alk is a therapeutic target for lethal sepsis · model of septic shock (22). thus, the sting...

SC I ENCE TRANS LAT IONAL MED I C I N E | R E S EARCH ART I C L E

SEPS I S

1State Key Laboratory of Trauma, Burns and Combined Injury, Research Institute ofSurgery, Research institute for Traffic Medicine of People’s Liberation Army, DapingHospital, Third Military Medical University, Chongqing 400042, China. 2The Third Af-filiated Hospital, Center for DAMP Biology, Key Laboratory for Major Obstetric Diseasesof Guangdong Province, Key Laboratory of Reproduction and Genetics of GuangdongHigher Education Institutes, Key Laboratory of Protein Modification andDegradation ofGuangdong Higher Education Institutes, Guangzhou Medical University, Guangzhou,Guangdong 510510, China. 3Department of Surgery, University of Pittsburgh, Pittsburgh,PA 15219, USA. 4Department of Pediatrics, Xiangya Hospital, Central South University,Changsha, Hunan 410008, China. 5Laboratory of Emergency Medicine, North Shore Uni-versity Hospital and The Feinstein Institute for Medical Research, Manhasset, NY 11030,USA.*Corresponding author. Email: [email protected] (D.T.); [email protected] (J.J.)

Zeng et al., Sci. Transl. Med. 9, eaan5689 (2017) 18 October 2017

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ALK is a therapeutic target for lethal sepsisLing Zeng,1,2,3 Rui Kang,3 Shan Zhu,2 Xiao Wang,1 Lizhi Cao,4 Haichao Wang,5 Timothy R. Billiar,3

Jianxin Jiang,1* Daolin Tang2,3*

Sepsis, a life-threatening organ dysfunction caused by infection, is a major public health concern with limitedtherapeutic options. We provide evidence to support a role for anaplastic lymphoma kinase (ALK), a tumor-associated receptor tyrosine kinase, in the regulation of innate immunity during lethal sepsis. The genetic dis-ruption of ALK expression diminishes the stimulator of interferon genes (STING)–mediated host immuneresponse to cyclic dinucleotides in monocytes and macrophages. Mechanistically, ALK directly interactswith epidermal growth factor receptor (EGFR) to trigger serine-threonine protein kinase AKT phosphorylationand activate interferon regulatory factor 3 (IRF3) and nuclear factor kB (NF-kB) signaling pathways, enablingSTING-dependent rigorous inflammatory responses. Moreover, pharmacological or genetic inhibition of theALK-STING pathway confers protection against lethal endotoxemia and sepsis in mice. The ALK pathway isup-regulated in patients with sepsis. These findings uncover a key role for ALK in modulating the inflammatorysignaling pathway and shed light on the development of ALK-targeting therapeutics for lethal systemic inflam-matory disorders.

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INTRODUCTIONSepsis is among the most common causes of death in hospitals and oneof the most elusive syndromes in medicine (1). Although the word“sepsis” was first introduced by Hippocrates, clinical criteria for thedefinition of sepsis and septic shock remain challenging (2). Sepsis isnow defined as life-threatening organ dysfunction due to a dysregulatedhost response to infection (3). Pathogenesis of the sepsis syndrome reliescritically on the activationof innate immunity by a large family of patternrecognition receptors (PRRs) in response tomicrobial pathogens, includ-ing especially Gram-negative bacilli (Escherichia coli and Pseudomonasaeruginosa) (4).Mechanistically, immunechemicals (cytokines, chemokines,and growth factors) released by various innate immune cells triggerboth pro- and anti-inflammatory immune responses, which can leadto organ dysfunction or failure, and even death (5). In these contexts,pharmacological inhibition of key inflammatory regulators that con-trol the overwhelming immune response could be useful for therapy.

The stimulator of interferon genes (STING) is a transmembraneadaptor protein critically involved in the innate immune response tocyclic dinucleotides (CDNs) that are produced by bacteria or meta-bolized from double-stranded DNA (dsDNA) by cyclic guanosinemonophosphate–adenosine monophosphate (cGAMP) synthase(cGAS) (6–12). Impairment of the STING pathway has been associatedwith the pathogenesis of several human diseases, including infections,inflammatory and autoimmune diseases, and cancers (13–15). Structur-ally, STING forms a complexwith theTANK-binding kinase 1 (TBK1) toenable its phosphorylation, which results in activation of both interferonregulatory factor 3 (IRF3) and nuclear factor kB (NF-kB) signaling path-

ways (16–18), leading to the consequent production of type I interferons(IFNs) and other proinflammatory cytokines. Despite substantial inves-tigation of the signaling pathways leading to STING activation, other keyregulators of the STING signaling pathway remain to be elucidated.

Here, we screened a library of 464 kinase inhibitors for STING-modulating capacities and found that some inhibitors specific foranaplastic lymphoma kinase (ALK) displayed the strongest suppres-sion of the STING-mediated type I IFN immune response in macro-phages andmonocytes.We provide evidence to support a critical roleof ALK in the regulation of STING activation inmonocytes andmacro-phages, which contribute to dysregulation of the innate immuneresponse and pathogenesis of experimental and clinical sepsis. Thesecond-generation ALK inhibitor LDK378, a U.S. Food and Drug Ad-ministration (FDA)–approved oral anticancer drug, exhibitedpromising anti-inflammatory activity in animal models of lethal sepsis,and theALKpathwaywas up-regulated in patientswith sepsis.Our dataindicate a paradigm for how host innate immunity is regulated throughthe ALK signaling pathway in innate immune cells, and suggest thatALK inhibitors could be potential therapeutic agents for lethal systemicinflammatory diseases.

RESULTSBioactive compound screening identifies STING modulatorsTo ensure a timely response to bacteria-derived CDN, an effectiveinnate recognition system consisting of STING and other unknowntransmembrane regulators has evolved in mammals (19). The 3′3′-cGAMP is a type of CDN and serves as a canonical STING ligand toinduce the production of type I IFNs (IFNa and IFNb) (20, 21). Toidentify other potential endogenous regulators of the STING signalingpathway in innate immunecells,we screeneda libraryof 464 compoundsthat selectively target 174 signaling molecules in immortalized bonemarrow–derived macrophages (iBMDMs) from B6 mice. Each com-pound was selected on the basis of its ability to principally interactwith a single target, leading to minimal off-target activity. We foundthat 3′3′-cGAMP–induced IFNb release in iBMDMs was changed byseveral target-selective inhibitors (Fig. 1A). The top five compoundsthat promoted the 3′3′-cGAMP–induced IFNb release included lido-caine (a selective inverse peripheral histamine H1 receptor agonist),

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stavudine [a nucleoside analog reverse transcriptase inhibitor (NARTI)active against HIV], thiazovivin [a novel Rho-associated coiled-coilcontaining protein kinase (ROCK) inhibitor], AM1241 (a selectivecannabinoid CB2 receptor agonist), and AS-252424 [a novel andpotent phosphatidylinositol-4,5-bisphosphate 3-kinase catalytic sub-unit g (PI3Kg) inhibitor] (Fig. 1B). In contrast, the top five compoundsthat blocked 3′3′-cGAMP–induced IFNb release in iBMDMs includedAZD3463 (a novel orally bioavailable ALK inhibitor), KPT-330 (anorally bioavailable selective exportin-1 inhibitor), KU-60019 [a potentand specific ataxia telangiectasia mutated (ATM) inhibitor],PRT062607 [a novel and highly selective spleen-associated tyrosine ki-nase (Syk) inhibitor], and LDK378 (an inhibitor against ALK) (Fig. 1B).These top five bioactive compounds were further tested in primaryperitoneal macrophages (pPMs) from B6 mice and human primaryperipheral blood mononuclear cells (pPBMCs), which confirmedtheir inhibitory properties in mouse iBMDMs (Fig. 1C), mouse pPMs(Fig. 1D), and human pPBMCs (Fig. 1E). Although STING plays di-vergent and stimulus-dependent roles in innate immunity (13–15), a


recent study revealed that activation of STING by bacteria acceleratedthe inflammatory response, organ dysfunction, and death in a mousemodel of septic shock (22). Thus, the STING pathway seems to be aviable target for pharmacologic intervention during bacterial sepsis.After further analysis of the 174 molecular targets, we found that ALKwas the top-ranked signaling molecule that promoted 3′3′-cGAMP–induced STING activation, based on IFNb release from iBMDMs(Fig. 1F). Together, these findings suggest that ALK is a possiblekey modulator of STING activation during bacterial infections.

Pharmacologic inhibition of ALK blocks STING activationAs secretory cells, monocytes and macrophages are vital to the regula-tion of immune responses and the development of inflammation (23).However, little information is available concerning the expression andactivity of ALK in innate immune cells. We observed that ALK wasabundantly expressed in primary or immortalized monocytes andmacrophages (iBMDMs, pPMs, and pPBMCs; RAW264.7, J774A.1,and THP1 cells) frommice or humans (fig. S1A). Functionally, all three

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Fig. 1. Identification of bioactive compounds modulating STING activation. (A) Heatmap of STING activity changes based on IFNb release from iBMDMs after 3′3′-cGAMP (10 mg/ml, 16 hours) stimulation in the absence or presence of 464 bioactive compounds (10 mM). (B) Structure of the compound identified to inhibit (blue) orpromote (red) STING activity. (C to E) IFNb release assayed using enzyme-linked immunosorbent assay (ELISA) from iBMDMs (C), pPMs (D), and pPBMCs (E) treated with3′3′-cGAMP (10 mg/ml) in the absence or presence of indicated bioactive compounds (10 mM) for 16 hours [n = 3; data are means ± SD; *P < 0.05 versus 3′3′-cGAMPgroup, analysis of variance (ANOVA) least significant difference (LSD) test]. (F) Heatmap of STING activity changes as judged by IFNb release from iBMDMs after 3′3′-cGAMP (10 mg/ml, 16 hours) stimulation in the absence or presence of 174 signaling modulating compounds. The top five negative (inhibitory) and positive (agonistic)regulators are noted.

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ALKinhibitors (AZD3463, LDK378, andAP26113) froma target-selectiveinhibitory library diminished 3′3′-cGAMP–induced IFNb release iniBMDMs (fig. S1B). With respect to the tumor-killing activity of ALKinhibitors (24), we addressed whether AZD3463, LDK378, andAP26113 inhibit STING activation in macrophages through triggeringcell death. AZD3463 exhibited cytotoxicity against iBMDMs, pPMs,and RAW264.7 and THP1 cells (fig. S1C). In contrast, LDK378 andAP26113 did not affect cell viability in these cells (fig. S1C), suggestingthat the suppressive effect of LDK378 andAP26113 onSTINGactivationin innate immune cells was not dependent on their cytotoxic capacities.In addition to 3′3′-cGAMP, a number of natural or enzymaticallysynthesized STING ligands [2′3′-cGAMP, 2′2′-cGAMP, cyclic dimericadenosine monophosphate (c-di-AMP), cyclic dimeric guanosinemonophosphate (c-di-GMP), cyclic dimeric inosine monophosphate(c-di-IMP), and 5,6-dimethylxanthenone-4-acetic acid (DMXAA)] withdifferent structures also induce type I IFNs (8, 20, 25, 26). Both LDK378and AP26113 inhibited IFNb release induced by these different STINGligands in iBMDMs (Fig. 2, A and B), RAW264.7 cells (Fig. 2B andfig. S2A), J774A.1 cells (Fig. 2B and fig. S2B), THP1 cells (Fig. 2B andfig. S2C), or pPMs (Fig. 2B and fig. S2D). Notably, only DMXAA(also known as vadimezan or ASA404) targets the STING pathwayin a mouse-specific manner (fig. S2C) (27, 28). Consistent with theirinhibition of IFNb protein release, pharmacologic inhibition of ALKby LDK378 and AP26113 also resulted in the attenuation of STINGligand–induced IFNbmRNA expression in iBMDMs (Fig. 2, C and D),RAW264.7 cells (Fig. 2D and fig. S2E), J774A.1 cells (Fig. 2D andfig. S2F), THP1 cells (Fig. 2D and fig. S2G), or pPMs (Fig. 2D andfig. S2H). Thus, ALK seems to play an important role in the regulationof STINGpathwayactivation in response to awide arrayof STING ligands.

A common event in STING activation by different ligands is thephosphorylation of TBK1 (p-TBK1) (16). We therefore examinedthe effect of ALK inhibition on the expression and phosphorylationof TBK1. Both LDK378 and AP26113 time-dependently reduced3′3′-cGAMP–induced p-TBK1, but not total TBK1, in iBMDMs(Fig. 2E) and J774A.1 (Fig. 2F), RAW264.7 (fig. S3A), and THP1(fig. S3B) cells. Similar to 3′3′-cGAMP, LDK378 and AP26113 alsoinhibited c-di-AMP– or DMXAA-induced p-TBK1, but not totalTBK1, in iBMDMs (Fig. 2G) and J774A.1 (Fig. 2H), RAW264.7(fig. S3C), and THP1 (fig. S3D) cells. Direct downstream targets ofp-TBK1 include phosphorylation of IRF3 (p-IRF3) and NF-kB (p-p65)(16–18). Both LDK378 and AP26113 also inhibited 3′3′-cGAMP–,c-di-AMP–, and DMXAA-induced p-IRF3 and p-p65 in iBMDMs(Fig. 2, E and G) and J774A.1 (Fig. 2, F and H), RAW264.7 (fig. S3,A and C), and THP1 (fig. S3, B and D) cells. These results stronglysuggest that pharmacologic inhibition of ALK blocks STING pathwayactivation through interfering with TBK1-mediated signaling transduc-tion in monocytes and macrophages.

Genetic inhibition of ALK limits STING activationBecause pharmacological inhibitors often have undesirable off-targeteffects, we thus determinedwhetherALKgene knockdownhas a similarimpact on STING activation. We generated stable ALK knockdownmacrophages using two different specific short hairpin RNAs (shRNAs)and achieved 85 to 95% ALK knockdown after antibiotic selection iniBMDMs (Fig. 3A) and RAW264.7 (fig. S4A), J774A.1 (fig. S4A), andTHP1 (fig. S4A) cells, as confirmed using Western blot analysis.

As aforementioned, different ALK inhibitors exhibit divergentimpacts on macrophage cell viabilities. To assess this behavior, wecarefully analyzed cell morphology, cell viability, and cell proliferation


with or without STING ligand (3′3′-cGAMP and c-di-AMP) treatmentin ALK knockdown iBMDMs. Like control shRNA cells, these ALKknockdown iBMDM cell lines were not associated with a change in cellmorphology (Fig. 3B), cell viability (Fig. 3C), and cell cycle (Fig. 3D)after treatment with 3′3′-cGAMP and c-di-AMP, suggesting thatALK depletion may not lead to macrophage death upon STINGactivation. Similar to pharmacological ALK inhibition, genetic inhibi-tion of ALK by shRNA also attenuated STING ligand (3′3′-cGAMP,2′3′-cGAMP, 2′2′-cGAMP, c-di-AMP, c-di-GMP, c-di-IMP, andDMXAA)–induced IFNb expression and release in iBMDMs (Fig. 3,E to H) and RAW264.7 (Fig. 3, G and H, and fig. S4, B and C),J774A.1 (Fig. 3, G and H, and fig. S4, D and E), and THP1 (Fig. 3, Gand H, and fig. S4, F and G) cells, indicating that ALK expression isrequired for STING activation. To corroborate these findings, wefurther examined protein phosphorylation of key STING signalingmolecules in ALK knockdown and control cells. Consistent withpharmacologic inhibition of ALK by LDK378 and AP26113, geneticsuppression ofALKexpression also reduced 3′3′-cGAMP–, c-di-AMP–,andDMXAA-induced p-TBK1, p-IRF3, and p-p65 in iBMDMs (Fig. 3I)and RAW264.7 (fig. S4H), J774A.1 (fig. S4I), and THP1 (fig. S4J) cells.These data strongly supportALK as an important regulator of activationof the STING signaling pathway.

ALK-EGFR-AKT pathway promotes STING activationIt has been suggested that the phosphorylation of ALK (p-ALK) atTyr1078 is required for its activation in tumor cells (29). To determinewhetherALK is similarly phosphorylated by STING ligands in innate im-mune cells, we analyzed the expression of p-ALK and ALK in iBMDMsand RAW264.7 and THP1 cells after STING activation. Expression ofp-ALK (but not total ALK)was enhanced in these cells by 3′3′-cGAMP,c-di-AMP, and DMXAA (Fig. 4A), suggesting that ALK is possiblyactivated by a wide array of STING ligands.

To elucidate the possible role of ALK in the regulation of the STINGsignaling pathway, we tested whether ALK promotes the phosphoryl-ation of core components of the STING pathway (STING, TBK1, andcGAS) through protein-protein interaction using coimmunoprecipita-tion techniques. We did not observe a direct interaction between ALKand these cytosolic signaling molecules in iBMDMs (fig. S5A) andRAW264.7 (fig. S5B) and THP1 (fig. S5C) cells after treatment with3′3′-cGAMP and c-di-AMP. Immunoprecipitation analysis also didnot reveal evidence of ALKbinding to other recently identified cytosolicSTING-interacting partners such as TIR [Toll/interleukin-1 (IL-1)receptor] domain–containing adapter-inducing IFNb (TRIF) (30)or the ribosomal protein S6 kinase (fig. S5, A to C) (31). These findingssuggest thatALK-mediated STINGactivationmay not be dependent ondirect binding to known cytosolic regulators of the STING pathway inmacrophages and monocytes.

It is still possible thatALK, amember of the receptor tyrosine kinases(RTKs), may interact with other RTKs in the cell surface to mediatesignal transduction into the cytoplasm under STING activation. To testthis possibility, we used a proteome profiler antibody array to surveythe phosphorylation of 49 RTKs in iBMDMs after stimulation with3′3′-cGAMP or c-di-AMP. The phosphorylation of certain RTKswas changed by exposure to 3′3′-cGAMP and c-di-AMP (Fig. 4B andfig. S6). Among them, the phosphorylation of epidermal growth factorreceptor (EGFR) was up-regulated by 3′3′-cGAMP and c-di-AMP(Fig. 4C and fig. S6), whereas LDK378 or knockdown of ALK impairedthe STING ligand–induced up-regulated phosphorylation of variousRTKs, including EGFR, in iBMDMs (Fig. 4C and fig. S6). These data

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Fig. 2. Pharmacologic inhibition of ALK impairs STING activation. (A) iBMDMs were stimulated with indicated STING ligands (10 mg/ml) in the absence or presenceof LDK378 (10 mM), AP26113 (10 mM), or control vehicle [dimethyl sulfoxide (DMSO)] for 16 hours, and the release of IFNb was assayed using ELISA (n = 3; data aremeans ± SD; *P < 0.05 versus DMSO group, ANOVA LSD test). (B) Heatmap of IFNb release changes in macrophages or monocytes after STING ligand (10 mg/ml)stimulation in combination with LDK378 (10 mM), AP26113 (10 mM), or vehicle (DMSO) for 16 hours. (C) iBMDMs were stimulated with indicated STING ligands (10 mg/ml)in the absence or presence of LDK378 (10 mM), AP26113 (10 mM), or vehicle (DMSO) for 16 hours, and IFNb mRNA was assayed with quantitative polymerase chain reaction(n = 3; data are means ± SD; *P < 0.05 versus DMSO group, ANOVA LSD test). (D) Heatmap of IFNbmRNA changes in macrophages or monocytes after STING ligand (10 mg/ml)stimulation in combination with LDK378 (10 mM), AP26113 (10 mM), or vehicle (DMSO) for 16 hours. AU, arbitrary units. (E and F) Western blot analysis of indicated proteinexpression in iBMDMs (E) or J774A.1 cells (F) after 3′3′-cGAMP (10 mg/ml) stimulation in combination with LDK378 (10 mM), AP26113 (10 mM), or vehicle (DMSO) for 3 to16 hours. (G and H) Western blot analysis of indicated protein expression in iBMDMs (G) or J774A.1 cells (H) after c-di-AMP (10 mg/ml) or DMXAA (10 mg/ml) stimulationin combination with LDK378 (10 mM), AP26113 (10 mM), or vehicle (DMSO) for 16 hours.

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Fig. 3. Genetic silencing of ALK limits STING activation. (A) Western blot analysis of ALK expression in ALK stable knockdown iBMDMs (n = 3; data are means ± SD;*P < 0.05 versus control shRNA group, t test). GAPDH, glyceraldehyde-3-phosphate dehydrogenase. (B to D) Indicated iBMDMs were stimulated with 3′3′-cGAMP (10 mg/ml)or c-di-AMP (10 mg/ml) for 16 hours, and cell morphology (B), viability (C), and cell cycle phase (D) were assayed (scale bars, 200 mm). (E and F) Indicated iBMDMs werestimulated with indicated STING ligands (10 mg/ml) for 16 hours, and IFNb protein release (E) and IFNbmRNA (F) were assayed [n = 3; data are means ± SD; *P < 0.05 versuscontrol (Ctrl) shRNA group, ANOVA LSD test]. (G and H) Heatmap of IFNb protein release (G) and IFNb mRNA expression (H) changes in indicated ALK-WT (wild-type) andALK-knockdown macrophages or monocytes after STING ligand (10 mg/ml) stimulation for 16 hours. (I) Western blot analysis of indicated protein expression in ALK-WT andALK-knockdown iBMDMs after stimulation with 3′3′-cGAMP (10 mg/ml), c-di-AMP (10 mg/ml), or DMXAA (10 mg/ml) for 16 hours.






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Fig. 4. ALK/EGFR binding triggers AKT-dependentSTING activation. (A) Western blot analysis of indicatedprotein expression in iBMDMs andRAW264.7 and THP1 cellsafter stimulation with 3′3′-cGAMP (10 mg/ml), c-di-AMP(10 mg/ml), or DMXAA (10 mg/ml) for 16 hours. (B) HeatmapofRTKsphosphorylationchanges in iBMDMsafter 3′3′-cGAMP(10 mg/ml) or c-di-AMP (10 mg/ml) stimulation for 16 hourswith or without pharmacologic (LDK378, 10 mM) or geneticinhibition of ALK. (C) Relative EGFR phosphorylation assayed

in parallel to (B). (D) Immunoprecipitation (IP) analysis of the interaction between ALK and EGFR in iBMDMs after 3′3′-cGAMP (10 mg/ml) or c-di-AMP (10 mg/ml) stimulation for 16 hourwith orwithout LDK378 (10 mM)orOSI-420 (10 mM). IB, immunoblotting. (E)Western blot analysis of indicatedprotein expression in iBMDMs after treatmentwith 3′3′-cGAMP (10 mg/mlor c-di-AMP (10 mg/ml) for 16 hours with or without LDK378 (10 mM), OSI-420 (10 mM), or GDC-0068 (10 mM). (F) Western blot analysis of EGFR expression in EGFR stable knockdowniBMDMs. (G) Western blot analysis of indicated protein expression in EGFR-WT and EGFR-knockdown iBMDMs after stimulationwith 3′3′-cGAMP (10 mg/ml) or c-di-AMP (10 mg/mlfor 16 hours. (H and I) iBMDMswere treatedwith 3′3′-cGAMP (10mg/ml) or c-di-AMP (10 mg/ml) for 16hourswith orwithout LDK378 (10 mM),OSI-420 (10 mM), orGDC-0068 (10 mM)and IFNb protein release (H) and IFNb mRNA expression (I) were assayed (n = 3; data are means ± SD; *P < 0.05 versus 3′3′-cGAMP or c-di-AMP group, ANOVA LSD test).




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suggest that RTK phosphorylation might be widely implicated in theSTING pathway.

Previous observation demonstrated that the interplay between ALKand EGFR coordinately regulates AKT phosphorylation to promotetumor growth (32,33).We therefore testedwhether theALK-EGFR-AKTpathway is also a critical driver of STING activation in innate immunecells. First, the interaction between ALK and EGFR was found to beincreased in iBMDMs (Fig. 4D) and THP1 cells (fig. S7) after treatmentwith 3′3′-cGAMP or c-di-AMP but was reduced by inhibitors specificfor both ALK (LDK378) and EGFR (OSI-420) (Fig. 4D and fig. S7).Second, these ALK (LDK378) and EGFR (OSI-420) inhibitors alsoattenuated the 3′3′-cGAMP– or c-di-AMP–induced phosphorylationof ALK, EGFR, and AKT in iBMDMs (Fig. 4E) and RAW264.7(fig. S8A) and THP1 (fig. S8B) cells. In contrast, the pan-AKT inhibitorGDC-0068 only blocked the phosphorylation of AKT, but not ALK orEGFR, in activated iBMDMs (Fig. 4E) and RAW264.7 (fig. S8A) andTHP1 (fig. S8B) cells. Third, all inhibitors (LDK378, OSI-420, andGDC-0068) similarly diminished the STING ligand–induced phospho-rylation of TBK1, IRF3, and p65 in iBMDMs (Fig. 4E) and RAW264.7(fig. S8A) and THP1 (fig. S8B) cells. Fourth, the ability of EGFR andAKT to promote the phosphorylation of TBK1, IRF3, and p65 wassimilarly impaired by stable genetic knockdown of EGFR via two dif-ferent shRNAs in iBMDMs (Fig. 4, F and G) and RAW264.7 cells(fig. S9). Finally, pharmacologic inhibition of the ALK-EGFR-AKTpathway attenuated STING ligand (3′3′-cGAMP and c-di-AMP)–induced IFNb release and mRNA expression in iBMDMs (Fig. 4,H and I), RAW264.7 cells (fig. S10, A and B), THP1 cells (fig. S10,C and D), and pPMs (fig. S10, E and F). Together, these data indicatethat the interplay between ALK and EGFR contributes to the AKT-dependent STING activation in macrophages and monocytes.

ALK and STING regulate immune chemical releaseThe production and release of various immune chemicals such as cyto-kines, chemokines, and growth factors, as well as damage-associatedmolecular patterns, are generally considered a final effector during animmune response. Several clinical studies have suggested that immunechemical profiles, especially cytokines, are markers of disease severity,prognosis, and potential future therapeutic targets in patients withsepsis (34–36). Thus, to correlate symptoms with different phases ofsepsis, it is important to survey the profile of multiple cytokines (37).

Like bacteria-derived CDN, lipopolysaccharide (LPS), the majorcomponent of the outer membrane of Gram-negative bacteria, is alsoa critical pathogen-associated molecular pattern (PAMP) involved inthe pathogenesis of sepsis (38). Using a proteome profiler antibodyarray of 111 immune chemicals, we observed that stimulation with3′3′-cGAMP, c-di-AMP, or LPS led to the release of different proteinsfrom iBMDMs (Fig. 5A and fig. S11A). For example, all three stimuliinduced the release of TNFa (tumor necrosis factor–a), IL-6, andserpin E1/PAI-1 (plasminogen activator inhibitor-1) (Fig. 5B),whereas only 3′3′-cGAMPand c-di-AMPmarkedly increasedE-selectinrelease (Fig. 5B). In contrast, both 3′3′-cGAMP and LPS up-regulatedthe release of P-selectin and resistin (Fig. 5B), and only c-di-AMPor LPSenhanced the release of GDF-15 and CXCL10 (Fig. 5B). Collectively,these findings support the notion that different PAMPs might causethe release of different immune chemicals during innate immunityactivation.

Given that signal transduction elements interact through complexbiochemically related networks, we next sought to identify theoverlapping and distinct immune effects of ALK and STING on im-


mune chemical release in response to 3′3′-cGAMP, c-di-AMP, orLPS (Fig. 5A and fig. S11A). The knockdown of ALK and STINGimpaired the release of CRP (complement-reactive protein), IL-2,IL-3, C5a (complement component 5a), ICAM1 (intercellular adhesionmolecule 1), coagulation factor III, chitinase 3–like 1, and MMP9(matrix metalloproteinase 9) (Fig. 5C). Notably, most of these ALT(alanine aminotransferase)– and STING-related common immunechemicals play important roles inmediating sepsis-associated dissem-inated intravascular coagulation and thromboembolic disease. In ad-dition, the expression profiling assays also revealed that ALK andSTING occupied distinct roles in the regulation of most chemokinesreleased in activated iBMDMs (Fig. 5C), suggesting that other unknownsignaling molecules or feedback loops may also contribute to the regu-lation of different chemokines. LPS also has the ability to activate TBK1to coordinate the activation of the IRF3 andNF-kBpathway in immunecells (39, 40). LDK378 also inhibited the LPS-induced phosphorylationof TBK1, IRF3, and p65 (fig. S11B) as well as IFNb release (fig. S11C) iniBMDMs. These findings indicate that ALK contributes to LPS-inducedactivation of the TBK1–IRF3–NF-kB pathway in macrophages.

Inhibition of the ALK-STING pathway protects mice againstseptic deathOneultimate aim is to evaluate the therapeutic potential ofALK-STINGpathway–targeting agents in sepsis and septic shock in vivo. Over theyears, multiple animal models of sepsis have been developed, of whichthe cecal ligation and puncture (CLP) model is the most relevant toclinical sepsis (41, 42). To determine the effect of the ALK inhibitorLDK378 on polymicrobial sepsis, B6 mice were subjected to CLP with22-gauge syringe needles (Fig. 6A). Repetitive administration ofLDK378 [20 mg/kg, intraperitoneally (ip)] 2, 24, 48, and 72 hours afterthe onset of CLP conferred protection against lethality (Fig. 6B), whichwas associatedwith reduced injury in the lung, small intestine, andothertissues (Fig. 6C and fig. S12). For instance, septic lungs showed alveolarseptal wall thickening, increase in leukocyte infiltrates, and alveolarcongestion and edema, whereas septic intestines exhibited signs ofinjury characterized by the loss of goblet cells and loss of villi (Fig. 6C).These CLP-induced pathological changes were attenuated by LDK378administration in septic mice (Fig. 6C). Biochemical measurementof tissue enzymes also revealed protective effects of LDK378 againstdysfunction of the heart [creatine kinase (CK)], pancreas [amylase(AMYL)], kidney [blood urea nitrogen (BUN)], and liver (ALT)(Fig. 6D). Moreover, LDK378 administration reduced CLP-inducedTNFa, IFNb, MCP1 (monocyte chemoattractant protein-1), and IL-7mRNA expression (Fig. 6E) and systemic release and accumulation inthe serum (Fig. 6, F and G, and fig. S13). In an animal model of lethalendotoxemia (LPS, 10 mg/kg, ip) (Fig. 7A), LDK378 promoted similarprotection against endotoxemic lethality (Fig. 7B), endotoxemia-induced tissue injury (Fig. 7C and fig. S14), organ dysfunction(Fig. 7D), and proinflammatory cytokine expression (Fig. 7E) andrelease (Fig. 7, F and G, and fig. S15). Thus, LDK378 protects miceagainst polymicrobial sepsis and lethal endotoxemia.

We next sought to test whether STING−/−mice aremore resistant topolymicrobial sepsis and lethal endotoxemia. Like pharmacologic inhi-bition of ALK by LDK378, genetic STING depletion reduced animaldeath in both polymicrobial sepsis (Fig. 6B) and lethal endotoxemiamodels (Fig. 7B), which was associated with attenuated tissue injury suchas tissue destruction, necrosis, and leukocyte infiltration (Figs. 6C and7C), organ dysfunction (Figs. 6D and 7D), and proinflammatory cy-tokine expression (Figs. 6E and 7E) and release (Figs. 6, F and G, and 7,

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F andG). Collectively, these in vivodata agreewith the in vitro data ob-tained in macrophages and mono-cytes and suggest that activation ofthe ALK-STINGpathwaymediatesthe pathophysiology of sepsis andseptic shock.

It is possible that theALK-STINGpathwaymay still be needed to in-still effective innate immunity againstpathogens in response to mild orsublethal infections. During severeor lethal infections, the dysregulatedoveractivation of the ALK-STINGpathwaymay tilt the balance towardpromoting overzealous inflamma-tory responses that may contributeto the pathogenesis of sepsis. To de-termine whether the ALK-STINGpathway’s contribution to mousesepsis depends on the severity ofthe disease model, B6 mice weresubjected to CLP with syringeneedles with gauges ranging from17 to 27. Increasing the needle thick-ness decreased the percent surviv-al from 86.66% (using a 27-gaugeneedle, “low-grade sepsis”) to41.17% (using a 22-gauge needle,“middle-grade sepsis”) to 0% (usinga 17-gauge needle, “high-gradesepsis”). Treatment with LDK378prolonged animal survival in low-,middle-, and high-grade sepsismodels (fig. S16, A to C). In con-trast, STING-deficient mice hadprolonged survival only in high-and middle-grade sepsis models(fig. S16, B and C), suggestingthat the STING signaling pathwaymight still be needed for the hostto instill an appropriate innateimmunity against pathogens inresponse to mild and sublethalinfections. Notably, LDK378conferred further protection toSTING-deficient mice in responseto high-grade sepsis (fig. S16C),indicating that ALK and STINGhave both overlapping and dis-tinct functions in septic death.Genetic or pharmacologic inhi-bition of ALK or STING alsoled to changes in the release ofoverlapping and distinct im-mune chemicals in response toCDN, LPS, or CLP in vitro orin vivo (Figs. 5, 6, F and G, and7, F and G).

Zeng et al., Sci. Transl. Med. 9, eaan5689 (2

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Fig. 5. ALK and STING have overlapping and distinct im-mune functions in immune chemical release. (A) Heatmapof immune chemical profile in WT, ALK-knockdown (KD), orSTING-knockout (KO) iBMDMs after stimulation with LPS(1 mg/ml), 3′3′-cGAMP (10 mg/ml), or c-di-AMP (10 mg/ml) for16 hours with or without LDK378 (10 mM). (B) Changes in im-mune chemical release in WT iBMDMs after LPS, 3′3′-cGAMP,and c-di-AMP treatment. (C) Changes in immune chemical re-lease between ALK-KD and STING-KO iBMDMs in response to3′3′-cGAMP, c-di-AMP, or LPS.

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Intestine Lung

STING+/+ + vehicle STING+/+ + LDK378 STING–/– + vehicle STING+/+ + vehicle STING+/+ + LDK378 STING–/– + vehicle

Fig. 7. Inhibition of the ALK-STING pathway protects mice against LPS-induced endotoxemia. (A) Schematic depicting the endotoxemia model. (B) Ad-ministration of LDK378 or depletion of STING in mice prevented LPS (10 mg/kg)–induced animal death (n = 18 mice per group; *P < 0.05, Kaplan-Meier survivalanalysis). (C to G) In parallel, tissue hematoxylin and eosin staining (24 hours; scale bars, 200 mm) (C), serum enzyme activity (12 to 48 hours) (D), cytokine mRNA(24 hours) (E), serum antibody array (24 hours) (F), and heatmap of immune chemical profile (24 hours) (G) were assayed (n = 3 to 5 mice per group; each barrepresents the mean of the data; *P < 0.05, ANOVA LSD test). The top five down-regulated circulating immune chemical mediators in LDK378 and STING−/−

groups compared with control group included EGF, CD14, CXCL1, endoglin, and CCL22. High-resolution images related to (C), (F), and (G) are shown in figs. S14and S15.





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ALK-STING pathway is changed in human sepsisAlthough the murine endotoxemia and CLP models mimic manyfeatures of human sepsis, the translation of findings and inferencesfrom these animal sepsis models to human sepsis remains a challenge(41, 42). Thus, we next determinedwhether theALK-STINGpathway issimilarly altered in the PBMCs of patients with sepsis. Compared with ahealthy control group, the mRNA expression of ALK, EGFR, STING,TBK1, and IRF3 in PBMCs was increased in the sepsis group (Fig. 8,A and B). Moreover, the expression of total and phosphorylatedALK, EGFR, STING, TBK1, and IRF3 proteins was also increased inthe sepsis group (Fig. 8C), indicating an overall activation of ALK-STING signaling pathways during human sepsis. These findings furthersupport a potential pathogenic role of the ALK-STING pathway inhuman sepsis.

DISCUSSIONThe innate immune system constitutes the first line of defense againstpathogen invasion.However, insufficient, excessive, or poorly controlledactivation of PRRs can cause an imbalance in the inflammation-immune


network, leading to sepsis, septic shock,and ultimately death. The elucidation ofthis complex network can shed light oncritical pathways andkeymolecules drivingsepsis progression.We provide evidence tosupport ALK as a regulator of innate im-mune STING activation that contributesto the pathogenesis of microbial sepsis(fig. S17). Genetic or pharmacological inhi-bitionof theALK-STINGsignalingpathwaycorrected excessive host response to infec-tion and rendered mice more resistant tosepsis and septic shock, supporting thetherapeutic potential of ALK inhibitors inthe treatment of human sepsis.

ALK, a tyrosinekinase receptorbelongingto the insulin receptor superfamily, wasoriginally discovered as a fusion proteinwith nucleophosmin in anaplastic, large-cell non-Hodgkin’s lymphoma in 1994(43). Various alterations in the ALK geneor protein have been implicated in humancancer tumorigenesis, especially in non–small-cell lung cancer (NSCLC) (44). Incancercells,ALKinitiatesseveralsignaltrans-ductionpathways[Januskinase(JAK)–signaltransducer andactivatorof transcription3(STAT3), EGFR-AKT, andRAS–mitogen-activatedproteinkinase (MAPK)] involvedin cell proliferation and transformation(44). In normal healthy tissues, the expres-sionofALKisrelatively low,withtheexcep-tion of the nervous system (45, 46). Despitethis, global knockout of ALK in mice doesnot cause serious behavioral phenotypes,whichhinders our understanding ofALK’sphysiological role in mammals (47, 48).Here, we demonstrated that ALK is abun-dantly expressed in innate immune cells

(monocytes and macrophages) and instigates proinflammatory re-sponses to PAMPs, including DNAs, during lethal infection. ThismaypartlyexplainwhyALK-positive cancerpatientshavean increasedrisk of developing infections (49).

Clinically, patients with sepsis frequently have elevated circulatingDNA from invading pathogens or damaged host cells, which is oftenassociatedwith poor outcomes (50–52). Although the underlying causesremain elusive, it has been suggested that the inability to efficiently elim-inate DNA or abnormal DNA-sensing pathways contributes to dysreg-ulated systemic inflammation in sepsis. Almost two decades ago,STING was suggested as a key adaptor protein for most DNA-sensingsignaling pathways (6, 10). Our present study has established the criticalinvolvement of another transmembrane tyrosine kinase, ALK, in theSTING-dependent innate recognition of microbial DNA during sepsis.In septic patients, we found that the expression of ALK and STING isincreased in circulating PBMCs. Thus, pharmacologically blocking theALK-STING signaling pathway may therapeutically modulate theDNA-induced excessive inflammation response in sepsis.

Bacterial CDN has long been shown to gain access to the inside ofinnate immune cells and directly bind cytosolic STING to initiate

B Clinical characteristics of sepsis patients and the healthy control individuals

4 (25)

Sepsis group (n = 16)

Control group (n = 16)

Age, mean (SD)

Gender n (%)

Male

Female

SOFA, mean (SD)

In-hospital mortality, n (%)

Length of stay, days, median (range)

Yes

No

38.9 (18.9)

10 (62.5)

6 (37.5)

N/A

N/A

N/A

N/A

48.5 (14.3)

12 (75)

4 (25)

5.8 (2.4)

24.5 (3, 49)

12 (75)

N/A, not applicable

A

ALK

mRN

A

*

0.0.5

1.01.52.02.53.0

EGFR

mRN

A

*

0

1

2

3

4

STIN

G m

RNA

*

01234567

0123456

IRF3

mRN

A

SepsisControl

*

TBK1

mRN

A

*

0.0

.5

1.01.5

2.0

2.5

C SepsisControl

1 2 1 2

p-TBK1

TBK1

p-IRF3

IRF3

p-STING

STING

Actin

p-ALK

ALK

p-EGFR

EGFR

Fig. 8. Gene and protein changes in ALK-dependent STING pathways in human sep-sis. (A) Box plots comparing measures of ALK,EGFR, STING, TBK1, and IRF3 mRNA in PBMCsamples of sepsis patients (n = 16) and healthycontrols (n = 16). The mRNAs are presented asmedian value (black line), interquartile range(box), and minimum and maximum of all data(black line). *P < 0.05 versus control group, t test.(B) Table depicting clinical characteristics ofsepsis patients and healthy control individuals.(C) Western blot analysis of indicated proteinexpression in PBMC samples of sepsis patientsand healthy controls.

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IRF3- and NF-kB–dependent immune responses (8, 20). Host self-DNA passively released by injured cells can also enter and accumulatein the cytoplasm of innate immune cells to bind and activate STING(53). Here, we provided evidence for an alternative transmembranereceptor–dependent pathway, by which extracellular DNA activatesSTING through transmembrane ALK/EGFR-dependent mechanisms(fig. S17). Our finding supports the notion that cell surface receptorscan mediate extracellular DNA activity in inflammation and immuneresponse (54, 55). We propose that various types of STING ligandstrigger ALK/EGFR interaction and activation (phosphorylation),leading to subsequent AKT phosphorylation and consequent activationof the cytosolic STING pathway. We did not observe direct interactionbetween ALK and STING or its downstream signaling components(TBK1, cGAS, TRIF, and S6), suggesting that ALK is likely not a directadaptor for cytosolic STING. Given the possible interaction betweenEGFR, AKT, TBK1 and IRF3 (56, 57), it will be important to determinewhether the ALK/EGFR complex could recruit TBK1, IRF3, or AKT totrigger their phosphorylation and activation, thereby activating theSTING and TRIF pathways. Previous studies have established the in-volvement of AKT in the positive regulation of the STING signalingpathway and IFNb production (58, 59), although a recent study sug-gested a negative regulatory role of AKT in the regulation of STINGsignaling pathways during viral infection (60). It is not yet knownwhether AKT divergently regulates STING activation during viraland bacterial infections. Nevertheless, it has been suggested that STINGoccupies different roles in innate immune responses to viral versus bac-terial infections (13–15), supporting the notion that innate immune cellscan distinguish between viral and bacterial pathogens tomount a diver-gent immune responses (61). Regardless, phosphorylation of STINGhas been considered an essential and conserved mechanism of innateimmune activation to both viral and bacterial infections (16, 62, 63),which now appears to depend on ALK activation.

During the last few decades, numerous phase 3 clinical trials ofsingle-target therapies have failed to show efficacy in the clinical man-agement of human sepsis. For complex systemic inflammatory syn-dromes, it is difficult to translate successful animal studies intoclinical applications, partly because of the pitfalls in the selection of non-feasible therapeutic targets or nonrealistic clinical outcome measuressuch as survival rates. However, the investigation of pathogenic cyto-kines in animal models of diseases has led to the development of suc-cessful cytokine-targeting therapeutic strategies for autoimmunediseases like rheumatoid arthritis, such as the chimeric anti-TNFmono-clonal antibody infliximab and the soluble TNF receptor–Fc fusion pro-tein etanercept (64, 65). Here, we demonstrated that LDK378, an ALKinhibitor also known as ceritinib, FDA-approved for the treatment ofmetastatic ALK-positive NSCLC (66), conferred significant protectionagainst both lethal endotoxemia and sepsis in mice. Because LDK378also inhibited LPS-induced phosphorylation of TBK1, IRF3, and p65of NF-kB, and conferred further protection against both low- andhigh-grade sepsis, it is possible that LDK378 confers protection againstlethal sepsis potentially via inhibiting both TRIF and STING pathways.With its well-defined pharmacokinetics, safety profile, and tolerabilityin cancer patients (66), it is possible and important to explore its ther-apeutic potential for the treatment of human sepsis.

In summary, we have revealed a role for ALK in regulating theSTING-mediated innate immune response and provided a potentialALK-targeting strategy for the clinicalmanagement of sepsis. Activationof the STING pathway by ALK may be a crucial step for its immuno-logical activity andmay contribute to the pathogenesis of sepsis and sep-


tic shock. Inhibition of ALK and STING led to divergent changes ofimmune chemical expression profiles, suggesting that nonoverlappingfunctions of ALK and STING exist in innate immune responses. ALKregulated both bacterial CDN- andLPS-inducedmacrophage activationin vitro, andALK inhibition increased septic animal survival in STING-deficient mice in vivo. The underlying molecular mechanism responsi-ble for the immune functional differences between ALK and STINGawaits further investigation.

MATERIALS AND METHODSStudy designThe objective of our study was to identify potential drugs targetingthe STING pathway for the treatment of sepsis. Through a kinaseinhibitor library screen, we identified ALK inhibitors as the top in-hibitors for STING activation in monocytes and macrophages. Wenext defined the molecular mechanism by which ALK promotesSTING activation through EGFR and AKT. We also evaluated theefficacy of ALK-targeting strategies for the management of poly-microbial sepsis and lethal endotoxemia in mice. Finally, we de-termined whether the ALK-STING pathway is similarly altered in thePBMCs of patients with sepsis. In all experiments, animals were ran-domized to different treatment groups without blinding. Sample sizein experiments was specified in each figure legend. We did not excludesamples or animals. For every figure, statistical tests are justified as ap-propriate. All data meet the assumptions of the tests. No statisticalmethods were used to predetermine sample sizes, but our sample sizesare similar to those generally used in the field. All reagent sources arelisted in table S1.

Animal models of endotoxemia and sepsisC57BL/6J wild-type mice (#000664) and STING−/− mice [strain name:B6(cg)-Tmem173tm1.2Cambgt/J, #017537] were purchased from theJackson Laboratory. All mice were maintained in the University ofPittsburgh animal care facility. Mice were housed with their littermatesin groups of four animals per cage and kept on a regular 12-hour lightand dark cycle (7:00 to 19:00 light period). Food and water were avail-able ad libitum. Experiments were carried out under pathogen-freeconditions, and the health status of mouse lines was routinely checkedby veterinary staff. Experiments were carried out with randomly chosenlittermates of the same sex andmatched age and body weight. We con-ducted all animal care and experimentation in accordance with theAssociation for Assessment and Accreditation of Laboratory AnimalCare guidelines (www.aaalac.org) and with approval from the Univer-sity of Pittsburgh Institutional Animal Care and Use Committees.CLP modelSepsis was induced inmale or female C57BL/6Jmice (8 to 10 weeks old,22 to 26 g) using a surgical procedure as previously described (67). Brief-ly, anesthesia was induced with ketamine (80 to 100 mg/kg, ip) andxylazine (10 to 12.5 mg/kg, ip). A small midline abdominal incisionwas made, and the cecum was exteriorized and ligated with 4-0 silkimmediately distal to the ileocecal valve without causing intestinalobstruction. The cecumwas then punctured twice with a 17- to 27-gaugeneedle. The abdomen was closed in two layers, and mice were injectedsubcutaneously with 1 ml of Ringer’s solution including analgesia(buprenorphine, 0.05 mg/kg). LDK378 (20 mg/kg) was dissolved invehicle [10% dimethyl sulfoxide, 20% cremophor/ethanol (3:1), and70% phosphate-buffered saline (PBS)] and repeatedly administeredorally to mice at 2, 24, 48, and 72 hours after CLP.

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Endotoxemia modelLPS (E. coli 0111:B4, 10 mg/kg, #L4391, Sigma) was dissolved in PBS.Male or female C57BL/6J mice (8 to 10 weeks old, 22 to 26 g) received asingle oral dose of LDK378 (20 mg/kg) or vehicle and then an infusionof LPS (10mg/kg, ip) 60min later.Mice were retreated with LDK378 orvehicle 6, 12, and 24 hours after LPS infusion.

Patient samplesPBMCs from patients with sepsis (n = 16) and healthy controls (n = 16)were collected from Daping Hospital and Xiangya Hospital. Collectionof samples was approved by the Institutional Review Board. Sepsis wasidentified according to The Third International Consensus Definitionsfor Sepsis and Septic Shock (Sepsis-3) (3).

Cell cultureiBMDMs (a gift from K. Fitzgerald at University of MassachusettsMedical School), murine macrophage-like RAW264.7 [AmericanType Culture Collection (ATCC), #TIB-71], murine J774A.1(ATCC, #TIB-67), and human monocytic THP1 cell lines (ATCC,#TIB-202) were cultured in Dulbecco’s modified Eagle’s mediumsupplemented with 10% fetal bovine serum (FBS) and 1× penicillin-streptomycin. Human PBMCswere purchased fromLifeline Cell Tech-nology (#1207).Macrophages/monocytesweremaintained in a 5%CO2

incubator at 37°C. All cells were mycoplasma-free and authenticatedwith short tandem repeat DNA profiling analysis.

Mouse pPMs were isolated from C57BL/6J mice as previously de-scribed (68). In brief, 8-week-old female or male C57BL/6J mice wereinjected with 3.0% thioglycollate medium (2 ml per mouse) into theperitoneum. Three days after injection, mice were sacrificed andinjected with 3 ml of 0.05% EDTA-PBS into the peritoneum to harvestperitoneal macrophages. Collected cells were centrifuged at 1000 rpmfor 5min at 4°C, and the cell pellet waswashedwith PBS and centrifugedagain. The cell pellet was then suspended inDulbecco’s modified Eagle’smedium supplemented with 10% FBS and 1× penicillin-streptomycinand cultured in a culture dish.

Immunoblotting and immunoprecipitationFor immunoblotting, cells were lysed in cell lysis buffer (#9803, CellSignaling Technology) with protease inhibitor cocktail (Promega),phosphatase inhibitor cocktail (Sigma), and 1 mM Na3VO4 (69).Cleared lysates were resolved by SDS-PAGE (polyacrylamide gel elec-trophoresis; #3450124, Bio-Rad) and then transferred onto poly-vinylidene difluoride membranes (#1704273, Bio-Rad). Themembranes were blocked with tris-buffered saline Tween 20 (TBST)containing 5% skim milk for 1 hour at room temperature and then in-cubated with the indicated primary antibodies (1:1000 to 1:5000)overnight at 4°C. After being washed with TBST, the membranes wereincubated with a horseradish peroxidase (HRP)–linked anti-mouse im-munoglobulinG (IgG) secondary antibody (#7076, Cell SignalingTech-nology) orHRP-linked anti-rabbit IgG secondary antibody (#7074, CellSignaling Technology) for 1 hour at room temperature. The mem-branes were washed three times in TBST and then visualized and ana-lyzed with a ChemiDoc Touch Imaging System (#1708370, Bio-Rad).The intensities of bands were analyzed with Image Lab software.

For immunoprecipitation, cells were lysed at 4°C in ice-coldmodified radioimmunoprecipitation lysis buffer (#9806, CellSignaling Technology), and cell lysates were cleared by centrifugation(12,000g, 10 min). Concentrations of proteins in the supernatant weredetermined by bicinchoninic acid assay. Before immunoprecipitation,


samples containing equal amounts of proteins were precleared withprotein A/G agarose/Sepharose beads (#20423, Thermo Fisher ScientificInc.) (4°C, 3 hours) and subsequently incubated with various irrelevantIgG or anti-ALK (#ab190934, Abcam) or anti-EGFR antibodies(#2232S, Cell Signaling Technology) in the presence of protein A/Gagarose/Sepharose beads overnight at 4°C with gentle shaking. Afterincubation, agarose/Sepharose beads were washed extensively withPBS, and proteins were eluted by boiling in 2× SDS sample bufferbefore SDS-PAGE electrophoresis.

The antibodies to p-STING (#85735; 1:1000), STING (#13647;1:1000), p-TBK1/NAK (#S172; 1:1000) (#5483; 1:1000), TBK1/NAK(#3504; 1:1000), IRF3 (#4962; 1:1000), p-IRF3 (S396; #4947S; 1:1000),p-p65 (S536; #3033P; 1:1000), p-EGFR (Y1068; #3777T; 1:1000), EGFR(#2232; 1:1000), p-AKT (S473; #4060; 1:1000), and S6 (#2317; 1:1000)were obtained fromCell Signaling Technology. The antibody to p-ALK(Y1057; #ab192809; 1:1000)was obtained fromAbcam.The antibody toALK (#sc-398791; 1:100) was obtained from Santa Cruz Biotechnology.The antibody to TRIF (#A01872; 1:500) was obtained from Boster.

Statistical analysisData are expressed as means ± SD. Unpaired Student’s t tests were usedto compare the means of two groups. One-way ANOVA was used forcomparison among the different groups. When ANOVA was signifi-cant, post hoc testing of differences between groups was performedusing the LSD test. The Kaplan-Meier method was used to comparedifferences in mortality rates between groups. A P value of <0.05 wasconsidered statistically significant. Individual subject-level data areshown in table S2.

SUPPLEMENTARY MATERIALSwww.sciencetranslationalmedicine.org/cgi/content/full/9/412/eaan5689/DC1Materials and MethodsFig. S1. ALK inhibitors block STING activation.Fig. S2. Pharmacologic inhibition of ALK blocks STING ligand–induced IFNb release andexpression.Fig. S3. Pharmacologic inhibition of ALK blocks STING activation.Fig. S4. Genetic inhibition of ALK limits STING activation.Fig. S5. ALK does not bind known STING regulators.Fig. S6. Inhibition of ALK limits RTK phosphorylation in STING activation.Fig. S7. ALK binds EGFR during STING activation.Fig. S8. The ALK-EGFR-AKT pathway mediates STING activation.Fig. S9. Knockdown of EGFR inhibits STING activation.Fig. S10. The ALK-EGFR-AKT pathway mediates STING ligand–induced IFNb release andexpression.Fig. S11. ALK mediates LPS-induced macrophage activation.Fig. S12. Histological analysis of tissue injury in CLP-treated mice.Fig. S13. Heatmap of circulating immune chemical profile in indicated mice.Fig. S14. Histological analysis of tissue injury in LPS-treated mice.Fig. S15. Heatmap of circulating immune chemical profile in indicated mice.Fig. S16. Effects of targeting the ALK-STING pathway on CLP-induced septic death.Fig. S17. Schematic depicting the pathologic role of ALK-dependent STING pathways in lethalsepsis.Table S1. Reagent sources.Table S2. Individual-level data corresponding to the different figures (provided as an Excel file).Reference (70)

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Acknowledgments: We thank C. Heiner (Department of Surgery, University of Pittsburgh) forher critical reading of the manuscript. Funding: This work was supported by grants fromthe U.S. NIH (R01GM115366, R01CA160417, R01AT005076, R01GM063075, R01GM44100, andR01CA211070), the National Key Technology R&D Program in China (2012BAI11B01), theNatural Science Foundation of Guangdong Province (2016A030308011), the National NaturalScience Foundation of China (31671435, 81400132, and 81772508), and GuangdongProvince Universities and Colleges Pearl River Scholar Funded Scheme (2017). This projectpartly used University of Pittsburgh Cancer Institute shared resources supported throughaward P30CA047904. Author contributions: D.T. and J.J. conceived and designed theexperiments. L.Z., R.K., S.Z., X.W., L.C., J.J., and D.T. performed the experiments. L.Z., H.W.,T.R.B., J.J., and D.T. analyzed the data. D.T. wrote the paper. H.W. and T.R.B. edited andcommented on the manuscript. Competing interests: The authors declare that they have nocompeting interests. Data and materials availability: All data and materials are availablefrom the authors upon reasonable request.

Submitted 2 May 2017Resubmitted 30 June 2017Accepted 22 September 2017Published 18 October 201710.1126/scitranslmed.aan5689

Citation: L. Zeng, R. Kang, S. Zhu, X. Wang, L. Cao, H. Wang, T. R. Billiar, J. Jiang, D. Tang, ALK isa therapeutic target for lethal sepsis. Sci. Transl. Med. 9, eaan5689 (2017).

b/

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y guest on August 23, 2019


ALK is a therapeutic target for lethal sepsis

TangLing Zeng, Rui Kang, Shan Zhu, Xiao Wang, Lizhi Cao, Haichao Wang, Timothy R. Billiar, Jianxin Jiang and Daolin

DOI: 10.1126/scitranslmed.aan5689, eaan5689.9Sci Transl Med

a useful target for drug development for sepsis.bedrug treatment improved survival in mouse models of sepsis and endotoxemia. The ALK-STING pathway could

through downstream serine-threonine protein kinase AKT. Inhibiting ALK-STING signaling genetically or with oralactivated by anaplastic lymphoma kinase (ALK), which interacts with epidermal growth factor receptor and signals pathway, which was up-regulated in mononuclear cells from patients with sepsis. The authors found that STING isscreened a library of kinase inhibitors to identify drugs that targeted the STING (stimulator of interferon genes)

.et alDespite the existence of antibiotic therapy, sepsis is associated with a high mortality rate. Zeng Taking the STING out of sepsis

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