Role of Tumor Necrosis Factor-α in the Human Systemic Endotoxin-Induced Transcriptome

TNFα has been implicated in the pathogenesis of various inflammatory diseases. Different strategies to inhibit TNFα in patients with sepsis and chronic inflammatory conditions have shown contrasting outcomes. Although TNFα inhibitors are widely used in clinical practice, the impact of TNFα antagonism on white blood cell gene expression profiles during acute inflammation in humans in vivo has not been assessed. We here leveraged the established model of human endotoxemia to examine the effect of the TNFα antagonist, etanercept, on the genome-wide transcriptional responses in circulating leukocytes induced by intravenous LPS administration in male subjects. Etanercept pre-treatment resulted in a markedly dampened transcriptional response to LPS. Gene co-expression network analysis revealed this LPS-induced transcriptome can be categorized as TNFα responsive and non-responsive modules. Highly significant TNFα responsive modules include NF-kB signaling, antiviral responses and T-cell mediated responses. Within these TNFα responsive modules we delineate fundamental genes involved in epigenetic modifications, transcriptional initiation and elongation. Thus, we provide comprehensive information about molecular pathways that might be targeted by therapeutic interventions that seek to inhibit TNFα activity during human inflammatory diseases.


Introduction
Tumor necrosis factor (TNF) a is a pleiotropic proinflammatory cytokine that mediates both beneficial and detrimental biological processes [1,2]. TNFa is rapidly released after trauma, infection or exposure to endotoxin (lipopolysaccharide, LPS) and is one of the most abundant mediators of inflammation at local tissue level [3]. TNFa has been implicated in the pathogenesis of several inflammatory diseases. Indeed, TNFa inhibitors have been shown to be an effective therapy for patients with rheumatoid arthritis, psoriasis, psoriatic arthritis, ankylosing spondylitis and inflammatory bowel disease [3]. In contrast, different strategies to inhibit TNFa in patients with sepsis revealed no overall benefit with regard to mortality reduction [4]. Sustained anti-TNFa therapy has been shown to heighten the risk of infections [5,6], which can be considered a reflection of the delicate balance of innate immunity, where abundant activation may cause collateral damage (such as in sepsis and endotoxemia) while modest activation serves to protect the host against invading pathogens [7,8]. The fundamental genomic responses that ensue as a consequence of TNFa antagonism in vivo still require exploration.
Pan-genomic expression profiling of human endotoxemia coupled with knowledge-based analysis has provided valuable insights into the transcriptional responses that activate and resolve systemic inflammation in a setting of a predictable recovery [9]. Intravenous injection of LPS into healthy humans induces changes in whole genome mRNA expression profiles in blood leukocytes that show strong resemblance to the ''genomic storm'' induced by burn trauma or sepsis in patients [10,11]. A recently conducted systematic comparison of the whole blood leukocyte genomic response elicited by inflammatory diseases or intravenous LPS in humans with that in the corresponding experimental models in mice revealed that while the genomic responses to different acute inflammatory stresses are highly similar in humans, these responses are not reproduced in mouse models [11]. These data indicate that mouse experiments are less relevant for insight in which inflammatory pathways are responsive to TNFa inhibition. Although TNFa inhibitors are widely used in clinical practice, the impact of TNFa antagonism on white blood cell gene expression profiles during acute inflammation in humans in vivo has not been studied before. We here leveraged the established model of human endotoxemia to examine the effect of TNFa inhibition on the genome-wide transcriptional responses in circulating leukocytes induced by intravenous LPS administration. Our study provides a benchmark characterization of the transcriptional responses in acute inflammation mediated by TNFa in human males in vivo.

Ethics statement
The study was approved by the institutional review board of the Academic Medical Center, Amsterdam, and conducted according to the declaration of Helsinki. Written informed consent was obtained from all volunteers.

Subjects and study design
Twenty-one young and healthy male Caucasian subjects were enrolled in this study and described elsewhere [12]. They were administered placebo (normal saline) (n = 13) or etanercept (n = 8; EnbrelH 50 mg; Pfizer, USA) intramuscularly 48 hours prior to receiving a bolus infusion of 1 ng/kg body weight Escherichia coli LPS (cat. # 1235503, lot G2B274; United States Pharmacopeial Convention Inc., Rockville, MD). After an overnight fast, the volunteers had a catheter inserted into the antecubital vein of each arm. Baseline blood samples were collected in EDTA tubes before LPS infusion in the antecubital vein of the contralateral arm (t = 0). Blood was withdrawn and collected in EDTA tubes 4 hours after LPS infusion (t = 4). Leukocyte counts and differentials were determined in whole blood by standard flow cytometry [12]. PAXgene blood was collected from 8 etanercept-treated and 8 placebo-treated subjects (total n = 16) for microarray analysis.
Whole-blood leukocyte RNA preparation and genomewide transcriptional profiling by microarray Peripheral blood mRNA was obtained using the PAXgene TM tube and PAXgene TM RNA isolation system (PreAnalytiX TM , Qiagen, Venlo, Netherlands) as described by the manufacturer. Total RNA yield and purity (260 nm:280 nm) were determined spectrophotometrically (Nanodrop). The integrity of the resuspended total RNA was determined using the RNA Nano Chip Kit on the Bioanalyzer 2100 and the 2100 Expert software (Agilent). To increase the sensitivity of our gene expression assay the overload of globin mRNA of whole blood samples was reduced by applying the human GLOBINclear kit (Ambion/Appied Biosystems). Synthesis, amplification and purification of anti-sense RNA was performed using 300 ng of enriched mRNA per sample and the Illumina TotalPrep RNA Amplification Kit (Ambion/ Applied Biosystems) following the Illumina Sentrix Array Matrix expression protocol. A total of 750 ng biotinylated cRNA was hybridized onto the HumanHT-12v3 expression bead chips (Illumina) containing 48,803 probes derived from the National Center for Biotechnology Information (NCBI) Reference Sequence RefSeq (Build 36.2, Rel 22) and the UniGene (Build 99) databases targeting more than 25,000 annotated genes. The GenomeStudioH Data Analysis Software (Illumina) was used for data collection of the scanned Beadchips (BeadScan 3.5.31). Missing values were imputed by using the k-nearest-neighbor algorithm (k = 15) as previously described [13]. The raw scan and imputed data were read using the lumi package [14], available through Bioconductor [15]. This was carried out using the R statistical package (version 2.13.1; R Foundation for Statistical Computing, Vienna, Austria). Quality control checks of the raw non-normalized data included visualization of the similarity matrix and hierarchical clustering analysis [16]. Preparation of cRNA and chip hybridization was carried out at SIRS-Lab GmbH (Jena, Germany). After quality assessment one subject in the placebo group was removed from further analyses. Variance stabilizing normalization (vsn) [17] was applied. All subsequent analyses were performed on vsn-transformed intensity values. Filtering the nonexpressed probes (detection p-value,0.05) yielded 18,419 probes for statistical analysis. Non-normalized and normalized data are available at the gene expression omnibus (GEO) with accession number GSE36177.

Gene co-expression network analysis
The weighted gene co-expression network construction algorithm was used to build the systemic LPS-induced gene coexpression network using normalized expression data (n = 8168 transcripts, q,0.01). This was carried out using the R statistical package (version 2.13.1; R Foundation for Statistical Computing, Vienna, Austria) as described in detail by Langfelder and Horvath [18]. Briefly, the Pearson's correlation matrix of 8168 probes was transformed into an adjacency matrix by using a ''soft'' power function to ensure scale free network construction [18]. The adjacency matrix was further transformed into a topological overlap matrix to enable the identification of modules (clusters) of highly correlating genes by implementing the previously described dynamic tree cut algorithm [19]. These modules are composed of sets of genes with high ''topological overlap'' [20]. Thus, the topological overlap matrix enables the detection of not only a direct interaction between a pair of genes but also their indirect interactions with all other genes in the network. Each module represents a cluster of co-expressed genes with a distinct expression pattern from other identified modules. In order to define module hub genes we made use of the module eigengene concept, defined as the first principal component of the module expression matrix, and, the module membership measure, k [18,21]. Hub genes were defined on the basis of a high correlation between gene significance (t statistic) and module membership [18,21,22]. Coexpression network visualization was achieved by means of the CytoscapeH software (www.cytoscape.org) version 2.8.3 [23].

Quantitative real-time PCR
Total RNA was treated with RQ1 RNase-Free DNase (Promega, Leiden, The Netherlands) and reverse transcribed using oligo (dT) primer and Moloney murine leukemia virus reverse transcriptase (Invitrogen, Breda, The Netherlands) according to supplier recommendations. We used the LightCycler system (LC480, Roche Applied Science) to perform quantitative PCR analysis targeting transcripts encoded by IL1RN, IRAK3, TNFAIP3, GPR84 and MARCKS genes. Results were normalized to B2M transcript. Primer pairs used were designed to avoid overlap with array probes (Table S2 of File S1).

Statistical analysis
Pairwise analysis by Student t statistics was employed to assess differential gene expression in paired samples. Linear models ANOVA was employed to define endotoxin-induced transcripts influenced by etanercept treatment. Unless otherwise stated, a false-discovery-rate (FDR) corrected p-value (q-value) was used to define genome-wide significance.

Systemic characteristics in response to LPS and TNFa antagonism
Twenty-one young healthy male subjects were challenged with an intravenous infusion of LPS (1 ng/kg body weight) as previously described [12]. Eight of these subjects were pre-treated intramuscularly with the TNFa antagonist etanercept (48 hours prior to LPS infusion); whereas the other thirteen received placebo by intramuscular injection. Etanercept treated subjects showed a strong rise in the circulating levels of soluble TNF receptor type II, providing evidence for effective administration [12]. Etanercept strongly inhibited LPS-induced systemic inflammatory responses known to be mediated by TNFa, including interleukin (IL)-6 and C-reactive protein release, indicating that etanercept effectively inhibited TNFa activity [12]. ''Considering the sixteen subject samples used in the microarray analysis, no differences in cell counts were observed in the etanercept-treated group (n = 8) when compared to the placebo-treated group (n = 8) prior to LPS infusion ( Table 1).''. Intravenous LPS induced a significant increase in total leukocyte counts, primarily caused by a rise in neutrophil numbers; monocyte and lymphocyte counts decreased after endotoxin infusion. Etanercept did not influence the LPSinduced changes in leukocyte counts or differentials ( Table 1).

Impact of TNFa inhibition on the genome-wide transcriptional response to intravenous LPS administration
Genome-wide transcriptional analysis was performed in whole blood leukocytes obtained before (t = 0) and 4 hours after LPS injection (t = 4) to study the impact of LPS challenge on gene expression. Considering a q-value threshold of 0.01, we detected 8168 probes that were differentially expressed. Figure 1A shows the volcano plot (integrating fold-changes and t-test criteria) for the LPS response in subjects treated with placebo. We detected 693 probes (q,0.01) with a fold change $1.5 or #21.5. GPR84, IL1RN, MMP9, IRAK3, TNFAIP3, SOCS3, IL1b and IL8 were among the highly induced transcripts ( Figure 1A). Next, we assessed the transcriptional response to LPS challenge with TNFa inhibitor by comparing the signal intensities of probes obtained from etanercept-treated baseline (t = 0) and etanercept-treated LPS-challenged (t = 4 hours) samples. We detected 6583 probes that were significantly different under TNFa antagonism (q,0.01). Etanercept treatment resulted in a substantial effect on the LPSinduced transcriptional response ( Figure 1B): only 106 probes (q,0.01) had a fold-change $1.5 or #21.5. To assess the direct influence of TNFa inhibition on the LPS-induced transcriptional response we constructed and compared two linear models: 1. post-LPS response (t4) as a function of baseline gene expression (t0) and etanercept treated post-LPS response (t4); 2. the post-LPS response (t4) as a function of baseline gene expression (t0). Using an analysis of variance (ANOVA) we detected 4077 significant probes (q,0.05) that were responsive to TNFa inhibition. Figure 1C shows the unsupervised hierarchical clustering heat map of these 4077 probes. Of note, in the context of LPS-induced repression of gene expression, etanercept treament predominantly diminished the magnitude of those repressed genes. However, 2 significant transcripts (ANOVA q,0.05, foldchange $1.5), namely CXCR4 and KIAA0319L, exhibited a directional change in their expression pattern, that is decreased by LPS while increased in expression post-etanercept treament. Interestingly, the LPS-inducible genes TNF and TNFRSF1B (TNFR2) were not significantly influenced by etanercept treatment (q = 0.18 and q = 0.17, respectively). However, TNFRSF1A (TNFR1) gene expression was significantly decreased (q = 0.0028) by etanercept. The complete list of those 4077 significant transcripts, their fold changes, pand q-values, is tabulated in Table S1. Quantitative RT-PCR analysis on a few select transcripts was performed as a means of technical validation ( Figure S1 of File S1). Of note, etanercept administration had no statistically significant effect on basal gene expression, that is between placebo (t0) and etanercept-treated (t0) samples.

Identification of LPS-induced TNFa responsive and nonresponsive co-expression modules
In order to understand the relationship and organization of the LPS-induced transcriptome we applied the weighted gene coexpression network analysis approach [18,25,26] on the normal- Table 1. White blood cell counts and differentials before and 4 hours after intravenous endotoxin administration in healthy subjects pretreated with etanercept or placebo. ized expression data of the 8168 LPS-response transcripts (q,0.01). Considering the weighted Pearson's correlation matrix of these gene expression profiles 38 transcriptional modules, each encompassing more than 30 transcripts, were identified. Table 2 lists the enriched canonical pathways per co-expression network module (cluster) as identified by Ingenuity pathway analysis (IPA). These biological pathways include NF-kB signaling, role of PKR in interferon induction and antiviral response, T cell receptor signaling, regulation of IL-2 expression in activated and anergic T lymphocytes, ephrin receptor signaling, ceramide signaling, IL-10 signaling, B cell development and natural killer cell signaling. Each module was summarized by its module eigengene (first principal component) [18,25] followed by pair-wise analysis (t statistic) between LPS-challenged (t = 4 hours) placebo-and etanercepttreated samples. This analysis identified 17 modules significantly associated (Bonferroni corrected p-value threshold = 0.0013) to TNFa antagonism (Figure 2A). LPS-induced and TNFa responsive modules include NF-kB signaling, role of PKR in interferon induction and antiviral response, T cell receptor signaling and regulation of IL-2 expression in activated and anergic T lymphocytes. LPS-induced and TNFa non-responsive modules include IL4 signaling, B cell development, natural killer cell signaling and LPS/IL-1 mediated inhibition of RXR function. Figure 2B illustrates the number of genes within their respective modules that are induced (log2 foldchange .0.5) or reduced (log2 foldchange ,20.5) in expression after LPS challenge, with or without etanercept treatment. In so doing we observed that among the TNFa responsive modules, TNFa antagonism heralds a decrease in expression of modules harboring genes predominantly involved in innate immune response reactions, such as NF-kB signaling and interferon signaling; whereas, in contrast, an increase in expression of modules comprised of genes involved in T cell responses, such as regulation of IL-2 expression in activated and anergic T lymphocytes ( Figure 2B).

LPS-induced and TNFa mediated co-expression module hub genes and in silico immune cell-specific enrichment
A fundamental property of biological networks is the emergence of a few greatly connected genes (nodes), often referred to as ''hubs'', which suggests that these hub proteins possess a special biological role [21]. Genes within co-expression modules are interconnected by correlation and the relative importance of each gene within its respective module can be estimated by the connectivity value, k, and module membership, k MM [18,22,25].
The top module hub genes for the LPS-induced transcriptome influenced by TNFa antagonism are tabulated in Table 3. Functional signatures of these hub genes include epigenetic regulation of transcription, transcription factor activity and translation initiation/repression activity. Unsupervised hierarchical clustering of the hub gene expression patterns among LPSinduced TNFa responsive modules is shown in Figure 3A. This shows that the gene expression profiles of these LPS-induced and TNFa responsive module hub genes not only cluster according to experimental group as expected, but can be categorized into two groups of up-regulated and down-regulated transcripts. Figure 3B illustrates the Cytoscape cFiles organic visualization of the 17 LPSinduced and TNFa responsive transcriptional modules. In so doing, we show that NF-kB signaling, ephrin receptor signaling, role of PKR in interferon induction and antiviral response, regulation of IL-2 expression in activated and anergic T lymphocytes and IL10 signaling co-expression modules are highly connected. To better understand the cell-specific implications of these up-and down-regulated module hubs together with their respective module genes, we analyzed the clustered modules for enrichment in the coexpression atlas of the Immunological Genome Project (Immgen.org) [27] through the ToppGene bioinformatics suite [24]. TNFa-responsive down-regulated module hubs and peripheral genes were enriched for myeloid cells, including CD11b+ Ly6-G+ granulocytes (GSM854338, bonfer-

Specific epigenetic regulators, transcription initiation and elongation factors influenced by TNFa antagonism of the LPS-induced transcriptome
Induction of transcription is triggered by signal-dependent activation of DNA-binding transcription factors, accounting for the specific response to exogenous stimuli, which in turn recruit chromatin modifiers and RNA polymerase II [28]. Furthermore, these transcription factors can recruit histone-modifying enzymes such as histone acetyltransferases, deacetylases and methylases  [29], which provide a landscape for signal-specific transcriptional initiation and elongation [30]. Thus, we inspected the TNFa responsive co-expression modules for epigenetic regulators, transcription initiation and elongation factors. Table 3 lists those LPS-inducible epigenetic and transcription initiation/elongation factors that cluster in TNFa-responsive modules. Among these genes, CBX7, encoding chromobox homolog 7, and POLR2G, encoding the DNA-directed RNA polymerase II subunit RPB7, were also designated as hub genes for the role of PKR in interferon induction and antiviral response, and pyrimidine ribonucleotides interconversion co-expression modules, respectively ( Table 2). The NF-kB signaling, role of PKR in interferon induction and antiviral response, IL10 signaling, ephrin receptor signaling and regulation of IL-2 expression in activated and anergic T lymphocytes constitute core co-expression modules of the LPSinduced and TNFa-responsive transcriptome ( Figure 3A and B). Integration of the IPA (IngenuityH systems) further refined these core co-expression modules to a highly interconnected interactome network anchored at putative ''driver'' genes (module hubs) (Figure 4). This interactome is comprised of nuclear genes that include the methyltransferases DNMT1 and RNMT, histone acetlyase/deacetlyases HAT1, HDAC2 and HDAC3, as well as transcription factors that include ATF3, IRF1, IRF9, NFKBIB, RELB, BCL6, BCL3, STAT1, STAT5A and STAT6. Notably, ATF3, HDAC2 and STAT5A exhibit pronounced differences in expression between the LPS response and etanercept treated LPS response ( Figure 4). Cytosolic signaling molecules including IRAK2, IRAK3, MARCKS and the negative regulator of cytokine signaling CISH Figure 3. TNFa responsive module hub (driver) genes and co-expression network visualization. Genes within transcriptional modules can be categorized as peripheral or hubs on the basis of how correlated a gene is with all other genes in the network, defined as the genes' connectivity measure, k. High intramodulr connectivities denote highly important module genes oftentimes possessing transcriptional factor activity. A. Unsupervised hierarchical clustering heatmap plot of the TNFa responsive module hub genes. Red denotes high expression; blue denotes low expression. The relative importance of each module within the co-expression network can be highlighted by unsupervised visualizations of each genes' weighted correlation coefficient. This was implemented in the CytoscapeH platform B. TNFa responsive co-expression modules were visualized by an organic layout considering weighted correlation coefficients .0.1 (equivalent to correlation coefficient .0.9). doi:10.1371/journal.pone.0079051.g003 Table 3. LPS-induced TNFa responsive module genes linked to transcriptional initiation, elongation and epigenetic regulation. are prominent. Moreover, extracellular factors including EBI3, CCL20, TNFAIP6 and the negative regulator of IL1 signaling, IL1RN are markedly influenced by etanercept treatment of the LPS response (Figure 4).

Discussion
The majority of inducible transcriptional cascades are comprised of primary and secondary response genes. Stimulus-induced TNFa release constitutes a fundamental primary response in innate immunity, which leads to TNFa signal-specific secondary response cascades that encompass hundreds of genes. In the present study, we constructed a gene co-expression network for the human male systemic transcriptome induced by LPS challenge and identified those transcriptional modules influenced by TNFa inhibition. We demonstrate that the LPS-induced transcriptome is organized into functional modules enriched for genes involved in distinct biological themes exhibiting TNFa responsive and nonresponsive elements. LPS-induced modules that were strongly influenced by TNFa inhibition include NF-kB signaling and pathways associated with T cell function, and further analyses suggested that TNFa antagonism inhibited transcriptional events in myeloid cells while enhancing transcription in lymphoid cells. In addition, we show that TNFa responsive modules are comprised of epigenetic regulators, transcription initiation and elongation factors. This study is the first to report on the role of TNFa in the systemic genomic response to an acute inflammatory stimulus in human males, using a controlled and reproducible model with relevance for acute inflammatory diseases [9][10][11].
Systems-level approaches, like the one we present in this study, will play an increasingly important role in defining the higherorder gene interactions that respond to exogenous and endogenous factors. Reductionist approaches alone limit the efficient interpretation of an overwhelming diversity in physiological responses to a stimulus, such as the response to the proinflammatory cytokine TNFa. Previous studies have documented TNFa dependence of certain systemic inflammatory responses, measured at protein level in plasma, induced by intravenous LPS administration in humans [12,31,32]. Since plasma TNFa levels peak 1.5-2 hours after LPS injection [12,31,32], and taking into account the dynamics of the genomic response to intravenous LPS [9], we chose the 4 hour post-LPS time point to evaluate the role of TNFa in the LPS-induced transcriptome in peripheral blood leukocytes. The co-expression network approach we adopted aided in constructing a scale-free leukocyte transcriptional network of pair-wise relationships in gene expression that respond in concert to LPS-induced TNFa release. Moreover, we leveraged the concepts of co-expression network hub genes, which are understood to be very important features of a gene co-expression network [21,33]. In concordance with previous studies [9], upon LPS injection we observed a substantial reduction in nuclear, ribosomal and mitochondrial related processes, which include NRF2-mediated oxidative stress response, EIF2 signaling and mitochondrial dysfunction modules, respectively ( Figure 2). Treatment with the TNFa inhibitor etanercept diminished, at least in part, the extent at which nuclear and ribosomal processes are reduced by LPS stimulation, whereas the mitochondrial pathway was not influenced by TNFa inhibition. Dysfunction in mitochondrial processes has been implicated in the severity and outcome of septic shock [34]. In addition, we show that genes involved in the regulation of T-cell activation present a significant reduction in transcript abundance after LPS challenge. TNFa inhibition dampens the LPS-induced reduction in transcription of genes in the regulation of IL-2 expression in activated and anergic Table 3. Cont.  T lymphocytes module (Figure 2), which include CD6, IL7R, IL11RA and LAT (Figure 4). Of note, the protein encoded by the CD6 gene (cluster of differentiation 6) is a member of the scavenger receptor cysteine-rich superfamily [35], which was demonstrated to engage E.coli LPS [36]. Mice injected intraperitoneally with recombinant CD6 were protected from lethality due to endotoxemia and presented a reduction in serum TNFa abundance [36]. Our analyses categorized CD6 as the T cell activation module hub gene. Disturbed lymphocyte function is a recognized hallmark feature of sepsis [37,38]; our results suggest that these in part may be mediated by TNFa-mediated signaling. Mechanistically, these transcriptomic changes may arise due to altered TNF signaling within a cell therefore affecting the individual cells' transcriptional output, aberrant release of soluble mediators that respond to TNF in extravascular tissue and tissue-resident cells (for example, the liver Kupffer cell population), and differences in blood cell composition. Etanercept treatment had no significant effect on the cell counts and differentials ( Table 1); thereby suggesting that the transcriptional changes were largely due to altered TNF signaling in individual circulatory cells and/or tissue-resident cells.

Transcription elongation factors
Transcription of genes within the NF-kB signaling module was highly increased after LPS-challenge and greatly influenced by TNFa inhibition (Figure 2). Central genes include RELB, encoding for a transcriptional factor that recognizes kappab promoter elements [39], and IRAK3 (IRAK-M), a negative regulator of Toll-like receptor signaling [40], have been shown to be components of the cellular events that impart endotoxin tolerance [41,42]. Endotoxin tolerance (or ''leukocyte reprogramming'') is a typical property of circulating cells isolated from endotoxin challenged subjects or septic patients, characterized by a reduced capacity to release pro-inflammatory cytokines upon restimulation with LPS [43]. This immunosuppressive phenomenon has rightly received attention in developing new strategies for sepsis therapy [38,44]. Our findings provide a network-based view of the transcriptional relationships that may conspire in immunosuppressive cellular states where the NF-kB signaling module hub gene HIVEP1, encoding human immunodeficiency virus type I enhancer binding protein 1, is predicted to be a highly influential ( Figure 4). HIVEP1 specifically recognizes and binds to the DNA sequence motif GGGACTTTCC within enhancer elements of both viral and host cellular genes suggesting a role in transcriptional regulation [45]. We predict HIVEP1 as a LPS-induced and TNFa signal-specific modulator of the LPS-induced NF-kB signaling transcriptional module.
Transcriptional control of the LPS response is a highly ordered process of temporally distinct responses [11]. This involves a primary signal-specific (LPS-TLR4 axis) response (0.5-2 hrs) of post-translational modifications and subsequent nuclear translocation of key transcription factors including NF-kB. These primary response events are followed by a second wave of response genes [46]. Transcriptional control of these inducible genes has been linked to signal-dependent epigenetic modifications, transcriptional initiation and elongation [30]. Our findings provide evidence for TNFa signal-specific transcriptional modulation of a number of transcription initiation, elongation factors, as well as epigenetic regulators such as methyltransferases, deacetylases, chromodomain and bromodomain containing proteins ( Table 3). The latter includes BRD3, encoding bromodomain containing 3, which participates in histone acetylation-dependant chromatin complexes; recently targeted by a potent immune suppressive histone mimic (termed I-BET), thereby highlighting its essentiality in selective inflammatory gene transcriptional programs [47]. Among the LPS-induced TNFa responsive epigenetic regulators CBX7, encoding the methylated histone residue binding transcriptional repressor chromobox homolog 7, was also identified as a coexpression module hub gene (Table 2 and 3; Figure 4). Our analysis further delineated peripheral transcripts, including the infectious disease susceptibility gene CISH [48], encoding cytokine inducible SH2-containing protein, and EBI3, encoding Epstein-Barr virus induced 3, putatively modulated by TNFa signaling (Figure 4). In the absence of significant differences in cell composition and differentials between our placebo-and etanercept-treated LPS-challenged subjects ( Table 1), CISH and EBI3 gene transcription is significantly down-regulated by TNFa inhibition of the LPS-induced response. Notably, EBI3, a subunit of IL-27 has been recently unmasked as a potential sepsis biomarker by genome-wide expression profiling [49]. Moreover, EBI3 2/2 mice were protected from sepsis-induced lethality by cecal ligation and puncture [50]. The impact of anti-TNF therapy on critically-ill septic patients presenting high serum IL-27 certainly warrants exploration.
Our study has limitations. The transcriptional cascades that ensue in whole-blood leukocytes post-LPS stimulation follow a highly ordered and temporally distinct path. Analyzing the genomic response to LPS stimulation and etanercept treatment solely at a 4-hour timepoint represents a portion of the leukocyte response; therefore, studies of the temporal properties governing the leukocyte transcriptional responses to LPS and TNFa antagonism is warranted. In addition to TNFa, etanercept has been reported to block lymphotoxin (TNFb), which possibly limits the specificity of the observed effects.
Most knowledge of the role of endogenous TNFa during inflammatory disorders is derived from murine studies. Recent studies have underscored the relevance of the human endotoxemia model for investigating the genomic response in human inflammatory diseases [10,11]. Importantly, while the genomic responses to different inflammatory stresses such as endotoxemia, burn and trauma are highly similar in humans, these responses are not reproduced in mice [11], further emphasizing the importance of dissecting the function of biological pathways such as those induced by TNFa in humans, rather than relying on mouse models. We here revealed an intriguing framework of a variety of biological and cellular pathways that are influenced by LPSinduced TNFa inhibition in humans in vivo. By combining genome-wide transcriptional profiling with the concepts of network biology we not only highlighted differentially expressed genes between comparisons but also defined co-expressed transcriptional networks anchored at module hub genes that predominantly possess transcriptional regulatory properties, including DNA binding, histone modifying and RNA polymerase II activity. These results provide comprehensive information about molecular pathways that might be targeted by therapeutic interventions that seek to inhibit TNFa activity during human inflammatory diseases.

Supporting Information
Table S1 List of 4077 significant transcripts, their fold changes, pand q-values.