“Changing Paradigm in Hemolytic Uremic Syndrome”

A recent study from the January 2016 Pediatrics (thanks to Michael Hart for this reference) demonstrates that more aggressive early volume expansion improved outcomes in hemolytic uremic syndrome compared with historical controls.  The full abstract is below.  An associated editorial (Shifting the Paradigm in Hemolytic Uremic Syndrome by David N. Cornfield) makes several points:

1. “The elegantly simple study design led to a relatively straightforward, yet palpably important conclusion that upon presentation, timely administration of sufficient intravenous fluids to increase the child’s body weight by 10% meaningfully decreases length of stay, need for admission to a PICU, use of renal replacement therapy, and the incidence of long-term sequelae.”

2. “The authors were willing, and able, to effectively challenge the standard approach for treatment of STEC-HUS. Over the course of the past several decades, care providers were wary of providing intravenous fluids in the context of renal insufficiency, owing to concerns over potential for fluid overload.”

3. “That the authors were able to demonstrate efficacy after enrolling only 38 children is remarkable. Outcomes were improved for almost every end point studied. The important end points that did not reach statistical significance, death, and central nervous system involvement likely result from a justifiable type 2 error.”

Abstract

BACKGROUND: Hemolytic uremic syndrome associated with Shiga toxin–producing Escherichia coli (STEC-HUS) is a severe acute illness without specific treatment except supportive care; fluid management is concentrated on preventing fluid overload for patients, who are often oligoanuric. Hemoconcentration at onset is associated with more severe disease, but the benefits of volume expansion after hemolytic uremic syndrome (HUS) onset have not been explored.

METHODS: All the children with STEC-HUS referred to our center between 2012 and 2014 received intravenous infusion targeted at inducing an early volume expansion (+10% of working weight) to restore circulating volume and reduce ischemic or hypoxic tissue damage. The short- and long-term outcomes of these patients were compared with those of 38 historical patients referred to our center during the years immediately before, when fluid intake was routinely restricted.

RESULTS: Patients undergoing fluid infusion soon after diagnosis showed a mean increase in body weight of 12.5% (vs 0%), had significantly better short-term outcomes with a lower rate of central nervous system involvement (7.9% vs 23.7%, P = .06), had less need for renal replacement therapy (26.3% vs 57.9%, P = .01) or intensive care support (2.0 vs. 8.5 days, P = .02), and needed fewer days of hospitalization (9.0 vs 12.0 days, P = .03). Long-term outcomes were also significantly better in terms of renal and extrarenal sequelae (13.2% vs 39.5%, P = .01).

CONCLUSIONS: Patients with STEC-HUS had great benefit from early volume expansion. It is speculated that early and generous fluid infusions can reduce thrombus formation and ischemic organ damage, thus having positive effects on both short- and long-term disease outcomes.

Related study showing that more aggressive fluid management also helpful in a pediatric cohort with clinical sepsis/shock: AA Arikan et al. J Pediatr 2015; 1301-5. “A protocol-driven implementation of a resuscitation bundle in the pediatric ED decreased acute kidney injury and need for renal-replacement therapy, as well as PICU and hospital LOS and mortality. Compared with patients prior to this bundle, there was increased fluid given (mean 56 mL/kg vs. 49 mL/kg) and initial bolus was given sooner (mean 34 min compared to 65 min).

Mt. Ranier

Mt. Ranier

1 thought on ““Changing Paradigm in Hemolytic Uremic Syndrome”

  1. Pingback: Better Hydration May Lead to Better Outcomes For Hemolytic Uremic Syndrome due to E coli | gutsandgrowth

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