Characterizing Patients with Recurrent Urinary Tract Infections in Vesicoureteral Reflux: A Pilot Study of the Urinary Proteome

Recurrent urinary tract infections (UTIs) pose a significant burden on the health care system. Underlying mechanisms predisposing children to UTIs and associated changes in the urinary proteome are not well understood. We aimed to investigate the urinary proteome of a subset of children who have vesicoureteral reflux (VUR) and recurrent UTIs because of their risk of developing infection-related renal damage. Improving diagnostic modalities to identify UTI risk factors would significantly alter the clinical management of children with VUR. We profiled the urinary proteomes of 22 VUR patients with low grade VUR (1–3 out of 5), a history of recurrent UTIs, and renal scarring, comparing them to those obtained from 22 age-matched controls. Urinary proteins were analyzed by mass spectrometry followed by protein quantitation based on spectral counting. Of the 2,551 proteins identified across both cohorts, 964 were robustly quantified, as defined by meeting criteria with spectral count (SC) ≥2 in at least 7 patients in either VUR or control cohort. Eighty proteins had differential expression between the two cohorts, with 44 proteins significantly up-regulated and 36 downregulated (q <0.075, FC ≥1.2). Urinary proteins involved in inflammation, acute phase response (APR), modulation of extracellular matrix (ECM), and carbohydrate metabolism were altered among the study cohort. Recurrent urinary tract infections (UTIs) pose a significant burden on the health care system. Underlying mechanisms predisposing children to UTIs and associated changes in the urinary proteome are not well understood. We aimed to investigate the urinary proteome of a subset of children who have vesicoureteral reflux (VUR) and recurrent UTIs because of their risk of developing infection-related renal damage. Improving diagnostic modalities to identify UTI risk factors would significantly alter the clinical management of children with VUR. We profiled the urinary proteomes of 22 VUR patients with low grade VUR (1–3 out of 5), a history of recurrent UTIs, and renal scarring, comparing them to those obtained from 22 age-matched controls. Urinary proteins were analyzed by mass spectrometry followed by protein quantitation based on spectral counting. Of the 2,551 proteins identified across both cohorts, 964 were robustly quantified, as defined by meeting criteria with spectral count (SC) ≥2 in at least 7 patients in either VUR or control cohort. Eighty proteins had differential expression between the two cohorts, with 44 proteins significantly up-regulated and 36 downregulated (q <0.075, FC ≥1.2). Urinary proteins involved in inflammation, acute phase response (APR), modulation of extracellular matrix (ECM), and carbohydrate metabolism were altered among the study cohort. Urinary tract infections (UTIs) 1The abbreviations used are:UTIurinary tract infectionsVURvesicoureteral refluxECMextracellular matrixUPJOureteropelvic junction obstructionVCUGvoiding cystourethrogramDMSAdimercaptosuccinic acidPISpooled internal standardAPPacute phase proteins. 1The abbreviations used are:UTIurinary tract infectionsVURvesicoureteral refluxECMextracellular matrixUPJOureteropelvic junction obstructionVCUGvoiding cystourethrogramDMSAdimercaptosuccinic acidPISpooled internal standardAPPacute phase proteins. pose a significant burden on the health care system, with annual societal cost of $3.5 billion in the United States (1Flores-Mireles A.L. Walker J.N. Caparon M. Hultgren S.J. Urinary tract infections: epidemiology, mechanisms of infection and treatment options.Nat. Rev. Microbiol. 2015; 13: 269-284Crossref PubMed Scopus (1647) Google Scholar). In select populations, UTIs can lead to pyelonephritis (kidney infections), causing renal scarring and long-term renal damage, the latter being exacerbated with repeated infections. Molecular mechanisms characterizing patients predisposed to recurrent UTIs have not been completely elucidated. Since the urinary proteome is a source of several host defense proteins, it may provide insights into better understanding the etiology of recurrent UTI. urinary tract infections vesicoureteral reflux extracellular matrix ureteropelvic junction obstruction voiding cystourethrogram dimercaptosuccinic acid pooled internal standard acute phase proteins. urinary tract infections vesicoureteral reflux extracellular matrix ureteropelvic junction obstruction voiding cystourethrogram dimercaptosuccinic acid pooled internal standard acute phase proteins. The urinary tract has both mechanical and molecular host defense mechanisms (2Abraham S.N. Miao Y. The nature of immune responses to urinary tract infections.Nat. Rev. Immunol. 2015; 15: 655-663Crossref PubMed Scopus (154) Google Scholar, 3Neal Jr., D.E. Host defense mechanisms in urinary tract infections.Urol. Clin. North Am. 1999; 26: 677, vii-686Abstract Full Text Full Text PDF Scopus (17) Google Scholar). Molecular host defense encompasses innate and adaptive immune responses involving immune cell activity and soluble factors secreted into urine such as uromodulin. Mechanical defense includes physical or anatomic barriers, such as the glycosaminoglycan layer lining the urothelium, complete voiding to eliminate residual urine with bacteria, and valvular mechanisms which isolate the bladder from the kidneys during micturition. Vesicoureteral reflux (VUR) is a congenital condition where failure of this lattermost anatomic mechanical host defense causes backwards flow of urine to the kidneys from the bladder and contributes to incomplete urinary clearance. It is a common condition that often resolves without symptoms or intervention. However, during a UTI, VUR propagates the translocation of pathogenic bacteria from the bladder to the kidney, which can then lead to pyelonephritis and long-term sequalae such as renal scarring (4American Urological Association Mangement and Screening of Primary Vesicoureteral Reflux in Children. http://www.auanet.org/guidelines/vesicoureteral-reflux-. (2010-reviewed-and-validity-confirmed-2017)Google Scholar, 5Peters C.A. Skoog S.J. Arant Jr., B.S. Copp H.L. Elder J.S. Hudson R.G. Khoury A.E. Lorenzo A.J. Pohl H.G. Shapiro E. Snodgrass W.T. Diaz M. Summary of the AUA Guideline on Management of Primary Vesicoureteral Reflux in Children.J. Urol. 2010; 184: 1134-1144Crossref PubMed Scopus (407) Google Scholar). Patients with VUR and a predisposition for recurrent UTIs are more likely to be at greater risk for long-term kidney damage and may merit earlier medical or surgical intervention (4American Urological Association Mangement and Screening of Primary Vesicoureteral Reflux in Children. http://www.auanet.org/guidelines/vesicoureteral-reflux-. (2010-reviewed-and-validity-confirmed-2017)Google Scholar, 5Peters C.A. Skoog S.J. Arant Jr., B.S. Copp H.L. Elder J.S. Hudson R.G. Khoury A.E. Lorenzo A.J. Pohl H.G. Shapiro E. Snodgrass W.T. Diaz M. Summary of the AUA Guideline on Management of Primary Vesicoureteral Reflux in Children.J. Urol. 2010; 184: 1134-1144Crossref PubMed Scopus (407) Google Scholar, 6Investigators R.T. Hoberman A. Greenfield S.P. Mattoo T.K. Keren R. Mathews R. Pohl H.G. Kropp B.P. Skoog S.J. Nelson C.P. Moxey-Mims M. Chesney R.W. Carpenter M.A. Antimicrobial prophylaxis for children with vesicoureteral reflux.N. Engl. J. Med. 2014; 370: 2367-2376Crossref PubMed Scopus (349) Google Scholar). Although VUR itself is accurately diagnosed by current, albeit invasive, modalities, it is impossible to identify these patients who are at higher risk for UTI. Because of the inability to determine the need for intervention, VUR patients are often overmanaged and overtreated both medically and surgically (6Investigators R.T. Hoberman A. Greenfield S.P. Mattoo T.K. Keren R. Mathews R. Pohl H.G. Kropp B.P. Skoog S.J. Nelson C.P. Moxey-Mims M. Chesney R.W. Carpenter M.A. Antimicrobial prophylaxis for children with vesicoureteral reflux.N. Engl. J. Med. 2014; 370: 2367-2376Crossref PubMed Scopus (349) Google Scholar). Patients are placed on long-term daily antibiotic prophylaxis that can lead to antimicrobial resistance and associated side effects (6Investigators R.T. Hoberman A. Greenfield S.P. Mattoo T.K. Keren R. Mathews R. Pohl H.G. Kropp B.P. Skoog S.J. Nelson C.P. Moxey-Mims M. Chesney R.W. Carpenter M.A. Antimicrobial prophylaxis for children with vesicoureteral reflux.N. Engl. J. Med. 2014; 370: 2367-2376Crossref PubMed Scopus (349) Google Scholar, 7Uhari M. Nuutinen M. Turtinen J. Adverse reactions in children during long-term antimicrobial therapy.Pediatr. Infect. Dis. J. 1996; 15: 404-408Crossref PubMed Scopus (52) Google Scholar, 8Karpman E. Kurzrock E.A. Adverse reactions of nitrofurantoin, trimethoprim and sulfamethoxazole in children.J. Urol. 2004; 172: 448-453Crossref PubMed Scopus (82) Google Scholar, 9Williams G. Craig J.C. Long-term for recurrent urinary tract infection in Rev. Scholar, J.C. and in and children to antibiotic PubMed Scopus Google Scholar). for of VUR patients to and is for patients in the condition or for those who recurrent UTIs antibiotic (4American Urological Association Mangement and Screening of Primary Vesicoureteral Reflux in Children. http://www.auanet.org/guidelines/vesicoureteral-reflux-. (2010-reviewed-and-validity-confirmed-2017)Google Scholar, 5Peters C.A. Skoog S.J. Arant Jr., B.S. Copp H.L. Elder J.S. Hudson R.G. Khoury A.E. Lorenzo A.J. Pohl H.G. Shapiro E. Snodgrass W.T. Diaz M. Summary of the AUA Guideline on Management of Primary Vesicoureteral Reflux in Children.J. Urol. 2010; 184: 1134-1144Crossref PubMed Scopus (407) Google Scholar, 6Investigators R.T. Hoberman A. Greenfield S.P. Mattoo T.K. Keren R. Mathews R. Pohl H.G. Kropp B.P. Skoog S.J. Nelson C.P. Moxey-Mims M. Chesney R.W. Carpenter M.A. Antimicrobial prophylaxis for children with vesicoureteral reflux.N. Engl. J. Med. 2014; 370: 2367-2376Crossref PubMed Scopus (349) Google Scholar). The of intervention has the of patients who a of without or need M. C.A. R.W. The of vesicoureteral reflux management in the of acid a health Urol. PubMed Scopus Google Scholar). the these of to and of which can and (6Investigators R.T. Hoberman A. Greenfield S.P. Mattoo T.K. Keren R. Mathews R. Pohl H.G. Kropp B.P. Skoog S.J. Nelson C.P. Moxey-Mims M. Chesney R.W. Carpenter M.A. Antimicrobial prophylaxis for children with vesicoureteral reflux.N. Engl. J. Med. 2014; 370: 2367-2376Crossref PubMed Scopus (349) Google Scholar, 7Uhari M. Nuutinen M. Turtinen J. Adverse reactions in children during long-term antimicrobial therapy.Pediatr. Infect. Dis. J. 1996; 15: 404-408Crossref PubMed Scopus (52) Google Scholar, 8Karpman E. Kurzrock E.A. Adverse reactions of nitrofurantoin, trimethoprim and sulfamethoxazole in children.J. Urol. 2004; 172: 448-453Crossref PubMed Scopus (82) Google Scholar, 9Williams G. Craig J.C. Long-term for recurrent urinary tract infection in Rev. Scholar, J.C. and in and children to antibiotic PubMed Scopus Google Scholar, G. for in the PubMed Scopus Google Scholar, the of and PubMed Scopus Google Scholar). 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