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Allinovi M, Farella I, Giacalone M, Lugli G, Cirillo L, Parri N, Becherucci F. Lung Ultrasound to Evaluate Fluid Status and Optimize Early Volume-Expansion Therapy in Children with Shiga Toxin-Producing Escherichia Coli-Haemolytic Uremic Syndrome: A Pilot Study. J Clin Med 2024; 13:3024. [PMID: 38892735 PMCID: PMC11172783 DOI: 10.3390/jcm13113024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 05/19/2024] [Accepted: 05/20/2024] [Indexed: 06/21/2024] Open
Abstract
Background: Shiga toxin-producing Escherichia coli-haemolytic uremic syndrome (STEC-HUS) can result in kidney and neurological complications. Early volume-expansion therapy has been shown to improve outcomes, but caution is required to avoid fluid overload. Lung ultrasound scanning (LUS) can be used to detect fluid overload and may be useful in monitoring hydration therapy. Methods: This prospective observational pilot study involved children with STEC-HUS who were recruited from a regional paediatric nephrology centre. B-line quantification by LUS was used to assess fluid status at the emergency department (ED) admission and correlated with the decrease in patient weight from the target weight. A control group of children on chronic dialysis therapy with episodes of symptomatic fluid overload was also enrolled in order to establish a B-line threshold indicative of severe lung congestion. Another cohort of "healthy" children, without renal or lung-related diseases, and without clinical signs of fluid overload was also enrolled in order to establish a B-line threshold indicative of euvolemia. Results: LUS assessment was performed in 10 children with STEC-HUS at ED admission, showing an average of three B-lines (range 0-10). LUS was also performed in 53 euvolemic children admitted to the ED not showing kidney and lung disease (healthy controls), showing a median value of two B-lines (range 0-7), not significantly different from children with STEC-HUS at admission (p = 0.92). Children with STEC-HUS with neurological involvement during the acute phase and those requiring dialysis presented a significantly lower number of B-lines at admission compared to patients with a good clinical course (p < 0.001). Patients with long-term renal impairment also presented a lower number of B-lines at disease onset (p = 0.03). Conclusions: LUS is a useful technique for monitoring intravenous hydration therapy in paediatric patients with STEC-HUS. A low number of B-lines at ED admission (<5 B-lines) was associated with worse short-term and long-term outcomes. Further studies are needed to determine the efficacy and safety of an LUS-guided strategy for reducing complications in children with STEC-HUS.
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Affiliation(s)
- Marco Allinovi
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, 50134 Florence, Italy;
| | - Ilaria Farella
- Clinica Medica “A. Murri”, Department of Biomedical Sciences & Human Oncology, University of Bari “Aldo Moro”, 70121 Bari, Italy;
| | - Martina Giacalone
- Department of Emergency Medicine and Trauma Center, Meyer University Children’s Hospital IRCCS, 50139 Florence, Italy; (M.G.); (N.P.)
| | - Gianmarco Lugli
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, 50134 Florence, Italy;
| | - Luigi Cirillo
- Nephrology and Dialysis Unit, Meyer Children’s Hospital IRCCS, 50139 Florence, Italy; (L.C.); (F.B.)
| | - Niccolò Parri
- Department of Emergency Medicine and Trauma Center, Meyer University Children’s Hospital IRCCS, 50139 Florence, Italy; (M.G.); (N.P.)
| | - Francesca Becherucci
- Nephrology and Dialysis Unit, Meyer Children’s Hospital IRCCS, 50139 Florence, Italy; (L.C.); (F.B.)
- Department of Biomedical, Experimental and Clinical Sciences “Mario Serio”, University of Florence, 50121 Florence, Italy
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Balestracci A, Meni Battaglia L, Toledo I, Martin SM, Beaudoin L. Duration of prodromal phase and severity of hemolytic uremic syndrome. Pediatr Nephrol 2024; 39:213-219. [PMID: 37526769 DOI: 10.1007/s00467-023-06104-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 07/16/2023] [Accepted: 07/17/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND Some data have recognized an association between shorter prodromal phase and severe episode of Shiga toxin-producing Escherichia coli-related hemolytic uremic syndrome (STEC-HUS). Our aims were to confirm such association and analyze characteristics of STEC-HUS patients according to duration of the prodromal phase. METHODS Patients treated from 2000 to 2022 were compared according to the presence of severe (> 10 days of dialysis and/or extra-renal complications) or non-severe disease. Association between prodromal phase duration and disease severity was assessed by ROC curve and by classifying the cohort in 3 groups according to time to diagnosis. RESULTS Non-severe (n = 145) and severe (n = 71) cases were compared. The latter had shorter prodromal phase, higher leukocyte count, hemoglobin, lactic dehydrogenase, liver enzymes, C-reactive protein, urea and creatinine, and lower albumin and sodium; only prodromal phase duration (p = 0.02) and leukocyte count (p = 0.02) remained significant in multivariate analysis. By ROC curve analysis, time to diagnosis resulted in a poor predictor of outcomes (AUC = 0.27). Since prodromal phase duration was 5 days (IQR 3-7), we divided the cohort into Groups A (1-2 days), B (3-7 days), and C (≥ 8 days). Rates of severe disease were 75.8%, 29.6%, and 11.4%, respectively. Taking Group B as reference, Group A patients had higher risk of complications (p = 0.00001; OR 7.4, 95% CI: 2.98-18.7) while Group C ones had significantly less risk (p = 0.02; OR 0.3, 95% CI: 0.1-0.91). CONCLUSIONS This study found that duration of prodromal phase is an independent predictor of complicated STEC-HUS and confirms that shorter prodromal phase is associated with worse prognosis. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Alejandro Balestracci
- Nephrology Unit, Hospital General de Niños Pedro de Elizalde, Montes de Oca 40, CP 1270, Ciudad Autónoma de Buenos Aires, Argentina.
| | - Luciana Meni Battaglia
- Nephrology Unit, Hospital General de Niños Pedro de Elizalde, Montes de Oca 40, CP 1270, Ciudad Autónoma de Buenos Aires, Argentina
| | - Ismael Toledo
- Nephrology Unit, Hospital General de Niños Pedro de Elizalde, Montes de Oca 40, CP 1270, Ciudad Autónoma de Buenos Aires, Argentina
| | - Sandra Mariel Martin
- Nephrology Unit, Hospital General de Niños Pedro de Elizalde, Montes de Oca 40, CP 1270, Ciudad Autónoma de Buenos Aires, Argentina
| | - Laura Beaudoin
- Nephrology Unit, Hospital General de Niños Pedro de Elizalde, Montes de Oca 40, CP 1270, Ciudad Autónoma de Buenos Aires, Argentina
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Mouliou DS. C-Reactive Protein: Pathophysiology, Diagnosis, False Test Results and a Novel Diagnostic Algorithm for Clinicians. Diseases 2023; 11:132. [PMID: 37873776 PMCID: PMC10594506 DOI: 10.3390/diseases11040132] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 09/15/2023] [Accepted: 09/19/2023] [Indexed: 10/25/2023] Open
Abstract
The current literature provides a body of evidence on C-Reactive Protein (CRP) and its potential role in inflammation. However, most pieces of evidence are sparse and controversial. This critical state-of-the-art monography provides all the crucial data on the potential biochemical properties of the protein, along with further evidence on its potential pathobiology, both for its pentameric and monomeric forms, including information for its ligands as well as the possible function of autoantibodies against the protein. Furthermore, the current evidence on its potential utility as a biomarker of various diseases is presented, of all cardiovascular, respiratory, hepatobiliary, gastrointestinal, pancreatic, renal, gynecological, andrological, dental, oral, otorhinolaryngological, ophthalmological, dermatological, musculoskeletal, neurological, mental, splenic, thyroid conditions, as well as infections, autoimmune-supposed conditions and neoplasms, including other possible factors that have been linked with elevated concentrations of that protein. Moreover, data on molecular diagnostics on CRP are discussed, and possible etiologies of false test results are highlighted. Additionally, this review evaluates all current pieces of evidence on CRP and systemic inflammation, and highlights future goals. Finally, a novel diagnostic algorithm to carefully assess the CRP level for a precise diagnosis of a medical condition is illustrated.
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Luna M, Kamariski M, Principi I, Bocanegra V, Vallés PG. Severely ill pediatric patients with Shiga toxin-associated hemolytic uremic syndrome (STEC-HUS) who suffered from multiple organ involvement in the early stage. Pediatr Nephrol 2021; 36:1499-1509. [PMID: 33205220 DOI: 10.1007/s00467-020-04829-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 09/24/2020] [Accepted: 10/15/2020] [Indexed: 01/23/2023]
Abstract
BACKGROUND Shiga toxin-producing Escherichia coli-associated hemolytic uremic syndrome (STEC-HUS) is the main cause of pediatric acute kidney injury (AKI) in Argentina. Endothelial injury is the trigger event in the microangiopathic process. The host inflammatory response to toxin and E. coli lipopolysaccharide (LPS) is involved in disease pathophysiology. METHODS This retrospective study describes pediatric STEC-HUS patients with multiorgan involvement at the initial phase of disease. A retrospective study of critically ill HUS patients with evidence of E. coli infection was conducted through a period of 15 years. RESULTS Forty-four patients 35.4 ± 4.1 months were admitted to the intensive care unit for 21 ± 2 days. Mechanical ventilation was required in 41 patients, early inotropic support in 37, and 28 developed septic shock. Forty-one patients required kidney replacement therapy for 12 ± 1 days. Forty-one patients showed neurological dysfunction. Dilated cardiomyopathy was demonstrated in 3 patients, left ventricular systolic dysfunction in 4, and hypertension in 17. Four patients had pulmonary hemorrhage, and acute respiratory distress syndrome in 2. Colectomy for transmural colonic necrosis was performed in 3 patients. Thirty-seven patients were treated with therapeutic plasma exchange, and 28 patients received methylprednisolone (10 mg/kg for 3 days). Of the surviving 32 patients, neurological sequelae were seen in 11 and chronic kidney failure in 5. CONCLUSIONS Severe clinical outcome at onset suggests an amplified inflammatory response after exposure to Shiga toxin and/or E. coli LPS. STEC-HUS associated with severe neurological involvement, hemodynamic instability, and AKI requires intensive care and focused therapy.
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Affiliation(s)
- Mariana Luna
- Servicio de Nefrología, Departamento de Pediatría, Hospital Humberto Notti, Mendoza, Argentina
| | - Mariana Kamariski
- Servicio de Nefrología, Departamento de Pediatría, Hospital Humberto Notti, Mendoza, Argentina
| | - Iliana Principi
- Servicio de Nefrología, Departamento de Pediatría, Hospital Humberto Notti, Mendoza, Argentina
| | - Victoria Bocanegra
- Instituto de Medicina y Biología Experimental de Cuyo (IMBECU), Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Mendoza, Argentina
| | - Patricia G Vallés
- Servicio de Nefrología, Departamento de Pediatría, Hospital Humberto Notti, Mendoza, Argentina. .,Área de Fisiopatología, Departamento de Patología, Facultad de Ciencias Médicas, Universidad Nacional de Cuyo, Mendoza, Argentina.
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McKee RS, Schnadower D, Tarr PI, Xie J, Finkelstein Y, Desai N, Lane RD, Bergmann KR, Kaplan RL, Hariharan S, Cruz AT, Cohen DM, Dixon A, Ramgopal S, Rominger A, Powell EC, Kilgar J, Michelson KA, Beer D, Bitzan M, Pruitt CM, Yen K, Meckler GD, Plint AC, Bradin S, Abramo TJ, Gouin S, Kam AJ, Schuh A, Balamuth F, Hunley TE, Kanegaye JT, Jones NE, Avva U, Porter R, Fein DM, Louie JP, Freedman SB. Predicting Hemolytic Uremic Syndrome and Renal Replacement Therapy in Shiga Toxin-producing Escherichia coli-infected Children. Clin Infect Dis 2021; 70:1643-1651. [PMID: 31125419 DOI: 10.1093/cid/ciz432] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 05/23/2019] [Indexed: 12/27/2022] Open
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.
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Affiliation(s)
- Ryan S McKee
- Section of Pediatric Emergency Medicine, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City
| | - David Schnadower
- Division of Emergency Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Ohio
| | - Phillip I Tarr
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri
| | - Jianling Xie
- Section of Pediatric Emergency Medicine, Department of Pediatrics, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary
| | - Yaron Finkelstein
- Divisions of Emergency Medicine, and Clinical Pharmacology and Toxicology, Hospital for Sick Children, University of Toronto, Ontario
| | - Neil Desai
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| | - Roni D Lane
- Division of Pediatric Emergency Medicine, University of Utah School of Medicine, Salt Lake City
| | - Kelly R Bergmann
- Department of Emergency Medicine, Children's Minnesota, Minneapolis
| | - Ron L Kaplan
- Department of Pediatrics, Division of Emergency Medicine, University of Washington School of Medicine, Seattle Children's Hospital
| | - Selena Hariharan
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri
| | - Andrea T Cruz
- Sections of Pediatric Emergency Medicine and Pediatric Infectious Diseases, Baylor College of Medicine, Houston, Texas
| | - Daniel M Cohen
- Division of Emergency Medicine, Nationwide Children's Hospital and Ohio State University, Columbus
| | - Andrew Dixon
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Stollery Children's Hospital, Women and Children's Research Institute, University of Alberta, Edmonton, Canada
| | - Sriram Ramgopal
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine Children's Hospital, Pennsylvania
| | - Annie Rominger
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Louisville, Kentucky
| | - Elizabeth C Powell
- Division of Emergency Medicine, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jennifer Kilgar
- Department of Pediatrics and Division of Emergency Medicine, Children's Hospital, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | | | - Darcy Beer
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| | - Martin Bitzan
- Division of Nephrology, Department of Pediatrics, McGill University Health Centre, Montreal, Québec, Canada
| | - Christopher M Pruitt
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Alabama at Birmingham
| | - Kenneth Yen
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Texas Southwestern, Children's Health, Dallas
| | - Garth D Meckler
- Division of Pediatric Emergency Medicine, Departments of Pediatrics and Emergency Medicine, University of British Columbia, Vancouver
| | - Amy C Plint
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Ottawa, Ontario, Canada
| | - Stuart Bradin
- Departments of Pediatrics and Emergency Medicine, University of Michigan Health System, Ann Arbor
| | - Thomas J Abramo
- Departments of Pediatrics and Emergency Medicine, University of Arkansas School of Medicine, Arkansas Children's Hospital Research Institute, Little Rock
| | - Serge Gouin
- Departments of Pediatric Emergency Medicine and Pediatrics, Université de Montréal, Québec
| | - April J Kam
- Division of Pediatric Emergency Medicine, Department of Pediatrics, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Abigail Schuh
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Medical College of Wisconsin, Milwaukee
| | - Fran Balamuth
- University of Pennsylvania Perelman School of Medicine, Children's Hospital of Philadelphia
| | - Tracy E Hunley
- Division of Pediatric Nephrology, Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - John T Kanegaye
- Department of Pediatrics, University of California, San Diego School of Medicine, La Jolla.,Rady Children's Hospital San Diego, California
| | - Nicholas E Jones
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, Georgia
| | - Usha Avva
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Hackensack Meridian School of Medicine at Seton Hall, Joseph M. Sanzari Children's Hospital, New Jersey
| | - Robert Porter
- Discipline of Pediatrics, Faculty of Medicine, Memorial University of Newfoundland, St John's, Newfoundland and Labrador, Canada
| | - Daniel M Fein
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - Jeffrey P Louie
- Department of Pediatrics, Division of Emergency Medicine, University of Minnesota, Masonic Children's Hospital, Minneapolis
| | - Stephen B Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital and Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada
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