Predicting Hemolytic Uremic Syndrome and Renal Replacement Therapy in Shiga Toxin–producing Escherichia coli–infected Children

Abstract

Background Shiga toxin–producing Escherichia coli (STEC) infections are leading causes of pediatric acute renal failure. Identifying hemolytic uremic syndrome (HUS) risk factors is needed to guide care. Methods We conducted a multicenter, historical cohort study to identify features associated with development of HUS (primary outcome) and need for renal replacement therapy (RRT) (secondary outcome) in STEC-infected children without HUS at initial presentation. Children aged <18 years who submitted STEC-positive specimens between January 2011 and December 2015 at a participating study institution were eligible. Results Of 927 STEC-infected children, 41 (4.4%) had HUS at presentation; of the remaining 886, 126 (14.2%) developed HUS. Predictors (all shown as odds ratio [OR] with 95% confidence interval [CI]) of HUS included younger age (0.77 [.69–.85] per year), leukocyte count ≥13.0 × 103/μL (2.54 [1.42–4.54]), higher hematocrit (1.83 [1.21–2.77] per 5% increase) and serum creatinine (10.82 [1.49–78.69] per 1 mg/dL increase), platelet count <250 × 103/μL (1.92 [1.02–3.60]), lower serum sodium (1.12 [1.02–1.23 per 1 mmol/L decrease), and intravenous fluid administration initiated ≥4 days following diarrhea onset (2.50 [1.14–5.46]). A longer interval from diarrhea onset to index visit was associated with reduced HUS risk (OR, 0.70 [95% CI, .54–.90]). RRT predictors (all shown as OR [95% CI]) included female sex (2.27 [1.14–4.50]), younger age (0.83 [.74–.92] per year), lower serum sodium (1.15 [1.04–1.27] per mmol/L decrease), higher leukocyte count ≥13.0 × 103/μL (2.35 [1.17–4.72]) and creatinine (7.75 [1.20–50.16] per 1 mg/dL increase) concentrations, and initial intravenous fluid administration ≥4 days following diarrhea onset (2.71 [1.18–6.21]). Conclusions The complex nature of STEC infection renders predicting its course a challenge. Risk factors we identified highlight the importance of avoiding dehydration and performing close clinical and laboratory monitoring.

Diagnostic sensitivity of extended renal and hematologic criteria to define hemolytic uremic syndrome

“…From a clinical perspective, it is worth noting that diagnosis should be established as soon as possible so that the patient is admitted to the hospital for the timely implementation of the necessary support measures. 7,19 Both the strict and the usual definitions require the presence of anemia; [7][8][9][10][11] the absence of this condition was the most common cause of a wrong diagnosis across the series. A high hematocrit level indicates dehydration secondary to gastrointestinal losses, which has been observed in more than one third of patients at the time of admission.…”

Sensibilidad diagnóstica de la ampliación de los criterios hematológicos y renales para la definición de síndrome urémico hemolítico

“…Desde el punto de vista clínico, es importante que el diagnóstico se establezca lo antes posible para indicar la hospitalización del paciente para que se instauren, de manera oportuna, las medidas de sostén necesarias. 7,19 Tanto la definición estricta como la habitual exigen la presencia de anemia, [7][8][9][10][11] su ausencia fue la causa más frecuente de falla diagnóstica en toda la serie. El hematocrito elevado refleja deshidratación secundaria a pérdidas gastrointestinales, hecho que se ha observado en más de un tercio de los pacientes al momento de la internación.…”

Hemoconcentration and predictors in Shiga toxin-producing E. coli-hemolytic uremic syndrome (STEC-HUS)

“…Several easily accessible clinical parameters have been evaluated or identified as prognostic markers in STEC-HUS. This includes parameters of thromboinflammation (e.g., leukocytosis [8][9][10], elevated D-dimers [11], complement activation [12]), urea [12], sodium [13], and lactate dehydrogenase (LDH) [14][15][16].…”

“…Additionally, high hematocrit or hemoglobin levels as surrogate parameters of hemoconcentration have been associated with developing STEC-HUS or a more severe course of STEC-HUS [5,9,13,15,[17][18][19][20]. Based on these findings, Ardissino et al suggested a score (hemoglobin (g/dL) + 2 × creatinine (mg/dL) on admission) to identify patients at high risk for a severe course.…”