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Predicting Hemolytic Uremic Syndrome and Renal Failure in Shiga Toxin-Producing Escherichia coli Infected Children

McKee, R. S.; Schnadower, D.; Tarr, P. I.; Xie, J.; Finkelstein, Y.; Desai, N.; Lane, R. D.; Bergmann, K. R.; Kaplan, R. L.; Hariharan, S.; Cruz, A. T.; Cohen, D. M.; Dixon, A.; Ramgopal, S.; Rominger, A.; Powell, E. C.; Kilgar, J.; Michelson, K. A.; Beer, D.; Bitzan, M.; Pruitt, C. M.; Yen, K.; Meckler, G. D.; Plint, A. C.; Bradin, S.; Abramo, T. J.; Gouin, S.; Kam, A. J.; Schuh, A.; Balamuth, F.; Hunley, T. E.; Kanegaye, J. T.; Jones, N. E.; Avva, U.; Porter, R.; Fein, D. M.; Louie, J. P.; Freedman, S. B.

Clin Infect Dis. 2019 May 28

Abstract

BACKGROUND: Shiga toxin-producing Escherichia coli (STEC) infections are leading causes of pediatric acute renal failure. Identifying hemolytic uremic syndrome (HUS) risk factors is needed to guide care. METHODS: We conducted a multicenter, historical-cohort study to identify features associated with development of HUS (primary outcome) and need for renal replacement therapy (RRT) (secondary outcome) in STEC-infected children without HUS at initial presentation. Children <18 years who submitted STEC-positive specimens between January 2011 and December 2015 at a participating study institution were eligible. RESULTS: Of 927 STEC-infected children, 41 (4.4%) had HUS at presentation; of the remaining 886, 126 (14.2%) developed HUS. Predictors of HUS included younger age (OR: 0.77; 95%CI: 0.69, 0.85/year), leukocyte count >/=13.0x103/muL (2.54; 1.42, 4.54), higher hematocrit (1.83; 1.21, 2.77/5% increase) and serum creatinine (10.82; 1.49, 78.69/1 mg/dL increase), platelet count <250 x103/muL (1.92; 1.02, 3.60), lower serum sodium (1.12; 1.02, 1.23/1 mmol/L decrease), and intravenous fluid administration initiated >/=4 days following diarrhea onset (2.50; 1.14, 5.46). A longer interval from diarrhea onset to index visit was associated with reduced HUS risk (0.70; 0.54, 0.90). RRT predictors included female sex (2.27; 1.14, 4.50), younger age (0.83; 0.74, 0.92/year), lower serum sodium (1.15; 1.04, 1.27/mmol/L decrease), higher leukocyte count >/=13.0x103/muL (2.35; 1.17, 4.72) and creatinine (7.75; 1.20, 50.16/1 mg/dL increase) concentrations, and initial intravenous fluid administration >/=4 days following diarrhea onset (2.71; 1.18, 6.21). CONCLUSIONS: The complex nature of STEC infection renders predicting its course a challenge. Risk factors we identified highlight the importance of avoiding dehydration and performing close clinical and laboratory monitoring.

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