A plea for standardized terminology within the haemolytic uraemic syndromes.
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Biomedical subjects
Publications and source records attributed to C M Taylor.
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Lipid peroxidation may play a role in the pathogenesis of the haemolytic-uraemic syndrome (HUS). Thirteen children with the post-enteropathic form of HUS were studied using conjugated diene lipids as markers of in vivo lipid peroxidation. Levels of total conjugated diene lipids and 9,11-linoleic acid, the principal conjugated diene in human plasma, were greater in the acute phase of this disorder than in controls. The ratio of plasma vitamin E to lipid was lower than that in children with other renal diseases, and the expected positive correlation between vitamin E and lipids did not hold for HUS patients. These data provide further evidence of lipid peroxidation in HUS and a disturbance in the metabolism of the principal lipid-bound anti-oxidant vitamin E.
We examined the prognostic value of changes in the amount of proteinuria, measured as protein/creatinine ratios in early-morning urine samples, in 40 children who had had diarrhea-associated hemolytic-uremic syndrome. One year after diagnosis, 87% of those who seemed to have fully recovered had normal urinary protein/creatinine ratios, compared with none of those with poor outcomes (p less than 0.001). None of those with poor outcomes achieved normal protein/creatinine ratios during follow-up to a maximum of 5 1/2 years, but 93% of those who made a full clinical recovery no longer had proteinuria. Measurement of the protein/creatinine ratio in an early-morning sample of urine is a simple, cost-effective, and noninvasive means of monitoring the progress of patients with diarrhea-associated hemolytic-uremic syndrome, provided that a technique sensitive at low protein concentrations is employed.
Endothelial cell stimulating angiogenesis factor (ESAF) is a potent, low molecular mass mitogen, specific for endothelial cells. In common with various protein growth factors, it displays angiogenic activity in a variety of biological test systems. However, it differs from these other factors by virtue of its low molecular mass and its ability to activate latent matrix metalloproteinases in a dose dependent manner. This activity has been used to quantify the factor in both normal and diseased brain tissue. The concentration of ESAF determined in biopsies from different types of intracranial tumours varied: in some tumour types the level was close to that of control samples whereas in others it rose to levels comparable to those encountered in the pineal gland, the richest source of ESAF in mature mammals. Tumours considered to be benign contained significantly less ESAF than those neoplasms classified as being malignant (P = 0.025). There was also a correlation between the mitotic activity of tumour samples, as determined by conventional H & E histochemical staining and the ESAF concentration present. These findings agree with previous studies in which elevated ESAF levels have been found in tissue where proliferation of vascular elements has been observed.
1. Capillary density is greater in skeletal muscles comprised of predominantly oxidative (type I) fibres than in those comprised of mainly glycolytic (type II) fibres. In order to investigate further the angiogenic mechanisms involved in muscle capillarization, endothelial-cell-stimulating angiogenic factor activities in various rodent skeletal muscles were compared. 2. Eleven untrained adult male Wistar rats were killed and the predominantly oxidative (type I) muscle,s soleus and heart, the predominantly glycolytic (type II) muscle, extensor digitorum longus, and the mixed-fibre muscle, gastrocnemius, were removed. Each sample was separately homogenized and centrifuged and the supernatants were diafiltered to isolate the low-molecular-mass fraction containing endothelial-cell-stimulating angiogenic activity. This was assayed for its ability to activate latent collagenase and was expressed as units, where 1 unit represents the percentage activation of the enzyme h-1 (mg of protein in the supernatant)-1. 3. The results (medians and ranges) demonstrated significantly greater endothelial-cell-stimulating angiogenic factor activity in extensor digitorum longus muscle (2.14 units, 0.62-2.87 units, n = 13) than in soleus (0.82 units, 0.59-1.79 units, n = 15), gastrocnemius (0.34 units, 0.28-0.40 units, n = 4) or heart (0.43 units, 0.16-0.52 units, n = 11) (P less than 0.01 for each) muscle. 4. These findings suggest that endothelial-cell-stimulating angiogenic activity in muscle is either inversely or not related to the local capillary density, which may be at or near a maximum in physiologically contracting, predominantly oxidative muscles.
The mechanisms involved in the homeostatic regulation of zinc were studied in five male subjects by using stable 70Zn as a marker. When dietary zinc was reduced from 85 to 12 mumol/d, adaptation was achieved by a mean (+/- SEM) reduction in urine zinc of 48 +/- 7% and in fecal zinc of 46 +/- 12% over 25 d in four subjects. The latter was caused by an increase in the efficiency of zinc absorption from 38 +/- 3% to 93 +/- 1% after 15 d of zinic deprivation and by a reduction in intestinal endogenous losses of zinc. In a fifth subject, who had some evidence of a resolving alcohol-induced hepatitis, urine and fecal zinc were reduced by 64% and 41%, respectively, in 15 d and zinc absorption increased from 46% to 93%. More information on adaptive responses is needed to enable current dietary recommendations to be reconsidered.
The observed increase in plasma von Willebrand factor antigen (vWF:Ag) in patients with the haemolytic-uraemic syndrome is presumed to be secondary to endothelial damage, which is a central event in these diseases. As the prognostic value of such changes has not been previously evaluated, vWF:Ag has been measured in plasma from children reported to a national survey of haemolytic-uraemic syndrome. Human neutrophil elastase was also measured, as an initial neutrophilia has been shown to have prognostic value in diarrhoea-associated haemolytic-uraemic syndrome. Despite a significant elevation of plasma vWF:Ag concentration in these patients at presentation, the values did not correlate with the period of thrombocytopenia, the need for dialysis, or outcome. However, children with a poor outcome had significantly greater plasma elastase concentrations compared to those who had a good outcome.
An analysis was made of clinical and laboratory findings in children with the diarrheal form of the hemolytic uremic syndrome (HUS) treated at The Children's Hospital, Birmingham between 1970 und 1987. From 1982 the rate of referral increased, the prodromal illness more often consisted of bloody diarrhea, and the mean age at presentation doubled from 2 to 4 years. For patients with a good outcome there was an excess of males in the period 1970-81, and females in the period 1982-87. Moreover, in the years 1982-87 the disorder was distinguished from that of the earlier time by a positive correlation between adverse outcome and both neutrophil leukocytosis and a higher hemoglobin concentration at presentation. Prognostic scores obtained by logistic regression analysis were specific for each period. From July 1983 stool samples were analyzed for verocytotoxin-producing Escherichia coli (VTEC) and neutralizable verotoxin. Positive results were obtained in 39% of cases. The nature of HUS has changed and the new form of the disorder is associated with VTEC infection.
The absorption and intestinal losses of endogenous Cu in response to a low Zn diet were studied in five young male subjects using stable 65Cu as an oral tracer. The subjects received a semi-purified formula diet providing 85 mumol (5.6 mg) Zn/d during 15-day baseline and repletion phases and 12 mumol (0.8 mg) Zn/d during an intervening period of 25 days. Thirty-eight mumol (2.4 mg) Cu/d was provided throughout the study. In four of the subjects, the mean +/- SEM luminal disappearance of 65Cu was 37 +/- 4 per cent during the baseline phase and was unaffected by Zn deprivation (32 +/- 7 per cent) or repletion (30 +/- 7 per cent) as were intestinal losses of endogenous Cu [7 +/- 4, 8 +/- 3, 8 +/- 3 mumol/d (0.4 +/- 0.1, 0.5 +/- 0.1, 0.5 +/- 0.1 mg/d) during baseline, Zn deprivation and Zn repletion phases, respectively]. In a fifth subject, who had some evidence of a resolving alcohol-induced hepatitis, the luminal disappearance of 65Cu was 31, 44 and 42 per cent and the intestinal losses of endogenous Cu 11, 2 and 6 mumol/d (0.7, 0.1 and 0.4 mg/d) during the baseline, Zn deprivation and Zn repletion phases respectively. Plasma Cu concentrations, however, fell throughout the study in all the subjects, despite consistently positive Cu balances. There may be subtle effects of a low dietary intake of Zn on Cu metabolism which were not revealed by the methods used in this study.
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von Willebrand protein (vWF) is reduced by dithiothreitol (DTT) and, as a result, is not detected by enzyme-linked immunosorbent assay (ELISA). Plasma samples from normal subjects, children with haemolytic uraemic syndrome (HUS), and adults with vasculitis and vWF prepared from endothelium were treated with DTT before vWF assay. vWF in HUS and vasculitis resembled the endothelial form in being resistant to reduction. DTT modification of the ELISA assay may be useful as a marker of disease severity in conditions associated with endothelial cell damage.
Live yeast cell derivative is an alcoholic extract from yeast (Saccharomyces cerevisiae) that has previously been shown by three groups of workers to stimulate wound healing. Live yeast cell derivative is a complex mixture, and it was not known which of its many components was responsible for the biological activity. This study describes the separation and analysis of the major components, one of which is a peptide fraction that stimulates wound healing. The fraction consists of a mixture of peptides from 6000 to 17,000 d. It causes angiogenesis in a chick embryo yolk sac membrane assay and in a rabbit cornea assay, and it dramatically stimulates wound healing in the "Schilling/Hunt" wire mesh cylinder model at concentrations 25-fold lower than those required for the intact live yeast cell derivative.
Blood group P1 expression was scored by direct agglutination in 32 patients who had previously developed post-enteropathic haemolytic uraemic syndrome (HUS). Sixty-six children of similar ages undergoing venepuncture for other renal disorders acted as controls. The expression of P1 in controls was that expected from the normal caucasian population, 23% being negative. By contrast, there was an excess of HUS patients with weak or absent expression of P1 (chi 2 for linear trend 5.45, P less than 0.02), and this was particularly evident in those with a poor outcome. Verotoxin (VT), which is associated with HUS, requires the terminal disaccharide of the P1 antigen to bind to cells, and after internalization disrupts the transcription of ribonucleic acid. Mature erythrocytes do not synthesize protein and may be toxin resistant. We postulate that strong expression of P1 antigen may promote the binding of VT to red cells and thus reduce the dose to vulnerable nucleated endothelial cells. P1 positivity may be protective, and P1 negativity a risk factor in HUS.
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A prospective study of the clinical and epidemiological features of the haemolytic uraemic syndromes was conducted over a three year period in the British Isles. Two hundred and ninety eight children were reported. In two thirds of cases stool samples were analysed for the presence of Verocytotoxin producing Escherichia coli (VTEC) and neutralisable Verocytotoxin. A total of 273 (95%) patients had a prodrome of diarrhoea. In these a seasonal variation in the incidence of haemolytic uraemic syndrome was demonstrated, the 1-2 year age range was most often affected, and the peripheral blood neutrophil count correlated positively with an adverse outcome. Patients presenting without diarrhoea showed none of these associations and had a significantly greater morbidity and mortality. Evidence for VTEC infection was found in 58 (33%) of 178 diarrhoea associated cases whose stools were analysed, although VTEC were identified in five of eight (62%) patients whose stools were collected within three days of the onset of diarrhoea. Most isolates produced VT2 either alone, or together with VT1. There was no evidence of VTEC infection in patients without prodromal diarrhoea.
In a three year study of children under 16 years with haemolytic uraemic syndrome faecal samples were examined for the presence of Verocytotoxin producing Escherichia coli (VTEC) using DNA probes and for free neutralisable Verocytotoxin in a Vero cell assay with specific antisera. There was evidence of VTEC infection in 58 of 185 (31%) samples. A total of 53 VTEC was identified from patients with haemolytic uraemic syndrome. Thirty eight VTEC belonged to serotype O157:H7 or O157:H-, 34 produced VT2 only, and four strains produced both VT1 and VT2. The remaining 15 VTEC belonged to nine different O serogroups; three strains produced VT1, 10 produced VT2, and two were positive for VT1 and VT2. Three control groups of patients without haemolytic uraemic syndrome were also examined. There was evidence of VTEC infection in 8%, 6%, and 4% of specimens from individuals with bloody diarrhoea, those with diarrhoea only, and healthy controls respectively. VTEC from the bloody diarrhoeal and diarrhoeal controls were O157:H7 but those from the healty controls could not be O serogrouped. This study confirms the association of VTEC, and particularly strains of O157:H7, with haemolytic uraemic syndrome. Strains producing VT1, VT2, or both toxins were isolated, although over 94% of VTEC produced VT2 alone or together with VT1.
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