Renal Infection Research Articles

Acute Renal Infection in Adult, Part 1: An Overview of What the Radiologist Needs to Know

AbstractAcute renal infection or acute pyelonephritis (AP) denotes the process of inflammation of the renal parenchyma and its collecting system and the urothelium following infection. Uncomplicated AP commonly affects otherwise healthy, young women without structural or functional urinary tract abnormalities and without relevant comorbidities. More severe and complicated AP occurs in patients with a structurally or functionally abnormal genitourinary tract, or in persons with a predisposing medical condition like immune compromised state and diabetes. Complicated AP is characterized by a broader spectrum of clinical presentations, a wider variety of infecting organisms, and a greater risk of progression to a complication, such as intrarenal or perinephric abscess or emphysematous pyelonephritis and has the capacity to damage the organ and at times maybe life threatening. Role of imaging in renal infection is secondary, and in most situations, imaging is done to confirm the clinical diagnosis, map progression of disease in immune-compromised group of patients, or to evaluate for potential complications and therapeutic interventions. This article attempts to discuss the pathophysiology of AP from the standpoint of medical imaging and also brings out illustrative examples of various manifestations of AP and its complications. It provides imaging insight into various stages of inflammation, development of complication, and a roadmap for understanding AP through cross-sectional imaging.

Cytomegalovirus renal infection: Rare manifestation of a common post-transplant viral infection-A case series.

Cytomegalovirus is the most common viral infection in organ transplant recipients that usually affects the brain, lungs, liver, and gastrointestinal tract. Renal involvement of Cytomegalovirus (CMV) is otherwise rare. We present six cases of biopsy-proven CMV renal infection. Five out of the six patients had detectable CMV viremia. Kidney biopsy revealed glomerulopathy in four cases and tubulointerstitial involvement in two cases. All patients exhibited decline in renal function at the onset of infection. Four out of six patients had improvement of renal function following treatment of CMV disease. To date, this is the largest case series of purebiopsy-proven CMV renal infection described in a single center.

Imaging Manifestations of Acute and Chronic Renal Infection That Mimics Malignancy: How to Make the Diagnosis Using Computed Tomography and Magnetic Resonance Imaging

PurposeTo review the computed tomography and magnetic resonance imaging manifestations of acute and chronic renal infections that may mimic malignancy and to provide useful tips to establish an imaging diagnosis. ConclusionAcute and chronic bacterial pyelonephritis are usually readily diagnosed clinically and on imaging when the diagnosis is suspected based upon clinical presentation. When unsuspected, focal, extensive or mass-like, acute and chronic bacterial pyelonephritis may mimic infiltrative tumours such as urothelial cell carcinoma (UCC), lymphoma, and metastatic disease. Infection may be suspected when patients are young and otherwise healthy when there is marked associated perinephric changes and in the absence of metastatic adenopathy or disease elsewhere in the abdomen and pelvis. Renal abscesses, from bacterial or atypical microbial agents, can appear as complex cystic renal masses mimicking cystic renal cell carcinoma. Associated inflammatory changes in and around the kidney and local invasion favour infection. Emphysematous pyelonephritis can mimic necrotic or fistulizing tumour; however, infection is more likely and should always be considered first. Xanthogranulomatous pyelonephritis can mimic malignancy when focal or multifocal and in cases without associated renal calculi. Malacoplakia is an inflammatory process that may mimic malignancy and should be considered in patients with chronic infection. Bacillus Calmette-Guerin (BCG)-induced pyelonephritis is rare but can mimic renal malignancy and should be considered in patients presenting with a renal mass when being treated with BCG for urinary bladder UCC.

Dietary Inflammatory Index Score and Cardiovascular Disease Risk Markers in Women with Systemic Lupus Erythematosus

BackgroundPatients with systemic lupus erythematosus (SLE), a chronic inflammatory autoimmune disease, have an increased risk of developing cardiovascular diseases. Environmental factors like diet and nutrition are known to play a key role in modulating inflammation and the prognosis of cardiovascular diseases. ObjectiveTo investigate the relationship between Dietary Inflammatory Index score and cardiovascular disease risk markers in a population of women with SLE. DesignA cross-sectional study was conducted in women with SLE recruited from 2016 through 2017. Participants/settingsClinically stable women with SLE were enrolled from three public hospitals in the Andalusian region of Spain. Participants with chronic renal failure, active infections, recent trauma, pregnancy, and/or other autoimmune diseases were excluded. Main outcome measuresA 24-hour diet recall was used to estimate Dietary Inflammatory Index score and physical activity was assessed through the International Physical Activity Questionnaires. Cardiovascular disease risk markers included blood lipid profile (total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and triglyceride levels), high-sensitivity C-reactive protein levels, and homocysteine levels, along with diagnosis of obesity, diabetes mellitus, hypertension, dyslipidemia, and ankle-brachial index measurement. Statistical analysisComparisons of cardiovascular disease risk markers across Dietary Inflammatory Index score tertiles were analyzed through a one-way analysis of variance and linear regressions adjusting for age, physical activity level, and medical treatment. ResultsA total of 105 women (aged 45.4±12.8 years) were included. Linear regression analysis revealed that Dietary Inflammatory Index score was significantly associated with total cholesterol levels (β=.26, 95% CI 1.66 to 14.28; P=0.014) after adjusting for age, physical activity, and the use of medical treatment. No significant associations were observed between Dietary Inflammatory Index score and the other cardiovascular markers considered. ConclusionsHigher inflammatory potential of the diet was positively associated with higher total cholesterol levels in women with SLE. These findings suggest that the inflammatory potential of a person’s diet may play a role in lipid profiles in this population. Future intervention studies are needed to build on these results and explore the effect of anti-inflammatory diets on health outcomes in individuals with SLE.

Analysis of clinical characteristics of severe and critically ill influenza A (H1N1)

To investigate the clinical features, laboratory results, chest CT imaging manifestations and treatments of severe and critical influenza A (H1N1), and to analyze the relationship with the prognosis. The clinical data of 54 adult patients with severe and critical H1N1 admitted to the Fourth People's Hospital of Nanning from November 2018 to February 2019 were analyzed retrospectively. Throat swab specimens of the patients were determined for nucleic acid detection of influenza A (H1N1) virus, and all of the patients were confirmed. The gender, age, course of disease, underlying diseases, symptoms, body temperature, hospital stays, chest CT findings and laboratory results were collected, and the treatments and prognosis were recorded. Of 54 patients, 38 patients were enrolled in severe group, and 16 in critical group. Fever, cough, sputum, shortness of breath and so on could be found in the two groups. The CD4+T lymphocytes were less than normal reference value (410-1 590/μL) in both groups. The chest CT findings manifestations of severe group were scattered patchy shadows and ground glass appearance, all of them were cured and discharged after antiviral, antibiotics, and oxygen treatment. In critical group, the time in hospital was longer, the disease progresses varied faster, the shortness of breath was more apparent, and a large patch of fuzzy and real change shadows on both lungs could be found from CT findings. Compared with the severe group, creatine kinase (CK), lactic dehydrogenase (LDH), C-reactive protein (CRP) and procalcitonin (PCT) levels in the critical group were increased more significantly [CK (U/L): 704.50 (908.50) vs. 146.00 (220.75), LDH (U/L): 614.50 (492.25) vs. 217.00 (142.75), CRP (mg/L): 85.65 (56.13) vs. 18.80 (50.63), PCT (μg/L): 1.30 (5.00) vs. 0.10 (0.16), all P < 0.01], white blood cells count (WBC) and neutrophil ratio were also increased more significantly [WBC (×109/L): 12.37±7.63 vs. 8.29±3.32, neutrophil ratio: 0.81±0.11 vs. 0.75±0.11] without statistical differences (both P > 0.05). Nine patients in critical group were cured with cure rate of 56.25%. Seven patients died with mortality of 43.75%, including 2 patients with acquired immunodeficiency syndrome (AIDS) and uremia respectively, who had multiple organ failure (MOF) on admission and waive the mechanical ventilation treatment; 3 patients complicated with acute renal failure but abandon hemodialysis; 1 patient with nasopharyngeal carcinoma radiotherapy after operation; and 1 patient with chronic renal failure uremia period combined multiple drug-resistant bacteria infection, and died from MOF finally. The patients with severe and critical influenza A (H1N1) show fever, cough, dyspnea, and organ dysfunction in varying degrees. Severe patients were mainly pulmonary lesions, while critical patients show MOF such as heart, lung and kidney, and the lesions progressed rapidly. The major cause of death for critical influenza A (H1N1) may be chronic underlying diseases and MOF.

Impact of diabetes on outcomes of cardiac surgery in a multiethnic Southeast Asian population.

Although diabetes is rapidly increasing in Asia and has been shown to be associated with worse cardiac surgery outcomes, no research has been done to study the impact of diabetes on cardiac surgery outcomes in a Southeast Asian cohort. Hence, this study aims to delineate the predictors and impact of diabetes after cardiac surgery in a multi-ethnic Southeast Asian cohort. We analysed data from 2831 adult patients undergoing elective cardiac surgery, from 2008 to 2010 in Singapore. Diabetes was found to significantly increase the odds of intensive care unit readmission by 1.70 (95% confidence interval 1.171-2.480, p = 0.005), postoperative infection by 1.73 (95% confidence interval 1.003-2.976, p = 0.049), acute kidney injury by 1.36 (95% confidence interval 1.137-1.626, p = 0.001), postoperative hyperglycaemia by 6.00 (95% confidence interval 4.893-7.348, p < 0.001), and new need for dialysis by 1.71 (95% 1.086-5.360, p = 0.021). In conclusion, diabetes is associated with increased risk for renal dysfunction, hyperglycaemia, and infection after cardiac surgery, similar to the relative risks of diabetes patients observed in Western populations.

Selection of percutaneous coronary intervention in elderly patients with acute myocardial infarction in tertiary hospital.

To investigate the status of percutaneous coronary intervention (PCI) in elderly patients with acute myocardial infarction (AMI) and analyze the reasons for not receiving PCI.A cohort of 387 consecutive hospitalized AMI patients aged ≥80 years were recruited from 2005 to 2014. Their clinical data were collected and analyzed.Among 387 elderly patients with AMI (190 men and 197 women, mean age 84.1 ± 3.9 years), there were 171 patients with ST-elevation myocardial infarction (STEMI) and 216 patients with non-ST-elevation myocardial infarction (NSTEMI). The emergency and elective PCI treatment rate was 40.6% and 12.1%, respectively, in patients with STEMI; and 1% and 18%, respectively, in patients with NSTEMI. PCI treatment rate of elderly AMI patients enrolled after 2009 showed no significant difference compared to that before 2009 (P > .05). The in-hospital mortality decreased significantly in PCI treatment group. After adjustment for age, sex, and other factors, PCI treatment was identified as the independent protective factors for in-hospital mortality (odds ratio = 0.323, 95% confidence interval 0.147–0.710, P = .005). The main influence factors for not receiving PCI treatment were hemorrhage, severe renal dysfunction, infection, or severe anemia-associated complications, whereas delayed treatment was the important reason for patients not undergoing emergency PCI.PCI treatment is the independent protective factor for in-hospital mortality of elderly patients with AMI. Due to various complications, PCI treatment rate is still low in elderly patients with AMI and has not been improved recently. Paying attention to performing PCI treatment for elderly patients with AMI has positive significance.

Ammoides verticillata Essential Oil as Biocontrol Agent of Selected Fungi and Pest of Olive Tree.

Ammoides verticillata Briq is an aromatic and medicinal herb that has been widely used in folk medicine for treatment of several types of pathologies such as respiratory problems, colds, fever, headache, gastric disorders and renal infections. Essential oils have been subjected of numerous works for their antimicrobial and insecticidal properties which have been valued by hundreds of publications and patents. The main objective of this work was to evaluate the chemical composition, and the in vitro and in vivo antifungal, and insecticidal properties of essential oil of Ammoides verticillata. In this work, the air-dried aerial parts of Ammoides verticillata were hydrodistilled in a Clevenger-type apparatus. The essential oil isolated was analyzed using gas chromatography (GC) and mass spectrometry (GC/MS). The in vitro antifungal activity of the essential oil was investigated against four plant fungi using radial growth technique. The effect of the essential oil on disease development of olive caused by Penicillium crustosum and Aspergillus niger in the in vivo conditions. The fumigation test of the essential oil was evaluated against L3 stages, pupas and adults of Bactrocera oleae known as the olive fly. The essential oil of A. verticillata was characterized mainly by carvacrol (44.3%), limonene (19.3%) and p-cymene (19.2%). The result of in vitro antifungal activity of essential oil showed an interesting antifungal inhibition against Alternaria alternata and Fusarium solani strains with percentage inhibition of 89%. Furthermore, oil of A. verticillata has demonstrated promising in vivo antifungal activity to control infections of olives caused by Aspergillus niger and Penicillium crustosum. In addition, the essential oil exhibited fumigation toxicity against Bactrocera oleae with mortality percentage of 100% at 2 μL/L air. The results showed that essential oil of A. verticillata has interesting biological activities, which suggests that oil have the potential to be used as biocide to protect olives of pathogenic fungi and pests.

PS1421 HONEUR (HEAMATOLOGY OUTCOMES NETWORK IN EUROPE) – DISTRIBUTED STATISTICS IN A FEDERATED MODEL TO SUPPORT REAL WORLD DATA RESEARCH IN HEMATOLOGY

Background: Lenalidomide (LEN)-based treatment (Tx) until disease progression is a standard approach for many newly diagnosed multiple myeloma (NDMM) patients (pts). The safety and efficacy of this approach in transplant-ineligible NDMM pts has been validated in multiple clinical trials, including the phase 3 FIRST trial. Aims: This observational, non-interventional post-authorization safety study (PASS; NCT03106324) is investigating the safety and tolerability of LEN-based Tx (LEN cohort) compared with non–LEN-based Tx (non-LEN cohort) in transplant-ineligible NDMM pts, including adverse events (AEs) of interest and second primary malignancies (SPMs). Methods: This ongoing PASS is enrolling transplant-ineligible NDMM pts initiating their first antimyeloma Tx. Pts already receiving Tx at the time of enrollment are eligible if they have received < 2 cycles. Tx is per routine clinical practice and is determined before enrollment in the trial. The observation period for patients on Tx is up to 3 years, with a follow-up period of 5 years, during which SPMs and survival will be assessed. The primary endpoint is incidence of cardiovascular events. Secondary endpoints are incidences of renal impairment, infections, and SPMs, as well as further characterization of safety. Results: As of 10 December 2018, 116 pts were enrolled in the LEN cohort and 119 pts were enrolled in the non-LEN cohort. Bortezomib-based Tx was the most common Tx in the non-LEN cohort. Median age was 79.0 yrs in the LEN cohort and 76.0 yrs in the non-LEN cohort. ISS stage I/II/III was 16.4%/22.4%/21.6% in the LEN cohort and 10.9%/24.4%/29.4% in the non-LEN cohort. Tx was ongoing in 86 pts (74.1%) and 77 pts (64.7%), respectively. There were 6 (5.2%) cardiovascular events in the LEN cohort: 2 (1.7%) angina pectoris, and 1 (0.9%) each of troponin increased, cardiac failure congestive, cardiovascular insufficiency, and acute pulmonary edema. Eight (6.7%) cardiovascular events were reported in the non-LEN cohort: 4 (3.4%) cardiac failure, 2 (1.7%) myocardial infarction, and 1 (0.8%) each of arterial bypass occlusion and cardiopulmonary failure. Rates of grade 3/4 AEs were generally low (Table 1). Similar proportions of pts in both cohorts experienced ≥ 1 grade 3/4 AE (LEN cohort, 38.8%; non-LEN cohort, 41.2%), but the proportions of pts who experienced ≥ 1 AE leading to death was higher in the non-LEN cohort (10.1%) than in the LEN cohort (5.2%). In the LEN cohort, 51 pts (44.0%) had ≥ 1 AE related to LEN. LEN discontinuations and reductions or interruptions due to ≥ 1 AE occurred in 11 pts (9.5%) and 48 pts (41.4%), respectively. In both cohorts, there were 2 solid tumor SPMS (LEN, 1 lung cancer and 1 prostate cancer; non-LEN, 1 lung cancer and 1 bladder cancer). Both cohorts had 1 nonmelanoma skin cancer (squamous cell carcinoma); this was a recurrence in the non-LEN cohort. There were no reported hematologic SPMs.Summary/Conclusion: The current results of this ongoing observational, non-interventional study demonstrate that LEN-based Tx in transplant-ineligible NDMM pts in a real-world setting has a safety profile consistent with what has been observed in clinical trials. The incidence of cardiovascular events and other AEs was low, and no new safety signals for LEN-based Tx have been identified.

Implications of environmental and pathogen-specific determinants on clinical presentations and disease outcome in melioidosis patients.

BackgroundMelioidosis is gaining recognition as an emerging infectious disease with diverse clinical manifestations and high-case fatality rates worldwide. However, the molecular epidemiology of the disease outside the endemic regions such as northeast part of Thailand and northern Australia remains unclear.Methodology/Principal findingsClinical data and B. pseudomallei isolates obtained from 199 culture-confirmed cases of melioidosis diagnosed during 2006–2016 in South India were used to elucidate the host and pathogen specific variable virulence determinants associated with clinical presentations and disease outcome. Further, we determined the temporal variations and the influence of ecological factors on B.pseudomallei Lipopolysaccharide (LPS) genotypes causing infections. Severe forms of the disease were observed amongst 169 (85%) patients. Renal dysfunction and infection due to B.pseudomallei harboring BimABm variant had significant associations with severe forms of the disease. Diabetes mellitus, septicemic melioidosis and infection due to LPSB genotype were independent risk factors for mortality. LPSB (74%) and LPSA (20.6%) were the prevalent genotypes causing infections. Both genotypes demonstrated temporal variations and had significant correlations with rainfall and humidity.Conclusion/SignificanceOur study findings suggest that the pathogen specific virulence traits under the influence of ecological factors are the key drivers for geographical variations in the molecular epidemiology of melioidosis.

Cause-Specific Mortality in Multiethnic South East Asians With Type 2 Diabetes Mellitus

Data on specific causes of mortality in South East Asians with type 2 diabetes mellitus (T2DM) remain scarce. We followed 2061 outpatients with T2DM (Chinese 63%, Malays 20%, and Asian Indians 17%) for an average of 5.5 (standard deviation = 2.9) years and identified 365 death events by data linkage with national death registry. Cardiovascular disease was the main cause of mortality (44%), followed by renal disease (17%), infection (17%), cancer (14%), and others causes (8%). Survival analyses revealed that risks for all-cause and cause-specific mortality vary greatly among ethnic groups. Presence of diabetic kidney disease was an independent risk factor for death attributable to cardiovascular disease, renal disease, and infection, while HbA1c level predicted all major causes of deaths even after accounting for multiple other risk factors. These data reinforce the importance of glycemic control and prevention of diabetic kidney disease for mitigation of mortality burden in multiethnic Asians with T2DM.

Pyelonephritis: A Historical Reappraisal.

There is no human knowledge which cannot lose its scientific character when we forget the conditions under which it originated, the questions it answered and the function it was created to serve.[1][1] As with most diseases of the kidney, pyelonephritis is an old ailment, which as a diagnosis, is a

Lack of P2X7 Receptors Protects against Renal Fibrosis after Pyelonephritis with α-Hemolysin–Producing Escherichia coli

Severe urinary tract infections are commonly caused by sub-strains of Escherichia coli secreting the pore-forming virulence factor α-hemolysin (HlyA). Repeated or severe cases of pyelonephritis can cause renal scarring that subsequently can lead to progressive failure. We have previously demonstrated that HlyA releases cellular ATP directly through its membrane pore and that acute HlyA-induced cell damage is completely prevented by blocking ATP signaling. Local ATP signaling and P2X7 receptor activation play a key role in the development of tissue fibrosis. This study investigated the effect of P2X7 receptors on infection-induced renal scarring in a murine model of pyelonephritis. Pyelonephritis was induced by injecting 100 million HlyA-producing, uropathogenic E. coli into the urinary bladder of BALB/cJ mice. A similar degree of pyelonephritis and mortality was confirmed at day 5 after infection in P2X7+/+ and P2X7-/- mice. Fibrosis was first observed 2 weeks after infection, and the data clearly demonstrated that P2X7-/- mice and mice exposed to the P2X7 antagonist, brillian blue G, show markedly less renal fibrosis 14 days after infection compared with controls (P<0.001). Immunohistochemistry revealed comparable early neutrophil infiltration in the renal cortex from P2X7+/+ and P2X7-/- mice. Interestingly, lack of P2X7 receptors resulted in diminished macrophage infiltration and reduced neutrophil clearance in the cortex of P2X7-/- mice. Hence, this study suggests the P2X7 receptor to be an appealing antifibrotic target after renal infections.

Association of Time to Therapeutic Calcineurin Inhibitor (CNI) Levels to Biopsy-Proven Acute Rejection (BPAR) after Heart Transplantation

Purpose The optimal timing for CNI initiation in patients receiving rabbit anti-thymocyte globulin (rATG) induction in heart transplant has not been established. This study explored the association of time to therapeutic CNI levels and outcomes in order to evaluate the safety and efficacy of an early versus delayed strategy in this patient population. Methods This single-center, observational, retrospective review included 83 adult patients who underwent heart transplantation between January 2012 - October 2017 and received induction therapy with rATG at the time of transplant. Patients were stratified into four groups by time to therapeutic CNI levels post-transplant: ≤ 7 days (Group 1), 8 - 30 days (Group 2), 31 - 60 days (Group 3), and > 60 days (Group 4). Patients who did not receive a CNI as maintenance immunosuppression during initial hospitalization, or received a multi-organ transplant, alemtuzumab or basiliximab as part of induction therapy, a CNI minimization strategy using everolimus or sirolimus , or no induction therapy were excluded. The primary objective was freedom from BPAR at 1, 3, 6 and 12 months. Secondary objectives included time to first rejection; renal function via serum creatinine (SCr) pre-transplant, pre- and post-CNI initiation, and at discharge; and one-year survival. Results BPAR rates at 12 months were statistically lower in Groups 1 and 4 at 25% and 13%, respectively (p = 0.02). Time to first rejection and SCr were not significantly different, however, trended towards an increase in SCr post-CNI initiation (1.3 mg/dL) in Group 1. One-year survival favored Groups 2 and 3 at 93% and 100%, respectively (p = 0.12). Risk of infection was highest in Group 1 (79%, p = 0.005). Conclusion While a strategy of early time to therapeutic CNI levels had an associated risk of renal injury and infection , delayed time to therapeutic CNI levels (> 30 days post-transplant) was not associated with an increased risk of BPAR.

Preoperative prealbumin and transferring: Relation to 30-day risk of complication in elective spine surgical patients.

There is growing interest in identifying nutritional biomarkers associated with poor outcomes of elective spine surgery. Prealbumin and transferrin are both biomarkers of nutritional status that can be obtained from clinical laboratories. However, associations of preoperative measures of these nutritional biomarkers across their range with risk of complications from spine surgery have not been fully investigated. Determine associations of preoperative prealbumin and transferrin levels with 30-day risk of complication among elective spine surgery patients. Cohort study with preoperative prealbumin and transferrin collected as standard of care. 30-day risk of medical complication. Data were obtained from medical records of 274 consecutive adult patients ages ≥50 years who underwent elective spine surgery from June 2013 to June 2014. Prealbumin (mg/dL), serum transferrin (mg/dL), and preoperative factors were abstracted from medical records. Prealbumin and transferrin levels were categorized into quartiles and as below versus median or higher. The primary outcome measure was 30-day risk of medical complication, such as renal failure or infections. Associations of the biomarkers with outcome risk were assessed with chi-square tests and with risk ratios (RR) and 95% confidence intervals (CI) estimated with multivariable log-binomial regression. The 274 adults studied had a median prealbumin level of 27.4 mg/dL and a median transferrin level of 265.0 mg/dL. The 30-day risk of complication was 12.8% (95% CI: 8.8%-16.7%). Risk of complication did not vary by quartile for either prealbumin (P = .26) or transferrin (P = .49) and was not associated either with prealbumin (below median, RR = 1.1, 95% CI: 0.8, 1.5) or transferrin (below median, RR = 1.1, 95% CI: 0.8, 1.6). Among adults undergoing elective spine surgery, the 30-day risk of complication was not associated with prealbumin or transferrin. Nutrition status, as measured by prealbumin and transferrin, does not appear to be associated with complication risk. Level III.

Effect of Glucocorticoid Pulse Therapy on Short-term Prognosis of Anti-neutrophil Cytoplasmic Antibodies-associated Glomerulonephritis

Objective To investigate the prognosis predictors of anti-neutrophil cytoplasmic antibody(ANCA)-associated glomerulonephritis treated with glucocorticoid(GC).Methods The clinicopathological data of patients with biopsy-confirmed ANCA-associated glomerulonephritis were retrospective analyzed by retrieving the medical database in Peking Union Medical College Hospital from January 2000 to May 2015. Pathological categories were re-classified. Renal remission rates,infection rates,and death events were compared between intravenous glucocorticoid(GC)pulse therapy group and non-pulse group. Logistic regression analysis was performed to analyze factors influencing the short-term prognosis.Results Among the 81 patients with ANCA-associated glomerulonephritis,49(60.5%)received GC pulse therapy and 32(39.5%)did not. The GC pulse group had significantly lower estimated glomerular filtration rate at baseline(eGFR0)than the non-pulse group(t=3.003,P=0.015)but significantly higher 24-hour urinary protein(24 hUP)(t=2.394,P=0.002)and Birmingham Systemic Vasculitis Activity Score(BVAS)(t=0.049,P=0.013). There was no significant difference in the cumulative amount of cyclophosphamide(CTX)(t=1.336,P=0.245)between these two groups. The overall renal remission rate of GC pulse group in the 6 th month was significantly lower(48.7% vs. 79.3%;χ 2=6.591,P=0.024). Univariate analysis showed that baseline 24 hUP(t=6.222,P=0.017),eGFR0(t=3.727,P=0.046),and pathological category(χ 2=7.654,P=0.045)were associated with the overall renal remission rate in the 6 th month. Multivariate analysis showed the crescent category was an independent factor(OR=20.63,95%CI:2.217-191.973,P=0.008;compared with sclerotic category)for overall renal remission rate in the 6 th month,while GC pulse therapy was not an predictor(OR=0.271,95%CI:0.062-1.179,P=0.082). A total of 37 patients experienced infections within 6 months. The infection rate in GC pulse group(55.1%,27/49)was significantly higher than that of non-pulse group(31.3%,10/32)(P=0.042). Univariate regression analysis showed that eGFR0(t=1.912,P=0.049),baseline BVAS(t=-3.360,P=0.001)and GC pulse(χ 2=6.249,P=0.014)were associated with infection events within 6 months. Multivariate analysis showed that the baseline BVAS was the only predictor with 1.089 times for every 1 point increase in BVAS(OR=1.089,95%CI:1.006-1.179,P=0.034). Conclusions Crescentic category favors renal remission independently compared with sclerotic category. Patients with crescentic category may benefit more from intensive treatment. BVAS acts as an independent risk factor of infection.

Pyuria and microbiology in acute bacterial focal nephritis: a systematic review.

Presentation and imaging findings of acute focal bacterial nephritis, a localized renal infection not containing drainable pus, have been extensively addressed. The aim of this review was to assess the prevalence of cases without pyuria or bacteriuria and the spectrum of microorganisms underlying this condition. We conducted a systematic review of the literature in the National Library of Medicine and Excerpta Medica databases. For the final analysis, we retained 54 reports published between 1981 and 2018 describing 251 patients affected by focal bacterial nephritis, who have been specifically investigated with respect to urinalysis and standard bacterial cultures. They were 177 (102 females and 75 males) subjects ≤20 and 74 (57 females and 17 males) >20 years of age. Pyuria and bacteriuria were absent in 33 cases, while pyuria was not associated with bacteriuria in 5 further cases. The vast majority of culture-positive cases were caused by Enterobacteriaceae (slightly less than 80%) and Pseudomonas species (approximately 10%). Enterococcus species and Staphylococcus aureus were isolated in slightly more than 10% of the cases. A large subset of patients affected by focal bacterial nephritis present without pyuria and significant bacteriuria. The initial management consists of broad-spectrum antimicrobials with high tissue penetration, active against Enterobacteriaceae, Pseudomonas species, Enterococcus species and Staphylococcus aureus.

Grading of Complications After Cervical Deformity-corrective Surgery: Are Existing Classification Systems Applicable?

This is a retrospective review of prospective multicenter cervical deformity (CD) database. Assess the impact of complication type and Clavien complication (Cc) grade on clinical outcomes of surgical CD patients BACKGROUND:: Validated for general surgery, the Clavien-Dindo complication classification system allows for broad comparison of postoperative complications; however, the applicability of this system is unclear in CD-specific populations. Surgical CD patients above 18 years with baseline and postoperative clinical data were included. Primary outcomes were complication type (renal, infection, cardiac, pulmonary, gastrointestinal, neurological, musculoskeletal, implant-related, radiographic, operative, wound) and Cc grade (I, II, III, IV, V). Secondary outcomes were estimated blood loss (EBL), length of stay (LOS), reoperation, and health-related quality of life (HRQL) score. The univariate analysis assessed the impact of complication type and Cc grade on improvement markers and 1-year postoperative HRQL outcomes. In total, 153 patients (61±10 y, 61% female) underwent surgery for CD (8.1±4.6 levels fused; surgical approach included 48% posterior, 18% anterior, 34% combined). Overall, 63% of patients suffered at least 1 complication. Complication breakdown by type: renal (2.0%), infection (5.2%), cardiac (7.2%), pulmonary (3.9%), gastrointestinal (2.0%), neurological (26.1%), musculoskeletal (0.0%), implant-related (3.9%), radiographic (16.3%), operative (7.8%), and wound (5.2%). Of complication types, only operative complications were associated with increased EBL (P=0.004), whereas renal, cardiac, pulmonary, gastrointestinal, neurological, radiographic, and wound infections were associated with increased LOS (P<0.050). Patients were also assessed by Cc grade: I (28%), II (14.3%), III (16.3%), IV (6.5%), and V (0.7%). Grades I and V were associated with increased EBL (both P<0.050); Cc grade V was the only complication not associated with increased LOS (P=0.610). Increasing complication severity was correlated with increased risk of reoperation (r=0.512; P<0.001), but not inferior 1-year HRQL outcomes (all P>0.05). Increasing complication severity, assessed by the Clavien-Dindo classification system, was not associated with increased EBL, inpatient LOS, or inferior 1-year postoperative HRQL outcomes. Only operative complications were associated with increased EBL. These results suggest a need for modification of the Clavien system to increase applicability and utility in CD-specific populations.

Urease is an essential component of the acid response network of Staphylococcus aureus and is required for a persistent murine kidney infection.

Staphylococcus aureus causes acute and chronic infections resulting in significant morbidity. Urease, an enzyme that generates NH3 and CO2 from urea, is key to pH homeostasis in bacterial pathogens under acidic stress and nitrogen limitation. However, the function of urease in S. aureus niche colonization and nitrogen metabolism has not been extensively studied. We discovered that urease is essential for pH homeostasis and viability in urea-rich environments under weak acid stress. The regulation of urease transcription by CcpA, Agr, and CodY was identified in this study, implying a complex network that controls urease expression in response to changes in metabolic flux. In addition, it was determined that the endogenous urea derived from arginine is not a significant contributor to the intracellular nitrogen pool in non-acidic conditions. Furthermore, we found that during a murine chronic renal infection, urease facilitates S. aureus persistence by promoting bacterial fitness in the low-pH, urea-rich kidney. Overall, our study establishes that urease in S. aureus is not only a primary component of the acid response network but also an important factor required for persistent murine renal infections.

Infectious Disease Risk in Dialysis Patients: A Transdisciplinary Approach.

Purpose of review:Infections are a major contributor to morbidity and mortality in end-stage renal disease (ESRD) patients. A better understanding of the interplay between infectious processes and ESRD may eventually lead to the development of targeted treatment strategies aimed at lowering overall disease morbidity and mortality. Monogenic causes are a major contributor to the development of adult chronic kidney disease (CKD). Recent studies identified a genetic cause in 10% to 20% of adults with CKD. With the introduction of whole-exome sequencing (WES) into clinical mainstay, this proportion is expected to increase in the future. Once patients develop CKD/ESRD due to a genetic cause, secondary changes, such as a compromised immune status, affect overall disease progression and clinical outcomes. Stratification according to genotype may enable us to study its effects on secondary disease outcomes, such as infectious risk. Moreover, this knowledge will enable us to better understand the molecular interplay between primary disease and secondary disease outcomes.Sources of information:We conducted a literature review using search engines such as PubMed, PubMed central, and Medline, as well as cumulative knowledge from our respective areas of expertise.Methods:This is a transdisciplinary perspective on infectious complications in ESRD due to monogenic causes, such as autosomal dominant polycystic kidney disease (ADPKD), combining expertise in genomics and immunology.Key findings:In ADPKD, infection is a frequent complication manifesting primarily as lower urinary tract infection and less frequently as renal infection. Infectious episodes may be a direct consequence of a specific underlying structural abnormality, for example the characteristic cysts, among others. However, evidence suggests that infectious disease risk is also increased in ESRD due to secondary not-well-understood disease mechanisms. These disease mechanisms may vary depending on the underlying nature of the primary disease. While the infectious disease risk is well documented in ADPKD, there are currently insufficient data on the risk in other monogenic causes of ESRD. WES in combination with novel technologies, such as RNA sequencing and single-cell RNA sequencing, can provide insight into the molecular mechanisms of disease progression in different monogenic causes of CKD/ESRD and may lead to the development of novel risk-stratification profiles in the future.Limitations:This is not a systematic review of the literature and the proposed perspective is tainted by the authors’ point of view on the topic.Implications:WES in combination with novel technologies such as RNA sequencing may enable us to fully unravel underlying disease mechanisms and secondary disease outcomes in monogenic causes of CKD and better characterize individual risk profiles. This understanding will hopefully facilitate the development of novel targeted therapies.