglia comprise only 5% to 12% of total cells in the brain [35] and autophagy of other types of cells in the brain was uncertain, it was difficult to precisely observe changes in autophagy of microglia from the animal model. For this reason, we use cultured BV-2 microglia cells instead for signaling pathway detection. In the cell study, we investigated the role of the mTOR-autophagy signaling pathway in regulating microglia polarization by hydrogen. Autophagy is a kind of self-digestion process through which the useless

known that M1 macrophage polarization exerts a destructive effect, whereas M2 polarization plays a beneficial role in tissue recovery [32]. As the resident macrophages in the CNS, microglia play similar roles by shifting polarization. Several studies have found that M1 microglia polarization has neurotoxic effects by secreting pro-inflammatory factors, such as TNF-a, IL-6 (“early” pro-inflammatory factors) and HMGB1 (“late” pro-inflammatory factor). M2 polarization, on the contrary, has neuroprotective effects by secreting anti-inflammatory factors, such as IL-10, TGF-β and IGF-1[17]. The balance between M1 and M2 polarization of microglia may partially determine the outcome of CNS function in patients with sepsis [33]. As presented by this research, sepsis-induced cerebral impairment was verified by cognitive assessment, inflammatory cytokines and M1/M2 polarization detection. Therefore, it is reasonable to speculate that modulating microglia polarization is a potential strategy to alleviate sepsis-induced CNS damage. Based on the assumptions above, we used animal and cell models and discovered that microglia underwent activation and polarization changes after CLP or LPS treatment, which was accompanied by increased levels of inflammatory factors. As expected, hydrogen treatment decreased M1 polarization, increased M2 polarization, decreased pro-inflammatory cytokines and increased anti-inflammatory cytokines in both animal and cell models. It is worth noting that inflammatory cytokines detected in vivo were secreted by both microglia and 8

International Immunopharmacology 81 (2020) 106287

X. Zhuang, et al.

molecular hydrogen may be a promising agent for alleviating encephalopathy induced by sepsis.

organelles and small molecular fragments are degraded and reused to sustain normal cellular functions [36]. mTOR was reported to play a key role in the regulation of autophagy and it is regulated by the upstream kinase of AMPK. mTOR dephosphorylation resulted in autophagy promotion and phosphorylation resulted in autophagy depression [37]. Some studies reported that moderate autophagy promotion could perform therapeutic benefits by attenuating neuropathy [38,39]. In contrast, others discovered that excessive autophagy may lead to cell apoptosis and even death [40]. For research on SAE, some have reported that strategies to promote autophagy could exert protective effects [41,42]. For markers of autophagy detected in this research, LC3, Beclin-1 and p62 were chosen. In the autophagy process, LC3-I is recruited from cytosol to autophagosomes and then changes into LC3-II, a hallmark protein of autophagy [43]. Beclin-1 can bind to Class III PI3K Kinase and play a critical role in autophagy modulation [31]. p62 affects autophagy flux termination. p62 selectively recruits ubiquitin proteins and transmits them into the lysosome for degradation and thus is associated with lysosomal degradation [43]. For signaling pathway investigation, the phosphorylation of AMPK(Thr183 & Thr172) and mTOR (Ser2448) was detected. The results demonstrated mTOR promotion, AMPK and autophagy depression after LPS incubation. Hydrogen treatment reversed the situation with mTOR depression, AMPK and autophagy promotion, suggesting that transforming microglia polarization was accompanied with changes to AMPK and mTOR activity and autophagy state. To further ascertain the crosstalk between the mTOR-autophagy signaling pathway and microglia polarization, the mTOR activator, MHY1485, was used with hydrogen treatment in vitro, and its effect was confirmed by Western blot. Interestingly, mTOR activation and consequent autophagy inhibition abolished the protective effect of hydrogen by increasing pro-inflammatory cytokines, reducing anti-inflammatory cytokines, suppressing M2 microglia polarization and promoting M1 polarization. These results further confirmed that hydrogen modulated microglia polarization through regulation of the mTOR-autophagy signaling pathway and our conclusion was consistent with our previous research [11], which indicated that mTOR disruption or autophagy promotion could exert protective effects against cerebral inflammation by switching microglia polarization. Further, the activation of AMPK by hydrogen was not obviously affected by the mTOR activator, indicated that hydrogen attenuated microglia polarization via AMPK mediated mTOR suppression. TREM-2 is an immune signaling protein expressed on the membranes of microglia in the brain and was regarded as a regulator of inflammation. It was reported that up-regulating TREM-2 could promote microglia M2 polarization and alleviate neuroinflammation [44,45]. In this research, similarly, we observed that TREM-2 was suppressed by LPS incubation while promoted by hydrogen treatment. In addition, MHY1485 didn’t obviously affected TREM-2 expression. This may be explained by the regulatory relationship between TREM-2 and mTOR. It is reported that TREM-2 play an important role in helping microglia sense pathological stress and sustaining metabolic states through mTOR pathway regulation [46]. We speculated that TREM-2 may affect mTOR phosphorylation in some way as an upstream mediator. However, previous research demonstrated that TREM-2 deficiency could lead to excessive autophagy in microglia [46], which seems to contradict the results of ours. This discrepancy may be explained by the different experiment models and diverse pathological changes. The relationship between TREM-2 and autophagy in microglia under the challenge of sepsis still needs further investigation.

Conflict of interest statement All authors declare no competing financial interests. CRediT authorship contribution statement Xinqi Zhuang: Methodology, Software, Data curation, Writing original draft. Yang Yu: Conceptualization, Writing - review & editing. Yi Jiang: Methodology, Data curation. Sen Zhao: Methodology, Software. Yuzun Wang: Software, Validation. Lin Su: Methodology. Keliang Xie: Methodology. Yonghao Yu: Supervision. Yuechun Lu: Conceptualization, Software. Guoyi Lv: Data curation, Software. Acknowledgements This study was supported by the National Natural Science Foundation of China (No. 81671888 to Yonghao Yu, 81772043 and 81971879 to Keliang Xie), Beijing, China, the Natural Science Foundation of Tianjin, Tianjin, China (No. 17JCYBJC24800 to Keliang Xie) and the Science and Technology Support Key Program Affiliated to the Key Research and Development Plan of Tianjin Science and Technology Project, Tianjin, China (No. 18YFZCSY00560 to Keliang Xie). We thank Elsevier Webshop Support for its linguistic assistance during the preparation of this manuscript. References [1] J.L. Vincent, S.M. Opal, J.C. Marshall, K.J. Tracey, Sepsis definitions: time for change, Lancet 381 (9868) (2013) 774–775. [2] C. Fleischmann, A. Scherag, N.K. Adhikari, C.S. Hartog, T. Tsaganos, P. Schlattmann, D.C. Angus, K.T. Reinhart, Assessment of global incidence and mortality of hospital-treated sepsis. current estimates and limitations, Am. J. Respir. Crit. Care Med. 193 (3) (2016) 259–272. [3] E. Iacobone, J. Bailly-Salin, A. Polito, D. Friedman, R.D. Stevens, T. Sharshar, Sepsis-associated encephalopathy and its differential diagnosis, Crit. Care Med. 37 (10 Suppl) (2009) S331–S336. [4] M. Singer, C.S. Deutschman, C.W. Seymour, M. Shankar-Hari, D. Annane, M. Bauer, R. Bellomo, G.R. Bernard, J.D. Chiche, C.M. Coopersmith, R.S. Hotchkiss, M.M. Levy, J.C. Marshall, G.S. Martin, S.M. Opal, G.D. Rubenfeld, T. van der Poll, J.L. Vincent, D.C. Angus, The third international consensus definitions for sepsis and septic shock (sepsis-3), JAMA 315 (8) (2016) 801–810. [5] T. Barichello, M.R. Martins, A. Reinke, G. Feier, C. Ritter, J. Quevedo, F. Dal-Pizzol, Cognitive impairment in sepsis survivors from cecal ligation and perforation, Crit. Care Med. 33 (1) (2005) 221–223 discussion 262–263. [6] K. Thompson, B. Venkatesh, S. Finfer, Sepsis and septic shock: current approaches to management, Intern. Med. J. 49 (2) (2019) 160–170. [7] K. Xie, L. Liu, Y. Yu, G. Wang, Hydrogen gas presents a promising therapeutic strategy for sepsis, Biomed. Res. Int. 2014 (2014) 807635. [8] Y. Yu, Y. Yang, M. Yang, C. Wang, K. Xie, Y. Yu, Hydrogen gas reduces HMGB1 release in lung tissues of septic mice in an Nrf2/HO-1-dependent pathway, Int. Immunopharmacol. 69 (2019) 11–18. [9] M. Yan, Y. Yu, X. Mao, J. Feng, Y. Wang, H. Chen, K. Xie, Y. Yu, Hydrogen gas inhalation attenuates sepsis-induced liver injury in a FUNDC1-dependent manner, Int. Immunopharmacol. 71 (2019) 61–67. [10] Y. Yu, Y. Yang, Y. Bian, Y. Li, L. Liu, H. Zhang, K. Xie, G. Wang, Y. Yu, Hydrogen gas protects against intestinal injury in wild type but not Nrf2 knockout mice with severe sepsis by regulating HO-1 and HMGB1 release, Shock 48 (3) (2017) 364–370. [11] L. Liu, K. Xie, H. Chen, X. Dong, Y. Li, Y. Yu, G. Wang, Y. Yu, Inhalation of hydrogen gas attenuates brain injury in mice with cecal ligation and puncture via inhibiting neuroinflammation, oxidative stress and neuronal apoptosis, Brain Res. 1589 (2014) 78–92. [12] Y. Xin, H. Liu, P. Zhang, L. Chang, K. Xie, Molecular hydrogen inhalation attenuates postoperative cognitive impairment in rats, Neuro Report 28 (11) (2017) 694–700. [13] H. He, T. Geng, P. Chen, M. Wang, J. Hu, L. Kang, W. Song, H. Tang, NK cells promote neutrophil recruitment in the brain during sepsis-induced neuroinflammation, Sci. Rep. 6 (2016) 27711. [14] L.G. Danielski, A.D. Giustina, M. Badawy, T. Barichello, J. Quevedo, F. Dal-Pizzol, F. Petronilho, Brain barrier breakdown as a cause and consequence of neuroinflammation in sepsis, Mol. Neurobiol. 55 (2) (2018) 1045–1053. [15] Y. Tang, F. Soroush, S. Sun, E. Liverani, J.C. Langston, Q. Yang, L.E. Kilpatrick, M.F. Kiani, Protein kinase C-delta inhibition protects blood-brain barrier from sepsis-induced vascular damage, J. Neuroinflammat. 15 (1) (2018) 309.

5. Conclusion In conclusion, we found that molecular hydrogen could attenuate sepsis-induced neuroinflammation by modulating microglia polarization in the present study. This therapeutic effect was mediated by the mTOR-autophagy signaling pathway. Our results demonstrated that 9

International Immunopharmacology 81 (2020) 106287

X. Zhuang, et al.

Immunol. 181 (6) (2008) 3733–3739. [33] D.J. Loane, A. Kumar, Microglia in the TBI brain: The good, the bad, and the dysregulated, Exp. Neurol. 275 (Pt 3) (2016) 316–327. [34] S.A. Liddelow, K.A. Guttenplan, L.E. Clarke, F.C. Bennett, C.J. Bohlen, L. Schirmer, M.L. Bennett, A.E. Munch, W.S. Chung, T.C. Peterson, D.K. Wilton, A. Frouin, B.A. Napier, N. Panicker, M. Kumar, M.S. Buckwalter, D.H. Rowitch, V.L. Dawson, T.M. Dawson, B. Stevens, B.A. Barres, Neurotoxic reactive astrocytes are induced by activated microglia, Nature 541 (7638) (2017) 481–487. [35] K.M. Lenz, M.M. McCarthy, A starring role for microglia in brain sex differences, Neuroscientist 21 (3) (2015) 306–321. [36] F. Guo, X. Liu, H. Cai, W. Le, Autophagy in neurodegenerative diseases: pathogenesis and therapy, Brain Pathol. 28 (1) (2018) 3–13. [37] Y.C. Kim, K.L. Guan, mTOR: a pharmacologic target for autophagy regulation, J. Clin. Invest. 125 (1) (2015) 25–32. [38] Y.C. Chung, J.H. Lim, H.M. Oh, H.W. Kim, M.Y. Kim, E.N. Kim, Y. Kim, Y.S. Chang, H.W. Kim, C.W. Park, Calcimimetic restores diabetic peripheral neuropathy by ameliorating apoptosis and improving autophagy, Cell Death Dis. 9 (12) (2018) 1163. [39] S. Sifuentes-Franco, F.P. Pacheco-Moises, A.D. Rodriguez-Carrizalez, A.G. MirandaDiaz, The role of oxidative stress, mitochondrial function, and autophagy in diabetic polyneuropathy, J. Diabet. Res. 2017 (2017) 1673081. [40] R.R. Bartz, H.B. Suliman, C.A. Piantadosi, Redox mechanisms of cardiomyocyte mitochondrial protection, Front Physiol. 6 (2015) 291. [41] M.J. Kim, S.H. Bae, J.C. Ryu, Y. Kwon, J.H. Oh, J. Kwon, J.S. Moon, K. Kim, A. Miyawaki, M.G. Lee, J. Shin, Y.S. Kim, C.H. Kim, S.W. Ryter, A.M. Choi, S.G. Rhee, J.H. Ryu, J.H. Yoon, SESN2/sestrin2 suppresses sepsis by inducing mitophagy and inhibiting NLRP3 activation in macrophages, Autophagy 12 (8) (2016) 1272–1291. [42] M.J. Kim, J.H. Yoon, J.H. Ryu, Mitophagy: a balance regulator of NLRP3 inflammasome activation, BMB Rep 49 (10) (2016) 529–535. [43] H. Cha-Molstad, J.E. Yu, Z. Feng, S.H. Lee, J.G. Kim, P. Yang, B. Han, K.W. Sung, Y.D. Yoo, J. Hwang, T. McGuire, S.M. Shim, H.D. Song, S. Ganipisetti, N. Wang, J.M. Jang, M.J. Lee, S.J. Kim, K.H. Lee, J.T. Hong, A. Ciechanover, I. Mook-Jung, K.P. Kim, X.Q. Xie, Y.T. Kwon, B.Y. Kim, p62/SQSTM1/Sequestosome-1 is an Nrecognin of the N-end rule pathway which modulates autophagosome biogenesis, Nat. Commun. 8 (1) (2017) 102. [44] Q. Xu, W. Xu, H. Cheng, H. Yuan, X. Tan, Efficacy and mechanism of cGAMP to suppress Alzheimer's disease by elevating TREM2, Brain Behav. Immun. 81 (2019) 495–508. [45] J. Zhang, Y. Zheng, Y. Luo, Y. Du, X. Zhang, J. Fu, Curcumin inhibits LPS-induced neuroinflammation by promoting microglial M2 polarization via TREM2/ TLR4/ NF-κB pathways in BV2 cells, Mol. Immunol. 116 (2019) 29–37. [46] T.K. Ulland, W.M. Song, S.C. Huang, J.D. Ulrich, A. Sergushichev, W.L. Beatty, A.A. Loboda, Y. Zhou, N.J. Cairns, A. Kambal, E. Loginicheva, S. Gilfillan, M. Cella, H.W. Virgin, E.R. Unanue, Y. Wang, M.N. Artyomov, D.M. Holtzman, M. Colonna, TREM2 Maintains Microglial Metabolic Fitness in Alzheimer's Disease, Cell 170 (4) (2017) 649–663.

[16] M. Tian, L. Qingzhen, Y. Zhiyang, C. Chunlong, D. Jiao, L. Zhang, W. Li, Attractylone attenuates sepsis-associated encephalopathy and cognitive dysfunction by inhibiting microglial activation and neuroinflammation, J. Cell Biochem. 120 (5) (2019) 7101–7108. [17] H.M. Yang, S. Yang, S.S. Huang, B.S. Tang, J.F. Guo, Microglial activation in the pathogenesis of Huntington's disease, Front Aging Neurosci. 9 (2017) 193. [18] M. Michels, B. Sonai, F. Dal-Pizzol, Polarization of microglia and its role in bacterial sepsis, J. Neuroimmunol. 303 (2017) 90–98. [19] M. Laplante, D.M. Sabatini, mTOR signaling at a glance, J. Cell Sci. 122 (20) (2009) 3589–3594. [20] Y. Liu, H. Yang, X. Tang, W. Bai, G. Wang, X. Tian, Repetitive transcranial magnetic stimulation regulates L-type Ca(2+) channel activity inhibited by early sevoflurane exposure, Brain Res. 1646 (2016) 207–218. [21] T. Weichhart, mTOR as regulator of lifespan, aging, and cellular senescence: a minireview, Gerontology 64 (2) (2018) 127–134. [22] K. Switon, K. Kotulska, A. Janusz-Kaminska, J. Zmorzynska, J. Jaworski, Molecular neurobiology of mTOR, Neuroscience 341 (2017) 112–153. [23] P. Fabbrizio, S. Amadio, S. Apolloni, C. Volonte, P2X7 receptor activation modulates autophagy in SOD1-G93A mouse microglia, Front. Cell Neurosci. 11 (2017) 249. [24] D. Li, C. Wang, Y. Yao, L. Chen, G. Liu, R. Zhang, Q. Liu, F.D. Shi, J. Hao, mTORC1 pathway disruption ameliorates brain inflammation following stroke via a shift in microglia phenotype from M1 type to M2 type, FASEB J. 30 (10) (2016) 3388–3399. [25] C. Wang, Q. Wang, Y. Lou, J. Xu, Z. Feng, Y. Chen, Q. Tang, G. Zheng, Z. Zhang, Y. Wu, N. Tian, Y. Zhou, H. Xu, X. Zhang, Salidroside attenuates neuroinflammation and improves functional recovery after spinal cord injury through microglia polarization regulation, J. Cell Mol. Med. 22 (2) (2018) 1148–1166. [26] Y. Zhou, T.K. Ulland, M. Colonna, TREM2-dependent effects on microglia in Alzheimer's disease, Front Aging Neurosci. 10 (2018) 202. [27] Y. Yu, X. Ma, T. Yang, B. Li, K. Xie, D. Liu, G. Wang, Y. Yu, Protective effect of hydrogen-rich medium against high glucose-induced apoptosis of Schwann cells in vitro, Mol. Med. Rep. 12 (3) (2015) 3986–3992. [28] Y. Bian, C. Qin, Y. Xin, Y. Yu, H. Chen, G. Wang, K. Xie, Y. Yu, Itraq-based quantitative proteomic analysis of lungs in murine polymicrobial sepsis with hydrogen gas treatment, Shock 49 (2) (2018) 187–195. [29] C. Bussi, J.M. Peralta Ramos, D.S. Arroyo, E.A. Gaviglio, J.I. Gallea, J.M. Wang, M.S. Celej, P. Iribarren, Autophagy down regulates pro-inflammatory mediators in BV2 microglial cells and rescues both LPS and alpha-synuclein induced neuronal cell death, Sci. Rep. 7 (2017) 43153. [30] D. Bar-Or, M. Carrick, A. Tanner 2nd, M.J. Lieser, L.T. Rael, E. Brody, Overcoming the Warburg Effect: Is it the key to survival in sepsis? J. Crit. Care 43 (2018) 197–201. [31] A.L. Chang, A. Ulrich, H.B. Suliman, C.A. Piantadosi, Redox regulation of mitophagy in the lung during murine staphylococcus aureus sepsis, Free Radic. Biol. Med. 78 (2015) 179–189. [32] M. Benoit, B. Desnues, J.L. Mege, Macrophage polarization in bacterial infections, J.

10