Physiological aspects of Toll‐like receptor 4 activation in sepsis‐induced acute kidney injury

Sepsis‐induced acute kidney injury (SI‐AKI) is common and associated with high mortality. Survivors are at increased risk of chronic kidney disease. The precise mechanism underlying SI‐AKI is unknown, and no curative treatment exists. Toll‐like receptor 4 (TLR4) activates the innate immune system in response to exogenous microbial products. The result is an inflammatory reaction aimed at clearing a potential infection. However, the consequence may also be organ dysfunction as the immune response can cause collateral damage to host tissue. The purpose of this review is to describe the basis for how ligand binding to TLR4 has the potential to cause renal dysfunction and the mechanisms by which this may take place in gram‐negative sepsis. In addition, we highlight areas for future research that can further our knowledge of the pathogenesis of SI‐AKI in relation to TLR4 activation. TLR4 is expressed in the kidney. Activation of TLR4 causes cytokine and chemokine release as well as renal leucocyte infiltration. It also results in endothelial and tubular dysfunction in addition to altered renal metabolism and circulation. From a physiological standpoint, inhibiting TLR4 in large animal experimental SI‐AKI significantly improves renal function. Thus, current evidence indicates that TLR4 has the ability to mediate SI‐AKI by a number of mechanisms. The strong experimental evidence supporting a role of TLR4 in the pathogenesis of SI‐AKI in combination with the availability of pharmacological tools to target TLR4 warrants future human studies.     

Dual assessment of kidney perfusion and pH by exploiting a dynamic CEST‐MRI approach in an acute kidney ischemia–reperfusion injury murine model

Several factors can lead to acute kidney injury, but damage following ischemia and reperfusion injuries is the main risk factor and usually develops into chronic disease. MRI has often been proposed as a method with which to assess renal function. It does so by measuring the renal perfusion of an injected Gd‐based contrast agent. The use of pH‐responsive agents as part of the CEST (chemical exchange saturation transfer)‐MRI technique has recently shown that pH homeostasis is also an important indicator of kidney functionality. However, there is still a need for methods that can provide more than one type of information following the injection of a single contrast agent for the characterization of renal function. Herein we propose, for the first time, dynamic CEST acquisition following iopamidol injection to quantify renal function by assessing both perfusion and pH homeostasis. The aim of this study is to assess renal functionality in a murine unilateral ischemia–reperfusion injury model at two time points (3 and 7 days) after acute kidney injury. The renal‐perfusion estimates measured with iopamidol were compared with those obtained with a gadolinium‐based agent, via a dynamic contrast enhanced (DCE)‐MRI approach, to validate the proposed method. Compared with the contralateral kidneys, the clamped ones showed a significant decrease in renal perfusion, as measured using the DCE‐MRI approach, which is consistent with reduced filtration capability. Dynamic CEST‐MRI findings provided similar results, indicating that the clamped kidneys displayed significantly reduced renal filtration that persisted up to 7 days after the damage. In addition, CEST‐MRI pH imaging showed that the clamped kidneys displayed significantly increased pH values, reflecting the disturbance to pH homeostasis. Our results demonstrate that a single CEST‐MRI contrast agent can provide multiple types of information related to renal function and can discern healthy kidneys from pathological ones by combining perfusion measurements with renal pH mapping.     

The hemodynamic and metabolic effects of spironolactone treatment in acute kidney injury assessed by hyperpolarized MRI

Renal ischemia‐reperfusion injury (IRI) is one of the most common types of acute kidney injury. Spironolactone has shown promising kidney protective effects in renal IRI in rats. We investigated the hemodynamic and metabolic effects of spironolactone (100 mg/kg) administered immediately after 40 min unilateral kidney ischemia in rats. Hyperpolarized MRI using co‐polarized [1‐¹³C]pyruvate and [¹³C,¹⁵N₂]urea as well as ¹H dynamic contrast‐enhanced (DCE) MRI was performed 24 h after induction of ischemia. We found a significant decrease in renal blood flow (RBF) in the ischemic kidney compared with the contralateral one measured using DCE and [¹³C,¹⁵N₂]urea. The RBF measured using [1‐¹³C]pyruvate and [¹³C,¹⁵N₂]urea was significantly altered by spironolactone. The RBFs in the ischemic kidney compared with the contralateral kidney were decreased similarly as measured using both [¹³C,¹⁵N₂]urea and [1‐¹³C]pyruvate in the spironolactone‐treated group. Spironolactone treatment increased the perfusion‐corrected pyruvate metabolism by 54% in both the ischemic and contralateral kidney. Furthermore, we showed a correlation between vascular permeability using a histological Evans blue analysis and the ratio of the volumes of distribution (VoDs), ie VoD‐[¹³C,¹⁵N₂]urea/VoD‐[1‐¹³C]pyruvate. This suggests that [¹³C,¹⁵N₂]urea/[1‐¹³C]pyruvate VoD ratio may be a novel indicator of renal vascular permeability associated with renal damage in rodents.     

Dynamic contrast-enhanced CEST MRI using a low molecular weight dextran

Natural and synthetic sugars have great potential for developing highly biocompatible and translatable chemical exchange saturation transfer (CEST) MRI contrast agents. In this study, we aimed to develop the smallest clinically available form of dextran, Dex1 (molecular weight, MW ~ 1 kDa), as a new CEST agent. We first characterized the CEST properties of Dex1 in vitro at 11.7 T and showed that the Dex1 had a detectable CEST signal at ~1.2 ppm, attributed to hydroxyl protons. In vivo CEST MRI studies were then carried out on C57BL6 mice bearing orthotopic GL261 brain tumors (n = 5) using a Bruker BioSpec 11.7 T MRI scanner. Both steady-state full Z-spectral images and single offset (1.2 ppm) dynamic dextran-enhanced (DDE) images were acquired before and after the intravenous injection of Dex1 (2 g/kg). The steady-state Z-spectral analysis showed a significantly higher CEST contrast enhancement in the tumor than in contralateral brain (∆MTR_asym^{1.2 ppm} = 0.010 ± 0.006 versus 0.002 ± 0.008, P = 0.0069) at 20 min after the injection of Dex1. Pharmacokinetic analyses of DDE were performed using the area under the curve (AUC) in the first 10 min after Dex1 injection, revealing a significantly higher uptake of Dex1 in the tumor than in brain tissue for tumor-bearing mice (AUC[0-10 min] = 21.9 ± 4.2 versus 5.3 ± 6.4%·min, P = 0.0294). In contrast, no Dex1 uptake was foundling in the brains of non-tumor-bearing mice (AUC[0-10 min] = −1.59 ± 2.43%·min). Importantly, the CEST MRI findings were consistent with the measurements obtained using DCE MRI and fluorescence microscopy, demonstrating the potential of Dex1 as a highly translatable CEST MRI contrast agent for assessing tumor hemodynamics.     

Increased CEST specificity for amide and fast‐exchanging amine protons using exchange‐dependent relaxation rate

Chemical exchange saturation transfer (CEST) imaging of amides at 3.5 ppm and fast‐exchanging amines at 3 ppm provides a unique means to enhance the sensitivity of detection of, for example, proteins/peptides and neurotransmitters, respectively, and hence can provide important information on molecular composition. However, despite the high sensitivity relative to conventional magnetic resonance spectroscopy (MRS), in practice, CEST often has relatively poor specificity. For example, CEST signals are typically influenced by several confounding effects, including direct water saturation (DS), semi‐solid non‐specific magnetization transfer (MT), the influence of water relaxation times (T_1w) and nearby overlapping CEST signals. Although several editing techniques have been developed to increase the specificity by removing DS, semi‐solid MT and T_1w influences, it is still challenging to remove overlapping CEST signals from different exchanging sites. For instance, the amide proton transfer (APT) signal could be contaminated by CEST effects from fast‐exchanging amines at 3 ppm and intermediate‐exchanging amines at 2 ppm. The current work applies an exchange‐dependent relaxation rate (R_ex) to address this problem. Simulations demonstrate that: (1) slowly exchanging amides and fast‐exchanging amines have distinct dependences on irradiation powers; and (2) R_ex serves as a resonance frequency high‐pass filter to selectively reduce CEST signals with resonance frequencies closer to water. These characteristics of R_ex provide a means to isolate the APT signal from amines. In addition, previous studies have shown that CEST signals from fast‐exchanging amines have no distinct features around their resonance frequencies. However, R_ex gives Lorentzian lineshapes centered at their resonance frequencies for fast‐exchanging amines and thus can significantly increase the specificity of CEST imaging for amides and fast‐exchanging amines.     

Quantitative description of radiofrequency (RF) power‐based ratiometric chemical exchange saturation transfer (CEST) pH imaging

Chemical exchange saturation transfer (CEST) MRI holds great promise for the imaging of pH. However, routine CEST measurement varies not only with the pH‐dependent chemical exchange rate, but also with CEST agent concentration, providing pH‐weighted information. Conventional ratiometric CEST imaging normalizes the confounding concentration factor by analyzing the relative CEST effect from different exchangeable groups, requiring CEST agents with multiple chemically distinguishable labile proton sites. Recently, a radiofrequency (RF) power‐based ratiometric CEST MRI approach has been developed for concentration‐independent pH MRI using CEST agents with a single exchangeable group. To facilitate quantification and optimization of the new ratiometric analysis, we quantified the RF power‐based ratiometric CEST ratio (rCESTR) and derived its signal‐to‐noise and contrast‐to‐noise ratios. Using creatine as a representative CEST agent containing a single exchangeable site, our study demonstrated that optimized RF power‐based ratiometric analysis provides good pH sensitivity. We showed that rCESTR follows a base‐catalyzed exchange relationship with pH independent of creatine concentration. The pH accuracy of RF power‐based ratiometric MRI was within 0.15–0.20 pH units. Furthermore, the absolute exchange rate can be obtained from the proposed ratiometric analysis. To summarize, RF power‐based ratiometric CEST analysis provides concentration‐independent pH‐sensitive imaging and complements conventional multiple labile proton group‐based ratiometric CEST analysis. Copyright © 2015 John Wiley & Sons, Ltd.     

Noninvasive evaluation of renal pH homeostasis after ischemia reperfusion injury by CEST‐MRI

Acute kidney injury (AKI) in mice caused by sustained ischemia followed by reperfusion is associated with acute tubular necrosis and renal dysfunctional blood flow. Although the principal role of the kidney is the maintenance of acid–base balance, current imaging approaches are unable to assess this important parameter, and clinical biomarkers are not robust enough in evaluating the severity of kidney damage. Therefore, novel noninvasive imaging approaches are needed to assess the acid–base homeostasis in vivo. This study investigates the usefulness of MRI‐chemical exchange saturation transfer (CEST) pH imaging (through iopamidol injection) in characterizing moderate and severe AKI in mice following unilateral ischemia reperfusion injury. Moderate (20 min) and severe (40 min) ischemia were induced in Balb/C mice, which were imaged at several time points thereafter (Days 0, 1, 2, 7). A significant increase of renal pH values was observed as early as one day after the ischemia reperfusion damage for both moderate and severe ischemia. MRI‐CEST pH imaging distinguished the evolution of moderate from severe AKI. A recovery of normal renal pH values was observed for moderate AKI, whereas a persisting renal pH increase was observed for severe AKI on Day 7. Renal filtration fraction was significantly lower for clamped kidneys (0.54–0.57) in comparison to contralateral kidneys (0.84–0.86) following impairment of glomerular filtration. The severe AKI group showed a reduced filtration fraction even after 7 days (0.38 for the clamped kidneys). Notably, renal pH values were significantly correlated with the histopathological score. In conclusion, MRI‐CEST pH mapping is a valid tool for the noninvasive evaluation of both acid–base balance and renal filtration in patients with ischemia reperfusion injury.     

Thiol‐water proton exchange of glutathione,cysteine, and N‐acetylcysteine: Implications for CEST MRI

Amide‐, amine‐, and hydroxyl‐water proton exchange can generate MRI contrast through chemical exchange saturation transfer (CEST). In this study, we show that thiol‐water proton exchange can also generate quantifiable CEST effects under near‐physiological conditions (pH = 7.2 and 37°C) through the characterization of the pH dependence of thiol proton exchange in phosphate‐buffered solutions of glutathione, cysteine, and N‐acetylcysteine. The spontaneous, base‐catalyzed, and buffer‐catalyzed exchange contributions to the thiol exchange were analyzed. The thiol‐water proton exchange of glutathione and cysteine was found to be too fast to generate a CEST effect around neutral pH due to significant base catalysis. The thiol‐water proton exchange of N‐acetylcysteine was found to be much slower, yet still in the fast‐exchange regime with significant base and buffer catalysis, resulting in a 9.5% attenuation of the water signal at pH 7.2 in a slice‐selective CEST NMR experiment. Furthermore, the N‐acetylcysteine thiol CEST was also detectable in human serum albumin and agarose phantoms.     

Snapshot‐CEST: Optimizing spiral‐centric‐reordered gradient echo acquisition for fast and robust 3D CEST MRI at 9.4 T

Gradient echo (GRE)‐based acquisition provides a robust readout method for chemical exchange saturation transfer (CEST) at ultrahigh field (UHF). To develop a snapshot‐CEST approach, the transient GRE signal and point spread function were investigated in detail, leading to optimized measurement parameters and reordering schemes for fast and robust volumetric CEST imaging. Simulation of the transient GRE signal was used to determine the optimal sequence parameters and the maximum feasible number of k‐space lines. Point spread function analysis provided an insight into the induced k‐space filtering and the performance of different rectangular reordering schemes in terms of blurring, signal‐to‐noise ratio (SNR) and relaxation dependence. Simulation results were confirmed in magnetic resonance imaging (MRI) measurements of healthy subjects. Minimal repetition time (TR) is beneficial for snapshot‐GRE readout. At 9.4 T, for TR = 4 ms and optimal flip angle close to the Ernst angle, a maximum of 562 k‐space lines can be acquired after a single presaturation, providing decent SNR with high image quality. For spiral‐centric reordered k‐space acquisition, the image quality can be further improved using a rectangular spiral reordering scheme adjusted to the field of view. Application of the derived snapshot‐CEST sequence for fast imaging acquisition in the human brain at 9.4 T shows excellent image quality in amide and nuclear Overhauser enhancement (NOE), and enables guanidyl CEST detection. The proposed snapshot‐CEST establishes a fast and robust volumetric CEST approach ready for the imaging of known and novel exchange‐weighted contrasts at UHF.     

Dual‐frequency irradiation CEST‐MRI of endogenous bulk mobile proteins

A novel MRI contrast is proposed which enables the selective detection of endogenous bulk mobile proteins in vivo. Such a non‐invasive imaging technique may be of particular interest for many diseases associated with pathological alterations of protein expression, such as cancer and neurodegenerative disorders. Specificity to mobile proteins was achieved by the selective measurement of intramolecular spin diffusion and the removal of semi‐solid macromolecular signal components by a correction procedure. For this purpose, the approach of chemical exchange saturation transfer (CEST) was extended to a radiofrequency (RF) irradiation scheme at two different frequency offsets (dualCEST). Using protein model solutions, it was demonstrated that the dualCEST technique allows the calculation of an image contrast which is exclusively sensitive to changes in concentration, molecular size and the folding state of mobile proteins. With respect to application in humans, dualCEST overcomes the selectivity limitations at relatively low magnetic field strengths, and thus enables examinations on clinical MR scanners. The feasibility of dualCEST examinations in humans was verified by a proof‐of‐principle examination of a brain tumor patient at 3 T. With its specificity for the mobile fraction of the proteome, its comparable sensitivity to conventional water proton MRI and its applicability to clinical MR scanners, this technique represents a further step towards the non‐invasive imaging of proteomic changes in humans.     

CEST MRI reveals a correlation between visceral fat mass and reduced myocardial creatine in obese individuals despite preserved ventricular structure and function

Systolic cardiac function is typically preserved in obese adults, potentially masking underlying declines in cardiomyocyte metabolism that may contribute to heart failure. We used chemical exchange saturation transfer (CEST) MRI, a sensitive method for measurement of myocardial creatine, to examine whether myocardial creatine levels correlate with cardiac structure, contractile function, or visceral fat mass in obese adults. In this study, obese (body mass index, BMI > 30, n = 20) and healthy (BMI < 25, n = 11) adults were examined with dual‐energy x‐ray absorptiometry to quantify fat masses. Cine MRI and myocardial tagging were performed at 1.5 T to measure ventricular structure and global function. CEST imaging with offsets in the range of ±10 parts per million (ppm) were performed in one mid‐ventricular slice, where creatine CEST contrast was calculated at 1.8 ppm following field homogeneity correction. Ventricular structure, global function (ejection fraction 69.4 ± 4.3% healthy versus 69.6 ± 9.3% obese, NS), and circumferential strain (?17.0 ± 2.3% healthy versus ?16.5 ± 1.5% obese, NS) and strain rate were preserved in obese adults. However, creatine CEST contrast was significantly reduced in obese adults (6.8 ± 1.3% healthy versus 4.1 ± 2.7% obese, p = 0.001). Creatine CEST contrast was inversely correlated with total body fat% (ρ = ?0.45, p = 0.011), visceral fat mass (ρ = ?0.58, p = 0.001), and septal wall thickness (ρ = ?0.44, p = 0.013), but uncorrelated to ventricular function or contractile function. In conclusion, creatine CEST‐MRI reveals a strong correlation between heightened body and visceral fat masses and reduced myocardial metabolic function that is independent of ventricular structure and global function in obese adults.     

Sepsis-induced acute kidney injury

Acute kidney injury (AKI) is a common sequel of sepsis in the intensive care unit. It is being suggested that sepsis-induced AKI may have a distinct pathophysiology and identity. Availability of biomarkers now enable us to detect AKI as early as four hours after it''s inception and may even help us to delineate sepsis-induced AKI. Protective strategies such as preferential use of vasopressin or prevention of intra-abdominal hypertension may help, in addition to the other global management strategies of sepsis. Pharmacologic interventions have had limited success, may be due to their delayed usage. Newer developments in extracorporeal blood purification techniques may proffer effects beyond simple replacement of renal function, such as metabolic functions of the kidney or modulation of the sepsis cascade.     

Quantitative evaluation of pulmonary gas‐exchange function using hyperpolarized 129Xe CEST MRS and MRI

Hyperpolarized ¹²⁹Xe gas MR has been a powerful tool for evaluating pulmonary structure and function due to the extremely high enhancement in spin polarization, the good solubility in the pulmonary parenchyma, and the excellent chemical sensitivity to its surrounding environment. Generally, the quantitative structural and functional information of the lung are evaluated using hyperpolarized ¹²⁹Xe by employing the techniques of chemical shift saturation recovery (CSSR) and xenon polarization transfer contrast (XTC). Hyperpolarized ¹²⁹Xe chemical exchange saturation transfer (Hyper‐CEST) is another method for quantifying the exchange information of hyperpolarized ¹²⁹Xe by using the exchange of xenon signals according to its different chemical shifts, and it has been widely used in biosensor studies in vitro. However, the feasibility of using hyperpolarized ¹²⁹Xe CEST to quantify the pulmonary gas exchange function in vivo is still unclear. In this study, the technique of CEST was used to quantitatively evaluate the gas exchange in the lung globally and regionally via hyperpolarized ¹²⁹Xe MRS and MRI, respectively. A new parameter, the pulmonary apparent gas exchange time constant (T_app), was defined, and it increased from 0.63 s to 0.95 s in chronic obstructive pulmonary disease (COPD) rats (induced by cigarette smoke and lipopolysaccharide exposure) versus the controls with a significant difference (P = 0.001). Additionally, the spatial distribution maps of T_app in COPD rats' pulmonary parenchyma showed a regionally obvious increase compared with healthy rats. These results indicated that hyperpolarized ¹²⁹Xe CEST MR was an effective method for globally and regionally quantifying the pulmonary gas exchange function, which would be helpful in diagnosing lung diseases that are related to gas exchange, such as COPD.     

Aggregation‐induced changes in the chemical exchange saturation transfer (CEST) signals of proteins

Chemical exchange saturation transfer (CEST) is an MRI technique that allows mapping of biomolecules (small metabolites, proteins) with nearly the sensitivity of conventional water proton MRI. In living organisms, several tissue‐specific CEST effects have been observed and successfully applied to diagnostic imaging. In these studies, particularly the signals of proteins showed a distinct correlation with pathological changes. However, as CEST effects depend on various properties that determine and affect the chemical exchange processes, the origins of the observed signal changes remain to be understood. In this study, protein aggregation was identified as an additional process that is encoded in the CEST signals of proteins. Investigation of distinct proteins that are involved in pathological disorders, namely amyloid beta and huntingtin, revealed a significant decrease of all protein CEST signals upon controlled aggregation. This finding is of particular interest with regard to diagnostic imaging of patients with neurodegenerative diseases that involve amyloidogenesis, such as Alzheimer's or Huntington's disease. To investigate whether the observed CEST signal decrease also occurs in heterogeneous mixtures of aggregated cellular proteins, and thus prospectively in tissue, heat‐shocked yeast cell lysates were employed. Additionally, investigation of different cell compartments verified the assignment of the protein CEST signals to the soluble part of the proteome. The results of in vitro experiments demonstrate that aggregation affects the CEST signals of proteins. This observation can enable hypotheses for CEST imaging as a non‐invasive diagnostic tool for monitoring pathological alterations of the proteome in vivo.     

Quantitative chemical exchange saturation transfer (qCEST) MRI – omega plot analysis of RF‐spillover‐corrected inverse CEST ratio asymmetry for simultaneous determination of labile proton ratio and exchange rate

Chemical exchange saturation transfer (CEST) MRI is sensitive to labile proton concentration and exchange rate, thus allowing measurement of dilute CEST agent and microenvironmental properties. However, CEST measurement depends not only on the CEST agent properties but also on the experimental conditions. Quantitative CEST (qCEST) analysis has been proposed to address the limitation of the commonly used simplistic CEST‐weighted calculation. Recent research has shown that the concomitant direct RF saturation (spillover) effect can be corrected using an inverse CEST ratio calculation. We postulated that a simplified qCEST analysis is feasible with omega plot analysis of the inverse CEST asymmetry calculation. Specifically, simulations showed that the numerically derived labile proton ratio and exchange rate were in good agreement with input values. In addition, the qCEST analysis was confirmed experimentally in a phantom with concurrent variation in CEST agent concentration and pH. Also, we demonstrated that the derived labile proton ratio increased linearly with creatine concentration (P < 0.01) while the pH‐dependent exchange rate followed a dominantly base‐catalyzed exchange relationship (P < 0.01). In summary, our study verified that a simplified qCEST analysis can simultaneously determine labile proton ratio and exchange rate in a relatively complex in vitro CEST system. Copyright © 2015 John Wiley & Sons, Ltd.     

On the interference from agar in chemical exchange saturation transfer MRI parameter optimization in model solutions

Chemical exchange saturation transfer (CEST) MRI is currently set to become part of clinical routine as it enables indirect detection of low concentrated molecules and proteins. Recently, intermediate to fast exchanging functional groups of glucose and its derivatives, glutamate and dextran, have gained attention as promising CEST contrast agents. To increase the specificity of CEST MRI for certain functional groups, the presaturation module is commonly optimized. At an early stage, this is performed in well‐defined model solutions, in which, for instance, the relaxation times are adjusted to mimic in vivo conditions. This often involves agar, assuming the substance would not yield significant CEST effects by itself, which the current study proves to be an invalid assumption. Model solutions at different pH values and concentrations of agar were investigated at different temperatures at a 9.4 T human whole body MR scanner. High power presaturation of around 4 μT, optimal for investigating intermediate to fast exchanging groups, was applied. Postprocessing included spatiotemporal corrections for B₀ and spatial corrections for B₁⁺. CEST effects of up to 3 % of the bulk water signal were observed. From pH, concentration and temperature dependency, it was concluded that the observed behavior reflects a CEST effect of agar. It was also shown how to remove this undesirable contribution from CEST MRI data. It was concluded that if agar is involved in the CEST MRI parameter optimization process, its contribution to the observed effects has to be taken into account. CEST agent concentration must be sufficiently high to be able to neglect the contribution of agar, or a control sample at matched pH is necessary for correction. Experiments on pure agarose showed reduced CEST effects compared with agar but did not provide a neutral baseline either.     

Quantitative pulsed CEST‐MRI using Ω‐plots

Chemical exchange saturation transfer (CEST) allows the indirect detection of dilute metabolites in living tissue via MRI of the tissue water signal. Selective radio frequency (RF) with amplitude B₁ is used to saturate the magnetization of protons of exchanging groups, which transfer the saturation to the abundant water pool. In a clinical setup, the saturation scheme is limited to a series of short pulses to follow regulation of the specific absorption rate (SAR). Pulsed saturation is difficult to describe theoretically, thus rendering quantitative CEST a challenging task. In this study, we propose a new analytical treatment of pulsed CEST by extending a former interleaved saturation–relaxation approach. Analytical integration of the continuous wave (cw) eigenvalue as a function of the RF pulse shape leads to a formula for pulsed CEST that has the same structure as that for cw CEST, but incorporates two form factors that are determined by the pulse shape. This enables analytical Z‐spectrum calculations and permits deeper insight into pulsed CEST. Furthermore, it extends Dixon's Ω‐plot method to the case of pulsed saturation, yielding separately, and independently, the exchange rate and the relative proton concentration. Consequently, knowledge of the form factors allows a direct comparison of the effect of the strength and B₁ dispersion of pulsed CEST experiments with the ideal case of cw saturation. The extended pulsed CEST quantification approach was verified using creatine phantoms measured on a 7 T whole‐body MR tomograph, and its range of validity was assessed by simulations. Copyright © 2015 John Wiley & Sons, Ltd.     

Hemorrhagic fever with renal syndrome in Albania. Focus on predictors of acute kidney injury in HFRS

BackgroundHemorrhagic fever with renal syndrome (HFRS) is a rodent borne zoonosis, caused by the members of the family Bunyaviridae, genus Hantavirus. The main clinical features of the infection by this virus family are fever, thrombocytopenia and acute kidney injury.ObjectiveThe aim of our study was to identify, for the first time, characteristic features of HFRS in the Albanian population.Study designThe study comprised 33 consecutive patients admitted with suspected HFRS from April 2011–April 2016 at one center. Clinical diagnosis was confirmed by ELISA and real-time PCR. Statistical analysis was performed to identify prognostic markers and indicators of disease severity.ResultsThe virus strain causing HFRS was Dobrava type in all 33 cases. The disease outbreaks occurred during the period June–July. Mean hospital stay was 15.7 ± 6.9 days. 29 (88%) of the patients were male. The mean age was 39.7 ± 14.1. 16 (48.5%) patients were from Northeast Albania. 8 (24.2%) patients required dialysis. The strongest correlation was the inverse relationship of nadir platelet count with urea and creatinine, p < 0.0001, p < 0.0079 respectively. Creatinine and hyponatremia were inversely correlated p = 0.0007, whereas hyponatremia and nadir platelet count had the highest sensitivity and specificity for development of severe AKI, 92.6%, 100%; 88.9%, 83.3% respectively. Mortality rate was 9.09%.ConclusionHFRS is a severe viral disease in Albania caused by Dobrava strain. It is associated with high mortality, 9.09% in our cohort. In our study, thrombocytopenia, urinary volume, hyponatremia were indicators of more severe disease.