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Macrophage metabolism reprogramming in sepsis: Pathogenesis and therapeutic implications (Review)

  • Authors:
    • Tong Zhao
    • Wenzhe Zhang
    • Zixuan Ren
    • Xiujing Feng
  • View Affiliations / Copyright

    Affiliations: Department of Critical Care Medicine, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Shandong Institute of Anesthesia and Respiratory Critical Medicine, Jinan, Shandong 250014, P.R. China, School of Clinical and Basic Medical Sciences, Shandong First Medical University and Shandong Academy of Medical Sciences, Jinan, Shandong 250117, P.R. China
    Copyright: © Zhao et al. This is an open access article distributed under the terms of Creative Commons Attribution License.
  • Article Number: 152
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    Published online on: April 3, 2026
       https://doi.org/10.3892/ijmm.2026.5823
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Abstract

Sepsis is a life‑threatening syndrome of organ dysfunction caused by infection, characterized by complex pathogenesis and high clinical mortality. As innate immune cells, macrophages serve a pivotal role in the initiation, progression and resolution of sepsis. The present review focuses on the key molecular nodes and signaling pathways of macrophage metabolic reprogramming in the process of sepsis. Key mechanisms include: i) The mammalian target of rapamycin‑hypoxia inducible factor‑1α (HIF‑1α)‑pyruvate kinase M2 axis as the primary regulator of glycolytic flux and pro‑inflammatory cytokine production; ii) tricarboxylic acid cycle interruption leading to succinate accumulation, which amplifies HIF‑1a signaling and promotes interleukin‑1β release via G protein‑coupled receptor 91, thereby exacerbating inflammation; iii) triggering receptor expressed on myeloid cells 2‑SH2‑containing protein tyrosine phosphatase‑1 axis‑mediated impairment of fatty acid oxidation, promoting lipid accumulation and pro‑inflammatory activation; and iv) amino acid depletion contributing to immune paralysis. In view of the 31.5% global mortality (21.4 million mortalities in 2021) caused by sepsis, a shift from supportive treatment to precise immune metabolism intervention is needed. The present article uniquely integrates the coordinated regulation of glucose, lipid and amino acid metabolic networks of macrophages in sepsis, and expounds the research status of immune metabolism in sepsis, in order to provide reference for the clinical treatment of sepsis. Targeted modulation of macrophage metabolism offers a new direction for individualized immunometabolic therapy in sepsis.
View Figures

Figure 1

Comparison of macrophage glucose
metabolism reprogramming under physiological and sepsis states.
Under physiological conditions (left), the AMPK pathway in
macrophages is phosphorylated and activated. Macrophages use OXPHOS
as their core metabolic mode, relying on the complete TCA cycle and
ETC to provide stable energy supply to support the
anti-inflammatory/reparative phenotype of M2 macrophages. In sepsis
(right), PAMPs (such as LPS) activate the AMPK-mTOR-HIF-1α-PKM2
axis and inhibits AMPK through TLR4 or GLUT1, driving the
expression of key glycolytic enzymes (PKM2, GLUT1, HK2, PFKFB3,
LDH, PFK-1), leading to an increase in the conversion of pyruvate
to lactate. The G-6-P produced during glycolysis also increases the
activity of the PPP pathway. Lactic acid produced through
glycolysis pathway or recovered through GPPR81 promotes HMGB1
acetylation/acetylation through p300/CBP dependent mechanism, which
is released in the form of exosomes, exacerbating endothelial
damage and DIC. The dimeric form of PKM2 can interact with HMGB1 to
promote glycolytic transcription. In addition, succinic acid
accumulation caused by TCA cycle interruption can also be taken up
by GPR91 cells, further increasing inflammatory factors and
inhibiting SDH. The glycolysis pathway and intermediates of the TCA
cycle, such as citrate and succinate, can serve as important
metabolic branching points for lipid synthesis and epigenetic
signaling. AMPK, adenosine 5'-monophosphate (AMP)-activated protein
kinase; OXPHOS, oxidative phosphorylation; TCA cycle, tricarboxylic
acid cycle; PPP, pentose phosphate pathway; NADPH, nicotinamide
adenine dinucleotide phosphate hydrogen; PAMPs, pathogen-associated
molecular patterns; LPS, lipopolysaccharide; HIF-1α, hypoxia
inducible factor-1α; PI3K, phosphatidylinositol 3-kinase; AKT, also
known as protein kinase B or PKB; mTOR, mammalian target of
rapamycin; TLR4, toll-like receptor 4; GLUT1, glucose transporter
1; PKM2, pyruvate kinase M2; HK2, hexokinase 2; PFKFB3,
6-phosphofructo-2-kinase/fructose-2,6-biphosphatase 3; LDH, lactate
dehydrogenase; ROS, reactive oxygen species; G-6-P,
glucose-6-phosphate; HMGB1, high mobility group box-1; P300/CBP,
p300 and CREB-binding protein; GPR81, G protein-coupled receptor
81; DIC, disseminated intravascular coagulation; GPR91, G
protein-coupled receptor 91; IL-1β, interleukin-1β; SDH, succinate
dehydrogenase; PFK-1, phosphofructokinase-1.

Figure 2

Comparison diagram of macrophage
lipid metabolism reprogramming between physiological state and
sepsis states. Under physiological conditions (left), macrophages
maintain FAO dominated energy metabolism through CD36 and CPT1a
mediated lipid uptake, while acetyl CoA enters the TCA cycle to
support OXPHOS. ABCA1/ABCG1 mediates cholesterol efflux to
stabilize cell membrane function. Anti-inflammatory factors promote
M2 polarization through PPARγ signaling. In sepsis (right figure),
lipid uptake (increased CD36) increases while FAO is impaired
(especially inhibited by TREM2-SHP1 axis), leading to lipid
accumulation and lipotoxicity. Cholesterol efflux disorder
exacerbates lipid raft aggregation and TLR inflammatory signaling.
In addition, saturated fatty acids and NLRP3 inflammasome
activation drive M1 polarization dominant inflammation, while
anti-inflammatory pathways such as PPARγ/LXR are inhibited. This
lipid metabolic network is functionally coupled with glucose
metabolism, where glycolytic-derived acetyl-CoA supports de
novo lipogenesis, reflecting a high degree of substrate
interdependency. FAO, fatty acid oxidation; CD36, cluster of
differentiation 36; CPT1a, carnitine palmitoyltransferase 1a; TCA,
tricarboxylic acid; OXPHOS, oxidative phosphorylation; ABCA1,
ATP-binding cassette protein A1; ABCG1, ATP-binding cassette
protein G1; IL, interleukin; PPARγ, peroxisome proliferator
activated receptor γ; FFA, free fatty acids; TLR, toll-like
receptor; TNF-α, tumor necrosis factor-α; NLRP3, NOD-like receptor
domain-containing protein 3; LXR, liver X receptors; HNF4,
hepatocyte nuclear factor 4; TREM2, triggering receptor expressed
on myeloid cells 2; SHP1, SH2-containing protein tyrosine
phosphatase-1.

Figure 3

Comparison of amino acid metabolism
reprogramming of macrophages under physiological and sepsis
conditions. Under physiological conditions (left), amino acid
metabolism maintains dynamic balance: Try regulates immune
homeostasis by producing a small amount of KYN through low activity
IDO. Gln maintains TCA cycle energy supply, produces Glu through
glutaminase and supports antioxidant (GSH synthesis). Arginine
produces appropriate amounts of NO (antibacterial) and ornithine
(tissue repair) through the balance of NOS and Arg, respectively.
In a sepsis state (right), amino acid metabolism is disrupted.
IFN-γ induces high expression of IDO and accelerates the metabolism
of Try along the KYN pathway. Phe metabolism is closely related to
SA-AKI and can also cause toxicity to antibodies. The increase in
Gln consumption enhances glycolysis and pro-inflammatory M1
polarization through mTOR activation. The TLR4/EGFR mTOR axis
drives metabolic imbalance in sepsis, leading to M1 polarization
dominance and the release of pro-inflammatory cytokines. Inhibition
of EGFR can partially activate PPARγ to enhance Gln uptake and
promote M2 repair. Overactivation of iNOS leads to depletion of
arginine and excessive production of NO, and may inhibit the mTOR
signaling pathway. When the glycolysis or lipid pathways are
damaged, the metabolic flux of amino acids, especially the
generated glutamine, can serve as an energy buffer to maintain
mitochondrial integrity. Try, tryptophan; KYN, kynurenine; IDO,
indoleamine 2,3-dioxygenase; Gln, glutamine; Glu, glutamate; GSH,
glutathione; NO, nitric oxide; NOS, nitric oxide synthase; Arg,
arginine; IFN-γ, interferon-γ; NF-κB, nuclear factor κB; Phe,
phenylalanine; SA-AKI, sepsis associated-acute kidney injury; TLR4,
toll-like receptor 4; EGFR, epidermal growth factor receptor; mTOR,
mammalian target of rapamycin; PPARγ, peroxisome proliferator
activated receptor γ; iNOS, inducible nitric oxide synthase; ETC,
electron transfer chain; ROS, reactive oxygen species; Pro,
proline; TNF-α, tumor necrosis factor-α; a-KG, α-ketoglutaric acid;
TCA, tricarboxylic acid.

Figure 4

Comprehensive metabolism of
macrophages in sepsis. The figure illustrates the non-linear
interdependencies among carbohydrate, lipid and amino acid
metabolism. Key regulatory nodes include the citrate-to-acetyl-CoA
shunt for lipid accumulation, the glutamine-to-α-KG anaplerotic
pathway for mitochondrial buffering and the lactate-H3K18la axis
driving arginine metabolic shifts. Potential therapeutic agents
(such as 2-DG, metformin and PPAR agonists) are mapped to specific
metabolic checkpoints to provide a roadmap for precision
immunometabolic therapy. Arg1, arginase 1; α-KG, α-ketoglutarate;
H3K18la, histone H3 lysine 18 lactylation; AMPK, adenosine
5'-monophosphate (AMP)-activated protein kinase; mTOR, mammalian
target of rapamycin; HIF-1α, hypoxia inducible factor-1α; PKM2,
pyruvate kinase M2; ETC, electron transport chain; TCA,
tricarboxylic acid; NADPH, nicotinamide adenine dinucleotide
phosphate hydrogen; FFA, free fatty acid; PPAR, peroxisome
proliferator activated receptor; ABCA1, ATP-binding cassette
protein A1; ABCG1, ATP-binding cassette protein G1; 2-DG,
2-deoxy-d-glucose.
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Copy and paste a formatted citation
Spandidos Publications style
Zhao T, Zhang W, Ren Z and Feng X: Macrophage metabolism reprogramming in sepsis: Pathogenesis and therapeutic implications (Review). Int J Mol Med 57: 152, 2026.
APA
Zhao, T., Zhang, W., Ren, Z., & Feng, X. (2026). Macrophage metabolism reprogramming in sepsis: Pathogenesis and therapeutic implications (Review). International Journal of Molecular Medicine, 57, 152. https://doi.org/10.3892/ijmm.2026.5823
MLA
Zhao, T., Zhang, W., Ren, Z., Feng, X."Macrophage metabolism reprogramming in sepsis: Pathogenesis and therapeutic implications (Review)". International Journal of Molecular Medicine 57.6 (2026): 152.
Chicago
Zhao, T., Zhang, W., Ren, Z., Feng, X."Macrophage metabolism reprogramming in sepsis: Pathogenesis and therapeutic implications (Review)". International Journal of Molecular Medicine 57, no. 6 (2026): 152. https://doi.org/10.3892/ijmm.2026.5823
Copy and paste a formatted citation
x
Spandidos Publications style
Zhao T, Zhang W, Ren Z and Feng X: Macrophage metabolism reprogramming in sepsis: Pathogenesis and therapeutic implications (Review). Int J Mol Med 57: 152, 2026.
APA
Zhao, T., Zhang, W., Ren, Z., & Feng, X. (2026). Macrophage metabolism reprogramming in sepsis: Pathogenesis and therapeutic implications (Review). International Journal of Molecular Medicine, 57, 152. https://doi.org/10.3892/ijmm.2026.5823
MLA
Zhao, T., Zhang, W., Ren, Z., Feng, X."Macrophage metabolism reprogramming in sepsis: Pathogenesis and therapeutic implications (Review)". International Journal of Molecular Medicine 57.6 (2026): 152.
Chicago
Zhao, T., Zhang, W., Ren, Z., Feng, X."Macrophage metabolism reprogramming in sepsis: Pathogenesis and therapeutic implications (Review)". International Journal of Molecular Medicine 57, no. 6 (2026): 152. https://doi.org/10.3892/ijmm.2026.5823
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