1
|
Landoni VI, Pittaluga JR, Carestia A, Castillo LA, Nebel MDC, Martire-Greco D, Birnberg-Weiss F, Schattner M, Schierloh P, Fernández GC. Neutrophil Extracellular Traps Induced by Shiga Toxin and Lipopolysaccharide-Treated Platelets Exacerbate Endothelial Cell Damage. Front Cell Infect Microbiol 2022; 12:897019. [PMID: 35811684 PMCID: PMC9262415 DOI: 10.3389/fcimb.2022.897019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 05/18/2022] [Indexed: 11/13/2022] Open
Abstract
Hemolytic uremic syndrome (HUS) is the most common cause of acute renal failure in the pediatric population. The etiology of HUS is linked to Gram-negative, Shiga toxin (Stx)-producing enterohemorrhagic bacterial infections. While the effect of Stx is focused on endothelial damage of renal glomerulus, cytokines induced by Stx or bacterial lipopolysaccharide (LPS) and polymorphonuclear cells (PMNs) are involved in the development of the disease. PMN release neutrophil extracellular traps (NETs) to eliminate pathogens, although NETs favor platelets (Plts) adhesion/thrombus formation and can cause tissue damage within blood vessels. Since thrombus formation and occlusion of vessels are characteristic of HUS, PMN–Plts interaction in the context of Stx may promote netosis and contribute to the endothelial damage observed in HUS. The aim of this study was to determine the relevance of netosis induced by Stx in the context of LPS-sensitized Plts on endothelial damage. We observed that Stx2 induced a marked enhancement of netosis promoted by Plts after LPS stimulation. Several factors seemed to promote this phenomenon. Stx2 itself increased the expression of its receptor on Plts, increasing toxin binding. Stx2 also increased LPS binding to Plts. Moreover, Stx2 amplified LPS induced P-selectin expression on Plts and mixed PMN–Plts aggregates formation, which led to activation of PMN enhancing dramatically NETs formation. Finally, experiments revealed that endothelial cell damage mediated by PMN in the context of Plts treated with LPS and Stx2 was decreased when NETs were disrupted or when mixed aggregate formation was impeded using an anti-P-selectin antibody. Using a murine model of HUS, systemic endothelial damage/dysfunction was decreased when NETs were disrupted, or when Plts were depleted, indicating that the promotion of netosis by Plts in the context of LPS and Stx2 plays a fundamental role in endothelial toxicity. These results provide insights for the first time into the pivotal role of Plts as enhancers of endothelial damage through NETs promotion in the context of Stx and LPS. Consequently, therapies designed to reduce either the formation of PMN–Plts aggregates or NETs formation could lessen the consequences of endothelial damage in HUS.
Collapse
Affiliation(s)
- Verónica Inés Landoni
- Laboratorio de Fisiología de los Procesos Inflamatorios, Instituto de Medicina Experimental (IMEX)-Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET)/Academia Nacional de Medicina de Buenos Aires, Ciudad Autónoma de Buenos Aires (CABA), Argentina
| | - Jose R. Pittaluga
- Laboratorio de Fisiología de los Procesos Inflamatorios, Instituto de Medicina Experimental (IMEX)-Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET)/Academia Nacional de Medicina de Buenos Aires, Ciudad Autónoma de Buenos Aires (CABA), Argentina
| | - Agostina Carestia
- Laboratorio de Trombosis Experimental e Inmunobiología de la Inflamación, Instituto de Medicina Experimental (IMEX)-Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET)/Academia Nacional de Medicina de Buenos Aires, Ciudad Autónoma de Buenos Aires (CABA), Argentina
| | - Luis Alejandro Castillo
- Laboratorio de Fisiología de los Procesos Inflamatorios, Instituto de Medicina Experimental (IMEX)-Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET)/Academia Nacional de Medicina de Buenos Aires, Ciudad Autónoma de Buenos Aires (CABA), Argentina
| | - Marcelo de Campos Nebel
- Laboratorio de Mutagénesis, Instituto de Medicina Experimental (IMEX)-Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET)/Academia Nacional de Medicina de Buenos Aires, Ciudad Autónoma de Buenos Aires (CABA), Argentina
| | - Daiana Martire-Greco
- Laboratorio de Fisiología de los Procesos Inflamatorios, Instituto de Medicina Experimental (IMEX)-Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET)/Academia Nacional de Medicina de Buenos Aires, Ciudad Autónoma de Buenos Aires (CABA), Argentina
| | - Federico Birnberg-Weiss
- Laboratorio de Fisiología de los Procesos Inflamatorios, Instituto de Medicina Experimental (IMEX)-Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET)/Academia Nacional de Medicina de Buenos Aires, Ciudad Autónoma de Buenos Aires (CABA), Argentina
| | - Mirta Schattner
- Laboratorio de Trombosis Experimental e Inmunobiología de la Inflamación, Instituto de Medicina Experimental (IMEX)-Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET)/Academia Nacional de Medicina de Buenos Aires, Ciudad Autónoma de Buenos Aires (CABA), Argentina
| | - Pablo Schierloh
- Instituto de Investigación y Desarrollo en Bioingeniería y Bioinformática, Centro Científico Tecnológico Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Santa Fe, Argentina
| | - Gabriela C. Fernández
- Laboratorio de Fisiología de los Procesos Inflamatorios, Instituto de Medicina Experimental (IMEX)-Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET)/Academia Nacional de Medicina de Buenos Aires, Ciudad Autónoma de Buenos Aires (CABA), Argentina
- *Correspondence: Gabriela C. Fernández, ;
| |
Collapse
|
2
|
Enterohemorrhagic Escherichia coli and a Fresh View on Shiga Toxin-Binding Glycosphingolipids of Primary Human Kidney and Colon Epithelial Cells and Their Toxin Susceptibility. Int J Mol Sci 2022; 23:ijms23136884. [PMID: 35805890 PMCID: PMC9266556 DOI: 10.3390/ijms23136884] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 06/07/2022] [Accepted: 06/17/2022] [Indexed: 02/06/2023] Open
Abstract
Enterohemorrhagic Escherichia coli (EHEC) are the human pathogenic subset of Shiga toxin (Stx)-producing E. coli (STEC). EHEC are responsible for severe colon infections associated with life-threatening extraintestinal complications such as the hemolytic-uremic syndrome (HUS) and neurological disturbances. Endothelial cells in various human organs are renowned targets of Stx, whereas the role of epithelial cells of colon and kidneys in the infection process has been and is still a matter of debate. This review shortly addresses the clinical impact of EHEC infections, novel aspects of vesicular package of Stx in the intestine and the blood stream as well as Stx-mediated extraintestinal complications and therapeutic options. Here follows a compilation of the Stx-binding glycosphingolipids (GSLs), globotriaosylceramide (Gb3Cer) and globotetraosylceramide (Gb4Cer) and their various lipoforms present in primary human kidney and colon epithelial cells and their distribution in lipid raft-analog membrane preparations. The last issues are the high and extremely low susceptibility of primary renal and colonic epithelial cells, respectively, suggesting a large resilience of the intestinal epithelium against the human-pathogenic Stx1a- and Stx2a-subtypes due to the low content of the high-affinity Stx-receptor Gb3Cer in colon epithelial cells. The review closes with a brief outlook on future challenges of Stx research.
Collapse
|
3
|
Friebel J, Schinnerling K, Geelhaar‐Karsch A, Allers K, Schneider T, Moos V. Intestinal barrier dysfunction mediates Whipple's disease immune reconstitution inflammatory syndrome (IRIS). Immun Inflamm Dis 2022; 10:e622. [PMID: 35478447 PMCID: PMC9046915 DOI: 10.1002/iid3.622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/17/2022] [Accepted: 03/30/2022] [Indexed: 12/05/2022] Open
Abstract
Background & Aims Classical Whipple's disease (CWD) affects the gastrointestinal tract and causes chronic diarrhea, malabsorption, and barrier dysfunction with microbial translocation (MT). Immune reconstitution inflammatory syndrome (IRIS) is a serious complication during antimicrobial treatment of CWD. The pathomechanisms of IRIS have not been identified and mucosal barrier integrity has not been studied in patients with IRIS CWD. Methods In 96 CWD patients (n = 23 IRIS, n = 73 non‐IRIS) and 30 control subjects, we analysed duodenal morphology by histology, measured serum markers of MT, and proinflammatory cytokines in biopsy supernatants, and correlated microbial translocation with T cell reconstitution and activation. Results Before treatment, duodenal specimens from patients who later developed IRIS exhibited a more pronounced morphological transformation that suggested a disturbed barrier integrity when compared with the non‐IRIS group. Villous atrophy was mediated by increased apoptosis of epithelial cells, which was insufficiently counterbalanced by regenerative proliferation of crypt cells. Pretreatment deficiencies in the mucosal secretion of proinflammatory cytokines and chemokines (e.g., IL‐6, CCL2) in these patients markedly resolved after therapy induction. High serum levels of lipopolysaccharides (LPS), soluble CD14 (sCD14), and LPS‐binding protein (LBP) combined with low endotoxin core antibody (EndoCAb) titres suggested systemic MT in CWD patients developing IRIS. CD4+ T cell count and activation in IRIS CWD patients correlated positively with sCD14 levels and negatively with EndoCAb titres. Furthermore, the degree of intestinal barrier dysfunction and MT was predictive for the onset of IRIS. Conclusion Prolonged MT across a dysfunctional intestinal mucosal barrier due to severe tissue damage favors dysbalanced immune reconstitution and systemic immune activation in IRIS CWD. Therefore, the monitoring of inflammatory and MT markers in CWD patients might be helpful in identifying patients who are at risk of developing IRIS. Therapeutic strategies to reconstitute the mucosal barrier and control inflammation could assist in the prevention of IRIS.
Collapse
Affiliation(s)
- Julian Friebel
- Department of Cardiology Charité‐University Medicine Berlin Germany
- Berlin Institute of Health at Charité‐Universitätsmedizin Berlin, BIH Biomedical Innovation Academy BIH Charité Clinician Scientist Program Berlin Germany
| | - Katina Schinnerling
- Medical Department I, Gastroenterology, Infectious Diseases and Rheumatology Charité‐University Medicine Berlin Germany
| | - Anika Geelhaar‐Karsch
- Medical Department I, Gastroenterology, Infectious Diseases and Rheumatology Charité‐University Medicine Berlin Germany
| | - Kristina Allers
- Medical Department I, Gastroenterology, Infectious Diseases and Rheumatology Charité‐University Medicine Berlin Germany
| | - Thomas Schneider
- Medical Department I, Gastroenterology, Infectious Diseases and Rheumatology Charité‐University Medicine Berlin Germany
| | - Verena Moos
- Medical Department I, Gastroenterology, Infectious Diseases and Rheumatology Charité‐University Medicine Berlin Germany
| |
Collapse
|
4
|
Abbas F, Abbas SF. De Novo and Recurrent Thrombotic Microangiopathy After Renal Transplantation: Current Concepts in Management. EXP CLIN TRANSPLANT 2021; 20:549-557. [PMID: 34546154 DOI: 10.6002/ect.2021.0069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Thrombotic microangiopathy is a well-recognized complication of kidney transplantation that leads frequently to allograft failure. This serious outcome can greatly depend on the underlying etiology and on the timing of therapeutic interventions. Thrombotic microangiopathy syndrome may occur with no previous history of thrombotic microangiopathy (that is, de novo thrombotic microangiopathy), mostly due to medica tions or infections. More frequently, it may recur after kidney transplant in patients with endstage renal failure due to atypical hemolytic uremic syndrome. However, for patients with Shiga-toxininduced hemolytic uremic syndrome, particularly pediatric patients, there is a favorable prognosis. A fundamental tool for management of this disease is genetic screening for abnormal mutations; this can recognize the suggested approach of therapy and may determine the outcome of the disease to a large extent. Although patients with complement factor H and I mutations have worse prognosis, other patients with membrane cofactor protein mutations, for example, have a more favorable prognosis. Accordingly, the plan of therapy can be tailored with a better chance of cure. Unfortunately, the successful use of the biological agent eculizumab, an anti-C5 agent, in some of these syndromes is largely impeded by its high cost, which is linked to its use as a life-long therapy. However, newly suggested therapeutic options may ameliorate this drawback.
Collapse
Affiliation(s)
- Fedaei Abbas
- From the Nephrology Department, Jaber El Ahmed Military Hospital, Safat, Kuwait.,the Faculty of Health and Science, University of Liverpool, Institute of Learning and Teaching, School of Medicine, Liverpool, United Kingdom
| | | |
Collapse
|
5
|
Vázquez-Carballo C, Guerrero-Hue M, García-Caballero C, Rayego-Mateos S, Opazo-Ríos L, Morgado-Pascual JL, Herencia-Bellido C, Vallejo-Mudarra M, Cortegano I, Gaspar ML, de Andrés B, Egido J, Moreno JA. Toll-Like Receptors in Acute Kidney Injury. Int J Mol Sci 2021; 22:ijms22020816. [PMID: 33467524 PMCID: PMC7830297 DOI: 10.3390/ijms22020816] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 01/09/2021] [Accepted: 01/11/2021] [Indexed: 12/16/2022] Open
Abstract
Acute kidney injury (AKI) is an important health problem, affecting 13.3 million individuals/year. It is associated with increased mortality, mainly in low- and middle-income countries, where renal replacement therapy is limited. Moreover, survivors show adverse long-term outcomes, including increased risk of developing recurrent AKI bouts, cardiovascular events, and chronic kidney disease. However, there are no specific treatments to decrease the adverse consequences of AKI. Epidemiological and preclinical studies show the pathological role of inflammation in AKI, not only at the acute phase but also in the progression to chronic kidney disease. Toll-like receptors (TLRs) are key regulators of the inflammatory response and have been associated to many cellular processes activated during AKI. For that reason, a number of anti-inflammatory agents targeting TLRs have been analyzed in preclinical studies to decrease renal damage during AKI. In this review, we updated recent knowledge about the role of TLRs, mainly TLR4, in the initiation and development of AKI as well as novel compounds targeting these molecules to diminish kidney injury associated to this pathological condition.
Collapse
Affiliation(s)
- Cristina Vázquez-Carballo
- Renal, Vascular and Diabetes Research Laboratory, IIS-Fundación Jiménez Díaz, Universidad Autónoma de Madrid, 28040 Madrid, Spain; (C.V.-C.); (S.R.-M.); (L.O.-R.); (C.H.-B.)
| | - Melania Guerrero-Hue
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Hospital Universitario Reina Sofía, 14004 Córdoba, Spain; (M.G.-H.); (C.G.-C.); (J.L.M.-P.); (M.V.-M.)
| | - Cristina García-Caballero
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Hospital Universitario Reina Sofía, 14004 Córdoba, Spain; (M.G.-H.); (C.G.-C.); (J.L.M.-P.); (M.V.-M.)
| | - Sandra Rayego-Mateos
- Renal, Vascular and Diabetes Research Laboratory, IIS-Fundación Jiménez Díaz, Universidad Autónoma de Madrid, 28040 Madrid, Spain; (C.V.-C.); (S.R.-M.); (L.O.-R.); (C.H.-B.)
| | - Lucas Opazo-Ríos
- Renal, Vascular and Diabetes Research Laboratory, IIS-Fundación Jiménez Díaz, Universidad Autónoma de Madrid, 28040 Madrid, Spain; (C.V.-C.); (S.R.-M.); (L.O.-R.); (C.H.-B.)
- Spanish Biomedical Research Centre in Diabetes and Associated Metabolic Disorders (CIBERDEM), 28040 Madrid, Spain
| | - José Luis Morgado-Pascual
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Hospital Universitario Reina Sofía, 14004 Córdoba, Spain; (M.G.-H.); (C.G.-C.); (J.L.M.-P.); (M.V.-M.)
| | - Carmen Herencia-Bellido
- Renal, Vascular and Diabetes Research Laboratory, IIS-Fundación Jiménez Díaz, Universidad Autónoma de Madrid, 28040 Madrid, Spain; (C.V.-C.); (S.R.-M.); (L.O.-R.); (C.H.-B.)
| | - Mercedes Vallejo-Mudarra
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Hospital Universitario Reina Sofía, 14004 Córdoba, Spain; (M.G.-H.); (C.G.-C.); (J.L.M.-P.); (M.V.-M.)
| | - Isabel Cortegano
- Immunobiology Department, Carlos III Health Institute, 28220 Majadahonda (Madrid), Spain; (I.C.); (M.L.G.); (B.d.A.)
| | - María Luisa Gaspar
- Immunobiology Department, Carlos III Health Institute, 28220 Majadahonda (Madrid), Spain; (I.C.); (M.L.G.); (B.d.A.)
| | - Belén de Andrés
- Immunobiology Department, Carlos III Health Institute, 28220 Majadahonda (Madrid), Spain; (I.C.); (M.L.G.); (B.d.A.)
| | - Jesús Egido
- Renal, Vascular and Diabetes Research Laboratory, IIS-Fundación Jiménez Díaz, Universidad Autónoma de Madrid, 28040 Madrid, Spain; (C.V.-C.); (S.R.-M.); (L.O.-R.); (C.H.-B.)
- Spanish Biomedical Research Centre in Diabetes and Associated Metabolic Disorders (CIBERDEM), 28040 Madrid, Spain
- Correspondence: (J.E.); (J.A.M.); Tel.: +34-915504800 (J.E.); +34-957-218039 (J.A.M.)
| | - Juan Antonio Moreno
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Hospital Universitario Reina Sofía, 14004 Córdoba, Spain; (M.G.-H.); (C.G.-C.); (J.L.M.-P.); (M.V.-M.)
- Biomedical Research Networking Center on Cardiovascular Diseases (CIBERCV), 28029 Madrid, Spain
- Department of Cell Biology, Physiology and Immunology, University of Cordoba, 140471 Cordoba, Spain
- Correspondence: (J.E.); (J.A.M.); Tel.: +34-915504800 (J.E.); +34-957-218039 (J.A.M.)
| |
Collapse
|
6
|
Severe acute kidney injury in a 3-year-old boy with fever and pleural effusion: Answers. Pediatr Nephrol 2020; 35:2279-2283. [PMID: 32468115 DOI: 10.1007/s00467-020-04591-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 04/22/2020] [Indexed: 10/24/2022]
|
7
|
Galarce N, Sánchez F, Fuenzalida V, Ramos R, Escobar B, Lapierre L, Paredes-Osses E, Arriagada G, Alegría-Morán R, Lincopán N, Fuentes-Castillo D, Vera-Leiva A, González-Rocha G, Bello-Toledo H, Borie C. Phenotypic and Genotypic Antimicrobial Resistance in Non-O157 Shiga Toxin-Producing Escherichia coli Isolated From Cattle and Swine in Chile. Front Vet Sci 2020; 7:367. [PMID: 32754621 PMCID: PMC7365902 DOI: 10.3389/fvets.2020.00367] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 05/27/2020] [Indexed: 01/09/2023] Open
Abstract
Non-O157 Shiga toxin-producing Escherichia coli (STEC) is a zoonotic pathogen that causes bloody diarrhea and hemolytic-uremic syndrome in humans, and a major cause of foodborne disease. Despite antibiotic treatment of STEC infections in humans is not recommended, the presence of antimicrobial-resistant bacteria in animals and food constitutes a risk to public health, as the pool of genes from which pathogenic bacteria can acquire antibiotic resistance has increased. Additionally, in Chile there is no information on the antimicrobial resistance of this pathogen in livestock. Thus, the aim of this study was to characterize the phenotypic and genotypic antimicrobial resistance of STEC strains isolated from cattle and swine in the Metropolitan region, Chile, to contribute relevant data to antimicrobial resistance surveillance programs at national and international level. We assessed the minimal inhibitory concentration of 18 antimicrobials, and the distribution of 12 antimicrobial resistance genes and class 1 and 2 integrons in 54 STEC strains. All strains were phenotypically resistant to at least one antimicrobial drug, with a 100% of resistance to cefalexin, followed by colistin (81.5%), chloramphenicol (14.8%), ampicillin and enrofloxacin (5.6% each), doxycycline (3.7%), and cefovecin (1.9%). Most detected antibiotic resistance genes were dfrA1 and tetA (100%), followed by tetB (94.4%), blaTEM−1 (90.7%), aac(6)-Ib (88.9%), blaAmpC (81.5%), cat1 (61.1%), and aac(3)-IIa (11.1%). Integrons were detected only in strains of swine origin. Therefore, this study provides further evidence that non-O157 STEC strains present in livestock in the Metropolitan region of Chile exhibit phenotypic and genotypic resistance against antimicrobials that are critical for human and veterinary medicine, representing a major threat for public health. Additionally, these strains could have a competitive advantage in the presence of antimicrobial selective pressure, leading to an increase in food contamination. This study highlights the need for coordinated local and global actions regarding the use of antimicrobials in animal food production.
Collapse
Affiliation(s)
- Nicolás Galarce
- Departamento de Medicina Preventiva Animal, Facultad de Ciencias Veterinarias y Pecuarias, Universidad de Chile, Santiago, Chile
| | - Fernando Sánchez
- Departamento de Medicina Preventiva Animal, Facultad de Ciencias Veterinarias y Pecuarias, Universidad de Chile, Santiago, Chile
| | - Verónica Fuenzalida
- Departamento de Medicina Preventiva Animal, Facultad de Ciencias Veterinarias y Pecuarias, Universidad de Chile, Santiago, Chile
| | - Romina Ramos
- Departamento de Medicina Preventiva Animal, Facultad de Ciencias Veterinarias y Pecuarias, Universidad de Chile, Santiago, Chile
| | - Beatriz Escobar
- Departamento de Medicina Preventiva Animal, Facultad de Ciencias Veterinarias y Pecuarias, Universidad de Chile, Santiago, Chile
| | - Lisette Lapierre
- Departamento de Medicina Preventiva Animal, Facultad de Ciencias Veterinarias y Pecuarias, Universidad de Chile, Santiago, Chile
| | - Esteban Paredes-Osses
- Departamento de Salud Ambiental, Instituto de Salud Pública de Chile, Santiago, Chile
| | - Gabriel Arriagada
- Instituto de Ciencias Agroalimentarias, Animales y Ambientales, Universidad de O'Higgins, San Fernando, Chile
| | - Raúl Alegría-Morán
- Departamento de Medicina Preventiva Animal, Facultad de Ciencias Veterinarias y Pecuarias, Universidad de Chile, Santiago, Chile.,Facultad de Ciencias Agropecuarias, Universidad Pedro de Valdivia, Santiago, Chile
| | - Nilton Lincopán
- Departamento de Microbiología, Instituto de Ciências Biomedicas, Universidade de São Paulo, São Paulo, Brazil
| | - Danny Fuentes-Castillo
- Departamento de Patologia, Faculdade de Medicina Veterinária e Zootecnia, Universidade de São Paulo, São Paulo, Brazil
| | - Alejandra Vera-Leiva
- Laboratorio de Investigación en Agentes Antibacterianos, Facultad de Ciencias Biológicas, Universidad de Concepción, Concepción, Chile
| | - Gerardo González-Rocha
- Laboratorio de Investigación en Agentes Antibacterianos, Facultad de Ciencias Biológicas, Universidad de Concepción, Concepción, Chile.,Millenium Nucleus on Interdisciplinary Approach to Antimicrobial Resistance, Santiago, Chile
| | - Helia Bello-Toledo
- Laboratorio de Investigación en Agentes Antibacterianos, Facultad de Ciencias Biológicas, Universidad de Concepción, Concepción, Chile.,Millenium Nucleus on Interdisciplinary Approach to Antimicrobial Resistance, Santiago, Chile
| | - Consuelo Borie
- Departamento de Medicina Preventiva Animal, Facultad de Ciencias Veterinarias y Pecuarias, Universidad de Chile, Santiago, Chile
| |
Collapse
|
8
|
Valid Presumption of Shiga Toxin-Mediated Damage of Developing Erythrocytes in EHEC-Associated Hemolytic Uremic Syndrome. Toxins (Basel) 2020; 12:toxins12060373. [PMID: 32512916 PMCID: PMC7354503 DOI: 10.3390/toxins12060373] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 06/02/2020] [Accepted: 06/03/2020] [Indexed: 02/06/2023] Open
Abstract
The global emergence of clinical diseases caused by enterohemorrhagic Escherichia coli (EHEC) is an issue of great concern. EHEC release Shiga toxins (Stxs) as their key virulence factors, and investigations on the cell-damaging mechanisms toward target cells are inevitable for the development of novel mitigation strategies. Stx-mediated hemolytic uremic syndrome (HUS), characterized by the triad of microangiopathic hemolytic anemia, thrombocytopenia, and acute renal injury, is the most severe outcome of an EHEC infection. Hemolytic anemia during HUS is defined as the loss of erythrocytes by mechanical disruption when passing through narrowed microvessels. The formation of thrombi in the microvasculature is considered an indirect effect of Stx-mediated injury mainly of the renal microvascular endothelial cells, resulting in obstructions of vessels. In this review, we summarize and discuss recent data providing evidence that HUS-associated hemolytic anemia may arise not only from intravascular rupture of erythrocytes, but also from the extravascular impairment of erythropoiesis, the development of red blood cells in the bone marrow, via direct Stx-mediated damage of maturing erythrocytes, leading to “non-hemolytic” anemia.
Collapse
|
9
|
Maeda R, Kawasaki Y, Kume Y, Go H, Suyama K, Hosoya M. Involvement of high mobility group box 1 in the pathogenesis of severe hemolytic uremic syndrome in a murine model. Am J Physiol Renal Physiol 2019; 317:F1420-F1429. [DOI: 10.1152/ajprenal.00263.2019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Typical hemolytic uremic syndrome is caused by Shiga toxin (Stx2) and lipopolysaccharide (LPS) of Escherichia coli and leads to acute kidney injury. The role of innate immunity in this pathogenesis is unclear. We analyzed the role of high mobility group box 1 (HMGB1) at the onset of disease in a murine model. C57BL/6 mice were intraperitoneally administered saline ( group A), anti-HMGB1 monoclonal antibody ( group B), Stx2 and LPS to elicit severe disease ( group C), or Stx2, LPS, and anti-HMGB1 antibody ( group D). While all mice in group C died by day 5 of the experiment, all mice in group D survived. Anemia and thrombocytopenia were pronounced and plasma creatinine levels were significantly elevated in group C only at 72 h. While at 72 h after toxin administration the glomerulus tissue in group C showed pathology similar to that of humans, mesangial cell proliferation was seen in group D. Plasma HMGB1 levels in group C peaked 3 h after administration and were higher than those in other groups. Expression of the receptor of advanced glycation end products and NF-κB, involved in HMGB1 signaling, was significantly elevated in group C but not in group D. Administration of anti-HMGB1 antibody in a murine model of severe disease inhibited plasma HMGB1 and promoted amelioration of tissue damage. HMGB1 was found to be involved in the disease pathology; therefore, controlling HMGB1 activity might inhibit disease progression.
Collapse
Affiliation(s)
- Ryo Maeda
- Department of Pediatrics, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Yukihiko Kawasaki
- Department of Pediatrics, Fukushima Medical University School of Medicine, Fukushima, Japan
- Department of Pediatrics, Sapporo Medical University School of Medicine, Hokkaido, Japan
| | - Yohei Kume
- Department of Pediatrics, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Hayato Go
- Department of Pediatrics, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Kazuhide Suyama
- Department of Pediatrics, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Mitsuaki Hosoya
- Department of Pediatrics, Fukushima Medical University School of Medicine, Fukushima, Japan
| |
Collapse
|
10
|
Kallianpur AR, Bradford Y, Mody RK, Garman KN, Comstock N, Lathrop SL, Lyons C, Saupe A, Wymore K, Canter JA, Olson LM, Palmer A, Jones TF. Genetic Susceptibility to Postdiarrheal Hemolytic-Uremic Syndrome After Shiga Toxin-Producing Escherichia coli Infection: A Centers for Disease Control and Prevention FoodNet Study. J Infect Dis 2019; 217:1000-1010. [PMID: 29216383 DOI: 10.1093/infdis/jix633] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 12/01/2017] [Indexed: 12/15/2022] Open
Abstract
Background Postdiarrheal hemolytic-uremic syndrome (D+HUS) following Shiga toxin-producing Escherichia coli (STEC) infection is a serious condition lacking specific treatment. Host immune dysregulation and genetic susceptibility to complement hyperactivation are implicated in non-STEC-related HUS. However, genetic susceptibility to D+HUS remains largely uncharacterized. Methods Patients with culture-confirmed STEC diarrhea, identified through the Centers for Disease Control and Prevention FoodNet surveillance system (2007-2012), were serotyped and classified by laboratory and/or clinical criteria as having suspected, probable, or confirmed D+HUS or as controls and underwent genotyping at 200 loci linked to nondiarrheal HUS or similar pathologies. Genetic associations with D+HUS were explored by multivariable regression, with adjustment for known risk factors. Results Of 641 enrollees with STEC O157:H7, 80 had suspected D+HUS (41 with probable and 32 with confirmed D+HUS). Twelve genes related to cytokine signaling, complement pathways, platelet function, pathogen recognition, iron transport, and endothelial function were associated with D+HUS in multivariable-adjusted analyses (P ≤ .05). Of 12 significant single-nucleotide polymorphisms (SNPs), 5 were associated with all levels of D+HUS (intergenic SNP rs10874639, TFRC rs3804141, EDN1 rs5370, GP1BA rs121908064, and B2M rs16966334), and 7 SNPs (6 non-complement related) were associated with confirmed D+HUS (all P < .05). Conclusions Polymorphisms in many non-complement-related genes may contribute to D+HUS susceptibility. These results require replication, but they suggest novel therapeutic targets in patients with D+HUS.
Collapse
Affiliation(s)
- Asha R Kallianpur
- Genomic Medicine Institute, Lerner Research Institute, Cleveland Clinic Foundation, Cleveland, Ohio.,Department of Molecular Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Yuki Bradford
- Department of Biomedical and Translational Informatics, Geisinger Health System, Danville, Pennsylvania
| | - Rajal K Mody
- Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Nicole Comstock
- Colorado Department of Public Health and Environment, Denver
| | - Sarah L Lathrop
- Department of Pathology, University of New Mexico, Albuquerque
| | - Carol Lyons
- Connecticut Emerging Infections Program, Yale University School of Public Health, New Haven, Connecticut
| | - Amy Saupe
- Minnesota Department of Health, St. Paul, Oakl
| | | | - Jeffrey A Canter
- Department of Molecular Physiology and Biophysics, Nashville, Tennessee
| | - Lana M Olson
- Center for Quantitative Sciences, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Amanda Palmer
- Maryland Department of Health and Mental Hygiene, Baltimore
| | | |
Collapse
|
11
|
Jepson RE, Cardwell JM, Cortellini S, Holm L, Stevens K, Walker D. Cutaneous and Renal Glomerular Vasculopathy: What Do We Know so Far? Vet Clin North Am Small Anim Pract 2019; 49:745-762. [PMID: 30961997 DOI: 10.1016/j.cvsm.2019.02.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Cutaneous renal glomerular vasculopathy (CRGV), colloquially named "Alabama rot," is an emerging condition in the United Kingdom, previously reported from the United States and Germany. The cause of CRGV is not yet determined; no definitive link to an infectious agent has been made. Dogs diagnosed with CRGV initially develop cutaneous lesions, and a proportion of these dogs go on to manifest acute kidney injury, which may result in oligoanuric acute renal failure. Antemortem diagnosis is challenging given the lack of a specific diagnostic test, and confirmation of CRGV is therefore currently dependent on identification of thrombotic microangiopathy on renal histopathology.
Collapse
Affiliation(s)
- Rosanne E Jepson
- Department of Clinical Science and Services, Royal Veterinary College, Queen Mother Hospital for Animals, Hawkshead Lane, North Mymms, Herts, London AL9 7TA, UK.
| | - Jacqueline M Cardwell
- Department of Pathobiology and Population Sciences, Royal Veterinary College, Hawkshead Lane, North Mymms, Herts, London AL9 7TA, UK
| | - Stefano Cortellini
- Department of Clinical Science and Services, Royal Veterinary College, Queen Mother Hospital for Animals, Hawkshead Lane, North Mymms, Herts, London AL9 7TA, UK
| | - Laura Holm
- Anderson Moores Veterinary Specialists, The Granary, Bunstead Barns, Poles Lane, Hursley, Winchester SO21 2LL, UK
| | - Kim Stevens
- Department of Pathobiology and Population Sciences, Royal Veterinary College, Hawkshead Lane, North Mymms, Herts, London AL9 7TA, UK
| | - David Walker
- Anderson Moores Veterinary Specialists, The Granary, Bunstead Barns, Poles Lane, Hursley, Winchester SO21 2LL, UK
| |
Collapse
|
12
|
Caprylic acid and nonanoic acid upregulate endogenous host defense peptides to enhance intestinal epithelial immunological barrier function via histone deacetylase inhibition. Int Immunopharmacol 2018; 65:303-311. [PMID: 30342347 DOI: 10.1016/j.intimp.2018.10.022] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 10/06/2018] [Accepted: 10/14/2018] [Indexed: 12/13/2022]
Abstract
The intestinal epithelial barrier plays a critical role in the etiopathogenesis of ulcerative colitis. This study aims to explore the potential effects and underlying mechanisms of medium chain fatty acids (caprylic acid and nonanoic acid) on intestinal epithelial barrier function. Using the porcine jejunal epithelial cell line IPEC-J2, a well-established model, challenged with Escherichia coli ATCC 43889 (O157:H7), we found that treatment with caprylic acid (C8) and nonanoic acid (C9) significantly reduced bacterial translocation, enhanced antibacterial activity, and remarkably increased the secretion of porcine β-defensins 1 (pBD-1) and pBD-2. Mechanistically, like TSA (a histone deacetylase inhibitor), C8 and C9 attenuated the activity of the classical histone deacetylase pathway to facilitate the acetylation of histone 3 lysine 9 (H3K9) at the promoters pBD-1 and pBD-2, and consequently augmented the gene expression of pBD-1 and pBD-2. In conclusion, with their combined antibacterial and defense peptide-induced roles, the use of C8 and C9 may provide a novel method to protect the intestinal barrier of animals and humans from bacterial infection.
Collapse
|
13
|
Schneidewend R, Epperla N, Friedman KD. Thrombotic Thrombocytopenic Purpura and the Hemolytic Uremic Syndromes. Hematology 2018. [DOI: 10.1016/b978-0-323-35762-3.00134-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
|
14
|
Rafat C, Coppo P, Fakhouri F, Frémeaux-Bacchi V, Loirat C, Zuber J, Rondeau E. [Hemolytic and uremic syndrome and related thrombotic microangiopathies: Epidemiology, pathophysiology and clinics]. Rev Med Interne 2017; 38:817-824. [PMID: 28711159 DOI: 10.1016/j.revmed.2017.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 06/01/2017] [Indexed: 01/25/2023]
Abstract
Thrombotic microangiopathies (TMA) represent an eclectic group of conditions, which share hemolytic anemia and thrombocytopenia as a common defining basis. Remarkable breakthroughs in the physiopathological setting have allowed for a thorough recomposition of the disparate syndromes, which form the constellation of TMA. In this view, clinicians now discriminate thrombocytopenic thrombotic purpura (TTP) defined by a severe deficiency in ADAMTS13, which is rarely associated with a severe renal involvement and the hemolytic and uremic syndrome (HUS) in which renal impairment is the most prominent clinical feature. HUS can result from toxins stemming from bacterial infections of the digestive tract, alternate complement pathway abnormalities, metabolic or coagulation disorders or, lastly, drug and various toxic compounds. The diverse forms of HUS reflect the insights gained in the understanding of the pathophysiological mechanisms underpinning TMA. In this first part, a broad overview of the epidemiological, physiopathological and clinical aspects of HUS and related TMA syndromes is presented.
Collapse
Affiliation(s)
- C Rafat
- Urgences néphrologiques et transplantation rénale, hôpital Tenon, Assistance publique des Hôpitaux de Paris, Paris, France; Centre national de référence des microangiopathies thrombotiques (CNR-MAT), AP-HP, Paris, France.
| | - P Coppo
- Centre national de référence des microangiopathies thrombotiques (CNR-MAT), AP-HP, Paris, France; Service d'hématologie, hôpital Saint-Antoine, Assistance publique des Hôpitaux de Paris, Paris, France; Unité Inserm UMR 1170, Villejuif, France
| | - F Fakhouri
- Centre national de référence des microangiopathies thrombotiques (CNR-MAT), AP-HP, Paris, France; Service de néphrologie et d'immunologie, unité Inserm UMR 643, centre hospitalo-universitaire de Nantes, Nantes, France
| | - V Frémeaux-Bacchi
- Centre national de référence des microangiopathies thrombotiques (CNR-MAT), AP-HP, Paris, France; Laboratoire d'immunologie, hôpital européen Georges-Pompidou, Assistance publique des Hôpitaux de Paris, Paris, France
| | - C Loirat
- Centre national de référence des microangiopathies thrombotiques (CNR-MAT), AP-HP, Paris, France; Service de néphrologie pédiatrique, hôpital Robert-Debré, Assistance publique des Hôpitaux de Paris, Paris, France
| | - J Zuber
- Centre national de référence des microangiopathies thrombotiques (CNR-MAT), AP-HP, Paris, France; Service de transplantation rénale, unité Inserm UMR_S1163, institut imagine, hôpital Necker, Assistance publique des Hôpitaux de Paris, Paris, France
| | - E Rondeau
- Centre national de référence des microangiopathies thrombotiques (CNR-MAT), AP-HP, Paris, France; Urgences néphrologiques et transplantation rénale, unité Inserm UMR 1155, hôpital Tenon, Assistance publique des Hôpitaux de Paris, Paris, France
| |
Collapse
|
15
|
Kottke-Marchant K. Diagnostic approach to microangiopathic hemolytic disorders. Int J Lab Hematol 2017; 39 Suppl 1:69-75. [DOI: 10.1111/ijlh.12671] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Accepted: 03/03/2017] [Indexed: 01/29/2023]
Affiliation(s)
- K. Kottke-Marchant
- Medical Director Hemostasis and Thrombosis Robert J; Tomsich Pathology and Laboratory Medicine Institute Cleveland Clinic; 9500 Euclid Avenue LL3-1 Cleveland, OH 44195
| |
Collapse
|
16
|
Xiong H, Guo B, Gan Z, Song D, Lu Z, Yi H, Wu Y, Wang Y, Du H. Butyrate upregulates endogenous host defense peptides to enhance disease resistance in piglets via histone deacetylase inhibition. Sci Rep 2016; 6:27070. [PMID: 27230284 PMCID: PMC4882515 DOI: 10.1038/srep27070] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 05/15/2016] [Indexed: 01/05/2023] Open
Abstract
Butyrate has been used to treat different inflammatory disease with positive outcomes, the mechanisms by which butyrate exerts its anti-inflammatory effects remain largely undefined. Here we proposed a new mechanism that butyrate manipulate endogenous host defense peptides (HDPs) which contributes to the elimination of Escherichia coli O157:H7, and thus affects the alleviation of inflammation. An experiment in piglets treated with butyrate (0.2% of diets) 2 days before E. coli O157:H7 challenge was designed to investigate porcine HDP expression, inflammation and E. coli O157:H7 load in feces. The mechanisms underlying butyrate-induced HDP gene expression and the antibacterial activity and bacterial clearance of macrophage 3D4/2 cells in vitro were examined. Butyrate treatment (i) alleviated the clinical symptoms of E. coli O157:H7-induced hemolytic uremic syndrome (HUS) and the severity of intestinal inflammation; (ii) reduced the E. coli O157:H7 load in feces; (iii) significantly upregulated multiple, but not all, HDPs in vitro and in vivo via histone deacetylase (HDAC) inhibition; and (iv) enhanced the antibacterial activity and bacterial clearance of 3D4/2 cells. Our findings indicate that butyrate enhances disease resistance, promotes the clearance of E. coli O157:H7, and alleviates the clinical symptoms of HUS and inflammation, partially, by affecting HDP expression via HDAC inhibition.
Collapse
Affiliation(s)
- Haitao Xiong
- Key Laboratory of Animal Nutrition and Feed Science (Eastern of China), Ministry of Agriculture, College of Animal Sciences, Zhejiang University, Hangzhou, 310058, P.R. China
| | - Bingxiu Guo
- Key Laboratory of Animal Nutrition and Feed Science (Eastern of China), Ministry of Agriculture, College of Animal Sciences, Zhejiang University, Hangzhou, 310058, P.R. China
| | - Zhenshun Gan
- Key Laboratory of Animal Nutrition and Feed Science (Eastern of China), Ministry of Agriculture, College of Animal Sciences, Zhejiang University, Hangzhou, 310058, P.R. China
| | - Deguang Song
- Key Laboratory of Animal Nutrition and Feed Science (Eastern of China), Ministry of Agriculture, College of Animal Sciences, Zhejiang University, Hangzhou, 310058, P.R. China
| | - Zeqing Lu
- Key Laboratory of Animal Nutrition and Feed Science (Eastern of China), Ministry of Agriculture, College of Animal Sciences, Zhejiang University, Hangzhou, 310058, P.R. China
| | - Hongbo Yi
- Key Laboratory of Animal Nutrition and Feed Science (Eastern of China), Ministry of Agriculture, College of Animal Sciences, Zhejiang University, Hangzhou, 310058, P.R. China
| | - Yueming Wu
- Key Laboratory of Animal Nutrition and Feed Science (Eastern of China), Ministry of Agriculture, College of Animal Sciences, Zhejiang University, Hangzhou, 310058, P.R. China
| | - Yizhen Wang
- Key Laboratory of Animal Nutrition and Feed Science (Eastern of China), Ministry of Agriculture, College of Animal Sciences, Zhejiang University, Hangzhou, 310058, P.R. China
| | - Huahua Du
- Key Laboratory of Animal Nutrition and Feed Science (Eastern of China), Ministry of Agriculture, College of Animal Sciences, Zhejiang University, Hangzhou, 310058, P.R. China
| |
Collapse
|
17
|
Kuo KHM, Khan S, Rand ML, Mian HS, Brnjac E, Sandercock LE, Akula I, Julien JP, Pai EF, Chesney AE. EspP, an Extracellular Serine Protease from Enterohemorrhagic E. coli, Reduces Coagulation Factor Activities, Reduces Clot Strength, and Promotes Clot Lysis. PLoS One 2016; 11:e0149830. [PMID: 26934472 PMCID: PMC4775034 DOI: 10.1371/journal.pone.0149830] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Accepted: 02/07/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND EspP (E. coli secreted serine protease, large plasmid encoded) is an extracellular serine protease produced by enterohemorrhagic E. coli (EHEC) O157:H7, a causative agent of diarrhea-associated Hemolytic Uremic Syndrome (D+HUS). The mechanism by which EHEC induces D+HUS has not been fully elucidated. OBJECTIVES We investigated the effects of EspP on clot formation and lysis in human blood. METHODS Human whole blood and plasma were incubated with EspP(WT )at various concentrations and sampled at various time points. Thrombin time (TT), prothrombin time (PT), and activated partial thromboplastin time (aPTT), coagulation factor activities, and thrombelastgraphy (TEG) were measured. RESULTS AND CONCLUSIONS Human whole blood or plasma incubated with EspP(WT) was found to have prolonged PT, aPTT, and TT. Furthermore, human whole blood or plasma incubated with EspP(WT) had reduced activities of coagulation factors V, VII, VIII, and XII, as well as prothrombin. EspP did not alter the activities of coagulation factors IX, X, or XI. When analyzed by whole blood TEG, EspP decreased the maximum amplitude of the clot, and increased the clot lysis. Our results indicate that EspP alters hemostasis in vitro by decreasing the activities of coagulation factors V, VII, VIII, and XII, and of prothrombin, by reducing the clot strength and accelerating fibrinolysis, and provide further evidence of a functional role for this protease in the virulence of EHEC and the development of D+HUS.
Collapse
Affiliation(s)
- Kevin H. M. Kuo
- Division of Medical Oncology and Hematology, University Health Network, Toronto, ON, Canada
- * E-mail:
| | - Shekeb Khan
- Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
- Campbell Family Cancer Research Institute, Ontario Cancer Institute, University Health Network, Toronto, ON, Canada
| | - Margaret L. Rand
- Division of Hematology, Hospital for Sick Children, Toronto, ON, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
- Department of Biochemistry, University of Toronto, Toronto, ON, Canada
| | - Hira S. Mian
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Elena Brnjac
- Department of Clinical Pathology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Linda E. Sandercock
- Campbell Family Cancer Research Institute, Ontario Cancer Institute, University Health Network, Toronto, ON, Canada
| | - Indira Akula
- Program in Molecular Structure and Function, The Hospital for Sick Children Research Institute, Toronto, ON, Canada
| | - Jean-Philippe Julien
- Department of Biochemistry, University of Toronto, Toronto, ON, Canada
- Program in Molecular Structure and Function, The Hospital for Sick Children Research Institute, Toronto, ON, Canada
- Department of Immunology, University of Toronto, Toronto, ON, Canada
| | - Emil F. Pai
- Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
- Campbell Family Cancer Research Institute, Ontario Cancer Institute, University Health Network, Toronto, ON, Canada
- Department of Biochemistry, University of Toronto, Toronto, ON, Canada
- Department of Molecular Genetics, University of Toronto, Toronto, ON, Canada
| | - Alden E. Chesney
- Department of Clinical Pathology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| |
Collapse
|
18
|
Abstract
Enterohemorrhagic Escherichia coli (EHEC) is a highly pathogenic bacterial strain capable of causing watery or bloody diarrhea, the latter termed hemorrhagic colitis, and hemolytic-uremic syndrome (HUS). HUS is defined as the simultaneous development of non-immune hemolytic anemia, thrombocytopenia, and acute renal failure. The mechanism by which EHEC bacteria colonize and cause severe colitis, followed by renal failure with activated blood cells, as well as neurological symptoms, involves the interaction of bacterial virulence factors and specific pathogen-associated molecular patterns with host cells as well as the host response. The innate immune host response comprises the release of antimicrobial peptides as well as cytokines and chemokines in addition to activation and/or injury to leukocytes, platelets, and erythrocytes and activation of the complement system. Some of the bacterial interactions with the host may be protective in nature, but, when excessive, contribute to extensive tissue injury, inflammation, and thrombosis, effects that may worsen the clinical outcome of EHEC infection. This article describes aspects of the host response occurring during EHEC infection and their effects on specific organs.
Collapse
|
19
|
Abstract
Shiga toxin (Stx) is the primary cause of severe host responses including renal and central nervous system (CNS) disease in Shiga toxin-producing E. coli (STEC) infections. The interaction of Stx with different eukaryotic cell types is described. Host responses to Stx and bacterial lipopolysaccharide (LPS) are compared as related to the features of the STEC-associated Hemolytic Uremic Syndrome (HUS). Data derived from animal models of HUS and CNS disease, in vivo, and eukaryotic cells, in vitro, are evaluated in relation to HUS disease of humans.
Collapse
|
20
|
Benz R. Channel formation by RTX-toxins of pathogenic bacteria: Basis of their biological activity. BIOCHIMICA ET BIOPHYSICA ACTA-BIOMEMBRANES 2015; 1858:526-37. [PMID: 26523409 DOI: 10.1016/j.bbamem.2015.10.025] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 10/10/2015] [Accepted: 10/28/2015] [Indexed: 12/15/2022]
Abstract
The pore-forming cytolysins of the RTX-toxin (Repeats in ToXin) family are a relatively small fraction of a steadily increasing family of proteins that contain several functionally important glycine-rich and aspartate containing nonapeptide repeats. These cytolysins produced by a variety of Gram-negative bacteria form ion-permeable channels in erythrocytes and other eukaryotic cells. Hemolytic and cytolytic RTX-toxins represent pathogenicity factors of the toxin-producing bacteria and are very often important key factors in pathogenesis of the bacteria. Channel formation by RTX-toxins lead to the dissipation of ionic gradients and membrane potential across the cytoplasmic membrane of target cells, which results in cell death. Here we discuss channel formation and channel properties of some of the best known RTX-toxins, such as α-hemolysin (HlyA) of Escherichia coli and the uropathogenic EHEC strains, the adenylate cyclase toxin (ACT, CyaA) of Bordetella pertussis and the RTX-toxins (ApxI, ApxII and ApxIII) produced by different strains of Actinobacillus pleuropneumoniae. The channels formed by these RTX-toxins in lipid bilayers share some common properties such as cation selectivity and voltage-dependence. Furthermore the channels are transient and show frequent switching between different ion-conducting states. This article is part of a Special Issue entitled: Pore-Forming Toxins edited by Mauro Dalla Serra and Franco Gambale.
Collapse
Affiliation(s)
- Roland Benz
- Department of Life Sciences and Chemistry, Jacobs University, Campus Ring 1, 28759, Bremen, Germany.
| |
Collapse
|
21
|
Chromek M. The role of the antimicrobial peptide cathelicidin in renal diseases. Pediatr Nephrol 2015; 30:1225-32. [PMID: 25159719 DOI: 10.1007/s00467-014-2895-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Revised: 06/17/2014] [Accepted: 06/23/2014] [Indexed: 12/18/2022]
Abstract
The balance between the human body and surrounding microorganisms is crucial for homeostasis and health. A disturbance in host-pathogen interactions causes disease. Two important diseases of the kidney and urinary tract are directly caused by bacteria or bacterial toxins: urinary tract infection (UTI) and diarrhea-associated hemolytic uremic syndrome (HUS). In the majority of cases, UTIs are caused by bacteria ascending from the perineum through the urethra to the urinary tract. In contrast, HUS is caused by non-invasive bacteria, such as enterohemorrhagic Escherichia coli, which colonize the gut and do not enter the blood stream. In this latter case, the bacteria release Shiga toxin, which binds to blood cells and thus reaches the target organs, mainly kidneys. Interactions between Shiga toxin, blood cells and endothelial cells in the kidney lead to cell apoptosis and inflammation. Innate immunity and the antimicrobial peptide cathelicidin seem to play important roles in the pathogenesis of both UTI and HUS. Moreover, influencing cathelicidin production and release might offer new therapeutic and prophylactic strategies for both diseases.
Collapse
Affiliation(s)
- Milan Chromek
- Paediatric Nephrology Unit, Astrid Lindgren Children's Hospital, Karolinska University Hospital Huddinge, B57, SE-14186, Stockholm, Sweden,
| |
Collapse
|
22
|
Doulgere J, Otto B, Nassour M, Wolters-Eisfeld G, Rohde H, Magnus T, Wagener C, Streichert T. Soluble plasma VE-cadherin concentrations are elevated in patients with STEC infection and haemolytic uraemic syndrome: a case-control study. BMJ Open 2015; 5:e005659. [PMID: 25757942 PMCID: PMC4360836 DOI: 10.1136/bmjopen-2014-005659] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES To investigate whether the adherens junction protein vascular endothelial cadherin (VE-cadherin) is released during Shiga toxin 2 producing Escherichia coli (STEC) infection with haemolytic uraemic syndrome (HUS) and thus could be used to assist diagnosis. DESIGN Using data from the large 2011 STEC outbreak in northern Europe, we determined VE-cadherin plasma concentrations in 356 patients distributed over three patient cohorts: patients with STEC infection accompanied by HUS (STEC-HUS), STEC patients without HUS (STEC) and control patients with diarrhoea but without STEC infection. We then looked for associations between VE-cadherin concentrations and disease severity defined by changes in lactate dehydrogenase, haemoglobin, creatinine, platelet count, haptoglobin and neurological symptoms. SETTING This study was conducted at the University Medical Center Hamburg-Eppendorf, Germany. PARTICIPANTS 79 STEC-HUS patients, 77 STEC patients and 200 control patients were enrolled in the study. RESULTS We analysed 864 specimens (207 STEC, 449 STEC-HUS and 208 controls) in total. At admission, VE-cadherin concentration tended to be lower in STEC-HUS patients compared to other patients. However, HUS patients later showed an increase in VE-cadherin concentrations with prolonged elevation beyond remission. This pattern clearly differs from that observed in non-HUS patients. CONCLUSIONS VE-cadherin concentrations are elevated in STEC-HUS patients and might be a biomarker reflecting endothelial damage in patients with HUS.
Collapse
Affiliation(s)
- Julia Doulgere
- Department of Clinical Chemistry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Benjamin Otto
- Department of Clinical Chemistry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maher Nassour
- Department of Clinical Chemistry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gerrit Wolters-Eisfeld
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Holger Rohde
- Department of Medical Microbiology, Virology and Hygiene, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tim Magnus
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christoph Wagener
- Department of Clinical Chemistry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Streichert
- Department of Clinical Chemistry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Clinical Chemistry, University Hospital Cologne, Cologne, Germany
| |
Collapse
|
23
|
Suyama K, Kawasaki Y, Miyazaki K, Kanno S, Ono A, Ohara S, Sato M, Hosoya M. The efficacy of recombinant human soluble thrombomodulin for the treatment of shiga toxin-associated hemolytic uremic syndrome model mice. Nephrol Dial Transplant 2015; 30:969-77. [PMID: 25694534 DOI: 10.1093/ndt/gfv004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Accepted: 12/24/2014] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Recombinant human soluble thrombomodulin (rhTM) is a promising therapeutic natural anticoagulant that is comparable to antithrombin, tissue factor pathway inhibitor and activated protein C. In order to clarify the efficacy of rhTM for the treatment of typical hemolytic uremic syndrome (t-HUS), we examined changes in renal damage in t-HUS mice treated with rhTM or vehicle alone. METHODS We used severe and moderate t-HUS mice injected with shiga toxin (Stx) and lipopolysaccharide (LPS). The severe t-HUS mice were divided into two subgroups [an rhTM subgroup (Group A) and a saline subgroup (Group B)] along with the moderate t-HUS mice [an rhTM subgroup (Group C) and a saline subgroup (Group D)]. Groups E and F were healthy mice treated with rhTM or saline, respectively. RESULTS All mice in Group B died at 80-90 h post-administration of Stx2 and LPS whereas all mice in Group A remained alive. Loss of body weight, serum creatinine level, endothelial injury and mesangiolysis scores at 24 h after administration in the t-HUS mice treated with rhTM were lower than those in t-HUS mice treated with saline. The levels of hemoglobin at 6 h and platelet counts at 24 h after administration in Group A were higher than those in Group B. Serum interleukin (IL)-6, IL-1β and tumor necrotic factor (TNF)-α levels at 24 h after administration in Group A were lower than those in Group B. Serum C5b-9 levels at 24 h after the administration and serum fibrinogen degradation product (FDP) at 72 h after the administration of Stx2 and LPS were lower in Group A than in Group B. CONCLUSIONS These results indicate that rhTM might afford an efficacious treatment for t-HUS model mice via the inhibition of further thrombin formation and amelioration of hypercoagulant status.
Collapse
Affiliation(s)
- Kazuhide Suyama
- Department of Pediatrics, Fukushima Medical University School of Medicine, Fukushima City, Fukushima, Japan
| | - Yukihiko Kawasaki
- Department of Pediatrics, Fukushima Medical University School of Medicine, Fukushima City, Fukushima, Japan
| | - Kyohei Miyazaki
- Department of Pediatrics, Fukushima Medical University School of Medicine, Fukushima City, Fukushima, Japan
| | - Syuto Kanno
- Department of Pediatrics, Fukushima Medical University School of Medicine, Fukushima City, Fukushima, Japan
| | - Atsushi Ono
- Department of Pediatrics, Fukushima Medical University School of Medicine, Fukushima City, Fukushima, Japan
| | - Shinichiro Ohara
- Department of Pediatrics, Fukushima Medical University School of Medicine, Fukushima City, Fukushima, Japan
| | - Masatoki Sato
- Department of Pediatrics, Fukushima Medical University School of Medicine, Fukushima City, Fukushima, Japan
| | - Mitsuaki Hosoya
- Department of Pediatrics, Fukushima Medical University School of Medicine, Fukushima City, Fukushima, Japan
| |
Collapse
|
24
|
Hemolysin of enterohemorrhagic Escherichia coli: Structure, transport, biological activity and putative role in virulence. Int J Med Microbiol 2014; 304:521-9. [DOI: 10.1016/j.ijmm.2014.05.005] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Revised: 05/09/2014] [Accepted: 05/11/2014] [Indexed: 11/19/2022] Open
|
25
|
Kawasaki Y, Suyama K, Maeda R, Yugeta E, Takano K, Suzuki S, Sakuma H, Nemoto K, Sato T, Nagasawa K, Hosoya M. Incidence and index of severity of hemolytic uremic syndrome in a 26 year period in Fukushima Prefecture, Japan. Pediatr Int 2014; 56:77-82. [PMID: 23937579 DOI: 10.1111/ped.12193] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Revised: 07/09/2013] [Accepted: 07/31/2013] [Indexed: 12/25/2022]
Abstract
BACKGROUND There have been a number of reports on large outbreaks of hemolytic uremic syndrome (HUS), but there have been no long-term studies of sporadic HUS in Japan. This study therefore investigated the epidemiology and prognosis of HUS in Fukushima Prefecture over a 26 year period. METHODS The medical records of 26 patients with HUS between 1987 and 2012 were collected. These children were divided into two groups: those with HUS following an episode of gastroenteritis, often with bloody diarrhea (D + HUS; n = 24) and those with HUS not associated with prodromal diarrhea (D-HUS; n = 2). The D + HUS group was further subdivided into group A (11 patients requiring dialysis) and group B (13 patients not requiring dialysis). The epidemiological and clinical data, as well as prognosis, were retrospectively investigated for each group. RESULTS Approximately 90% of HUS patients belonged to the D + HUS group. In this group, the mean number of patients per year from 1987 to 1999, and from 2000 to 2012 was 0.92 ± 0.95, and 1.08 ± 0.86, respectively. On admission, lactate dehydrogenase (LDH), alanine aminotransferase (ALT), blood urea nitrogen (BUN), serum creatinine and serum fibrinogen degradation product (FDP) levels in group A were all higher than in group B. Serum albumin level and estimated glomerular filtration rate (eGFR) in group A were lower than in group B. At 6 months after the onset of HUS in the D + HUS group, renal function was normal. CONCLUSIONS The frequency of HUS was constant from 1987 to 2012 in Fukushima. and serum LDH, ALT, BUN, creatinine, and FDP levels as well as eGFR might be risk factors for dialysis in D + HUS children.
Collapse
Affiliation(s)
- Yukihiko Kawasaki
- Department of Pediatrics, Fukushima Medical University School of Medicine, Fukushima, Japan
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Abstract
The thrombotic microangiopathies include both hemolytic uremic syndrome (HUS) and thrombotic thrombocytopenic purpura (TTP). Although debate exists as to whether these are separate entities or a spectrum of disease, both result in the clinical picture of thrombocytopenia, hemolytic anemia, and varying degrees of renal and neurologic involvement. Etiology of HUS includes diarrheal infection due to Shiga toxin-producing bacteria, complement deficiency, pneumococcal infection, and cobalamin deficiency. In disease ascribed to TTP, the main etiologic factor is deficiency of an enzyme known as a disintegrin-like and metalloprotease with thrombospondin type 1 repeats, number 13 (ADAMTS-13). The clinical manifestations may vary, but neurologic involvement can be significant, with reports of hypertensive encephalopathy, seizures, thrombosis and infarct. In nondiarrheal forms of disease, recurrence may occur and clinical diagnosis is essential in order to provide a targeted therapy for the suspected etiology. Therapies include supportive care, cobalamin supplementation, as well as plasma infusion and exchange. End stage renal disease may result and transplantation is curative for some forms of the disease. More recent research focuses on targeted immunotherapy to prevent autoantibody prevention. As of yet, there is no one cure for these potentially devastating diseases, and diagnosis and treatment selection presents a challenge to the clinician.
Collapse
Affiliation(s)
- Kathleen Webster
- Department of Pediatrics, Loyola University Medical Center, Maywood, IL, USA.
| | - Eugene Schnitzler
- Department of Neurology, Loyola University Medical Center, Maywood, IL, USA
| |
Collapse
|
27
|
Lukasz A, Beneke J, Menne J, Vetter F, Schmidt BMW, Schiffer M, Haller H, Kümpers P, Kielstein JT. Serum neutrophil gelatinase-associated lipocalin (NGAL) in patients with Shiga toxin mediated haemolytic uraemic syndrome (STEC-HUS). Thromb Haemost 2013; 111:365-72. [PMID: 24172823 DOI: 10.1160/th13-05-0387] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Accepted: 09/27/2013] [Indexed: 02/07/2023]
Abstract
Neutrophil gelatinase-associated lipocalin (NGAL) is an increasingly used biomarker for acute kidney injury (AKI). Its utility in adult patients with AKI caused by Shiga toxin producing Escherichia coli infection (STEC)-associated haemolytic-uraemic syndrome (HUS), remains unknown. We aimed to evaluate the prognostic value of serum NGAL admission levels for the need of renal replacement therapy (RRT) in STEC-HUS patients. Baseline serum NGAL was determined by ELISA in 39 patients with STEC O104:H4 infection cared for at Hannover Medical School during the outbreak in Germany through May-July 2011. Patients with HUS had significant higher NGAL levels than healthy controls (379 [248 - 540] vs 39.0 [37.5-45] ng/ml, p < 0.0001). During clinical course, 24 patients required RRT at a median of five days after admission. NGAL admission levels were higher in patients requiring RRT (476 (344-639) ng/ml) compared to patients not requiring RRT (257 (196-426) ng/ml; p < 0.001). Unadjusted and adjusted logistic regression analyses identified NGAL as an independent predictor for need of RRT. In a combined model, a joint NGAL/AKIN classification approach improved the predictive accuracy for need of RRT over either marker alone. The combined categorical cut-off point defined by NGAL ≥ 330 ng/ml and presence of AKI (AKIN ≥ I) on admission correctly identified 20 of 24 patients requiring RRT (odds ratio 20, sensitivity 83%, specificity 80%, negative predictive value 75%, positive predictive value 87%). NGAL may serve as an adjunctive tool to improve risk prediction in patients with STEC-HUS.
Collapse
Affiliation(s)
- Alexander Lukasz
- Alexander Lukasz, MD, Department of Medicine D, Division of General Internal Medicine, Nephrology, and Rheumatology, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany, Tel.: +49 251 8347516, Fax: +49 251 8346979, E-mail:
| | | | | | | | | | | | | | | | | |
Collapse
|
28
|
Kawasaki Y, Suyama K, Ono A, Oikawa T, Ohara S, Suzuki Y, Sakai N, Hosoya M. Efficacy of recombinant human soluble thrombomodulin for childhood hemolytic uremic syndrome. Pediatr Int 2013; 55:e139-42. [PMID: 24134770 DOI: 10.1111/ped.12165] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Revised: 06/03/2013] [Accepted: 06/14/2013] [Indexed: 12/01/2022]
Abstract
Recombinant human soluble thrombomodulin (rhTM) is a promising therapeutic natural anticoagulant and is used clinically for the treatment of disseminated intravascular coagulation (DIC). Herein is reported the cases of two HUS children treated with rhTM. The patients were diagnosed as having typical HUS on the basis of thrombocytopenia, hemolytic anemia, acute renal failure, and the detection Escherichia coli 0157. I.v. rhTM was started as an anti-coagulant drug. At 2 days after the first treatment in both patients, fibrin/fibrinogen degradation products and d-dimer levels were significantly decreased, and there was a subsequent slight improvement in thrombocytopenia, and a decrease in serum lactate dehydrogenase level. Urinary protein excretion gradually diminished and a decrease in serum creatinine level was observed. The patients did not require dialysis therapy. The present results suggest that rhTM may be a safe and effective treatment for DIC complicated with HUS in children.
Collapse
Affiliation(s)
- Yukihiko Kawasaki
- Department of Pediatrics, Fukushima Medical University School of Medicine, Fukushima, Japan
| | | | | | | | | | | | | | | |
Collapse
|
29
|
Szilágyi A, Kiss N, Bereczki C, Tálosi G, Rácz K, Túri S, Györke Z, Simon E, Horváth E, Kelen K, Reusz GS, Szabó AJ, Tulassay T, Prohászka Z. The role of complement in Streptococcus pneumoniae-associated haemolytic uraemic syndrome. Nephrol Dial Transplant 2013; 28:2237-45. [PMID: 23787556 DOI: 10.1093/ndt/gft198] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Atypical forms of haemolytic uraemic syndrome (aHUS) include HUS caused by defects in the regulation of alternative complement pathway and HUS linked to neuraminidase-producing pathogens, such as Streptococcus pneumoniae. Increasing data support a pathogenic role of neuraminidase in the development of S. pneumoniae-associated haemolytic uraemic syndrome (SP-HUS), but the role of complement has never been clarified in detail. Therefore, we aimed to investigate whether the pathologic complement profile and genetic risk factors of aHUS are present in patients with SP-HUS. METHODS Enrolling five patients with SP-HUS classical and alternative pathway activity, besides C3, C4, factors H, B, I and anti-factor H autoantibody levels were determined. The coding regions of CFH, CFI, CD46 (MCP), THBD, C3 and CFB genes were sequenced and the copy number of CFI, CD46, CFH and related genes were also analyzed. RESULTS We found that in the acute phase samples of SP-HUS patients, complement components C4, C3 and activity of the classical and alternative pathways were decreased, indicating severe activation and complement consumption, but most of these alterations normalized later in remission. Three of the patients carried mutations and risk haplotypes in complement-mediated aHUS associated genes. The identified mutations include a previously published CFI variant (P50A) and two novel ones in CFH (R1149X) and THBD (T44I) genes. CONCLUSIONS Our results suggest that severe complement dysregulation and consumption accompany the progress of invasive pneumococcal disease (IPD)-associated SP-HUS and genetic variations of complement genes may contribute to the development of this complication in a proportion of the affected patients.
Collapse
Affiliation(s)
- Agnes Szilágyi
- 3rd Department of Medicine, Research Laboratory, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
30
|
Burlaka I, Liu XL, Rebetz J, Arvidsson I, Yang L, Brismar H, Karpman D, Aperia A. Ouabain protects against Shiga toxin-triggered apoptosis by reversing the imbalance between Bax and Bcl-xL. J Am Soc Nephrol 2013; 24:1413-23. [PMID: 23744887 DOI: 10.1681/asn.2012101044] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Hemolytic uremic syndrome, a life-threatening disease often accompanied by acute renal failure, usually occurs after gastrointestinal infection with Shiga toxin 2 (Stx2)-producing Escherichia coli. Stx2 binds to the glycosphingolipid globotriaosylceramide receptor, expressed by renal epithelial cells, and triggers apoptosis by activating the apoptotic factor Bax. Signaling via the ouabain/Na,K-ATPase/IP3R/NF-κB pathway increases expression of Bcl-xL, an inhibitor of Bax, suggesting that ouabain might protect renal cells from Stx2-triggered apoptosis. Here, exposing rat proximal tubular cells to Stx2 in vitro resulted in massive apoptosis, upregulation of the apoptotic factor Bax, increased cleaved caspase-3, and downregulation of the survival factor Bcl-xL; co-incubation with ouabain prevented all of these effects. Ouabain activated the NF-κB antiapoptotic subunit p65, and the inhibition of p65 DNA binding abolished the antiapoptotic effect of ouabain in Stx2-exposed tubular cells. Furthermore, in vivo, administration of ouabain reversed the imbalance between Bax and Bcl-xL in Stx2-treated mice. Taken together, these results suggest that ouabain can protect the kidney from the apoptotic effects of Stx2.
Collapse
Affiliation(s)
- Ievgeniia Burlaka
- Department of Women's and Children's Health, Karolinska Institutet, Astrid Lindgren Children's Hospital, Research Lab, Stockholm, Sweden
| | | | | | | | | | | | | | | |
Collapse
|
31
|
Secondary, profound, sensorineural hearing loss after recovery from haemolytic uraemic syndrome due to enterohaemorrhagic Escherichia coli, and subsequent cochlear implantation, in two Japanese children. The Journal of Laryngology & Otology 2013; 127:306-10. [PMID: 23406716 DOI: 10.1017/s0022215113000145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES To describe two cases of profound hearing loss secondary to enterohaemorrhagic Escherichia coli infection, and to report the efficacy of subsequent cochlear implantation. RESULTS The first case was a four-year-old girl admitted to hospital with Escherichia coli O157 infection and haemolytic uraemic syndrome. Mild hearing loss was confirmed five months after discharge, progressing to profound loss three months later. At the age of seven years, she underwent cochlear implantation, with remarkable improvement in speech perception and production. The second case was a three-year-old boy admitted with haemolytic uraemic syndrome caused by Escherichia coli O111 infection. One year after disease onset, profound hearing loss was confirmed. Cochlear implantation at the age of five years produced significant recovery of auditory function. CONCLUSION This study represents the first published report of secondary hearing loss after recovery from haemolytic uraemic syndrome caused by enterohaemorrhagic Escherichia coli. It indicates that cochlear implantation can restore hearing function in such patients.
Collapse
|
32
|
Karpman D, Tati R. Complement activation in thrombotic microangiopathy. Hamostaseologie 2013; 33:96-104. [PMID: 23411690 DOI: 10.5482/hamo-12-12-0025] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2012] [Accepted: 01/23/2013] [Indexed: 01/01/2023] Open
Abstract
The endothelium lining the vascular lumen is continuously exposed to complement from the circulation. When erroneously activated on host cells, complement may generate a deleterious effect on the vascular wall leading to endothelial injury, exposure of the subendothelial matrix and platelet activation. In this review the contribution of complement activation to formation and maintenance of the pathological lesion termed thrombotic microangiopathy (TMA) is discussed. TMA is defined by vessel wall thickening affecting mainly arterioles and capillaries, detachment of the endothelial cell from the basement membrane and intraluminal thrombosis resulting in occlusion of the vessel lumen. The TMA lesion occurs in haemolytic uraemic syndrome (HUS) and thrombotic thrombocytopenic purpura (TTP). HUS is further sub-classified as associated with Shiga toxin-producing Escherichia coli (STEC-HUS) or with complement dysregulation (atypical HUS) as well as other less common forms. The contribution of dysregulated complement activation to endothelial injury and platelet aggregation is reviewed as well as specific complement involvement in the development of HUS and TTP.
Collapse
Affiliation(s)
- D Karpman
- Department of Paediatrics, Clinical Sciences Lund, Lund University, Lund, Sweden.
| | | |
Collapse
|
33
|
Bauwens A, Betz J, Meisen I, Kemper B, Karch H, Müthing J. Facing glycosphingolipid-Shiga toxin interaction: dire straits for endothelial cells of the human vasculature. Cell Mol Life Sci 2013; 70:425-57. [PMID: 22766973 PMCID: PMC11113656 DOI: 10.1007/s00018-012-1060-z] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Revised: 05/25/2012] [Accepted: 06/14/2012] [Indexed: 12/23/2022]
Abstract
The two major Shiga toxin (Stx) types, Stx1 and Stx2, produced by enterohemorrhagic Escherichia coli (EHEC) in particular injure renal and cerebral microvascular endothelial cells after transfer from the human intestine into the circulation. Stxs are AB(5) toxins composed of an enzymatically active A subunit and the pentameric B subunit, which preferentially binds to the glycosphingolipid globotriaosylceramide (Gb3Cer/CD77). This review summarizes the current knowledge on Stx-caused cellular injury and the structural diversity of Stx receptors as well as the initial molecular interaction of Stxs with the human endothelium of different vascular beds. The varying lipoforms of Stx receptors and their spatial organization in lipid rafts suggest a central role in different modes of receptor-mediated endocytosis and intracellular destiny of the toxins. The design and development of tailored Stx neutralizers targeting the oligosaccharide-toxin recognition event has become a very real prospect to ameliorate or prevent life-threatening renal and neurological complications.
Collapse
Affiliation(s)
- Andreas Bauwens
- Institute for Hygiene, University of Münster, Robert-Koch-Str. 41, 48149 Münster, Germany
| | - Josefine Betz
- Institute for Hygiene, University of Münster, Robert-Koch-Str. 41, 48149 Münster, Germany
| | - Iris Meisen
- Institute for Hygiene, University of Münster, Robert-Koch-Str. 41, 48149 Münster, Germany
- Interdisciplinary Center for Clinical Research, University of Münster, Domagkstr. 3, 48149 Münster, Germany
| | - Björn Kemper
- Center for Biomedical Optics and Photonics, University of Münster, Robert-Koch-Str. 45, 48149 Münster, Germany
| | - Helge Karch
- Institute for Hygiene, University of Münster, Robert-Koch-Str. 41, 48149 Münster, Germany
| | - Johannes Müthing
- Institute for Hygiene, University of Münster, Robert-Koch-Str. 41, 48149 Münster, Germany
- Interdisciplinary Center for Clinical Research, University of Münster, Domagkstr. 3, 48149 Münster, Germany
| |
Collapse
|
34
|
Abstract
Hemolytic uremic syndromes can have devastating consequences in childhood. The common feature of a microangiopathic hemolytic anemia and thrombocytopenia associated with varying degrees of renal injury often creates diagnostic confusion. The inability to arrive at a definitive diagnosis quickly can lead to a delay in initiating renal-preserving and sometimes life-saving treatment. Currently, both the treatment plan and the prognosis vary substantially according to the presumed diagnosis. The availability of anti-complement therapy makes differentiating the cause of the hemolytic uremic syndrome particularly critical. Therefore, it is imperative that consideration be given to each of the possible syndromes at presentation in order to facilitate correct diagnosis and development of an appropriate treatment strategy for both the acute phase and for the long-term care of the patient.
Collapse
Affiliation(s)
- Carla M Nester
- Departments of Internal Medicine and Pediatrics, Rare Renal Disease Clinic, University of Iowa, Iowa City, IA 52242-1081, USA.
| |
Collapse
|
35
|
Chromek M, Arvidsson I, Karpman D. The antimicrobial peptide cathelicidin protects mice from Escherichia coli O157:H7-mediated disease. PLoS One 2012; 7:e46476. [PMID: 23077510 PMCID: PMC3471911 DOI: 10.1371/journal.pone.0046476] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2012] [Accepted: 08/30/2012] [Indexed: 12/16/2022] Open
Abstract
This study investigated the role of the antimicrobial peptide cathelicidin in Escherichia coli O157:H7 infection and subsequent renal damage. Mouse and human cathelicidin, CRAMP and LL-37, respectively, killed E. coli O157:H7 in vitro. Intestines from healthy wild-type (129/SvJ) and cathelicidin-knock-out (Camp−/−) mice were investigated, showing that cathelicidin-deficient mice had a thinner colonic mucus layer compared with wild-type mice. Wild-type (n = 11) and cathelicidin-knock-out (n = 11) mice were inoculated with E. coli O157:H7. Cathelicidin-deficient animals exhibited higher fecal counts of E. coli O157:H7 and bacteria penetrated the mucus forming attaching-and-effacing lesions to a much higher extent than in wild-type animals. Cathelicidin knock-out mice developed symptoms (9/11) as well as anemia, thrombocytopenia and extensive renal tubular damage while all cathelicidin-producing mice remained asymptomatic with normal laboratory findings. When injected with Shiga toxin intraperitoneally, both murine strains developed the same degree of renal tubular damage and clinical disease indicating that differences in sensitivity to infection between the murine strains were related to the initial intestinal response. In conclusion, cathelicidin substantially influenced the antimicrobial barrier in the mouse colon mucosa. Cathelicidin deficiency lead to increased susceptibility to E. coli O157:H7 infection and subsequent renal damage. Administration of cathelicidin or stimulation of endogenous production may prove to be novel treatments for E. coli O157:H7-induced hemolytic uremic syndrome.
Collapse
Affiliation(s)
| | | | - Diana Karpman
- Department of Pediatrics, Clinical Sciences Lund, Lund University, Lund, Sweden
- * E-mail:
| |
Collapse
|
36
|
Lorenzen JM, Menne J, Schmidt BMW, Schmidt M, Martino F, Dietrich R, Samiri S, Worthmann H, Heeren M, Weissenborn K, Haller H, Schiffer M, Kielstein JT, Thum T. Circulating microRNAs in patients with Shiga-Toxin-producing E. coli O104:H4 induced hemolytic uremic syndrome. PLoS One 2012; 7:e47215. [PMID: 23071762 PMCID: PMC3469502 DOI: 10.1371/journal.pone.0047215] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2012] [Accepted: 09/10/2012] [Indexed: 11/18/2022] Open
Abstract
Background In early May 2011, an outbreak of hemorrhagic colitis associated with hemolytic–uremic syndrome (HUS) first developed in Northern Germany and spread to 15 other countries in Europe. The outbreak-strain O104:H4, which combined virulence factors of typical enteroaggregative and Shiga-Toxin–producing E. coli was associated with an unusual high rate of hemolytic uremic syndrome. Also an unexpected high rate of coma and seizures leading to mechanical ventilation and ICU treatment was observed. MicroRNAs are small ribonucleotides orchestrating gene expression. We tested whether circulating microRNAs in serum of HUS patients during the 2011 epidemics are altered in this patient cohort and related to clinical manifestations. Methodology/Principal Findings We profiled microRNAs using RNA isolated from serum of patients and healthy age-matched controls. The results were validated in 38 patients at baseline, 29 patients during follow-up and 21 age-matched healthy controls by miRNA-specific quantitative RT-PCR. Circulating levels of miR-24, miR-126 were increased in HUS patients versus controls. There was no association between these microRNAs and renal function or the need for renal replacement therapy. In contrast, levels of miR-126 were associated with neurological symptoms at baseline and during follow-up. In addition, miR-126 (on admission) and miR-24 (on admission and during follow-up) were associated with platelet count. Conclusions/Significance Circulating microRNAs are strongly altered in this patient cohort and associated with neurological symptoms as well as platelet count.
Collapse
Affiliation(s)
- Johan M. Lorenzen
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS), Hannover, Germany
- Division of Nephrology and Hypertension, Department of Medicine, Hanover Medical School, Hannover, Germany
- * E-mail: (JML); (TT)
| | - Jan Menne
- Division of Nephrology and Hypertension, Department of Medicine, Hanover Medical School, Hannover, Germany
| | - Bernhard MW. Schmidt
- Division of Nephrology and Hypertension, Department of Medicine, Hanover Medical School, Hannover, Germany
| | - Mascha Schmidt
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS), Hannover, Germany
| | - Filippo Martino
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS), Hannover, Germany
| | - Robert Dietrich
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS), Hannover, Germany
- Division of Nephrology and Hypertension, Department of Medicine, Hanover Medical School, Hannover, Germany
| | - Senguel Samiri
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS), Hannover, Germany
- Division of Nephrology and Hypertension, Department of Medicine, Hanover Medical School, Hannover, Germany
| | - Hans Worthmann
- Department of Neurology, Hanover Medical School, Hannover, Germany
| | - Meike Heeren
- Department of Neurology, Hanover Medical School, Hannover, Germany
| | | | - Hermann Haller
- Division of Nephrology and Hypertension, Department of Medicine, Hanover Medical School, Hannover, Germany
| | - Mario Schiffer
- Division of Nephrology and Hypertension, Department of Medicine, Hanover Medical School, Hannover, Germany
| | - Jan T. Kielstein
- Division of Nephrology and Hypertension, Department of Medicine, Hanover Medical School, Hannover, Germany
| | - Thomas Thum
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS), Hannover, Germany
- Centre for Clinical and Basic Research, IRCCS San Raffaele, Rome, Italy
- * E-mail: (JML); (TT)
| |
Collapse
|
37
|
Barbour T, Johnson S, Cohney S, Hughes P. Thrombotic microangiopathy and associated renal disorders. Nephrol Dial Transplant 2012; 27:2673-85. [PMID: 22802583 PMCID: PMC3398067 DOI: 10.1093/ndt/gfs279] [Citation(s) in RCA: 136] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2012] [Accepted: 04/07/2012] [Indexed: 12/17/2022] Open
Abstract
Thrombotic microangiopathy (TMA) is a pathological process involving thrombocytopenia, microangiopathic haemolytic anaemia and microvascular occlusion. TMA is common to haemolytic uraemic syndrome (HUS) associated with shiga toxin or invasive pneumococcal infection, atypical HUS (aHUS), thrombotic thrombocytopenic purpura (TTP) and other disorders including malignant hypertension. HUS complicating infection with shiga toxin-producing Escherichia coli (STEC) is a significant cause of acute renal failure in children worldwide, occurring sporadically or in epidemics. Studies in aHUS have revealed genetic and acquired factors leading to dysregulation of the alternative complement pathway. TTP has been linked to reduced activity of the ADAMTS13 cleaving protease (typically with an autoantibody to ADAMTS13) with consequent disruption of von Willebrand factor multimer processing. However, the convergence of pathogenic pathways and clinical overlap create diagnostic uncertainty, especially at initial presentation. Furthermore, recent developments are challenging established management protocols. This review addresses the current understanding of molecular mechanisms underlying TMA, relating these to clinical presentation with an emphasis on renal manifestations. A diagnostic and therapeutic approach is presented, based on international guidelines, disease registries and published trials. Early treatment remains largely empirical, consisting of plasma replacement/exchange with the exception of childhood STEC-HUS or pneumococcal sepsis. Emerging therapies such as the complement C5 inhibitor eculizumab for aHUS and rituximab for TTP are discussed, as is renal transplantation for those patients who become dialysis-dependent as a result of aHUS.
Collapse
Affiliation(s)
- Thomas Barbour
- Imperial College, Centre for Complement and Inflammation Research, London, UK.
| | | | | | | |
Collapse
|
38
|
Malina M, Roumenina LT, Seeman T, Le Quintrec M, Dragon-Durey MA, Schaefer F, Fremeaux-Bacchi V. Genetics of hemolytic uremic syndromes. Presse Med 2012; 41:e105-14. [PMID: 22265161 DOI: 10.1016/j.lpm.2011.10.028] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Accepted: 10/20/2011] [Indexed: 12/25/2022] Open
Abstract
Hemolytic uremic syndrome (HUS) is a very rare disease (two cases per year per 1 million population) but represents the most common cause of acute renal failure in young children that require dialysis. The majority of cases in childhood (90%) is caused by Shiga toxin producing Escherichia coli infection. This typical form of the disease does not relapse and has a good prognosis if the acute status can be managed successfully. Atypical HUS (aHUS) is a severe and frequently relapsing disorder with the same triad of thrombocytopenia, hemolysis and acute renal failure in the absence of Shiga toxin E. coli infection. More than 50% of patients with atypical HUS progress to chronic renal dysfunction and 10% die due to complications of the disease. Atypical HUS appears to have a genetic basis. Mutations in genes coding for components of the alternative complement pathway are found in about 60% of cases. The clinical presentation of aHUS overlaps with that of other thrombotic microangiopathies, rendering the diagnosis on clinical grounds alone extremely difficult. In recent years, genetic testing has opened the way for molecular diagnostics and helped establishing therapeutically and prognostically useful genotype-phenotype correlations. This review summarizes recent findings regarding the genetic basis of the HUS. The pathophysiology of the disease and the implication of genetic abnormalities in the complement system for the different types of HUS are discussed.
Collapse
Affiliation(s)
- Michal Malina
- Center for Pediatrics and Adolescent Medicine Heidelberg, Division of Paediatric Nephrology, 69120 Heidelberg, Germany
| | | | | | | | | | | | | |
Collapse
|
39
|
Ohara S, Kawasaki Y, Abe Y, Watanabe M, Ono A, Suyama K, Hashimoto K, Honda T, Suzuki J, Hosoya M. Role of vascular endothelial growth factor and angiopoietin 1 in renal injury in hemolytic uremic syndrome. Am J Nephrol 2012; 36:516-23. [PMID: 23171542 DOI: 10.1159/000345142] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Accepted: 10/11/2012] [Indexed: 01/28/2023]
Abstract
BACKGROUND/AIMS The recovery process from renal injury in hemolytic uremic syndrome (HUS) remains obscure. In order to clarify the role of vascular endothelial growth factor (VEGF) and angiopoietin 1 (Ang-1) in the renal recovery from HUS, we produced a model of mild HUS and examined the renal recovery process. METHODS We investigated three groups of mice. Group 1 consisted of mice that received an injection of Shiga toxin 2 (Stx2) and lipopolysaccharide (LPS); group 2 consisted of mice that received an injection of low dose of Stx2 and LPS, and group 3 consisted of control mice. RESULTS Serum Cr levels in group 1 were greater than those in group 2, and all mice in group 1 died, whereas all mice in group 2 remained alive. Endothelial injury at 24 h in group 1 was higher than in group 2. Electron-microscopic findings demonstrated that the endothelial cells formed immature capillary-like lumina from 7 to 28 days with increases in the expression of CD31-positive cells. Glomerular VEGF expression decreased at 72 h in group 1, but gradually increased in group 2. Glomerular Ang-1 expression peaked from 72 h to 28 days. Ang-1 expression was frequently found in the endothelial cell region of vesicle walls simultaneous with increased CD31-positive staining. CONCLUSION Our findings suggest that VEGF and Ang-1 play important roles in the recovery process, particularly in the regeneration of endothelial injury.
Collapse
Affiliation(s)
- Shinichiro Ohara
- Department of Pediatrics, Fukushima Medical University School of Medicine, Fukushima, Japan
| | | | | | | | | | | | | | | | | | | |
Collapse
|
40
|
Abstract
The kidneys are the major organs affected in diarrhea-associated hemolytic uremic syndrome (D(+)HUS). The pathophysiology of renal disease in D(+)HUS is largely the result of the interaction between bacterial virulence factors such as Shiga toxin and lipopolysaccharide and host cells in the kidney and in the blood circulation. This chapter describes in detail the current knowledge of how these bacterial toxins may lead to kidney disease and renal failure. The toxin receptors expressed by specific blood and resident renal cell types are also discussed as are the actions of the toxins on these cells.
Collapse
|
41
|
Greinacher A, Friesecke S, Abel P, Dressel A, Stracke S, Fiene M, Ernst F, Selleng K, Weissenborn K, Schmidt BMW, Schiffer M, Felix SB, Lerch MM, Kielstein JT, Mayerle J. Treatment of severe neurological deficits with IgG depletion through immunoadsorption in patients with Escherichia coli O104:H4-associated haemolytic uraemic syndrome: a prospective trial. Lancet 2011; 378:1166-73. [PMID: 21890192 DOI: 10.1016/s0140-6736(11)61253-1] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND In May 2011, an outbreak of Shiga toxin-producing enterohaemorrhagic E coli O104:H4 in northern Germany led to a high proportion of patients developing post-enteritis haemolytic uraemic syndrome and thrombotic microangiopathy that were unresponsive to therapeutic plasma exchange or complement-blocking antibody (eculizumab). Some patients needed ventilatory support due to severe neurological complications, which arose 1 week after onset of enteritis, suggesting an antibody-mediated mechanism. Therefore, we aimed to assess immunoadsorption as rescue therapy. METHODS In our prospective non-controlled trial, we enrolled patients with severe neurological symptoms and confirmed recent E coli O104:H4 infection without other acute bacterial infection or raised procalcitonin concentrations. We did IgG immunoadsorption processing of 12 L plasma volumes on 2 consecutive days, followed by IgG replacement (0·5 g/kg intravenous IgG). We calculated a composite neurological symptom score (lowest score was best) every day and assessed changes before and after immunoadsorption. FINDINGS We enrolled 12 patients who initially presented with enteritis and subsequent renal failure; 10 (83%) of 12 patients needed renal replacement therapy by a median of 8·0 days (range 5-12). Neurological complications (delirium, stimulus sensitive myoclonus, aphasia, and epileptic seizures in 50% of patients) occurred at a median of 8·0 days (range 5-15) and mandated mechanical ventilation in nine patients. Composite neurological symptom scores increased in the 3 days before immunoadsorption to 3·0 (SD 1·1, p=0·038), and improved to 1·0 (1·2, p=0·0006) 3 days after immunoadsorption. In non-intubated patients, improvement was apparent during immunoadsorption (eg, disappearance of aphasia). Five patients who were intubated were weaned within 48 h, two within 4 days, and two patients needed continued ventilation for respiratory problems. All 12 patients survived and ten had complete neurological and renal function recovery. INTERPRETATION Antibodies are probably involved in the pathogenesis of severe neurological symptoms in patients with E coli O104:H4-induced haemolytic uraemic syndrome. Immunoadsorption can safely be used to rapidly ameliorate these severe neurological complications. FUNDING Greifswald University and Hannover Medical School.
Collapse
Affiliation(s)
- Andreas Greinacher
- Institut für Immunologie und Transfusionsmedizin, Ernst-Moritz-Arndt-Universität, Greifswald, Germany.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|