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Early fluids critical in preventing renal failure from hemolytic uremic syndrome

Reuters Health • The Doctor's Channel Daily Newscast

NEW YORK (Reuters Health) – Kidney failure during hemolytic uremic syndrome is less likely to develop in children with diarrhea due to virulent E. coli infection if they’re given IV fluids early, according to a report in the Archives of Pediatrics and Adolescent Medicine online July 22.

“Intravenous volume expansion is an underused intervention that could decrease the frequency of oligoanuric renal failure in patients at risk of HUS (hemolytic uremic syndrome),” conclude Dr. Phillip I. Tarr, at Washington University School of Medicine in St. Louis, Missouri, and colleagues.

They note that HUS typically follows diarrhea caused by Shiga toxin-producing bacteria, most often E. coli O157:H7. A journal press release points out that there have been more than 900 cases of HUS reported in Europe and North America since an E. coli outbreak began in Germany in May this year, so the study is being released early because of its important public health implications.

The “pathological cascade” leading to renal failure in HUS might be interrupted by improving renal perfusion, the researchers explain, as long the risk is recognized early enough during the diarrheal phase. Indeed, an earlier trial indicated that IV volume expansion was nephroprotective in this setting.

To investigate further, the team conducted a prospective observational study of 50 children aged 1 to 17 years admitted to 11 pediatric hospitals in the US and Scotland with a diagnosis of HUS. A brief period of oliguria followed by prolonged anuria developed in 34 of the patients.

“Children who developed oligoanuric HUS received less volume and less sodium during the entire pre-HUS interval than those whose HUS was nonoligoanuric,” the team found.

The difference was most pronounced in terms of early volume expansion, with oligoanuria developing in 21 of 25 children (84%) not given IV fluids in the first 4 days of illness compared to 13 of 25 children (52%) who did receive fluids in that period, according to the report.

This translated to a relative risk of oligoanuria of 1.6 (p=0.06) when no intravenous fluids were given during the first 4 pre-HUS days.

Dr. Tarr and colleagues advise: “Clinical profiling can identify patients who might be infected with E coli O157:H7 (detailed in several reviews) and are at risk of developing HUS. Expeditious microbiological diagnosis and hospitalization of possibly infected patients is encouraged because the interval during which volume expansion is most effective and safest might be brief.”

Nevertheless, they point out, “Volume expansion does not completely protect against oligoanuria during HUS. The surest way to prevent oligoanuric HUS is to prevent E coli O157:H7 infections.”

Reference:
Early Volume Expansion During Diarrhea and Relative Nephroprotection During Subsequent Hemolytic Uremic Syndrome
Arch Pediatr Adolesc Med 2011.