Blood urea nitrogen to serum creatinine ratio is an accurate predictor of outcome in diarrhea-associated hemolytic uremic syndrome, a preliminary study


Diarrhea-associated hemolytic uremic syndrome (D+HUS) is a common thrombotic microangiopathy during childhood and early identification of parameters predicting poor outcome could enable timely intervention. This study aims to establish the accuracy of BUN-to-serum creatinine ratio at admission, in addition to other parameters in predicting the clinical course and outcome. Records were searched for children between 1 January 2008 and 1 January 2015 admitted with D+HUS. A complicated course was defined as developing one or more of the following: neurological dysfunction, pancreatitis, cardiac or pulmonary involvement, hemodynamic instability, and hematologic complications while poor outcome was defined by death or development of chronic kidney disease. Thirty-four children were included from which 11 with a complicated disease course/poor outcome. Risk of a complicated course/poor outcome was strongly associated with oliguria (p = 0.000006) and hypertension (p = 0.00003) at presentation. In addition, higher serum creatinine (p = 0.000006) and sLDH (p = 0.02) with lower BUN-to-serum creatinine ratio (p = 0.000007) were significantly associated with development of complications. A BUN-to-sCreatinine ratio ≤40 at admission was a sensitive and highly specific predictor of a complicated disease course/poor outcome.

Conclusion: A BUN-to-serum Creatinine ratio can accurately identify children with D+HUS at risk for a complicated course and poor outcome.

What is Known:
Oliguria is a predictor of poor long-term outcome in D+HUS
What is New:
BUN-to-serum Creatinine ratio at admission is an entirely novel and accurate predictor of poor outcome and complicated clinical outcome in D+HUS
Early detection of the high risk group in D+HUS enabling early treatment and adequate monitoring

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Fig. 1
Fig. 2



Area under the curve


Blood urea nitrogen


Confidence interval


Chronic kidney disease


Estimated creatinine clearance


Enterohemorrhagic E. coli


Hemolytic uremic syndrome


Interquartile range


Plasma exchange


Receiver operating characteristic


Serum creatinine


Serum lactate dehydrogenase


Shiga Toxin producing Enterohemorrhagic E.coli


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We would like to thank and acknowledge Ghent University for their ongoing support and cooperation, enabling this study to be performed.

Authors’ contributions

Dr. Werner Keenswijk wrote the initial draft of this paper and all authors were involved in gathering data, paper revision, analysis and final approval of this paper.

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Corresponding author

Correspondence to Werner Keenswijk.

Ethics declarations

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Conflict of interest

The authors declare that they have no conflict of interest.

Informed consent

No informed consent was obtained do to the retrospective nature of this study but ethical approval was obtained and patient anonymity was strictly protected.


No funding was provided to perform this study.

Additional information

Communicated by Mario Bianchetti

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Keenswijk, W., Vanmassenhove, J., Raes, A. et al. Blood urea nitrogen to serum creatinine ratio is an accurate predictor of outcome in diarrhea-associated hemolytic uremic syndrome, a preliminary study. Eur J Pediatr 176, 355–360 (2017).

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  • Shigatoxin
  • Hemolytic uremic syndrome
  • BUN-to-sCreatinine ratio
  • Complicated course
  • Poor outcome
  • Thrombothic micro-angiopathy (TMA)