Uremic toxin indoxyl sulfate induces trained immunity via the AhR-dependent arachidonic acid pathway in ESRD

Reviewer #1 (Public Review):

In this study, Kim et al. investigated the mechanism by which uremic toxin indoxyl sulfate (IS) induces trained immunity, resulting in augmented pro-inflammatory cytokine production such as TNF and IL-6. The authors claim that IS treatment induced epigenetic and metabolic reprogramming, and the aryl hydrocarbon receptor (AhR)-mediated arachidonic acid pathway is required for establishing trained immunity in human monocytes. They also demonstrated that uremic sera from end-stage renal disease (ESRD) patients can generate trained immunity in healthy control-derived monocytes.

These are interesting results that introduce the important new concept of trained immunity and its importance in showing endogenous inflammatory stimuli-induced innate immune memory. Additional evidence proposing that IS plays a critical role in the initiation of inflammatory immune responses in patients with CKD is also interesting and a potential advance of the field. This study is in large part well done, but some components of the study are still incomplete and additional efforts are required to nail down the main conclusions.

Specific comments:

1. Of greatest concern, there are concerns about the rigor of these experiments, whether the interpretation and conclusions are fully supported by the data. 1) Although many experiments have been sporadically conducted in many fields such as epigenetic, metabolic regulation, and AhR signaling, the causal relationship between each mechanism is not clear. 2) Throughout the manuscript, no distinction was made between the group treated with IS for 6 days and the group treated with the second LPS (addressed below). 3) Besides experiments using non-specific inhibitors, genetic experiments including siRNA or KO mice should be examined to strengthen and justify central suggestions.
2. The authors showed that IS-trained monocytes showed no change in TNF or IL-6, but increased the expression levels of TNF and IL-6 in response to the second LPS (Fig. 1B). This suggests that the different LPS responsiveness in IS-trained monocytes caused altered gene expression of TNF and IL-6. However, the authors also showed that IS-trained monocytes without LPS stimulation showed increased levels of H3K4me3 at the TNF and IL-6 loci, as well as highly elevated ECAR and OCR, leading to no changes in TNF and IL-6. Therefore, it is unclear why or how the epigenetic and metabolic states of IS-trained monocytes induce different LPS responses. For example, increased H3K4me3 in HK2 and PFKP is important for metabolic rewiring, but why increased H3K4me3 in TNF and IL6 does not affect gene expression needs to be explained.
3. The authors used human monocytes cultured in human serum without growth factors such as MCSF for 5-6 days. When we consider the short lifespan of monocytes (1-3 days), the authors need to explain the validity of the experimental model.
4. The authors' ELISA results clearly showed increased levels of TNF and IL-6 proteins, but it is well established that LPS-induced gene expression of TNF and IL-6 in monocytes peaked within 1-4 hours and returned to baseline by 24 hours. Therefore, authors need to investigate gene expression at appropriate time points.
5. It is a highly interesting finding that IS induces trained immunity via the AhR pathway. The authors also showed that the pretreatment of FICZ, an AhR agonist, was good enough to induce trained immunity in terms of the expression of TNF and IL-6. However, from this point of view, the authors need to discuss why trained immunity was not affected by kynurenic acid (KA), which is a well-known AhR ligand accumulated in CKD and has been reported to be involved in innate immune memory mechanisms (Fig. S1A).
6. The authors need to clarify the role of IL-10 in IS-trained monocytes. IL-10, an anti-inflammatory cytokine that can be modulated by AhR, whose expression (Fig. 1E, Fig. 4D) may explain the inflammatory cytokine expression of IS-trained monocytes.
7. The authors need to show H3K4me3 levels in TNF and IL6 genes in all conditions in one figure. (Fig. 2B). Comparing Fig. 2B and Fig. S2B, H3K4me3 does not appear to be increased at all by LPS in the IL6 region.
8. The authors need to address the changes of H3K4me3 in the presence of MTA.
9. Interpretation of ChIP-seq results is not entirely convincing due to doubts about the quality of sequencing results. First, authors need to provide information on the quality of ChIP-seq data in reliable criteria such as Encode Pipeline. It should also provide representative tracks of H3K4me3 in the TNF and IL-6 genes (Fig. 2F). And in Fig. 2F, the author showed the H3K4me3 track of replicates, but the results between replicates were very different, so there are concerns about reproducibility. Finally, the authors need to show the correlation between ChIP-seq (Fig. 2) and RNA-seq (Fig. 5).
10. AhR changes in the cell nucleus should be provided (Fig. 4A).
11. Do other protein-bound uremic toxins (PBUTs), such as PCS, HA, IAA, and KA, change the mRNA expression of ALOX5, ALOX5AP, and LTB4R1? In the absence of genetic studies, it is difficult to be certain of the ALOX5-related mechanism claimed by the authors.
12. Fig.6 is based on the correlated expression of inflammatory genes or AA pathway genes. It does not clarify any mechanisms the authors claimed in the previous figures.

Reviewer #2 (Public Review):

Manuscript entitled "Uremic toxin indoxyl sulfate (IS) induces trained immunity via the AhR-dependent arachidonic acid pathway in ESRD" presented some interesting findings. The manuscript strengths included use of H3K4me3-CHIP-Seq, AhR antagonist, IS treated cell RNA-Seq, ALOX5 inhibitor, MTA inhibitor to determine the roles of IS-AhR in trained immunity related to ESRD inflammation and trained immunity.

Reviewer #3 (Public Review):

The manuscript entitled, "Uremic toxin indoxyl sulfate induces trained immunity via the AhR-dependent arachidonic acid pathway in ESRD" demonstrates that indoxyl sulfate (IS) induces trained immunity in monocytes via epigenetic and metabolic reprogramming, resulting in augmented cytokine production. The authors conducted well-designed experiments to show that the aryl hydrocarbon receptor (AhR) contributes to IS-trained immunity by enhancing the expression of arachidonic acid (AA) metabolism-related genes such as arachidonate 5-lipoxygenase (ALOX5) and ALOX5 activating protein (ALOX5AP). Overall, this is a very interesting study that highlights that IS mediated trained immunity may have deleterious outcomes in augmented immune responses to the secondary insult in ESRD. Key findings would help to understand accelerated inflammation in CKD or RSRD.