Providing fluid intravenously during the first four days of onset of diarrhoea is associated with a reduced risk for renal failure among children at risk for hemolytic uremic syndrome (HUS), according to a report released Online First today by Archives of Pediatrics and Adolescent Medicine, one of the JAMA/Archives journals. There have been more than 900 cases of HUS reported in 16 countries in Europe and North America since an Escherichia coli (E. coli) outbreak began in Germany in May 2011. The article is being released early because of its important public health implications.
According to background information in the article, HUS usually occurs after diarrhoea caused by Shiga toxin-producing bacteria, particularly E. coli O157:H7. The condition consists of haemolytic anaemia (destruction of red blood cells), thrombocytopenia (low levels of platelets in the blood) and impaired renal function. Patients whose HUS is oligoanuric (decreased kidney function, with a urine output of less than 0.5 milliliters per kilogram of body weight per hour, for at least one day) are more likely to need dialysis and longer hospital stays and to have more chronic complications than those whose HUS is nonoligoanuric. “The pathophysiologic cascade leading to renal failure might provide an opportunity to mitigate renal damage,” write the authors. “If patients at risk for HUS are recognised early in illness, then the brief interval between first presentation with diarrhoea and HUS onset could be exploited to maintain or improve renal perfusion, possibly averting renal shutdown.”
Christina A. Hickey, M.D., from Washington University School of Medicine and St. Louis Children’s Hospital, and colleagues conducted a prospective, observational cohort study at 11 paediatric hospitals in the United States and Scotland. Investigators identified 50 patients, ages 17 years and younger, from across the United States and in Glasgow, Scotland, who had a postdiarrhoeal illness that met the case definition of HUS.
Of the 50 patients included, 34 (68 percent) developed oligoanuric HUS. Those who developed oligoanuric renal failure had received less volume of intravenous fluids and less sodium before developing HUS than did those whose HUS was not oligoanuric. Those who received no intravenous fluids in the first four days of illness were 1.6 times more likely to have oligoanuric HUS. After multivariate analysis was conducted, volume of intravenous fluids was the most significant factor associated with the risk of oligoanuric HUS.
“In summary, intravenous volume expansion early in illness was associated with better renal outcome during HUS in this second, and independent, systematic cohort study of pre-HUS clinical events and variables,” the authors state. “Intravenous volume expansion is an underused intervention that could decrease the frequency of oligoanuric renal failure in patients at risk of HUS.”