Persistent inflammation, immunosuppression, and catabolism syndrome (PICS): a review of definitions, potential therapies, and research priorities

Abstract

Persistent Inflammation, Immunosuppression, and Catabolism Syndrome (PICS) is a clinical endotype of chronic critical illness. PICS consists of a self-perpetuating cycle of ongoing organ dysfunction, inflammation, and catabolism resulting in sarcopenia, immunosuppression leading to recurrent infections, metabolic derangements, and changes in bone marrow function. There is heterogeneity regarding the definition of PICS. Currently, there are no licensed treatments specifically for PICS. However, findings can be extrapolated from studies in other conditions with similar features to repurpose drugs, and in animal models. Drugs that can restore immune homeostasis by stimulating lymphocyte production could have potential efficacy. Another treatment could be modifying myeloid-derived suppressor cell (MDSC) activation after day 14 when they are immunosuppressive. Drugs such as interleukin (IL)-1 and IL-6 receptor antagonists might reduce persistent inflammation, although they need to be given at specific time points to avoid adverse effects. Antioxidants could treat the oxidative stress caused by mitochondrial dysfunction in PICS. Possible anti-catabolic agents include testosterone, oxandrolone, IGF-1 (insulin-like growth factor-1), bortezomib, and MURF1 (muscle RING-finger protein-1) inhibitors. Nutritional support strategies that could slow PICS progression include ketogenic feeding and probiotics. The field would benefit from a consensus definition of PICS using biologically based cut-off values. Future research should focus on expanding knowledge on underlying pathophysiological mechanisms of PICS to identify and validate other potential endotypes of chronic critical illness and subsequent treatable traits. There is unlikely to be a universal treatment for PICS, and a multimodal, timely, and personalised therapeutic strategy will be needed to improve outcomes for this growing cohort of patients.

Keywords: PICS; chronic critical illness; critical care; persistent inflammation, immunosuppression, and catabolism syndrome; post-intensive care syndrome.

Fig 1

Summary diagram of potential treatments for Persistent Inflammation, Immunosuppression, and Catabolism Syndrome (PICS). This illustration highlights a range of potential treatments, organised by the specific component of PICS. It suggests that a multimodal, well-timed, personalised treatment strategy may be sufficient to break the self-perpetuating cycle of inflammation, immunosuppression, and catabolism that underlies PICS and promote recovery. G-CSF, granulocyte colony-stimulating factor; IFN-γ, interferon gamma; IGF-1, insulin-like growth factor 1; IL-1R, interleukin-1 receptor; IL-6R, interleukin-6 receptor; IL-7, interleukin-7; MDSC, myeloid-derived suppressor cell; omega-3FA, omega-3 fatty acids; PD-L1, programmed death ligand-1; PD-1, programmed death protein 1 (Created with BioRender.com).