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Balestracci A, Meni Battaglia L, Toledo I, Martin SM, Beaudoin L. Duration of prodromal phase and severity of hemolytic uremic syndrome. Pediatr Nephrol 2024; 39:213-219. [PMID: 37526769 DOI: 10.1007/s00467-023-06104-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 07/16/2023] [Accepted: 07/17/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND Some data have recognized an association between shorter prodromal phase and severe episode of Shiga toxin-producing Escherichia coli-related hemolytic uremic syndrome (STEC-HUS). Our aims were to confirm such association and analyze characteristics of STEC-HUS patients according to duration of the prodromal phase. METHODS Patients treated from 2000 to 2022 were compared according to the presence of severe (> 10 days of dialysis and/or extra-renal complications) or non-severe disease. Association between prodromal phase duration and disease severity was assessed by ROC curve and by classifying the cohort in 3 groups according to time to diagnosis. RESULTS Non-severe (n = 145) and severe (n = 71) cases were compared. The latter had shorter prodromal phase, higher leukocyte count, hemoglobin, lactic dehydrogenase, liver enzymes, C-reactive protein, urea and creatinine, and lower albumin and sodium; only prodromal phase duration (p = 0.02) and leukocyte count (p = 0.02) remained significant in multivariate analysis. By ROC curve analysis, time to diagnosis resulted in a poor predictor of outcomes (AUC = 0.27). Since prodromal phase duration was 5 days (IQR 3-7), we divided the cohort into Groups A (1-2 days), B (3-7 days), and C (≥ 8 days). Rates of severe disease were 75.8%, 29.6%, and 11.4%, respectively. Taking Group B as reference, Group A patients had higher risk of complications (p = 0.00001; OR 7.4, 95% CI: 2.98-18.7) while Group C ones had significantly less risk (p = 0.02; OR 0.3, 95% CI: 0.1-0.91). CONCLUSIONS This study found that duration of prodromal phase is an independent predictor of complicated STEC-HUS and confirms that shorter prodromal phase is associated with worse prognosis. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Alejandro Balestracci
- Nephrology Unit, Hospital General de Niños Pedro de Elizalde, Montes de Oca 40, CP 1270, Ciudad Autónoma de Buenos Aires, Argentina.
| | - Luciana Meni Battaglia
- Nephrology Unit, Hospital General de Niños Pedro de Elizalde, Montes de Oca 40, CP 1270, Ciudad Autónoma de Buenos Aires, Argentina
| | - Ismael Toledo
- Nephrology Unit, Hospital General de Niños Pedro de Elizalde, Montes de Oca 40, CP 1270, Ciudad Autónoma de Buenos Aires, Argentina
| | - Sandra Mariel Martin
- Nephrology Unit, Hospital General de Niños Pedro de Elizalde, Montes de Oca 40, CP 1270, Ciudad Autónoma de Buenos Aires, Argentina
| | - Laura Beaudoin
- Nephrology Unit, Hospital General de Niños Pedro de Elizalde, Montes de Oca 40, CP 1270, Ciudad Autónoma de Buenos Aires, Argentina
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Tasaki Y, Inoue N, Shimizu M, Sugimoto N, Ishikawa S, Mizuta M, Yokoyama T, Kuroda M, Ohta K, Yachie A, Wada T. Serum insulin-like growth factor-binding protein 2 levels as an indicator for disease severity in enterohemorrhagic Escherichia coli induced hemolytic uremic syndrome. Ren Fail 2021; 43:382-387. [PMID: 33641616 PMCID: PMC7928034 DOI: 10.1080/0886022x.2021.1885445] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background Insulin-like growth factor-binding protein (IGFBP) 2 plays an important role in the regulation of cell adhesion, migration, growth, and apoptosis. This study aimed to investigate the clinical significance of serum IGFBP2 as a biomarker for disease activity and severity in hemolytic uremic syndrome (HUS) induced by enterohemorrhagic Escherichia coli (EHEC). Methods IGFBP2 production by human renal glomerular endothelial cells (RGECs) after exposure to Shiga toxin 2 (Stx-2) was investigated in vitro. Serum IGFBP2 levels in blood samples obtained from 22 patients with HUS and 10 healthy controls (HCs) were quantified using an enzyme-linked immunosorbent assay. The results were compared to the clinical features of HUS and serum tau and cytokine levels. Results Stx-2 induced the production of IGFBP2 in RGECs in a dose-dependent manner. Serum IGFBP2 levels were significantly higher in patients with HUS than in HCs and correlated with disease severity. Additionally, serum IGFBP2 levels were significantly higher in patients with encephalopathy than in those without encephalopathy. A serum IGFBP2 level above 3585 pg/mL was associated with a high risk of encephalopathy. Furthermore, serum IGFBP2 levels significantly correlated with serum levels of tau and inflammatory cytokines associated with the development of HUS. Conclusions Correlation of serum IGFBP2 level with disease activity in patients with HUS suggests that IGFBP2 may be considered as a possible indicator for disease activity and severity in HUS. Larger studies and additional experiments using various cells in central nervous system should elucidate the true value of IGFBP2 as a clinical diagnostic marker. Abbreviations IGFBP: insulin-like growth factor-binding protein; HUS: hemolytic uremic syndrome; EHEC: enterohemorrhagic Escherichia coli; RGECs: renal glomerular endothelial cells; STx-2: Shiga toxin 2; HCs: healthy controls; LPS: lipopolysaccharide; ROC: receiver operating characteristic; sTNFR: soluble tumor necrosis factor receptor.
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Affiliation(s)
- Yuko Tasaki
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical, and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Natsumi Inoue
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical, and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Masaki Shimizu
- Department of Child Health and Development, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Naotoshi Sugimoto
- Department of Physiology, School of Medicine, Institute of Medical, Pharmaceutical, and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Sayaka Ishikawa
- Department of Pediatrics, Fukui Saiseikai Hospital, Fukui, Japan
| | - Mao Mizuta
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical, and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Tadafumi Yokoyama
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical, and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Mondo Kuroda
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical, and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Kazuhide Ohta
- Department of Pediatrics, National Hospital Organization, Kanazawa Medical Center, Kanazawa, Japan
| | - Akihiro Yachie
- Division of Medical Safety, Kanazawa University Hospital, Kanazawa, Japan
| | - Taizo Wada
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical, and Health Sciences, Kanazawa University, Kanazawa, Japan
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Bonany P, Bilkis MD, Iglesias G, Braun A, Tello J, Ratto V, Vargas A, Koch E, Jannello P, Monteverde E. Fluid restriction versus volume expansion in children with diarrhea-associated HUS: a retrospective observational study. Pediatr Nephrol 2021; 36:103-109. [PMID: 32681274 DOI: 10.1007/s00467-020-04673-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 06/07/2020] [Accepted: 06/12/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Fifty percent of patients with typical diarrhea-associated hemolytic uremic syndrome (D+HUS) require kidney replacement therapy (KRT). In these patients, dehydration worsens disease prognosis. We evaluated dialysis requirement, presence of seizures, and mortality rate among patients diagnosed with D+HUS treated with volume expansion (VE) versus fluid restriction (FR). METHODS Thirty-five patients with D+HUS were enrolled; 16 received VE and 19 were historical patients who received conventional FR. RESULTS Upon admission or during treatment, neither group presented evidence of fluid overload. The VE group received higher volumes of saline (VE 27 ml/kg [10-30] over a 3-h period vs. FR 0 ml), had higher urine output after 12 h (VE vs. FR: OR 6.2 [1.2-41.6], P = 0.03), and required less dialysis (VE 2 [12.5%, CI 95% 0-29] vs. FR 9 [47.4%, CI 95% 24-70], P = 0.035). The VE group had an absolute risk reduction of 0.34 (CI 95% 0.07-0.63); hence, three patients treated with VE were required to avoid one KRT. VE also corrected initial hyponatremia and maintained serum sodium within normal ranges. No statistical differences were observed regarding number of patients with seizures (P = 0.08) or mortality (P = 1.0). CONCLUSIONS VE markedly reduces the number of patients requiring KRT and keeps serum sodium within a normal range. We propose to initially hydrate every patient with D+HUS and without signs of fluid overload, with 10 ml/kg/h 0.9% saline solution IV, over a 3-h period. Afterwards, if urine output is ≥ 0.5 ml/kg/h, it is recommended to not dialyze and continue IV hydration schedule with isotonic (D5) saline solution, according to their needs.
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Affiliation(s)
- Pablo Bonany
- Pediatrics Service, Establecimiento Asistencial Dr. Lucio Molas de Santa Rosa, Raúl B Díaz y Pilcomayo, 6300, Santa Rosa, La Pampa, Argentina.
| | - Manuel D Bilkis
- Emergency Department, Hospital de Niños Dr. Ricardo Gutiérrez, Gallo 1330, 1425, Buenos Aires, Argentina.
| | - Guillermo Iglesias
- Pediatrics Service, Establecimiento Asistencial Dr. Lucio Molas de Santa Rosa, Raúl B Díaz y Pilcomayo, 6300, Santa Rosa, La Pampa, Argentina
| | - Amalia Braun
- Pediatrics Service, Establecimiento Asistencial Dr. Lucio Molas de Santa Rosa, Raúl B Díaz y Pilcomayo, 6300, Santa Rosa, La Pampa, Argentina
| | - Juliana Tello
- Pediatrics Service, Establecimiento Asistencial Dr. Lucio Molas de Santa Rosa, Raúl B Díaz y Pilcomayo, 6300, Santa Rosa, La Pampa, Argentina
| | - Viviana Ratto
- Nephrology Service, Fundación Hospitalaria, Buenos Aires, Argentina
| | - Ana Vargas
- Pediatrics Service, Policlínico Central U.O.M.R.A., Buenos Aires, Argentina
| | - Emilio Koch
- Pediatrics Service, Policlínico Central U.O.M.R.A., Buenos Aires, Argentina
| | - Patricia Jannello
- Pediatrics Service, Sanatorio San Cayetano - OSMATA, Buenos Aires, Argentina
| | - Ezequiel Monteverde
- Emergency Department, Hospital de Niños Dr. Ricardo Gutiérrez, Gallo 1330, 1425, Buenos Aires, Argentina
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Hirata C, Kenzaka T, Akita H. Late onset of hemolytic uremic syndrome after the appearance of prodromal gastrointestinal tract symptoms. Clin Case Rep 2020; 8:1910-1913. [PMID: 33088517 PMCID: PMC7562874 DOI: 10.1002/ccr3.3020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 05/04/2020] [Accepted: 05/19/2020] [Indexed: 11/07/2022] Open
Abstract
Hemolytic uremic syndrome (HUS) may occur late after the onset and improvement of gastrointestinal tract symptoms. Clinicians need to carefully monitor for the onset of HUS, even if the patients have few symptoms.
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Affiliation(s)
- Chihiro Hirata
- Department of Internal MedicineHyogo Prefectural Tamba Medical CenterTambaJapan
| | - Tsuneaki Kenzaka
- Department of Internal MedicineHyogo Prefectural Tamba Medical CenterTambaJapan
- Division of Community Medicine and Career DevelopmentKobe University Graduate School of MedicineKobeJapan
| | - Hozuka Akita
- Department of Internal MedicineHyogo Prefectural Tamba Medical CenterTambaJapan
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5
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Talathi S, Barnes M, Aban I, Dimmitt R, Askenazi DJ. Serum Transaminases at Presentation and Association with Acute Dialysis in Children with Hemolytic Uremic Syndrome. KIDNEY360 2020; 1:337-342. [PMID: 35369368 PMCID: PMC8809299 DOI: 10.34067/kid.0000222020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 03/10/2020] [Indexed: 06/14/2023]
Abstract
BACKGROUND To determine whether serum transaminases at presentation predict the need for dialysis in children with hemolytic uremic syndrome (HUS). METHODS Single-center, retrospective chart review of pediatric patients with HUS. Data collected included demographics, clinical and laboratory parameters, and need for dialysis. These factors were compared between two groups: "dialysis" versus "no dialysis." Continuous data were compared using a t test whereas categoric data were compared by the chi-squared test. Multivariate logistic regression was performed on a prior set of variables to determine if serum transaminases independently predict the need for dialysis. RESULTS A total of 70 children were included in the study, of which, 39 (27%) received dialysis. The no-dialysis group had a higher proportion of white patients compared with the dialysis group (74% dialysis versus 94% no dialysis). The only clinical sign at admission associated with dialysis was reduced urine output (56% versus 16%, P<0.001). Univariate logistic regression identified admission serum creatinine, aspartate transaminase (AST), and alanine transaminase (ALT) to be associated with the need for dialysis. Multivariate logistic regression showed serum AST and ALT to be independent predictors of the need for dialysis, with both improving the performance of the regression model. Sensitivity analysis showed a cutoff of 129 U/L for AST and 83 U/L for ALT with high specificity. CONCLUSIONS Serum transaminases at presentation are independently associated with the subsequent need for dialysis in patients with HUS. Our study suggests that when both serum ALT and AST are normal, the likelihood to need dialysis is very low; alternatively, when both serum ALT and AST are more than two times the upper level of normal, the need for dialysis is very high.
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Affiliation(s)
- Saurabh Talathi
- Division of Pediatric Gastroenterology, Department of Pediatrics, Hepatology and Nutrition, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Margaux Barnes
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Inmaculada Aban
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Reed Dimmitt
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - David J. Askenazi
- Division of Pediatric Nephrology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
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Shimizu M. Pathogenic functions and diagnostic utility of cytokines/chemokines in EHEC-HUS. Pediatr Int 2020; 62:308-315. [PMID: 31742829 DOI: 10.1111/ped.14053] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 10/07/2019] [Accepted: 11/15/2019] [Indexed: 12/13/2022]
Abstract
Hemolytic - uremic syndrome (HUS) is a severe complication of infection by Shiga toxin (STx)-producing enterohemorrhagic Escherichia coli. Hemolytic - uremic syndrome is defined clinically as a triad of non-immune microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injuries. Neurologic complications such as acute encephalopathy are also observed. In humans, endothelial cells, proximal tubular epithelial cells, mesangial cells, podocytes, intestinal epithelial cells, and monocytes / macrophages are susceptible to STx-mediated injury. Shiga toxin induces the secretion of inflammatory cytokines and chemokines from susceptible cells, including tumor necrosis factor-α interleukin (IL)-1, IL-6, and IL-8. These cytokines and chemokines contribute to the pathogenesis of HUS and encephalopathy by enhancing STx-induced cytotoxicity and inducing inflammatory cell infiltration. Serum cytokine/chemokine levels are therefore useful as indicators of disease activity and predictors of progression from acute kidney injury to chronic kidney disease. Anti-inflammation therapy combined with apheresis to remove excessive cytokines / chemokines and methylprednisolone pulse therapy to suppress cytokine/chemokine production may be an effective treatment regimen for severe E. coli-associated HUS. However, this regimen requires careful monitoring of potential side effects, such as infections, thrombus formation, and hypertension.
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Affiliation(s)
- Masaki Shimizu
- Department of Pediatrics, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
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7
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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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8
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Alconcher LF, Coccia PA, Suarez ADC, Monteverde ML, Perez Y Gutiérrez MG, Carlopio PM, Missoni ML, Balestracci A, Principi I, Ramírez FB, Estrella P, Micelli S, Leroy DC, Quijada NE, Seminara C, Giordano MI, Hidalgo Solís SB, Saurit M, Caminitti A, Arias A, Rivas M, Risso P, Liern M. Hyponatremia: a new predictor of mortality in patients with Shiga toxin-producing Escherichia coli hemolytic uremic syndrome. Pediatr Nephrol 2018; 33:1791-1798. [PMID: 29961127 DOI: 10.1007/s00467-018-3991-6] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 05/12/2018] [Accepted: 05/29/2018] [Indexed: 01/22/2023]
Abstract
OBJECTIVES (1) Evaluate mortality rate in patients with Shiga toxin-producing Escherichia coli hemolytic uremic syndrome, (2) determine the leading causes of death, and (3) identify predictors of mortality at hospital admission. METHODS We conducted a multicentric, observational, retrospective, cross-sectional study. It included patients under 18 years old with Shiga toxin-producing Escherichia coli hemolytic uremic syndrome hospitalized between January 2005 and June 2016. Clinical and laboratory data were obtained from the Argentine National Epidemiological Surveillance System of Hemolytic Uremic Syndrome. Clinical and laboratory variables were compared between deceased and non-deceased patients. Univariate and multivariate analyses were performed. ROC curves and area under the curve were obtained. RESULTS Seventeen (3.65%) out of the 466 patients died, being central nervous system involvement the main cause of death. Predictors of death were central nervous system involvement, the number of days since the beginning of diarrhea to hospitalization, hyponatremia, high hemoglobin, high leukocyte counts, and low bicarbonate concentration on admission. In the multivariate analysis, central nervous system involvement, sodium concentration, and hemoglobin were independent predictors. The best cut off for sodium was ≤ 128 meq/l and for hemoglobin ≥ 10.8 g/dl. CONCLUSIONS Mortality was low in children with Shiga toxin-producing Escherichia coli hemolytic uremic syndrome, being central nervous system involvement the main cause of death. The best mortality predictors found were central nervous system involvement, hemoglobin, and sodium concentration. Hyponatremia may be a new Shiga toxin-producing Escherichia coli hemolytic uremic syndrome mortality predictor.
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Affiliation(s)
- Laura F Alconcher
- Pediatric Nephrology Unit, Pediatric Department, Hospital Dr. José Penna, Lainez 2401, (8000), Bahía Blanca, Argentina.
| | - Paula A Coccia
- Department of Pediatrics Hospital Italiano Ciudad Autónoma de Buenos Aires (CABA), Pediatric Nephrology Division, Buenos Aires, Argentina
| | - Angela Del C Suarez
- Department of Nephrology Hospital de Niños Sor María Ludovica La Plata, Buenos Aires, Argentina
| | - Marta L Monteverde
- Hospital Nacional de Pediatría JP Garrahan CABA, Buenos Aires, Argentina
| | | | - Paula M Carlopio
- Department of Pediatrics Hospital Posadas Buenos Aires, Pediatric Nephrolgy Division, Buenos Aires, Argentina
| | - Mabel L Missoni
- Department of Pediatrics Hospital Zonal Padre Pedro Tardivio Caleta Olivia Santa Cruz, Buenos Aires, Argentina
| | - Alejandro Balestracci
- Nephrology Unit Hospital General de Niños Pedro de Elizalde CABA, Buenos Aires, Argentina
| | - Illiana Principi
- Department of Nephrology Hospital Pediátrico Humberto J Notti Mendoza, Mendoza, Argentina
| | - Flavia B Ramírez
- Pediatric Nephrolgy Division Department of Pediatrics Hospital Dr. Castro Rendon Neuquén, Neuquén, Argentina
| | - Patricia Estrella
- Dirección de Epidemiologia de La Pampa, Hospital Lucio Molas Santa Rosa La Pampa, Santa Rosa, Argentina
| | - Susana Micelli
- Department of Nephrology Hospital del Niño Jesús Tucumán, San Miguel de Tucumán, Argentina
| | - Daniela C Leroy
- Department of Pediatrics Hospital Interzonal de Agudos Abrahan Piñeyro Junín, Buenos Aires, Argentina
| | | | | | | | | | - Mariana Saurit
- Hospital Público Materno Infantil de Salta, Salta, Argentina
| | - Alejandra Caminitti
- Department of Nephrology Hospital Provincial de Santa Fé, Santa Fé, Argentina
| | - Andrea Arias
- Department of Nephrology Hospital Materno Infantil Dr. Héctor Quintana Jujuy, San Salvador de Jujuy, Argentina
| | - Marta Rivas
- Instituto Nacional de Enfermedades Infecciosas-ANLIS "Dr. Carlos G. Malbrán", Buenos Aires, Argentina
| | - Paula Risso
- PhD student, PhD scholarship by Comisión de Investigaciones Científicas de la provincia de Buenos Aires, Teaching assistant in Classic and Bayesian Biostatistics Cathedra, Facultad de Cincias Veterinarias, Universidad Nacional de La Plata, Buenos Aires, Argentina
| | - Miguel Liern
- Department of Nephrology Hospital Gutiérrez CABA, Buenos Aires, Argentina
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9
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Postdiarrheal hemolytic and uremic syndrome with severe multiorgan involvement and associated early risk factors. Arch Pediatr 2018; 25:118-125. [PMID: 29395881 DOI: 10.1016/j.arcped.2017.12.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Revised: 11/08/2017] [Accepted: 12/10/2017] [Indexed: 12/24/2022]
Abstract
AIM Identifying early clinical and biological factors associated with severe forms of postdiarrheal hemolytic uremic syndrome (D+HUS) that may help practitioners determine appropriate treatment. METHODS This retrospective study was conducted in 49 children with D+HUS between 2001 and 2011. Severe forms were defined as occurrence of one of the following conditions: death, major neurological involvement, cardiovascular involvement, and/or the presence of sequelae (neurological, cardiovascular, pancreatic, or renal). RESULTS During the acute phase, 35 children exhibited at least one type of extrarenal involvement including 13 severe forms with a median delayed occurrence after admission of 4.5 days (range: 1-8) for comatose children and 5 days (range: 2-6) for cardiovascular involvement; 32 children required dialysis and three died. In multivariate analysis, (i) major neurological involvement (n=13), (ii) dialysis (n=32), and (iii) sequelae (n=12) were associated with (i) fever during the prodromal phase requiring dialysis at admission, (ii) C-reactive protein level (CRP) >22mg/L at admission, and (iii) major neurological involvement and a white blood cell count (WBC)>20×103/mm3 during the acute stage, respectively. CONCLUSIONS D+HUS is a multiorgan disease with a delayed occurrence of life-threatening extrarenal organ involvement. Severe forms appear to be associated with early biological and clinical inflammatory parameters.
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Abstract
The encephalopathy that occurs in association with hemolytic uremic syndrome (HUS), which is caused by enterohemorrhagic Escherichia coli (E. coli), has a high mortality rate and patients sometimes present sequelae. We herein describe the case of a 20-year-old woman who developed encephalopathy during the convalescent stage of HUS caused by E.coli O26. Hyperintense lesions were detected in the pons, basal ganglia, and cortex on diffusion-weighted brain MRI. From the onset of HUS encephalopathy, we treated the patient with methylprednisolone (mPSL) pulse therapy alone. Her condition improved, and she did not present sequelae. Our study shows that corticosteroids appear to be effective for the treatment of some patients with HUS encephalopathy.
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Affiliation(s)
- Takashi Hosaka
- Department of Neurology, Division of Clinical Medicine, Faculty of Medicine, University of Tsukuba, Japan
| | - Kiyotaka Nakamagoe
- Department of Neurology, Division of Clinical Medicine, Faculty of Medicine, University of Tsukuba, Japan
| | - Akira Tamaoka
- Department of Neurology, Division of Clinical Medicine, Faculty of Medicine, University of Tsukuba, Japan
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11
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Ninchoji T, Nozu K, Nakanishi K, Horinouchi T, Fujimura J, Yamamura T, Minamikawa S, Ishimori S, Nakanishi K, Yoshikawa N, Morioka I, Kaito H, Iijima K. Clinical characteristics and long-term outcome of diarrhea-associated hemolytic uremic syndrome: a single center experience. Clin Exp Nephrol 2017; 21:889-894. [PMID: 28074307 DOI: 10.1007/s10157-016-1376-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Accepted: 12/20/2016] [Indexed: 01/04/2023]
Abstract
OBJECTIVES To clarify the clinical characteristics and long-term outcomes of patients with diarrhea-associated hemolytic uremic syndrome (D + HUS) with a particular focus on time course. METHODS We retrospectively analyzed the medical records of 61 patients with D + HUS who were admitted to Kobe University Hospital between 1995 and 2015. The onset of D + HUS was defined as day 1 of diarrhea. RESULTS The age of onset was 4.1 (1.5-13.4) years, and the period between onset and diagnosis of D + HUS was 5 (3-18) days. The platelet count was lowest on day 7 (4-24), and the lactase dehydrogenase level was maximal on day 8 (4-25). Twenty-three patients required dialysis for 13 (2-37) days, starting at day 5-9. Seventeen patients showed central nervous system (CNS) symptoms at day 4-18. They were followed up for 3.7 (0-18.4) years. At the final follow-up, estimated glomerular filtration rate was 113.7 (57.9-159.9) ml/min/1.73 m2 with five patients having chronic kidney disease. Three patients developed CNS sequelae. The time to diagnosis was significantly shorter in the group of patients receiving dialysis than without dialysis (p = 0.018) and in the group with CNS complications than without (p = 0.013). CONCLUSION CNS complications were often apparent after blood examination results improved. Moreover, a shorter period between the onset of diarrhea and a diagnosis of D + HUS indicated a more severe clinical course or long-term sequelae, and it should be considered as a risk factor for poor prognosis.
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Affiliation(s)
- Takeshi Ninchoji
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-2 Kusunokicho, Chuo, Kobe, 6500017, Japan.
| | - Kandai Nozu
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-2 Kusunokicho, Chuo, Kobe, 6500017, Japan
| | - Keita Nakanishi
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-2 Kusunokicho, Chuo, Kobe, 6500017, Japan
| | - Tomoko Horinouchi
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-2 Kusunokicho, Chuo, Kobe, 6500017, Japan
| | - Junya Fujimura
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-2 Kusunokicho, Chuo, Kobe, 6500017, Japan
| | - Tomohiko Yamamura
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-2 Kusunokicho, Chuo, Kobe, 6500017, Japan
| | - Shogo Minamikawa
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-2 Kusunokicho, Chuo, Kobe, 6500017, Japan
| | - Shingo Ishimori
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-2 Kusunokicho, Chuo, Kobe, 6500017, Japan
| | - Koichi Nakanishi
- Department of Pediatrics, Wakayama Medical University, Wakayama, Japan
| | | | - Ichiro Morioka
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-2 Kusunokicho, Chuo, Kobe, 6500017, Japan
| | - Hiroshi Kaito
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-2 Kusunokicho, Chuo, Kobe, 6500017, Japan
| | - Kazumoto Iijima
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-2 Kusunokicho, Chuo, Kobe, 6500017, Japan
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Abstract
Post-infectious hemolytic uremic syndrome (HUS) is caused by specific pathogens in patients with no identifiable HUS-associated genetic mutation or autoantibody. The majority of episodes is due to infections by Shiga toxin (Stx) producing Escherichia coli (STEC). This chapter reviews the epidemiology and pathogenesis of STEC-HUS, including bacterial-derived factors and host responses. STEC disease is characterized by hematological (microangiopathic hemolytic anemia), renal (acute kidney injury) and extrarenal organ involvement. Clinicians should always strive for an etiological diagnosis through the microbiological or molecular identification of Stx-producing bacteria and Stx or, if negative, serological assays. Treatment of STEC-HUS is supportive; more investigations are needed to evaluate the efficacy of putative preventive and therapeutic measures, such as non-phage-inducing antibiotics, volume expansion and anti-complement agents. The outcome of STEC-HUS is generally favorable, but chronic kidney disease, permanent extrarenal, mainly cerebral complication and death (in less than 5 %) occur and long-term follow-up is recommended. The remainder of this chapter highlights rarer forms of (post-infectious) HUS due to S. dysenteriae, S. pneumoniae, influenza A and HIV and discusses potential interactions between these pathogens and the complement system.
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Affiliation(s)
- Denis F. Geary
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario Canada
| | - Franz Schaefer
- Division of Pediatric Nephrology, University of Heidelberg, Heidelberg, Germany
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Igarashi T, Ito S, Sako M, Saitoh A, Hataya H, Mizuguchi M, Morishima T, Ohnishi K, Kawamura N, Kitayama H, Ashida A, Kaname S, Taneichi H, Tang J, Ohnishi M. Guidelines for the management and investigation of hemolytic uremic syndrome. Clin Exp Nephrol 2016; 18:525-57. [PMID: 25099085 DOI: 10.1007/s10157-014-0995-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Takashi Igarashi
- National Center for Child Health and Development (NCCHD), 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan,
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Shimizu M, Inoue N, Kuroda M, Mizuta M, Sugimoto N, Kaneda H, Ohta K, Yachie A. Angiopoietin-1 and -2 as markers for disease severity in hemolytic uremic syndrome induced by enterohemorrhagic Escherichia coli. Clin Exp Nephrol 2016; 21:76-82. [PMID: 26945868 DOI: 10.1007/s10157-016-1254-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 02/24/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Angiopoietin (Ang)-1 and -2 play important roles in maintaining vascular homeostasis. This study aimed to assess the roles of angiopoietin (Ang)-1 and -2 and to investigate the clinical significance of their serum levels in patients with hemolytic uremic syndrome (HUS) induced by enterohemorrhagic Escherichia coli (EHEC). METHODS Twenty patients with HUS and 15 healthy controls were studied. Serum Ang-1 and Ang-2 levels were quantified using enzyme-linked immunosorbent assay. The results were compared with the clinical features of HUS. RESULTS During the HUS phase, serum Ang-1 levels were significantly decreased, whereas serum Ang-2 levels and the Ang-2/Ang-1 ratio were significantly elevated. Compared with patients without encephalopathy, serum Ang-2 levels and Ang-2/Ang-1 ratio were significantly elevated in patients with encephalopathy. Patients with HUS and serum Ang-2 levels of >7061 pg/mL or Ang2/Ang1 ratios of >2.29 were at high risk of encephalopathy. Serum Ang-1 levels were significantly decreased in patients in the pre-HUS phase compared with those in healthy controls. CONCLUSION Disruption of homeostasis of vascular endothelial function by Ang-1 and -2 may be closely associated with the development of HUS. Serum Ang-1 and -2 levels and the Ang-2/Ang-1 ratio may be promising indicators of disease activity in HUS and the development of encephalopathy.
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Affiliation(s)
- Masaki Shimizu
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, 13-1 Takara-machi, Kanazawa, 920-8641, Japan.
| | - Natsumi Inoue
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, 13-1 Takara-machi, Kanazawa, 920-8641, Japan
| | - Mondo Kuroda
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, 13-1 Takara-machi, Kanazawa, 920-8641, Japan
| | - Mao Mizuta
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, 13-1 Takara-machi, Kanazawa, 920-8641, Japan
| | - Naotoshi Sugimoto
- Department of Physiology, School of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Hisashi Kaneda
- Department of Pediatrics, Toyama City Hospital, Toyama, Japan
| | - Kazuhide Ohta
- Department of Pediatrics, Kanazawa Medical Center, Kanazawa, Japan
| | - Akihiro Yachie
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, 13-1 Takara-machi, Kanazawa, 920-8641, Japan
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Balestracci A, Martin SM, Toledo I, Alvarado C, Wainsztein RE. Laboratory predictors of acute dialysis in hemolytic uremic syndrome. Pediatr Int 2014; 56:234-9. [PMID: 24266872 DOI: 10.1111/ped.12245] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Revised: 08/03/2013] [Accepted: 10/24/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Strict guidelines on use of dialysis in children with post-diarrheal hemolytic uremic syndrome (D + HUS) are lacking. This study investigated laboratory predictors of acute dialysis because they are more objective than clinical features. Added to this, given that urine output is also an objective parameter, its ability to predict dialysis requirements was also investigated. METHODS Out of 153 D + HUS children reviewed, 88 received dialysis and 65 did not. Initial laboratory parameters and diuresis between both groups were analyzed. RESULTS Dialyzed patients had higher creatinine, urea, alanine aminotransferase, hematocrit and leukocyte count; and lower sodium, bicarbonate, and pH compared to non-dialyzed ones. Serum creatinine was the only independent predictor (P = 0.003) of dialysis; therefore, its ability to predict dialysis was estimated on receiver operating characteristic (ROC) curve analysis and using the Acute Kidney Injury Network (AKIN) staging system. Area under the ROC curve was 0.92 (95% confidence interval [95%CI]: 0.83-1) with a creatinine cut-off of 1.25 mg/dL (sensitivity, 100%; specificity, 76.5%) for children <1 year, and 0.93 (95%CI: 0.88-0.98) with a threshold of 2 mg/dL (sensitivity, 91%; specificity, 87.5%) for older children. AKIN stage 3 at admission predicted dialysis with a sensitivity of 92% and specificity of 84.2%. Urine output had the highest accuracy for dialysis prediction (sensitivity, 100%; specificity, 95.3%). CONCLUSIONS Initial serum creatinine concentration was the best laboratory predictor of dialysis, but the first 24 h diuresis was even better for this purpose. But, given that serum creatinine is an immediate available parameter, the cut-offs identified may label D + HUS children who will probably need dialysis, prompting early referral to centers able to provide dialysis.
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Affiliation(s)
- Alejandro Balestracci
- Nephrology Unit, Pedro de Elizalde Children's Hospital, Buenos Aires City, Argentina
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Kawasaki Y, Suyama K, Maeda R, Yugeta E, Takano K, Suzuki S, Sakuma H, Nemoto K, Sato T, Nagasawa K, Hosoya M. Incidence and index of severity of hemolytic uremic syndrome in a 26 year period in Fukushima Prefecture, Japan. Pediatr Int 2014; 56:77-82. [PMID: 23937579 DOI: 10.1111/ped.12193] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Revised: 07/09/2013] [Accepted: 07/31/2013] [Indexed: 12/25/2022]
Abstract
BACKGROUND There have been a number of reports on large outbreaks of hemolytic uremic syndrome (HUS), but there have been no long-term studies of sporadic HUS in Japan. This study therefore investigated the epidemiology and prognosis of HUS in Fukushima Prefecture over a 26 year period. METHODS The medical records of 26 patients with HUS between 1987 and 2012 were collected. These children were divided into two groups: those with HUS following an episode of gastroenteritis, often with bloody diarrhea (D + HUS; n = 24) and those with HUS not associated with prodromal diarrhea (D-HUS; n = 2). The D + HUS group was further subdivided into group A (11 patients requiring dialysis) and group B (13 patients not requiring dialysis). The epidemiological and clinical data, as well as prognosis, were retrospectively investigated for each group. RESULTS Approximately 90% of HUS patients belonged to the D + HUS group. In this group, the mean number of patients per year from 1987 to 1999, and from 2000 to 2012 was 0.92 ± 0.95, and 1.08 ± 0.86, respectively. On admission, lactate dehydrogenase (LDH), alanine aminotransferase (ALT), blood urea nitrogen (BUN), serum creatinine and serum fibrinogen degradation product (FDP) levels in group A were all higher than in group B. Serum albumin level and estimated glomerular filtration rate (eGFR) in group A were lower than in group B. At 6 months after the onset of HUS in the D + HUS group, renal function was normal. CONCLUSIONS The frequency of HUS was constant from 1987 to 2012 in Fukushima. and serum LDH, ALT, BUN, creatinine, and FDP levels as well as eGFR might be risk factors for dialysis in D + HUS children.
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Affiliation(s)
- Yukihiko Kawasaki
- Department of Pediatrics, Fukushima Medical University School of Medicine, Fukushima, Japan
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Shimizu M, Kuroda M, Inoue N, Konishi M, Igarashi N, Taneichi H, Kanegane H, Ito M, Saito S, Yachie A. Extensive serum biomarker analysis in patients with enterohemorrhagic Escherichia coli O111-induced hemolytic-uremic syndrome. Cytokine 2013; 66:1-6. [PMID: 24548418 DOI: 10.1016/j.cyto.2013.12.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Revised: 11/14/2013] [Accepted: 12/09/2013] [Indexed: 01/22/2023]
Abstract
Proinflammatory cytokines are related to the pathogenesis of enterohemorrhagic Escherichia coli infection and hemolytic-uremic syndrome (HUS). We employed an antibody array that simultaneously detects 174 serum cytokines. We identified five serum biomarkers, namely insulin growth factor-binding protein-2, angiopoietin-2, soluble interleukin-6 receptor, soluble tumor necrosis factor receptor type II, and matrix metalloprotease protein-3 whose levels increased with the development of HUS. Furthermore, the levels of these cytokines were significantly increased in severe HUS compared with mild HUS. These cytokines might play an important role in the pathogenesis of HUS and may also be used to predict the severity of HUS.
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Affiliation(s)
- Masaki Shimizu
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Japan.
| | - Mondo Kuroda
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Japan
| | - Natsumi Inoue
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Japan
| | - Michio Konishi
- Department of Pediatrics, Tonami General Hospital, Japan
| | - Noboru Igarashi
- Department of Pediatrics, Toyama Prefectural Central Hospital, Japan
| | - Hiromichi Taneichi
- Department of Pediatrics, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Japan
| | - Hirokazu Kanegane
- Department of Pediatrics, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Japan
| | - Mika Ito
- Department of Obstetrics and Gynaecology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Japan
| | - Shigeru Saito
- Department of Obstetrics and Gynaecology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Japan
| | - Akihiro Yachie
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Japan
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18
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Impact of platelet transfusions in children with post-diarrheal hemolytic uremic syndrome. Pediatr Nephrol 2013; 28:919-25. [PMID: 23386110 DOI: 10.1007/s00467-013-2414-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2012] [Revised: 01/06/2013] [Accepted: 01/07/2013] [Indexed: 10/27/2022]
Abstract
BACKGROUND Platelet transfusions should be avoided in children with post-diarrheal hemolytic uremic syndrome (D + HUS) because they might increase microthrombi formation, thereby aggravating the disease. As this possibility has not yet been explored, we investigated whether platelet transfusion in patients with D + HUS would lead to a worse disease course compared to that in patients who did not receive platelet transfusion. METHODS This was a case-control study in which data from D + HUS children who received platelet transfusions (cases, n = 23) and those who did not (controls, n = 54) were retrospectively reviewed and compared. RESULTS Both patient groups were similar in age (p = 0.3), gender (p = 0.53), weight (p = 0.86), height (p = 0.45), prior use of non-steroidal anti-inflammatory drugs (p = 0.59) or antibiotics (p = 0.45) and presence of dehydration at admission (p = 0.79). The two groups also did not differ in initial leukocyte count (p = 0.98), hematocrit (p = 0.44) and sodium (p = 0.11) and alanine aminotransferase levels (p = 0.11). During hospitalization, dialysis duration (p = 0.08), number of erythrocyte transfusions (p = 0.2), serum creatinine peak (p = 0.22), presence of severe bowel (p = 0.43) or neurologic (p = 0.97) injury, arterial hypertension (p = 0.71), need for intensive care (p = 0.33) and death (p = 1.00) were also comparable. CONCLUSION Our findings suggest that platelet transfusion does not aggravate the course of the disease. Conversely, no hemorrhagic complications were observed in the group of patients who did not receive a platelet transfusion. Until these observations are confirmed by further studies, the benefits and risk of platelet transfusion should be thoughtfully balanced on an individual case basis.
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Tsuji S, Iharada A, Kimata T, Shimo T, Hirabayashi M, Kaneko K. Production of nitric oxide is lower in Shiga toxin-stimulated neutrophils of infants compared to those of children or adults. TOHOKU J EXP MED 2013; 228:247-52. [PMID: 23089636 DOI: 10.1620/tjem.228.247] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Hemolytic uremic syndrome (HUS) in infants is mainly caused by the Shiga toxin (Stx), which is produced by pathogenic Escherichia coli O157:H7. Infants are prone to develop HUS in comparison to older children and adults, but its underlying mechanism remains unknown. Recent observations suggest that reactive oxygen species (ROS) and reactive nitrogen species (RNS) including nitric oxide (NO) may be involved in the pathogenesis of HUS. We therefore measured NO production by neutrophils prepared from infants (6-27 months old), children (5.3-11 years old) or adults (25-47 years old). The NO production was measured by a flow cytometric analysis with a fluorescent indicator (expressed as mean fluorescence intensity), and mRNA expression of inducible NO synthase (iNOS) was analyzed by reverse transcription-polymerase chain reaction (RT-PCR). The amount of NO produced was significantly lower in Stx-stimulated neutrophils prepared from infants (45.8 ± 23.3) than that in those from children (120.5 ± 81.5) or adults (127.7 ± 45.8) (n = 10 each group, P < 0.05). The expression level of iNOS mRNA was lower in Stx-stimulated neutrophils of the infants than the level in those of children or adults. In conclusion, Stx increased NO production in neutrophils probably via iNOS. Importantly, the degree of the Stx-mediated increase in NO production was lower in neutrophils of infants compared to those of children or adults, which may explain the higher incidence of HUS in infants. These results suggest that NO may contribute to the cellular defense mechanisms against Stx.
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Affiliation(s)
- Shoji Tsuji
- Department of Pediatrics, Kansai Medical University, Osaka, Japan.
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20
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Shimizu M, Kuroda M, Sakashita N, Konishi M, Kaneda H, Igarashi N, Yamahana J, Taneichi H, Kanegane H, Ito M, Saito S, Ohta K, Taniguchi T, Furuichi K, Wada T, Nakagawa M, Yokoyama H, Yachie A. Cytokine profiles of patients with enterohemorrhagic Escherichia coli O111-induced hemolytic-uremic syndrome. Cytokine 2012; 60:694-700. [PMID: 22929411 DOI: 10.1016/j.cyto.2012.07.038] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2012] [Revised: 06/28/2012] [Accepted: 07/29/2012] [Indexed: 11/15/2022]
Abstract
Proinflammatory cytokines are related to the pathogenesis of enterohemorrhagic Escherichia coli (EHEC) infection and hemolytic-uremic syndrome (HUS). We assessed the kinetics of the release of cytokines such as neopterin, interleukin (IL)-6, IL-8 and tumour necrosis factor (TNF)-α and the soluble forms of type I and II TNF receptors during EHEC O111-induced HUS (EHEC O111/HUS). Fourteen patients with EHEC O111/HUS were enrolled in this study. Serum concentrations of all cytokines other than TNF-α were significantly elevated in patients with severe HUS compared with those in patients with mild HUS. Although serum concentrations of TNF-α were not significantly higher in patients with severe HUS, most patients with acute encephalopathy showed elevated TNF-α levels. Serum concentrations of these cytokines rapidly and markedly increased, and massive hypercytokinaemia developed 1 day before the diagnosis of HUS in patients with severe HUS. Changes in the number of white blood cells and concentration of serum lactate dehydrogenase were significantly larger between the onset of hemorrhagic colitis and the time of the diagnosis of HUS in patients with severe HUS compared with those in patients with mild HUS. Proinflammatory cytokines play an important role in the pathogenesis of EHEC infection and development of severe complications, including HUS and encephalopathy. Monitoring the cytokine profile may be useful for assessing disease activity of EHEC O111 infections.
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Affiliation(s)
- Masaki Shimizu
- Department of Pediatrics, School of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Japan.
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Quiviger S, Fléchelles O, Cécile W, Hatchuel Y. Syndrome hémolytique et urémique secondaire à Streptococcus pneumoniae de sérotype 3. Arch Pediatr 2012; 19:599-602. [DOI: 10.1016/j.arcped.2012.03.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2011] [Revised: 01/15/2012] [Accepted: 03/23/2012] [Indexed: 12/25/2022]
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Dierkes F, Andriopoulos N, Sucker C, Kuhr K, Hollenbeck M, Hetzel GR, Burst V, Teschner S, Rump LC, Benzing T, Grabensee B, Kurschat CE. Indicators of acute and persistent renal damage in adult thrombotic microangiopathy. PLoS One 2012; 7:e30886. [PMID: 22292070 PMCID: PMC3264649 DOI: 10.1371/journal.pone.0030886] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2011] [Accepted: 12/28/2011] [Indexed: 11/29/2022] Open
Abstract
Background Thrombotic microangiopathies (TMA) in adults such as thrombotic thrombocytopenic purpura (TTP) and hemolytic uremic syndrome (HUS) are life-threatening disorders if untreated. Clinical presentation is highly variable and prognostic factors for clinical course and outcome are not well established. Methods We performed a retrospective observational study of 62 patients with TMA, 22 males and 40 females aged 16 to 76 years, treated with plasma exchange at one center to identify clinical risk factors for the development of renal insufficiency. Results On admission, 39 of 62 patients (63%) had acute renal failure (ARF) with 32 patients (52%) requiring dialysis treatment. High systolic arterial pressure (SAP, p = 0.009) or mean arterial pressure (MAP, p = 0.027) on admission was associated with acute renal failure. Patients with SAP>140 mmHg on admission had a sevenfold increased risk of severe kidney disease (OR 7.464, CI 2.097–26.565). MAP>100 mmHg indicated a fourfold increased risk for acute renal failure (OR 4.261, CI 1.400–12.972). High SAP, diastolic arterial pressure (DAP), and MAP on admission were also independent risk factors for persistent renal insufficiency with the strongest correlation for high MAP. Moreover, a high C-reactive protein (CRP) level on admission correlated with renal failure in the course of the disease (p = 0.003). At discharge, renal function in 11 of 39 patients (28%) had fully recovered, 14 patients (23%) remained on dialysis, and 14 patients (23%) had non-dialysis-dependent chronic kidney disease. Seven patients (11%) died. We identified an older age as risk factor for death. Conclusions High blood pressure as well as high CRP serum levels on admission are associated with renal insufficiency in TMA. High blood pressure on admission is also a strong predictor of sustained renal insufficiency. Thus, adult TMA patients with high blood pressure may require special attention to prevent persistent renal failure.
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Affiliation(s)
- Firuseh Dierkes
- Department of Nephrology, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Nikolaos Andriopoulos
- Renal Division, Department of Medicine and Center for Molecular Medicine, University of Cologne, Cologne, Germany
| | - Christoph Sucker
- Department of Hemostasis and Transfusion Medicine, Heinrich-Heine-University Medical Center, Düsseldorf, Germany
| | - Kathrin Kuhr
- Institute of Medical Statistics, Informatics and Epidemiology, University of Cologne, Cologne, Germany
| | - Markus Hollenbeck
- Department of Nephrology and Rheumatology, Knappschaftskrankenhaus, Bottrop, Germany
| | - Gerd R. Hetzel
- Department of Nephrology, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Volker Burst
- Renal Division, Department of Medicine and Center for Molecular Medicine, University of Cologne, Cologne, Germany
| | - Sven Teschner
- Renal Division, Department of Medicine and Center for Molecular Medicine, University of Cologne, Cologne, Germany
| | - Lars C. Rump
- Department of Nephrology, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Thomas Benzing
- Renal Division, Department of Medicine and Center for Molecular Medicine, University of Cologne, Cologne, Germany
- Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases, University of Cologne, Cologne, Germany
| | - Bernd Grabensee
- Department of Nephrology, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Christine E. Kurschat
- Renal Division, Department of Medicine and Center for Molecular Medicine, University of Cologne, Cologne, Germany
- Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases, University of Cologne, Cologne, Germany
- * E-mail:
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Imai H, Miura N. [108th Scientific Meeting of the Japanese Society of Internal Medicine: symposium: 3. The interaction between kidney and other organs; What should physicians know about it? (4) Hematological disorders and kidney involvement]. NIHON NAIKA GAKKAI ZASSHI. THE JOURNAL OF THE JAPANESE SOCIETY OF INTERNAL MEDICINE 2011; 100:2552-2558. [PMID: 22117350 DOI: 10.2169/naika.100.2552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- Hirokazu Imai
- Department of Internal Medicine, Division of Nephrology and Rheumatology, Aichi Medical University School of Medicine, Japan
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Syndrome hémolytique et urémique post-diarrhéique : Quand y penser ? Quel suivi ? Arch Pediatr 2011; 18:823-30. [DOI: 10.1016/j.arcped.2011.04.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2011] [Revised: 03/25/2011] [Accepted: 04/05/2011] [Indexed: 11/22/2022]
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Nathanson S, Kwon T, Elmaleh M, Charbit M, Launay EA, Harambat J, Brun M, Ranchin B, Bandin F, Cloarec S, Bourdat-Michel G, Piètrement C, Champion G, Ulinski T, Deschênes G. Acute neurological involvement in diarrhea-associated hemolytic uremic syndrome. Clin J Am Soc Nephrol 2010; 5:1218-28. [PMID: 20498239 DOI: 10.2215/cjn.08921209] [Citation(s) in RCA: 161] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Neurologic involvement is the most threatening complication of diarrhea-associated hemolytic uremic syndrome (D+HUS). DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We report a retrospective multicenter series of 52 patients with severe initial neurologic involvement that occurred in the course of D+HUS. RESULTS Verotoxigenic Escherichia coli infection was documented in 24. All except two patients had acute renal failure that required peritoneal dialysis, hemodialysis, or both techniques. A first group of eight patients remained with normal consciousness; five of them had protracted seizures. A second group of 23 patients had stuporous coma; five of these had protracted severe seizures, and 18 had a neurologic defect including pyramidal syndrome, hemiplegia or hemiparesia, and extrapyramidal syndrome. A third group of 21 patients had severe coma. Plasma exchanges were undertaken in 25 patients, 11 of whom were treated within 24 hours after the first neurologic sign; four died, two survived with severe sequelae, and five were alive without neurologic defect. Magnetic resonance imaging (MRI) for 29 patients showed that (1) every structure of the central nervous system was susceptible to involvement; (2) no correlation seemed to exist between special profile of localization on early MRI and the final prognosis; and (3) MRI did not exhibit any focal lesions in three patients. The overall prognosis of the series was marked by the death of nine patients and severe sequelae in 13. CONCLUSIONS Neurologic involvement is associated with a severe renal disease but does not lead systematically to death or severe disability.
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Affiliation(s)
- Sylvie Nathanson
- Pediatric Unit, Hôpital Mignot, 177 rue de Versailles, F-78150 le Chesnay, France.
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Management of diarrhea-associated hemolytic uremic syndrome in children. Clin Exp Nephrol 2008; 12:16-9. [DOI: 10.1007/s10157-007-0007-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2007] [Accepted: 09/12/2007] [Indexed: 10/22/2022]
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