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Cytokines that signal via STAT1 and STAT3 transcription factors instruct decisions affecting tissue homeostasis, anti-microbial host defense, and inflammation-induced tissue injury. To understand the coordination of these activities, we applied RNA-seq, ChIP-seq, and ATAC-seq to identify the transcriptional output of STAT1 and STAT3 in peritoneal tissues during acute resolving inflammation and inflammation primed to drive fibrosis. Bioinformatics focussed on the transcriptional signature of the immuno-modulatory cytokine IL-6 in both settings and examined how pro-fibrotic IFNγ-secreting CD4+T-cells altered the interpretation of STAT1 and STAT3 cytokine cues. In resolving inflammation, STAT1 and STAT3 cooperated to drive stromal gene expression affecting anti-microbial immunity and tissue homeostasis. The introduction of IFNγ-secreting CD4+T-cells altered this transcriptional program and channeled STAT1 and STAT3 to a previously latent GAS motif inAlu-like elements. STAT1 and STAT3 binding to this conserved sequence revealed evidence of reciprocal cross-regulation and gene signatures relevant to pathophysiology. Thus, we propose that effector T-cells re-tune the transcriptional output of IL-6 by shaping a regulatory interplay between STAT1 and STAT3 in inflammation.

Women with uncomplicated urinary tract infection (UTI) symptoms are commonly treated with empirical antibiotics, resulting in overuse of antibiotics, which promotes antimicrobial resistance. Available diagnostic tools are either not cost-effective or diagnostically sub-optimal. Here, we identified clinical and urinary immunological predictors for UTI diagnosis. We explored 17 clinical and 42 immunological potential predictors for bacterial culture among women with uncomplicated UTI symptoms using random forest or support vector machine coupled with recursive feature elimination. Urine cloudiness was the best performing clinical predictor to rule out (negative likelihood ratio [LR−] = 0.4) and rule in (LR+ = 2.6) UTI. Using a more discriminatory scale to assess cloudiness (turbidity) increased the accuracy of UTI prediction further (LR+ = 4.4). Urinary levels of MMP9, NGAL, CXCL8 and IL-1β together had a higher LR+ (6.1) and similar LR− (0.4), compared to cloudiness. Varying the bacterial count thresholds for urine culture positivity did not alter best clinical predictor selection, but did affect the number of immunological predictors required for reaching an optimal prediction. We conclude that urine cloudiness is particularly helpful in ruling out negative UTI cases. The identified urinary biomarkers could be used to develop a point of care test for UTI but require further validation.

Background and objectives\ud The inflammation-driven increase in peritoneal solute transport rate that occurs during long-term peritoneal dialysis is associated with higher mortality, hospitalization, and encapsulating peritoneal sclerosis. Because biocompatible solutions were developed to mitigate these effects, we examined the association with their use and longitudinal peritoneal solute transport rate.\ud \ud Design, setting, participants, & measurements\ud We analyzed subjects from the multinational prospective Global Fluid Study with three or more peritoneal solute transport rate measurements >2 months from the start of peritoneal dialysis. Follow-up was for 7.5 years (median, 2.3 years; interquartile range, 1.8–3.6) in biocompatible solutions and 12.8 years (median, 3.2 years; interquartile range, 1.9–4.3) for standard solutions. Using a random intercept/slopes multilevel model, we examined the association of patients using biocompatible solutions and peritoneal solute transport rate over time, adjusting for center effects, dialysate dextrose concentration, baseline dialysate IL-6 concentration, icodextrin use, residual kidney function, and peritonitis.\ud \ud Results\ud Of 366 patients, the 71 receiving biocompatible solutions throughout their time on peritoneal dialysis had a mean adjusted dialysate-to-plasma creatinine ratio of 0.67 compared with 0.72 for standard solutions (P=0.02). With duration of treatment, there was a continuous increase in peritoneal solute transport rate in patients using standard solutions (range, 2 months to 4 years). In contrast, patients using biocompatible solutions had peritoneal solute transport rates that plateaued after 2 years of therapy. These changes in peritoneal solute transport rate were independent of baseline inflammation and time-varying predictors of faster peritoneal solute transport rate. In patients suffering episodes of peritonitis while using standard solutions, there was an associated increase in peritoneal solute transport rate of 0.020 (95% confidence interval, 0.01 to 0.03) per episode, whereas in patients using biocompatible solutions, there was no change in this parameter (−0.014; 95% confidence interval, −0.03 to

Peritoneal dialysis (PD) is a cost-effective, home-based treatment option for patients with end-stage renal disease; however, PD is declining in many countries. A major reason for this is peritonitis, which commonly leads to technique failure and has led to negative perceptions of PD by clinicians and patients. To restore confidence in PD, better diagnostics are required to enable appropriate treatment to be started earlier; this needs to be coupled with improved understanding of the biology of peritonitis. Advances in culture-independent microbiological methods, in particular the use of bacterial flow cytometry and immune fingerprinting techniques, can enable organism detection and antimicrobial susceptibility testing to be performed in as little as 3 hours after samples are received. At the same time, improved understanding of peritoneal mesothelial cell responses to infection is providing insights into pathways that may be targeted to dampen deleterious elementsof the host immune response, promote healing, and preserve membrane function.

Peritonitis is the commonest complication of peritoneal dialysis and a major reason for treatment failure. Current diagnosis is based on clinical symptoms, cloudy effluent and a dialysate white cell count (over 100 cells/μl). A rapid point-of-care diagnostic test would accelerate diagnosis and potentially improve outcomes from infection. Here, in a clinical audit project, we used PERiPLEX®, a point-of-care device which detects when levels of matrix metalloproteinase-8 and interleukin-6 are elevated above a threshold within minutes in dialysis effluent, to assess whether it could confirm or exclude peritonitis in 107 patients undergoing peritoneal dialysis. Mean patient age was 64.6 years with a median duration of peritoneal dialysis of 13.3 months (interquartile range 6.3 – 33.5 months). Presence of peritonitis was confirmed by clinical criteria. There were 49 positive tests of which 41 patients had peritonitis, three had other causes of intra-peritoneal inflammation, three had severe urosepsis and two patients required no treatment. Fifty-eight tests were negative with one patient having a false negative result. The positive predictive value of the test was 83.7% (95% confidence interval 72.8 – 90.8) and the negative predictive value was 98.3% (89.1 – 99.8). Sensitivity and specificity were 97.6% (87.4 – 99.9) and 87.7% (77.2 – 94.5) respectively. Thus, PERiPLEX® could be used as a rapid point-of-care test that can aid the diagnosis or exclusion of peritonitis with a high negative predictive value.

It is not clear whether the association of increased peritoneal protein clearance (PPCl) with worse survival on peritoneal dialysis (PD) is a consequence of either local or systemic inflammation or indicative of generalized endothelial dysfunction associated with comorbidity. To investigate this we determined the relationship of PPCl to comorbidity, membrane area (equivalent to low molecular weight peritoneal solute transport rate), local and systemic inflammation and hypoalbuminaemia, and for each of these with patient survival. 257 incident patients from three GLOBAL Fluid Study centers were included in this analysis. Clinical profiles were collected at baseline along with a peritoneal equilibration test, 24-h dialysate protein and paired plasma and dialysate cytokine measurements. Although peritoneal protein clearance was associated with increased age and severe comorbidity on univariate analysis, only dialysate IL-6, peritoneal solute transport rate, plasma albumin and cardiac comorbidities (ischaemic heart disease and left ventricular dysfunction) were independent explanatory variables on multivariate analysis. While peritoneal protein clearance and daily peritoneal protein loss were associated with survival in univariate analysis, on multivariate analysis only plasma IL-6, age, residual kidney function, comorbidity, and plasma albumin were independent predictors. Peritoneal protein clearance is primarily a function of peritoneal membrane area and local membrane inflammation. The association with comorbidity and survival is predominantly explained by its inverse relationship to hypoalbuminaemia, especially in diabetics.

Peritoneal dialysis (PD) remains limited by dialysis failure due to peritoneal membrane fibrosis driven by inflammation caused by infections or sterile cellular stress. Given the fundamental role of Toll-like receptors (TLRs) and complement in inflammation, we assessed the potential of peritoneal TLR2, TLR4 and C5a receptors, C5aR and C5L2, as therapeutic targets in PD-associated fibrosis. We detected TLR2–, TLR4–, and C5aR–mediated proinflammatory and fibrotic responses to bacteria that were consistent with the expression of these receptors in peritoneal macrophages (TLR2/4, C5aR) and mesothelial cells (TLR2, C5aR). Experiments in knockout mice revealed a major role for TLR2, a lesser role for TLR4, a supplementary role for C5aR, and no apparent activity of C5L2 in infection–induced peritoneal fibrosis. Similarly, antibody blockade of TLR2, TLR4, or C5aR differentially inhibited bacteria–induced profibrotic and inflammatory mediator production by peritoneal leukocytes isolated from the peritoneal dialysis effluent (PDE) of noninfected uremic patients. Additionally, antibodies against TLR2, TLR4, or the coreceptor CD14 reduced the profibrotic responses of uremic leukocytes to endogenous components present in the PDE of noninfected patients. Enhancing TLR2-mediated inflammation increased fibrosis in vivo. Furthermore, soluble TLR2 (sTLR2), a negative modulator of TLRs that we detected in PDE, inhibited PDE–induced, TLR2– or TLR4–mediated profibrotic responses. Notably, sTLR2 treatment markedly reduced Gram–positive and –negative bacteria–induced fibrosis in vivo, inhibiting proinflammatory and fibrotic genes without affecting infection clearance. These findings reveal the influence of peritoneal TLR2 and TLR4 on PD-associated fibrosis and describe a therapeutic strategy against fibrosis.

♦ BackgroundPeritoneal dialysis (PD) patients develop progressive and cumulative peritoneal injury with longer time spent on PD. The present study aimed to a) describe the trend of peritoneal injury biomarkers, matrix metalloproteinase-2 (MMP-2) and tissue inhibitor of metalloproteinase-1 (TIMP-1), in incident PD patients, b) to explore the capacity of dialysate MMP-2 to predict peritoneal solute transport rate (PSTR) and peritonitis, and c) to evaluate the influence of neutral pH, low glucose degradation product (GDP) PD solution on these outcomes.♦ MethodsThe study included 178 participants from the balANZ trial who had at least 1 stored dialysate sample. Changes in PSTR and peritonitis were primary outcome measures, and the utility of MMP-2 in predicting these outcomes was analyzed using multilevel linear regression and multilevel Poisson regression, respectively.♦ResultsSignificant linear increases in dialysate MMP-2 and TIMP-1 concentrations were observed ( p < 0.001), but neither was affected by the type of PD solutions received (MMP-2: p = 0.07; TIMP-1: p = 0.63). An increase in PSTR from baseline was associated with higher levels of MMP-2 ( p = 0.02), and the use of standard solutions over longer PD duration ( p = 0.001). The risk of peritonitis was independently predicted by higher dialysate MMP-2 levels (incidence rate ratio [IRR] per ng/mL 1.01, 95% confidence interval [CI] 1.005 – 1.02, p = 0.002) and use of standard solutions (Biocompatible solution: IRR 0.45, 95% CI 0.24 – 0.85, p = 0.01).♦ ConclusionDialysate MMP-2 and TIMP-1 concentrations increased with longer PD duration. Higher MMP-2 levels were associated with faster PSTR and future peritonitis risk. Administration of biocompatible solutions exerted no significant effect on dialysate levels of MMP-2 or TIMP-1, but did counteract the increase in PSTR and the risk of peritonitis associated with the use of standard PD solutions. This is the first longitudinal study to examine the clinical utility of MMP-2 as a predictor of patient-level outcomes.

Peritoneal membrane failure due to fibrosis limits the use of peritoneal dialysis (PD). Peritoneal fibrosis may potentially be induced by sterile inflammation caused by ongoing cellular stress due to prolonged exposure to PD solutions (PDS). Effective therapies to prevent this process remain to be developed. Toll-like receptors (TLRs) mediate sterile inflammation by recognizing damage-associated molecular patterns (DAMPs) released by cellular stress. We evaluated the involvement of TLRs and DAMPs in PDS-induced fibrosis models and the therapeutic potential of TLR-DAMP targeting for preventing fibrosis. A range of PDS elicited pro-inflammatory and fibrotic responses from PD patient peritoneal leukocytes, mesothelial cells and mouse peritoneal leukocytes. TLR2/4 blockade of human peritoneal cells or TLR2/4 knockouts inhibited these effects. PDS did not induce rapid ERK phosphorylation or IκB-α degradation, suggesting that they do not contain components capable of direct TLR activation. However, PDS increased the release of Hsp70 and hyaluronan, both TLR2/4 DAMP ligands, by human and mouse peritoneal cells, and their blockade decreased PDS-driven inflammation. Soluble TLR2, a TLR inhibitor, reduced PDS-induced pro-inflammatory and fibrotic cytokine release ex vivo. Daily catheter infusion of PDS in mice caused peritoneal fibrosis, but co-administration of soluble TLR2 prevented fibrosis, suppressed pro-fibrotic gene expression and pro-inflammatory cytokine production, reduced leukocyte/neutrophil recruitment, recovered Treg cell levels and increased the Treg:Th17 ratio. Thus, TLR2/4, Hsp70 and hyaluronan showed major roles in PDS-induced peritoneal inflammation and fibrosis. The study demonstrates the therapeutic potential of a TLR-DAMP targeting strategy to prevent PDS-induced fibrosis.

Peritoneal dialysis (PD) therapy substantially requires biomarkers as tools to identify patients who are at the highest risk for PD-related complications and to guide personalized interventions that may improve clinical outcome in the individual patient. In this consensus article, members of the European Training and Research in Peritoneal Dialysis Network (EuTRiPD) review the current status of biomarker research in PD and suggest a selection of biomarkers that can be relevant to the care of PD patients and that are directly accessible in PD effluents. Currently used biomarkers such as interleukin-6, interleukin-8, ex vivo–stimulated interleukin-6 release, cancer antigen-125, and advanced oxidation protein products that were collected through a Delphi procedure were first triaged for inclusion as surrogate endpoints in a clinical trial. Next, novel biomarkers were selected as promising candidates for proof-of-concept studies and were differentiated into inflammation signatures (including interleukin-17, M1/M2 macrophages, and regulatory T cell/T helper 17), mesothelial-to-mesenchymal transition signatures (including microRNA-21 and microRNA-31), and signatures for senescence and inadequate cellular stress responses. Finally, the need for defining pathogen-specific immune fingerprints and phenotype-associated molecular signatures utilizing effluents from the clinical cohorts of PD patients and “omics” technologies and bioinformatics-biostatistics in future joint-research efforts was expressed. Biomarker research in PD offers the potential to develop valuable tools for improving patient management. However, for all biomarkers discussed in this consensus article, the association of biological rationales with relevant clinical outcomes remains to be rigorously validated in adequately powered, prospective, independent clinical studies.

Peritoneal dialysis (PD) is a life-saving form of renal replacement therapy for those with end-stage kidney disease. Mesothelial cells (MCs) line the peritoneal cavity and help define peritoneal response to treatment-associated injury, a major reason for treatment failure. miRNAs are important regulators, but their roles in peritoneal fibrosis are largely unknown. In this study, miR-21 was one of the most abundant miRNAs in primary MCs, and was up-regulated by the profibrotic cytokine transforming growth factor-β1 and in PD effluent-derived MCs exhibiting mesenchymal phenotypic change. Increased miR-21 was found in peritoneal membrane biopsy specimens from PD patients compared to healthy controls (PD biocompatible, 5.86×, P = 0.0001; PD conventional, 7.09×, P n = 11 per group). In PD effluent from a cohort of 230 patients, miR-21 was higher in those receiving the therapy long-term compared to new starters ( n = 230, miR-21 3.26×, P = 0.001) and associated with icodextrin use ( R = 0.52; 95% CI, 0.20–0.84), peritonitis count ( R = 0.16; 95% CI, 0.03–0.29), and dialysate cytokines. miR-21 down-regulated programmed cell death 4 and programmed cell death 4 protein was decreased in peritoneal membrane biopsy specimens from PD patients compared to healthy controls. New miR-21 targets were identified that may be important during PD fibrogenesis. These data identify miR-21 as an important effector of fibrosis in the peritoneal membrane, and a promising biomarker in the dialysis effluent for membrane change in patients receiving PD.

Accurate and timely diagnosis of bacterial infection is crucial for effective and targeted treatment, yet routine microbiological identification is inefficient and often delayed to an extent that makes it clinically unhelpful. The immune system is capable of a rapid, sensitive and specific detection of a broad spectrum of microbes, which has been optimized over millions of years of evolution. A patient's early immune response is therefore likely to provide far better insight into the true nature and severity of microbial infections than conventional tests. To assess the diagnostic potential of pathogen-specific immune responses, we characterized the local responses of 52 adult patients during episodes of acute peritoneal dialysis (PD)-associated peritonitis by multicolor flow cytometry and multiplex ELISA, and defined the immunologic signatures in relation to standard microbiological culture results and to clinical outcomes. We provide evidence that unique local "immune fingerprints" characteristic of individual organisms are evident in PD patients on the day of presentation with acute peritonitis and discriminate between culture-negative, Gram-positive, and Gram-negative episodes of infection. Those humoral and cellular parameters with the most promise for defining disease-specific immune fingerprints include the local levels of IL-1β, IL-10, IL-22, TNF-α, and CXCL10, as well as the frequency of local γδ T cells and the relative proportion of neutrophils and monocytes/macrophages among total peritoneal cells. Our data provide proof of concept for the feasibility of using immune fingerprints to inform the design of point-of-care tests that will allow rapid and accurate infection identification and facilitate targeted antibiotic prescription and improved patient management.

BACKGROUND: Human γδ T cells reactive to the microbial metabolite (E)-4-hydroxy-3-methyl-but-2-enyl pyrophosphate (HMB-PP) contribute to acute inflammatory responses. We have previously shown that peritoneal dialysis (PD)-associated infections with HMB-PP producing bacteria are characterized by locally elevated γδ T-cell frequencies and poorer clinical outcome compared with HMB-PP negative infections, implying that γδ T cells may be of diagnostic, prognostic and therapeutic value in acute disease. The regulation by local tissue cells of these potentially detrimental γδ T-cell responses remains to be investigated. METHODS: Freshly isolated γδ or αβ T cells were cultured with primary mesothelial cells derived from omental tissue, or with mesothelial cell-conditioned medium. Stimulation of cytokine production and proliferation by peripheral T cells in response to HMB-PP or CD3/CD28 beads was assessed by flow cytometry. RESULTS: Resting mesothelial cells were potent suppressors of pro-inflammatory γδ T cells as well as CD4+ and CD8+ αβ T cells. The suppression of γδ T-cell responses was mediated through soluble factors released by primary mesothelial cells and could be counteracted by SB-431542, a selective inhibitor of TGF-β and activin signalling. Recombinant TGF-β1 but not activin-A mimicked the mesothelial cell-mediated suppression of γδ T-cell responses to HMB-PP. CONCLUSIONS: The present findings indicate an important regulatory function of mesothelial cells in the peritoneal cavity by dampening pro-inflammatory T-cell responses, which may help preserve the tissue integrity of the peritoneal membrane in the steady state and possibly during the resolution of acute inflammation.

Peritoneal dialysis is a widely used mode of renal replacement therapy in which preservation of the structural and functional integrity of the peritoneal membrane is critical for continued success. Progressive scarring, or fibrosis, in the peritoneal membrane is now well described in peritoneal dialysis patients, but its extent is variable. While some patients survive for long periods on peritoneal dialysis, others suffer from ‘fibrosis-related’ membrane failure, or rarely, more severe complications such as encapsulating peritoneal sclerosis (EPS). The reasons for these variations in responses are unlikely to be explained by variations in the therapy, which has remained largely unchanged over the past 20 years, and are suggestive of a genetic component to the susceptibility of individuals to different outcomes. In this issue of NDT, Margetts et al. [1] describe how they used genetically different mouse strains to examine the variability in responses to a defined, constant pro-fibrotic stimulus in a model of peritoneal fibrosis. The data highlight a possible genetic linkage to susceptibility to fibrosis that adds significant insights into our understanding of the mechanisms driving peritoneal damage. The key to continued success of peritoneal dialysis as a therapy remains in preservation of the performance of the peritoneal membrane as a dialysing organ. In health, the visceral and parietal peritoneum and its phospholipid-rich secretions and anti-friction surfaces facilitate bowel motility within the abdominal cavity. The outer surface of the whole comprises a single layer of mesothelial cells, specialized to provide a low friction and non-adhesive surface. The mesothelium that lines the peritoneal membrane sits on the sub-mesothelial compact zone, comprising a collagen-rich extracellular matrix in which larger blood vessels and capillaries are sited. Peritoneal dialysis is associated with a spectrum of alterations in the morphology of the peritoneal membrane which includes alterations in the mesothelial cell morphology, thickening of the sub-mesothelial compact zone and progressive vascular damage (vasculopathy) [2]. Cross-sectional studies have linked these changes to long-term glucose exposure and episodic infection [2].These alterations to the peritoneal membrane associate with alterations in peritoneal solute transport, loss of ultrafiltration and eventual technique failure. More recent data suggest that the changes in the mesothelium play a key role in driving the changes in peritoneal structure and function. Data primarily from animal models and corroborated with the limited clinical studies suggest that the acquisition of a fibroblast-like phenotype by mesothelial cells, so-called trans-differentiation or epithelial-mesenchymal transition, is key in driving changes in extracellular matrix turnover and fibrogenesis (reviewed in [3]). As the genesis of peritoneal fibrosis is insidious without overt clinical symptoms, except in cases of EPS, there are at present no tests that can predict its onset, nor are there any therapeutic approaches other than a switch of renal replacement therapy modality from peritoneal dialysis to haemodialysis when membrane function is seriously compromised. In the case of EPS, surgery can be used to relieve intestinal obstruction, but while outcomes have improved from this intervention the risk of mortality from the condition remains significant. The clinical consequences of peritoneal fibrosis are thus clear, but the processes that initiate and drive it in peritoneal

BACKGROUND: Acute peritonitis is the most frequent complication of peritoneal dialysis (PD). Increased nitric oxide (NO) release by NO synthase (NOS) isoforms has been implicated in acute peritonitis, but the role played by the NOS isoforms expressed in the peritoneum is unknown. METHODS: We investigated the structural and functional consequences of acute peritonitis induced by LPS in wild-type (WT) mice versus knockout mice (KO) for the endothelial NOS (eNOS), the inducible NOS (iNOS) or the neuronal NOS (nNOS). RESULTS: The level of NO metabolites (NOx) in the dialysate was maximal 18 h after LPS injection. LPS induced a significant increase in the transport of small solutes and decreased ultrafiltration in WT mice. These changes, which occurred without vascular proliferation, were paralleled by the upregulation of nNOS and eNOS, and the induction of iNOS. The transport modifications induced by LPS were significantly reversed in eNOS KO mice, but not modified in mice lacking iNOS or nNOS. In contrast, the increase of dialysate NOx was abolished in iNOS KO mice and significantly reduced in eNOS KO mice, but left unchanged in mice lacking nNOS. Mice lacking iNOS also showed more severe inflammatory changes, and a trend towards increased mortality following LPS. CONCLUSION: These data demonstrate specific roles for NOS isoforms in the peritoneal membrane and suggest that selective eNOS inhibition may improve peritoneal transport during acute peritonitis.

The antimicrobial responsiveness and function of unconventional human T cells are poorly understood, with only limited access to relevant specimens from sites of infection. Peritonitis is a common and serious complication in individuals with end-stage kidney disease receiving peritoneal dialysis. By analyzing local and systemic immune responses in peritoneal dialysis patients presenting with acute bacterial peritonitis and monitoring individuals before and during defined infectious episodes, our data show that Vγ9/Vδ2(+) γδ T cells and mucosal-associated invariant T cells accumulate at the site of infection with organisms producing (E)-4-hydroxy-3-methyl-but-2-enyl pyrophosphate and vitamin B2, respectively. Such unconventional human T cells are major producers of IFN-γ and TNF-α in response to these ligands that are shared by many microbial pathogens and affect the cells lining the peritoneal cavity by triggering local inflammation and inducing tissue remodeling with consequences for peritoneal membrane integrity. Our data uncover a crucial role for Vγ9/Vδ2 T cells and mucosal-associated invariant T cells in bacterial infection and suggest that they represent a useful predictive marker for important clinical outcomes, which may inform future stratification and patient management. These findings are likely to be applicable to other acute infections where local activation of unconventional T cells contributes to the antimicrobial inflammatory response.

Encapsulating peritoneal sclerosis (EPS) is a potentially devastating complication of peritoneal dialysis\ud (PD). Diagnosis is often delayed due to the lack of effective and accurate diagnostic tools. We\ud therefore examined peritoneal effluent for potential biomarkers that could predict or confirm the\ud diagnosis of EPS and would be valuable in stratifying at-risk patients, and driving appropriate\ud interventions. Using prospectively collected samples from the Global Fluid Study and a cohort of\ud Greek PD patients, we utilized 2D SDSPAGE/ MS and iTRAQ to identify changes in the peritoneal\ud effluent proteome from patients diagnosed with EPS and controls matched for treatment exposure. We\ud employed a combinatorial peptide ligand library to compress the dynamic range of protein\ud concentrations, to aid identification of low-abundance proteins. In patients with stable membrane\ud function, fibrinogen γ-chain and heparan sulphate proteoglycan core protein progressively\ud increased over time on PD. In patients who developed EPS, collagen-α1(I), γ-actin and Complement\ud factors B and I were elevated up to five years prior to diagnosis. Orosomucoid-1 and a2-HSglycoprotein chain-B were elevated about one year before diagnosis, while apolipoprotein A-IV and\ud α1-antitrypsin were decreased compared to controls. Dynamic range compression resulted in an\ud increased number of proteins detected with improved resolution of protein spots, compared to the full\ud fluid proteome. Intelectin-1, dermatopontin, gelsolin and retinol binding protein-4 were elevated in\ud proteome-mined samples from patients with EPS compared to patients that had just commenced\ud peritoneal dialysis. Thus, prospective analysis of peritoneal effluent uncovered proteins indicative of\ud inflammatory and pro-fibrotic injury worthy of further evaluation as diagnostic/prognostic markers.

Background. Prolonged peritoneal dialysis (PD) therapy can result in the development of encapsulating peritoneal sclerosis (EPS), characterized by extensive sclerosis of the peritoneum with bowel adhesions often causing obstruction. Methods. As a proof-of-principle study, holistic profiling of endogenous metabolites has been applied in a prospective collection of PD effluent collected in multiple UK renal centres over 6 years in order to investigate metabolic differences in PD effluent between PD therapy patients who later developed clinically defined EPS (n ¼ 11) and controls, who were matched for PD vintage, age and gender (n ¼ 11). Results. ‘Fit-for-purpose’ analytical methods employing gas chromatography–mass spectrometry (MS), direct injection MS and quality control samples were developed and validated. These methods were applied in a proof-of-principle study to define metabolic differences in PD effluent related to subsequent development of EPS. Changes in amino acids, amines and derivatives, short-chain fatty acids and derivatives and sugars were observed prior to EPS developing, and changes in the metabolomic profiles could be detected. Conclusion. There is potential for applying metabolic profiles to identify patients at risk of developing EPS although long-term prospective studies with larger patient cohorts are required.

Objective In this study, we compared the activity of interleukin-6 (IL-6), a marker of ongoing peritoneal inflammation and biocompatibility, and its other signaling components, the soluble IL-6 receptor (sIL-6R) and soluble Gp130 (sGp130), in peritoneal effluent from patients treated with icodextrin-based (E) peritoneal dialysis (PD) solution and glucose-based bicarbonate/lactate–buffered (P) solution. Methods Using baseline peritoneal ultrafiltration capacity, 33 stable incident PD patients were allocated either to P only ( n = 20) or to P plus E for the overnight dwell ( n = 13). We used ELISA to determine IL-6, sIL-6R, and sGp130 in timed overnight effluent at 1, 6, and 12 months after PD initiation. Flow cytometry was used to measure expression of IL-6R and Gp130 on isolated peritoneal leukocytes at the same time points. Peritonitis was an exclusion criterion. Results At all time points, levels of IL-6 and sIL-6R, and the appearance rates of IL-6 (90.5 pg/min vs. 481.1 pg/min, p < 0.001; 138.6 pg/min vs. 1187.5 pg/min, p < 0.001; and 56.1 pg/min vs. 1386.0 pg/min, p < 0.001), sIL-6R (2035.3 pg/min vs. 4907.0 pg/min, p < 0.01; 1375.0 pg/min vs. 6348.4 pg/min, p < 0.01; and 1881.3 pg/min vs. 5437.8 pg/min, p < 0.01), and sGp130 (37.6 ng/min vs. 65.4 ng/min, p < 0.01; 39.2 ng/min vs. 80.6 ng/min, p < 0.01; 27.8 ng/min vs. 71.0 ng/min, p < 0.01) were significantly higher in peritoneal effluent from E-treated patients than from P-treated patients. Expression of IL6-R and Gp130 on individual leukocyte types isolated from PD effluent did not differ between E- and P-treated patients. The numbers of white blood cells present in effluent were higher in E-treated than in P-treated patients at all time points, but no significant differences were seen in the differential counts or in the number of exfoliated mesothelial cells. The IL-6 parameters in effluent from E-treated patients correlated with their plasma C-reactive protein. Despite the increased activation of the IL-6 system, no increase in peritoneal permeability as assessed by the dialysate-to-plasma ratio of creatinine in E effluent or by systemic inflammation was observed throughout the study. Conclusions Higher levels of IL-6, its soluble receptors, and leukocyte expression were observed in E-treated than in P-treated patients, but this difference was not associated with alterations in peritoneal permeability or systemic inflammation during 1 year of follow-up. Leukocyte counts in effluent from E-treated patients were within the normal range previously reported for glucose solutions. This lack of clinical consequences may be a result of a parallel rise in sIL-6R and sGp130, which are known to control the biologic activity of IL-6. The utility of IL-6 level determinations, in isolation, for assessing the biocompatibility of PD solutions is questionable.

TLR and complement activation ensures efficient clearance of infection. Previous studies documented synergism between TLRs and the receptor for the pro-inflammatory complement peptide C5a (C5aR/CD88), and regulation of TLR-induced pro-inflammatory responses by C5aR, suggesting crosstalk between TLRs and C5aR. However, it is unclear whether and how TLRs modulate C5a-induced pro-inflammatory responses. We demonstrate a marked positive modulatory effect of TLR activation on cell sensitivity to C5a in vitro and ex vivo and identify an underlying mechanistic target. Pre-exposure of PBMCs and whole blood to diverse TLR ligands or bacteria enhanced C5a-induced pro-inflammatory responses. This effect was not observed in TLR4 signalling-deficient mice. TLR-induced hypersensitivity to C5a did not result from C5aR upregulation or modulation of C5a-induced Ca(2+) mobilization. Rather, TLRs targeted another C5a receptor, C5L2 (acting as a negative modulator of C5aR), by reducing C5L2 activity. TLR-induced hypersensitivity to C5a was mimicked by blocking C5L2 and was not observed in C5L2KO mice. Furthermore, TLR activation inhibited C5L2 expression upon C5a stimulation. These findings identify a novel pathway of crosstalk within the innate immune system that amplifies innate host defense at the TLR-complement interface. Unravelling the mutually regulated activities of TLRs and complement may reveal new therapeutic avenues to control inflammation.

Background. Bacterial infection remains a major cause of morbidity and mortality in peritoneal dialysis (PD) patients worldwide. Previous studies have identified a key role for mesothelial cells, lining the peritoneal cavity, in coordinating inflammation and host defense. Toll-like receptor (TLR) involvement in early activation events within the mesothelium, however, remains poorly defined. To investigate the initiation of bacterial peritonitis, we characterized TLR activation by bacterial ligands in human peritoneal mesothelial cells (HPMC). Methods. Primary HPMC were isolated from omental biopsies and TLR expression detected by real-time polymerase chain reaction (PCR), reverse transcription (RT)–PCR and flow cytometry. The responsiveness of HPMC to specific bacterial TLR agonists was determined using chemokine production as a biological readout. The requirement for CD14 in HPMC responses to a clinically relevant Staphylococcus epidermidis cell-free supernatant (SES) was investigated using soluble CD14 or anti-CD14-blocking antibodies. Results. Real-time PCR detected TLR1-6 messenger RNA expression in HPMC and responses to TLR2/1 and TLR2/6 ligands and SES. No cell surface TLR4 expression or responses to lipopolysaccharide were detectable in HPMC, but they did respond to flagellin, a TLR5 ligand. SES-mediated responses were dependent on TLR2 but did not require CD14 in HPMC for optimal efficiency, unlike peripheral blood mononuclear cells. HPMC expression of TLR2 was also modulated by TLR2 ligands and inflammatory cytokines. Conclusions. These data suggest that mesothelial cell activation by TLR2/1, TLR2/6 and TLR5 contributes to bacterial recognition influencing the course of the infective process and has implications for improving treatment of infection in PD patients.

5-Lipoxygenase (5-LOX) plays key roles in infection and allergic responses. Herein, four 5-LOX–derived lipids comprising 5-hydroxyeicosatetraenoic acid (HETE) attached to phospholipids (PLs), either phosphatidylethanolamine (PE) or phosphatidylcholine (18:0p/5-HETE-PE, 18:1p/5-HETE-PE, 16:0p/5-HETE-PE, and 16:0a/5-HETE-PC), were identified in primary human neutrophils. They formed within 2 minutes in response to serum-opsonized Staphylococcus epidermidis or f-methionine-leucine-phenylalanine, with priming by lipopolysaccharide, granulocyte macrophage colony-stimulating factor, or cytochalasin D. Levels generated were similar to free 5-HETE (0.37 ± 0.14 ng vs 0.55 ± 0.18 ng/106 cells, esterified vs free 5-HETE, respectively). They remained cell associated, localizing to nuclear and extranuclear membrane, and were formed by fast esterification of newly synthesized free 5-HETE. Generation also required Ca2+, phospholipase C, cytosolic and secretory phospholipase A2, 5-LOX activating protein, and mitogen-activated protein kinase/extracellular signal-regulated kinase kinase 1. 5-HETE-PLs were detected in murine S epidermidis peritonitis, paralleling neutrophil influx, and in effluent from Gram-positive human bacterial peritonitis. Formation of neutrophil extracellular traps was significantly enhanced by 5-LOX inhibition but attenuated by HETE-PE, whereas 5-HETE-PE enhanced superoxide and interleukin-8 generation. Thus, new molecular species of oxidized PL formed by human neutrophils during bacterial infection are identified and characterized.

Epithelial-to-mesenchymal transition (EMT) in its simplest terms is a process by which cells that are not normally motile, i.e. epithelial cells, undergo morphological changes to become motile cells [1]. During embryonic development, EMT is a critically important process, with most adult tissues arising from a series of controlled epithelial-to-mesenchymal transitions [2]. In adult life, the inflammatory cytokine environment created during tissue injury can also drive myofibroblast formation by the same mechanism, and as such, EMT is a critical and helpful process in wound healing and tissue repair [3] [1]. While EMT plays these important ‘physiological roles’, it is now widely recognized that this transformation process has significant pathological implications. It has now been directly implicated in cancer progression and many fibrotic diseases [1,2]. A multitude of clinical studies have identified that epithelial cells in many different organs, e.g. renal tubules [4], lens epithelium [5], alveolar epithelial cells [6] and peritoneal mesothelial cells [7], appear to contribute significantly to tissue fibrosis by undergoing this transition to a myofibroblast and mature fibroblast phenotype. The major challenge impeding progress in this field has been the difficulty experienced in robustly determining that EMT has actually occurred. Fundamentally, detecting a change in cell phenotype or measuring movement of a cell is the only true way to establish EMT. These types of analysis, while feasible in vitro, are virtually impossible to detect in vivo particularly in humans where access to tissues at that particular stage of disease (where EMT is occurring) is rarely possible and ultra-structural identification of the process is open to interpretation. As a result, the vast majority of studies rely upon the detection of specific biomarkers that reflect a transition in the expression of

Tumor necrosis factor (TNF)-like cytokine (TL1A) is a T-cell costimulator that bolsters cytokine-induced activation through death receptor 3 (DR3). To explore the relationship between T-cell activation and TL1A responsiveness, flow cytometry profiled DR3 expression in resting and activated T cells. In human CD4+ T cells, DR3 was induced rapidly following activation and expressed prominently by interleukin (IL)-17-secreting T cells (Th17). Splenic T cells from wild-type and DR3-deficient mice showed that TL1A activation of DR3 inhibits Th17 generation (81±2.6% at 100 ng/ml TL1A) from naive T cells. This response was not associated with suppression of T-cell proliferation. Using neutralizing antibodies or T cells derived from genetically modified mice, TL1A inhibition of Th17 development was found to be independent of IL-2, IL-27, γIFN, IFNAR1, and STAT1. Under suboptimal TCR activation, TL1A continued to block IL-17A secretion, however, the reduced threshold of TCR engagement was now linked with an increase in TL1A-driven proliferation. In contrast, fully committed Th17 cells displayed an altered TL1A responsiveness and in the absence of TCR costimulation supported the maintenance of T cell IL-17A expression. Consequently, TL1A orchestrates unique outcomes in naive and effector T-helper cells, which may affect the proliferation, differentiation and maintenance of Th17 cells in peripheral compartments and inflamed tissues.—Jones, G. W., Stumhofer, J. S., Foster, T., Twohig, J.P., Hertzog, P., Topley, N., Williams, A. S., Hunter, C. A., Jenkins, B. J., Wang, E. C. Y., Jones, S. A. Naive and activated T cells display differential responsiveness to TL1A that affects Th17 generation, maintenance, and proliferation.

The application of proteomics (the study of protein products expressed by the genome) has become one of the leading post-genomic technologies given the increased understanding of the central role of proteins and protein–protein interactions in all aspects of cellular function [2]. Systematic global identification and quantification of proteins can, not only inform improved biomedical understanding of a particular system in healthy or diseased individuals, but also be used for protein biomarker discovery. The most popular of the many proteomic strategies available are summarized in Figure 1 and, whilst two-dimensional electrophoresis (2DE) gel-based approach remains popular, liquid chromatography–tandem mass spectrometry (LC-MS/MS) and gel electrophoresis then liquid chromatography mass spectrometry (geLC-MS) approaches are now preferred as state-of-the-art.

In this study, we compared the activity of interleukin-6 (IL-6), a marker of ongoing peritoneal inflammation and biocompatibility, and its other signaling components, the soluble IL-6 receptor (sIL-6R) and soluble Gp130 (sGp130), in peritoneal effluent from patients treated with icodextrin-based (E) peritoneal dialysis (PD) solution and glucose-based bicarbonate/lactate–buffered (P) solution.

The frequency and severity of episodes of peritonitis adversely affect the structure and function of the peritoneal membrane in patients treated with peritoneal dialysis (PD), but the underlying mechanisms are not well understood. Alterations in the phenotype and function of resident peritoneal cells may contribute. Because effector memory T cells play a pivotal role in maintaining peripheral tissue immunity, we hypothesized that these cells may initiate or perpetuate the peritoneal inflammatory response. Here, we characterized the phenotype and effector function of peritoneal memory T cells. We found that functional effector memory T cells capable of mounting long-term recall responses enrich the peritoneal cavity of PD patients. Peritoneal T cells were able to mount a Th1-polarized response to recall antigens, and these responses were greater in peritoneal T cells compared with T cells in the peripheral blood. We also observed that the peritoneal T cells had altered telomeres; some cells had ultrashort telomeres, suggesting a highly differentiated local population. In summary, we describe a resident population of memory T cells in the peritoneum of PD patients and speculate that these cells form part of the first line of defense against invading pathogens.

TLR overactivation may lead to end organ damage and serious acute and chronic inflammatory conditions. TLR responses must therefore be tightly regulated to control disease outcomes. We show in this study the ability of the soluble form of TLR2 (sTLR2) to regulate proinflammatory responses, and demonstrate the mechanisms underlying sTLR2 regulatory capacity. Cells overexpressing sTLR2, or stimulated in the presence of the sTLR2 protein, are hyporesponsive to TLR2 ligands. Regulation was TLR2 specific, and affected NF-κB activation, phagocytosis, and superoxide production. Natural sTLR2-depleted serum rendered leukocytes hypersensitive to TLR2-mediated stimulation. Mice administered sTLR2 together with Gram-positive bacteria-derived components showed lower peritoneal levels of the neutrophil (PMN) chemoattractant, keratinocyte-derived chemokine; lower PMN numbers; and a reduction in late apoptotic PMN. Mononuclear cell recruitment remained unaffected, and endogenous peritoneal sTLR2 levels increased. Notably, the capacity of sTLR2 to modulate acute inflammatory parameters did not compromise the ability of mice to clear live Gram-positive bacteria-induced infection. Mechanistically, sTLR2 interfered with TLR2 mobilization to lipid rafts for signaling, acted as a decoy microbial receptor, and disrupted the interaction of TLR2 with its coreceptor, CD14, by associating with CD14. These findings establish sTLR2 as a regulator of TLR2-mediated inflammatory responses, capable of blunting immune responses without abrogating microbial recognition and may inform the design of novel therapeutics against acute and chronic inflammatory conditions.

The peritoneal macrophage (Mφ) is the site of greatest 12/15-lipoxygenase (12/15-LOX) expression in the mouse; however, its immunoregulatory role in this tissue has not been explored. Herein, we show that 12/15-LOX is expressed by 95% of resident peritoneal CD11bhigh cells, with the remaining 5% being 12/15-LOX−. 12/15-LOX+ cells are phenotypically defined by high F4/80, SR-A, and Siglec1 expression, and enhanced IL-10 and G-CSF generation. In contrast, 12/15-LOX− cells are a dendritic cell population. Resident peritoneal Mφ numbers were significantly increased in 12/15-LOX−/− mice, suggesting alterations in migratory trafficking or cell differentiation in vivo. In vitro, Mφ from 12/15-LOX−/− mice exhibit multiple abnormalities in the regulation of cytokine/growth factor production both basally and after stimulation with Staphylococcus epidermidis cell-free supernatant. Resident adherent cells from 12/15-LOX−/− mice generate more IL-1, IL-3, GM-CSF, and IL-17, but less CCL5/RANTES than do cells from wild-type mice, while Staphylococcus epidermidis cell-free supernatant-elicited 12/15-LOX−/− adherent cells release less IL-12p40, IL-12p70, and RANTES, but more GM-CSF. This indicates a selective effect of 12/15-LOX on peritoneal cell cytokine production. In acute sterile peritonitis, 12/15-LOX+ cells and LOX products were cleared, then reappeared during the resolution phase. The peritoneal lavage of 12/15-LOX−/− mice showed elevated TGF-β1, along with increased immigration of monocytes/Mφ, but decreases in several cytokines including RANTES/CCL5, MCP-1/CCL2, G-CSF, IL-12-p40, IL-17, and TNF-α. No changes in neutrophil or lymphocyte numbers were seen. In summary, endogenous 12/15-LOX defines the resident MΦ population and regulates both the recruitment of monocytes/Mφ and cytokine response to bacterial products in vivo.

In this review we discuss how animal models have contributed to the understanding of pathological pathways that may be involved in the development of encapsulating peritoneal sclerosis. We review the various interventional procedures that, so far, have ameliorated disease progression in animals. Reviewing advancements in molecular biology and genetic technologies, we discuss how future experimental models may impact our understanding of the pathogenesis and treatment of this rare but complex disease.

OBJECTIVE: Local interaction between soluble mediators within the inflamed synovium is a key factor that governs the pathologic outcome of inflammatory arthritides. Our aim was to investigate the interplay between the Th1 lymphokine interferon-gamma (IFNgamma) and pivotal cytokines that drive rheumatoid arthritis (RA) pathology (interleukin-1beta [IL-1beta] and tumor necrosis factor alpha [TNFalpha]) in modulating inflammation and arthritis in vitro and in vivo. METHODS: Monarticular antigen-induced arthritis (AIA) was initiated in IFNgamma-deficient (IFNgamma(-/-)) mice and age-matched wild-type (IFNgamma(+/+)) mice. Joint swelling was measured and histologic analysis was performed in order to assess changes in both inflammatory and degenerative parameters in vivo. In vitro, the influence of IFNgamma in regulating IL-1beta- and TNFalpha-driven CXCL8 and CCL2 production was quantified by enzyme-linked immunosorbent assay. RESULTS: In murine AIA, both inflammatory and degenerative arthritis parameters were significantly exacerbated in the absence of IFNgamma. IFNgamma appeared to be a crucial factor in regulating CXCR2+ neutrophil influx in the joint. In in vitro studies using RA fibroblast-like synoviocytes, IFNgamma modulated both IL-1beta- and TNFalpha-driven chemokine synthesis, resulting in the down-regulation of CXCL8 production. CONCLUSION: IFNgamma exerts antiinflammatory, chondroprotective, and antiosteoclastogenic effects in murine AIA through a mechanism that involves the regulation of chemokine synthesis and local neutrophil recruitment. These studies suggest a potential therapeutic role of modulating IFNgamma signaling in the treatment of inflammatory arthritides.

Background Encapsulating peritoneal sclerosis (EPS) is an uncommon condition, strongly associated with a long duration of peritoneal dialysis (PD), which is itself associated with increased fibrosis in the peritoneal membrane. The peritoneal membrane is inflamed during PD and inflammation is often associated with fibrosis. We hypothesized that patients who subsequently develop EPS might have a more inflamed peritoneal membrane during PD. Methods We performed a nested, case–control study identifying all EPS cases in the UK arm of the GLOBAL Fluid Study and matching them by centre and duration of PD with two to three controls. Dialysate and plasma samples were taken during repeated peritoneal equilibration tests prior to cessation of PD from cases and controls. Samples were assayed by electrochemiluminescence immunoassay for interleukin-1β (IL-1β), tumour necrosis factor α (TNF-α), interferon-γ (IFN-γ) and IL-6. Results were analysed by linear mixed models adjusted for age and time on PD. Results Eleven EPS cases were matched with 26 controls. Dialysate TNF-α {0.64 [95% confidence interval (CI) 0.23, 1.05]} and IL-6 [0.79 (95% CI 0.03, 1.56)] were significantly higher in EPS cases, while IL-1β [1.06 (95% CI −0.11, 2.23)] and IFN-γ [0.62 (95% CI −0.06, 1.29)] showed a similar trend. Only IL-6 was significantly higher in the plasma [0.42 (95% CI 0.07, 0.78)]. Solute transport was not significantly different between cases and controls but did increase in both groups with the duration of PD. Conclusions The peritoneal cavity has higher levels of inflammatory cytokines during PD in patients who subsequently develop EPS, but neither inflammatory cytokines nor peritoneal solute transport clearly discriminates EPS cases. Increased systemic inflammation is also evident and is probably driven by increased peritoneal inflammation.

The linear glycosaminoglycan hyaluronan (HA) is synthesized at the plasma membrane by the HA synthase (HAS) enzymes HAS1, -2, and -3 and performs multiple functions as part of the vertebrate extracellular matrix. Up-regulation of HA synthesis in the renal corticointerstitium, and the resultant extracellular matrix expansion, is a common feature of renal fibrosis. However, the regulation of expression of these HAS isoforms at transcriptional and translational levels is poorly understood. We have recently described the genomic structures of the human HAS genes, thereby identifying putative promoter regions for each isoform. Further analysis of the HAS2 gene identified the transcription initiation site and showed that region F3, comprising the proximal 121 bp of promoter sequence, mediated full constitutive transcription. In the present study, we have analyzed this region in the human renal proximal tubular epithelial cell line HK-2. Electrophoretic mobility shift and promoter assay data demonstrated that transcription factors Sp1 and Sp3 bound to three sites immediately upstream of the HAS2 transcription initiation site and that mutation of the consensus recognition sequences within these sites ablated their transcriptional response. Furthermore, subsequent knockdown of Sp1 or Sp3 using small interfering RNAs decreased constitutive HAS2 mRNA synthesis. In contrast, significant binding of HK-2 nuclear proteins by putative upstream NF-Y, CCAAT, and NF-kappaB recognition sites was not observed. The identification of Sp1 and Sp3 as principal mediators of HAS2 constitutive transcription augments recent findings identifying upstream promoter elements and provides further insights into the mechanism of HAS2 transcriptional activation.

Background: Post-traumatic MOF results from local tissue injury because of migration and activation of dysfunctional polymorphonuclear leukocytes (PMN). Although fracture surgery exacerbates the postinjury inflammatory response, it is usually beneficial. This study compared changes in PMN receptor expression and migratory activity, in whole blood and following PMN isolation. Methods: IL-8 mediated PMN migration and expression of CXCR-1, CD11b, and CD18 was studied in isolated and whole blood PMN in normal controls. Migration was studied at admission and day 5 after surgery in trauma patients undergoing fracture surgery. Results: PMN isolation results in increased expression of surface receptors and enhanced migration in normal controls. In trauma patient samples, isolated PMN migration is enhanced after injury, but suppressed when migration from whole blood is studied, both after injury and fracture surgery. Conclusion: PMN isolation results in priming for migration, which has a relatively greater impact upon PMN in trauma patients. The observation that PMN activity may decline but priming potential remains enhanced is novel. Further refinements of whole blood and isolated PMN techniques are clearly warranted. This may help to resolve the mismatch in clinical and scientific experience in those patients with major fractures requiring surgical stabilization.

Background Elevated plasma elastase levels have been reported following major trauma and isolated femoral fracture. Reamed femoral nailing has been shown to further increase plasma elastase levels. The aim of this study was to investigate polymorphonuclear neutrophil (PMN) priming for degranulation following major trauma and isolated long-bone/pelvis fracture by assessing the ability of PMN to release elastase in vitro in response to a stimulus. Methods We further analyzed PMN surface expression of the integrins CD11b and CD18 as markers of PMN activation. Ten major trauma (Injury Severity Score>or=18) patients and 12 patients with isolated long-bone/pelvis fracture were included in the study. Patients in the isolated fracture group were further stratified into reamed nail and external-fixation groups following surgery. Results A significant increase in the capacity of PMN to release elastase was seen following major trauma, but not in isolated fracture patients. Surgery did not further alter PMN elastase release. CD11b and CD18 expression was essentially unaltered in all groups. Conclusions PMN is primed for increased degranulation following major trauma but not following isolated long-bone/pelvis fracture. Accumulation of primed, hyperactive PMN into tissues can lead to severe tissue damage and thus multiple organ failure.

The last 200 years have seen a dramatic reduction in the prevalence and severity of microbial infections, due to the implementation of groundbreaking measures ranging from improved sanitation and hygiene and the introduction of aseptic techniques to the development of successful vaccines and the discovery of effective antibiotics. Devastating infections that were common until the late nineteenth century such as cholera, diphtheria, plague, syphilis, tuberculosis, and typhoid came into the reach of effective control, at least in developed countries, and with a minimized risk of wound infections surgical procedures began to revolutionize modern medicine. Antibiotics, in particular, radically transformed the treatment and prevention of microbial infections and have saved millions of lives since their introduction (1). However, antibiotic usage is invariably linked to the selective pressure it exerts on the target organism to develop escape strategies (2). We are at present witnessing how the pendulum begins to swing backwards, with anti-microbial resistances developing on an unprecedented global scale. New classes of Gram-positive and Gramnegative “superbugs” are emerging and spreading at an alarming rate, some of which are virtually insusceptible to all available drugs (3–5). The once apocalyptic vision of a “post-antibiotic era” where common infections and minor injuries may result untreatable and eventually fatal is rapidly becoming a real possibility (1, 2, 6, 7), heralding what Margaret Chan, Director-General of the WHO, in 2012 called “the end of modern medicine as we know it.” The appearance of multidrugresistant bacteria has been identified by the WHO, the Centers for Disease Control and Prevention (CDC) in the USA and their European counterpart, the ECDC, as one of the major global health challenges humankind is facing in the twentyfirst century (8–10). According to Sally Davies, the UK Chief Medical Officer, “there are few public health issues of greater importance than anti-microbial resistance in terms of impact on society” (11). There is now an urgent call for antimicrobial stewardship programs that aim to prescribe antibiotics more prudently, and to tailor their use to defined patient groups who will benefit most. The fact that the prevalence of resistance appears to correlate directly with antibiotic consumption across different countries (12) argues in favor of the immediate effectiveness of such tightly controlled programs. As highlighted in a recent Outlook issue in Nature, “the potential to save lives with faster and more targeted diagnoses, decrease unnecessary and often incorrect prescriptions, and even help identify early on where bacterial resistance could occur, will have a drastic effect on the way patients are treated” (13).

Neutrophil-mediated tissue injury is the hallmark of acute respiratory distress syndrome (ARDS) following trauma. However, neutrophil migration into tissues is a critical, but poorly understood step. The authors investigated the changes in interleukin-(IL-)8-mediated neutrophil migration and associated receptor expression of the IL-8 receptor CXCR1, platelet endothelial cell adhesion molecule-1 (PECAM-1) and the integrins CD18/CD11b, in patients with isolated major lower-limb fractures undergoing fracture surgery. In this observational study, 18 patients with isolated major lower-limb fractures (pelvis, femur, tibia) with no serious preexisting disease were studied prospectively. Twelve underwent reamed nailing and six were treated with an external fixator. Eleven normal volunteers were used as controls. Blood samples were obtained within 4 ± 2 h of injury, at 24 h, day 3 and day 5. Neutrophils migration was assessed by an in vitro IL-8 assay and receptor expression by FACScan. Plasma IL-6 and its soluble receptor (sIL-6R) were measured by enzyme-linked immunosorbent assay (ELISA). Clinical progress was monitored over a 5-day period. Similar systemic responses to injury were demonstrated by elevated IL-6 (p < 0.01) and sIL-6R (p < 0.01) levels on admission in both groups of patients. Significantly greater numbers of patient neutrophils migrated on admission as compared with normal volunteers (p < 0.05); this was associated with a significant increase in CXCR1 (p < 0.05) and downregulation of PECAM-1 (p < 0.05). A further increase was observed following reamed nailing (p < 0.05) but not with external fixation. On day 5, migration was subnormal in those patients managed with external fixation (p < 0.01). Following major lower-limb fracture, neutrophils are primed for increased IL-8-mediated migration. Stabilization by reamed nailing further elevates this response and could increase the risk of ARDS.

Interleukin (IL)-6 signaling through its soluble receptor (IL-6 transsignaling) directs transition between innate and acquired immune responses by orchestrating the chemokine-directed attraction and apoptotic clearance of leukocytes. Through analysis of mononuclear cell infiltration in WT and IL-6-deficient mice during peritoneal inflammation, we now report that IL-6 selectively governs T cell infiltration by regulating chemokine secretion (CXCL10, CCL4, CCL5, CCL11, and CCL17) and chemokine receptor (CCR3, CCR4, CCR5, and CXCR3) expression on the CD3+infiltrate. Although blockade of IL-6 trans-signaling prevented chemokine release, chemokine receptor expression remained unaltered suggesting that this response is regulated by IL-6 itself. To dissect the signaling events promoting T cell migration, inflammation was established in knock-in mice expressing mutated forms of the universal signal-transducing element for IL-6-related cytokines gp130. In mice (gp130Y757F/Y757F) deficient in SHP2 and SOCS3 binding, but presenting hyperactivation of STAT1/3, T cell recruitment and CCL5 expression was enhanced. Conversely, both of these parameters were suppressed in mice with ablated gp130-mediated STAT1/3 activation (gp130ΔSTAT/ΔSTAT). T cell migration was related to STAT3 activity, because monoallelic deletion ofStat3ingp130Y757F/Y757Fmice (gp130Y757F/Y757F:Stat3+/-) corrected the exaggerated responses observed ingp130Y757F/Y757Fmice. Consequently, STAT3 plays a defining role in IL-6-mediated T cell migration.

Transforming growth factor (TGF)-beta1 is a key cytokine involved in the pathogenesis of fibrosis in many organs, whereas interleukin (IL)-6 plays an important role in the regulation of inflammation. Recent reports demonstrate interaction between the two cytokines in disease states. We have assessed the effect of IL-6 on TGF-beta1 signaling and defined the mechanism by which this occurred. Stimulation of Smad-responsive promoter (SBE)4-Lux activity by TGF-beta1 was significantly greater in the presence of IL-6 than that induced by TGF-beta1 alone. Augmented TGF-beta1 signaling following the addition of IL-6 appeared to be mediated through binding to the cognate IL-6 receptor, the presence of which was confirmed by fluorescence-activated cell sorting and Stat-specific signaling. TGF-beta1 receptors internalize by both caveolin-1 (Cav-1) lipid raft and early endosome antigen 1 (EEA-1) non-lipid raft pathways, with non-lipid raft-associated internalization increasing TGF-beta1 signaling. Affinity labeling of TGF-beta1 receptors demonstrated that IL-6 stimulation resulted in increased partitioning of TGF-beta receptors to the non-lipid raft fraction. There was no change in expression of Cav-1; however, following IL-6 stimulation, co-immunoprecipitation demonstrated decreased association of IL-6 receptor with Cav-1. Increased TGF-beta1-dependent Smad signaling by IL-6 was significantly attenuated by inhibition of clathrin-mediated endocytosis and augmented by depletion of membrane cholesterol. These results indicate that IL-6 increased trafficking of TGF-beta1 receptors to non-lipid raft-associated pools results in augmented TGF-beta1 Smad signaling.

Defense against the susceptibility and damaging effects of urinary tract infection is complex and vital, as injury can lead to progressive renal injury and chronic renal failure. Recently the defensins, a family of small cationic antimicrobial peptides found in neutrophils and renal epithelial cells, have been shown to have a number of key biological properties that equip them to undertake a pivotal role in combating infection. We describe the capability of these ubiquitous and abundant peptides in the process of innate immunity, and more recently discovered roles in the adaptive immune response to infection. Furthermore, we also discuss their potential to influence other key components of the inflammatory response to infection. Despite the current state of knowledge, we are only just beginning to understand the significance of defensins as pivotal peptides in host defence and their possibilities as therapeutic targets of the future.