2007 JASN IMPACT FACTOR 7.111	HOME   AUTHOR INFO   EDITORIAL BOARD   SUBSCRIBE   FEEDBACK   ALERTS   HELP
advanced	CURRENT ISSUE	ARCHIVES	JASN Express	ONLINE SUBMISSION

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by TE LOO, D. M. W. M. Articles by MONNENS, L. A. H. Search for Related Content PubMed PubMed Citation Articles by TE LOO, D. M. W. M. Articles by MONNENS, L. A. H.

Detection of Verocytotoxin Bound to Circulating Polymorphonuclear Leukocytes of Patients with Hemolytic Uremic Syndrome

D. MAROESKA W. M. TE LOO^*, VICTOR W. M. VAN HINSBERGH^,, LAMBERTUS P. W. J. VAN DEN HEUVEL^* and LEO A. H. MONNENS^*

^* Department of Pediatrics, University Hospital Nijmegen, Nijmegen, The Netherlands.
Gaubius Laboratory TNO-PG, Leiden, The Netherlands.
Institute for Cardiovascular Research, Vrije Universiteit, Amsterdam, The Netherlands.

Correspondence to Dr. Leo A. H. Monnens, Department of Pediatric Nephrology, University Hospital Nijmegen, 6500 HB Nijmegen, The Netherlands. Phone: +31-24-36-16872; Fax: +31-24-36-19348.

	Abstract

Top Abstract Introduction Materials and Methods Results Discussion References

 
Abstract. The epidemic form of hemolytic uremic syndrome (HUS) is the most common cause of acute renal failure in children and is characterized by a prodromal phase of sometimes bloody diarrhea. The role of verocytotoxin (VT)-producing Escherichia coli has been strongly implicated. Although antibodies against VT have been detected in the serum of patients with HUS, VT itself has never been detected in circulating blood. In this study, VT-2 was detected in the systemic circulation in 9 of 10 patients with the epidemic form of HUS. In those cases, VT-2 was bound exclusively to polymorphonuclear leukocytes (PMN). The detection of VT-2 bound to PMN was associated with the presence of diarrhea at the time the blood samples were obtained. The one patient for whom VT was not detected presented with atypical HUS. For 5 of the 10 patients with HUS who were studied, the time course of VT binding was analyzed; binding decreased in four patients. The finding of VT bound to PMN in the systemic circulation of patients with HUS is important for a clearer understanding of the pathogenesis of HUS and suggests new approaches for treatment in the future.

	Introduction

Top Abstract Introduction Materials and Methods Results Discussion References

 
The epidemic form of hemolytic uremic syndrome (HUS) is the most common cause of acute renal failure in children (1,2). Endothelial damage of predominantly glomeruli and to a lesser extent arterioles of the kidney appears to play an important role in the pathogenesis of HUS. In severe cases, however, endothelial cell damage is not limited to the kidney but extends to other organs, such as the brain and pancreas (3). In 90% of HUS cases, infection with Escherichia coli producing a verocytotoxin (VT) (also termed "Shiga" or "Shiga-like toxin"), especially serotype O157:H7, has been strongly implicated. E. coli can produce VT-1, VT-2, or both. Most common among patients with HUS are infections caused by VT-2-producing E. coli (4,5). VT can cause inhibition of overall protein synthesis after binding to the globotriaosylceramide (Gb3) receptor, which is found on endothelial cells after stimulation with inflammatory mediators (6,7). Serologic testing of patients with HUS for antibodies to the lipopolysaccharide of E. coli O157:H7 is often used to detect infection by VT-producing E. coli O157 (8,9,10). However, VT itself has never been detected in the blood of patients with HUS.

Recently, we investigated the binding of VT-1 and VT-2 in whole blood (11). In that study, we demonstrated that VT binds rapidly and exclusively to polymorphonuclear leukocytes (PMN) when incubated in whole blood in vitro. This binding occurs via selective binding to a specific receptor on PMN. Thin-layer chromatography demonstrated that the receptor exhibited an R_f value between those of Gb4 and Gb5. In addition, the receptor on PMN exhibited a 100-fold lower affinity, compared with that of the Gb3 receptor, which is found on endothelial cells. PMN previously loaded with VT were able to pass the ligand VT to tumor necrosis factor--stimulated glomerular microvascular endothelial cells in vitro, which then caused inhibition of protein synthesis (11). In this study, we demonstrate for the first time, to our knowledge, the presence of VT-2 in the systemic circulation of patients during the acute phase of HUS. Here we confirm that VT binds to PMN, as suggested by our in vitro studies, supporting our theory that PMN are responsible for transferring the ligand VT from the intestine to target organs.

	Materials and Methods

Top Abstract Introduction Materials and Methods Results Discussion References

 
Patients and Control Subjects
Ethylenediaminetetraacetate-treated blood was collected from 11 patients with HUS, during the acute phase of the disease. Ten of 11 patients exhibited a prodromal phase of sometimes bloody diarrhea, and antibodies against E. coli O157:H7 were detected for seven patients (Table 1, patients 2 to 11). The patient without a prodromal phase had an atypical form of HUS. No E. coli (O157 or other types) was present in stool, and no antibodies against lipopolysaccharide could be detected. All patients exhibited thrombocytopenia, hemolytic anemia with fragmented erythrocytes, and renal failure.

Clinical characteristics of the patients are presented in Table 1. Blood samples were analyzed for the presence of VT-2 within 2 h after withdrawal. Ethylenediaminetetraacetate-treated blood samples from 11 healthy volunteers and six patients with infectious diseases (one with peritonitis, two with influenza virus, one with otitis media, one with toxic shock syndrome, and one with an upper respiratory tract infection) were used as negative control samples for the presence of VT.

Detection of VT Using Indirect Immunofluorescence Assays and Flow Cytometry
PMN were isolated as described previously (11). Briefly, whole blood from patients with HUS and control subjects was underlaid with an aliquot of Ficoll (1.077 g/ml; Pharmacia, Uppsala, Sweden) and centrifuged at 200 x g for 20 min at 4°C, in a Sorvall centrifuge (Meyvis and Co., Bergen op Zoom, The Netherlands). The interphase, containing lymphocytes, monocytes, and a few PMN, was collected and washed with phosphate-buffered saline (PBS). The pellet contained PMN and erythrocytes. The pellet was resuspended and erythrocytes were lysed in ammonium chloride or fluorescence-activated cell sorting (FACS) lysing solution. The remaining PMN were washed twice with PBS. The total number of cells was counted, and 1 x 10⁶ cells were used in each experiment. PMN (1 x 10⁶ cells) and interphase samples (1 x 10⁶ cells) from patients and control subjects were incubated for 1 h, on ice, with a monoclonal antibody against VT-2B subunits (0.1 µg/µl; Toxin Technology; Kordia, Leiden, The Netherlands), in PBS with 10% fetal calf serum. Subsequently, cells were washed three times with PBS and incubated for 30 min, on ice, with FITC-conjugated goat anti-mouse Ig (1:1000; DAKO, Glostrup, Denmark). Cells were again washed three times with PBS, followed by incubation for 1 h, on ice, with CD13-phycoerythrin, CD14-phycoerythrin, or CD45-tetrarhodamine isothiocyanate (DAKO), to differentiate PMN, monocytes, and lymphocytes, respectively. Subsequently, cells were washed three times with PBS and resuspended in 0.5% paraformaldehyde for fixation. Cells were analyzed by using a Zeiss microscope (Aksioscope; Bakker and Co., Zwijndrecht, The Netherlands) with standard equipment or by FACS analysis. FACS analysis made it possible to quantify the percentage of positive cells.

	Results

Top Abstract Introduction Materials and Methods Results Discussion References

 
On the basis of the results of our in vitro work (11), we focused in this study on the binding of VT-2 to PMN. Indirect immunofluorescence assays demonstrated positive staining for VT-2 on PMN from nine of 10 patients in the acute phase of HUS (Table 1). The results of an indirect immunofluorescence assay for one representative patient are presented in Figure 1. VT-2 binding was observed only to PMN. To confirm that PMN were the only cells binding VT in blood, VT binding to purified blood cells from patients with HUS was studied. As suggested by our previous findings for blood cells from healthy donors (11), VT-2 bound only to PMN and not to lymphocytes, monocytes, or erythrocytes from patients with diarrhea-associated (D+) HUS in the acute phase of the disease.

View larger version (18K): [in this window] [in a new window] [as a PowerPoint slide]   Figure 1. Indirect immunofluorescence assay of verocytotoxin-2 (VT-2) bound to polymorphonuclear leukocytes (PMN) for one representative patient (patient 9) in the acute phase of hemolytic uremic syndrome (HUS). Magnification, x1000.

FACS analysis was used to quantify the indirect immunofluorescence results. No VT-2 binding was detected in control blood samples from any of the healthy volunteers (Figure 2, A, C, and E). In addition, no binding of VT-2 was observed for six patients with infectious diseases (see above).

View larger version (40K): [in this window] [in a new window] [as a PowerPoint slide]   Figure 2. Flow cytometric analysis for detection of VT-2 bound to PMN. (A and C) PMN isolated from control blood (from two different healthy volunteers) and incubated with a monoclonal antibody against VT-2, followed by incubation with FITC-conjugated goat anti-mouse IgG. No positive binding was observed. (E) Interphase sample from the same control subject, containing lymphocytes (L), monocytes (M), and PMN (P), incubated with a monoclonal antibody against VT-2. No binding of VT-2 was observed. (B) Results for the first sample of blood from a patient with HUS (patient 8), using the same incubation steps as used for the control sample. Of all PMN, 90% were positive for VT-2 binding. (D) Results showing that, 5 d later, VT-2 binding to PMN was reduced to 15%. (F) Results showing that, interestingly, monocytes were positive for VT-2 binding on day 5, whereas no binding was observed on day 1.

Figure 2B presents the results of VT binding to PMN from one patient (patient 8) on the first day after admission to the hospital; on the first day, 90% of the PMN were positive for VT-2 staining. Five days later, only 15% of PMN were still positive (Figure 2D), suggesting that VT was transferred to target cells (data not shown). Interestingly, at that time not only PMN but also monocytes (Figure 2E) were positive for VT binding, which is highly indicative of activated monocytes, as described by van Setten et al. (12). For patient 9, VT-2 binding to monocytes was also observed 5 d after collection of the first sample. No VT-2 binding to monocytes was observed for the other patients, and patient 10 exhibited no binding to PMN 5 d after collection of the first sample.

The time course of VT-2 binding to PMN was studied only for the five patients with the greatest numbers of VT-2-positive cells (patients 5, 8, 9, 10, and 11) (Figure 3A,3B). For patients 5, 8, 10, and 11, large decreases in the numbers of PMN positive for VT-2 were observed in the 5 d after collection of the first sample. The last sample for patient 9 was obtained 5 d after the first sample, and no significant decrease in VT-2 binding was observed. A possible explanation for this may be that additional toxin was absorbed from the circulation and transferred to the white blood cells as fast as the cells could transfer the toxin to Gb3-containing glomerular cells. Patient 9 had a very severe form of HUS, with neurologic involvement, and died on the day the last sample was obtained.

View larger version (40K): [in this window] [in a new window] [as a PowerPoint slide]   Figure 3. (A) Flow cytometric analysis for detection of VT-2 bound to PMN from patients 9, 10, and 11 on days 1 and 5 after admission. In all determinations performed, blood from a healthy volunteer was used as a control sample (left panels), to exclude nonspecific binding of the monoclonal antibody against VT-2. For patient 9, 96% of PMN were positive on the first day and 92% of the cells were still positive after 5 d. The fluorescence intensity decreased, indicating that less VT-2 was present on PMN. However, VT-2 binding to monocytes was simultaneously observed for this patient.

View larger version (26K): [in this window] [in a new window] [as a PowerPoint slide]   Figure 3. (B) Flow cytometric analysis of interphase samples from patients 9, 10, and 11 on days 1 (left) and 5 (right). For patient 10, 14% of the PMN (P) were positive for VT-2 binding on day 1. On day 5, no positive binding was observed (2% of the cells were nonspecifically labeled with FITC-conjugated goat anti-mouse Ig; this value was subtracted from the total numbers of positive cells, leading to the conclusion that no cells were positive for this patient). For patient 11, VT-2 binding to PMN was observed for 80% of the cells on day 1. On day 5, 20% of the cells were still positive. For patients 10 and 11, no binding to monocytes (M) or lymphocytes (L) was observed.

No positive staining for VT-2 was observed for patients 1 and 4. All patients who exhibited positive results for VT-2 binding to PMN were still experiencing sometimes bloody diarrhea at the time the blood samples were obtained. Patient 1 exhibited no prodromal phase of bloody diarrhea and experienced a HUS relapse just a few weeks later. He responded to treatment with plasmapheresis. Therefore, he was considered to have an atypical form of HUS.

	Discussion

Top Abstract Introduction Materials and Methods Results Discussion References

 
In this study, we demonstrated the presence of VT-2 in the systemic circulation of nine of 10 patients during the acute phase of the epidemic form of HUS. In 85% of all cases of D+ HUS in Western Europe, infections with VT-2-producing E. coli are found (13). Therefore, we investigated the presence of VT-2 in the systemic circulation of patients with D+ HUS, in the acute phase of the disease.

VT-2 bound to PMN and not to erythrocytes, monocytes, or lymphocytes during the period of diarrhea. There was a strong association between the detection of VT-2 bound to PMN and the simultaneous presence of bloody diarrhea. One patient with atypical HUS repeatedly exhibited no positive staining during the acute phase of the disease. In the other case in which no VT-2 binding was detected (patient 4), the result was probably negative because of late admission to the hospital. That patient had been without diarrhea for 7 d at the time the blood sample was obtained. An explanation for this observation may be that the toxin had already been transferred from the intestine to the kidney. Alternatively, this patient may have had an infection with VT-1-producing E. coli, which we could not detect with the VT-2-specific monoclonal antibody used in this study.

It has often been suggested that PMN may play a critical role in the pathogeneses of D+ HUS. PMN levels are elevated in HUS, and it has been suggested that the number of PMN is a predictive factor for the outcome of the disease (14,15). In addition, increased numbers of PMN were found in the glomeruli of kidney autopsy samples from patients with D+ HUS (16,17). Furthermore, PMN in patients with HUS are activated, and elevated levels of interleukin-8 and elastase are found (18). It has been suggested that PMN of patients with HUS may damage the endothelium through release of intracellular components, such as elastase, or formation of superoxide (19,20). In our in vitro experiments, we indeed demonstrated that PMN loaded with VT-1 were able to induce endothelial cell death, whereas VT-1 or PMN alone had no effect (11). In addition, a recently published study showed that apoptosis of PMN was inhibited by VT; those authors concluded that longer survival of neutrophils might aggravate neutrophil-mediated tissue damage (21). Finally, Zoja and colleagues (22) reported that VT-1 can cause increased adhesion of PMN to the endothelium under flow conditions, by up-regulating adhesive proteins. Administration of antibodies against E-selectin, intercellular adhesion molecule-1, or vascular cell adhesion molecule-1 reduced the adhesion of PMN to the endothelium.

Karmali and colleagues (23) investigated the presence of VT-1 in the serum of rabbits and demonstrated a short serum half-life (2 min) for VT-1. From those results, the authors concluded that VT is probably rapidly cleared from the systemic circulation and thus is not detectable in the circulation of patients with HUS. They did not consider a role for PMN in transporting VT, however. In our in vitro experiments, we demonstrated that VT binds rapidly and exclusively to PMN (11). No binding to other components of blood was observed. Interestingly, it has been suggested that PMN also play a very important role in the pathogenesis of Kawasaki disease, and it has been reported that lipopolysaccharide is bound and transported by PMN (24).

In line with our in vitro data are the findings that VT-2 bound to PMN in vivo in nine of 10 patients with the epidemic form of HUS. We think that VT has never been detected in the serum of patients with HUS because VT binds rapidly to PMN after entering the systemic circulation and thus is absent from the plasma or serum of patients with HUS.

The finding of VT-2 bound to PMN from patients with D+ HUS not only represents the missing link between intestinal infection and damage to target organs but also provides new approaches for therapy. Two patients with severe HUS whom we studied exhibited high percentages of PMN positive for VT-2 binding; in a later phase, binding to monocytes was also observed. We think that, during the phase of bloody diarrhea, VT traverses the intestine-blood barrier, binds to PMN, and thus is transferred to target organs.

Synsorb Pk, a synthetic analog of the Gb3 receptor, can bind VT in vitro and can neutralize VT when mixed in vitro with VT-positive stools from children with HUS (25,26). When Synsorb Pk is administered orally to patients with the epidemic form of HUS while they still have diarrhea, it reduces the amount of VT available; this reduction might prevent and/or decrease the binding of VT to PMN and the subsequent transfer of VT from the intestine to target organs. However, additional therapy is required in severe cases. We think that, on the basis of the finding that VT is bound to PMN in patients with D+ HUS, leukopheresis would be a possible solution in such cases. The presence of VT bound to PMN can be assessed rapidly, using a simple, reproducible, quick method, as we have described in this report. PMN loaded with VT can be removed using leukopheresis, thus preventing the transfer of VT to target organs or protecting target organs from severe damage.

In conclusion, our data demonstrate a new and crucial aspect in the pathogenesis of HUS, namely the specific binding and transfer of VT by PMN in the systemic circulation. We think that this observation is important for clarification of the pathogenesis of HUS and for treatment of patients with HUS. We suggest that in severe cases of D+ HUS, effective leukopheresis therapy should be considered.

	Acknowledgments

 
We thank all of the university hospitals that collaborated by collecting data on patients with HUS. We especially thank Dr. C. Schröder, University Hospital Utrecht; Dr. J. C. Davin, Amsterdam Medical Center; Dr. J. van de Walle, University Hospital Gent; Dr. J. Nauta, Sophia Kinderziekenhuis, Rotterdam; and Dr. K. van Daal, University Hospital Groningen. This investigation was supported by a grant from the Dutch Kidney Foundation (Grant 97.1645).

	References

Top Abstract Introduction Materials and Methods Results Discussion References

 

1. Fong JS, de Chadarevian JP, Kaplan BS: Hemolytic-uremic syndrome: Current concepts and management. Pediatr Clin North Am29 : 835-856,1982[Medline]
2. Remuzzi G, Ruggenenti P: The hemolytic uremic syndrome. Kidney Int 48:2 -19, 1995[Medline]
3. Siegler RL: The hemolytic uremic syndrome. Pediatr Clin North Am 42:1505 -1529, 1995[Medline]
4. Kaplan BS, Meyers KE, Schulman SL: The pathogenesis and treatment of hemolytic uremic syndrome. J Am Soc Nephrol9 : 1126-1133,1998[Medline]
5. Karmali MA, Petric M, Lim C, Fleming PC, Arbus GS, Lior H: The association between idiopathic hemolytic uremic syndrome and infection by verotoxin-producing Escherichia coli. J Infect Dis 151: 775-782,1985[Medline]
6. van de Kar NC, Monnens LA, Karmali MA, van Hinsbergh VW: Tumor necrosis factor and interleukin-1 induce expression of the verocytotoxin receptor globotriaosylceramide on human endothelial cells: Implications for the pathogenesis of the hemolytic uremic syndrome. Blood 80:2755 -2764, 1992[Abstract/Free Full Text]
7. van Setten PA, van Hinsbergh VW, van der Velden TJ, van de Kar NC, Vermeer M, Mahan JD, Assmann KJ, van den Heuvel LP, Monnens LA: Effects of TNF alpha on verocytotoxin cytotoxicity in purified human glomerular microvascular endothelial cells. Kidney Int51 : 1245-1256,1997[Medline]
8. Chart H, Smith HR, Scotland SM, Rowe B, Milford DV, Taylor CM: Serological identification of Escherichia coli O157:H7 infection in haemolytic uraemic syndrome. Lancet337 : 138-140,1991[Medline]
9. Nataro JP, Kaper JB: Diarrheagenic Escherichia coli. Clin Microbiol Rev 11:142 -201, 1998[Abstract/Free Full Text]
10. Paton JC, Paton AW: Pathogenesis and diagnosis of Shiga toxin-producing Escherichia coli infections. Clin Microbiol Rev 11:450 -479, 1998[Abstract/Free Full Text]
11. te Loo DMWM, Monnens LAH, van der Velden TJAM, Vermeer MA, Preyers F, Demacker PNM, van den Heuvel LPWJ, van Hinsbergh VWM: Binding and transfer of verocytotoxin by polymorphonuclear leukocytes in hemolytic uremic syndrome. Blood 95:3396 -3402, 2000[Abstract/Free Full Text]
12. van Setten PA, Monnens LAH, Verstraten RG, van den Heuvel LPWJ, van Hinsbergh VWM: Effects of verocytotoxin-1 on non-adherent human monocytes: Binding characteristics, protein synthesis, and induction of cytokine release. Blood 88:174 -183, 1996[Abstract/Free Full Text]
13. Heuvelink AE, van de Kar NCAJ, Meis JFGM, Monnens LAH, Melchers WJG: Characterization of verocytotoxin-producing Escherichia coli O157 isolates from patients with haemolytic uremic syndrome in Western Europe. Epidemiol Infect 115:1 -14, 1995[Medline]
14. Milford DV, Staten J, MacGreggor I, Dawes J, Taylor CM, Hill FG: Prognostic markers in diarrhoea-associated haemolytic-uraemic syndrome: Initial neutrophil count, human neutrophil elastase and von Willebrand factor antigen. Nephrol Dial Transplant6 : 232-237,1991
15. Hughes DA, Smith GC, Davidson JE, Murphy AV, Beattie TJ: The neutrophil oxidative burst in diarrhoea-associated haemolytic uraemic syndrome. Pediatr Nephrol 10:445 -447, 1996[Medline]
16. Inward CD, Howie AJ, Fitzpatrick MM, Rafaat F, Milford DV, Taylor CM: Renal histopathology in fatal cases of diarrhoea-associated haemolytic uraemic syndrome: British Association for Paediatric Nephrology. Pediatr Nephrol 11:556 -559, 1997[Medline]
17. Moghal NE, Ferreira MA, Howie AJ, Milford DV, Raafat E, Taylor CM: The late histologic findings in diarrhea-associated hemolytic uremic syndrome. J Pediatr 133:220 -223, 1998[Medline]
18. Fitzpatrick MM, Shah V, Filler G, Dillon MJ, Barratt TM: Neutrophil activation in the haemolytic uraemic syndrome: Free and complexed elastase in plasma. Pediatr Nephrol 6:50 -53, 1992[Medline]
19. King AJ, Sunderam S, Cendoroglo M, Acheson DW, Keusch GT: Shiga toxin induces superoxide production in polymorpho-nuclear cells with subsequent impairment of phagocytosis and responsiveness to phorbol esters. J Infect Dis 179:503 -507, 1999[Medline]
20. Forsyth KD, Simpson AC, Fitzpatrick MM, Barrat TM, Levinsky RJ: Neutrophil-mediated endothelial injury in haemolytic uraemic syndrome. Lancet 2:411 -414, 1989[Medline]
21. Liu J, Akoshi T, Sasahana T, Kitasato H, Namai R, Sasaki T, Inoue M, Kondo H: Inhibition of neutrophil apoptosis by verotoxin 2 derived from Escherichia coli O157:H7. Infect Immun67 : 6203-6205,1999[Abstract/Free Full Text]
22. Morigi M, Micheletti G, Figliuzzi M, Imberti B, Karmali MA, Remuzzi A, Remuzzi G, Zoja C: Verotoxin-1 promotes leukocyte adhesion to cultured endothelial cells under physiologic flow conditions. Blood 86:4553 -4558, 1995[Abstract/Free Full Text]
23. Richardson SE, Rotman TA, Jay V, Smith CR, Becker LE, Petric M, Olivieri NF, Karmali MA: Experimental verocytotoxemia in rabbits. Infect Immun 60:4154 -4167, 1992[Abstract/Free Full Text]
24. Takeshita S, Nakatani K, Kawase H, Seki S, Yamamoto M, Sekine I, Yoshioka S: The role of bacterial lipopolysaccharide-bound neutrophils in the pathogenesis of Kawasaki disease. J Infect Dis179 : 508-512,1999[Medline]
25. Armstrong GD, Rowe PC, Goodyear P, Orrbine E, Klassen TP, Wells G, MacKenzie A, Lior H, Blanchard C, Auclair F: A phase I study of chemically synthesized verotoxin (Shiga-like toxin) Pk-trisaccharide receptors attached to Chromosorb for preventing hemolytic-uremic syndrome. J Infect Dis 171:1042 -1045, 1995[Medline]
26. Takeda T, Yoshino K, Adachi E, Sato Y, Yamagata K: In vitro assessment of a chemically synthesized Shiga toxin receptor analog attached to Chromosorb P (Synsorb Pk) as a specific absorbing agent of Shiga toxin 1 and 2. Microbiol Immunol43 : 331-337,1999[Medline]

This article has been cited by other articles:

				K. A. D. Sauter, A. R. Melton-Celsa, K. Larkin, M. L. Troxell, A. D. O'Brien, and B. E. Magun Mouse Model of Hemolytic-Uremic Syndrome Caused by Endotoxin-Free Shiga Toxin 2 (Stx2) and Protection from Lethal Outcome by Anti-Stx2 Antibody Infect. Immun., October 1, 2008; 76(10): 4469 - 4478. [Abstract] [Full Text] [PDF]

				M. Brigotti, D. Carnicelli, E. Ravanelli, S. Barbieri, F. Ricci, A. Bontadini, A. E. Tozzi, G. Scavia, A. Caprioli, and P. L. Tazzari Interactions between Shiga toxins and human polymorphonuclear leukocytes J. Leukoc. Biol., October 1, 2008; 84(4): 1019 - 1027. [Abstract] [Full Text] [PDF]

				D. R. Baker, R. A. Moxley, M. B. Steele, J. T. LeJeune, J. Christopher-Hennings, D.-G. Chen, P. R. Hardwidge, and D. H. Francis Differences in Virulence among Escherichia coli O157:H7 Strains Isolated from Humans during Disease Outbreaks and from Healthy Cattle Appl. Envir. Microbiol., November 15, 2007; 73(22): 7338 - 7346. [Abstract] [Full Text] [PDF]

				T. P. Griener, G. L. Mulvey, P. Marcato, and G. D. Armstrong Differential binding of Shiga toxin 2 to human and murine neutrophils J. Med. Microbiol., November 1, 2007; 56(11): 1423 - 1430. [Abstract] [Full Text] [PDF]

				M. J. Flagler, J. E. Strasser, C. L. Chalk, and A. A. Weiss Comparative Analysis of the Abilities of Shiga Toxins 1 and 2 To Bind to and Influence Neutrophil Apoptosis Infect. Immun., February 1, 2007; 75(2): 760 - 765. [Abstract] [Full Text] [PDF]

				J. K. Roche, T. R. Keepers, L. K. Gross, R. M. Seaner, and T. G. Obrig CXCL1/KC and CXCL2/MIP-2 Are Critical Effectors and Potential Targets for Therapy of Escherichia coli O157:H7-Associated Renal Inflammation Am. J. Pathol., February 1, 2007; 170(2): 526 - 537. [Abstract] [Full Text] [PDF]

				M. Brigotti, A. Caprioli, A. E. Tozzi, P. L. Tazzari, F. Ricci, R. Conte, D. Carnicelli, M. A. Procaccino, F. Minelli, A. V. S. Ferretti, et al. Shiga Toxins Present in the Gut and in the Polymorphonuclear Leukocytes Circulating in the Blood of Children with Hemolytic-Uremic Syndrome J. Clin. Microbiol., February 1, 2006; 44(2): 313 - 317. [Abstract] [Full Text] [PDF]

				P. Marcato, T. P. Griener, G. L. Mulvey, and G. D. Armstrong Recombinant Shiga Toxin B-Subunit-Keyhole Limpet Hemocyanin Conjugate Vaccine Protects Mice from Shigatoxemia Infect. Immun., October 1, 2005; 73(10): 6523 - 6529. [Abstract] [Full Text] [PDF]

				M. Noris and G. Remuzzi Hemolytic Uremic Syndrome J. Am. Soc. Nephrol., April 1, 2005; 16(4): 1035 - 1050. [Full Text] [PDF]

				S. Tzipori, A. Sheoran, D. Akiyoshi, A. Donohue-Rolfe, and H. Trachtman Antibody Therapy in the Management of Shiga Toxin-Induced Hemolytic Uremic Syndrome Clin. Microbiol. Rev., October 1, 2004; 17(4): 926 - 941. [Abstract] [Full Text] [PDF]

				W. W. Lathem, T. Bergsbaken, and R. A. Welch Potentiation of C1 Esterase Inhibitor by StcE, a Metalloprotease Secreted by Escherichia coli O157:H7 J. Exp. Med., April 19, 2004; 199(8): 1077 - 1087. [Abstract] [Full Text] [PDF]

				H. Trachtman, A. Cnaan, E. Christen, K. Gibbs, S. Zhao, D. W. K. Acheson, R. Weiss, F. J. Kaskel, A. Spitzer, and G. H. Hirschman Effect of an Oral Shiga Toxin-Binding Agent on Diarrhea-Associated Hemolytic Uremic Syndrome in Children: A Randomized Controlled Trial JAMA, September 10, 2003; 290(10): 1337 - 1344. [Abstract] [Full Text] [PDF]

				R. L. Siegler Postdiarrheal Shiga Toxin-Mediated Hemolytic Uremic Syndrome JAMA, September 10, 2003; 290(10): 1379 - 1381. [Full Text] [PDF]

				I. Matise, N. A. Cornick, J. E. Samuel, and H. W. Moon Binding of Shiga Toxin 2e to Porcine Erythrocytes In Vivo and In Vitro Infect. Immun., September 1, 2003; 71(9): 5194 - 5201. [Abstract] [Full Text] [PDF]

				P. I. Tarr Basic Fibroblast Growth Factor and Shiga Toxin-O157:H7-Associated Hemolytic Uremic Syndrome J. Am. Soc. Nephrol., March 1, 2002; 13(3): 817 - 820. [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by TE LOO, D. M. W. M. Articles by MONNENS, L. A. H. Search for Related Content PubMed PubMed Citation Articles by TE LOO, D. M. W. M. Articles by MONNENS, L. A. H.