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Dehydration, higher hematocrit value linked to adverse outcomes for STEC-infected children
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Lack of fluid administration prior to onset of hemolytic uremic syndrome and increased hematocrit values at presentation predicted adverse outcomes among children with Shiga toxin-producing Escherichia coli, according to data published in JAMA Pediatrics.
“Among children with established [hemolytic uremic syndrome (HUS)], management remains supportive, focusing on the avoidance of fluid overload by matching fluid intake to insensible losses, plus urine and stool output, for those with evolving acute kidney injury,” Silviu Grisaru, MD, assistant professor in the department of pediatrics at Alberta Children’s Hospital Research Institute, and colleagues wrote. “However, recent reports indicating that anticipatory volume expansion during the diarrheal phase may prevent the development of oligoanuric renal failure in children with HUS prompted the reconsideration of fluid management practices.”
To determine the associations between hydration status in Shiga toxin-producing Escherichia coli (STEC)-infected patients and adverse outcomes, Grisaru and colleagues conducted a systematic review of available published literature, analyzed appropriate journal and scientific meetings, checked references from relevant studies, and contacted authors of published and unpublished studies. They focused on the developments of HUS, oligoanuric renal failure, the need for renal replacement therapy, central nervous system involvement and incidences of mortality. Further, two researchers independently identified studies including patients with documented hydration status, definite or presumed STEC infection, and HUS development.
The researchers defined HUS by the presence of microangiopathic hemolytic anemia, thrombocytopenia and renal insufficiency with increased serum creatinine levels. Intravenous fluid administration was assessed if patients received it within the first 4 days of diarrhea onset and before HUS, and anytime following medical attention until HUS diagnosis. Further, the researchers assessed risk for bias using the Newcastle-Ottawa Scale and assessed evidence quality to support the effect of outcomes.
They found eight studies totaling 1,511 patients. The median risk-of-bias score was 7.5 (range, 6-9). Meta-analysis showed a hematocrit value higher than 23% at presentation with HUS correlated with a risk for oligoanuric HUS (OR = 2.38; 95% CI, 1.3-4.35; I2 = 2%), renal replacement therapy (OR, 1.9; 95% CI, 1.25-2.9; I2 = 17%) and death (OR = 5.13; 95% CI, 1.5-17.57; I2 = 55%). Clinically dehydrated patients had an increased risk for mortality (OR = 3.71; 95% CI, 1.25-11.03). In addition, IV fluid administration prior to HUS diagnosis was associated with a decreased risk for renal replacement therapy (OR = 0.26; 95% CI, 0.11-0.6).
“The results of this meta-analysis indicate that dehydration and fluid management may alter disease progression and the possibility that intravascular volume expansion before HUS (ie, STEC infection without HUS) can attenuate the evolution of HUS,” the researchers wrote.
“Confirmation of these hypotheses will require robust prospective studies using uniform markers and outcome measures.” – by Kate Sherrer
Disclosure: Grisaru reports no relevant financial conflicts of interests. Please see the full study for all other researchers’ relevant financial disclosures.
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