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Böckenhauer J, Schild R, Kemper MJ, Henne T, Stein MV, Oh J, Loos S. Volume expansion mitigates Shiga toxin-producing E. coli-hemolytic uremic syndrome in children. Pediatr Nephrol 2024; 39:1901-1907. [PMID: 38240870 PMCID: PMC11026235 DOI: 10.1007/s00467-023-06276-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 12/21/2023] [Accepted: 12/22/2023] [Indexed: 04/19/2024]
Abstract
BACKGROUND Shiga toxin-producing E. coli-hemolytic uremic syndrome (STEC-HUS) is associated with high morbidity and relevant mortality. Previous small studies showed that volume expansion could improve the course and outcome of STEC-HUS. The aim of this single-center study was to evaluate the effect of volume expansion on the clinical course and outcome in STEC-HUS. METHODS Data of pediatric patients with STEC-HUS were analyzed retrospectively. Course and outcome of patients treated with volume expansion (VE) from 2019 to 2022 (n = 38) were compared to historical controls (HC) from 2009 to 2018 (n = 111). RESULTS Patients in the VE group had a significant relative median weight gain compared to HC (7.8% (3.4-11.3) vs. 1.2% (- 0.7-3.9), p < 0.0001) 48 h after admission. The need for dialysis was not reduced by VE (VE 21/38 (55.3%) vs. HC 64/111 (57.7%), p = 0.8). However, central nervous system involvement (impairment of consciousness, seizures, focal neurological deficits, and/or visual disturbances) was significantly reduced (VE 6/38 (15.8%) vs. HC 38/111 (34.2%), p = 0.039). None of the patients in the VE group died or developed chronic kidney disease (CKD) stage 5, whereas in the HC group, three patients died and three patients had CKD stage 5 at discharge. CONCLUSIONS This study suggests that volume expansion may be associated with the mitigation of the acute course of STEC-HUS, especially severe neurological involvement and the development of CKD. Prospective trials should lead to standardized protocols for volume expansion in children with STEC-HUS.
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Affiliation(s)
- Johannes Böckenhauer
- University Medical Center Hamburg-Eppendorf, University Children's Hospital, Martinistrasse 52, 20246, Hamburg, Germany
| | - Raphael Schild
- University Medical Center Hamburg-Eppendorf, University Children's Hospital, Martinistrasse 52, 20246, Hamburg, Germany
| | - Markus J Kemper
- Department of Pediatrics, Asklepios Klink Nord, Hamburg, Germany
| | - Thomas Henne
- University Medical Center Hamburg-Eppendorf, University Children's Hospital, Martinistrasse 52, 20246, Hamburg, Germany
| | - Marie V Stein
- University Medical Center Hamburg-Eppendorf, University Children's Hospital, Martinistrasse 52, 20246, Hamburg, Germany
| | - Jun Oh
- University Medical Center Hamburg-Eppendorf, University Children's Hospital, Martinistrasse 52, 20246, Hamburg, Germany
| | - Sebastian Loos
- University Medical Center Hamburg-Eppendorf, University Children's Hospital, Martinistrasse 52, 20246, Hamburg, Germany.
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Lee BJ, Arter Z, Doh J, Griffin SP, Vittayawacharin P, Atallah S, Shieh KR, Tran M, Jodele S, Kongtim P, Ciurea SO. Eculizumab for Shiga-toxin-induced hemolytic uremic syndrome in adults with neurological involvement. EJHAEM 2024; 5:548-553. [PMID: 38895057 PMCID: PMC11182416 DOI: 10.1002/jha2.902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 04/04/2024] [Accepted: 04/05/2024] [Indexed: 06/21/2024]
Abstract
The role of eculizumab in treating Shiga-toxin-producing Escherichia coli (STEC) hemolytic uremic syndrome (HUS) patients with neurological involvement remains unclear. We describe two distinctly different STEC-HUS patients with neurologic involvement successfully managed with eculizumab, and perform a literature review of all published cases. Both patients had complete resolution of neurological symptoms after initiation of eculizumab. Eighty patients with STEC-HUS treated with eculizumab were identified in the literature, 68.7% had complete resolution of neurological symptoms. Based on our experience and literature review, three prevailing themes were noted: 1) Early eculizumab administration optimized neurological outcomes, 2) Symptom resolution may not be immediate, neurological symptoms may initially worsen before improvement, and 3) Plasma exchange yielded no benefit. Early administration of eculizumab may reverse neurotoxicity in patients with STEC-HUS.
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Affiliation(s)
- Benjamin J. Lee
- Department of PharmacyUniversity of California Irvine HealthOrangeCaliforniaUSA
- Department of Clinical Pharmacy PracticeSchool of Pharmacy and Pharmaceutical SciencesUniversity of CaliforniaIrvineCaliforniaUSA
| | - Zhaohui Arter
- Department of MedicineDivision of Hematology‐OncologyChao Family Comprehensive Cancer CenterUniversity of California Irvine HealthOrangeCaliforniaUSA
| | - Jean Doh
- Department of PharmacyUniversity of California Irvine HealthOrangeCaliforniaUSA
| | - Shawn P. Griffin
- Department of PharmacyUniversity of California Irvine HealthOrangeCaliforniaUSA
- Department of Clinical Pharmacy PracticeSchool of Pharmacy and Pharmaceutical SciencesUniversity of CaliforniaIrvineCaliforniaUSA
| | - Pongthep Vittayawacharin
- Department of MedicineDivision of Hematology‐OncologyChao Family Comprehensive Cancer CenterUniversity of California Irvine HealthOrangeCaliforniaUSA
- Division of HematologyDepartment of MedicineFaculty of Medicine Siriraj HospitalMahidol UniversityBangkokThailand
| | - Steven Atallah
- Department of PharmacyUniversity of California Irvine HealthOrangeCaliforniaUSA
- Department of Clinical Pharmacy PracticeSchool of Pharmacy and Pharmaceutical SciencesUniversity of CaliforniaIrvineCaliforniaUSA
| | - Kevin R. Shieh
- Department of MedicineDivision of Hematology‐OncologyChao Family Comprehensive Cancer CenterUniversity of California Irvine HealthOrangeCaliforniaUSA
| | - Minh‐Ha Tran
- Department of Pathology and Laboratory MedicineDivision of Transfusion MedicineUniversity of California Irvine HealthOrangeCaliforniaUSA
| | - Sonata Jodele
- Division of Bone Marrow Transplantation and ImmuneDeficiencyCancer and Blood Disease InstituteCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
| | - Piyanuch Kongtim
- Department of MedicineDivision of Hematology‐OncologyChao Family Comprehensive Cancer CenterUniversity of California Irvine HealthOrangeCaliforniaUSA
| | - Stefan O. Ciurea
- Department of MedicineDivision of Hematology‐OncologyChao Family Comprehensive Cancer CenterUniversity of California Irvine HealthOrangeCaliforniaUSA
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Kirkland ME, Patfield S, Hughes AC, Hernlem B, He X. A novel Shiga toxin 2a neutralizing antibody therapeutic with low immunogenicity and high efficacy. Antimicrob Agents Chemother 2024; 68:e0059823. [PMID: 38047751 PMCID: PMC10777836 DOI: 10.1128/aac.00598-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 10/18/2023] [Indexed: 12/05/2023] Open
Abstract
Shiga toxin-producing Escherichia coli infections are difficult to treat due to the risk of antibiotic-induced stress upregulating the production of toxins, medical treatment is consequently limited to supportive care to prevent the development of hemolytic uremic syndrome (HUS). Here, we introduce a potentially therapeutic humanized mouse monoclonal antibody (Hu-mAb 2-5) targeting Stx2a, the most common Shiga toxin subtype identified from outbreaks. We demonstrate that Hu-mAb 2-5 has low immunogenicity in healthy adults ex vivo and high neutralizing efficacy in vivo, protecting mice from mortality and HUS-related tissue damage.
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Affiliation(s)
- Marina E. Kirkland
- United States Department of Agriculture, Agricultural Research Service, Western Regional Research Center, Albany, California, USA
- U.S. Department of Energy, Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee, USA
| | - Stephanie Patfield
- United States Department of Agriculture, Agricultural Research Service, Western Regional Research Center, Albany, California, USA
| | - Anna C. Hughes
- United States Department of Agriculture, Agricultural Research Service, Western Regional Research Center, Albany, California, USA
| | - Bradley Hernlem
- United States Department of Agriculture, Agricultural Research Service, Western Regional Research Center, Albany, California, USA
| | - Xiaohua He
- United States Department of Agriculture, Agricultural Research Service, Western Regional Research Center, Albany, California, USA
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4
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Wildes DM, Harvey S, Costigan CS, Sweeney C, Twomey É, Awan A, Gorman KM. Eculizumab in STEC-HUS: a paradigm shift in the management of pediatric patients with neurological involvement. Pediatr Nephrol 2024; 39:315-324. [PMID: 37491519 DOI: 10.1007/s00467-023-06102-w] [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: 05/03/2023] [Revised: 06/27/2023] [Accepted: 07/17/2023] [Indexed: 07/27/2023]
Abstract
BACKGROUND Eculizumab for the treatment of atypical hemolytic uremic syndrome (HUS) is a standard of care. Central nervous system (CNS) involvement in Shiga toxin-producing Escherichia coli (STEC)-HUS is associated with increased morbidity and mortality. There is no consensus on the use of plasma exchange and/or eculizumab. We report a series (n = 4) of children with CNS involvement in STEC-HUS with excellent outcomes after treatment with eculizumab only and supportive therapies. METHODS A retrospective chart review of patients with CNS involvement in STEC-HUS is managed with supportive therapies and eculizumab only. RESULTS Four patients (75% female) with a median age of 5 years and 11 months (IQR: 23.5-105.5 months) were admitted to a tertiary pediatric nephrology center with CNS involvement in STEC-HUS. Neurological symptoms presented between days 2 and 7 of illness and included ataxia, altered mental status, visual symptoms, and seizures. All had an abnormal MRI brain. All received two doses of eculizumab, 1 week apart (dosing according to weight). Resolution of neurological symptoms was evident at a mean of 60 h post-administration (range: 24-72 h). All patients have complete kidney and neurological recovery at 12-month follow-up. CONCLUSION We present a case series of four children with STEC-HUS and CNS involvement, managed with eculizumab only, in lieu of plasma exchange (as per our previous policy). The marked improvement in symptoms in our cohort supports the use of eculizumab, rather than plasma exchange in the CNS involvement of STEC-HUS.
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Affiliation(s)
- Dermot Michael Wildes
- Department of Paediatric Nephrology and Transplantation, Children's Health Ireland, Dublin, Ireland.
| | - Susan Harvey
- Department of Paediatric Neurology, Children's Health Ireland, Dublin, Ireland
- School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
| | - Caoimhe Suzanne Costigan
- Department of Paediatric Nephrology and Transplantation, Children's Health Ireland, Dublin, Ireland
| | - Clodagh Sweeney
- Department of Paediatric Nephrology and Transplantation, Children's Health Ireland, Dublin, Ireland
| | - Éilis Twomey
- Department of Paediatric Radiology, Children's Health Ireland, Dublin, Ireland
| | - Atif Awan
- Department of Paediatric Nephrology and Transplantation, Children's Health Ireland, Dublin, Ireland
- School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
- Department of Paediatrics and Child Health, Royal College of Surgeons in Ireland, 123 St. Stephen's Green, Dublin 2, Ireland
| | - Kathleen Mary Gorman
- Department of Paediatric Neurology, Children's Health Ireland, Dublin, Ireland
- School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
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5
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Freedman SB, van de Kar NCAJ, Tarr PI. Shiga Toxin-Producing Escherichia coli and the Hemolytic-Uremic Syndrome. N Engl J Med 2023; 389:1402-1414. [PMID: 37819955 DOI: 10.1056/nejmra2108739] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Affiliation(s)
- Stephen B Freedman
- From the Departments of Pediatrics and Emergency Medicine, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada (S.B.F.); the Department of Pediatric Nephrology, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, the Netherlands (N.C.A.J.K.); and the Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, and the Department of Molecular Microbiology, Washington University School of Medicine, St. Louis (P.I.T.)
| | - Nicole C A J van de Kar
- From the Departments of Pediatrics and Emergency Medicine, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada (S.B.F.); the Department of Pediatric Nephrology, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, the Netherlands (N.C.A.J.K.); and the Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, and the Department of Molecular Microbiology, Washington University School of Medicine, St. Louis (P.I.T.)
| | - Phillip I Tarr
- From the Departments of Pediatrics and Emergency Medicine, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada (S.B.F.); the Department of Pediatric Nephrology, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, the Netherlands (N.C.A.J.K.); and the Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, and the Department of Molecular Microbiology, Washington University School of Medicine, St. Louis (P.I.T.)
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6
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Bültmann E, Zapf A, Mussgnug HJ, Kanzelmeyer N, Hartmann H. Cerebral microstructural changes in children suffering from hemolytic uremic syndrome. Eur J Pediatr 2023; 182:4663-4672. [PMID: 37558834 PMCID: PMC10587265 DOI: 10.1007/s00431-023-05130-w] [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: 05/04/2023] [Revised: 07/19/2023] [Accepted: 07/21/2023] [Indexed: 08/11/2023]
Abstract
To evaluate microstructural cerebral changes in children suffering from typical hemolytic uremic syndrome (HUS) based on apparent diffusion coefficient (ADC) maps. For 12 pediatric HUS patients (0.8 - 14.6 years of age) conventional magnetic resonance imaging (cMRI) at 1.5 T was retrospectively analyzed. ADC values were measured in 35 different brain regions and compared with age-related, previously published ADC reference values from a healthy pediatric control group. The HUS cohort was divided into 2 subgroups depending on clinical outcome. Subgroup A showed poor neurological outcome whereas subgroup B demonstrated improvement without lasting neurological deficits. Qualitative analysis revealed lesions by diffusion-weighted imaging (DWI) with hypointense correlate on the ADC map in basal ganglia and/or thalami and corresponding T2 hyperintensities in the majority of patients in Subgroup A (80%). Those in Subgroup B did not show qualitative DWI alterations with ADC correlate even when T2 hyperintense lesions were detected in basal ganglia and/or thalami. Quantitative analysis demonstrated abnormal ADC values in all HUS patients with a trend to a greater number of affected regions in Subgroup A compared to Subgroup B (16 versus 11 median number of regions respectively, p = 0.56). Conclusion: Using DWI qualitative and quantitative differences were found between HUS patients showing poor neurological outcome and those without neurological deficits at discharge. While ADC values indicated more extensive cerebral changes than conventional qualitative findings, both may provide early prognostic indicators for neurological outcome in pediatric HUS patients. What is Known: • In patients with STEC-HUS and neurological symptoms, MRI may show hyperintense signals on T2 and altered diffusivity mostly affecting basal ganglia, thalami and periventricular white matter. What is New: • In such patients, early MRI including quantitative ADC measurements over different brain regions may allow for detection of signal alterations possibly reflecting microstructural changes in such patients.
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Affiliation(s)
- Eva Bültmann
- Institute of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Carl-Neuberg-Straße 1, D-30625, Hannover, Germany.
| | - Antonia Zapf
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hans Joachim Mussgnug
- Institute of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Carl-Neuberg-Straße 1, D-30625, Hannover, Germany
| | - Nele Kanzelmeyer
- Clinic for Pediatric Kidney, Liver, and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Hans Hartmann
- Clinic for Pediatric Kidney, Liver, and Metabolic Diseases, Hannover Medical School, Hannover, Germany
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7
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Wong W, Prestidge C, Dickens A, Ronaldson J. Diarrhoea-associated haemolytic uraemic syndrome and Shiga toxin-producing Escherichia coli infections in New Zealand children: Clinical features and short-term complications from a 23-year cohort study. J Paediatr Child Health 2023; 59:493-498. [PMID: 36655863 DOI: 10.1111/jpc.16332] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 12/26/2022] [Accepted: 01/08/2023] [Indexed: 01/20/2023]
Abstract
BACKGROUND Diarrhoea-associated haemolytic uraemic syndrome (D+HUS) is an important cause of acute kidney injury (AKI) in young children and it is most commonly associated with Shiga toxin-producing Escherichia coli (STEC). Gastrointestinal infections caused by STEC have been increasing in New Zealand over the past two decades, but little is known regarding the acute and short-term outcomes of New Zealand children who develop D+HUS. AIM To describe the clinical characteristics, complications and short-term outcomes of New Zealand children with D+HUS identified between 1 January 1998 and 31 December 2020. METHODS The New Zealand Paediatric Surveillance Unit sends out a monthly survey to all practising paediatricians regarding conditions under active surveillance. Paediatricians caring for a child aged 0-15 years of age with D+HUS over the prior month were requested to report their patient. Reporting clinicians were then contacted by the principal investigator and sent a questionnaire requesting patient clinical and laboratory information. RESULTS Two hundred and twenty-six children had D+HUS; median age 2.8 years (interquartile range 1.7-4.9). Acute dialysis was required in 128/226 (56.2%) of children for a median of 9 days (range 1-38). Children with shorter diarrhoeal prodrome, higher neutrophil count and haemoglobin had a longer duration of dialysis. Seizures occurred in 31/226 (13.7%) and were not associated with a greater HUS severity score. Acute mortality was 1.3%, all resulting from thrombotic microangiopathic cerebral injury. CONCLUSION D+HUS is a major cause of AKI in previously healthy young children. Earlier recognition of STEC infections in young children may reduce the need for dialysis and other extra-renal complications. The New Zealand incidence of acute dialysis, other major complications and mortality are consistent with other reported studies.
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Affiliation(s)
- William Wong
- Department of Paediatric Nephrology, Starship Children's Health, Te Whatu Ora Auckland, Auckland, New Zealand
| | - Chanel Prestidge
- Department of Paediatric Nephrology, Starship Children's Health, Te Whatu Ora Auckland, Auckland, New Zealand
| | - Amanda Dickens
- Department of Paediatric Nephrology, Starship Children's Health, Te Whatu Ora Auckland, Auckland, New Zealand
| | - Jane Ronaldson
- Department of Paediatric Nephrology, Starship Children's Health, Te Whatu Ora Auckland, Auckland, New Zealand
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Liu Y, Thaker H, Wang C, Xu Z, Dong M. Diagnosis and Treatment for Shiga Toxin-Producing Escherichia coli Associated Hemolytic Uremic Syndrome. Toxins (Basel) 2022; 15:10. [PMID: 36668830 PMCID: PMC9862836 DOI: 10.3390/toxins15010010] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 12/13/2022] [Accepted: 12/17/2022] [Indexed: 12/24/2022] Open
Abstract
Shiga toxin-producing Escherichia coli (STEC)-associated hemolytic uremic syndrome (STEC-HUS) is a clinical syndrome involving hemolytic anemia (with fragmented red blood cells), low levels of platelets in the blood (thrombocytopenia), and acute kidney injury (AKI). It is the major infectious cause of AKI in children. In severe cases, neurological complications and even death may occur. Treating STEC-HUS is challenging, as patients often already have organ injuries when they seek medical treatment. Early diagnosis is of great significance for improving prognosis and reducing mortality and sequelae. In this review, we first briefly summarize the diagnostics for STEC-HUS, including history taking, clinical manifestations, fecal and serological detection methods for STEC, and complement activation monitoring. We also summarize preventive and therapeutic strategies for STEC-HUS, such as vaccines, volume expansion, renal replacement therapy (RRT), antibiotics, plasma exchange, antibodies and inhibitors that interfere with receptor binding, and the intracellular trafficking of the Shiga toxin.
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Affiliation(s)
- Yang Liu
- Department of Nephrology, The First Hospital of Jilin University, Changchun 130021, China
- Department of Urology, Boston Children’s Hospital, Boston, MA 02115, USA
- Department of Microbiology, Harvard Medical School, Boston, MA 02115, USA
- Department of Surgery, Harvard Medical School, Boston, MA 02115, USA
| | - Hatim Thaker
- Department of Urology, Boston Children’s Hospital, Boston, MA 02115, USA
- Department of Microbiology, Harvard Medical School, Boston, MA 02115, USA
- Department of Surgery, Harvard Medical School, Boston, MA 02115, USA
| | - Chunyan Wang
- Department of Nephrology, Children’s Hospital of Fudan University, Shanghai 201102, China
| | - Zhonggao Xu
- Department of Nephrology, The First Hospital of Jilin University, Changchun 130021, China
| | - Min Dong
- Department of Urology, Boston Children’s Hospital, Boston, MA 02115, USA
- Department of Microbiology, Harvard Medical School, Boston, MA 02115, USA
- Department of Surgery, Harvard Medical School, Boston, MA 02115, USA
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9
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Minary K, Tanne C, Kwon T, Faudeux C, Clave S, Langevin L, Pietrement C, Enoch C, Parmentier C, Mariani-Kurkdjian P, Weill FX, Jones G, Djouadi N, Morin D, Fila M. Outbreak of hemolytic uremic syndrome with unusually severe clinical presentation caused by Shiga toxin-producing Escherichia coli O26:H11 in France. Arch Pediatr 2022; 29:448-452. [DOI: 10.1016/j.arcped.2022.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 04/04/2022] [Accepted: 05/12/2022] [Indexed: 12/01/2022]
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10
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Shah S, Joseph C, Srivaths P. Role of therapeutic apheresis in the treatment of pediatric kidney diseases. Pediatr Nephrol 2022; 37:315-328. [PMID: 33991255 DOI: 10.1007/s00467-021-05093-w] [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: 10/14/2020] [Revised: 04/01/2021] [Accepted: 04/22/2021] [Indexed: 11/26/2022]
Abstract
Therapeutic apheresis utilizes apheresis procedures in the treatment of a variety of conditions including kidney disease. Therapeutic plasma exchange (TPE) is the most common modality employed with the rationale of rapid reduction of a pathogenic substance distributed primarily in the intravascular compartment; however other techniques which adsorb such pathogenic substances or alter the immune profile have been utilized in diseases affecting native and transplanted kidneys. This article discusses the modalities and technical details of therapeutic apheresis and summarizes its role in individual diseases affecting the kidney. Complications related to pediatric apheresis procedures and specifically related to apheresis in kidney disease are also discussed. Though therapeutic apheresis modalities are employed frequently in children with kidney disease, most experiences are extrapolated from adult studies. International and national registries need to be established to elucidate the role of apheresis modalities in children with kidney disease.
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Affiliation(s)
- Shweta Shah
- Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA.
| | - Catherine Joseph
- Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
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11
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Costigan C, Raftery T, Carroll AG, Wildes D, Reynolds C, Cunney R, Dolan N, Drew RJ, Lynch BJ, O’Rourke DJ, Stack M, Sweeney C, Shahwan A, Twomey E, Waldron M, Riordan M, Awan A, Gorman KM. Neurological involvement in children with hemolytic uremic syndrome. Eur J Pediatr 2022; 181:501-512. [PMID: 34378062 PMCID: PMC8821508 DOI: 10.1007/s00431-021-04200-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 07/05/2021] [Accepted: 07/07/2021] [Indexed: 11/25/2022]
Abstract
Our objective was to establish the rate of neurological involvement in Shiga toxin-producing Escherichia coli-hemolytic uremic syndrome (STEC-HUS) and describe the clinical presentation, management and outcome. A retrospective chart review of children aged ≤ 16 years with STEC-HUS in Children's Health Ireland from 2005 to 2018 was conducted. Laboratory confirmation of STEC infection was required for inclusion. Neurological involvement was defined as encephalopathy, focal neurological deficit, and/or seizure activity. Data on clinical presentation, management, and outcome were collected. We identified 240 children with HUS; 202 had confirmed STEC infection. Neurological involvement occurred in 22 (11%). The most common presentation was seizures (73%). In the neurological group, 19 (86%) were treated with plasma exchange and/or eculizumab. Of the 21 surviving children with neurological involvement, 19 (91%) achieved a complete neurological recovery. A higher proportion of children in the neurological group had renal sequelae (27% vs. 12%, P = .031). One patient died from multi-organ failure.Conclusion: We have identified the rate of neurological involvement in a large cohort of children with STEC-HUS as 11%. Neurological involvement in STEC-HUS is associated with good long-term outcome (complete neurological recovery in 91%) and a low case-fatality rate (4.5%) in our cohort. What is Known: • HUS is associated with neurological involvement in up to 30% of cases. • Neurological involvement has been reported as predictor of poor outcome, with associated increased morbidity and mortality. What is New: • The incidence of neurological involvement in STEC-HUS is 11%. • Neurological involvement is associated with predominantly good long-term outcome (90%) and a reduced case-fatality rate (4.5%) compared to older reports.
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Affiliation(s)
- Caoimhe Costigan
- Department of Nephrology, Children’s Health Ireland At Temple Street and Crumlin, Dublin, Ireland
| | - Tara Raftery
- Department of Nephrology, Children’s Health Ireland At Temple Street and Crumlin, Dublin, Ireland
| | - Anne G. Carroll
- Department of Radiology, Children’s Health Ireland At Temple Street, Dublin, Ireland
| | - Dermot Wildes
- Department of Nephrology, Children’s Health Ireland At Temple Street and Crumlin, Dublin, Ireland
| | - Claire Reynolds
- Department of Nephrology, Children’s Health Ireland At Temple Street and Crumlin, Dublin, Ireland
| | - Robert Cunney
- Department of Clinical Microbiology, Children’s Health Ireland At Temple Street, Dublin, Ireland
- Irish Meningitis and Sepsis Reference Laboratory, Children’s Health Ireland At Temple Street, Dublin, Ireland
- Department of Clinical Microbiology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Niamh Dolan
- Department of Nephrology, Children’s Health Ireland At Temple Street and Crumlin, Dublin, Ireland
| | - Richard J. Drew
- Department of Clinical Microbiology, Children’s Health Ireland At Temple Street, Dublin, Ireland
- Irish Meningitis and Sepsis Reference Laboratory, Children’s Health Ireland At Temple Street, Dublin, Ireland
- Department of Clinical Microbiology, Royal College of Surgeons in Ireland, Dublin, Ireland
- Clinical Innovation Unit, Rotunda Hospital, Dublin, Ireland
| | - Bryan J. Lynch
- Department of Neurology and Clinical Neurophysiology, Children’s Health Ireland At Temple Street, Dublin, Ireland
| | - Declan J. O’Rourke
- Department of Neurology and Clinical Neurophysiology, Children’s Health Ireland At Temple Street, Dublin, Ireland
- School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
| | - Maria Stack
- Department of Nephrology, Children’s Health Ireland At Temple Street and Crumlin, Dublin, Ireland
| | - Clodagh Sweeney
- Department of Nephrology, Children’s Health Ireland At Temple Street and Crumlin, Dublin, Ireland
| | - Amre Shahwan
- Department of Neurology and Clinical Neurophysiology, Children’s Health Ireland At Temple Street, Dublin, Ireland
- Department of Pediatrics, Royal College of Surgeons, Dublin, Ireland
| | - Eilish Twomey
- Department of Radiology, Children’s Health Ireland At Temple Street, Dublin, Ireland
| | - Mary Waldron
- Department of Nephrology, Children’s Health Ireland At Temple Street and Crumlin, Dublin, Ireland
| | - Michael Riordan
- Department of Nephrology, Children’s Health Ireland At Temple Street and Crumlin, Dublin, Ireland
- Department of Pediatrics, Royal College of Surgeons, Dublin, Ireland
| | - Atif Awan
- Department of Nephrology, Children’s Health Ireland At Temple Street and Crumlin, Dublin, Ireland
- School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
- Department of Pediatrics, Royal College of Surgeons, Dublin, Ireland
| | - Kathleen M. Gorman
- Department of Neurology and Clinical Neurophysiology, Children’s Health Ireland At Temple Street, Dublin, Ireland
- School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
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12
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Hemoglobinuria for the early identification of STEC-HUS in high-risk children: data from the ItalKid-HUS Network. Eur J Pediatr 2021; 180:2791-2795. [PMID: 33759020 DOI: 10.1007/s00431-021-04016-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 02/01/2021] [Accepted: 03/04/2021] [Indexed: 10/21/2022]
Abstract
Hemolytic uremic syndrome (HUS) represents one of the main causes of severe acute kidney injury in children. The most frequent form of HUS is caused by Shiga toxin-2 (Stx2)-producing Escherichia coli. Hemoglobinuria and hematuria are markers of glomerular damage, but their use has never been validated in HUS. We retrospectively analyzed the presence of hemoglobinuria/urinary red blood cells (RBCs) in children with Stx2-positive bloody diarrhea (BD) or with already ongoing STEC-HUS with the aim of validating its role in early identifying HUS. We reviewed all the pediatric patients with Stx2+ BD (group 1) and with ongoing HUS (group 2) referred to our center from 2010 to 2019. A total of 100 children were eligible for the study. In group 1, 22 patients showed hemoglobinuria/hematuria, while 41 remained negative. In 15/22 positive patients (68.2%), blood tests ruled in HUS, while in 7 (31.8%), HUS was excluded. Among the 41 patients persistently negative for hemoglobinuria/hematuria, no one developed HUS. The 37 STEC-HUS children (group 2) all had hemoglobinuria/RBCs at admission.Conclusion: Hemoglobinuria/hematuria for the diagnosis of HUS in children with Stx2+ BD showed a sensitivity of 100% and a specificity of 85%. We strongly recommend patients with BD carrying Stx2 in stools to be closely monitored with urine dipstick/urinalysis to early identify HUS. What is Known • Children with bloody diarrhea secondary to Shiga toxin 2 are at high risk of hemolytic uremic syndrome, thus have to be carefully monitored for the development of the disease, in order to early be hospitalized and treated. What is New • Urine dipstick for hemoglobinuria can be used as an easy, inexpensive, and repeatable tool to early diagnose children with bloody diarrhea secondary to Shiga toxin 2 to have developed hemolytic uremic syndrome, with no risk of false-negative results.
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13
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Tavasoli A, Zafaranloo N, Hoseini R, Otukesh H, Nakhaiee S. Frequency of neurological involvement in patients with/without diarrhea hemolytic uremic syndrome: A Systematic review and meta-analysis. Med J Islam Repub Iran 2021; 35:91. [PMID: 34956937 PMCID: PMC8683803 DOI: 10.47176/mjiri.35.91] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Indexed: 11/25/2022] Open
Abstract
Background: Diarrhea-associated-hemolytic-uremic-syndrome (D+HUS) is a common from of HUS. Central-nervous-system (CNS) involvement is one of the most common extrarenal organ involvements in children with D+HUS. This systematic review and meta-analysis aim to recognize the frequency of neurological complications in pts with HUS. Methods: Databases of PubMed, Embase, and Web of Science were searched systematically to find the papers on neurological involvement in HUS pts. Two researchers independently assessed the papers' quality and extracted data. CMA v. 2.2.064. was used for data analysis. Heterogeneity was evaluated using the I-squared (I2) test, and a fixed/random-effects model was used when appropriate. Results: In this review, 21 studies including 2,189 participants with a median age between 1.3-40-year-old, entered the meta-analysis. The meta-analysis in D+HUS patients indicated 27.0% with neurological complications (95% CI, 22.0%-32.6%), 25.5% of symptoms weren't categorized (95% CI, 15.9%-38.3%), 20.8% of them developed the seizures (95% CI, 2.3%-74.4%). In D-HUS pts, 20.8% of them were presented neurological symptoms (95% CI, 17.9%-24.0%), of which 29.0% weren't categorized (95% CI, 19.2%-41.2%), 17.5% of pts got into coma (95% CI, 9.6%-29.7%), 5.6 % showed hemiparesis (95% CI, 2.8%-10.9%), 17.2% experienced lethargy (95% CI, 5.2%-44.1%), 30.5% developed the seizures (95% CI, 18.2%-46.2%), 7.4% manifested speech abnormalities (95% CI, 0.2%-7.22%), 6.4% of D-HUS pts presented visual-disturbances (95% CI, 3.4%-11.6%). Conclusion: This systematic review and meta-analysis indicated more than one-fourth of both D+HUS and D-HUS patients were presented with neurological symptoms, and the most prevalent symptoms were seizures, which can lead to an epilepsy sequel.
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Affiliation(s)
- Azita Tavasoli
- Ali-Asghar Children Hospital, Iran University of Medical and Sciences, Tehran, Iran
| | - Nazanin Zafaranloo
- Ali-Asghar Children Hospital, Iran University of Medical and Sciences, Tehran, Iran
| | - Rozita Hoseini
- Ali-Asghar Children Hospital, Iran University of Medical and Sciences, Tehran, Iran
| | - Hasan Otukesh
- Ali-Asghar Children Hospital, Iran University of Medical and Sciences, Tehran, Iran
| | - Shahrbanoo Nakhaiee
- Ali-Asghar Children Hospital, Iran University of Medical and Sciences, Tehran, Iran
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Travert B, Rafat C, Mariani P, Cointe A, Dossier A, Coppo P, Joseph A. Shiga Toxin-Associated Hemolytic Uremic Syndrome: Specificities of Adult Patients and Implications for Critical Care Management. Toxins (Basel) 2021; 13:306. [PMID: 33925836 PMCID: PMC8145702 DOI: 10.3390/toxins13050306] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 04/21/2021] [Accepted: 04/21/2021] [Indexed: 01/28/2023] Open
Abstract
Shiga toxin-producing Escherichia coli-associated hemolytic uremic syndrome (STEC-HUS) is a form of thrombotic microangiopathy secondary to an infection by an enterohemorrhagic E. coli. Historically considered a pediatric disease, its presentation has been described as typical, with bloody diarrhea at the forefront. However, in adults, the clinical presentation is more diverse and makes the early diagnosis hazardous. In this review, we review the epidemiology, most important outbreaks, physiopathology, clinical presentation and prognosis of STEC-HUS, focusing on the differential features between pediatric and adult disease. We show that the clinical presentation of STEC-HUS in adults is far from typical and marked by the prevalence of neurological symptoms and a poorer prognosis. Of note, we highlight knowledge gaps and the need for studies dedicated to adult patients. The differences between pediatric and adult patients have implications for the treatment of this disease, which remains a public health threat and lack a specific treatment.
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Affiliation(s)
- Benoit Travert
- Service de Médecine Interne, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, 75018 Paris, France; (B.T.); (A.D.)
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, 75012 Paris, France; (C.R.); (P.C.)
| | - Cédric Rafat
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, 75012 Paris, France; (C.R.); (P.C.)
- Urgences Néphrologiques et Transplantation Rénale, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, 75020 Paris, France
| | - Patricia Mariani
- Service de Microbiologie, Hôpital Robert Debré, Assistance Publique-Hôpitaux de Paris, 75019 Paris, France; (P.M.); (A.C.)
| | - Aurélie Cointe
- Service de Microbiologie, Hôpital Robert Debré, Assistance Publique-Hôpitaux de Paris, 75019 Paris, France; (P.M.); (A.C.)
| | - Antoine Dossier
- Service de Médecine Interne, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, 75018 Paris, France; (B.T.); (A.D.)
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, 75012 Paris, France; (C.R.); (P.C.)
| | - Paul Coppo
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, 75012 Paris, France; (C.R.); (P.C.)
- Service d’Hématologie, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, 75012 Paris, France
| | - Adrien Joseph
- Centre de Référence des Microangiopathies Thrombotiques (CNR-MAT), Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, 75012 Paris, France; (C.R.); (P.C.)
- Médecine Intensive Réanimation, Hôpital Saint Louis, Assistance Publique-Hôpitaux de Paris, 75010 Paris, France
- Centre de Recherche des Cordeliers, Équipe Labellisée par la Ligue Contre le Cancer, Inserm U1138, Université de Paris, Sorbonne Université, 75006 Paris, France
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15
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Monet-Didailler C, Chevallier A, Godron-Dubrasquet A, Allard L, Delmas Y, Contin-Bordes C, Brissaud O, Llanas B, Harambat J. Outcome of children with Shiga toxin-associated haemolytic uraemic syndrome treated with eculizumab: a matched cohort study. Nephrol Dial Transplant 2021; 35:2147-2153. [PMID: 31411695 DOI: 10.1093/ndt/gfz158] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 06/27/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Treatment with eculizumab in Shiga toxin-associated haemolytic and uraemic syndrome (STEC-HUS) remains controversial despite its increasing utilization. The aim of our study was to evaluate the outcomes of children treated with eculizumab for STEC-HUS in a single-centre matched cohort study. METHODS Data were retrospectively collected from medical records of children diagnosed with STEC-HUS. The outcomes of patients treated with eculizumab for STEC-HUS were compared with those of a control group of untreated patients matched for age, sex and severity of acute kidney injury with a 1:2 matching scheme. RESULTS Eighteen children (median age 40.6 months) with STEC-HUS treated with eculizumab were compared with 36 matched control patients (median age 36.4 months) who did not receive eculizumab. All patients survived in the two groups. Within 1 month of HUS onset, the evolution of haematological and renal parameters did not differ between the two groups. At 12 months of follow-up, renal outcome was not significantly different between the two groups. At the last follow-up, the prevalence of decreased glomerular filtration rate in the eculizumab group (27%) was not statistically different from that in controls (38%), as was the prevalence of proteinuria and high blood pressure. Children who received eculizumab more often had extrarenal sequelae during follow-up. Eculizumab treatment appeared to be safe in children with STEC-HUS. CONCLUSION The benefit of eculizumab on renal and extrarenal outcomes in STEC-HUS could not be established based on our findings. However, efficacy and safety are not best assessed by the observational design and small sample size of our study. Randomized controlled trials are thus required to determine the efficacy of eculizumab in this indication.
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Affiliation(s)
- Catherine Monet-Didailler
- Service de Pédiatrie, Unité de Néphrologie, Centre de référence Maladies Rénales Rares du Sud-ouest, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Audrey Chevallier
- Service de Pédiatrie, Unité de Néphrologie, Centre de référence Maladies Rénales Rares du Sud-ouest, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Astrid Godron-Dubrasquet
- Service de Pédiatrie, Unité de Néphrologie, Centre de référence Maladies Rénales Rares du Sud-ouest, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Lise Allard
- Service de Pédiatrie, Unité de Néphrologie, Centre de référence Maladies Rénales Rares du Sud-ouest, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Yahsou Delmas
- Service de Néphrologie, Centre de référence Maladies Rénales Rares du Sud-ouest, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Cécile Contin-Bordes
- Laboratoire d'Immunologie et Immunogénétique, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Olivier Brissaud
- Service de Réanimation Pédiatrique, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Brigitte Llanas
- Service de Pédiatrie, Unité de Néphrologie, Centre de référence Maladies Rénales Rares du Sud-ouest, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Jérôme Harambat
- Service de Pédiatrie, Unité de Néphrologie, Centre de référence Maladies Rénales Rares du Sud-ouest, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France.,Université de Bordeaux, Inserm, Bordeaux Population Health Research Center, UMR 1219, Bordeaux, France
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16
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Loos S, Oh J, van de Loo L, Kemper MJ, Blohm M, Schild R. Hemoconcentration and predictors in Shiga toxin-producing E. coli-hemolytic uremic syndrome (STEC-HUS). Pediatr Nephrol 2021; 36:3777-3783. [PMID: 34046736 PMCID: PMC8497454 DOI: 10.1007/s00467-021-05108-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 04/18/2021] [Accepted: 04/28/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Hemoconcentration has been identified as a risk factor for a complicated course in Shiga toxin-producing E. coli-hemolytic uremic syndrome (STEC-HUS). This single-center study assesses hemoconcentration and predictors at presentation in STEC-HUS treated from 2009-2017. METHODS Data of 107 pediatric patients with STEC-HUS were analyzed retrospectively. Patients with mild HUS (mHUS, definition: max. serum creatinine < 1.5 mg/dL and no major neurological symptoms) were compared to patients with severe HUS (sHUS, definition: max. serum creatinine ≥ 1.5 mg/dL ± major neurological symptoms). Additionally, predictors of complicated HUS (dialysis ± major neurological symptoms) were analyzed. RESULTS Sixteen of one hundred seven (15%) patients had mHUS. Admission of patients with sHUS occurred median 2 days earlier after the onset of symptoms than in patients with mHUS. On admission, patients with subsequent sHUS had significantly higher median hemoglobin (9.5 g/dL (3.6-15.7) vs. 8.5 g/dL (4.2-11.5), p = 0.016) than patients with mHUS. The product of hemoglobin (g/dL) and LDH (U/L) (cutoff value 13,302, sensitivity 78.0%, specificity of 87.5%) was a predictor of severe vs. mild HUS. Creatinine (AUC 0.86, 95% CI 0.79-0.93) and the previously published score hemoglobin (g/dL) + 2 × creatinine (mg/dL) showed a good prediction for development of complicated HUS (AUC 0.87, 95% CI 0.80-0.93). CONCLUSIONS At presentation, patients with subsequent severe STEC-HUS had a higher degree of hemoconcentration. This underlines that fluid loss or reduced fluid intake/administration may be a risk factor for severe HUS. The good predictive value of the score hemoglobin (g/dL) + 2 × creatinine (mg/dL) for complicated HUS could be validated in our cohort. A higher resolution version of the Graphical abstract is available as Supplementary Information.
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Affiliation(s)
- Sebastian Loos
- University Medical Center Hamburg-Eppendorf, University Children's Hospital, Martinistrasse 52, 20246, Hamburg, Germany.
| | - Jun Oh
- University Medical Center Hamburg-Eppendorf, University Children’s Hospital, Martinistrasse 52, 20246 Hamburg, Germany ,University Children’s Research@Kinder-UKE, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Laura van de Loo
- University Medical Center Hamburg-Eppendorf, University Children’s Hospital, Martinistrasse 52, 20246 Hamburg, Germany
| | - Markus J. Kemper
- Department of Pediatrics, Asklepios Klink Nord, Hamburg, Germany
| | - Martin Blohm
- University Medical Center Hamburg-Eppendorf, University Children’s Hospital, Martinistrasse 52, 20246 Hamburg, Germany
| | - Raphael Schild
- University Medical Center Hamburg-Eppendorf, University Children’s Hospital, Martinistrasse 52, 20246 Hamburg, Germany
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17
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Kim J, Park JY, Park YJ, Park SY, Lee MS, Koo C. A portable and high-sensitivity optical sensing system for detecting fluorescently labeled enterohaemorrhagic Escherichia coli Shiga toxin 2B-subunit. PLoS One 2020; 15:e0236043. [PMID: 32673369 PMCID: PMC7365435 DOI: 10.1371/journal.pone.0236043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 06/28/2020] [Indexed: 11/18/2022] Open
Abstract
We developed a stand-alone, real-time optical detection device capable of reading fluorescence intensities from cell samples with high sensitivity and precision, for use as a portable fluorescent sensor for sensing fluorescently labeled enterohemorrhagic Escherichia coli (EHEC) Shiga toxins (Stxs). In general, the signal intensity from the fluorescently labeled Stxs was weak due to the small number of molecules bound to each cell. To address this technical challenge, we used a highly sensitive light detector (photomultiplier tube: PMT) to measure fluorescence, and designed a portable optical housing to align optical parts precisely; the housing itself was fabricated on a 3D printer. In addition, an electric circuit that amplified PMT output was designed and integrated into the system. The system shows the toxin concentration in the sample on a liquid crystal display (LCD), and a microcontroller circuit is used to read PMT output, process data, and display results. In contrast to other portable fluorescent detectors, the system works alone, without any peripheral computer or additional apparatus; its total size is about 17 × 13 × 9 cm3, and it weighs about 770 g. The detection limit was 0.01 ppm of Alexa Fluor 488 in PBS, which is ten thousand times lower than those of other smartphone-based systems and sufficiently sensitive for use with a portable optical detector. We used the portable real-time optical sensing system to detect Alexa Fluor 488–tagged Stx2B-subunits bound to monocytic THP-1 cells expressing the toxin receptor globotriaosylceramide (Gb3). The device did not detect a signal from Gb3-negative PD36 cells, indicating that it was capable of specifically detecting Stxs bound to cells expressing the toxin receptor. Following the development of a rapid and autonomous method for fluorescently tagging cells in food samples, the optical detection system described here could be used for direct detection of Shiga toxins in food in the field.
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Affiliation(s)
- Jeongtae Kim
- Department of Electronics and Control Engineering, Hanbat National University, Daejeon, Republic of Korea
| | - Jun-Young Park
- Environmental Diseases Research Center, Korea Research Institute of Bioscience and Biotechnology, Daejeon, Republic of Korea
| | - Young-Jun Park
- Environmental Diseases Research Center, Korea Research Institute of Bioscience and Biotechnology, Daejeon, Republic of Korea
- Department of Biomolecular Science, KRIBB School of Bioscience, Korea University of Science and Technology (UST), Daejeon, Republic of Korea
| | - Seo-Young Park
- Environmental Diseases Research Center, Korea Research Institute of Bioscience and Biotechnology, Daejeon, Republic of Korea
| | - Moo-Seung Lee
- Environmental Diseases Research Center, Korea Research Institute of Bioscience and Biotechnology, Daejeon, Republic of Korea
- Department of Biomolecular Science, KRIBB School of Bioscience, Korea University of Science and Technology (UST), Daejeon, Republic of Korea
- * E-mail: (MSL); (CK)
| | - Chiwan Koo
- Department of Electronics and Control Engineering, Hanbat National University, Daejeon, Republic of Korea
- * E-mail: (MSL); (CK)
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18
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Mühlen S, Dersch P. Treatment Strategies for Infections With Shiga Toxin-Producing Escherichia coli. Front Cell Infect Microbiol 2020; 10:169. [PMID: 32435624 PMCID: PMC7218068 DOI: 10.3389/fcimb.2020.00169] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 03/31/2020] [Indexed: 01/07/2023] Open
Abstract
Infections with Shiga toxin-producing Escherichia coli (STEC) cause outbreaks of severe diarrheal disease in children and the elderly around the world. The severe complications associated with toxin production and release range from bloody diarrhea and hemorrhagic colitis to hemolytic-uremic syndrome, kidney failure, and neurological issues. As the use of antibiotics for treatment of the infection has long been controversial due to reports that antibiotics may increase the production of Shiga toxin, the recommended therapy today is mainly supportive. In recent years, a variety of alternative treatment approaches such as monoclonal antibodies or antisera directed against Shiga toxin, toxin receptor analogs, and several vaccination strategies have been developed and evaluated in vitro and in animal models. A few strategies have progressed to the clinical trial phase. Here, we review the current understanding of and the progress made in the development of treatment options against STEC infections and discuss their potential.
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Affiliation(s)
- Sabrina Mühlen
- Institute for Infectiology, University of Münster, Münster, Germany.,German Center for Infection Research (DZIF), Associated Site University of Münster, Münster, Germany
| | - Petra Dersch
- Institute for Infectiology, University of Münster, Münster, Germany.,German Center for Infection Research (DZIF), Associated Site University of Münster, Münster, Germany
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19
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Harkins VJ, McAllister DA, Reynolds BC. Shiga-Toxin E. coli Hemolytic Uremic Syndrome: Review of Management and Long-term Outcome. CURRENT PEDIATRICS REPORTS 2020. [DOI: 10.1007/s40124-020-00208-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Abstract
Purpose of Review
We review the pathophysiology of Shiga-Toxin Enteropathogenic–Hemolytic Uremic Syndrome (STEC-HUS), strategies to ameliorate or prevent evolution of STEC-HUS, management and the improved recognition of long-term adverse outcomes.
Recent Findings
Following on from the preclinical evidence of a role for the complement system in STEC-HUS, the use of complement blocking agents has been the major focus of most recent clinical research. Novel therapies to prevent or lessen HUS have yet to enter the clinical arena. The long-term outcomes of STEC-HUS, similarly to other causes of AKI, are not as benign as previously thought.
Summary
Optimizing supportive care in STEC-HUS is the only current recommended treatment. The administration of early isotonic fluids may reduce the severity and duration of STEC-HUS. The role of complement blockade in the management of STEC-HUS remains unclear. The long-term sequelae from STEC-HUS are significant and patients with apparent full renal recovery remain at risk.
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20
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Extrarenal manifestations of the hemolytic uremic syndrome associated with Shiga toxin-producing Escherichia coli (STEC HUS). Pediatr Nephrol 2019; 34:2495-2507. [PMID: 30382336 DOI: 10.1007/s00467-018-4105-1] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 09/26/2018] [Accepted: 09/27/2018] [Indexed: 10/28/2022]
Abstract
Hemolytic uremic syndrome is commonly caused by Shiga toxin-producing Escherichia coli (STEC). Up to 15% of individuals with STEC-associated hemorrhagic diarrhea develop hemolytic uremic syndrome (STEC HUS). Hemolytic uremic syndrome (HUS) is a disorder comprising of thrombocytopenia, microangiopathic hemolytic anemia, and acute kidney injury. The kidney is the most commonly affected organ and approximately half of the affected patients require dialysis. Other organ systems can also be affected including the central nervous system and the gastrointestinal, cardiac, and musculoskeletal systems. Neurological complications include altered mental status, seizures, stroke, and coma. Gastrointestinal manifestations may present as hemorrhagic colitis, bowel ischemia/necrosis, and perforation. Pancreatitis and pancreatic beta cell dysfunction resulting in both acute and chronic insulin dependant diabetes mellitus can occur. Thrombotic microangiopathy (TMA) in cardiac microvasculature and troponin elevation has been reported, and musculoskeletal involvement manifesting as rhabdomyolysis has also been described. Extrarenal complications occur not only in the acute setting but may also be seen well after recovery from the acute phase of HUS. This review will focus on the extrarenal complications of STEC HUS. To date, management remains mainly supportive, and while there is no specific therapy for STEC HUS, supportive therapy has significantly reduced the mortality rate.
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21
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Mahat U, Matar RB, Rotz SJ. Use of complement monoclonal antibody eculizumab in Shiga toxin producing Escherichia coli associated hemolytic uremic syndrome: A review of current evidence. Pediatr Blood Cancer 2019; 66:e27913. [PMID: 31286658 DOI: 10.1002/pbc.27913] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 06/19/2019] [Accepted: 06/21/2019] [Indexed: 12/11/2022]
Abstract
Complement activation plays an important role in the pathogenesis of atypical hemolytic uremic syndrome. Eculizumab is a monoclonal antibody that blocks complement activity and has been approved for use in the treatment of atypical hemolytic uremic syndrome (HUS). Less well appreciated is the role of complement in Shiga toxin-induced HUS (Shiga toxin producing Escherichia coli [STEC]-HUS). To a limited extent, eculizumab has been used off label in patients with severe STEC-HUS with neurological involvement. Through a systematic search of available databases, we identified 16 reports describing the use of eculizumab in STEC-HUS (eight case reports/series, seven retrospective studies, and one prospective cohort study). All studies described its use in severe STEC-HUS with neurological or multiorgan dysfunction; none were randomized or blinded. Four studies used the control groups. Although the overall quality of evidence is low, some published studies showed positive clinical improvement after treatment with eculizumab in severe STEC-HUS with progressive neurological involvement.
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Affiliation(s)
- Upendra Mahat
- Department of Pediatric Hematology Oncology and BMT, Cleveland Clinic Children's, Cleveland, Ohio
| | - Raed Bou Matar
- Center for Pediatric Nephrology, Cleveland Clinic Children's, Cleveland, Ohio
| | - Seth J Rotz
- Department of Pediatric Hematology Oncology and BMT, Cleveland Clinic Children's, Cleveland, Ohio
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22
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Bagga A, Khandelwal P, Mishra K, Thergaonkar R, Vasudevan A, Sharma J, Patnaik SK, Sinha A, Sethi S, Hari P, Dragon-Durey MA. Hemolytic uremic syndrome in a developing country: Consensus guidelines. Pediatr Nephrol 2019; 34:1465-1482. [PMID: 30989342 DOI: 10.1007/s00467-019-04233-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 01/06/2019] [Accepted: 03/07/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Hemolytic uremic syndrome (HUS) is a leading cause of acute kidney injury in children. Although international guidelines emphasize comprehensive evaluation and treatment with eculizumab, access to diagnostic and therapeutic facilities is limited in most developing countries. The burden of Shiga toxin-associated HUS in India is unclear; school-going children show high prevalence of anti-factor H (FH) antibodies. The aim of the consensus meeting was to formulate guidelines for the diagnosis and management of HUS in children, specific to the needs of the country. METHODS Four workgroups performed literature review and graded research studies addressing (i) investigations, biopsy, genetics, and differential diagnosis; (ii) Shiga toxin, pneumococcal, and infection-associated HUS; (iii) atypical HUS; and (iv) complement blockade. Consensus statements developed by the workgroups were discussed during a consensus meeting in March 2017. RESULTS An algorithm for classification and evaluation was developed. The management of Shiga toxin-associated HUS is supportive; prompt plasma exchanges (PEX) is the chief therapy in patients with atypical HUS. Experts recommend that patients with anti-FH-associated HUS be managed with a combination of PEX and immunosuppressive medications. Indications for eculizumab include incomplete remission with plasma therapy, life-threatening features, complications of PEX or vascular access, inherited defects in complement regulation, and recurrence of HUS in allografts. Priorities for capacity building in regional and national laboratories are highlighted. CONCLUSIONS Limited diagnostic capabilities and lack of access to eculizumab prevent the implementation of international guidelines for HUS in most developing countries. We propose practice guidelines for India, which will perhaps be applicable to other developing countries.
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Affiliation(s)
- Arvind Bagga
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India.
| | - Priyanka Khandelwal
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Kirtisudha Mishra
- Department of Pediatrics, Chacha Nehru Bal Chikitsalya, New Delhi, India
| | - Ranjeet Thergaonkar
- Department of Pediatrics, Indian Naval Hospital Ship, Kalyani, Visakhapatnam, India
| | - Anil Vasudevan
- Department of Pediatric Nephrology, St. Johns Medical College and Hospital, Bengaluru, India
| | - Jyoti Sharma
- Department of Pediatrics, KEM Hospital, Pune, India
| | - Saroj Kumar Patnaik
- Department of Pediatrics, Army Hospital Research & Referral, New Delhi, India
| | - Aditi Sinha
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Sidharth Sethi
- Department of Nephrology, Medanta Hospital, New Delhi, India
| | - Pankaj Hari
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Marie-Agnes Dragon-Durey
- Laboratory of Immunology, Hopital Europeen Georges Pompidou, INSERM UMRS 1138, Paris Descartes University, Paris, France
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Schoettler M, Duncan C, Lehmann L. Severe, persistent neurotoxicity after transplant-associated thrombotic microangiopathy in a pediatric patient despite treatment with eculizumab. Pediatr Transplant 2019; 23:e13381. [PMID: 30828947 PMCID: PMC6650335 DOI: 10.1111/petr.13381] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 09/11/2018] [Accepted: 01/04/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND TA-TMA is a described complication of aHCT in children with neuroblastoma. Outcomes are poor with mortality rates approaching 60%. Described late effects in survivors include chronic kidney disease and persistent pulmonary hypertension. CASE We report a case of a 2-year-old with neuroblastoma who developed severe TA-TMA 35 days after high dose chemotherapy and autologous stem cell rescue. He presented with respiratory failure, pericardial and pleural effusions, hemolysis, hypertension, and mild altered mental status. He was mechanically ventilated for 3 weeks and after sedation was lifted, he was minimally responsive. He was treated with eculizumab with resolution of hemolysis, kidney injury and polyserositis. Initially he was more responsive; however, after almost a year of intensive therapy he remained nonverbal and had persistent irritability and behavioral changes. He had an extensive negative evaluation. On day +345, he presented with severe, refractory epilepsy. Three years after TA-TMA, he continues to have severe neurologic disabilities. CONCLUSIONS To our knowledge, persistent neurologic toxicity has not been reported in TA-TMA. However, deficits and seizures are reported in other TMAs, particularly in children with atypical HUS who present with significant neurologic changes at diagnosis. Our patient's persistent neurologic disability despite eculizumab response in all other involved organs may reflect irreversible damage. This case describes a new long-term sequela of TA-TMA and highlights the need for further studies to understand both acute and long-term neurologic complications of this disease.
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Affiliation(s)
- Michelle Schoettler
- Dana Farber/Boston Children’s Cancer and Blood Disorders Center Boston Massachusetts
| | - Christine Duncan
- Dana Farber/Boston Children’s Cancer and Blood Disorders Center Boston Massachusetts
| | - Leslie Lehmann
- Dana Farber/Boston Children’s Cancer and Blood Disorders Center Boston Massachusetts
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24
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Giordano P, Netti GS, Santangelo L, Castellano G, Carbone V, Torres DD, Martino M, Sesta M, Di Cuonzo F, Resta MC, Gaeta A, Milella L, Chironna M, Germinario C, Scavia G, Gesualdo L, Giordano M. A pediatric neurologic assessment score may drive the eculizumab-based treatment of Escherichia coli-related hemolytic uremic syndrome with neurological involvement. Pediatr Nephrol 2019; 34:517-527. [PMID: 30362078 DOI: 10.1007/s00467-018-4112-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 10/02/2018] [Accepted: 10/04/2018] [Indexed: 01/10/2023]
Abstract
BACKGROUND Thrombotic microangiopathy (TMA) is a clinical syndrome encompassing a large group of rare but severe disorders including thrombotic thrombocytopenic purpura (TTP) and both typical and atypical forms of hemolytic uremic syndrome (HUS). The key role of the complement system is well known in TTP and atypical HUS, but recent reports describe its involvement in the pathogenesis of HUS secondary to gastrointestinal infections due to Shiga toxin-producing Escherichia coli (STEC). METHODS TMA mainly affects the kidney, but extra-renal complications are frequently described. The involvement of the central nervous system (CNS) represents often a life-threatening condition and it can result in serious long-term disability in HUS patients who overcome the acute phase of illness. In the present study, we retrospectively analyzed a pediatric cohort of a single tertiary pediatric hospital in Southern Italy, in which this complication occurred in 12/54 children (22% of cases), of whom five with severe neurological involvement had been successfully treated with eculizumab. RESULTS The great clinical variability of brain injury in our cohort has led us to retrospectively build a "neurological score" useful to assess the clinical severity of neurologic involvement. Subjects with higher neurologic score due to the most severe CNS involvement resulted in the group of patients early treated with eculizumab, obtaining a good clinical response (four out five patients). In conclusion, the early treatment with eculizumab in children with severe neurological involvement during STEC-HUS was associated with complete regression of both acute kidney injury (AKI) and neurological lesions observed at magnetic resonance imaging (MRI). CONCLUSIONS A "neurological score" may be a useful tool to drive the early treatment of CNS complications in STEC-HUS with eculizumab, although future perspective controlled studies are urgently needed to validate this therapeutic approach.
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Affiliation(s)
- Paolo Giordano
- Pediatric Nephrology and Dialysis Unit, Pediatric Hospital "Giovanni XXIII", Bari, Italy
| | - Giuseppe Stefano Netti
- Clinical Pathology Unit and Center for Molecular Medicine, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Luisa Santangelo
- Pediatric Nephrology and Dialysis Unit, Pediatric Hospital "Giovanni XXIII", Bari, Italy
| | - Giuseppe Castellano
- Nephrology, Dialysis and Transplantation Unit, Department of Emergency and Organ Transplantation, University of Bari "Aldo Moro", Bari, Italy
| | - Vincenza Carbone
- Pediatric Nephrology and Dialysis Unit, Pediatric Hospital "Giovanni XXIII", Bari, Italy
| | | | - Marida Martino
- Pediatric Nephrology and Dialysis Unit, Pediatric Hospital "Giovanni XXIII", Bari, Italy
| | - Michela Sesta
- Pediatric Neurology Unit, Pediatric Hospital "Giovanni XXIII", Bari, Italy
| | - Franca Di Cuonzo
- Department of Neuroradiology, University of Bari "Aldo Moro", Bari, Italy
| | - Maria Chiara Resta
- Department of Neuroradiology, University of Bari "Aldo Moro", Bari, Italy
| | - Alberto Gaeta
- Pediatric Radiology Unit, Pediatric Hospital "Giovanni XXIII", Bari, Italy
| | - Leonardo Milella
- Intensive Care Unit, Pediatric Hospital "Giovanni XXIII", Bari, Italy
| | - Maria Chironna
- Department of Biomedical Science and Human Oncology, University of Bari "Aldo Moro", Bari, Italy
| | - Cinzia Germinario
- Department of Biomedical Science and Human Oncology, University of Bari "Aldo Moro", Bari, Italy
| | - Gaia Scavia
- Food Safety, Nutrition and Veterinary Public Health Department, National Institute of Health, Rome, Italy
| | - Loreto Gesualdo
- Nephrology, Dialysis and Transplantation Unit, Department of Emergency and Organ Transplantation, University of Bari "Aldo Moro", Bari, Italy
| | - Mario Giordano
- Pediatric Nephrology and Dialysis Unit, Pediatric Hospital "Giovanni XXIII", Bari, Italy.
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Abstract
Hemolytic uremic syndrome (HUS) is the clinical triad of thrombocytopenia, anemia, and acute kidney injury. Classically associated with enterocolitis from Shiga toxin-producing Escherichia coli, HUS is also associated with Streptococcus pneumoniae infections; genetic dysregulation of the alternative complement pathway or coagulation cascade; and, rarely, a hereditary disorder of cobalamin C metabolism. These share a common final pathway of a prothrombotic and proinflammatory state on the endothelial cell surface, with fibrin and platelet deposition. Much work has been done to distinguish between the different mechanisms of disease, thereby informing the optimal therapeutic interventions for each entity.
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Affiliation(s)
- Ellen M Cody
- Department of Pediatrics, University of Colorado School of Medicine, 13123 East 16th Avenue, Box 158, Aurora, CO 80045, USA
| | - Bradley P Dixon
- Departments of Pediatrics & Medicine, University of Colorado School of Medicine, 12631 E. 17th Avenue, Aurora, CO 80045, USA.
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26
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Buelli S, Zoja C, Remuzzi G, Morigi M. Complement Activation Contributes to the Pathophysiology of Shiga Toxin-Associated Hemolytic Uremic Syndrome. Microorganisms 2019; 7:microorganisms7010015. [PMID: 30634669 PMCID: PMC6352217 DOI: 10.3390/microorganisms7010015] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 12/21/2018] [Accepted: 01/07/2019] [Indexed: 02/06/2023] Open
Abstract
Shiga toxin (Stx)-producing Escherichia coli (STEC) infections have become a threat to public health globally because of the severe illnesses that they can trigger, such as hemorrhagic colitis and the post-diarrheal hemolytic uremic syndrome (HUS), characterized by microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney failure. Glomerular endothelial cells are primary targets of Stx which, after binding to its specific receptor globotriaosylceramide, upregulates proinflammatory proteins involved both in the recruitment and adhesion of leukocytes and thrombus formation at the site of endothelial injury. In this review, we discuss the role of complement activation in promoting glomerular microvascular dysfunction, providing evidence from experimental models and patients with STEC-HUS. Within the glomerulus, an important target for Stx-induced complement activation is the podocyte, a cell type that is in close contact with endothelial cells and participates in maintaining the filtration barrier. Recently, podocyte injury and loss have been indicated as potential risk factors for long-term renal sequelae in patients with STEC-HUS. Therapeutic approaches targeting the complement system, that may be useful options for patients with STEC-HUS, will also be discussed.
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Affiliation(s)
- Simona Buelli
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, 24126 Bergamo, Italy.
| | - Carlamaria Zoja
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, 24126 Bergamo, Italy.
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, 24126 Bergamo, Italy.
- L. Sacco Department of Biomedical and Clinical Sciences, University of Milan, 20157 Milan, Italy.
| | - Marina Morigi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, 24126 Bergamo, Italy.
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27
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Eculizumab in the treatment of Shiga toxin haemolytic uraemic syndrome. Pediatr Nephrol 2019; 34:1485-1492. [PMID: 30058046 PMCID: PMC6660499 DOI: 10.1007/s00467-018-4025-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 07/02/2018] [Accepted: 07/11/2018] [Indexed: 12/26/2022]
Abstract
Haemolytic uraemic syndrome (HUS) remains a leading cause of paediatric acute kidney injury (AKI). Haemolytic uraemic syndrome is characterised by the triad of microangiopathic haemolytic anaemia, thrombocytopenia and AKI. In ~ 90% of cases, HUS is a consequence of infection with Shiga toxin-producing E. coli (STEC), most commonly serotype O157:H7. Acute mortality from STEC-HUS is now less than 5%; however, there is significant long-term renal morbidity in one third of survivors. Currently, no specific treatment exists for STEC-HUS. There is growing interest in the role of complement in the pathogenesis of STEC-HUS due to the discovery of inherited and acquired dysregulation of the alternative complement system in the closely related disorder, atypical HUS (aHUS). The treatment of aHUS has been revolutionised by the introduction of the anti-C5 monoclonal antibody, eculizumab. However, the role of complement and anti-complement therapy in STEC-HUS remains unclear. Herein, we review the current evidence of the role of complement in STEC-HUS focusing on the use of eculizumab in this disease.
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28
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Ağbaş A, Göknar N, Akıncı N, Yıldırım ZY, Taşdemir M, Benzer M, Gökçe İ, Candan C, Küçük N, Uzuner S, Özçelik G, Demirkol D, Sever L, Çalışkan S. Outbreak of Shiga toxin-producing Escherichia-coli-associated hemolytic uremic syndrome in Istanbul in 2015: outcome and experience with eculizumab. Pediatr Nephrol 2018; 33:2371-2381. [PMID: 30159625 DOI: 10.1007/s00467-018-4033-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 07/04/2018] [Accepted: 07/23/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND This study aims to identify epidemiological and clinical characteristics of patients and report our experience with eculizumab treatment during an outbreak of hemolytic uremic syndrome (HUS) caused by Shiga toxin-producing Escherichia coli (STEC) in Istanbul in 2015. METHODS Thirty-two children (21 females, median age 3.25 years) were included in this study. Demographic, clinical and laboratory data, and treatment details were retrospectively collected. Renal outcomes were assessed at last follow-up visit. To assess the effect of eculizumab on prognosis of STEC-HUS, subgroup analysis was performed on patients who required dialysis. RESULTS A high number of cases occurred within a certain region of Istanbul. Stool samples were cultured from 21 patients (65%), and enteroaggregative E. coli (EAEC; n = 7) and enterohemorrhagic E. coli (EHEC; n = 3) strains were detected. Rates of dialysis treatment, neurological manifestations, and death were 59%, 25%, and 3%, respectively. Mean follow-up duration was 8.6 ± 2.6 months (range 3-12 months). None of the patients (n = 25) was on dialysis at the final visit. The complete renal recovery rate was 54%. Nine patients were treated with eculizumab. At final follow-up visit, no differences in estimated glomerular filtration rate, proteinuria level, or hypertension incidence were observed between patients treated with eculizumab and those not treated with eculizumab. CONCLUSIONS An outbreak of EAEC occurred in a specific region of Istanbul. Livestock markets were suspected as the source. Evidence for beneficial effects of eculizumab on renal outcome was not clear in this cohort.
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Affiliation(s)
- Ayşe Ağbaş
- Pediatric Nephrology, Cerrahpaşa Faculty of Medicine, Istanbul University, Istanbul, Turkey.
| | - Nilüfer Göknar
- Pediatric Nephrology, Bezmialem Vakıf University, Istanbul, Turkey
| | - Nurver Akıncı
- Pediatric Nephrology, Şişli Hamidiye Etfal Education and Research Hospital, Istanbul, Turkey
| | - Zeynep Yürük Yıldırım
- Pediatric Nephrology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Mehmet Taşdemir
- Pediatric Nephrology, Faculty of Medicine, Koç University, Istanbul, Turkey
| | - Meryem Benzer
- Pediatric Nephrology, Bakırköy Dr Sadi Konuk Education and Research Hospital, Istanbul, Turkey
| | - İbrahim Gökçe
- Pediatric Nephrology, Faculty of Medicine, Marmara University, Istanbul, Turkey
| | - Cengiz Candan
- Pediatric Nephrology, Faculty of Medicine, Medeniyet University, Istanbul, Turkey
| | - Nuran Küçük
- Pediatric Nephrology, Kartal Education and Research Hospital, Istanbul, Turkey
| | - Selçuk Uzuner
- Pediatric Intensive Care Unit, Faculty of Medicine, Bezmialem Vakıf University, Istanbul, Turkey
| | - Gül Özçelik
- Pediatric Nephrology, Şişli Hamidiye Etfal Education and Research Hospital, Istanbul, Turkey
| | - Demet Demirkol
- Pediatric Intensive Care Unit, Faculty of Medicine, Koç University, Istanbul, Turkey.,Pediatric Intensive Care Unit, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Lale Sever
- Pediatric Nephrology, Cerrahpaşa Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Salim Çalışkan
- Pediatric Nephrology, Cerrahpaşa Faculty of Medicine, Istanbul University, Istanbul, Turkey
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29
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Keenswijk W, Raes A, De Clerck M, Vande Walle J. Is Plasma Exchange Efficacious in Shiga Toxin‐Associated Hemolytic Uremic Syndrome? A Narrative Review of Current Evidence. Ther Apher Dial 2018; 23:118-125. [DOI: 10.1111/1744-9987.12768] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Revised: 09/01/2018] [Accepted: 10/12/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Werner Keenswijk
- Department of Pediatrics, Pediatric NephrologyGhent University Hospital Ghent Belgium
- Department of PediatricsDiakonessenhuis Utrecht The Netherlands
| | - Ann Raes
- Department of Pediatrics, Pediatric NephrologyGhent University Hospital Ghent Belgium
| | - Marieke De Clerck
- Department of Pediatrics, Pediatric NephrologyGhent University Hospital Ghent Belgium
| | - Johan Vande Walle
- Department of Pediatrics, Pediatric NephrologyGhent University Hospital Ghent Belgium
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30
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Ardissino G, Tel F, Testa S, Paglialonga F, Longhi S, Martelli L, Consolo S, Picicco D, Dodaro A, Daprai L, Colombo R, Arghittu M, Perrone M, Chidini G, Scalia Catenacci S, Cropanese I, Consonni D. A simple prognostic index for Shigatoxin-related hemolytic uremic syndrome at onset: data from the ItalKid-HUS network. Eur J Pediatr 2018; 177:1667-1674. [PMID: 30094644 DOI: 10.1007/s00431-018-3198-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 06/09/2018] [Accepted: 06/19/2018] [Indexed: 10/28/2022]
Abstract
Shigatoxin Escherichia coli-related hemolytic uremic syndrome (eHUS) is a severe thrombotic microangiopathy (TMA) burdened by life-threatening complications and long-term sequelae. Since hemoconcentration is associated with worse outcome, we tried to develop a reliable and easy-to-calculate index for predicting complications and sequelae based on hemoglobin (Hb) at presentation. The first laboratory examinations with signs of TMA in eHUS patients were analyzed in relation to the outcomes with the receiver operating characteristic curves and their areas under the curve (AUC) for Hb and creatinine (sCr). A total of 197 eHUS patients were identified of whom 24% did not have anemia at presentation. Hb level was the best predictor of a poor outcome (AUC 0.67) but the combination of Hb with sCr, in the formula [(Hb in g/dL + (sCr in mg/dL × 2)], showed an even better AUC of 0.75. The described scoring system was also strongly associated and predictive of all complications and health care needs (8% of patients with scoring > 13 died or entered a permanent vegetative state compared with 0% of those with ≤ 13).Conclusion: The presented score is a simple and early predictor of both short- and long-term outcomes and identifies patients who should undergo rapid volume expansion to counteract hemoconcentration, the spreading of microvascular thrombosis, and the consequent increased organ damage. What is Known: • In eHUS, hemoconcentration is associated with worse short- and long-term outcome. • A prognostic index to identify patients at higher risk for complications at presentation is not available. What is New: • We developed a simple and early prognostic index for eHUS outcome with the combination of Hb and sCr at onset, in the following formula [(Hb in g/dL + (sCr in mg/dL × 2)]. • The proposed HUS Severity Score can promptly identify patients with good outcome and those with high risk of worse short- and long-term outcome.
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Affiliation(s)
- Gianluigi Ardissino
- Center for HUS Prevention Control and Management, Pediatric Nephrology, Dialysis and Transplantation Unit, IRCCS Foundation Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy.
| | - Francesca Tel
- Center for HUS Prevention Control and Management, Pediatric Nephrology, Dialysis and Transplantation Unit, IRCCS Foundation Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Sara Testa
- Center for HUS Prevention Control and Management, Pediatric Nephrology, Dialysis and Transplantation Unit, IRCCS Foundation Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Fabio Paglialonga
- Center for HUS Prevention Control and Management, Pediatric Nephrology, Dialysis and Transplantation Unit, IRCCS Foundation Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Selena Longhi
- Center for HUS Prevention Control and Management, Pediatric Nephrology, Dialysis and Transplantation Unit, IRCCS Foundation Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Laura Martelli
- Center for HUS Prevention Control and Management, Pediatric Nephrology, Dialysis and Transplantation Unit, IRCCS Foundation Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Silvia Consolo
- Center for HUS Prevention Control and Management, Pediatric Nephrology, Dialysis and Transplantation Unit, IRCCS Foundation Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Damiano Picicco
- Center for HUS Prevention Control and Management, Laboratory of Microbiology, IRCCS Foundation Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Antonella Dodaro
- Center for HUS Prevention Control and Management, Laboratory of Microbiology, IRCCS Foundation Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Laura Daprai
- Center for HUS Prevention Control and Management, Laboratory of Microbiology, IRCCS Foundation Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Rosaria Colombo
- Center for HUS Prevention Control and Management, Laboratory of Microbiology, IRCCS Foundation Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Milena Arghittu
- Center for HUS Prevention Control and Management, Laboratory of Microbiology, IRCCS Foundation Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Michela Perrone
- Center for HUS Prevention Control and Management, Neonatal Intensive Care Unit, IRCCS Foundation Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Giovanna Chidini
- Center for HUS Prevention Control and Management, Maternal-Child Anesthesia and Intensive Care Departement, IRCCS Foundation Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Stefano Scalia Catenacci
- Center for HUS Prevention Control and Management, Maternal-Child Anesthesia and Intensive Care Departement, IRCCS Foundation Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Isabella Cropanese
- Center for HUS Prevention Control and Management, Child and Adolescent Neuropsychiatric Unit, IRCCS Foundation Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy
| | - Dario Consonni
- Center for HUS Prevention Control and Management at the Epidemiology Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy
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31
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Eculizumab in STEC-HUS: need for a proper randomized controlled trial. Pediatr Nephrol 2018; 33:1277-1281. [PMID: 29774464 DOI: 10.1007/s00467-018-3972-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 04/30/2018] [Indexed: 10/16/2022]
Abstract
Hemolytic uremic syndrome caused by Shiga toxin-producing E. coli (STEC-HUS) is often associated with a severe morbidity including neurological involvement and a mortality of 1-5%. Although STEC-HUS is often self-limited, improvement of treatment strategies is needed for cases with complications and, among others, plasma exchange/plasmapheresis and use of antibiotics have been advocated. With the availability of the complement blocker eculizumab, now a standard treatment of atypical HUS, several series have addressed its use in STEC-HUS, with variable response; randomized controlled trials are lacking.In this issue of Pediatric Nephrology, Pecheron et al. present a cohort of 33 pediatric patients with severe HUS treated with eculizumab. Neurological involvement was observed in 85% of the patients and 94% required dialysis. Most patients (55%) did not benefit from eculizumab and renal dysfunction as well as neurological sequelae did not resolve. In a subgroup of patients, however, rapid neurological improvement was described. In the post-hoc-defined group of patients with favorable outcome, there was a trend towards more sustained complement inhibition, although this finding was not significant compared to patients with an unfavorable outcome.Because multiple interventions were used and the study did not include any control group, future controlled studies are urgently needed to resolve the debate as to whether eculizumab can be an effective treatment for both prevention and treatment of complications in STEC-HUS.
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32
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Percheron L, Gramada R, Tellier S, Salomon R, Harambat J, Llanas B, Fila M, Allain-Launay E, Lapeyraque AL, Leroy V, Adra AL, Bérard E, Bourdat-Michel G, Chehade H, Eckart P, Merieau E, Piètrement C, Sellier-Leclerc AL, Frémeaux-Bacchi V, Dimeglio C, Garnier A. Eculizumab treatment in severe pediatric STEC-HUS: a multicenter retrospective study. Pediatr Nephrol 2018; 33:1385-1394. [PMID: 29572749 DOI: 10.1007/s00467-018-3903-9] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Revised: 01/20/2018] [Accepted: 01/24/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Hemolytic uremic syndrome related to Shiga-toxin-secreting Escherichia coli infection (STEC-HUS) remains a common cause of acute kidney injury in young children. No specific treatment has been validated for this severe disease. Recently, experimental studies highlight the potential role of complement in STEC-HUS pathophysiology. Eculizumab (EC), a monoclonal antibody against terminal complement complex, has been used in severe STEC-HUS patients, mostly during the 2011 German outbreak, with conflicting results. METHODS On behalf of the French Society of Pediatric Nephrology, we retrospectively studied 33 children from 15 centers treated with EC for severe STEC-HUS. Indication for EC was neurologic involvement in 20 patients, cardiac and neurologic involvement in 8, cardiac involvement in 2, and digestive involvement in 3. Based on medical status at last follow-up, patients were divided into two groups: favorable (n = 15) and unfavorable outcomes (n = 18). RESULTS Among patients with favorable outcome, 11/14 patients (79%) displayed persistent blockade of complement activity before each EC reinjection. Conversely, in patients with unfavorable outcome, only 9/15 (53%) had persistent blockade (p = n.s.). Among 28 patients presenting neurological symptoms, 19 had favorable neurological outcome including 17 with prompt recovery following first EC injection. Only two adverse effects potentially related to EC treatment were reported. CONCLUSIONS Taken together, these results may support EC use in severe STEC-HUS patients, especially those presenting severe neurological symptoms. The study, however, is limited by absence of a control group and use of multiple therapeutic interventions in treatment groups. Thus, prospective, controlled trials should be undertaken.
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Affiliation(s)
- Lucas Percheron
- Service de Néphrologie Pédiatrique, Hôpital des enfants, CHU Purpan, Toulouse, France.
| | - Raluca Gramada
- Service de Neuroradiologie Diagnostique et Thérapeutique, CHU Purpan, Toulouse, France
| | - Stéphanie Tellier
- Service de Néphrologie Pédiatrique, Hôpital des enfants, CHU Purpan, Toulouse, France
| | - Remi Salomon
- Service de Néphrologie Pédiatrique, Hôpital Necker Enfants Malades, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Jérôme Harambat
- Service de Néphrologie Pédiatrique, Hôpital Pellegrin-Enfants, CHU Bordeaux, Bordeaux, France
| | - Brigitte Llanas
- Service de Néphrologie Pédiatrique, Hôpital Pellegrin-Enfants, CHU Bordeaux, Bordeaux, France
| | - Marc Fila
- Service de Néphrologie Pédiatrique, Hôpital Robert Debré-Paris, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Emma Allain-Launay
- Service de Néphrologie Pédiatrique, Hôpital Mère-Enfants, CHU Nantes, Nantes, France
| | - Anne-Laure Lapeyraque
- Service de Néphrologie Pédiatrique, CHU de Sainte-Justine à Montréal Canada, Montréal, Canada
| | - Valerie Leroy
- Service de Néphrologie Pédiatrique, Hôpital Jeanne de Flandre, CHU Lille, Lille, France
| | - Anne-Laure Adra
- Service de Néphrologie Pédiatrique, Hôpital Arnaud de Villeneuve, CHU Montpellier, Montpellier, France
| | - Etienne Bérard
- Service de Néphrologie Pédiatrique, Hôpital Archet 2, CHU Nice, Nice, France
| | | | - Hassid Chehade
- Service de Néphrologie Pédiatrique, CHU de Lausanne Suisse, Lausanne, Switzerland
| | - Philippe Eckart
- Service de Pédiatrie Médicale, Hôpital côte de nacre, CHU Caen, Caen, France
| | - Elodie Merieau
- Service de Néphrologie, Hôpital Clocheville, CHU Tours, Tours, France
| | | | | | - Véronique Frémeaux-Bacchi
- Laboratoire d'immunologie, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Chloe Dimeglio
- Biostatistiques, Informatique Médicale, UMR 1027 Inserm, Université Paul Sabatier, Toulouse, France
| | - Arnaud Garnier
- Service de Néphrologie Pédiatrique, Hôpital des enfants, CHU Purpan, Toulouse, France.
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Taroyan G, Juergens AL. Enterohemorrhagic colitis with disseminated intravascular coagulation. Proc (Bayl Univ Med Cent) 2018; 31:319-320. [DOI: 10.1080/08998280.2018.1463776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 04/05/2018] [Accepted: 04/09/2018] [Indexed: 10/16/2022] Open
Affiliation(s)
- Gregory Taroyan
- Department of Emergency Medicine, Scott & White Medical Center, Temple, Texas
| | - Andrew L. Juergens
- Department of Emergency Medicine, Scott & White Medical Center, Temple, Texas
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Fakhouri F, Loirat C. Anticomplement Treatment in Atypical and Typical Hemolytic Uremic Syndrome. Semin Hematol 2018; 55:150-158. [DOI: 10.1053/j.seminhematol.2018.04.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 04/13/2018] [Indexed: 01/06/2023]
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Molecular Mechanisms Governing "Hair-Trigger" Induction of Shiga Toxin-Encoding Prophages. Viruses 2018; 10:v10050228. [PMID: 29710828 PMCID: PMC5977221 DOI: 10.3390/v10050228] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 04/25/2018] [Accepted: 04/25/2018] [Indexed: 01/12/2023] Open
Abstract
Shiga toxin (Stx)-encoding E. coli (STEC) strains are responsible for sporadic outbreaks of food poisoning dating to 1982, when the first STEC strain, E. coli O157:H7, was isolated. Regardless of STEC serotype, the primary symptoms of STEC infections are caused by Stx that is synthesized from genes resident on lambdoid prophage present in STEC. Despite similar etiology, the severity of STEC-mediated disease varies by outbreak. However, it is unclear what modulates the severity of STEC-mediated disease. Stx production and release is controlled by lytic growth of the Stx-encoding bacteriophage, which in turn, is controlled by the phage repressor. Here, we confirm our earlier suggestion that the higher spontaneous induction frequency of Stx-encoding prophage is a consequence, in part, of lower intracellular repressor levels in STEC strains versus non-STEC strains. We also show that this lowered intracellular repressor concentration is a consequence of the utilization of alternative binding/regulatory strategies by the phage repressor. We suggest that a higher spontaneous induction frequency would lead to increased virulence.
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Radtke J, Schild R, Reismann M, Ridwelski RR, Kempf C, Nashan B, Rothe K, Koch M. Obstruction of peritoneal dialysis catheter is associated with catheter type and independent of omentectomy: A comparative data analysis from a transplant surgical and a pediatric surgical department. J Pediatr Surg 2018; 53:640-643. [PMID: 28728828 DOI: 10.1016/j.jpedsurg.2017.06.028] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Revised: 06/29/2017] [Accepted: 06/30/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND Peritoneal dialysis (PD) catheter occlusion is a common complication with up to 36% of catheter obstructions described in the literature. We present a comparison of complications and outcome after implantation of PD catheters in a transplant surgical and a pediatric surgical department. METHODS We retrospectively analyzed 154 PD catheters, which were implanted during 2009-2015 by transplant surgeons (TS, University Medical Center Hamburg-Eppendorf, Germany, n=85 catheters) and pediatric surgeons (PS, Charité University Medicine Berlin, Germany, n=69 catheters) in 122 children (median (range) age 3.0 (0.01-17.1) years) for acute (n=65) or chronic (n=89) renal failure. All catheters were one-cuffed or double-cuffed curled catheters, except that straight catheters were implanted into smaller children (n=19) by TS in Hamburg. RESULTS Patient characteristics and operation technique did not differ between the departments. Peritonitis was the most common complication (33 catheters, 21.4%). Leakage (n=18 catheters, 11.7%) occurred more often in children weighing <10kg (p<0.001). The incidence of obstruction and dysfunction was significantly higher in catheters used in PS than catheters used in TS (30.4% vs. 11.8%, p=0.004). Omentectomy did not reduce the incidence of catheter obstruction (p=1.0). Perforation at the catheter tips was larger and appeared to be rougher in catheters used in PS than the catheters in TS. CONCLUSIONS The type of catheter and presumably the type of perforation at the catheter tip may influence the incidence of peritoneal dialysis catheter obstruction.
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Affiliation(s)
- Josephine Radtke
- Department of Hepatobiliary and Transplant Surgery, University Medical Center Hamburg-Eppendorf UKE, University Transplantation Center UTC, Hamburg, Germany; Department of Pediatric Surgery, Charité University Medicine Berlin, Berlin, Germany.
| | - Raphael Schild
- Department of Pediatric Nephrology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marc Reismann
- Department of Pediatric Surgery, Charité University Medicine Berlin, Berlin, Germany
| | | | - Caroline Kempf
- Department of Pediatric Nephrology, Charité University Medicine Berlin, Berlin, Germany
| | - Bjoern Nashan
- Department of Hepatobiliary and Transplant Surgery, University Medical Center Hamburg-Eppendorf UKE, University Transplantation Center UTC, Hamburg, Germany
| | - Karin Rothe
- Department of Pediatric Surgery, Charité University Medicine Berlin, Berlin, Germany
| | - Martina Koch
- Department of Hepatobiliary and Transplant Surgery, University Medical Center Hamburg-Eppendorf UKE, University Transplantation Center UTC, Hamburg, Germany
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Keenswijk W, Raes A, Vande Walle J. Is eculizumab efficacious in Shigatoxin-associated hemolytic uremic syndrome? A narrative review of current evidence. Eur J Pediatr 2018; 177:311-318. [PMID: 29288280 DOI: 10.1007/s00431-017-3077-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Revised: 12/16/2017] [Accepted: 12/20/2017] [Indexed: 01/09/2023]
Abstract
UNLABELLED Severe complications due to Shigatoxin-associated hemolytic uremic syndrome (STEC-HUS) currently present a serious challenge since no specific treatment for this condition is available. Eculizumab, a terminal complement inhibitor, has been used especially in STEC-HUS patients with severe neurological involvement, but the efficacy remains undetermined. In order to determine its efficacy, we searched the databases Pubmed, Web of Science, Embase, and LiLACS for reports describing outcomes of eculizumab administration in STEC-HUS. We retrieved 11 reports ranging from case reports to cohort studies with the largest study population emanating from the 2011 German outbreak. Outcomes were variable and difficult to interpret in light of the absence of high-quality studies but seemed to point towards potential efficacy of eculizumab if administered early in the course. CONCLUSION The efficacy of eculizumab in STEC-HUS could not be established nor disproven based on current data, and there is a desperate need for randomized controlled trials. What is known? • Eculizumab has been used in complicated cases of Shigatoxin-associated hemolytic uremic syndrome but the efficacy remains unknown? What is new? • Eculizumab might be efficacious if given early in selected cases of Shigatoxin-associated hemolytic uremic syndrome; however, randomized trials are needed to assess this.
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Affiliation(s)
- Werner Keenswijk
- Department of Pediatrics, Pediatric Nephrology, Ghent University Hospital, Ghent, Belgium. .,Department of Pediatrics, Diakonessenhuis , Paramaribo, Suriname.
| | - Ann Raes
- Department of Pediatrics, Pediatric Nephrology, Ghent University Hospital, Ghent, Belgium
| | - Johan Vande Walle
- Department of Pediatrics, Pediatric Nephrology, Ghent University Hospital, Ghent, Belgium
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Loos S, Aulbert W, Hoppe B, Ahlenstiel-Grunow T, Kranz B, Wahl C, Staude H, Humberg A, Benz K, Krause M, Pohl M, Liebau MC, Schild R, Lemke J, Beringer O, Müller D, Härtel C, Wigger M, Vester U, Konrad M, Haffner D, Pape L, Oh J, Kemper MJ. Intermediate Follow-up of Pediatric Patients With Hemolytic Uremic Syndrome During the 2011 Outbreak Caused by E. coli O104:H4. Clin Infect Dis 2018; 64:1637-1643. [PMID: 28329394 DOI: 10.1093/cid/cix218] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Accepted: 03/07/2017] [Indexed: 11/15/2022] Open
Abstract
Background. In 2011 Escherichia coli O104:H4 caused an outbreak with >800 cases of hemolytic uremic syndrome (HUS) in Germany, including 90 children. Data on the intermediate outcome in children after HUS due to E. coli O104:H4 have been lacking. Methods. Follow-up data were gathered retrospectively from the medical records of patients who had been included in the German Pediatric HUS Registry during the 2011 outbreak. Results. Seventy-two of the 89 (81%) patients were included after a median follow-up of 3.0 (0.9-4.7) years. Hypertension and proteinuria were present in 19% and 28% of these patients, respectively. Of 4 patients with chronic kidney disease (CKD) > stage 2 at short-term follow-up, 1 had a normalized estimated glomerular filtration rate, and 3 (4%) had persistent CKD > stage 2. In 1 of these patients, CKD improved from stage 4 to 3; 1 who had CKD stage 5 at presentation received kidney transplantation; and 1 patient required further hemodialysis during follow-up. One patient (1.4%) still had major neurological symptoms at the latest follow-up. Dialysis during the acute phase (P = .01), dialysis duration (P = .01), and the duration of oligo-/anuria (P = .005) were associated with the development of renal sequelae. Patients treated with eculizumab (n = 11) and/or plasmapheresis (n = 13) during the acute phase of HUS had comparable outcomes. Conclusions. The overall outcome of pediatric patients after HUS due to E. coli O104:H4 was equivalent to previous reports on HUS due to other types of Shiga toxin-producing E. coli (STEC). Regular follow-up visits in patients are recommended after STEC-HUS.
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Affiliation(s)
- Sebastian Loos
- University Children's Hospital, University Medical Center Hamburg-Eppendorf
| | - Wiebke Aulbert
- University Children's Hospital, University Medical Center Hamburg-Eppendorf
| | - Bernd Hoppe
- Department of Pediatric Nephrology, University Children's Hospital Bonn
| | | | - Birgitta Kranz
- Department of General Pediatrics, Pediatric Nephrology, University Children's Hospital Muenster
| | | | - Hagen Staude
- Department of Pediatrics, University Hospital Rostock
| | - Alexander Humberg
- Department of Pediatrics, University Hospital Schleswig-Holstein, Lu¨beck
| | - Kerstin Benz
- Department of Pediatrics, University Hospital Erlangen
| | - Martin Krause
- Department of Pediatrics, University Hospital Schleswig-Holstein, Kiel
| | - Martin Pohl
- Department of Pediatrics, University Hospital Freiburg
| | - Max C Liebau
- Department of Pediatrics, Department II of Internal Medicine, Center for Molecular Medicine, Cologne Excellence Cluster on Cellular Stress Responses in Ageing-Associated Diseases (CECAD), and Systems Biology of Ageing Cologne (Sybacol), University of Cologne
| | - Raphael Schild
- University Children's Hospital, University Medical Center Hamburg-Eppendorf
| | - Johanna Lemke
- University Children's Hospital, University Medical Center Hamburg-Eppendorf
| | | | | | - Christoph Härtel
- Department of Pediatrics, University Hospital Schleswig-Holstein, Lu¨beck
| | | | - Udo Vester
- Department of Pediatrics, University Hospital Essen
| | - Martin Konrad
- Department of General Pediatrics, Pediatric Nephrology, University Children's Hospital Muenster
| | - Dieter Haffner
- Departement of Pediatric Nephrology, Medical School Hannover
| | - Lars Pape
- Departement of Pediatric Nephrology, Medical School Hannover
| | - Jun Oh
- University Children's Hospital, University Medical Center Hamburg-Eppendorf
| | - Markus J Kemper
- University Children's Hospital, University Medical Center Hamburg-Eppendorf
- Department of Pediatrics, AK Hamburg Nord, Asklepios Medical School, Germany
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Abstract
Thrombotic microangiopathy can manifest in a diverse range of diseases and is characterized by thrombocytopenia, microangiopathic hemolytic anemia, and organ injury, including AKI. It can be associated with significant morbidity and mortality, but a systematic approach to investigation and prompt initiation of supportive management and, in some cases, effective specific treatment can result in good outcomes. This review considers the classification, pathology, epidemiology, characteristics, and pathogenesis of the thrombotic microangiopathies, and outlines a pragmatic approach to diagnosis and management.
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Affiliation(s)
- Vicky Brocklebank
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne, Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, UK
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK; and
| | - Katrina M. Wood
- Department of Cellular Pathology, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, UK
| | - David Kavanagh
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne, Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, UK
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK; and
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Kampmeier S, Berger M, Mellmann A, Karch H, Berger P. The 2011 German Enterohemorrhagic Escherichia Coli O104:H4 Outbreak-The Danger Is Still Out There. Curr Top Microbiol Immunol 2018; 416:117-148. [PMID: 30062592 DOI: 10.1007/82_2018_107] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Enterohemorrhagic Escherichia coli (EHEC) are Shiga toxin (Stx) producing bacteria causing a disease characterized by bloody (or non-bloody) diarrhea, which might progress to hemolytic uremic syndrome (HUS). EHEC O104:H4 caused the largest ever recorded EHEC outbreak in Germany in 2011, which in addition showed the so far highest incidence rate of EHEC-related HUS worldwide. The aggressive outbreak strain carries an unusual combination of virulence traits characteristic to both EHEC-a chromosomally integrated Stx-encoding bacteriophage, and enteroaggregative Escherichia coli-pAA plasmid-encoded aggregative adherence fimbriae mediating its tight adhesion to epithelia cells. There are currently still open questions regarding the 2011 EHEC outbreak, e.g., with respect to the exact molecular mechanisms resulting in the hypervirulence of the strain, the natural reservoir of EHEC O104:H4, and suitable therapeutic strategies. Nevertheless, our knowledge on these issues has substantially expanded since 2011. Here, we present an overview of the epidemiological, clinical, microbiological, and molecular biological data available on the 2011 German EHEC O104:H4 outbreak.
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Affiliation(s)
| | - Michael Berger
- Institute of Hygiene, University of Münster, Münster, Germany
| | | | - Helge Karch
- Institute of Hygiene, University of Münster, Münster, Germany
| | - Petya Berger
- Institute of Hygiene, University of Münster, Münster, Germany.
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41
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Vaterodt L, Holle J, Hüseman D, Müller D, Thumfart J. Short- and Long-Term Renal Outcome of Hemolytic-Uremic Syndrome in Childhood. Front Pediatr 2018; 6:220. [PMID: 30131950 PMCID: PMC6090047 DOI: 10.3389/fped.2018.00220] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 07/18/2018] [Indexed: 12/16/2022] Open
Abstract
Introduction: Hemolytic-uremic syndrome (HUS) is a common cause for intrarenal acute kidney injury in childhood. More than 90% of HUS cases are associated with an infection by Shigatoxin-producing Escherichia coli (STEC) whereas the reminder comprises a heterogeneous group (here classified as Non-STEC-HUS). Renal impairment can persist in patients with HUS. This study presents data from four decades investigating the short- and long-term outcome of HUS in childhood. Materials and Methods: In a retrospective single-center-study clinical and laboratory data of the acute phase and of 1- to 10-year follow-up visits of children with HUS were analyzed. Results: 92 HUS-patients were identified from 1996 to 2014 (STEC-HUS-group: n = 76; Non-STEC-HUS-group: n = 16) and 220 HUS-patients between 1976 and 1995. STEC-HUS was increasingly caused by Non-O157 strains and mortality rate declined over the past decades (1.3 vs. 9.5%). Renal sequelae persisted more often in the group 1976-1995 (39.3%) than in the group 1996-2014 (28.3%), but more than 50% of all patients were lost to follow-up. Conclusion: Although renal outcome has improved over the investigated last decades, patients with HUS still face a high risk of permanent renal damage. These findings underline the importance of a consequent long-term follow-up in HUS-patients.
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Affiliation(s)
- Laura Vaterodt
- Department of Pediatric Gastroenterology, Nephrology and Metabolic Diseases, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Johannes Holle
- Department of Pediatric Pneumology and Immunology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Dieter Hüseman
- Department of Pediatrics, Werner-Forßmann-Krankenhaus, Eberswalde, Germany
| | - Dominik Müller
- Department of Pediatric Gastroenterology, Nephrology and Metabolic Diseases, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Julia Thumfart
- Department of Pediatric Gastroenterology, Nephrology and Metabolic Diseases, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Köckerling E, Karrasch L, Schweitzer A, Razum O, Krause G. Public Health Research Resulting from One of the World's Largest Outbreaks Caused by Entero-Hemorrhagic Escherichia coli in Germany 2011: A Review. Front Public Health 2017; 5:332. [PMID: 29312915 PMCID: PMC5732330 DOI: 10.3389/fpubh.2017.00332] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 11/23/2017] [Indexed: 02/04/2023] Open
Abstract
In 2011, Germany experienced one of the largest outbreaks of entero-hemorrhagic Escherichia coli (EHEC) ever reported. Four years thereafter, we systematically searched for scientific publications in PubMed and MEDPILOT relating to this outbreak in order to assess the pattern of respective research activities and to assess the main findings and recommendations in the field of public health. Following PRISMA guidelines, we selected 133 publications, half of which were published within 17 months after outbreak onset. Clinical medicine was covered by 71, microbiology by 60, epidemiology by 46, outbreak reporting by 11, and food safety by 9 papers. Those on the last three topics drew conclusions on methods in surveillance, diagnosis, and outbreak investigation, on resources in public health, as well as on inter-agency collaboration, and public communication. Although the outbreak primarily affected Germany, most publications were conducted by multinational cooperations. Our findings document how soon and in which fields research was conducted with respect to this outbreak.
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Affiliation(s)
- Elena Köckerling
- Department of Epidemiology and International Public Health, Bielefeld University, Bielefeld, Germany.,Department Münster, Institute for Rehabilitation Research IfR, Münster, Germany
| | - Laura Karrasch
- Department of Epidemiology and International Public Health, Bielefeld University, Bielefeld, Germany
| | - Aparna Schweitzer
- Department of Epidemiology, Helmholtz Centre for Infection Research, Braunschweig, Germany
| | - Oliver Razum
- Department of Epidemiology and International Public Health, Bielefeld University, Bielefeld, Germany
| | - Gérard Krause
- Department of Epidemiology, Helmholtz Centre for Infection Research, Braunschweig, Germany.,Hannover Medical School, Hannover, Germany
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Puentes SS, Dunstan M. Escherichia coli Complications in Pediatric Critical Care. Crit Care Nurs Clin North Am 2017; 30:149-156. [PMID: 29413210 DOI: 10.1016/j.cnc.2017.10.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Escherichia coli is a bacterium that is an important part of the intestinal tract; however, it has the potential to become pathogenic. Shiga toxin-producing E coli (STEC) is a leading cause of E coli infections and has led to outbreaks in North America. Transmission is through ingestion of contaminated food sources, and via infected humans and animals. Young children infected with STEC are at high risk for developing hemolytic uremic syndrome (HUS). HUS is a clinical syndrome characterized by macroangiopathic hemolytic anemia, thrombocytopenia, and acute renal failure. Early diagnosis and supportive treatment of HUS are essential to limit complications.
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Affiliation(s)
- Suzanne S Puentes
- Children's Emergency Room, Lehigh Valley Health Network, 1210 South Cedar Crest Boulevard, Allentown, PA 18103, USA.
| | - Michele Dunstan
- Lehigh Valley Health Network, 1210 South Cedar Crest Boulevard, Allentown, PA 18103, USA
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44
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Microvesicle Involvement in Shiga Toxin-Associated Infection. Toxins (Basel) 2017; 9:toxins9110376. [PMID: 29156596 PMCID: PMC5705991 DOI: 10.3390/toxins9110376] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 11/15/2017] [Accepted: 11/16/2017] [Indexed: 12/16/2022] Open
Abstract
Shiga toxin is the main virulence factor of enterohemorrhagic Escherichia coli, a non-invasive pathogen that releases virulence factors in the intestine, causing hemorrhagic colitis and, in severe cases, hemolytic uremic syndrome (HUS). HUS manifests with acute renal failure, hemolytic anemia and thrombocytopenia. Shiga toxin induces endothelial cell damage leading to platelet deposition in thrombi within the microvasculature and the development of thrombotic microangiopathy, mostly affecting the kidney. Red blood cells are destroyed in the occlusive capillary lesions. This review focuses on the importance of microvesicles shed from blood cells and their participation in the prothrombotic lesion, in hemolysis and in the transfer of toxin from the circulation into the kidney. Shiga toxin binds to blood cells and may undergo endocytosis and be released within microvesicles. Microvesicles normally contribute to intracellular communication and remove unwanted components from cells. Many microvesicles are prothrombotic as they are tissue factor- and phosphatidylserine-positive. Shiga toxin induces complement-mediated hemolysis and the release of complement-coated red blood cell-derived microvesicles. Toxin was demonstrated within blood cell-derived microvesicles that transported it to renal cells, where microvesicles were taken up and released their contents. Microvesicles are thereby involved in all cardinal aspects of Shiga toxin-associated HUS, thrombosis, hemolysis and renal failure.
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45
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Brocklebank V, Kavanagh D. Complement C5-inhibiting therapy for the thrombotic microangiopathies: accumulating evidence, but not a panacea. Clin Kidney J 2017; 10:600-624. [PMID: 28980670 PMCID: PMC5622895 DOI: 10.1093/ckj/sfx081] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 06/21/2017] [Indexed: 02/07/2023] Open
Abstract
Thrombotic microangiopathy (TMA), characterized by organ injury occurring consequent to severe endothelial damage, can manifest in a diverse range of diseases. In complement-mediated atypical haemolytic uraemic syndrome (aHUS) a primary defect in complement, such as a mutation or autoantibody leading to over activation of the alternative pathway, predisposes to the development of disease, usually following exposure to an environmental trigger. The elucidation of the pathogenesis of aHUS resulted in the successful introduction of the complement inhibitor eculizumab into clinical practice. In other TMAs, although complement activation may be seen, its role in the pathogenesis remains to be confirmed by an interventional trial. Although many case reports in TMAs other than complement-mediated aHUS hint at efficacy, publication bias, concurrent therapies and in some cases the self-limiting nature of disease make broader interpretation difficult. In this article, we will review the evidence for the role of complement inhibition in complement-mediated aHUS and other TMAs.
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Affiliation(s)
- Vicky Brocklebank
- The National Renal Complement Therapeutics Centre (NRCTC), Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - David Kavanagh
- The National Renal Complement Therapeutics Centre (NRCTC), Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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Fakhouri F, Zuber J, Frémeaux-Bacchi V, Loirat C. Haemolytic uraemic syndrome. Lancet 2017; 390:681-696. [PMID: 28242109 DOI: 10.1016/s0140-6736(17)30062-4] [Citation(s) in RCA: 313] [Impact Index Per Article: 44.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Revised: 10/19/2016] [Accepted: 10/25/2016] [Indexed: 12/17/2022]
Abstract
Haemolytic uraemic syndrome is a form of thrombotic microangiopathy affecting predominantly the kidney and characterised by a triad of thrombocytopenia, mechanical haemolytic anaemia, and acute kidney injury. The term encompasses several disorders: shiga toxin-induced and pneumococcus-induced haemolytic uraemic syndrome, haemolytic uraemic syndrome associated with complement dysregulation or mutation of diacylglycerol kinase ɛ, haemolytic uraemic syndrome related to cobalamin C defect, and haemolytic uraemic syndrome secondary to a heterogeneous group of causes (infections, drugs, cancer, and systemic diseases). In the past two decades, experimental, genetic, and clinical studies have helped to decipher the pathophysiology of these various forms of haemolytic uraemic syndrome and undoubtedly improved diagnostic approaches. Moreover, a specific mechanism-based treatment has been made available for patients affected by atypical haemolytic uraemic syndrome due to complement dysregulation. Such treatment is, however, still absent for several other disease types, including shiga toxin-induced haemolytic uraemic syndrome.
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Affiliation(s)
- Fadi Fakhouri
- Department of Nephrology, Centre Hospitalier Universitaire, and INSERM UMR S1064, Nantes, France
| | - Julien Zuber
- Assistance Publique-Hôpitaux de Paris, Department of Nephrology and Renal Transplantation, Hôpital Necker, Université Paris Descartes, Paris, France
| | - Véronique Frémeaux-Bacchi
- Assistance Publique-Hôpitaux de Paris, Department of Biological Immunology, Hôpital Européen Georges Pompidou, and INSERM UMR S1138, Complément et Maladies, Centre de Recherche des Cordeliers, Paris, France
| | - Chantal Loirat
- Assistance Publique-Hôpitaux de Paris, Department of Pediatric Nephrology, Hôpital Robert Debré, Université Paris Diderot, Sorbonne Paris Cité, Paris, France.
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Diffusion-weighted imaging of the kidneys in haemolytic uraemic syndrome. Eur Radiol 2017; 27:4591-4601. [PMID: 28500363 DOI: 10.1007/s00330-017-4848-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 03/15/2017] [Accepted: 04/10/2017] [Indexed: 12/20/2022]
Abstract
OBJECTIVES To evaluate the kidneys of patients with haemolytic uraemic syndrome (HUS) using diffusion-weighted imaging (DWI) and Doppler ultrasound (US) compared with healthy controls. MATERIALS AND METHODS Fifteen patients (mean age 33.3 years; three male; 12 female) with diarrhoea-positive HUS and 15 healthy volunteers were prospectively evaluated with DWI and Doppler US. A total apparent diffusion coefficient (ADCTOT), and ADCs predominantly reflecting microperfusion (ADCLOW) and diffusion (ADCHIGH) were calculated. Doppler US evaluated renal vascularity and flow. RESULTS When compared with controls, kidneys affected by HUS showed reduced cortical ADC values (ADCTOT 1.79±0.22 vs. 2.04±0.1x10-3 mm2/s, P 0.001), resulting in either low corticomedullary differences (11/15 patients) or an inverted corticomedullary pattern (4/15 patients). Reduction of cortical ADC values was associated with a decrease of cortical vascularity on Doppler US (ADCTOT, P<0.001; ADCLOW, P 0.047). Kidneys with complete absence of the cortical vasculature on Doppler US (four patients) also demonstrated limited diffusion (ADCHIGH, P 0.002). Low glomerular filtration rate, requirement for haemodialysis during hospitalization, and longer duration of haemodialysis were associated with decreased cortical diffusivity (ADCTOT: P 0.04, 0.007, and <0.001, respectively). CONCLUSION DWI shows qualitative and quantitative abnormalities in kidneys affected by HUS, thereby extending the non-invasive assessment of renal parenchymal damage. KEY POINTS • In HUS, DWI is feasible for functional characterization of kidney involvement. • Kidneys affected by HUS showed reduced cortical diffusivity. • Decreased cortical diffusivity was associated with lower kidney function. • Requirement and duration of haemodialysis was linked to degree of cortical alterations.
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Pérez-Cruz FG, Villa-Díaz P, Pintado-Delgado MC, Fernández_Rodríguez ML, Blasco-Martínez A, Pérez-Fernández M. Hemolytic uremic syndrome in adults: A case report. World J Crit Care Med 2017; 6:135-139. [PMID: 28529915 PMCID: PMC5415853 DOI: 10.5492/wjccm.v6.i2.135] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 03/23/2017] [Accepted: 04/10/2017] [Indexed: 02/07/2023] Open
Abstract
Thrombotic microangiopathies (TMA) are microvascular occlusive disorders characterized by platelet aggregation and mechanical damage to erythrocytes, clinically characterized by microangiopatic haemolytic anemia, thrombocytopenia and organ injury. We are reporting a case of a woman patient with severe hemolytic uremic syndrome associated to infectious diarrhoea caused by Shiga toxin-producing pathogen, who were admitted to our intensive care unit. The patient described developed as organ injury, neurological failure and acute renal failure, with need of haemodialysis technique. Due to the severity of the case and the delay in the results of the additional test that help us to the final diagnose, we treated her based on a syndromic approach of TMA with plasma exchange, with favourable clinical evolution with complete recovery of organ failures. We focus on the syndromic approach of these diseases, because thrombotic thrombocytopenic purpura, one of the disorders that are included in the syndromes of TMA, is considered a haematological urgency given their high mortality without treatment; and also review the TMA in adults: Their pathogenesis, management and outcomes.
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Abstract
Haemolytic uraemic syndrome (HUS) is defined by the simultaneous occurrence of nonimmune haemolytic anaemia, thrombocytopenia and acute renal failure. This leads to the pathological lesion termed thrombotic microangiopathy, which mainly affects the kidney, as well as other organs. HUS is associated with endothelial cell injury and platelet activation, although the underlying cause may differ. Most cases of HUS are associated with gastrointestinal infection with Shiga toxin-producing enterohaemorrhagic Escherichia coli (EHEC) strains. Atypical HUS (aHUS) is associated with complement dysregulation due to mutations or autoantibodies. In this review, we will describe the causes of HUS. In addition, we will review the clinical, pathological, haematological and biochemical features, epidemiology and pathogenetic mechanisms as well as the biochemical, microbiological, immunological and genetic investigations leading to diagnosis. Understanding the underlying mechanisms of the different subtypes of HUS enables tailoring of appropriate treatment and management. To date, there is no specific treatment for EHEC-associated HUS but patients benefit from supportive care, whereas patients with aHUS are effectively treated with anti-C5 antibody to prevent recurrences, both before and after renal transplantation.
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Affiliation(s)
- Diana Karpman
- Department of Pediatrics, Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Sebastian Loos
- Department of Pediatrics, Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Ramesh Tati
- Department of Pediatrics, Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Ida Arvidsson
- Department of Pediatrics, Clinical Sciences Lund, Lund University, Lund, Sweden
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Löbel U, Forkert ND, Schmitt P, Dohrmann T, Schroeder M, Magnus T, Kluge S, Weiler-Normann C, Bi X, Fiehler J, Sedlacik J. Cerebral Hemodynamics in Patients with Hemolytic Uremic Syndrome Assessed by Susceptibility Weighted Imaging and Four-Dimensional Non-Contrast MR Angiography. PLoS One 2016; 11:e0164863. [PMID: 27802295 PMCID: PMC5089757 DOI: 10.1371/journal.pone.0164863] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 10/03/2016] [Indexed: 11/18/2022] Open
Abstract
Background and Purpose Conventional magnetic resonance imaging (MRI) of patients with hemolytic uremic syndrome (HUS) and neurological symptoms performed during an epidemic outbreak of Escherichia coli O104:H4 in Northern Europe has previously shown pathological changes in only approximately 50% of patients. In contrast, susceptibility-weighted imaging (SWI) revealed a loss of venous contrast in a large number of patients. We hypothesized that this observation may be due to an increase in cerebral blood flow (CBF) and aimed to identify a plausible cause. Materials and Methods Baseline 1.5T MRI scans of 36 patients (female, 26; male, 10; mean age, 38.2±19.3 years) were evaluated. Venous contrast was rated on standard SWI minimum intensity projections. A prototype four-dimensional (time resolved) magnetic resonance angiography (4D MRA) assessed cerebral hemodynamics by global time-to-peak (TTP), as a surrogate marker for CBF. Clinical parameters studied were hemoglobin, hematocrit, creatinine, urea levels, blood pressure, heart rate, and end-tidal CO2. Results SWI venous contrast was abnormally low in 33 of 36 patients. TTP ranged from 3.7 to 10.2 frames (mean, 7.9 ± 1.4). Hemoglobin at the time of MRI (n = 35) was decreased in all patients (range, 5.0 to 12.6 g/dL; mean, 8.2 ± 1.4); hematocrit (n = 33) was abnormally low in all but a single patient (range, 14.3 to 37.2%; mean, 23.7 ± 4.2). Creatinine was abnormally high in 30 of 36 patients (83%) (range, 0.8 to 9.7; mean, 3.7 ± 2.2). SWI venous contrast correlated significantly with hemoglobin (r = 0.52, P = 0.0015), hematocrit (r = 0.65, P < 0.001), and TTP (r = 0.35, P = 0.036). No correlation of SWI with blood pressure, heart rate, end-tidal CO2, creatinine, and urea level was observed. Findings suggest that the loss of venous contrast is related to an increase in CBF secondary to severe anemia related to HUS. SWI contrast of patients with pathological conventional MRI findings was significantly lower compared to patients with normal MRI (mean SWI score, 1.41 and 2.05, respectively; P = 0.04). In patients with abnormal conventional MRI, mean TTP (7.45), mean hemoglobin (7.65), and mean hematocrit (22.0) were lower compared to patients with normal conventional MRI scans (mean TTP = 8.28, mean hemoglobin = 8.63, mean hematocrit = 25.23). Conclusion In contrast to conventional MRI, almost all patients showed pathological changes in cerebral hemodynamics assessed by SWI and 4D MRA. Loss of venous contrast on SWI is most likely the result of an increase in CBF and may be related to the acute onset of anemia. Future studies will be needed to assess a possible therapeutic effect of blood transfusions in patients with HUS and neurological symptoms.
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Affiliation(s)
- Ulrike Löbel
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- * E-mail:
| | - Nils Daniel Forkert
- Department of Radiology and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | | | - Torsten Dohrmann
- Department of Intensive Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maria Schroeder
- Department of Intensive Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tim Magnus
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christina Weiler-Normann
- Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Martin Zeitz Center for Rare Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Xiaoming Bi
- Siemens Healthcare, Los Angeles, California, United States
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jan Sedlacik
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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