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Fluid restriction versus volume expansion in children with diarrhea-associated HUS: a retrospective observational study

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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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Notes

  1. For the identification of STEC strains in fecal matter, the polymerase chain reaction (PCR) technique is used as screening, using the specific oligonucleotides or primers for the detection of the stx1, stx2, and rfbO157 genes. Genotypic characterization of accessory virulence factors, eae, and exhA is also performed by PCR. Positive Stx isolates are identified by standard biochemical techniques and serotyped using E. coli O and H antisera. In addition, detection of enterohemolysin, produced by Stx by specific cytotoxicity in Vero cells, and assays are performed for phenotypic characterization and antimicrobial sensitivity. The subtyping of the strains is completed with the identification of the stx and eae variants by analysis of the restriction fragment length polymorphism, phage typing of O157 strains, and by studying the clonal relationship applying the macro-restriction and separation technique by pulsed field electrophoresis (PFGE).

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Authors and Affiliations

  1. Pediatrics Service, Establecimiento Asistencial Dr. Lucio Molas de Santa Rosa, Raúl B Díaz y Pilcomayo, 6300, Santa Rosa, La Pampa, Argentina

    Pablo Bonany, Guillermo Iglesias, Amalia Braun & Juliana Tello

  2. Emergency Department, Hospital de Niños Dr. Ricardo Gutiérrez, Gallo 1330, 1425, Buenos Aires, Argentina

    Manuel D. Bilkis & Ezequiel Monteverde

  3. Nephrology Service, Fundación Hospitalaria, Buenos Aires, Argentina

    Viviana Ratto

  4. Pediatrics Service, Policlínico Central U.O.M.R.A., Buenos Aires, Argentina

    Ana Vargas & Emilio Koch

  5. Pediatrics Service, Sanatorio San Cayetano – OSMATA, Buenos Aires, Argentina

    Patricia Jannello

Authors
  1. Pablo Bonany
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  2. Manuel D. Bilkis
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  3. Guillermo Iglesias
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  4. Amalia Braun
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  5. Juliana Tello
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  6. Viviana Ratto
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  7. Ana Vargas
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  10. Ezequiel Monteverde
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Corresponding authors

Correspondence to Pablo Bonany or Manuel D. Bilkis.

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The research protocol for this study was approved by the Research Ethics Committee from Establecimiento Asistencial Dr. Lucio Molas from Santa Rosa City, La Pampa Province, Argentina. This study was carried out under the ethical principles of the declaration of Helsinki

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The authors declare that they have no conflicts of interest.

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Bonany, P., Bilkis, M.D., Iglesias, G. et al. Fluid restriction versus volume expansion in children with diarrhea-associated HUS: a retrospective observational study. Pediatr Nephrol 36, 103–109 (2021). https://doi.org/10.1007/s00467-020-04673-6

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  • DOI: https://doi.org/10.1007/s00467-020-04673-6

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