1
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Ramos S, Jeney V, Figueiredo A, Paixão T, Sambo MR, Quinhentos V, Martins R, Gouveia Z, Carlos AR, Ferreira A, Pais TF, Lainé H, Faísca P, Rebelo S, Cardoso S, Tolosano E, Penha-Gonçalves C, Soares MP. Targeting circulating labile heme as a defense strategy against malaria. Life Sci Alliance 2024; 7:e202302276. [PMID: 38307624 PMCID: PMC10837040 DOI: 10.26508/lsa.202302276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 01/23/2024] [Accepted: 01/24/2024] [Indexed: 02/04/2024] Open
Abstract
Severe presentations of malaria emerge as Plasmodium (P.) spp. parasites invade and lyse red blood cells (RBC), producing extracellular hemoglobin (HB), from which labile heme is released. Here, we tested whether scavenging of extracellular HB and/or labile heme, by haptoglobin (HP) and/or hemopexin (HPX), respectively, counter the pathogenesis of severe presentations of malaria. We found that circulating labile heme is an independent risk factor for cerebral and non-cerebral presentations of severe P. falciparum malaria in children. Labile heme was negatively correlated with circulating HP and HPX, which were, however, not risk factors for severe P. falciparum malaria. Genetic Hp and/or Hpx deletion in mice led to labile heme accumulation in plasma and kidneys, upon Plasmodium infection This was associated with higher incidence of mortality and acute kidney injury (AKI) in ageing but not adult Plasmodium-infected mice, and was corroborated by an inverse correlation between heme and HPX with serological markers of AKI in P. falciparum malaria. In conclusion, HP and HPX act in an age-dependent manner to prevent the pathogenesis of severe presentation of malaria in mice and presumably in humans.
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Affiliation(s)
- Susana Ramos
- https://ror.org/04b08hq31 Instituto Gulbenkian de Ciência, Oeiras, Portugal
| | - Viktoria Jeney
- https://ror.org/04b08hq31 Instituto Gulbenkian de Ciência, Oeiras, Portugal
| | - Ana Figueiredo
- https://ror.org/04b08hq31 Instituto Gulbenkian de Ciência, Oeiras, Portugal
| | - Tiago Paixão
- https://ror.org/04b08hq31 Instituto Gulbenkian de Ciência, Oeiras, Portugal
| | - Maria Rosário Sambo
- Hospital Pediátrico David Bernardino, Luanda, Angola
- Faculdade de Medicina, Universidade Agostinho Neto, Luanda, Angola
| | - Vatúsia Quinhentos
- Hospital Pediátrico David Bernardino, Luanda, Angola
- Faculdade de Medicina, Universidade Agostinho Neto, Luanda, Angola
| | - Rui Martins
- https://ror.org/04b08hq31 Instituto Gulbenkian de Ciência, Oeiras, Portugal
| | - Zélia Gouveia
- https://ror.org/04b08hq31 Instituto Gulbenkian de Ciência, Oeiras, Portugal
| | - Ana Rita Carlos
- https://ror.org/04b08hq31 Instituto Gulbenkian de Ciência, Oeiras, Portugal
| | - Ana Ferreira
- https://ror.org/04b08hq31 Instituto Gulbenkian de Ciência, Oeiras, Portugal
| | - Teresa F Pais
- https://ror.org/04b08hq31 Instituto Gulbenkian de Ciência, Oeiras, Portugal
| | - Hugo Lainé
- https://ror.org/04b08hq31 Instituto Gulbenkian de Ciência, Oeiras, Portugal
| | - Pedro Faísca
- https://ror.org/04b08hq31 Instituto Gulbenkian de Ciência, Oeiras, Portugal
| | - Sofia Rebelo
- https://ror.org/04b08hq31 Instituto Gulbenkian de Ciência, Oeiras, Portugal
| | - Silvia Cardoso
- https://ror.org/04b08hq31 Instituto Gulbenkian de Ciência, Oeiras, Portugal
| | - Emanuela Tolosano
- Department Molecular Biotechnology and Health Sciences, University of Torino, Torino, Italy
| | | | - Miguel P Soares
- https://ror.org/04b08hq31 Instituto Gulbenkian de Ciência, Oeiras, Portugal
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2
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Li Y, Chen R, Wang C, Deng J, Luo S. Double-edged functions of hemopexin in hematological related diseases: from basic mechanisms to clinical application. Front Immunol 2023; 14:1274333. [PMID: 38022615 PMCID: PMC10653390 DOI: 10.3389/fimmu.2023.1274333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 10/19/2023] [Indexed: 12/01/2023] Open
Abstract
It is now understood that hemolysis and the subsequent release of heme into circulation play a critical role in driving the progression of various diseases. Hemopexin (HPX), a heme-binding protein with the highest affinity for heme in plasma, serves as an effective antagonist against heme toxicity resulting from severe acute or chronic hemolysis. In the present study, changes in HPX concentration were characterized at different stages of hemolytic diseases, underscoring its potential as a biomarker for assessing disease progression and prognosis. In many heme overload-driven conditions, such as sickle cell disease, transfusion-induced hemolysis, and sepsis, endogenous HPX levels are often insufficient to provide protection. Consequently, there is growing interest in developing HPX therapeutics to mitigate toxic heme exposure. Strategies include HPX supplementation when endogenous levels are depleted and enhancing HPX's functionality through modifications, offering a potent defense against heme toxicity. It is worth noting that HPX may also exert deleterious effects under certain circumstances. This review aims to provide a comprehensive overview of HPX's roles in the progression and prognosis of hematological diseases. It highlights HPX-based clinical therapies for different hematological disorders, discusses advancements in HPX production and modification technologies, and offers a theoretical basis for the clinical application of HPX.
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Affiliation(s)
| | | | | | - Jun Deng
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shanshan Luo
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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3
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Vasquez M, Sica M, Namazzi R, Opoka RO, Sherman J, Datta D, Duran-Frigola M, Ssenkusu JM, John CC, Conroy AL, Rodriguez A. Xanthine oxidase levels and immune dysregulation are independently associated with anemia in Plasmodium falciparum malaria. Sci Rep 2023; 13:14720. [PMID: 37679382 PMCID: PMC10484935 DOI: 10.1038/s41598-023-41764-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 08/31/2023] [Indexed: 09/09/2023] Open
Abstract
Severe anemia is an important contributor to mortality in children with severe malaria. Anemia in malaria is a multi-factorial complication, since dyserythropoiesis, hemolysis and phagocytic clearance of uninfected red blood cells (RBCs) can contribute to this syndrome. High levels of oxidative stress and immune dysregulation have been proposed to contribute to severe malarial anemia, facilitating the clearance of uninfected RBCs. In a cohort of 552 Ugandan children with severe malaria, we measured the levels of xanthine oxidase (XO), an oxidative enzyme that is elevated in the plasma of malaria patients. The levels of XO in children with severe anemia were significantly higher compared to children with severe malaria not suffering from severe anemia. Levels of XO were inversely associated with RBC hemoglobin (ρ = - 0.25, p < 0.0001), indicating a relation between this enzyme and severe anemia. When compared with the levels of immune complexes and of autoimmune antibodies to phosphatidylserine, factors previously associated with severe anemia in malaria patients, we observed that XO is not associated with them, suggesting that XO is associated with severe anemia through an independent mechanism. XO was associated with prostration, acidosis, jaundice, respiratory distress, and kidney injury, which may reflect a broader relation of this enzyme with severe malaria pathology. Since inhibitors of XO are inexpensive and well-tolerated drugs already approved for use in humans, the validation of XO as a contributor to severe malarial anemia and other malaria complications may open new possibilities for much needed adjunctive therapy in malaria.
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Affiliation(s)
- Marilyn Vasquez
- New York University School of Medicine, 430E 29th St, New York, NY, 10016, USA
| | - Margaux Sica
- New York University School of Medicine, 430E 29th St, New York, NY, 10016, USA
| | - Ruth Namazzi
- Department of Paediatrics, Makerere University College of Health Sciences, Kampala, Uganda
- Global Health Uganda, Kampala, Uganda
| | - Robert O Opoka
- Department of Paediatrics, Makerere University College of Health Sciences, Kampala, Uganda
- Global Health Uganda, Kampala, Uganda
| | - Julian Sherman
- New York University School of Medicine, 430E 29th St, New York, NY, 10016, USA
| | - Dibyadyuti Datta
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
- Center for Global Health, Indiana University, Indianapolis, IN, 46202, USA
| | | | - John M Ssenkusu
- Department of Epidemiology and Biostatistics, Makerere University School of Public Health, Kampala, Uganda
| | - Chandy C John
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
- Center for Global Health, Indiana University, Indianapolis, IN, 46202, USA
| | - Andrea L Conroy
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN, 46202, USA
- Center for Global Health, Indiana University, Indianapolis, IN, 46202, USA
| | - Ana Rodriguez
- New York University School of Medicine, 430E 29th St, New York, NY, 10016, USA.
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4
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Adan D, Batte A, Namazzi R, Mufumba I, Kazinga C, Mellencamp KA, Bond C, Opoka RO, John CC, Conroy AL. Renin as a Biomarker of Acute Kidney Injury and Mortality in Children With Severe Malaria or Sickle Cell Disease. Cureus 2023; 15:e45124. [PMID: 37842390 PMCID: PMC10569743 DOI: 10.7759/cureus.45124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/11/2023] [Indexed: 10/17/2023] Open
Abstract
BACKGROUND Globally, a very high percentage of acute kidney injury (AKI) occurs in low- and middle-income countries (LMICs) where late recognition contributes to increased mortality. There are challenges with using existing biomarkers of AKI in LMICs. Emerging evidence suggests renin may serve as a biomarker of kidney injury that can overcome limitations in creatinine-based diagnostics. METHODS Two study populations in Uganda were assessed. Cohort #1 was a two-site, prospective cohort study enrolling 600 children with severe malaria (SM). Cohort #2 was a prospective cohort study enrolling 185 children with sickle cell disease (SCD) hospitalized with a vaso-occlusive crisis. Plasma or serum renin concentrations were measured in both cohorts of children at the time of hospital admission using Luminex® (Luminex Corporation, Austin, Texas, United States) or enzyme-linked immunosorbent assay (ELISA), respectively. We assessed the ability of renin to discriminate between children with or without AKI and between children who survived and children who died using receiver operating characteristic curves. RESULTS In both cohorts, renin concentrations were strongly associated with AKI and mortality. Renin was able to discriminate between children with or without AKI with an area under the curve (AUC) of 0.70 (95%CI, 0.65-0.74) in children with SM and 0.72 (95%CI, 0.6co3-0.81) in children with SCD. Renin was able to discriminate between children who survived and children who died with an AUC of 0.73 (95%CI, 0.63-0.83) in children with SM and 0.94 (95%CI, 0.89-0.99) in children with SCD. In Cohort #2, we compared renin against urine neutrophil gelatinase-associated lipocalin (NGAL) as the leading biomarker of AKI, and it had comparable performance in discriminating AKI and predicting mortality. CONCLUSIONS In two independent populations of children at risk of AKI with key differences in the etiology of kidney injury, renin was strongly associated with AKI and mortality and had moderate to good diagnostic performance to predict mortality.
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Affiliation(s)
- Daniel Adan
- Pediatric Infectious Diseases and Global Health, Indiana University School of Medicine, Indianapolis, USA
| | - Anthony Batte
- Child Health and Development Centre (CHDC), Makerere University College of Health Sciences, Kampala, UGA
| | - Ruth Namazzi
- Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, UGA
| | - Ivan Mufumba
- CHILD Laboratory, Global Health Uganda, Kampala, UGA
| | | | - Kagan A Mellencamp
- Pediatric Infectious Diseases and Global Health, Indiana University School of Medicine, Indianapolis, USA
| | - Caitlin Bond
- Pediatric Infectious Diseases and Global Health, Indiana University School of Medicine, Indianapolis, USA
| | - Robert O Opoka
- Undergraduate Medical Education, Aga Khan University Medical College, Nairobi, KEN
| | - Chandy C John
- Pediatric Infectious Diseases and Global Health, Indiana University School of Medicine, Indianapolis, USA
- Center for Global Health, Indiana University School of Medicine, Indianapolis, USA
| | - Andrea L Conroy
- Pediatric Infectious Diseases and Global Health, Indiana University School of Medicine, Indianapolis, USA
- CHILD Laboratory, Global Health Uganda, Kampala, UGA
- Center for Global Health, Indiana University School of Medicine, Indianapolis, USA
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Paasi G, Okalebo CB, Ongodia P, Namayanja C, Eregu EEI, Abongo G, Olupot M, Amorut D, Muhindo R, Okiror W, Ndila C, Olupot-Olupot P. PARIST study protocol: a phase I/II randomised, controlled clinical trial to assess the feasibility, safety and effectiveness of paracetamol in resolving acute kidney injury in children with severe malaria. BMJ Open 2023; 13:e068260. [PMID: 37524553 PMCID: PMC10391814 DOI: 10.1136/bmjopen-2022-068260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND Acute kidney injury (AKI) has in the past been considered a rare complication of malaria in children living in high-transmission settings. More recently, however, a growing number of paediatric case series of AKI in severe malaria studies in African children have been published (Artesunate vs Quinine in the Treatment of Severe P. falciparum Malaria in African children and Fluids Expansion as Supportive Therapy trials). The Paracetamol for Acute Renal Injury in Severe Malaria Trial (PARIST) therefore, aims to assess feasibility, safety and determine the effective dose of paracetamol, which attenuates nephrotoxicity of haemoproteins, red-cell free haemoglobin and myoglobin in children with haemoglobinuric severe malaria. METHODS PARIST is a phase I/II unblinded randomised controlled trial of 40 children aged >6 months and <12 years admitted with confirmed haemoglobinuric severe malaria (blackwater fever), a positive blood smear for P. falciparum malaria and either serum creatinine (Cr) increase by ≥0.3 mg/dL within 48 hours or to ≥1.5 times baseline and elevated blood urea nitrogen (BUN) >20 mg/dL. Children will be randomly allocated on a 1:1 basis to paracetamol intervention dose arm (20 mg/kg orally 6-hourly for 48 hours) or to a control arm to receive standard of care for temperature control (ie, tepid sponging for 30 min if fever persists give rescue treatment). Primary outcome is renal recovery at 48 hours as indicated by stoppage of progression and decrease of Cr level below baseline, BUN (<20 mg/dL). Data analysis will be on the intention-to-treat principle and a per-protocol basis.Results from this phase I/II clinical trial will provide preliminary effectiveness data of this highly potential treatment for AKI in paediatric malaria (in particular for haemoglobinuric severe malaria) for a larger phase III trial. ETHICS AND DISSEMINATION Ethical and regulatory approvals have been granted by the Mbale Hospital Institutional Ethics Review Committee (MRRH-REC OUT 002/2019), Uganda National Council of Science and Technology (UNCST-HS965ES) and the National drug Authority (NDA-CTC 0166/2021). We will be disseminating results through journals, conferences and policy briefs to policy makers and primary care providers. TRIAL REGISTRATION NUMBER ISRCTN84974248.
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Affiliation(s)
- George Paasi
- Clinical trials department, Mbale Clinical Research Institute, Mbale, Uganda
- Department of Community and Public Health, Busitema University Faculty of Health Sciences, Mbale, Uganda
| | - Charles Benard Okalebo
- Clinical trials department, Mbale Clinical Research Institute, Mbale, Uganda
- Department of Community and Public Health, Busitema University Faculty of Health Sciences, Mbale, Uganda
| | - Paul Ongodia
- Clinical trials department, Mbale Clinical Research Institute, Mbale, Uganda
| | - Cate Namayanja
- Clinical trials department, Mbale Clinical Research Institute, Mbale, Uganda
- Department of Paediatrics and Child Health, Busitema University Faculty of Health Sciences, Mbale, Uganda
| | - Egiru Emma Isaiah Eregu
- Department of Paediatrics and Child Health, Busitema University Faculty of Health Sciences, Mbale, Uganda
| | - Grace Abongo
- Clinical trials department, Mbale Clinical Research Institute, Mbale, Uganda
| | - Moses Olupot
- Clinical trials department, Mbale Clinical Research Institute, Mbale, Uganda
| | - Denis Amorut
- Clinical trials department, Mbale Clinical Research Institute, Mbale, Uganda
| | - Rita Muhindo
- Clinical trials department, Mbale Clinical Research Institute, Mbale, Uganda
| | - William Okiror
- Clinical trials department, Mbale Clinical Research Institute, Mbale, Uganda
- Department of Community and Public Health, Busitema University Faculty of Health Sciences, Mbale, Uganda
| | - Carolyne Ndila
- Clinical trials department, Mbale Clinical Research Institute, Mbale, Uganda
| | - Peter Olupot-Olupot
- Clinical trials department, Mbale Clinical Research Institute, Mbale, Uganda
- Faculty of Health Sciences, Department of Community and Public Health, Busitema University, Tororo, Uganda
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6
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de Lima F, Hounkpe BW, de Moraes CRP, Borba-Junior IT, Costa FF, De Paula EV. Safety and feasibility of the gene transfer of hemopexin for conditions with increased free heme. Exp Biol Med (Maywood) 2023; 248:1103-1111. [PMID: 37452705 PMCID: PMC10583756 DOI: 10.1177/15353702231182199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 03/16/2023] [Indexed: 07/18/2023] Open
Abstract
Heme is a fundamental molecule for several biological processes, but when released in the extracellular space such as in hemolytic diseases, it can be toxic to cells and tissues. Hemopexin (HPX) is a circulating protein responsible for removing free heme from the circulation, whose levels can be severely depleted in conditions such as sickle cell diseases. Accordingly, increasing HPX levels represents an attractive strategy to mitigate the deleterious effects of heme in these conditions. Gene transfer of liver-produced proteins with adeno-associated virus (AAV) has been shown to be an effective and safety strategy in animal and human studies mainly in hemophilia. Here, we report the feasibility of increasing HPX levels using an AAV8 vector expressing human HPX (hHPX). C57Bl mice were injected with escalating doses of our vector, and expression was assessed by enzyme immunoassay (ELISA), Western blot, and quantitative polymerase chain reaction (qPCR). In addition, the biological activity of transgenic hHPX was confirmed using two different models of heme challenge consisting of serial heme injections or phenylhydrazine-induced hemolysis. Sustained expression of hHPX was confirmed for up to 26 weeks in plasma. Expression was dose-dependent and not associated with clinical signs of toxicity. hHPX levels were significantly reduced by heme infusions and phenylhydrazine-induced hemolysis. No clinical toxicity or laboratory signs of liver damage were observed in preliminary short-term heme challenge studies. Our results confirm that long-term expression of hHPX is feasible and safe in mice, even in the presence of heme overload. Additional studies are needed to explore the effect of transgenic HPX protein in animal models of chronic hemolysis.
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Affiliation(s)
- Franciele de Lima
- School of Medical Sciences, University of Campinas, Campinas 13083-887, Brazil
| | | | | | | | - Fernando Ferreira Costa
- School of Medical Sciences, University of Campinas, Campinas 13083-887, Brazil
- Hematology and Hemotherapy Center, University of Campinas, Campinas 13083-878, Brazil
| | - Erich V De Paula
- School of Medical Sciences, University of Campinas, Campinas 13083-887, Brazil
- Hematology and Hemotherapy Center, University of Campinas, Campinas 13083-878, Brazil
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7
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Foko LPK, Narang G, Tamang S, Hawadak J, Jakhan J, Sharma A, Singh V. The spectrum of clinical biomarkers in severe malaria and new avenues for exploration. Virulence 2022; 13:634-653. [PMID: 36036460 PMCID: PMC9427047 DOI: 10.1080/21505594.2022.2056966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Globally, malaria is a public health concern, with severe malaria (SM) contributing a major share of the disease burden in malaria endemic countries. In this context, identification and validation of SM biomarkers are essential in clinical practice. Some biomarkers (C-reactive protein, angiopoietin 2, angiopoietin-2/1 ratio, platelet count, histidine-rich protein 2) have yielded interesting results in the prognosis of Plasmodium falciparum severe malaria, but for severe P. vivax and P. knowlesi malaria, similar evidence is missing. The validation of these biomarkers is hindered by several factors such as low sample size, paucity of evidence-evaluating studies, suboptimal values of sensitivity/specificity, poor clinical practicality of measurement methods, mixed Plasmodium infections, and good clinical value of the biomarkers for concurrent infections (pneumonia and current COVID-19 pandemic). Most of these biomarkers are non-specific to pathogens as they are related to host response and hence should be regarded as prognostic/predictive biomarkers that complement but do not replace pathogen biomarkers for clinical evaluation of SM patients. This review highlights the importance of research on diagnostic/predictive/therapeutic biomarkers, neglected malaria species, and clinical practicality of measurement methods in future studies. Finally, the importance of omics technologies for faster identification/validation of SM biomarkers is also included.
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Affiliation(s)
- Loick Pradel Kojom Foko
- Parasite and Host Biology Group, ICMR-National Institute of Malaria Research, New Delhi, India
| | - Geetika Narang
- Parasite and Host Biology Group, ICMR-National Institute of Malaria Research, New Delhi, India
| | - Suman Tamang
- Parasite and Host Biology Group, ICMR-National Institute of Malaria Research, New Delhi, India
| | - Joseph Hawadak
- Parasite and Host Biology Group, ICMR-National Institute of Malaria Research, New Delhi, India
| | - Jahnvi Jakhan
- Parasite and Host Biology Group, ICMR-National Institute of Malaria Research, New Delhi, India
| | - Amit Sharma
- Parasite and Host Biology Group, ICMR-National Institute of Malaria Research, New Delhi, India.,Molecular Medicine Group, International Centre for Genetic Engineering and Biotechnology, New Delhi, India
| | - Vineeta Singh
- Parasite and Host Biology Group, ICMR-National Institute of Malaria Research, New Delhi, India
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8
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Conroy AL, Hawkes MT, Leligdowicz A, Mufumba I, Starr MC, Zhong K, Namasopo S, John CC, Opoka RO, Kain KC. Blackwater fever and acute kidney injury in children hospitalized with an acute febrile illness: pathophysiology and prognostic significance. BMC Med 2022; 20:221. [PMID: 35773743 PMCID: PMC9248152 DOI: 10.1186/s12916-022-02410-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 05/17/2022] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Acute kidney injury (AKI) and blackwater fever (BWF) are related but distinct renal complications of acute febrile illness in East Africa. The pathogenesis and prognostic significance of BWF and AKI are not well understood. METHODS A prospective observational cohort study was conducted to evaluate the association between BWF and AKI in children hospitalized with an acute febrile illness. Secondary objectives were to examine the association of AKI and BWF with (i) host response biomarkers and (ii) mortality. AKI was defined using the Kidney Disease: Improving Global Outcomes criteria and BWF was based on parental report of tea-colored urine. Host markers of immune and endothelial activation were quantified on admission plasma samples. The relationships between BWF and AKI and clinical and biologic factors were evaluated using multivariable regression. RESULTS We evaluated BWF and AKI in 999 children with acute febrile illness (mean age 1.7 years (standard deviation 1.06), 55.7% male). At enrollment, 8.2% of children had a history of BWF, 49.5% had AKI, and 11.1% had severe AKI. A history of BWF was independently associated with 2.18-fold increased odds of AKI (95% CI 1.15 to 4.16). When examining host response, severe AKI was associated with increased immune and endothelial activation (increased CHI3L1, sTNFR1, sTREM-1, IL-8, Angpt-2, sFlt-1) while BWF was predominantly associated with endothelial activation (increased Angpt-2 and sFlt-1, decreased Angpt-1). The presence of severe AKI, not BWF, was associated with increased risk of in-hospital death (RR, 2.17 95% CI 1.01 to 4.64) adjusting for age, sex, and disease severity. CONCLUSIONS BWF is associated with severe AKI in children hospitalized with a severe febrile illness. Increased awareness of AKI in the setting of BWF, and improved access to AKI diagnostics, is needed to reduce disease progression and in-hospital mortality in this high-risk group of children through early implementation of kidney-protective measures.
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Affiliation(s)
- Andrea L Conroy
- Department of Pediatrics, Indiana University School of Medicine, 1044 West Walnut St., Building 4, Indianapolis, IN, 46202, USA.
| | - Michael T Hawkes
- Division of Pediatric Infectious Diseases, 3-593 Edmonton Clinic Health Academy, University of Alberta, Edmonton, AB, T6G1C9, Canada
| | - Aleksandra Leligdowicz
- Division of Critical Care Medicine, Robarts Research Institute, University of Western Ontario, 1511 Richmond St, London, ON, N6A 3K7, Canada
| | | | - Michelle C Starr
- Department of Pediatrics, Indiana University School of Medicine, 1044 West Walnut St., Building 4, Indianapolis, IN, 46202, USA
| | - Kathleen Zhong
- Sandra Rotman Centre for Global Health, Toronto General Hospital, University Health Network and University of Toronto, Toronto, ON, M5G1L7, Canada
| | | | - Chandy C John
- Department of Pediatrics, Indiana University School of Medicine, 1044 West Walnut St., Building 4, Indianapolis, IN, 46202, USA
| | - Robert O Opoka
- Global Health Uganda, Kampala, Uganda.,Department of Paediatrics and Child Health, Makerere University, Kampala, Uganda
| | - Kevin C Kain
- Sandra Rotman Centre for Global Health, Toronto General Hospital, University Health Network and University of Toronto, Toronto, ON, M5G1L7, Canada
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9
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Pathophysiology of Acute Kidney Injury in Malaria and Non-Malarial Febrile Illness: A Prospective Cohort Study. Pathogens 2022; 11:pathogens11040436. [PMID: 35456111 PMCID: PMC9031196 DOI: 10.3390/pathogens11040436] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 03/24/2022] [Accepted: 03/31/2022] [Indexed: 01/06/2023] Open
Abstract
Acute kidney injury (AKI) is a life-threatening complication. Malaria and sepsis are leading causes of AKI in low-and-middle-income countries, but its etiology and pathogenesis are poorly understood. A prospective observational cohort study was conducted to evaluate pathways of immune and endothelial activation in children hospitalized with an acute febrile illness in Uganda. The relationship between clinical outcome and AKI, defined using the Kidney Disease: Improving Global Outcomes criteria, was investigated. The study included 967 participants (mean age 1.67 years, 44.7% female) with 687 (71.0%) positive for malaria by rapid diagnostic test and 280 (29.1%) children had a non-malarial febrile illness (NMFI). The frequency of AKI was higher in children with NMFI compared to malaria (AKI, 55.0% vs. 46.7%, p = 0.02). However, the frequency of severe AKI (stage 2 or 3 AKI) was comparable (12.1% vs. 10.5%, p = 0.45). Circulating markers of both immune and endothelial activation were associated with severe AKI. Children who had malaria and AKI had increased mortality (no AKI, 0.8% vs. AKI, 4.1%, p = 0.005), while there was no difference in mortality among children with NMFI (no AKI, 4.0% vs. AKI, 4.6%, p = 0.81). AKI is a common complication in children hospitalized with acute infections. Immune and endothelial activation appear to play central roles in the pathogenesis of AKI.
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10
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Batte A, Menon S, Ssenkusu J, Kiguli S, Kalyesubula R, Lubega J, Mutebi EI, Opoka RO, John CC, Starr MC, Conroy AL. Acute kidney injury in hospitalized children with sickle cell anemia. BMC Nephrol 2022; 23:110. [PMID: 35303803 PMCID: PMC8933904 DOI: 10.1186/s12882-022-02731-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 03/08/2022] [Indexed: 01/06/2023] Open
Abstract
Background Children with sickle cell anemia (SCA) are at increased risk of acute kidney injury (AKI) that may lead to death or chronic kidney disease. This study evaluated AKI prevalence and risk factors in children with SCA hospitalized with a vaso-occlusive crisis (VOC) in a low-resource setting. Further, we evaluated whether modifications to the Kidney Disease: Improving Global Outcomes (KDIGO) definition would influence clinical outcomes of AKI in children with SCA hospitalized with a VOC. Methods We prospectively enrolled 185 children from 2 – 18 years of age with SCA (Hemoglobin SS) hospitalized with a VOC at a tertiary hospital in Uganda. Kidney function was assessed on admission, 24–48 h of hospitalization, and day 7 or discharge. Creatinine was measured enzymatically using an isotype-dilution mass spectrometry traceable method. AKI was defined using the original-KDIGO definition as ≥ 1.5-fold change in creatinine within seven days or an absolute change of ≥ 0.3 mg/dl within 48 h. The SCA modified-KDIGO (sKDIGO) definition excluded children with a 1.5-fold change in creatinine from 0.2 mg/dL to 0.3 mg/dL. Results Using KDIGO, 90/185 (48.7%) children had AKI with 61/185 (33.0%) AKI cases present on admission, and 29/124 (23.4%) cases of incident AKI. Overall, 23 children with AKI had a 1.5-fold increase in creatinine from 0.2 mg/dL to 0.3 m/dL. Using the sKDIGO-definition, 67/185 (36.2%) children had AKI with 43/185 (23.2%) cases on admission, and 24/142 (16.9%) cases of incident AKI. The sKDIGO definition, but not the original-KDIGO definition, was associated with increased mortality (0.9% vs. 7.5%, p = 0.024). Using logistic regression, AKI risk factors included age (aOR, 1.10, 95% CI 1.10, 1.20), hypovolemia (aOR, 2.98, 95% CI 1.08, 8.23), tender hepatomegaly (aOR, 2.46, 95% CI 1.05, 5.81), and infection (aOR, 2.63, 95% CI 1.19, 5.81) (p < 0.05). Conclusion These results demonstrate that AKI is a common complication in children with SCA admitted with VOC. The sKDIGO definition of AKI in children with SCA was a better predictor of clinical outcomes in children. There is need for promotion of targeted interventions to ensure early identification and treatment of AKI in children with SCA.
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Affiliation(s)
- Anthony Batte
- Child Health and Development Centre, Makerere University College of Health Sciences, P.O Box 6717, Kampala, Uganda.
| | - Sahit Menon
- San Diego School of Medicine, University of California, San Diego, USA
| | - John Ssenkusu
- Department of Epidemiology and Biostatistics, Makerere University School of Public Health, Kampala, Uganda
| | - Sarah Kiguli
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Joseph Lubega
- Pediatric Hematology and Oncology, Baylor College of Medicine, Texas, USA
| | | | - Robert O Opoka
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Chandy C John
- Department of Pediatrics, Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Michelle C Starr
- Department of Pediatrics, Division of Nephrology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Andrea L Conroy
- Department of Pediatrics, Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN, USA
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11
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Dalapati T, Moore JM. Hemozoin: a Complex Molecule with Complex Activities. CURRENT CLINICAL MICROBIOLOGY REPORTS 2022; 8:87-102. [PMID: 35096512 DOI: 10.1007/s40588-021-00166-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Purpose of Review Malaria is a disease caused by parasites that reside in host red blood cells and use hemoglobin as a nutrient source. Heme released by hemoglobin catabolism is modified by the parasite to produce hemozoin (HZ), which has toxic effects on the host. Experimentation aiming to elucidate how HZ contributes to malaria pathogenesis has utilized different preparations of this molecule, complicating interpretation and comparison of findings. We examine natural synthesis and isolation of HZ and highlight studies that have used multiple preparations, including synthetic forms, in a comparative fashion. Recent Findings Recent work utilizing sophisticated imaging and detection techniques reveals important molecular characteristics of HZ synthesis and biochemistry. Other recent studies further refine understanding of contributions of HZ to malaria pathogenesis yet highlight the continuing need to characterize HZ preparations and contextualize experimental conditions in the in vivo infection milieu. Summary This review highlights the necessity of collectively determining what is physiologically relevant HZ. Characterization of isolated natural HZ and use of multiple preparations in each study are recommended with application of in vivo studies whenever possible. Adoption of such practices is expected to improve reproducibility of results and elucidate the myriad of ways that HZ participates in malaria pathogenesis.
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Affiliation(s)
- Trisha Dalapati
- Duke University School of Medicine, Duke University, Durham, NC, USA
| | - Julie M Moore
- Department of Infectious Diseases and Immunology, College of Veterinary Medicine, University of Florida, Gainesville, FL, USA
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12
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Butt N, Ahmed E. Falciparum malaria associated acute kidney injury with polyneuropathy and intra-arterial thrombosis (stroke). Eur J Med Res 2022; 27:2. [PMID: 34991710 PMCID: PMC8734130 DOI: 10.1186/s40001-021-00627-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 12/27/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Malaria is still major problem in developing countries, such as Pakistan. Besides fever, body ache and vomiting it can present with acute kidney injury, proteinuria, hematuria and cerebral manifestations which are more common with falciparum malaria. Neurological manifestations are rare presentation of malaria and should be consider in patients who are admitting with features of neuropathy and stroke. CASE PRESENTATION We describe an unusual case of falciparum malaria, complicated by acute kidney injury who developed Polyneuropathy and intra-arterial thrombosis in middle cerebral artery territory. Our patient recovered his renal functions during admission and recovered his power and sensation in his limbs as well after 1 month. CONCLUSION Malaria cause neurological manifestations including axonal and sensory neuropathy, cerebral venous and arterial thrombosis, PMNS, cerebellar signs and symptoms, psychosis, etc. With prompt diagnosis and early treatment they can be cure and regain their motor and sensory functions to normal level.
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Affiliation(s)
- Nausheen Butt
- Sindh Institute of Urology and Transplant, Karachi, Sindh, Pakistan.
| | - Ejaz Ahmed
- Sindh Institute of Urology and Transplant, Karachi, Sindh, Pakistan
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13
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Vasquez M, Zuniga M, Rodriguez A. Oxidative Stress and Pathogenesis in Malaria. Front Cell Infect Microbiol 2021; 11:768182. [PMID: 34917519 PMCID: PMC8669614 DOI: 10.3389/fcimb.2021.768182] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 11/16/2021] [Indexed: 02/05/2023] Open
Abstract
Malaria is a highly inflammatory and oxidative disease. The production of reactive oxygen species by host phagocytes is an essential component of the host response to Plasmodium infection. Moreover, host oxidative enzymes, such as xanthine oxidase, are upregulated in malaria patients. Although increased production of reactive oxygen species contributes to the clearance of the parasite, excessive amounts of these free radicals can mediate inflammation and cause extensive damage to host cells and tissues, probably contributing to severe pathologies. Plasmodium has a variety of antioxidant enzymes that allow it to survive amidst this oxidative onslaught. However, parasitic degradation of hemoglobin within the infected red blood cell generates free heme, which is released at the end of the replication cycle, further aggravating the oxidative burden on the host and possibly contributing to the severity of life-threatening malarial complications. Additionally, the highly inflammatory response to malaria contributes to exacerbate the oxidative response. In this review, we discuss host and parasite-derived sources of oxidative stress that may promote severe disease in P. falciparum infection. Therapeutics that restore and maintain oxidative balance in malaria patients may be useful in preventing lethal complications of this disease.
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Affiliation(s)
| | | | - Ana Rodriguez
- Department of Microbiology, New York University Grossman School of Medicine, New York, NY, United States
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14
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Batte A, Berrens Z, Murphy K, Mufumba I, Sarangam ML, Hawkes MT, Conroy AL. Malaria-Associated Acute Kidney Injury in African Children: Prevalence, Pathophysiology, Impact, and Management Challenges. Int J Nephrol Renovasc Dis 2021; 14:235-253. [PMID: 34267538 PMCID: PMC8276826 DOI: 10.2147/ijnrd.s239157] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 05/26/2021] [Indexed: 01/02/2023] Open
Abstract
Acute kidney injury (AKI) is emerging as a complication of increasing clinical importance associated with substantial morbidity and mortality in African children with severe malaria. Using the Kidney Disease: Improving Global Outcomes (KDIGO) criteria to define AKI, an estimated 24–59% of African children with severe malaria have AKI with most AKI community-acquired. AKI is a risk factor for mortality in pediatric severe malaria with a stepwise increase in mortality across AKI stages. AKI is also a risk factor for post-discharge mortality and is associated with increased long-term risk of neurocognitive impairment and behavioral problems in survivors. Following injury, the kidney undergoes a process of recovery and repair. AKI is an established risk factor for chronic kidney disease and hypertension in survivors and is associated with an increased risk of chronic kidney disease in severe malaria survivors. The magnitude of the risk and contribution of malaria-associated AKI to chronic kidney disease in malaria-endemic areas remains undetermined. Pathways associated with AKI pathogenesis in the context of pediatric severe malaria are not well understood, but there is emerging evidence that immune activation, endothelial dysfunction, and hemolysis-mediated oxidative stress all directly contribute to kidney injury. In this review, we outline the KDIGO bundle of care and highlight how this could be applied in the context of severe malaria to improve kidney perfusion, reduce AKI progression, and improve survival. With increased recognition that AKI in severe malaria is associated with substantial post-discharge morbidity and long-term risk of chronic kidney disease, there is a need to increase AKI recognition through enhanced access to creatinine-based and next-generation biomarker diagnostics. Long-term studies to assess severe malaria-associated AKI’s impact on long-term health in malaria-endemic areas are urgently needed.
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Affiliation(s)
- Anthony Batte
- Child Health and Development Centre, Makerere University College of Health Sciences, Kampala, Uganda
| | - Zachary Berrens
- Department of Pediatrics, Pediatric Critical Care Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kristin Murphy
- Department of Pediatrics, Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Ivan Mufumba
- CHILD Research Laboratory, Global Health Uganda, Kampala, Uganda
| | | | - Michael T Hawkes
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Andrea L Conroy
- Department of Pediatrics, Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, IN, USA
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15
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Wijnsma KL, Veissi ST, de Wijs S, van der Velden T, Volokhina EB, Wagener FADTG, van de Kar NCAJ, van den Heuvel LP. Heme as Possible Contributing Factor in the Evolvement of Shiga-Toxin Escherichia coli Induced Hemolytic-Uremic Syndrome. Front Immunol 2020; 11:547406. [PMID: 33414780 PMCID: PMC7783363 DOI: 10.3389/fimmu.2020.547406] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 11/16/2020] [Indexed: 01/29/2023] Open
Abstract
Shiga-toxin (Stx)-producing Escherichia coli hemolytic-uremic syndrome (STEC-HUS) is one of the most common causes of acute kidney injury in children. Stx-mediated endothelial injury initiates the cascade leading to thrombotic microangiopathy (TMA), still the exact pathogenesis remains elusive. Interestingly, there is wide variability in clinical presentation and outcome. One explanation for this could be the enhancement of TMA through other factors. We hypothesize that heme, as released during extensive hemolysis, contributes to the etiology of TMA. Plasma levels of heme and its scavenger hemopexin and degrading enzyme heme-oxygenase-1 (HO-1) were measured in 48 STEC-HUS patients. Subsequently, the effect of these disease-specific heme concentrations, in combination with Stx, was assessed on primary human glomerular microvascular endothelial cells (HGMVECs). Significantly elevated plasma heme levels up to 21.2 µM were found in STEC-HUS patients compared to controls and were inversely correlated with low or depleted plasma hemopexin levels (R2 −0.74). Plasma levels of HO-1 are significantly elevated compared to controls. Interestingly, especially patients with high heme levels (n = 12, heme levels above 75 quartile range) had high plasma HO-1 levels with median of 332.5 (86–720) ng/ml (p = 0.008). Furthermore, heme is internalized leading to a significant increase in reactive oxygen species production and stimulated both nuclear translocation of NF-κB and increased levels of its target gene (tissue factor). In conclusion, we are the first to show elevated heme levels in patients with STEC-HUS. These increased heme levels mediate endothelial injury by promoting oxidative stress and a pro-inflammatory and pro-thrombotic state. Hence, heme may be a contributing and driving factor in the pathogenesis of STEC-HUS and could potentially amplify the cascade leading to TMA.
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Affiliation(s)
- Kioa L Wijnsma
- Department of Pediatric Nephrology, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, Netherlands
| | - Susan T Veissi
- Department of Pediatric Nephrology, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, Netherlands
| | - Sem de Wijs
- Department of Pediatric Nephrology, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, Netherlands
| | - Thea van der Velden
- Department of Pediatric Nephrology, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, Netherlands
| | - Elena B Volokhina
- Department of Pediatric Nephrology, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, Netherlands.,Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Frank A D T G Wagener
- Department of Dentistry-Orthodontics and Craniofacial Biology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Nicole C A J van de Kar
- Department of Pediatric Nephrology, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, Netherlands
| | - L P van den Heuvel
- Department of Pediatric Nephrology, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, Netherlands.,Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, Netherlands.,Department of Development and Regeneration, University Hospital Leuven, Leuven, Belgium
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16
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Lissner MM, Cumnock K, Davis NM, Vilches-Moure JG, Basak P, Navarrete DJ, Allen JA, Schneider D. Metabolic profiling during malaria reveals the role of the aryl hydrocarbon receptor in regulating kidney injury. eLife 2020; 9:60165. [PMID: 33021470 PMCID: PMC7538157 DOI: 10.7554/elife.60165] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 09/17/2020] [Indexed: 12/12/2022] Open
Abstract
Systemic metabolic reprogramming induced by infection exerts profound, pathogen-specific effects on infection outcome. Here, we detail the host immune and metabolic response during sickness and recovery in a mouse model of malaria. We describe extensive alterations in metabolism during acute infection, and identify increases in host-derived metabolites that signal through the aryl hydrocarbon receptor (AHR), a transcription factor with immunomodulatory functions. We find that Ahr-/- mice are more susceptible to malaria and develop high plasma heme and acute kidney injury. This phenotype is dependent on AHR in Tek-expressing radioresistant cells. Our findings identify a role for AHR in limiting tissue damage during malaria. Furthermore, this work demonstrates the critical role of host metabolism in surviving infection.
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Affiliation(s)
- Michelle M Lissner
- Department of Microbiology and Immunology, Stanford University, Stanford, United States
| | - Katherine Cumnock
- Department of Microbiology and Immunology, Stanford University, Stanford, United States
| | - Nicole M Davis
- Department of Microbiology and Immunology, Stanford University, Stanford, United States
| | - José G Vilches-Moure
- Department of Comparative Medicine, Stanford University, Stanford, United States
| | - Priyanka Basak
- Department of Microbiology and Immunology, Stanford University, Stanford, United States
| | - Daniel J Navarrete
- Department of Microbiology and Immunology, Stanford University, Stanford, United States
| | - Jessica A Allen
- Division of Health, Mathematics and Science, Columbia College, Columbia, United States
| | - David Schneider
- Department of Microbiology and Immunology, Stanford University, Stanford, United States
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17
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Erice C, Kain KC. New insights into microvascular injury to inform enhanced diagnostics and therapeutics for severe malaria. Virulence 2020; 10:1034-1046. [PMID: 31775570 PMCID: PMC6930010 DOI: 10.1080/21505594.2019.1696621] [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] [Indexed: 12/25/2022] Open
Abstract
Severe malaria (SM) has high mortality and morbidity rates despite treatment with potent antimalarials. Disease onset and outcome is dependent upon both parasite and host factors. Infected erythrocytes bind to host endothelium contributing to microvascular occlusion and dysregulated inflammatory and immune host responses, resulting in endothelial activation and microvascular damage. This review focuses on the mechanisms of host endothelial and microvascular injury. Only a small percentage of malaria infections (≤1%) progress to SM. Early recognition and treatment of SM can improve outcome, but we lack triage tools to identify SM early in the course of infection. Current point-of-care pathogen-based rapid diagnostic tests do not address this critical barrier. Immune and endothelial activation have been implicated in the pathobiology of SM. We hypothesize that measuring circulating mediators of these pathways at first clinical presentation will enable early triage and treatment of SM. Moreover, that host-based interventions that modulate these pathways will stabilize the microvasculature and improve clinical outcome over that of antimalarial therapy alone.
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Affiliation(s)
- Clara Erice
- Sandra-Rotman Centre for Global Health, Toronto General Research Institute, University Health Network-Toronto General Hospital, Toronto, Ontario, Canada
| | - Kevin C Kain
- Sandra-Rotman Centre for Global Health, Toronto General Research Institute, University Health Network-Toronto General Hospital, Toronto, Ontario, Canada.,Tropical Disease Unit, Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, Canada
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18
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Rivera-Correa J, Rodriguez A. Autoimmune Anemia in Malaria. Trends Parasitol 2020; 36:91-97. [PMID: 31864893 PMCID: PMC7101069 DOI: 10.1016/j.pt.2019.12.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 12/02/2019] [Accepted: 12/02/2019] [Indexed: 12/25/2022]
Abstract
Severe anemia is a major cause of death by malaria. The loss of uninfected erythrocytes is an important contributor to malarial anemia; however, the mechanisms underlying this pathology are not well understood. Malaria-induced anemia is related to autoimmune antibodies against the membrane lipid phosphatidylserine (PS). In mice, these antibodies induce the clearance of uninfected erythrocytes after binding to PS exposed in their membrane. In human malaria patients there is a strong correlation between anemia and anti-PS antibodies. During malaria, anti-PS antibodies are produced by atypical B cells, whose levels correlate with the development of anemia in patients. Autoimmune responses, which are documented frequently in different infections, contribute to the pathogenesis of malaria by inducing the clearance of uninfected erythrocytes.
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Affiliation(s)
- Juan Rivera-Correa
- New York University School of Medicine, New York, NY, USA; Current affiliations: Hospital for Special Surgery, New York, NY, USA; Weill-Cornell Medicine, New York, NY, USA
| | - Ana Rodriguez
- New York University School of Medicine, New York, NY, USA.
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19
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Malaria in Pregnancy and Adverse Birth Outcomes: New Mechanisms and Therapeutic Opportunities. Trends Parasitol 2019; 36:127-137. [PMID: 31864896 DOI: 10.1016/j.pt.2019.12.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 11/29/2019] [Accepted: 12/02/2019] [Indexed: 12/28/2022]
Abstract
Malaria infection during pregnancy is associated with adverse birth outcomes but underlying mechanisms are poorly understood. Here, we discuss the impact of malaria in pregnancy on three pathways that are important regulators of healthy pregnancy outcomes: L-arginine-nitric oxide biogenesis, complement activation, and the heme axis. These pathways are not mutually exclusive, and they collectively create a proinflammatory, antiangiogenic milieu at the maternal-fetal interface that interferes with placental function and development. We hypothesize that targeting these host-response pathways would mitigate the burden of adverse birth outcomes attributable to malaria in pregnancy.
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20
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Knackstedt SL, Georgiadou A, Apel F, Abu-Abed U, Moxon CA, Cunnington AJ, Raupach B, Cunningham D, Langhorne J, Krüger R, Barrera V, Harding SP, Berg A, Patel S, Otterdal K, Mordmüller B, Schwarzer E, Brinkmann V, Zychlinsky A, Amulic B. Neutrophil extracellular traps drive inflammatory pathogenesis in malaria. Sci Immunol 2019; 4:eaaw0336. [PMID: 31628160 PMCID: PMC6892640 DOI: 10.1126/sciimmunol.aaw0336] [Citation(s) in RCA: 94] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 06/04/2019] [Accepted: 09/17/2019] [Indexed: 12/13/2022]
Abstract
Neutrophils are essential innate immune cells that extrude chromatin in the form of neutrophil extracellular traps (NETs) when they die. This form of cell death has potent immunostimulatory activity. We show that heme-induced NETs are essential for malaria pathogenesis. Using patient samples and a mouse model, we define two mechanisms of NET-mediated inflammation of the vasculature: activation of emergency granulopoiesis via granulocyte colony-stimulating factor production and induction of the endothelial cytoadhesion receptor intercellular adhesion molecule-1. Soluble NET components facilitate parasite sequestration and mediate tissue destruction. We demonstrate that neutrophils have a key role in malaria immunopathology and propose inhibition of NETs as a treatment strategy in vascular infections.
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Affiliation(s)
- Sebastian Lorenz Knackstedt
- Max Planck Institute for Infection Biology, Department of Cellular Microbiology, Charitéplatz 1, 10117 Berlin, Germany
| | | | - Falko Apel
- Max Planck Institute for Infection Biology, Department of Cellular Microbiology, Charitéplatz 1, 10117 Berlin, Germany
| | - Ulrike Abu-Abed
- Max Planck Institute for Infection Biology, Microscopy Core Facility, Charitéplatz 1, 10117 Berlin, Germany
| | - Christopher A Moxon
- Wellcome Centre for Integrative Parasitology, Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
- Institute of Infection and Global Health, University of Liverpool, 8 West Derby Street, Liverpool L69 7BE, UK
| | | | - Bärbel Raupach
- Max Planck Institute for Infection Biology, Department of Cellular Microbiology, Charitéplatz 1, 10117 Berlin, Germany
| | | | - Jean Langhorne
- Francis Crick Institute, 1 Midland Road, London NW1 1AT, UK
| | - Renate Krüger
- Charité-Universitätsmedizin Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Pediatric Pneumology, Immunology and Intensive Care, Berlin, Germany
| | - Valentina Barrera
- Department of Eye and Vision Science, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | - Simon P Harding
- Department of Eye and Vision Science, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | - Aase Berg
- Stavanger University Hospital, Stavanger, Norway
| | - Sam Patel
- Maputo Central Hospital, Maputo, Mozambique
| | - Kari Otterdal
- Research Institute of Internal Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Benjamin Mordmüller
- Centre de Recherches Médicales de Lambaréné (CERMEL), Lambaréné, Gabon
- Universität Tübingen, Institut für Tropenmedizin, Wilhelmstraße 27, 72074 Tübingen, Germany
| | - Evelin Schwarzer
- Department of Oncology, University of Turin, Via Santena 5 bis, 10126 Turin, Italy
| | - Volker Brinkmann
- Max Planck Institute for Infection Biology, Microscopy Core Facility, Charitéplatz 1, 10117 Berlin, Germany
| | - Arturo Zychlinsky
- Max Planck Institute for Infection Biology, Department of Cellular Microbiology, Charitéplatz 1, 10117 Berlin, Germany
| | - Borko Amulic
- Max Planck Institute for Infection Biology, Department of Cellular Microbiology, Charitéplatz 1, 10117 Berlin, Germany.
- University of Bristol, School of Cellular and Molecular Medicine, Bristol BS8 1TD, UK
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21
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What Is Next in This "Age" of Heme-Driven Pathology and Protection by Hemopexin? An Update and Links with Iron. Pharmaceuticals (Basel) 2019; 12:ph12040144. [PMID: 31554244 PMCID: PMC6958331 DOI: 10.3390/ph12040144] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 09/08/2019] [Accepted: 09/19/2019] [Indexed: 02/07/2023] Open
Abstract
This review provides a synopsis of the published literature over the past two years on the heme-binding protein hemopexin (HPX), with some background information on the biochemistry of the HPX system. One focus is on the mechanisms of heme-driven pathology in the context of heme and iron homeostasis in human health and disease. The heme-binding protein hemopexin is a multi-functional protectant against hemoglobin (Hb)-derived heme toxicity as well as mitigating heme-mediated effects on immune cells, endothelial cells, and stem cells that collectively contribute to driving inflammation, perturbing vascular hemostasis and blood–brain barrier function. Heme toxicity, which may lead to iron toxicity, is recognized increasingly in a wide range of conditions involving hemolysis and immune system activation and, in this review, we highlight some newly identified actions of heme and hemopexin especially in situations where normal processes fail to maintain heme and iron homeostasis. Finally, we present preliminary data showing that the cytokine IL-6 cross talks with activation of the c-Jun N-terminal kinase pathway in response to heme-hemopexin in models of hepatocytes. This indicates another level of complexity in the cell responses to elevated heme via the HPX system when the immune system is activated and/or in the presence of inflammation.
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22
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Van Avondt K, Nur E, Zeerleder S. Mechanisms of haemolysis-induced kidney injury. Nat Rev Nephrol 2019; 15:671-692. [PMID: 31455889 DOI: 10.1038/s41581-019-0181-0] [Citation(s) in RCA: 89] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2019] [Indexed: 12/16/2022]
Abstract
Intravascular haemolysis is a fundamental feature of chronic hereditary and acquired haemolytic anaemias, including those associated with haemoglobinopathies, complement disorders and infectious diseases such as malaria. Destabilization of red blood cells (RBCs) within the vasculature results in systemic inflammation, vasomotor dysfunction, thrombophilia and proliferative vasculopathy. The haemoprotein scavengers haptoglobin and haemopexin act to limit circulating levels of free haemoglobin, haem and iron - potentially toxic species that are released from injured RBCs. However, these adaptive defence systems can fail owing to ongoing intravascular disintegration of RBCs. Induction of the haem-degrading enzyme haem oxygenase 1 (HO1) - and potentially HO2 - represents a response to, and endogenous defence against, large amounts of cellular haem; however, this system can also become saturated. A frequent adverse consequence of massive and/or chronic haemolysis is kidney injury, which contributes to the morbidity and mortality of chronic haemolytic diseases. Intravascular destruction of RBCs and the resulting accumulation of haemoproteins can induce kidney injury via a number of mechanisms, including oxidative stress and cytotoxicity pathways, through the formation of intratubular casts and through direct as well as indirect proinflammatory effects, the latter via the activation of neutrophils and monocytes. Understanding of the detailed pathophysiology of haemolysis-induced kidney injury offers opportunities for the design and implementation of new therapeutic strategies to counteract the unfavourable and potentially fatal effects of haemolysis on the kidney.
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Affiliation(s)
- Kristof Van Avondt
- Department of Immunopathology, Sanquin Research, and Landsteiner Laboratory, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands. .,Institute for Cardiovascular Prevention (IPEK), Ludwig Maximilian University of Munich, Munich, Germany.
| | - Erfan Nur
- Department of Haematology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Sacha Zeerleder
- Department of Immunopathology, Sanquin Research, and Landsteiner Laboratory, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands. .,Department of Haematology and Central Haematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland. .,Department for BioMedical Research, University of Bern, Bern, Switzerland.
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23
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Conroy AL, Opoka RO, Bangirana P, Idro R, Ssenkusu JM, Datta D, Hodges JS, Morgan C, John CC. Acute kidney injury is associated with impaired cognition and chronic kidney disease in a prospective cohort of children with severe malaria. BMC Med 2019; 17:98. [PMID: 31109328 PMCID: PMC6528242 DOI: 10.1186/s12916-019-1332-7] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 04/29/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is a recognized complication of pediatric severe malaria, but its long-term consequences are unknown. METHODS Ugandan children with cerebral malaria (CM, n = 260) and severe malaria anemia (SMA, n = 219) or community children (CC, n = 173) between 1.5 and 12 years of age were enrolled in a prospective cohort study. Kidney Disease: Improving Global Outcomes (KDIGO) criteria were used to retrospectively define AKI and chronic kidney disease (CKD). Cognitive testing was conducted using the Mullen Scales of Early Learning in children < 5 and Kaufman Assessment Battery for Children (K-ABC) second edition in children ≥ 5 years of age. RESULTS The prevalence of AKI was 35.1%, ranging from 25.1% in SMA to 43.5% in CM. In-hospital mortality was 11.9% in AKI compared to 4.2% in children without AKI (p = 0.001), and post-discharge mortality was 4.7% in AKI compared to 1.3% in children without AKI (p = 0.030) corresponding to an all-cause adjusted hazard ratio of 2.30 (95% CI 1.21, 4.35). AKI was a risk factor for short- and long-term neurocognitive impairment. At 1 week post-discharge, the frequency of neurocognitive impairment was 37.3% in AKI compared to 13.5% in children without AKI (adjusted odds ratio (aOR) 2.31 [95% CI 1.32, 4.04]); at 1-year follow-up, it was 13.3% in AKI compared to 3.4% in children without AKI (aOR 2.48 [95% CI 1.01, 6.10]), and at 2-year follow-up, it was 13.0% in AKI compared to 3.4% in children without AKI (aOR 3.03 [95% CI 1.22, 7.58]). AKI was a risk factor for CKD at 1-year follow-up: 7.6% of children with severe malaria-associated AKI had CKD at follow-up compared to 2.8% of children without AKI (p = 0.038) corresponding to an OR of 2.81 (95% CI 1.02, 7.73). The presenting etiology of AKI was consistent with prerenal azotemia, and lactate dehydrogenase as a marker of intravascular hemolysis was an independent risk factor for AKI in CM and SMA (p < 0.0001). In CM, AKI was associated with the presence and severity of retinopathy (p < 0.05) and increased cerebrospinal fluid albumin suggestive of blood-brain barrier disruption. CONCLUSIONS AKI is a risk factor for long-term neurocognitive impairment and CKD in pediatric severe malaria.
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Affiliation(s)
- Andrea L. Conroy
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, 1044 W. Walnut St., Indianapolis, IN 46202 USA
| | - Robert O. Opoka
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Paul Bangirana
- Department of Psychiatry, Makerere University College of Health Sciences, Kampala, Uganda
| | - Richard Idro
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - John M. Ssenkusu
- Department of Epidemiology and Biostatistics, Makerere University School of Public Health, Kampala, Uganda
| | - Dibyadyuti Datta
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, 1044 W. Walnut St., Indianapolis, IN 46202 USA
| | - James S. Hodges
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, USA
| | - Catherine Morgan
- Division of Pediatric Nephrology, University of Alberta, Edmonton, Canada
| | - Chandy C. John
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, 1044 W. Walnut St., Indianapolis, IN 46202 USA
- Division of Global Pediatrics, University of Minnesota Medical School, Minneapolis, USA
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24
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Conroy AL, Datta D, John CC. What causes severe malaria and its complications in children? Lessons learned over the past 15 years. BMC Med 2019; 17:52. [PMID: 30841892 PMCID: PMC6404293 DOI: 10.1186/s12916-019-1291-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 02/14/2019] [Indexed: 01/31/2023] Open
Abstract
Over the past 15 years, malaria mortality has reduced by approximately 50%. However, malaria still causes more than 400,000 deaths annually, most of which occur in African children under 5 years of age. Significant advances in understanding the pathogenesis of the disease provide a basis for future work to prevent severe malaria and its complications. Herein, we provide an overview of advances in our understanding of severe malaria in African children over the past 15 years, highlighting key complications and identifying priorities to further reduce malaria-associated mortality.
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Affiliation(s)
- Andrea L Conroy
- Ryan White Center for Pediatric Infectious Diseases and Global Health, Indiana University School of Medicine, 1044 W Walnut St R4 402D, Indianapolis, IN, USA
| | - Dibyadyuti Datta
- Ryan White Center for Pediatric Infectious Diseases and Global Health, Indiana University School of Medicine, 1044 W Walnut St R4 402D, Indianapolis, IN, USA
| | - Chandy C John
- Ryan White Center for Pediatric Infectious Diseases and Global Health, Indiana University School of Medicine, 1044 W Walnut St R4 402D, Indianapolis, IN, USA.
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25
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Gáll T, Pethő D, Nagy A, Hendrik Z, Méhes G, Potor L, Gram M, Åkerström B, Smith A, Nagy P, Balla G, Balla J. Heme Induces Endoplasmic Reticulum Stress (HIER Stress) in Human Aortic Smooth Muscle Cells. Front Physiol 2018; 9:1595. [PMID: 30515102 PMCID: PMC6255930 DOI: 10.3389/fphys.2018.01595] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 10/24/2018] [Indexed: 12/17/2022] Open
Abstract
Accumulation of damaged or misfolded proteins resulted from oxidative protein modification induces endoplasmic reticulum (ER) stress by activating the pathways of unfolded protein response. In pathologic hemolytic conditions, extracellular free hemoglobin is submitted to rapid oxidation causing heme release. Resident cells of atherosclerotic lesions, after intraplaque hemorrhage, are exposed to heme leading to oxidative injury. Therefore, we raised the question whether heme can also provoke ER stress. Smooth muscle cells are one of the key players of atherogenesis; thus, human aortic smooth muscle cells (HAoSMCs) were selected as a model cell to reveal the possible link between heme and ER stress. Using immunoblotting, quantitative polymerase chain reaction and immunocytochemistry, we quantitated the markers of ER stress. These were: phosphorylated eIF2α, Activating transcription factor-4 (ATF4), DNA-damage-inducible transcript 3 (also known as C/EBP homology protein, termed CHOP), X-box binding protein-1 (XBP1), Activating transcription factor-6 (ATF6), GRP78 (glucose-regulated protein, 78kDa) and heme responsive genes heme oxygenase-1 and ferritin. In addition, immunohistochemistry was performed on human carotid artery specimens from patients who had undergone carotid endarterectomy. We demonstrate that heme increases the phosphorylation of eiF2α in HAoSMCs and the expression of ATF4. Heme also enhances the splicing of XBP1 and the proteolytic cleavage of ATF6. Consequently, there is up-regulation of target genes increasing both mRNA and protein levels of CHOP and GRP78. However, TGFβ and collagen type I decreased. When the heme binding proteins, alpha-1-microglobulin (A1M) and hemopexin (Hpx) are present in cell media, the ER stress provoked by heme is inhibited. ER stress pathways are also retarded by the antioxidant N-acetyl cysteine (NAC) indicating that reactive oxygen species are involved in heme-induced ER stress. Consistent with these findings, elevated expression of the ER stress marker GRP78 and CHOP were observed in smooth muscle cells of complicated lesions with hemorrhage compared to either atheromas or healthy arteries. In conclusion, heme triggers ER stress in a time- and dose-dependent manner in HAoSMCs. A1M and Hpx as well as NAC effectively hamper heme-induced ER stress, supporting their use as a potential therapeutic approach to reverse such a deleterious effects of heme toxicity.
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Affiliation(s)
- Tamás Gáll
- HAS-UD Vascular Biology and Myocardial Pathophysiology Research Group, Hungarian Academy of Sciences, Debrecen, Hungary
- Department of Pediatrics, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Dávid Pethő
- Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Annamária Nagy
- Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Zoltán Hendrik
- Department of Pathology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Gábor Méhes
- Department of Pathology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - László Potor
- HAS-UD Vascular Biology and Myocardial Pathophysiology Research Group, Hungarian Academy of Sciences, Debrecen, Hungary
- Department of Pediatrics, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Magnus Gram
- Department of Clinical Sciences Lund, Infection Medicine, Lund University, Lund, Sweden
| | - Bo Åkerström
- Department of Clinical Sciences Lund, Infection Medicine, Lund University, Lund, Sweden
| | - Ann Smith
- Department of Molecular Biology and Biochemistry, School of Biological Sciences, University of Missouri-Kansas City, Kansas City, MO, United States
| | - Péter Nagy
- Department of Vascular Surgery, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - György Balla
- HAS-UD Vascular Biology and Myocardial Pathophysiology Research Group, Hungarian Academy of Sciences, Debrecen, Hungary
- Department of Pediatrics, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - József Balla
- HAS-UD Vascular Biology and Myocardial Pathophysiology Research Group, Hungarian Academy of Sciences, Debrecen, Hungary
- Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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26
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Barber BE, Grigg MJ, Piera KA, William T, Cooper DJ, Plewes K, Dondorp AM, Yeo TW, Anstey NM. Intravascular haemolysis in severe Plasmodium knowlesi malaria: association with endothelial activation, microvascular dysfunction, and acute kidney injury. Emerg Microbes Infect 2018; 7:106. [PMID: 29872039 PMCID: PMC5988665 DOI: 10.1038/s41426-018-0105-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 05/03/2018] [Accepted: 05/08/2018] [Indexed: 12/29/2022]
Abstract
Plasmodium knowlesi occurs throughout Southeast Asia, and is the most common cause of human malaria in Malaysia. Severe disease in humans is characterised by high parasite biomass, reduced red blood cell deformability, endothelial activation and microvascular dysfunction. However, the roles of intravascular haemolysis and nitric oxide (NO)-dependent endothelial dysfunction, important features of severe falciparum malaria, have not been evaluated, nor their role in acute kidney injury (AKI). In hospitalised Malaysian adults with severe (n = 48) and non-severe (n = 154) knowlesi malaria, and in healthy controls (n = 50), we measured cell-free haemoglobin (CFHb) and assessed associations with the endothelial Weibel–Palade body (WPB) constituents, angiopoietin-2 and osteoprotegerin, endothelial and microvascular function, and other markers of disease severity. CFHb was increased in knowlesi malaria in proportion to disease severity, and to a greater extent than previously reported in severe falciparum malaria patients from the same study cohort. In knowlesi malaria, CFHb was associated with parasitaemia, and independently associated with angiopoietin-2 and osteoprotegerin. As with angiopoietin-2, osteoprotegerin was increased in proportion to disease severity, and independently associated with severity markers including creatinine, lactate, interleukin-6, endothelial cell adhesion molecules ICAM-1 and E-selectin, and impaired microvascular reactivity. Osteoprotegerin was also independently associated with NO-dependent endothelial dysfunction. AKI was found in 88% of those with severe knowlesi malaria. Angiopoietin-2 and osteoprotegerin were both independent risk factors for acute kidney injury. Our findings suggest that haemolysis-mediated endothelial activation and release of WPB constituents is likely a key contributor to end-organ dysfunction, including AKI, in severe knowlesi malaria.
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Affiliation(s)
- Bridget E Barber
- Global and Tropical Health Division, Menzies School of Health Research, Darwin, NT, Australia. .,Infectious Diseases Society Sabah-Menzies School of Health Research Clinical Research Unit, Kota Kinabalu, Sabah, Malaysia.
| | - Matthew J Grigg
- Global and Tropical Health Division, Menzies School of Health Research, Darwin, NT, Australia.,Infectious Diseases Society Sabah-Menzies School of Health Research Clinical Research Unit, Kota Kinabalu, Sabah, Malaysia
| | - Kim A Piera
- Global and Tropical Health Division, Menzies School of Health Research, Darwin, NT, Australia
| | - Timothy William
- Infectious Diseases Society Sabah-Menzies School of Health Research Clinical Research Unit, Kota Kinabalu, Sabah, Malaysia.,Jesselton Medical Centre, Kota Kinabalu, Sabah, Malaysia.,Clinical Research Centre, Queen Elizabeth Hospital, Kota Kinabalu, Sabah, Malaysia
| | - Daniel J Cooper
- Global and Tropical Health Division, Menzies School of Health Research, Darwin, NT, Australia.,Infectious Diseases Society Sabah-Menzies School of Health Research Clinical Research Unit, Kota Kinabalu, Sabah, Malaysia
| | - Katherine Plewes
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand.,Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Arjen M Dondorp
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Tsin W Yeo
- Global and Tropical Health Division, Menzies School of Health Research, Darwin, NT, Australia.,Infectious Diseases Society Sabah-Menzies School of Health Research Clinical Research Unit, Kota Kinabalu, Sabah, Malaysia.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.,Institute of Infectious Disease and Epidemiology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Nicholas M Anstey
- Global and Tropical Health Division, Menzies School of Health Research, Darwin, NT, Australia.,Infectious Diseases Society Sabah-Menzies School of Health Research Clinical Research Unit, Kota Kinabalu, Sabah, Malaysia
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27
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Nath KA, Belcher JD, Nath MC, Grande JP, Croatt AJ, Ackerman AW, Katusic ZS, Vercellotti GM. Role of TLR4 signaling in the nephrotoxicity of heme and heme proteins. Am J Physiol Renal Physiol 2018; 314:F906-F914. [PMID: 28978536 PMCID: PMC6031913 DOI: 10.1152/ajprenal.00432.2017] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 09/29/2017] [Accepted: 10/01/2017] [Indexed: 12/23/2022] Open
Abstract
Destabilized heme proteins release heme, and free heme is toxic. Heme is now recognized as an agonist for the Toll-like receptor-4 (TLR4) receptor. This study examined whether the TLR4 receptor mediates the nephrotoxicity of heme, specifically, the effects of heme on renal blood flow and inflammatory responses. We blocked TLR4 signaling by the specific antagonist TAK-242. Intravenous administration of heme to mice promptly reduced renal blood flow, an effect attenuated by TAK-242. In vitro, TAK-242 reduced heme-elicited activation of NF-κB and its downstream gene monocyte chemoattractant protein-1(MCP-1); in contrast, TAK-242 failed to reduce heme-induced activation of the anti-inflammatory transcription factor Nrf2 and its downstream gene heme oxygenase-1 (HO-1). TAK-242 did not reduce heme-induced renal MCP-1 upregulation in vivo. TAK-242 did not reduce dysfunction and histological injury in the glycerol model of heme protein-induced acute kidney injury (AKI), findings corroborated by studies in TLR4+/+ and TLR4-/- mice. We conclude that 1) acute heme-mediated renal vasoconstriction occurs through TLR4 signaling; 2) proinflammatory effects of heme in renal epithelial cells involve TLR4 signaling, whereas the anti-inflammatory effects of heme do not; 3) TLR4 signaling does not mediate the proinflammatory effects of heme in the kidney; and 4) major mechanisms underlying glycerol-induced, heme protein-mediated AKI do not involve TLR4 signaling. These findings in the glycerol model are in stark contrast with findings in virtually all other AKI models studied to date and emphasize the importance of TLR4-independent pathways of heme protein-mediated injury in this model. Finally, these studies urge caution when using observations derived in vitro to predict what occurs in vivo.
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Affiliation(s)
- Karl A Nath
- Division of Nephrology and Hypertension, Mayo Clinic , Rochester, Minnesota
| | - John D Belcher
- Division of Hematology, Oncology and Transplantation, University of Minnesota , Minneapolis, Minnesota
| | - Meryl C Nath
- Department of Pathology, Mayo Clinic , Rochester, Minnesota
| | | | - Anthony J Croatt
- Division of Nephrology and Hypertension, Mayo Clinic , Rochester, Minnesota
| | - Allan W Ackerman
- Division of Nephrology and Hypertension, Mayo Clinic , Rochester, Minnesota
| | | | - Gregory M Vercellotti
- Division of Hematology, Oncology and Transplantation, University of Minnesota , Minneapolis, Minnesota
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28
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Cooper DJ, Plewes K, Grigg MJ, Rajahram GS, Piera KA, William T, Chatfield MD, Yeo TW, Dondorp AM, Anstey NM, Barber BE. The effect of regularly dosed paracetamol versus no paracetamol on renal function in Plasmodium knowlesi malaria (PACKNOW): study protocol for a randomised controlled trial. Trials 2018; 19:250. [PMID: 29690924 PMCID: PMC5926539 DOI: 10.1186/s13063-018-2600-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 03/19/2018] [Indexed: 11/27/2022] Open
Abstract
Background Plasmodium knowlesi is the most common cause of human malaria in Malaysia. Acute kidney injury (AKI) is a frequent complication. AKI of any cause can have long-term consequences, including increased risk of chronic kidney disease, adverse cardiovascular events and increased mortality. Additional management strategies are therefore needed to reduce the frequency and severity of AKI in malaria. In falciparum malaria, cell-free haemoglobin (CFHb)-mediated oxidative damage contributes to AKI. The inexpensive and widely available drug paracetamol inhibits CFHb-induced lipid peroxidation via reduction of ferryl haem to the less toxic Fe3+ state, and has been shown to reduce oxidative damage and improve renal function in patients with sepsis complicated by haemolysis as well as in falciparum malaria. This study aims to assess the ability of regularly dosed paracetamol to reduce the incidence and severity of AKI in knowlesi malaria by attenuating haemolysis-induced oxidative damage. Methods PACKNOW is a two-arm, open-label randomised controlled trial of adjunctive paracetamol versus no paracetamol in patients aged ≥ 5 years with knowlesi malaria, conducted over a 2-year period at four hospital sites in Sabah, Malaysia. The primary endpoint of change in creatinine from enrolment to 72 h will be evaluated by analysis of covariance (ANCOVA) using enrolment creatinine as a covariate. Secondary endpoints include longitudinal changes in markers of oxidative stress (plasma F2-isoprostanes and isofurans) and markers of endothelial activation/Weibel–Palade body release (angiopoietin-2, von Willebrand Factor, P-selectin, osteoprotegerin) over 72 h, as well as blood and urine biomarkers of AKI. This study will be powered to detect a difference between the two treatment arms in a clinically relevant population including adults and children with knowlesi malaria of any severity. Discussion Paracetamol is widely available and has an excellent safety profile; if a renoprotective effect is demonstrated, this trial will support the administration of regularly dosed paracetamol to all patients with knowlesi malaria. The secondary outcomes in this study will provide further insights into the pathophysiology of haemolysis-induced oxidative damage and acute kidney injury in knowlesi malaria and other haemolytic diseases. Trial registration Clinicaltrials.gov, NCT03056391. Registered on 12 October 2016. Electronic supplementary material The online version of this article (10.1186/s13063-018-2600-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Daniel J Cooper
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, NT, Australia. .,Infectious Diseases Society Sabah-Menzies School of Health Research Clinical Research Unit, Kota Kinabalu, Sabah, Malaysia.
| | - Katherine Plewes
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.,Division of Infectious Diseases, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Matthew J Grigg
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, NT, Australia.,Infectious Diseases Society Sabah-Menzies School of Health Research Clinical Research Unit, Kota Kinabalu, Sabah, Malaysia
| | - Giri S Rajahram
- Infectious Diseases Society Sabah-Menzies School of Health Research Clinical Research Unit, Kota Kinabalu, Sabah, Malaysia.,Infectious Diseases Unit, Clinical Research Centre, Queen Elizabeth Hospital, Kota Kinabalu, Sabah, Malaysia.,Sabah Department of Health, Kota Kinabalu, Sabah, Malaysia
| | - Kim A Piera
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, NT, Australia
| | - Timothy William
- Infectious Diseases Society Sabah-Menzies School of Health Research Clinical Research Unit, Kota Kinabalu, Sabah, Malaysia.,Jesselton Medical Centre, Kota Kinabalu, Sabah, Malaysia
| | - Mark D Chatfield
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, NT, Australia.,Queensland Institute of Medical Research, Brisbane, Australia
| | - Tsin Wen Yeo
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, NT, Australia.,Infectious Diseases Society Sabah-Menzies School of Health Research Clinical Research Unit, Kota Kinabalu, Sabah, Malaysia.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Arjen M Dondorp
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Nicholas M Anstey
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, NT, Australia.,Infectious Diseases Society Sabah-Menzies School of Health Research Clinical Research Unit, Kota Kinabalu, Sabah, Malaysia
| | - Bridget E Barber
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, NT, Australia.,Infectious Diseases Society Sabah-Menzies School of Health Research Clinical Research Unit, Kota Kinabalu, Sabah, Malaysia.,Queensland Institute of Medical Research, Brisbane, Australia
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29
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Conroy AL, Hawkes MT, Elphinstone R, Opoka RO, Namasopo S, Miller C, John CC, Kain KC. Chitinase-3-like 1 is a biomarker of acute kidney injury and mortality in paediatric severe malaria. Malar J 2018; 17:82. [PMID: 29448936 PMCID: PMC5815237 DOI: 10.1186/s12936-018-2225-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 02/07/2018] [Indexed: 12/16/2022] Open
Abstract
Background Chitinase-3-like 1 (CHI3L1) is a glycoprotein elevated in paediatric severe malaria, and an emerging urinary biomarker of acute kidney injury (AKI). Based on the hypothesis that elevated CHI3L1 levels in malaria are associated with disease severity, the relationship between plasma CHI3L1 levels, AKI and mortality was investigated in Ugandan children enrolled in a clinical trial evaluating inhaled nitric oxide (iNO) as an adjunctive therapy for severe malaria. Methods Plasma CHI3L1 levels were measured daily for 4 days in children admitted to hospital with severe malaria and at day 14 follow up. AKI was defined using the Kidney Disease: Improving Global Outcomes consensus criteria. This is a secondary analysis of a randomized double-blind placebo-controlled trial of iNO versus placebo as an adjunctive therapy for severe malaria. Inclusion criteria were: age 1–10 years, and selected criteria for severe malaria. Exclusion criteria included suspected bacterial meningitis, known chronic illness including renal disease, haemoglobinopathy, or severe malnutrition. iNO was administered by non-rebreather mask for up to 72 h at 80 ppm. Results CHI3L1 was elevated in patients with AKI and remained higher over hospitalization (p < 0.0001). Admission CHI3L1 levels were elevated in children who died. By multivariable analysis logCHI3L1 levels were associated with increased risk of in-hospital death (relative risk, 95% CI 4.10, 1.32–12.75, p = 0.015) and all-cause 6 month mortality (3.21, 1.47–6.98, p = 0.003) following correction for iNO and AKI. Treatment with iNO was associated with delayed CHI3L1 recovery with a daily decline of 34% in the placebo group versus 29% in the iNO group (p = 0.012). CHI3L1 levels correlated with markers of inflammation (CRP, sTREM-1, CXCL10), endothelial activation (Ang-2, sICAM-1) and intravascular haemolysis (LDH, haem, haemopexin). Conclusions CHI3L1 is a novel biomarker of malaria-associated AKI and an independent risk factor for mortality that is associated with well-established pathways of severe malaria pathogenesis including inflammation, endothelial activation, and haemolysis. Trial registration Clinicaltrials.gov, NCT01255215. Registered December 7th 2010 Electronic supplementary material The online version of this article (10.1186/s12936-018-2225-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Andrea L Conroy
- Department of Pediatrics, Indiana University School of Medicine, 1044 West Walnut St., Building 4, Indianapolis, IN, 46202, USA. .,Sandra Rotman Centre for Global Health, Toronto General Hospital, University Health Network, MaRS Centre, 101 College St. TMDT 10-360A, Toronto, ON, M5G 1L7, Canada. .,Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, ON, Canada.
| | - Michael T Hawkes
- Division of Pediatric Infectious Diseases, 3-593 Edmonton Clinic Health Academy, University of Alberta, Edmonton, AB, T6G1C9, Canada
| | - Robyn Elphinstone
- Sandra Rotman Centre for Global Health, Toronto General Hospital, University Health Network, MaRS Centre, 101 College St. TMDT 10-360A, Toronto, ON, M5G 1L7, Canada
| | - Robert O Opoka
- Department of Pediatrics and Child Health, Makerere University, Kampala, Uganda
| | - Sophie Namasopo
- Department of Pediatrics, Jinja Regional Referral Hospital, P.O. Box 43, Jinja, Uganda
| | | | - Chandy C John
- Department of Pediatrics, Indiana University School of Medicine, 1044 West Walnut St., Building 4, Indianapolis, IN, 46202, USA
| | - Kevin C Kain
- Sandra Rotman Centre for Global Health, Toronto General Hospital, University Health Network, MaRS Centre, 101 College St. TMDT 10-360A, Toronto, ON, M5G 1L7, Canada.,Division of Infectious Diseases, Department of Medicine, University of Toronto, Toronto, ON, Canada
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Plewes K, Turner GD, Dondorp AM. Pathophysiology, clinical presentation, and treatment of coma and acute kidney injury complicating falciparum malaria. Curr Opin Infect Dis 2018; 31:69-77. [PMID: 29206655 PMCID: PMC5768231 DOI: 10.1097/qco.0000000000000419] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW Cerebral impairment and acute kidney injury (AKI) are independent predictors of mortality in both adults and children with severe falciparum malaria. In this review, we present recent advances in understanding the pathophysiology, clinical features, and management of these complications of severe malaria, and discuss future areas of research. RECENT FINDINGS Cerebral malaria and AKI are serious and well recognized complications of severe malaria. Common pathophysiological pathways include impaired microcirculation, due to sequestration of parasitized erythrocytes, systemic inflammatory responses, and endothelial activation. Recent MRI studies show significant brain swelling in both adults and children with evidence of posterior reversible encephalopathy syndrome-like syndrome although targeted interventions including mannitol and dexamethasone are not beneficial. Recent work shows association of cell-free hemoglobin oxidation stress involved in the pathophysiology of AKI in both adults and children. Paracetamol protected renal function likely by inhibiting cell-free-mediated oxidative stress. It is unclear if heme-mediated endothelial activation or oxidative stress is involved in cerebral malaria. SUMMARY The direct causes of cerebral and kidney dysfunction remain incompletely understood. Optimal treatment involves prompt diagnosis and effective antimalarial treatment with artesunate. Renal replacement therapy reduces mortality in AKI but delayed diagnosis is an issue.
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Affiliation(s)
- Katherine Plewes
- Faculty of Tropical Medicine, Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Division of Infectious Diseases, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Gareth D.H. Turner
- Department of Cellular Pathology, John Radcliffe Hospital
- Nuffield Department of Clinical Medicine, Center for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Arjen M. Dondorp
- Faculty of Tropical Medicine, Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Nuffield Department of Clinical Medicine, Center for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
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31
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Varo R, Crowley VM, Sitoe A, Madrid L, Serghides L, Kain KC, Bassat Q. Adjunctive therapy for severe malaria: a review and critical appraisal. Malar J 2018; 17:47. [PMID: 29361945 PMCID: PMC5781278 DOI: 10.1186/s12936-018-2195-7] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 01/19/2018] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Despite recent efforts and successes in reducing the malaria burden globally, this infection still accounts for an estimated 212 million clinical cases, 2 million severe malaria cases, and approximately 429,000 deaths annually. Even with the routine use of effective anti-malarial drugs, the case fatality rate for severe malaria remains unacceptably high, with cerebral malaria being one of the most life-threatening complications. Up to one-third of cerebral malaria survivors are left with long-term cognitive and neurological deficits. From a population point of view, the decrease of malaria transmission may jeopardize the development of naturally acquired immunity against the infection, leading to fewer total cases, but potentially an increase in severe cases. The pathophysiology of severe and cerebral malaria is not completely understood, but both parasite and host determinants contribute to its onset and outcomes. Adjunctive therapy, based on modulating the host response to infection, could help to improve the outcomes achieved with specific anti-malarial therapy. RESULTS AND CONCLUSIONS In the last decades, several interventions targeting different pathways have been tested. However, none of these strategies have demonstrated clear beneficial effects, and some have shown deleterious outcomes. This review aims to summarize evidence from clinical trials testing different adjunctive therapy for severe and cerebral malaria in humans. It also highlights some preclinical studies which have evaluated novel strategies and other candidate therapeutics that may be evaluated in future clinical trials.
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Affiliation(s)
- Rosauro Varo
- Centro de Investigação em Saúde de Manhiça, Rua 12, vila da Manhiça, 1929, Maputo, Mozambique.
- ISGlobal, Barcelona Institute for Global Health, Hospital Clínic, Universitat de Barcelona, Rosselló 132, 5th Floor, 08036, Barcelona, Spain.
| | - Valerie M Crowley
- S. A. Rotman Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Canada
| | - Antonio Sitoe
- Centro de Investigação em Saúde de Manhiça, Rua 12, vila da Manhiça, 1929, Maputo, Mozambique
| | - Lola Madrid
- Centro de Investigação em Saúde de Manhiça, Rua 12, vila da Manhiça, 1929, Maputo, Mozambique
- ISGlobal, Barcelona Institute for Global Health, Hospital Clínic, Universitat de Barcelona, Rosselló 132, 5th Floor, 08036, Barcelona, Spain
| | - Lena Serghides
- Toronto General Research Institute (TGRI), University Health Network, Toronto, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, Canada
- Department of Immunology and Institute of Medical Sciences, University of Toronto, Toronto, Canada
| | - Kevin C Kain
- S. A. Rotman Laboratories, Sandra Rotman Centre for Global Health, University Health Network-Toronto General Hospital, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Tropical Diseases Unit, Division of Infectious Diseases, Department of Medicine, UHN-Toronto General Hospital, Toronto, ON, Canada
| | - Quique Bassat
- Centro de Investigação em Saúde de Manhiça, Rua 12, vila da Manhiça, 1929, Maputo, Mozambique.
- ISGlobal, Barcelona Institute for Global Health, Hospital Clínic, Universitat de Barcelona, Rosselló 132, 5th Floor, 08036, Barcelona, Spain.
- ICREA, Pg. Lluís Companys 23, 08010, Barcelona, Spain.
- Pediatric Infectious Diseases Unit, Pediatrics Department, Hospital Sant Joan de Déu (University of Barcelona), Barcelona, Spain.
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Zauberman A, Vagima Y, Tidhar A, Aftalion M, Gur D, Rotem S, Chitlaru T, Levy Y, Mamroud E. Host Iron Nutritional Immunity Induced by a Live Yersinia pestis Vaccine Strain Is Associated with Immediate Protection against Plague. Front Cell Infect Microbiol 2017; 7:277. [PMID: 28680860 PMCID: PMC5478729 DOI: 10.3389/fcimb.2017.00277] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Accepted: 06/06/2017] [Indexed: 12/29/2022] Open
Abstract
Prompt and effective elicitation of protective immunity is highly relevant for cases of rapidly deteriorating fatal diseases, such as plague, which is caused by Yersinia pestis. Here, we assessed the potential of a live vaccine to induce rapid protection against this infection. We demonstrated that the Y. pestis EV76 live vaccine protected mice against an immediate lethal challenge, limiting the multiplication of the virulent pathogen and its dissemination into circulation. Ex vivo analysis of Y. pestis growth in serum derived from EV76-immunized mice revealed that an antibacterial activity was produced rapidly. This activity was mediated by the host heme- and iron-binding proteins hemopexin and transferrin, and it occurred in strong correlation with the kinetics of hemopexin induction in vivo. We suggest a new concept in which a live vaccine is capable of rapidly inducing iron nutritional immunity, thus limiting the propagation of pathogens. This concept could be exploited to design novel therapeutic interventions.
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Affiliation(s)
- Ayelet Zauberman
- Department of Biochemistry and Molecular Genetics, Israel Institute for Biological ResearchNess-Ziona, Israel
| | | | | | | | | | | | | | | | - Emanuelle Mamroud
- Department of Biochemistry and Molecular Genetics, Israel Institute for Biological ResearchNess-Ziona, Israel
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Immenschuh S, Vijayan V, Janciauskiene S, Gueler F. Heme as a Target for Therapeutic Interventions. Front Pharmacol 2017; 8:146. [PMID: 28420988 PMCID: PMC5378770 DOI: 10.3389/fphar.2017.00146] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 03/07/2017] [Indexed: 12/30/2022] Open
Abstract
Heme is a complex of iron and the tetrapyrrole protoporphyrin IX with essential functions in aerobic organisms. Heme is the prosthetic group of hemoproteins such as hemoglobin and myoglobin, which are crucial for reversible oxygen binding and transport. By contrast, high levels of free heme, which may occur in various pathophysiological conditions, are toxic via pro-oxidant, pro-inflammatory and cytotoxic effects. The toxicity of heme plays a major role for the pathogenesis of prototypical hemolytic disorders including sickle cell disease and malaria. Moreover, there is increasing appreciation that detrimental effects of heme may also be critically involved in diseases, which usually are not associated with hemolysis such as severe sepsis and atherosclerosis. In mammalians homeostasis of heme and its potential toxicity are primarily controlled by two physiological systems. First, the scavenger protein hemopexin (Hx) non-covalently binds extracellular free heme with high affinity and attenuates toxicity of heme in plasma. Second, heme oxygenases (HOs), in particular the inducible HO isozyme, HO-1, can provide antioxidant cytoprotection via enzymatic degradation of intracellular heme. This review summarizes current knowledge on the pathophysiological role of heme for various diseases as demonstrated in experimental animal models and in humans. The functional significance of Hx and HOs for the regulation of heme homeostasis is highlighted. Finally, the therapeutic potential of pharmacological strategies that apply Hx and HO-1 in various clinical settings is discussed.
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Affiliation(s)
- Stephan Immenschuh
- Institute for Transfusion Medicine, Hannover Medical SchoolHannover, Germany
| | - Vijith Vijayan
- Institute for Transfusion Medicine, Hannover Medical SchoolHannover, Germany
| | | | - Faikah Gueler
- Department of Nephrology, Hannover Medical SchoolHannover, Germany
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Smith A, McCulloh RJ. Mechanisms of haem toxicity in haemolysis and protection by the haem-binding protein, haemopexin. ACTA ACUST UNITED AC 2017. [DOI: 10.1111/voxs.12340] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- A. Smith
- School of Biological Sciences; University of Missouri-Kansas City; Kansas City MO USA
| | - R. J. McCulloh
- Department of Pediatrics; Children's Mercy Hospital; Kansas City MO USA
- University of Missouri-Kansas City School of Medicine; Kansas City MO USA
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Gillrie MR, Ho M. Dynamic interactions of Plasmodium spp. with vascular endothelium. Tissue Barriers 2017; 5:e1268667. [PMID: 28452684 PMCID: PMC5362994 DOI: 10.1080/21688370.2016.1268667] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 11/24/2016] [Accepted: 11/30/2016] [Indexed: 12/18/2022] Open
Abstract
Plasmodial species are protozoan parasites that infect erythrocytes. As such, they are in close contact with microvascular endothelium for most of the life cycle in the mammalian host. The host-parasite interactions of this stage of the infection are responsible for the clinical manifestations of the disease that range from a mild febrile illness to severe and frequently fatal syndromes such as cerebral malaria and multi-organ failure. Plasmodium falciparum, the causative agent of the most severe form of malaria, is particularly predisposed to modulating endothelial function through either direct adhesion to endothelial receptor molecules, or by releasing potent host and parasite products that can stimulate endothelial activation and/or disrupt barrier function. In this review, we provide a critical analysis of the current clinical and laboratory evidence for endothelial dysfunction during severe P. falciparum malaria. Future investigations using state-of-the-art technologies such as mass cytometry and organs-on-chips to further delineate parasite-endothelial cell interactions are also discussed.
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Affiliation(s)
- Mark R. Gillrie
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - May Ho
- Department of Microbiology, Immunology and Infectious Diseases, University of Calgary, Calgary, Alberta, Canada
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