- Email: [email protected]
Urine concentrations of human beta-defensins and ribonuclease 7 in urinary tract infection and asymptomatic bacteriuria
Urine concentrations of human beta-defensins and ribonuclease 7 in urinary tract infection and asymptomatic bacteriuria ˚ Charlott Kj¨olvmark, Per Akesson, Lisa I P˚ahlman PII: DOI: Reference:
S0732-8893(17)30187-6 doi: 10.1016/j.diagmicrobio.2017.06.010 DMB 14371
To appear in:
Diagnostic Microbiology and Infectious Disease
Received date: Revised date: Accepted date:
7 April 2017 9 June 2017 12 June 2017
Please cite this article as: Kj¨olvmark Charlott, ˚ Akesson Per, P˚ ahlman Lisa I, Urine concentrations of human beta-defensins and ribonuclease 7 in urinary tract infection and asymptomatic bacteriuria, Diagnostic Microbiology and Infectious Disease (2017), doi: 10.1016/j.diagmicrobio.2017.06.010
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Urine concentrations of human beta-defensins and ribonuclease 7 in
RI P
T
urinary tract infection and asymptomatic bacteriuria
Division of Infection Medicine, Hospital of Helsingborg, 2Department of Clinical Sciences,
MA NU
1
SC
Charlott Kjölvmark, MD 1, PhD 2, Per Åkesson, MD, PhD 2, Lisa I Påhlman, MD, PhD 2
Division of Infection Medicine, Lund University, Lund Word count: 997
ED
Keywords: Human beta-defensins, Ribonuclease 7, urinary tract infection, asymptomatic bacteriuria
Södra
Vallgatan
5,
SE-25187
Helsingborg,
Sweden.
E-mail:
CE
Helsingborg,
PT
Corresponding author: Charlott Kjölvmark: Division of Infection Medicine, Hospital of
AC
[email protected], Phone number: +46-424061000, Fax number: +46-424062362 Alternative corresponding author: Lisa I Påhlman: Department of Clinical Sciences, Division of Infection Medicine, Lund University Hospital, SE-221 85 Lund, Sweden. E-mail: [email protected], Phone number: +46-46323895, Fax number: +46-46323895
1
ACCEPTED MANUSCRIPT ABSTRACT Antimicrobial peptides (AMPs) provide a first line of defense against bacterial infections.
T
Here we report that urine levels of AMPs, locally produced in the urinary tract, are lower in
RI P
individuals with asymptomatic bacteriuria (ABU) compared to patients with urinary tract
MA NU
SC
infection (UTI).
Urinary tract infections (UTI) range from mild and local infection of the urine bladder, cystitis, to ascending and more serious infection in the kidney, pyelonephritis. The latter can develop into severe sepsis and septic shock with high mortality rates if untreated. In addition,
ED
the urinary tract can become colonized with bacteria without causing symptoms. This condition is called asymptomatic bacteriuria (ABU) and is common in the elderly population
PT
with a prevalence of over 20 % among healthy women over 80 years of age and up to 50 %
CE
among residents at nursing homes (1). Both UTI and ABU patients respond with pyuria, and dipstick tests used in routine practice cannot distinguish the two conditions. However, little is
AC
known about how the urothelium responds in ABU compared to UTI. Antimicrobial peptides (AMPs) are components of the innate immune system, and act as a first line of defense in the urinary tract to maintain sterile conditions and prevent UTI (2). AMPs are small cationic peptides with antimicrobial activity against uropathogenic bacteria (2-4). The peptides are expressed by the uroepithelium or released from phagocytic white blood cells. The most well studied AMPs in the urinary tract are the human alpha- and beta-defensins, cathelicidin/LL-37 (5-10), and ribonuclease 7 (RNase 7) (11). The aim of this study was to compare urine levels of the urothelium-derived AMPs human beta-defensin (HBD)-1, HBD-2, HBD-3 and RNase 7 in adult patients with cystitis, pyelonephritis, ABU and healthy controls. Details on the recruitments, inclusion and 2
ACCEPTED MANUSCRIPT exclusion criteria and sample technics have been described previously (12, 13). Briefly, cystitis patients had at least one symptom of UTI (dysuria, frequency, urgency, supra-pubic
T
pain, hematuria) and positive urine culture. Patients with pyelonephritis had fever, chills,
RI P
and/or elevated plasma C-reactive protein in addition to the criteria for cystitis. Exclusion criteria were antibiotic treatment during the past 7 days. ABU individuals were recruited from
SC
nursing homes. Inclusion criteria were two consecutive positive urine cultures with the same bacterium for women, and one for men. Exclusion criteria were symptoms of UTI, cognitive
MA NU
impairment/dementia and antibiotic use the past seven days. Control urine samples were obtained from two primary care offices. None of the control subjects had an underlying urogenital disease, signs of UTI symptoms during the last 3 months, or bacterial growth in the urine culture. The study was approved by the Medical Ethic Committee of Lund University.
ED
Informed consent was obtained from all participants.
PT
Urine was analyzed with dipstick test and urine culture. AMPs were analyzed from cell-free
CE
supernatants. The definition of a positive urine culture for patients with UTI were: primary pathogen (Escherichia coli (E. coli) or Staphylococcus saprophyticus) ≥104 colony-forming
AC
units (CFU)/mL or growth of a secondary pathogen of ≥105 CFU/mL in the urine culture from a midstream sample. The definition of a positive urine culture for individuals with ABU were growth of ≥105 CFU/mL of a single bacterial species, in one (men) or two consecutive midstream urine samples (women). E. coli was the most common bacterial species; 77 % among patients with UTI and 87 % in the ABU group. Urinary AMP levels from individuals with UTI, patients with ABU and control subjects are presented in figure 1 A-C and table 1. AMP concentrations were higher in urine from UTI patients compared to healthy controls. HBD-1 was significantly elevated in both the pyelonephritis and cystitis groups (Fig 1A). HBD-2 was higher in urine from pyelonephritis subjects only (Fig 2B), whereas RNase 7 was only significantly elevated in the cystitis group 3
ACCEPTED MANUSCRIPT (Fig 1C). HBD-3 levels were low and did not allow comparison between groups as most samples were below detection limit of the assay (data not shown).
T
Compared to UTI patients, individuals with ABU had overall low urine levels of AMPs.
RI P
HBD-1 concentrations in ABU urine were in the same range as controls, and significantly lower than the two UTI groups (Fig 1A). Urine levels of HBD-2 were significantly lower in
MA NU
to both two UTI groups as well as controls (Fig 1C).
SC
ABU compared to pyelonephritis (Fig 1B), and RNase 7 was lower in ABU urine compared
Presence of white blood cells in urine was common among patients with UTI and ABU, 99% and 87% respectively. Only 28% of the controls had pyuria. Among UTI and control samples, levels of all AMPs increased significantly with pyuria (data not shown). In contrast, ABU
ED
samples showed no differences in AMP levels with increasing numbers of white blood cells in
PT
urine (data not shown), which could indicate a role for HBD-2, HBD-1 and RNase 7 in the pathogenesis and diagnosis of ABU.
CE
In response to bacteria, the urothelium is activated, leading to expression of inflammatory
AC
mediators, secretion of AMPs, and the recruitment of inflammatory cells to the site of infection. The pathogenesis behind whether bacteriuria develops into ABU or UTI is not fully understood, but both bacterial factors such as altered P-fimbriae, LPS and hemolysin in E. coli (14-16), and host factors such as genetic variations in Toll-like receptor (TLR) 4 (17, 18), have been proposed. Neutrophils are recruited to a similar extent in ABU and UTI, but other aspects of the host response differ between the two conditions. For example, increased levels of urinary cytokines from patients with UTI compared to individuals with ABU have earlier been reported from others and from our research group (1, 13, 17). Here, we show that urinary levels of urothelium-derived AMPs are elevated in patients with UTI compared to controls with negative urine cultures, which have also been described in previous studies (9, 19, 20).
4
ACCEPTED MANUSCRIPT In contrast, AMPs were lower in ABU compared to UTI. This has not been described before, and indicates that the urothelium responds differently to bacteriuria in the two conditions.
T
In conclusion, the present study demonstrates elevated levels of urinary AMPs in UTI,
RI P
whereas concentrations in ABU urine were low and in the same range as control subjects. The data may help explain why ABU strains can colonize the bladder, although further studies are
ACKNOWLEDGEMENTS
MA NU
SC
needed to understand the pathogenesis behind these observations.
We wish to thank Gisela Hovold for excellent technical assistance. This work was funded by
ED
the Swedish Government Funds for Clinical Research (ALF), the Swedish Heart and Lung
PT
foundation, the Alfred Österlund and Magnus Bergvall foundations, Stig and Ragna Gorthon foundation and Mrs. Thelma Zoégas foundation.
2. 3.
4.
5.
6.
7.
Rodhe N, Löfgren S, Strindhall J, Matussek A, Mölstad S. Cytokines in urine in elderly subjects with acute cystitis and asymptomatic bacteriuria. Scandinavian journal of primary health care. 2009;27(2):74-9. Epub 2009/02/28. Zasloff M. Antimicrobial peptides of multicellular organisms. Nature. 2002;415(6870):389-95. Epub 2002/01/25. Zasloff M. Antimicrobial peptides, innate immunity, and the normally sterile urinary tract. Journal of the American Society of Nephrology : JASN. 2007;18(11):2810-6. Epub 2007/10/19. Ali AS, Townes CL, Hall J, Pickard RS. Maintaining a sterile urinary tract: the role of antimicrobial peptides. The Journal of urology. 2009;182(1):21-8. Epub 2009/05/19. Spencer JD, Hains DS, Porter E, Bevins CL, DiRosario J, Becknell B, et al. Human alpha defensin 5 expression in the human kidney and urinary tract. PloS one. 2012;7(2):e31712. Epub 2012/02/24. Nitschke M, Wiehl S, Baer PC, Kreft B. Bactericidal activity of renal tubular cells: the putative role of human beta-defensins. Experimental nephrology. 2002;10(5-6):332-7. Epub 2002/10/17. Townes CL, Ali A, Robson W, Pickard R, Hall J. Tolerance of bacteriuria after urinary diversion is linked to antimicrobial peptide activity. Urology. 2011;77(2):509 e1-8. Epub 2010/11/26.
AC
1.
CE
REFERENCES
5
ACCEPTED MANUSCRIPT
13.
14.
15.
16.
17.
18.
19.
20.
T
RI P
SC
MA NU
12.
ED
11.
PT
10.
Dobrindt U, Zdziarski J, Salvador E, Hacker J. Bacterial genome plasticity and its impact on adaptation during persistent infection. International journal of medical microbiology : IJMM. 2010;300(6):363-6. Epub 2010/05/11. Grönberg-Hernandez J, Sundén F, Connolly J, Svanborg C, Wullt B. Genetic control of the variable innate immune response to asymptomatic bacteriuria. PloS one. 2011;6(11):e28289. Epub 2011/12/06. Ragnarsdottir B, Samuelsson M, Gustafsson MC, Leijonhufvud I, Karpman D, Svanborg C. Reduced toll-like receptor 4 expression in children with asymptomatic bacteriuria. The Journal of infectious diseases. 2007;196(3):47584. Epub 2007/06/29. Spencer JD, Schwaderer AL, Wang H, Bartz J, Kline J, Eichler T, et al. Ribonuclease 7, an antimicrobial peptide upregulated during infection, contributes to microbial defense of the human urinary tract. Kidney international. 2013;83(4):615-25. Epub 2013/01/11. Hiratsuka T, Nakazato M, Ihi T, Minematsu T, Chino N, Nakanishi T, et al. Structural analysis of human beta-defensin-1 and its significance in urinary tract infection. Nephron. 2000;85(1):34-40. Epub 2000/04/25.
CE
9.
Chromek M, Slamova Z, Bergman P, Kovacs L, Podracka L, Ehren I, et al. The antimicrobial peptide cathelicidin protects the urinary tract against invasive bacterial infection. Nature medicine. 2006;12(6):636-41. Epub 2006/06/06. Nielsen KL, Dynesen P, Larsen P, Jakobsen L, Andersen PS, Frimodt-Möller N. Role of urinary cathelicidin LL-37 and human beta-defensin 1 in uncomplicated Escherichia coli urinary tract infections. Infection and immunity. 2014;82(4):1572-8. Epub 2014/01/24. Becknell B, Spencer JD, Carpenter AR, Chen X, Singh A, Ploeger S, et al. Expression and antimicrobial function of beta-defensin 1 in the lower urinary tract. PloS one. 2013;8(10):e77714. Epub 2013/11/10. Spencer JD, Schwaderer AL, Dirosario JD, McHugh KM, McGillivary G, Justice SS, et al. Ribonuclease 7 is a potent antimicrobial peptide within the human urinary tract. Kidney international. 2011;80(2):174-80. Epub 2011/04/29. Kjölvmark C, Påhlman LI, Åkesson P, Linder A. Heparin-binding protein: a diagnostic biomarker of urinary tract infection in adults. Open forum infectious diseases. 2014;1(1):ofu004. Epub 2015/03/04. Kjölvmark C, Tschernij E, Öberg J, Påhlman LI, Linder A, Åkesson P. Distinguishing asymptomatic bacteriuria from urinary tract infection in the elderly - the use of urine levels of heparin-binding protein and interleukin-6. Diagnostic microbiology and infectious disease. 2016. Epub 2016/04/04. Klemm P, Roos V, Ulett GC, Svanborg C, Schembri MA. Molecular characterization of the Escherichia coli asymptomatic bacteriuria strain 83972: the taming of a pathogen. Infection and immunity. 2006;74(1):781-5. Epub 2005/12/22. Andersson P, Engberg I, Lidin-Janson G, Lincoln K, Hull R, Hull S, et al. Persistence of Escherichia coli bacteriuria is not determined by bacterial adherence. Infection and immunity. 1991;59(9):2915-21. Epub 1991/09/01. 19.
AC
8.
6
ACCEPTED MANUSCRIPT Figure 1. Levels of human beta-defensin 1 (A), human beta-defensin 2 (B), and ribonuclease
AC
CE
PT
ED
MA NU
SC R
IP T
7 (C) in urine. Each dot represents one individual. Bars represent median values.
7
ACCEPTED MANUSCRIPT
Cystitis
ABU
Control
HBD-1 (ng/ml)
76.4 (19.1-124.7)
25.8 (4.0-85.2)
4.0 (4.0-22.5)
4.0 (4.0-39.5)
HBD-2 (pg/ml)
380.7 (172.6654.5)
8.0 (8.0-130.4)
44.8 (8-378.6)
76.4 (8-173.7)
RNase 7 (pg/ml)
429.5 (194.01138.0)
466.0 (233.5977.8)
78.0 (78.0165.8)
239.0 (78.0565.0)
AC
CE
PT
ED
MA NU
SC
T
Pyelonephritis
RI P
Table 1 AMP levels expressed as median and interquartile range
8
S0732-8893(17)30187-6 doi: 10.1016/j.diagmicrobio.2017.06.010 DMB 14371
To appear in:
Diagnostic Microbiology and Infectious Disease
Received date: Revised date: Accepted date:
7 April 2017 9 June 2017 12 June 2017
Please cite this article as: Kj¨olvmark Charlott, ˚ Akesson Per, P˚ ahlman Lisa I, Urine concentrations of human beta-defensins and ribonuclease 7 in urinary tract infection and asymptomatic bacteriuria, Diagnostic Microbiology and Infectious Disease (2017), doi: 10.1016/j.diagmicrobio.2017.06.010
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Urine concentrations of human beta-defensins and ribonuclease 7 in
RI P
T
urinary tract infection and asymptomatic bacteriuria
Division of Infection Medicine, Hospital of Helsingborg, 2Department of Clinical Sciences,
MA NU
1
SC
Charlott Kjölvmark, MD 1, PhD 2, Per Åkesson, MD, PhD 2, Lisa I Påhlman, MD, PhD 2
Division of Infection Medicine, Lund University, Lund Word count: 997
ED
Keywords: Human beta-defensins, Ribonuclease 7, urinary tract infection, asymptomatic bacteriuria
Södra
Vallgatan
5,
SE-25187
Helsingborg,
Sweden.
E-mail:
CE
Helsingborg,
PT
Corresponding author: Charlott Kjölvmark: Division of Infection Medicine, Hospital of
AC
[email protected], Phone number: +46-424061000, Fax number: +46-424062362 Alternative corresponding author: Lisa I Påhlman: Department of Clinical Sciences, Division of Infection Medicine, Lund University Hospital, SE-221 85 Lund, Sweden. E-mail: [email protected], Phone number: +46-46323895, Fax number: +46-46323895
1
ACCEPTED MANUSCRIPT ABSTRACT Antimicrobial peptides (AMPs) provide a first line of defense against bacterial infections.
T
Here we report that urine levels of AMPs, locally produced in the urinary tract, are lower in
RI P
individuals with asymptomatic bacteriuria (ABU) compared to patients with urinary tract
MA NU
SC
infection (UTI).
Urinary tract infections (UTI) range from mild and local infection of the urine bladder, cystitis, to ascending and more serious infection in the kidney, pyelonephritis. The latter can develop into severe sepsis and septic shock with high mortality rates if untreated. In addition,
ED
the urinary tract can become colonized with bacteria without causing symptoms. This condition is called asymptomatic bacteriuria (ABU) and is common in the elderly population
PT
with a prevalence of over 20 % among healthy women over 80 years of age and up to 50 %
CE
among residents at nursing homes (1). Both UTI and ABU patients respond with pyuria, and dipstick tests used in routine practice cannot distinguish the two conditions. However, little is
AC
known about how the urothelium responds in ABU compared to UTI. Antimicrobial peptides (AMPs) are components of the innate immune system, and act as a first line of defense in the urinary tract to maintain sterile conditions and prevent UTI (2). AMPs are small cationic peptides with antimicrobial activity against uropathogenic bacteria (2-4). The peptides are expressed by the uroepithelium or released from phagocytic white blood cells. The most well studied AMPs in the urinary tract are the human alpha- and beta-defensins, cathelicidin/LL-37 (5-10), and ribonuclease 7 (RNase 7) (11). The aim of this study was to compare urine levels of the urothelium-derived AMPs human beta-defensin (HBD)-1, HBD-2, HBD-3 and RNase 7 in adult patients with cystitis, pyelonephritis, ABU and healthy controls. Details on the recruitments, inclusion and 2
ACCEPTED MANUSCRIPT exclusion criteria and sample technics have been described previously (12, 13). Briefly, cystitis patients had at least one symptom of UTI (dysuria, frequency, urgency, supra-pubic
T
pain, hematuria) and positive urine culture. Patients with pyelonephritis had fever, chills,
RI P
and/or elevated plasma C-reactive protein in addition to the criteria for cystitis. Exclusion criteria were antibiotic treatment during the past 7 days. ABU individuals were recruited from
SC
nursing homes. Inclusion criteria were two consecutive positive urine cultures with the same bacterium for women, and one for men. Exclusion criteria were symptoms of UTI, cognitive
MA NU
impairment/dementia and antibiotic use the past seven days. Control urine samples were obtained from two primary care offices. None of the control subjects had an underlying urogenital disease, signs of UTI symptoms during the last 3 months, or bacterial growth in the urine culture. The study was approved by the Medical Ethic Committee of Lund University.
ED
Informed consent was obtained from all participants.
PT
Urine was analyzed with dipstick test and urine culture. AMPs were analyzed from cell-free
CE
supernatants. The definition of a positive urine culture for patients with UTI were: primary pathogen (Escherichia coli (E. coli) or Staphylococcus saprophyticus) ≥104 colony-forming
AC
units (CFU)/mL or growth of a secondary pathogen of ≥105 CFU/mL in the urine culture from a midstream sample. The definition of a positive urine culture for individuals with ABU were growth of ≥105 CFU/mL of a single bacterial species, in one (men) or two consecutive midstream urine samples (women). E. coli was the most common bacterial species; 77 % among patients with UTI and 87 % in the ABU group. Urinary AMP levels from individuals with UTI, patients with ABU and control subjects are presented in figure 1 A-C and table 1. AMP concentrations were higher in urine from UTI patients compared to healthy controls. HBD-1 was significantly elevated in both the pyelonephritis and cystitis groups (Fig 1A). HBD-2 was higher in urine from pyelonephritis subjects only (Fig 2B), whereas RNase 7 was only significantly elevated in the cystitis group 3
ACCEPTED MANUSCRIPT (Fig 1C). HBD-3 levels were low and did not allow comparison between groups as most samples were below detection limit of the assay (data not shown).
T
Compared to UTI patients, individuals with ABU had overall low urine levels of AMPs.
RI P
HBD-1 concentrations in ABU urine were in the same range as controls, and significantly lower than the two UTI groups (Fig 1A). Urine levels of HBD-2 were significantly lower in
MA NU
to both two UTI groups as well as controls (Fig 1C).
SC
ABU compared to pyelonephritis (Fig 1B), and RNase 7 was lower in ABU urine compared
Presence of white blood cells in urine was common among patients with UTI and ABU, 99% and 87% respectively. Only 28% of the controls had pyuria. Among UTI and control samples, levels of all AMPs increased significantly with pyuria (data not shown). In contrast, ABU
ED
samples showed no differences in AMP levels with increasing numbers of white blood cells in
PT
urine (data not shown), which could indicate a role for HBD-2, HBD-1 and RNase 7 in the pathogenesis and diagnosis of ABU.
CE
In response to bacteria, the urothelium is activated, leading to expression of inflammatory
AC
mediators, secretion of AMPs, and the recruitment of inflammatory cells to the site of infection. The pathogenesis behind whether bacteriuria develops into ABU or UTI is not fully understood, but both bacterial factors such as altered P-fimbriae, LPS and hemolysin in E. coli (14-16), and host factors such as genetic variations in Toll-like receptor (TLR) 4 (17, 18), have been proposed. Neutrophils are recruited to a similar extent in ABU and UTI, but other aspects of the host response differ between the two conditions. For example, increased levels of urinary cytokines from patients with UTI compared to individuals with ABU have earlier been reported from others and from our research group (1, 13, 17). Here, we show that urinary levels of urothelium-derived AMPs are elevated in patients with UTI compared to controls with negative urine cultures, which have also been described in previous studies (9, 19, 20).
4
ACCEPTED MANUSCRIPT In contrast, AMPs were lower in ABU compared to UTI. This has not been described before, and indicates that the urothelium responds differently to bacteriuria in the two conditions.
T
In conclusion, the present study demonstrates elevated levels of urinary AMPs in UTI,
RI P
whereas concentrations in ABU urine were low and in the same range as control subjects. The data may help explain why ABU strains can colonize the bladder, although further studies are
ACKNOWLEDGEMENTS
MA NU
SC
needed to understand the pathogenesis behind these observations.
We wish to thank Gisela Hovold for excellent technical assistance. This work was funded by
ED
the Swedish Government Funds for Clinical Research (ALF), the Swedish Heart and Lung
PT
foundation, the Alfred Österlund and Magnus Bergvall foundations, Stig and Ragna Gorthon foundation and Mrs. Thelma Zoégas foundation.
2. 3.
4.
5.
6.
7.
Rodhe N, Löfgren S, Strindhall J, Matussek A, Mölstad S. Cytokines in urine in elderly subjects with acute cystitis and asymptomatic bacteriuria. Scandinavian journal of primary health care. 2009;27(2):74-9. Epub 2009/02/28. Zasloff M. Antimicrobial peptides of multicellular organisms. Nature. 2002;415(6870):389-95. Epub 2002/01/25. Zasloff M. Antimicrobial peptides, innate immunity, and the normally sterile urinary tract. Journal of the American Society of Nephrology : JASN. 2007;18(11):2810-6. Epub 2007/10/19. Ali AS, Townes CL, Hall J, Pickard RS. Maintaining a sterile urinary tract: the role of antimicrobial peptides. The Journal of urology. 2009;182(1):21-8. Epub 2009/05/19. Spencer JD, Hains DS, Porter E, Bevins CL, DiRosario J, Becknell B, et al. Human alpha defensin 5 expression in the human kidney and urinary tract. PloS one. 2012;7(2):e31712. Epub 2012/02/24. Nitschke M, Wiehl S, Baer PC, Kreft B. Bactericidal activity of renal tubular cells: the putative role of human beta-defensins. Experimental nephrology. 2002;10(5-6):332-7. Epub 2002/10/17. Townes CL, Ali A, Robson W, Pickard R, Hall J. Tolerance of bacteriuria after urinary diversion is linked to antimicrobial peptide activity. Urology. 2011;77(2):509 e1-8. Epub 2010/11/26.
AC
1.
CE
REFERENCES
5
ACCEPTED MANUSCRIPT
13.
14.
15.
16.
17.
18.
19.
20.
T
RI P
SC
MA NU
12.
ED
11.
PT
10.
Dobrindt U, Zdziarski J, Salvador E, Hacker J. Bacterial genome plasticity and its impact on adaptation during persistent infection. International journal of medical microbiology : IJMM. 2010;300(6):363-6. Epub 2010/05/11. Grönberg-Hernandez J, Sundén F, Connolly J, Svanborg C, Wullt B. Genetic control of the variable innate immune response to asymptomatic bacteriuria. PloS one. 2011;6(11):e28289. Epub 2011/12/06. Ragnarsdottir B, Samuelsson M, Gustafsson MC, Leijonhufvud I, Karpman D, Svanborg C. Reduced toll-like receptor 4 expression in children with asymptomatic bacteriuria. The Journal of infectious diseases. 2007;196(3):47584. Epub 2007/06/29. Spencer JD, Schwaderer AL, Wang H, Bartz J, Kline J, Eichler T, et al. Ribonuclease 7, an antimicrobial peptide upregulated during infection, contributes to microbial defense of the human urinary tract. Kidney international. 2013;83(4):615-25. Epub 2013/01/11. Hiratsuka T, Nakazato M, Ihi T, Minematsu T, Chino N, Nakanishi T, et al. Structural analysis of human beta-defensin-1 and its significance in urinary tract infection. Nephron. 2000;85(1):34-40. Epub 2000/04/25.
CE
9.
Chromek M, Slamova Z, Bergman P, Kovacs L, Podracka L, Ehren I, et al. The antimicrobial peptide cathelicidin protects the urinary tract against invasive bacterial infection. Nature medicine. 2006;12(6):636-41. Epub 2006/06/06. Nielsen KL, Dynesen P, Larsen P, Jakobsen L, Andersen PS, Frimodt-Möller N. Role of urinary cathelicidin LL-37 and human beta-defensin 1 in uncomplicated Escherichia coli urinary tract infections. Infection and immunity. 2014;82(4):1572-8. Epub 2014/01/24. Becknell B, Spencer JD, Carpenter AR, Chen X, Singh A, Ploeger S, et al. Expression and antimicrobial function of beta-defensin 1 in the lower urinary tract. PloS one. 2013;8(10):e77714. Epub 2013/11/10. Spencer JD, Schwaderer AL, Dirosario JD, McHugh KM, McGillivary G, Justice SS, et al. Ribonuclease 7 is a potent antimicrobial peptide within the human urinary tract. Kidney international. 2011;80(2):174-80. Epub 2011/04/29. Kjölvmark C, Påhlman LI, Åkesson P, Linder A. Heparin-binding protein: a diagnostic biomarker of urinary tract infection in adults. Open forum infectious diseases. 2014;1(1):ofu004. Epub 2015/03/04. Kjölvmark C, Tschernij E, Öberg J, Påhlman LI, Linder A, Åkesson P. Distinguishing asymptomatic bacteriuria from urinary tract infection in the elderly - the use of urine levels of heparin-binding protein and interleukin-6. Diagnostic microbiology and infectious disease. 2016. Epub 2016/04/04. Klemm P, Roos V, Ulett GC, Svanborg C, Schembri MA. Molecular characterization of the Escherichia coli asymptomatic bacteriuria strain 83972: the taming of a pathogen. Infection and immunity. 2006;74(1):781-5. Epub 2005/12/22. Andersson P, Engberg I, Lidin-Janson G, Lincoln K, Hull R, Hull S, et al. Persistence of Escherichia coli bacteriuria is not determined by bacterial adherence. Infection and immunity. 1991;59(9):2915-21. Epub 1991/09/01. 19.
AC
8.
6
ACCEPTED MANUSCRIPT Figure 1. Levels of human beta-defensin 1 (A), human beta-defensin 2 (B), and ribonuclease
AC
CE
PT
ED
MA NU
SC R
IP T
7 (C) in urine. Each dot represents one individual. Bars represent median values.
7
ACCEPTED MANUSCRIPT
Cystitis
ABU
Control
HBD-1 (ng/ml)
76.4 (19.1-124.7)
25.8 (4.0-85.2)
4.0 (4.0-22.5)
4.0 (4.0-39.5)
HBD-2 (pg/ml)
380.7 (172.6654.5)
8.0 (8.0-130.4)
44.8 (8-378.6)
76.4 (8-173.7)
RNase 7 (pg/ml)
429.5 (194.01138.0)
466.0 (233.5977.8)
78.0 (78.0165.8)
239.0 (78.0565.0)
AC
CE
PT
ED
MA NU
SC
T
Pyelonephritis
RI P
Table 1 AMP levels expressed as median and interquartile range
8