Leptospirosis is an overlooked zoonotic disease caused by pathogenic Leptospira depended on virulence of Leptospira and the host–pathogen interaction. Kidney is the major organ infected by Leptospira which causes tubulointerstitial nephritis. Leptospira outer membrane contains several virulence factors and an outer membrane protein A (OmpA) like protein (Loa22) is essential for virulence. Pull-down assays suggested that Loa22 was a potential Toll-Like Receptor 2 (TLR2) binding candidates from pathogenic Leptospira. Confocal microscopy was employed to observe the co-localization of TLR2 and Loa22-LPGN (Leptospira peptidoglycan) complexes. Atomic force microscopy (AFM), side-directed mutagenesis, and enzyme-linked immunosorbent assay (ELISA) were performed to investigate the affinity between rLoa22, LPGN, and TLR2. Real time PCR was applied to measure the cytokines expression. Downstream signal transduction components were verified by western blot to evaluate the gene regulations. Mutation of two Loa22 key residues (Asp¹²² and Arg¹⁴³) attenuated the affinities for LPGN. rLoa22-LPGN complexes were observed to co-localize with TLR2 and provoked inflammatory responses including CXCL8/IL8, hCCL2/MCP-1, and hTNF-α. Affinity studies suggested that Loa22-LPGN complexes elevated the affinity to TLR2 as compared to Loa22 protein. Downstream signals from TLR2 including p38, ERK, and JNK were regulated under rLoa22-LPGN complexes treatments. This study identified LPGN mediates interactions between Loa22 and TLR2 and induces downstream signals to trigger inflammatory responses. rLoa22-LPGN-TLR2 complexes reveal a novel binding mechanism for the innate immune system.

Endophthalmitis is a severe eye infection leading to disabling outcome. Because there were only a few case report illustrating endophthalmitis in chronic dialysis patient, we would like to investigate the epidemiology and clinical features of endophthalmitis in chronic dialysis patient in a tertiary referral center. We searched the health information system in the study hospital with ICD9 encoding endophthalmitis during Jan. 2002 to Dec. 2015. A total of 32 episodes of endophthalmitis occurred in chronic dialysis patients. We performed an 1:2 case-control match on propensity score. The demographic features, clinical manifestation, infection focus and visual outcome were recorded. Of the total of 32 patients, 25 were classified as endogenous endophthalmitis and another seven were exogenous. Most patients presented with ophthalmalgia (n = 32, 100%) and periocular swelling (n = 31, 96.8%), whereas half of the patients suffered blurred vision (n = 16, 50%). Staphylococcus aureus, Klebsiella pneumoniae, and Pseudomonas aeruginosa were the most frequent causative pathogens. Dialysis vascular infection was also a possible unique focus for bacteremia. The visual acuity of the endogenous groups were less likely to improve in the chronic dialysis patients compared with control group. This is the first and the largest case series focusing on endophthalmitis in chronic dialysis patients. Our study showed different pathogen spectrum, an unique bacterial origin and worse visual outcome in these group of patients. Prompt referral to ophthalmologists when the patients present with suspicious symptoms (blurred vision, ophthalmalgia and periocular swelling) is crucial.

Cirrhotic patients admitted to an intensive care unit (ICU) have high mortality rates. The present study compared the characteristics and outcomes of critically ill patients admitted to the ICU with and without cirrhosis using the matched Acute Physiology and Chronic Health Evaluation III (APACHE III) and Sequential Organ Failure Assessment (SOFA) scores. A retrospective case-control study was performed at the medical ICU of a tertiary-care hospital between January 2006 and December 2009. Patients were admitted with life-threatening complications and were matched for APACHE III and SOFA scores. Of 336 patients enrolled in the study, 87 in the cirrhosis or noncirrhosis group were matched according to the APACHE III scores. Another 55 patients with cirrhosis were matched to the 55 patients without cirrhosis according to the SOFA scores. Demographic data, aetiology of ICU admission, and laboratory variables were also evaluated. The overall hospital mortality rate in the patients with cirrhosis in the APACHE III-matched group was more than that in their counterparts (73.6% vs 57.5%, P = .026) but the rate did not differ significantly in the SOFA-matched group (61.8% vs 67.3%). In the APACHE III-matched group, the SOFA scores of patients with cirrhosis were significantly higher than those of patients without cirrhosis (P < .001), whereas the difference in APACHE III scores was nonsignificant between the SOFA-matched patients with and without cirrhosis. Score-matched analytical data showed that the SOFA scores significantly differentiated the patients admitted to the ICU with cirrhosis from those without cirrhosis in APACHE III-matched groups, whereas difference in the APACHE III scores between the patients with and without cirrhosis were nonsignificant in the SOFA-matched group.

BACKGROUND: Chronic hepatitis B and C infections are major causes of morbidity and mortality in end-stage kidney disease (ESKD) patients on hemodialysis (HD). The Fibrosis-4 (FIB-4) score is a non-invasive method to evaluate chronic liver disease. However, it is unclear whether there is a connection between the FIB-4 score and major adverse cardiovascular events (MACEs) and mortality in patients on HD. This study investigates the relationship between FIB-4 scores, MACEs, and mortality in HD patients. METHODS: A 5-year retrospective study included 198 HD patients with chronic hepatitis B and C from Chang Gung Memorial Hospital. FIB-4 scores were categorized into high (>2.071), middle (1.030~2.071), and low (<1.030) tertiles for cross-sectional analyses. MACEs and mortality were tracked longitudinally. RESULTS: Patients with high FIB-4 scores had lower hemoglobin and albumin levels. Cox multivariate analysis showed that high FIB-4 scores (aHR: 1.589) and diabetes mellitus (aHR: 5.688) were significant factors for all-cause mortality. The optimal FIB-4 score for 5-year mortality was 2.942. FIB-4 scores were not significant for predicting 5-year MACEs. CONCLUSIONS: High FIB-4 scores are associated with increased 5-year all-cause mortality risk in HD patients with chronic hepatitis virus infection.

Leptospirosis is an overlooked zoonotic disease caused by pathogenic Leptospira. The kidney is the major organ infected by Leptospira which causes tubulointerstitial nephritis. Leptospira outer membrane components contain several virulence factors that play important roles in the pathogenesis of leptospirosis. Among them, OmpA-like protein Loa22 is essential for leptospiral virulence. However, the pathogenic mechanisms of tubulointerstitial nephritis involving this virulence factor are still unclear and need further investigation. In this study, pull-down assays suggested that Toll-like receptor 2 (TLR2) proteins interacted with Loa22 from Leptospira outer membrane extractions. Combination of Atomic force microscopy (AFM) and side-directed mutagenesis suggested that Loa22 exhibited high affinity for Leptospira peptidoglycan (LPGN) and the residues of Loa22 were involved in LPGN interaction. Mutation of two key residues within the OmpA-like domain of Loa22, Asp ¹²² and Arg ¹⁴³ , significantly attenuated their relative affinities for LPGN indicating that these two residues were responsible for LPGN binding. Thus Loa22 OmpA domain was responsible for interacting with LPGN and the two indicated residues may participate in binding to LPGN. Recombinant Loa22 (rLoa22) protein was further complexed with LPGN and incubated with HEK293-TLR2 cells to monitor inflammatory responses. Inflammatory responses were provoked by rLoa22-LPGN complexes, but not rLoa22 alone, involved CXCL8/IL8, hCCL2/MCP-1, and hTNF-α activation. Confocal microscopy further identified the co-localization of Loa22-LPGN complexes and TLR2 receptors on HEK293-TLR2 cell surface. The affinity between Loa22-LPGN complexes and TLR2 were further confirmed and measured by AFM and ELISA. Downstream signals from TLR2 including p38, ERK, and JNK were observed by western blotting induced by Loa22-LPGN complexes. In summary, this study identified LPGN in leptospira mediates interactions between Loa22 and TLR2 and induces downstream signals to trigger inflammatory responses. Interactions between Loa22-LPGN-TLR2 reveal a novel binding mechanism for the innate immune system and infection induced by leptospira. Author summary: Leptospirosis is one of the most overlooked zoonotic diseases caused by pathogenic Leptospira in warm and humid regions worldwide. With the infection by Leptospira, many organs are invaded and can result in multiple-organ failure (Weil’s syndrome). Kidney is the major organ infected by pathogenic Leptospira, which would manifest as tubulointerstitial nephritis. In this study, we focused on the outer membrane lipoprotein Loa22 ( Leptospira l OmpA-like domain 22) from pathogenic Leptospira which triggers inflammatory responses on renal tubular cell. Protein domain prediction indicated that Loa22 contains an important domain termed OmpA-like domain and the function of this domain is peptidoglycan (PGN) binding. From sequence alignments of Loa22 with other OmpA proteins, two important amino acids, Asp ¹²² and Arg ¹⁴³ , were found to be highly conserved. The role of the two conserved residues in AbOmpA (OmpA protein in A. baumannii ) and Pal (peptidoglycan-associated lipoprotein in E. coli) proteins are important for PGN binding. These two residues in Loa22 were altered by site-directed mutagenesis to obtain D122A and R143A variants. In pull-down and AFM analysis, the binding capacities of Loa22 variants to Leptospira PGN (LPGN) were significantly decreased as compared to rLoa22WT, indicating that the two residues are involved in LPGN binding. Furthermore, recombinant Loa22 and its variants in the absence or presence of LPGN, were incubated with HEK293-TLR2 cells, to confirm the role of LPGN in triggering inflammatory responses involving CXCL8/IL8, hCCL2/MCP-1, and hTNF-α. These factors are involved in downstream signaling of inflammatory responses through Toll-like receptor 2 (TLR2). In addition, confocal microscopy was employed to observe the co-localization of Loa22-LPGN complexes and TLR2 receptors on HEK293-TLR2 cell surfaces. Finally, the interaction forces between rTLR2 and rLoa22-LPGN complexes were measured by AFM and ELISA to conclude the necessary role of LPGN in rLoa22-TLR2 complex formation. In summary, these results demonstrate that the interaction of Loa22 protein with the important cell wall component, PGN, concomitantly triggered inflammatory responses of host cells through interaction with TLR2.

Background: Invasive aspergillosis (IA) carries high mortality, yet outcomes in patients with concomitant kidney disease are poorly characterized. We examined mortality and pragmatic clinical and mycological markers in hospitalized adults with both conditions. Methods: We retrospectively evaluated 88 adults hospitalized from 2002 to 2020 with proven or probable IA and kidney disease. Renal status was re-adjudicated into four mutually exclusive phenotypes; acute renal replacement therapy (RRT) was recorded separately. qSOFA was assessed at IA diagnosis. Bronchoalveolar lavage (BAL) fungal culture results were available for all 88 patients. In-hospital outcome was defined at discharge, and long-term follow-up was assessed from the index admission. Results: In-hospital mortality was 58.0% (51/88); 25 (28.4%) and 24 (27.3%) patients were documented alive at 1 and 2 years, respectively. Renal phenotypes were maintenance dialysis/end-stage kidney disease requiring long-term dialysis in 24 (27.3%), chronic kidney disease (CKD)CKD without acute kidney injury (AKI) in seven (8.0%), AKI without documented pre-existing CKD in 28 (31.8%), and AKI-on-CKD in 29 (33.0%); 26/64 non-maintenance-dialysis patients (40.6%) received acute RRT. qSOFA ≥ 2 occurred in 98.0% of nonsurvivors versus 40.5% of survivors (p < 0.001). BAL Aspergillus culture was positive in 30/88 (34.1%) and more frequent among nonsurvivors (45.1% vs. 18.9%; p = 0.013). A. fumigatus was the most frequently recorded BAL species (19/30, including mixed cultures). qSOFA ≥ 2 and BAL culture positivity were associated with in-hospital and 2-year mortality in exploratory adjusted analyses. Conclusions: Adults hospitalized with IA and kidney disease had poor outcomes. Acute physiologic severity and BAL Aspergillus culture provided complementary prognostic information, while renal re-phenotyping demonstrated marked host heterogeneity. Contemporary validation is needed.