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Zhang Y, Chen C, Mitsnefes M, Huang B, Devarajan P. Evaluation of diagnostic accuracy of urine neutrophil gelatinase-associated lipocalin in patients with symptoms of urinary tract infections: a meta-analysis. Front Pediatr 2024; 12:1368583. [PMID: 38840804 PMCID: PMC11150804 DOI: 10.3389/fped.2024.1368583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 04/23/2024] [Indexed: 06/07/2024] Open
Abstract
Introduction Early and accurate diagnosis of urinary tract infection (UTI) can prevent serious sequelae including chronic kidney disease. Multiple individual studies have identified urine neutrophil gelatinase-associated lipocalin (uNGAL) as a promising biomarker for early diagnosis of UTI. We sought to understand the distribution and diagnostic accuracy of uNGAL values in patients presenting with UTI symptoms. Methods Our systematic literature reviews in PubMed, Embase, and Cochrane Reviews up to March 2024, identified 25 studies reporting mean/median, standard deviation/quartiles, and detection limits of uNGAL in symptomatic patients with and without culture-confirmed UTI. Seventeen studies were in children. Meta-analyses were performed using the quantile estimation (QE) method estimating the distributions of uNGAL, which were then compared between the UTI and non-UTI groups for identifying the best cut-off points maximizing the Youden index. Sensitivity analyses were performed on all 25 studies including adult patients. Results We found that uNGAL levels were significantly higher in samples with confirmed UTI compared to those without. In pediatric studies, median and 95% confidence interval (CI) of uNGAL values were 22.41 (95% CI of 9.94, 50.54) ng/mL in non-UTI group vs. 118.85 (95% CI of 43.07, 327.97) ng/mL in UTI group. We estimated the cut-off point of 48.43 ng/mL with highest sensitivity (96%) and specificity (97%) in children. Sensitivity analysis including both pediatric and adult studies yielded similar results. Discussion The level of uNGAL in symptomatic patients with confirmed UTI is much higher than that reported in patients without UTI. It may be used as a diagnostic tool to identify UTI early among symptomatic patients. The range of uNGAL concentrations and cut-off points reported in subjects with UTI is much lower than that reported in patients with acute intrinsic kidney injury. Systematic Review Registration https://www.crd.york.ac.uk/, PROSPERO (CRD42023370451).
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Affiliation(s)
- Yin Zhang
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
| | - Chen Chen
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
| | - Mark Mitsnefes
- Division of Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Bin Huang
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Prasad Devarajan
- Division of Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
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2
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Bilsen MP, Treep MM, Aantjes MJ, van Andel E, Stalenhoef JE, van Nieuwkoop C, Leyten EMS, Delfos NM, van Uhm JIM, Sijbom M, Akintola AA, Numans ME, Achterberg WP, Mooijaart SP, van der Beek MT, Cobbaert CM, Conroy SP, Visser LG, Lambregts MMC. Diagnostic accuracy of urine biomarkers for urinary tract infection in older women: a case-control study. Clin Microbiol Infect 2024; 30:216-222. [PMID: 37805035 DOI: 10.1016/j.cmi.2023.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 09/27/2023] [Accepted: 09/30/2023] [Indexed: 10/09/2023]
Abstract
OBJECTIVES Urinary tract infection (UTI) is common among older women. However, diagnosis is challenging because of frequent chronic lower urinary tract symptoms, cognitive impairment, and a high prevalence of asymptomatic bacteriuria (ASB). Current urine diagnostics lack specificity, leading to unnecessary treatment and antimicrobial resistance. This study aimed to evaluate the diagnostic accuracy of 12 urine biomarkers for diagnosing UTI in older women. METHODS In this case-control study, cases were women ≥65 years with ≥2 new-onset lower urinary tract symptoms, pyuria, and one uropathogen ≥104 CFU/mL. Controls were asymptomatic and classified as ASB (one uropathogen ≥105 CFU/mL), negative culture, or mixed flora. Urine biomarker concentrations were measured through liquid chromatography-mass spectrometry and ELISA. Diagnostic accuracy parameters of individual biomarkers and a biomarker model were derived from receiver operating characteristic curves. RESULTS We included 162 community-dwelling and institutionalized older women. Five urine inflammatory biomarkers demonstrated high discriminative ability (area under the curve ≥0.80): interleukin 6, azurocidin, neutrophil gelatinase-associated lipocalin, tissue inhibitor of metalloproteinases 2, and C-X-C motif chemokine 9. Azurocidin exhibited the highest diagnostic accuracy (sensitivity 86% [95% CI 75%-93%] and specificity 89% [95% CI 82%-94%] at 16.7 ng/mmol creatinine). A combined biomarker and pyuria model showed improved diagnostic accuracy in patients with UTI and ASB, compared with pyuria alone. DISCUSSION We identified several urine biomarkers that accurately differentiated older women with UTI from asymptomatic women, including ASB. These findings represent a potential advancement towards improved diagnostics for UTI in older women and warrant validation in a diverse population.
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Affiliation(s)
- Manu P Bilsen
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands.
| | - Maxim M Treep
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Margaretha J Aantjes
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
| | - Esther van Andel
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Cees van Nieuwkoop
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, The Netherlands; Department of Public Health and Primary Care, Leiden University Medical Center, Health Campus The Hague, The Netherlands
| | - Eliane M S Leyten
- Department of Internal Medicine, Haaglanden Medisch Centrum, The Hague, The Netherlands
| | - Nathalie M Delfos
- Department of Internal Medicine, Alrijne Hospital, Leiderdorp, The Netherlands
| | - Janneke I M van Uhm
- Department of Urology, Leiden University Medical Center, Leiden, The Netherlands
| | - Martijn Sijbom
- Department of Public Health and Primary Care, Leiden University Medical Center, Health Campus The Hague, The Netherlands
| | - Abimbola A Akintola
- Department of Public Health and Primary Care, Leiden University Medical Center, Health Campus The Hague, The Netherlands
| | - Mattijs E Numans
- Department of Public Health and Primary Care, Leiden University Medical Center, Health Campus The Hague, The Netherlands
| | - Wilco P Achterberg
- Department of Public Health and Primary Care, Leiden University Medical Center, Health Campus The Hague, The Netherlands; LUMC Center for Medicine for Older People, Leiden University Medical Center, Leiden, The Netherlands
| | - Simon P Mooijaart
- LUMC Center for Medicine for Older People, Leiden University Medical Center, Leiden, The Netherlands; Department of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Martha T van der Beek
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Christa M Cobbaert
- Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Simon P Conroy
- Medical Research Council Unit for Lifelong Health and Ageing at University College London, University College London, London, United Kingdom
| | - Leo G Visser
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
| | - Merel M C Lambregts
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
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3
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Haley E, Luke N, Mathur M, Festa RA, Wang J, Jiang Y, Anderson LA, Baunoch D. The Prevalence and Association of Different Uropathogens Detected by M-PCR with Infection-Associated Urine Biomarkers in Urinary Tract Infections. Res Rep Urol 2024; 16:19-29. [PMID: 38221993 PMCID: PMC10787514 DOI: 10.2147/rru.s443361] [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: 10/06/2023] [Accepted: 12/16/2023] [Indexed: 01/16/2024] Open
Abstract
Background Many emerging uropathogens are currently identified by multiplex polymerase chain reaction (M-PCR) in suspected UTI cases. Standard urine culture (SUC) has significantly lower detection rates, raising questions about whether these organisms are associated with UTIs and truly cause inflammation. Objective To determine if microbes detected by M-PCR were likely causative of UTI by measuring inflammatory biomarkers in the urine of symptomatic patients. Design Setting and Participants Midstream voided urine was collected from subjects ≥60 years presenting to urology clinics with symptoms of UTI (n = 1132) between 01/2023 and 05/2023. Microbe detection was by M-PCR and inflammation-associated biomarker (neutrophil gelatinase-associated lipocalin, interleukin 8, and interleukin 1β) was by enzyme-linked immunosorbent assay. Biomarker positivity was measured against individual and groups of organisms, E. coli and non-E. coli cases, emerging uropathogens, monomicrobial and polymicrobial cases. Outcome Measurements and Statistical Analysis Distributions were compared using 2-sample Wilcoxon Rank Sum test with 2-tailed p-values < 0.05 considered statistically significant. Results and Limitations M-PCR was positive in 823 (72.7%) specimens with 28 of 30 (93%) microorganisms/groups detected. Twenty-six of twenty-eight detected microorganisms/groups (93%) had ≥2 biomarkers positive in >66% of cases. Both non-E. coli cases and E. coli cases had significant biomarker positivity (p < 0.05). Limitations were that a few organisms had low prevalence making inferences about their individual significance difficult. Conclusion The majority of microorganisms identified by M-PCR were associated with active inflammation measured by biomarker positivity, indicating they are likely causative of UTIs in symptomatic patients. This includes emerging uropathogens frequently not detected by standard urine culture.
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Affiliation(s)
- Emery Haley
- Department of Clinical Research, Pathnostics, Irvine, CA, USA
| | - Natalie Luke
- Department of Clinical Research, Pathnostics, Irvine, CA, USA
| | - Mohit Mathur
- Department of Medical Affairs, Pathnostics, Irvine, CA, USA
| | - Richard A Festa
- Department of Research and Development, Pathnostics, Irvine, CA, USA
| | - Jimin Wang
- Department of Statistical Analysis, Stat4Ward, Pittsburgh, PA, USA
| | - Yan Jiang
- Department of Statistical Analysis, Stat4Ward, Pittsburgh, PA, USA
| | - Lori A Anderson
- L.Anderson Diagnostic Market Access Consulting, San Diego, CA, USA
| | - David Baunoch
- Department of Research and Development, Pathnostics, Irvine, CA, USA
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Haley E, Luke N, Mathur M, Festa RA, Wang J, Jiang Y, Anderson L, Baunoch D. Comparison Shows that Multiplex Polymerase Chain Reaction Identifies Infection-associated Urinary Biomarker-positive Urinary Tract Infections That Are Missed by Standard Urine Culture. EUR UROL SUPPL 2023; 58:73-81. [PMID: 38152485 PMCID: PMC10751541 DOI: 10.1016/j.euros.2023.10.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2023] [Indexed: 12/29/2023] Open
Abstract
Background Multiplex polymerase chain reaction (M-PCR) has increased sensitivity for microbial detection compared with standard urine culture (SUC) in cases diagnosed as urinary tract infections (UTIs), leading to questions whether detected microbes are likely causative of UTIs or are incidental findings. Objective To compare infection-associated biomarker levels against M-PCR and SUC results in symptomatic cases with a presumptive diagnosis of a UTI by a urologist. Design setting and participants Participants were ≥60 yr old and presented to urology clinics between January and April 2023 with symptoms of UTIs (n = 583). Urine microbial detection was by M-PCR and SUC. Three infection-associated biomarkers (neutrophil gelatinase-associated lipocalin, interleukin-8, and interleukin-1β) were measured by enzyme-linked immunosorbent assay. Symptomatic cases with elevated biomarkers, detection of uropathogens, and a specialist clinical diagnosis of a UTI were considered definitive UTI cases. Outcome measurements and statistical analysis Distributions were compared using two-sample Wilcoxon rank sum test, with two-tailed p values of <0.05 considered statistically significant. Results and limitations In cases with M-PCR-positive/SUC-negative results (n = 80), all median biomarker levels were significantly higher (p < 0.0001) than in cases with M-PCR-negative/SUC-negative results (n = 107). Two or more biomarkers were positive in 76% of M-PCR-positive/SUC-negative specimens. Limitation was an inability to examine associations between each individual organism and inflammation. Conclusions A significant number of M-PCR-positive/SUC-negative cases had elevated levels of infection-related urinary biomarkers, especially when infection was caused by organisms other than Escherichia coli. This is a strong indication that microbes detected by M-PCR, which would be missed by SUC, are associated with UTIs. Patient summary We compared infection-associated biomarkers in patients diagnosed with urinary tract infections (UTIs) against the detection of microorganisms by standard urine culture (SUC) and multiplex polymerase chain reaction (M-PCR). We found that most patients with microorganisms detected by M-PCR, which were missed by SUC, had elevated markers of inflammation, indicating that these organisms were likely causative of UTIs.
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Affiliation(s)
- Emery Haley
- Department of Clinical Research, Pathnostics, Irvine, CA, USA
| | - Natalie Luke
- Department of Clinical Research, Pathnostics, Irvine, CA, USA
| | - Mohit Mathur
- Department of Medical Affairs, Pathnostics, Irvine, CA, USA
| | - Richard A. Festa
- Department of Research and Development, Pathnostics, Irvine, CA, USA
| | - Jimin Wang
- Department of Statistical Analysis, Stat4Ward, Pittsburgh, PA, USA
| | - Yan Jiang
- Department of Statistical Analysis, Stat4Ward, Pittsburgh, PA, USA
| | - Lori Anderson
- L. Anderson Diagnostic Market Access Consulting, San Diego, CA, USA
| | - David Baunoch
- Department of Research and Development, Pathnostics, Irvine, CA, USA
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Yamamoto A, Nakayama S, Wakabayashi Y, Yoshino Y, Kitazawa T. Urine neutrophil gelatinase-associated lipocalin as a biomarker of adult pyelonephritis. J Infect Chemother 2023; 29:508-512. [PMID: 36621764 DOI: 10.1016/j.jiac.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 11/10/2022] [Accepted: 01/04/2023] [Indexed: 01/07/2023]
Abstract
BACKGROUND Pyelonephritis is a common infection at any age. Urine neutrophil gelatinase-associated lipocalin (NGAL), a novel biomarker of acute renal failure, is related to pyelonephritis in pediatric patients, although the significance of this urine biomarker in adult patients are not clear. We investigated the relationship between urine NGAL of pyelonephritis and non-pyelonephritis. PATIENTS AND METHODS We prospectively enrolled adult patients who were hospitalized due to pyelonephritis or non-pyelonephritis. Pyelonephritis was diagnosed in patients with fever and bacteriuria, with no any other infection focuses. Non-pyelonephritis was diagnosed in patients who had fever and another infection focus without bacteriuria. Urine samples were collected on days 0, 3 and 7. Urine NGAL levels were measured by ELISA. RESULTS There were 35 patients in the pyelonephritis group and 19 patients in the non-pyelonephritis group. Urine NGAL level were significantly higher in the pyelonephritis group than the non-pyelonephritis group on day 0 (median 302 ng/mL vs 25 ng/mL, p = 0.006). The area under the receiver operating characteristic curve of NGAL was 0.78 (p = 0.006). Urine NGAL level had a specificity of 66.7% and sensitivity of 87.0% at the cut-off level of 250 ng/mL for diagnosing pyelonephritis. CONCLUSIONS Urine NGAL level at the diagnosis of infection are elevated in adult patients with pyelonephritis, but not in those with non-pyelonephritis. Urine NGAL might be a supportive biomarker for the diagnosis of pyelonephritis.
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Affiliation(s)
- Ai Yamamoto
- Department of Internal Medicine, Teikyo University, 2-11-1 Kaga, Itabashi-ku, Tokyo, Japan
| | - Shin Nakayama
- Department of Internal Medicine, Teikyo University, 2-11-1 Kaga, Itabashi-ku, Tokyo, Japan
| | - Yoshitaka Wakabayashi
- Department of Internal Medicine, Teikyo University, 2-11-1 Kaga, Itabashi-ku, Tokyo, Japan
| | - Yusuke Yoshino
- Department of Internal Medicine, Teikyo University, 2-11-1 Kaga, Itabashi-ku, Tokyo, Japan
| | - Takatoshi Kitazawa
- Department of Internal Medicine, Teikyo University, 2-11-1 Kaga, Itabashi-ku, Tokyo, Japan.
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Abstract
More than half of women will experience a urinary tract infection (UTI), with uropathogenic Escherichia coli (UPEC) causing ~80% of uncomplicated cases. Iron acquisition systems are essential for uropathogenesis, and UPEC strains encode highly diverse iron acquisition systems, underlining their importance. However, a recent UPEC clinical isolate, HM7, lacks this diversity and instead encodes the synthesis pathway for a sole siderophore, enterobactin. To determine if HM7 possesses unidentified iron acquisition systems, we performed RNA sequencing under iron-limiting conditions and demonstrated that the ferric citrate uptake system (fecABCDE and fecIR) was highly upregulated. Importantly, there are high levels of citrate within urine, some of which is bound to iron, and the fec system is enriched in UPEC isolates compared to fecal strains. Therefore, we hypothesized that HM7 and other similar strains use the fec system to acquire iron in the host. Deletion of both enterobactin biosynthesis and ferric citrate uptake (ΔfecA/ΔentB) abrogates use of ferric citrate as an iron source, and fecA provides an advantage in human urine in the absence of enterobactin. However, in a UTI mouse model, fecA is a fitness factor independent of enterobactin production, likely due to the action of host lipocalin-2 chelating ferrienterobactin. These findings indicate that ferric citrate uptake is used as an iron source when siderophore efficacy is limited, such as in the host during UTI. Defining these novel compensatory mechanisms and understanding the nutritional hierarchy of preferred iron sources within the urinary tract are important in the search for new approaches to combat UTI.
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7
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Horváth J, Wullt B, Naber KG, Köves B. Biomarkers in urinary tract infections - which ones are suitable for diagnostics and follow-up? GMS INFECTIOUS DISEASES 2020; 8:Doc24. [PMID: 33299741 PMCID: PMC7705555 DOI: 10.3205/id000068] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Introduction: Urinary tract infections (UTIs) are one of the most common infections worldwide. Under special circumstances, clinicians must rely on laboratory findings, which might have a weak predicting value, misguiding the practitioners and leading to incorrect diagnosis and overuse of antibiotics. Therefore, there is an urgent need for reliable biomarkers in UTIs. Methods: We performed a literature search for biomarkers used in UTIs from January 1999 until May 2020. We used "urinary tract infection" and "biomarker" as the main key words in the PubMed, Medline and Cochrane databases. After peer review, we excluded the duplicates and identified the suitable articles, from which we collected the data and divided the available biomarkers into 5 groups: i) conventional markers; ii) promising, thoroughly studied biomarkers; iii) promising biomarkers that need further studies; iv) biomarkers of unknown significance; v) controversial, not useful markers. Results: We found 131 articles, mostly from the paediatric population. Neutrophil gelatinase-associated lipocalin (NGAL) and interleukins (IL) have a leading role in diagnosing and differentiating UTIs based on a lot of observational, comparative trials. Heparin Binding Protein (HBP), Lactoferrin (LF), Heat-Shock Protein-70 (HSP-70), Human Defensin-5 (HD-5), Lipopolysaccharide Binding Protein (LBP) and mass spectrometry studies are promising, but confirming data are lacking. The measurable components of the innate immune system and local host cell response could be appropriate biomarkers, but their significance is currently unknown. Conclusions: Conventional biomarkers for UTIs have low specificity. The use of urinary NGAL and interleukins could improve the sensitivity and specificity of laboratory diagnosis of UTIs.
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Affiliation(s)
- József Horváth
- BKMK SZTE ÁOK Okt. Kh. Urológiai Osztálya, Kecskemét, Hungary
| | - Björn Wullt
- Division of Microbiology, Immunology and Glycobiology, Lund University, Lund, Sweden
| | - Kurt G. Naber
- Department of Urology, Technical University of Munich, Munich, Germany
| | - Béla Köves
- Jahn Ferenc Dél-pesti Kórház és Rendelőintézet, Budapest, Hungary
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8
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Forster CS, Loechtenfeldt AM, Shah SS, Goldstein S. Urine neutrophil gelatinase-associated lipocalin in girls with recurrent urinary tract infections. Pediatr Nephrol 2020; 35:2121-2128. [PMID: 32564279 DOI: 10.1007/s00467-020-04654-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 06/01/2020] [Accepted: 06/05/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Children who experience more than one urinary tract infection (UTI) are at increased risk of kidney scarring due to their UTIs. Girls are at especially high risk for developing kidney scarring as a result of recurrent UTIs. Prior work suggested that neutrophil gelatinase-associated lipocalin (NGAL) may be lower in children with recurrent UTI compared with those without. The objective of this work was to compare urine NGAL concentrations in matched urine samples in girls with single and recurrent UTIs. METHODS Girls less than 6 years of age who presented with signs and symptoms of a UTI were eligible for enrollment. Both acute, obtained from residual urine collected as part of their clinical evaluation, and follow-up urine samples, obtained after the completion of antibiotics when the patient was in their usual state of health, were collected from patients. Acute and follow-up urine NGAL concentrations were compared between girls with single and recurrent UTIs, as well as those with negative cultures who served as controls. RESULTS Seventy girls were included in this study, 6 controls, 43 single UTIs, and 20 girls with recurrent UTIs. Patients in the control group had lower median acute NGAL concentrations than either those with single or recurrent UTI. There were no differences in either acute or follow-up urine NGAL concentrations between those with single and recurrent UTIs. CONCLUSION In this cohort of girls less than 6 years of age, there is no difference in urine NGAL concentrations between those with single and recurrent UTIs.
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Affiliation(s)
- Catherine S Forster
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA. .,Children's National Health System, 111 Michigan Ave NW, Suite 4800M, Washington DC, 20010, USA.
| | - Allison M Loechtenfeldt
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Samir S Shah
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Stuart Goldstein
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Panagiotou A, Trendelenburg M, Heijnen IAFM, Moser S, Bonati LH, Breidthardt T, Fahrni G, Kaiser C, Jeger R, Osthoff M. A Randomized Trial of Recombinant Human C1-Esterase-Inhibitor in the Prevention of Contrast-Induced Kidney Injury. JACC Cardiovasc Interv 2020; 13:833-842. [PMID: 32171721 DOI: 10.1016/j.jcin.2019.11.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 10/22/2019] [Accepted: 11/12/2019] [Indexed: 01/07/2023]
Abstract
OBJECTIVES This study sought to determine the efficacy profile and safety of recombinant human C1 esterase inhibitor (rhC1INH) in the prevention of contrast-associated acute kidney injury after elective coronary angiography. BACKGROUND Contrast-associated acute kidney injury is caused by tubular cytotoxicity and ischemia/reperfusion injury. rhC1INH is effective in reducing renal ischemia/reperfusion injury in experimental models. METHODS In this placebo-controlled, double-blind, single-center trial 77 patients with chronic kidney disease were randomized to receive 50 IU/kg rhC1INH before and 4 h after elective coronary angiography or placebo. The primary outcome was the peak change of urinary neutrophil gelatinase-associated lipocalin within 48 h, a surrogate marker of kidney injury. RESULTS Median peak change of urinary neutrophil gelatinase-associated lipocalin was lower in the rhC1INH group (4.7 ng/ml vs. 22.5 ng/ml; p = 0.038) in the per-protocol population but not in the modified intention-to-treat analysis, and in patients with percutaneous coronary interventions (median, 1.8 ng/ml vs. 26.2 ng/ml; p = 0.039 corresponding to a median proportion peak change of 11% vs. 205%; p = 0.002). The incidence of a cystatin C increase ≥10% within 24 h was lower in the rhC1INH group (16% vs. 33%; p = 0.045), whereas the frequency of contrast-associated acute kidney injury was comparable. Adverse events during a 3-month follow-up were similarly distributed. CONCLUSIONS Administration of rhC1INH before coronary angiography may attenuate renal injury as reflected by urinary neutrophil gelatinase-associated lipocalin and cystatin C. The safety profile of rhC1INH was favorable in a patient population with multiple comorbidities. (Recombinant Human C1 Esterase Inhibitor in the Prevention of Contrast-induced Nephropathy in High-risk Subjects [PROTECT]; NCT02869347).
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Affiliation(s)
- Anneza Panagiotou
- Division of Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Marten Trendelenburg
- Division of Internal Medicine, University Hospital Basel, Basel, Switzerland; Department of Clinical Research and Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Ingmar A F M Heijnen
- Division of Medical Immunology, Laboratory Medicine, University Hospital Basel, Basel, Switzerland
| | - Stephan Moser
- Division of Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Leo H Bonati
- Division of Neurology and Stroke Center, Department of Clinical Research, University Hospital Basel and University of Basel, Basel Switzerland
| | - Tobias Breidthardt
- Division of Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Gregor Fahrni
- Department of Cardiology, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Christoph Kaiser
- Department of Cardiology, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Raban Jeger
- Department of Cardiology, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Michael Osthoff
- Division of Internal Medicine, University Hospital Basel, Basel, Switzerland; Department of Clinical Research and Department of Biomedicine, University of Basel, Basel, Switzerland.
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10
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Gupta S, Preece J, Haynes A, Becknell B, Ching C. Differentiating Asymptomatic Bacteriuria From Urinary Tract Infection in the Pediatric Neurogenic Bladder Population: NGAL As a Promising Biomarker. Top Spinal Cord Inj Rehabil 2020; 25:214-221. [PMID: 31548788 DOI: 10.1310/sci2503-214] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Objective: To evaluate whether urinary antimicrobial peptides (AMPs) can discriminate between asymptomatic bacteriuria (ASB) and urinary tract infection (UTI) in pediatric patients with neurogenic bladder (NGB). Design/Methods: Bladder urine was collected from pediatric patients (≤18 years old) with NGB without augmentation cystoplasty. Patients were divided into the following groups based on symptomatology and results of urinalysis/urine culture: (a) UTI, (b) ASB, and (c) sterile. Urine AMPs β defense 1 (BD-1), neutrophil gelatinase-associated lipocalin (NGAL), cathelicidin (LL-37), hepatocarcinoma-intestine-pancreas/pancreatitis-associated protein (HIP/PAP), and human α defensin 5 (HD-5) were compared between groups by enzyme-linked immunosorbent assays. In addition, urines from pediatric controls without NGB or UTI were also analyzed. Significance was determined using Student's t test for parametric or Mann-Whitney U test for nonparametric data. A p value of <.05 was considered significant. Results: Thirty-six patients with NGB from a spinal dysraphism were evaluated: UTI, n = 6; ASB, n = 18; sterile, n = 12. These groups did not differ significantly by age but did significantly differ by gender (p = .0139). NGAL significantly differed between UTI and ASB groups (median 38.5 ng/mg vs 15.5 ng/mg, respectively; p = .0197) with a sensitivity and specificity of 82.4% and 83.3%, respectively. HIP/PAP, BD-1, HD-5, LL-37, and NGAL levels were all significantly higher in sterile NGB urines compared to 17 non-NGB pediatric controls (p < .0001, p = .0020, p = .0035, p = .0006, and p = .0339, respectively). Conclusion: All five urinary AMPs evaluated were significantly elevated in NGB patients compared to controls. NGAL levels may help differentiate between UTI and ASB in pediatric NGB patients.
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Affiliation(s)
- Sudipti Gupta
- Division of Urology, Nationwide Children's Hospital, Columbus, Ohio.,Center for Clinical and Translational Research, Nationwide Children's Hospital, Columbus, Ohio
| | - Janae Preece
- Department of Urology, Children's Hospital of Michigan, Detroit, Michigan
| | - Andria Haynes
- Division of Urology, Nationwide Children's Hospital, Columbus, Ohio
| | - Brian Becknell
- Division of Nephrology, Nationwide Children's Hospital, Columbus, Ohio
| | - Christina Ching
- Division of Urology, Nationwide Children's Hospital, Columbus, Ohio.,Center for Clinical and Translational Research, Nationwide Children's Hospital, Columbus, Ohio
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11
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Gadalla AAH, Friberg IM, Kift-Morgan A, Zhang J, Eberl M, Topley N, Weeks I, Cuff S, Wootton M, Gal M, Parekh G, Davis P, Gregory C, Hood K, Hughes K, Butler C, Francis NA. Identification of clinical and urine biomarkers for uncomplicated urinary tract infection using machine learning algorithms. Sci Rep 2019; 9:19694. [PMID: 31873085 PMCID: PMC6928162 DOI: 10.1038/s41598-019-55523-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 11/19/2019] [Indexed: 12/14/2022] Open
Abstract
Women with uncomplicated urinary tract infection (UTI) symptoms are commonly treated with empirical antibiotics, resulting in overuse of antibiotics, which promotes antimicrobial resistance. Available diagnostic tools are either not cost-effective or diagnostically sub-optimal. Here, we identified clinical and urinary immunological predictors for UTI diagnosis. We explored 17 clinical and 42 immunological potential predictors for bacterial culture among women with uncomplicated UTI symptoms using random forest or support vector machine coupled with recursive feature elimination. Urine cloudiness was the best performing clinical predictor to rule out (negative likelihood ratio [LR−] = 0.4) and rule in (LR+ = 2.6) UTI. Using a more discriminatory scale to assess cloudiness (turbidity) increased the accuracy of UTI prediction further (LR+ = 4.4). Urinary levels of MMP9, NGAL, CXCL8 and IL-1β together had a higher LR+ (6.1) and similar LR− (0.4), compared to cloudiness. Varying the bacterial count thresholds for urine culture positivity did not alter best clinical predictor selection, but did affect the number of immunological predictors required for reaching an optimal prediction. We conclude that urine cloudiness is particularly helpful in ruling out negative UTI cases. The identified urinary biomarkers could be used to develop a point of care test for UTI but require further validation.
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Affiliation(s)
- Amal A H Gadalla
- Division of Population Medicine, School of Medicine, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom.
| | - Ida M Friberg
- Division of Infection & Immunity, School of Medicine, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom
| | - Ann Kift-Morgan
- Division of Infection & Immunity, School of Medicine, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom
| | - Jingjing Zhang
- Division of Infection & Immunity, School of Medicine, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom
| | - Matthias Eberl
- Division of Infection & Immunity, School of Medicine, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom.,Systems Immunity Research Institute, Cardiff University, Cardiff, United Kingdom
| | - Nicholas Topley
- Division of Infection & Immunity, School of Medicine, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom.,Systems Immunity Research Institute, Cardiff University, Cardiff, United Kingdom
| | - Ian Weeks
- Systems Immunity Research Institute, Cardiff University, Cardiff, United Kingdom.,Clinical Innovation Hub, School of Medicine, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom
| | - Simone Cuff
- Division of Infection & Immunity, School of Medicine, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom.,Systems Immunity Research Institute, Cardiff University, Cardiff, United Kingdom.,Clinical Innovation Hub, School of Medicine, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom
| | - Mandy Wootton
- Specialist Antimicrobial Chemotherapy Unit, Public Health Wales Microbiology Cardiff, University Hospital of Wales, Cardiff, United Kingdom
| | - Micaela Gal
- Division of Population Medicine, School of Medicine, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom
| | - Gita Parekh
- Mologic Ltd., Bedford Technology Park, Thurleigh, Bedford, United Kingdom
| | - Paul Davis
- Mologic Ltd., Bedford Technology Park, Thurleigh, Bedford, United Kingdom
| | - Clive Gregory
- Division of Population Medicine, School of Medicine, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom
| | - Kerenza Hood
- Centre for Trials Research, School of Medicine, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom
| | - Kathryn Hughes
- Division of Population Medicine, School of Medicine, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom
| | - Christopher Butler
- Division of Population Medicine, School of Medicine, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom.,Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Nick A Francis
- Division of Population Medicine, School of Medicine, College of Biomedical and Life Sciences, Cardiff University, Cardiff, United Kingdom.,Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, United Kingdom
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12
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Diagnostic accuracy of urine neutrophil gelatinase-associated lipocalin and urine kidney injury molecule-1 as predictors of acute pyelonephritis in young children with febrile urinary tract infection. Cent Eur J Immunol 2019; 44:174-180. [PMID: 31530987 PMCID: PMC6745542 DOI: 10.5114/ceji.2019.87069] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 04/17/2019] [Indexed: 12/25/2022] Open
Abstract
Introduction We assessed whether two urinary biomarkers of acute kidney injury, neutrophil gelatinase associated lipocalin (uNGAL) and kidney injury molecule-1 (uKIM-1), can be useful for predicting acute pyelonephritis (APN) in children aged 1-24 months with the first febrile urinary tract infection (UTI). Material and methods A prospective study included 54 children divided into two groups (24 with APN, 30 with lower UTI), according to the dimercaptosuccinic acid (DMSA) renal scintigraphy results. Laboratory tests: uNGAL, uKIM-1, procalcitonin (PCT), C-reactive protein (CRP), white blood count (WBC) were performed. Results We did not find significant differences in normalized and non-normalized values of uNGAL and uKIM-1 in children with APN and lower UTI. Positive correlations were determined between uNGAL and pyuria (r = 0.28, p < 0.05) and between uNGAL/uCr and uKIM-1/uCr (r = 0.53, p < 0.001) in the all UTI groups. Univariate logistic regression analysis demonstrated that only PCT (p < 0.0001) and CRP (p < 0.05) were important diagnostic factors of APN. Receiver operating curve (ROC) analysis showed good diagnostic profiles of PCT with the best cut-off value of 1.66 ng/ml and of CRP with the best cut-off value of 4.3 mg/dl for predicting APN (area under the curve [AUC]: 0.894 and 0.719, sensitivity: 75% and 96%, specificity: 93% and 43%, respectively). Conclusions uNGAL and uKIM-1 are not effective diagnostic markers for APN in young children with febrile UTI and cannot be used in clinical practice to differentiate APN from lower UTI.
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13
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Serum neutrophil gelatinase-associated lipocalin for predicting acute pyelonephritis in infants with urinary tract infection. Cent Eur J Immunol 2019; 44:45-50. [PMID: 31114436 PMCID: PMC6526589 DOI: 10.5114/ceji.2019.84016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Accepted: 12/17/2018] [Indexed: 11/17/2022] Open
Abstract
Introduction Fever and elevated inflammatory markers have been used for diagnosis of acute pyelonephritis (APN) in infants with urinary tract infection (UTI). The aim of the study was to compare the usefulness of serum neutrophil gelatinase-associated lipocalin (sNGAL) with inflammatory markers for predicting APN in infants with UTI. Material and methods The prospective study included 46 infants with a first episode of UTI, divided into two groups (APN 23, lower UTI 23), according to the DMSA scan results. The following laboratory tests were performed: sNGAL, PCT, CRP, WBC, and ESR. Results Significantly elevated levels of sNGAL, PCT, CRP, and ESR were observed in infants with APN compared to those with lower UTI. Higher sNGAL, CRP, and ESR values, presence of fever, and longer duration of fever before antibiotic treatment were associated with APN [odds ratio (OR) 1.02, 1.27, 1.03, 13.46, 2.12, respectively]. Receiver operating characteristic (ROC) analysis showed better diagnostic profiles for sNGAL, PCT, and CRP than for ESR for predicting APN [area under the curve (AUC) 0.808, 0.819, 0.841, and 0.750, respectively]. The appropriate cut-off values of sNGAL, PCT and CRP were 100.8 ng/ml, 0.15 ng/ml, 5.3 mg/dl (all sensitivity and specificity 82.6%), and that of ESR was 40 mm/h (sensitivity 78.3%, specificity 60.9%). Conclusions sNGAL shows similar usefulness as PCT and CRP for predicting APN in infants with UTI, the diagnostic value of ESR is smaller, and WBC is not useful at all. The presence of fever and longer duration of fever are important predictors of APN in infants with UTI.
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14
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Bladder-Drained Pancreas Transplantation: Urothelial Innate Defenses and Urinary Track Infection Susceptibility. J Surg Res 2019; 235:288-297. [DOI: 10.1016/j.jss.2018.09.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 07/19/2018] [Accepted: 09/11/2018] [Indexed: 12/26/2022]
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15
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Abedi SM, Mohammadjafari H, Rafiei A, Bazi S, Yazdani P. Urinary matrix metalloproteinase 9 and tissue inhibitor of metalloproteinase 1 biomarkers for predicting renal scar in children with urinary tract infection. Turk J Urol 2017; 43:536-542. [PMID: 29201521 DOI: 10.5152/tud.2017.06337] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 06/16/2017] [Indexed: 11/22/2022]
Abstract
Objective Urinary tract infection occurs in 1.8-6.6% of children under 6 years old. The aim of this study was to assess the urinary concentrations of matrix metalloproteinase 9 (MMP9) and tissue inhibitor of metalloproteinase 1 (TIMP1), in children with acute pyelonephritis (APN) and the potential to develop renal scarring. Material and methods Children who had experienced an episode of APN were divided into 2 groups. Group 1 included children with APN who exhibited scarring and group 2 included children with APN who had a normal 99mTechnetium dimercaptosuccinic acid scan. Urinary levels of MMP9 and TIMP1 were measured in the acute phase of infection. A receiver operating characteristic curve was generated to allow calculation of cut-off values. Results Sixty-one children were enrolled across the 2 groups: group 1 contained 16 patients (all female); group 2, 38 children (36 female and 2 male). Urinary levels of MMP9 and TIMP1 were significantly higher in group 1 than in group 2 (p=0.037 and 0.022 respectively). For comparison of groups 1 and 2, the cut-off values were measured as 75.5 ng/mL (sensitivity 62.5%, specificity 71.1%, positive predictive value, PPV, 48%, negative predictive value, NPV, 82%), 16.1 ng/mL (sensitivity 75%, specificity 55.3%, PPV 41%, NPV 84%), and 1310.7 ng/mL (sensitivity 75% specificity 60.5%, PPV 44%, NPV 85%) for MMP9, TIMP1, and MMP9×TIMP1 levels, respectively. Conclusion Evaluation of urinary MMP9 and TIMP1 levels may help to identify children with APN who are at risk of developing renal scarring.
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Affiliation(s)
- Seyed Mohammad Abedi
- Department of Radiology, Mazandaran University of Medical Sciences School of Medicine, Pasdaran Avenue Sari, Iran
| | - Hamid Mohammadjafari
- Antimicrobial Resistant Nosocomial Infection Research Center, Mazandaran University of Medical Sciences, Pasdaran Avenue Sari, Iran
| | - Alireza Rafiei
- Molecular and Cell Biology Research Center, Department of Immunology, Mazandaran University of Medical Sciences School of Medicine, Pasdaran Avenue Sari, Iran
| | - Sara Bazi
- Department of Pediatrics, Mazandaran University of Medical Sciences, School of Medicine, Pasdaran Avenue Sari, Iran
| | - Pooneh Yazdani
- Medical Student, Mazandaran University of Medical Sciences, Sari, Iran
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16
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Han P, Huang Y, Xie Y, Yang W, Wang Y, Xiang W, Hylands PJ, Legido-Quigley C. Metabolic phenotyping in the mouse model of urinary tract infection shows that 3-hydroxybutyrate in plasma is associated with infection. PLoS One 2017; 12:e0186497. [PMID: 29036204 PMCID: PMC5643114 DOI: 10.1371/journal.pone.0186497] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 10/03/2017] [Indexed: 02/08/2023] Open
Abstract
Urinary tract infection is one of the most common bacterial infections worldwide. Current diagnosis of urinary tract infection chiefly relies on its clinical presentation, urine dipstick tests and urine culture. Small molecules found in bio-fluids related with both infection and recovery would facilitate diagnosis and management of UTI. Mass spectrometry-based fingerprinting of plasma and urine at 3 time points, pre-infection (t = -24h), infection (t = 24h) and post 3-day treatment (t = 112h), were acquired in the following four groups: mice which were healthy, infected but not treated, infected and treated with ciprofloxacin, and infected and treated with Relinqing® granules (n = 6 per group). A metabolomics workflow including multivariate analysis and ROC regression was employed to select metabolic features that correlated with UTI and its treatment. Circa 4,000 molecular features were acquired for each sample. The small acid 3-hydroxybutyrate in plasma was found to be differentiated for urinary tract infection, with an area under the curve = 0.97 (95% confidence interval: 0.93–1.00, accuracy = 0.91, sensitivity = 0.92 and specificity = 0.91). The level of 3-hydroxybutyrate in plasma was depleted after infection with a fold change of -22 (q < 0.0001). Correlation between plasma 3-hydroxybutyrate and urine bacterial number in all groups and time points was r = -0.753 (p < 0.0001). The findings show that 3-hydroxybutyrate is depleted in blood and strongly associated with UTI at both infection and post-treatment stage in a UTI mouse model. Further work is envisaged to assess the clinical potential of blood tests to assist with UTI management.
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Affiliation(s)
- Pei Han
- Institute of Pharmaceutical Science, Faculty of Life Sciences & Medicine, King’s College London, London, United Kingdom
| | - Yong Huang
- Provincial Key Laboratory of Pharmaceutics in Guizhou Province, School of Pharmacy, Guiyang Medical University, Guiyang, Guizhou, China
| | - Yumin Xie
- Provincial Key Laboratory of Pharmaceutics in Guizhou Province, School of Pharmacy, Guiyang Medical University, Guiyang, Guizhou, China
| | - Wu Yang
- Provincial Key Laboratory of Pharmaceutics in Guizhou Province, School of Pharmacy, Guiyang Medical University, Guiyang, Guizhou, China
| | - Yaoyao Wang
- Institute of Pharmaceutical Science, Faculty of Life Sciences & Medicine, King’s College London, London, United Kingdom
| | - Wenying Xiang
- Provincial Key Laboratory of Pharmaceutics in Guizhou Province, School of Pharmacy, Guiyang Medical University, Guiyang, Guizhou, China
| | - Peter J. Hylands
- Institute of Pharmaceutical Science, Faculty of Life Sciences & Medicine, King’s College London, London, United Kingdom
- * E-mail: (CLQ); (PJH)
| | - Cristina Legido-Quigley
- Institute of Pharmaceutical Science, Faculty of Life Sciences & Medicine, King’s College London, London, United Kingdom
- * E-mail: (CLQ); (PJH)
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