RESUMEN
BACKGROUND: A substantial proportion of patients with Escherichia coli-hemolytic uremic syndrome (STEC-HUS) evolve to chronic kidney disease (CKD). The objectives of this study were to evaluate long-term kidney outcomes and to identify CKD predictors. METHODS: In this single-center retrospective study, long-term outcomes of patients were analyzed according to the presence of complete recovery (CR) or CKD at last visit. Then, they were grouped into favorable (CR + CKD1) or poor (CKD2-5) outcome to compare predictors at diagnosis (sex, age, leukocytes, creatinine, hemoglobin, HUS severity score), dialysis duration, and follow-up time between them. RESULTS: Of 281 patients followed up for a median of 12 years, 139 (49%) had CR, 104 (37%) CKD1, 27 (10%) CKD2-4, and 11 (4%) CKD5. Thirty-eight patients progressed to CKD2-5 after a median of 4.8 years, 7% in the first 5 years, increasing to 8%, 10%, and 14% after 5-10 years, 10-15 years, and > 15 years, respectively. They were younger, had higher baseline hemoglobin and leukocytes, and required longer dialysis and follow-up than those with favorable outcome. By multivariate analysis, days of dialysis and follow-up time remained as independent predictors of poor outcome. The best cutoff for days of dialysis was 10 days. After 5 years, 20% of those dialyzed ≥ 10 days evolved to CKD2-5 versus 1% of those non-dialyzed or dialyzed < 10 days. CONCLUSIONS: Fifty-one percent of patients evolved to CKD after 12 years of follow-up and 14% to CKD2-5. Ten days of dialysis was the best cutoff to recognize outcomes. In some cases, kidney damage was evident after 15 years of surveillance, highlighting the need for follow-up until adulthood in all STEC-HUS patients.
Asunto(s)
Infecciones por Escherichia coli , Síndrome Hemolítico-Urémico , Insuficiencia Renal Crónica , Escherichia coli Shiga-Toxigénica , Humanos , Adulto , Estudios de Seguimiento , Estudios Retrospectivos , Infecciones por Escherichia coli/complicaciones , Infecciones por Escherichia coli/epidemiología , Diálisis Renal/efectos adversos , Riñón , Síndrome Hemolítico-Urémico/complicaciones , Insuficiencia Renal Crónica/complicaciones , Progresión de la Enfermedad , HemoglobinasRESUMEN
El síndrome urémico hemolítico (SUH), descripto en 1955, se caracteriza por la tríada de anemia hemolítica no inmunomediada, trombocitopenia y lesión renal aguda. En su patogenia interviene la toxina Shiga, producida con mayor frecuencia por E. coli O157:H. Puede manifestarse a cualquier edad, aunque es infrecuente en adultos, y se desarrolla en forma esporádica o en brote. Se presenta con un cuadro de dolor abdominal, diarrea, fiebre y vómitos. Puede afectar el sistema nervioso central, pulmones, páncreas y corazón. En adultos, el síndrome evoluciona tras un período de incubación de 1 semana posterior a la diarrea y tiene alta morbimortalidad, a diferencia de los casos pediátricos. Presentamos el caso de una paciente adulta, que cursó internación por síndrome urémico hemolítico. (AU)
Hemolytic uremic syndrome (HUS), described in 1955, is characterized by the triad of non-immune mediated hemolytic anemia, thrombocytopenia, and acute kidney injury. Shiga toxin, produced most frequently by E coli O157:H, is involved in its pathogenesis. Hus can manifest at any age, although it is rare in adults and develops sporadically or in outbreaks. HUS presents with a picture of abdominal pain, diarrhea, fever and vomiting. It can affect the central nervous system, lungs, pancreas, and heart.In adults, the syndrome evolves after an incubation period of 1 week after diarrhea, with high morbidity and mortality, unlike pediatric cases.We present the case of an adult patient who was hospitalized for hemolytic uremic syndrome. (AU)
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Humanos , Femenino , Persona de Mediana Edad , Escherichia coli O157/aislamiento & purificación , Infecciones por Escherichia coli/complicaciones , Síndrome Hemolítico-Urémico/patología , Síndrome Hemolítico-Urémico/diagnóstico por imagen , Reacción en Cadena de la Polimerasa , Diarrea/etiología , Síndrome Hemolítico-Urémico/dietoterapia , Síndrome Hemolítico-Urémico/sangre , Síndrome Hemolítico-Urémico/terapia , Infusiones Parenterales , Pruebas de Función RenalRESUMEN
BACKGROUND: Long-term kidney outcomes of non-dialyzed children with Shiga-toxin Escherichia Coli hemolytic uremic syndrome (STEC-HUS) have been scantily studied. Therefore, we aimed to evaluate kidney outcomes and prognostic markers in these patients. METHODS: Non-dialyzed STEC-HUS patients followed for at least 5 years were included. They were grouped and compared according to kidney status at last visit: complete recovery (CR) or chronic kidney disease (CKD). Predictors of CKD evaluated at diagnosis were sex, age, leukocytes, hematocrit, hemoglobin (Hb), and serum creatinine (sCr). Peak sCr and time of follow-up were also analyzed. RESULTS: A total of 122 patients (62 female, median age at diagnosis 1.6 years) with a median follow-up of 11.3 years were included. At last visit, 82 (67%) had CR, 36 (30%) had CKD stage 1, and 4 (3%) had stage 2. No patient developed CKD stage 3-5. Median time to CKD was 5 years (IQR 3.1-8.76 years). Of the 122 patients, 18% evolved to CKD in the first 5 years, increasing to 28% at 10 and 33% at 20 years of follow-up. Serum Cr at diagnosis and peak sCr were significantly higher in patients with CKD than in those with CR. CONCLUSIONS: One third of non-dialyzed STEC-HUS patients evolved to CKD after a median time of 5 years. However, CKD may appear even after 15 years of CR. Serum Cr was significantly higher among patients who evolved to CKD. These data reinforce that all non-dialyzed patients should be followed until adulthood. A higher resolution version of the Graphical abstract is available as Supplementary information.
Asunto(s)
Infecciones por Escherichia coli , Síndrome Hemolítico-Urémico , Insuficiencia Renal Crónica , Escherichia coli Shiga-Toxigénica , Niño , Humanos , Femenino , Adulto , Lactante , Toxina Shiga , Infecciones por Escherichia coli/complicaciones , Infecciones por Escherichia coli/diagnóstico , Riñón , Síndrome Hemolítico-Urémico/complicaciones , Síndrome Hemolítico-Urémico/terapia , Síndrome Hemolítico-Urémico/diagnóstico , Insuficiencia Renal Crónica/complicacionesRESUMEN
BACKGROUND: Hemolytic uremic syndrome (HUS) is characterized by microangiopathic hemolysis, thrombocytopenia, and thrombus formation leading to tissue injury. HUS is classified according to its etiology as post-diarrheal or atypical HUS. Differential diagnosis of both entities continues to be a challenge for pediatric physicians. METHODS: The aim was to improve the rapid etiological diagnosis of post-diarrheal HUS cases based on the detection of Shiga toxin (Stx)-producing Escherichia coli (STEC) infection by screening of stx1/stx2 and rfbO157 in cultured stools by multiplex PCR, and the additional detection of anti-lipopolysaccharide (anti-LPS) O157, O145, and O121 antibodies by Glyco-iELISA test. In addition, we studied patients' relatives to detect circulating pathogenic strains that could contribute to HUS diagnosis and/or lead to the implementation of measures to prevent dissemination of familial outbreaks. This study describes the diagnosis of 31 HUS patients admitted to Hospital Municipal de Niños Prof Dr Ramón Exeni during the 2017-2020 period. RESULTS: Stool PCR confirmed the diagnosis of STEC associated with HUS in 38.7% of patients (12/31), while anti-LPS serology did in 88.9% (24/27). In those patients in which both methods were carried out (n = 27), a strong association between the results obtained was found. We found that 30.4% of HUS patients had at least one relative positive for STEC. CONCLUSIONS: We could identify 96.3% (26/27) of HUS cases as secondary to STEC infections when both methods (genotyping and serology) were used. The results demonstrated a high circulation of STEC in HUS families and the prevalence of the STEC O157 serotype (83%) in our pediatric cohort. A higher-resolution version of the Graphical abstract is available as Supplementary information.
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Síndrome Hemolítico Urémico Atípico , Infecciones por Escherichia coli , Escherichia coli Shiga-Toxigénica , Niño , Humanos , Diarrea/diagnóstico , Diarrea/etiología , Diarrea/epidemiología , Serogrupo , Lipopolisacáridos , Anticuerpos Antibacterianos , Infecciones por Escherichia coli/complicaciones , Infecciones por Escherichia coli/diagnóstico , Infecciones por Escherichia coli/epidemiologíaRESUMEN
Shiga toxin 2 (Stx2) from enterohemorrhagic Escherichia coli (EHEC) produces hemorrhagic colitis, hemolytic uremic syndrome (HUS), and acute encephalopathy. The mortality rate in HUS increases significantly when the central nervous system (CNS) is involved. Besides, EHEC also releases lipopolysaccharide (LPS). Many reports have described cognitive dysfunctions in HUS patients, the hippocampus being one of the brain areas targeted by EHEC infection. In this context, a translational murine model of encephalopathy was employed to establish the deleterious effects of Stx2 and the contribution of LPS in the hippocampus. The purpose of this work is to elucidate the signaling pathways that may activate the inflammatory processes triggered by Stx2, which produces cognitive alterations at the level of the hippocampus. Results demonstrate that Stx2 produced depression-like behavior, pro-inflammatory cytokine release, and NF-kB activation independent of the ERK1/2 signaling pathway, while co-administration of Stx2 and LPS reduced memory index. On the other hand, LPS activated NF-kB dependent on ERK1/2 signaling pathway. Cotreatment of Stx2 with LPS aggravated the pathologic state, while dexamethasone treatment succeeded in preventing behavioral alterations. Our present work suggests that the use of drugs such as corticosteroids or NF-kB signaling inhibitors may serve as neuroprotectors from EHEC infection.
Asunto(s)
Encefalopatías , Disfunción Cognitiva , Escherichia coli Enterohemorrágica , Infecciones por Escherichia coli , Síndrome Hemolítico-Urémico , Ratones , Humanos , Animales , Toxina Shiga II/toxicidad , Lipopolisacáridos/farmacología , Sistema de Señalización de MAP Quinasas , FN-kappa B , Encéfalo/patología , Infecciones por Escherichia coli/complicaciones , Infecciones por Escherichia coli/tratamiento farmacológico , Infecciones por Escherichia coli/patología , Hipocampo/patología , CogniciónRESUMEN
BACKGROUND: Chronic kidney-related sequelae after STEC-HUS occur in 20-40% of patients. Hyperuricemia (HU) may cause acute and chronic toxicity involving the kidneys. We retrospectively assessed if there was an association between the presence of HU during the acute illness and that of kidney-related sequelae in children with STEC-HUS. METHODS: Children with STEC-HUS who had clinical and laboratory data at 2 years of follow-up were included in this case-control study. Univariate and multivariate analyses were performed between patients with (cases) or without (controls) kidney-related sequelae to identify factors associated with outcomes, including different measures of serum uric acid (sUA) (baseline level, peak, and duration of HU). HU was defined as sUA > 8 mg/dL. RESULTS: Of 86 patients included, 77.9% had HU. Patients with sequelae (n = 41) had a higher prevalence of HU (41/41 vs. 26/45, p < 0.01), higher baseline leukocyte count, serum creatinine (sCr), and sUA levels as well as lower sodium than controls. During hospitalization, cases also had higher sCr peak, sUA peak and duration of HU, requirement and duration of dialysis, extrarenal complications, and hypertension. By multivariate analysis, after adjusting for length of dialysis, only duration of HU (p = 0.0005; OR 1.7, 95% CI 1.27-2.36) remained as an independent predictor of sequelae, with a best cutoff of 5.5 days (AUC 0.95, specificity 80%, sensitivity 100%). CONCLUSIONS: The presence of HU is a common finding in children with STEC-HUS and its duration during the acute stage was associated with kidney-related sequelae, regardless of the duration of dialysis. A higher resolution version of the Graphical abstract is available as Supplementary Information.
Asunto(s)
Infecciones por Escherichia coli , Síndrome Hemolítico-Urémico , Hiperuricemia , Escherichia coli Shiga-Toxigénica , Niño , Humanos , Hiperuricemia/complicaciones , Hiperuricemia/epidemiología , Estudios Retrospectivos , Estudios de Casos y Controles , Ácido Úrico , Diálisis Renal/efectos adversos , Riñón , Síndrome Hemolítico-Urémico/complicaciones , Síndrome Hemolítico-Urémico/epidemiología , Factores de Riesgo , Progresión de la Enfermedad , Infecciones por Escherichia coli/complicacionesRESUMEN
BACKGROUND: Hemolytic uremic syndrome secondary to Shiga-toxin-producing Escherichia coli infection (STEC-HUS) generally shows a favorable outcome. Few cases develop extra-renal complications, since neurological involvement is an important cause of morbidity and mortality. The role of complement in STEC-HUS has been recently highlighted, and the use of eculizumab in severe cases has been communicated. HUS results from environmental and genetic factors, but the simultaneous occurrence of STEC and complement mutations remains undetermined. METHODS: A pediatric case with severe STEC-HUS carrying CFH mutations, with favorable response to eculizumab is analyzed. RESULTS: STEC-HUS was diagnosed in a 4-year-old girl with classic HUS, including low C3. Peritoneal dialysis was started due to hypertension, oligoanuria, and pleural effusion. She evolved with generalized tonic-clonic seizures and required mechanical ventilation. MRI reported multiple supra- and infratentorial ischemic lesions with laminar/striatal cortical necrosis and leukoencephalopathy. After two eculizumab doses, a significative stabilization in diuresis, blood pressure, creatinine, and C3 was achieved. At the third week, episodes of massive digestive bleeding and a life-threatening condition required a colectomy thus preserving the ileocecal valve. Due to atypical evolution, a genetic study was considered, identifying two heterozygous variants (CFH S1191L/V1197A). CONCLUSION: STEC-HUS in patients with a genetic predisposition has been previously reported, but the low frequency of occurrence makes it a rare disease. As in the present case, patients with atypical course might benefit from genetic analysis to evaluate early eculizumab initiation and to better understand its phenotype. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Infecciones por Escherichia coli , Síndrome Hemolítico-Urémico , Escherichia coli Shiga-Toxigénica , Femenino , Humanos , Infecciones por Escherichia coli/complicaciones , Escherichia coli Shiga-Toxigénica/genética , Síndrome Hemolítico-Urémico/complicaciones , Síndrome Hemolítico-Urémico/tratamiento farmacológico , Síndrome Hemolítico-Urémico/genética , Proteínas del Sistema Complemento , MutaciónAsunto(s)
Infecciones por Escherichia coli , Síndrome Hemolítico-Urémico , Escherichia coli Shiga-Toxigénica , Infecciones por Escherichia coli/complicaciones , Infecciones por Escherichia coli/diagnóstico , Femenino , Síndrome Hemolítico-Urémico/complicaciones , Síndrome Hemolítico-Urémico/diagnóstico , Humanos , Masculino , PronósticoRESUMEN
Enteropathogenic (EPEC) and enteroaggregative (EAEC) Escherichia coli are two of the major pathotypes of diarrheagenic E. coli causing disease worldwide. Here, we report a diarrheal outbreak caused by E. coli of serotype O3:H2, harboring virulence markers from EPEC (eae) and/or EAEC (aggR). This is likely the first E. coli diarrheal outbreak caused by a hybrid atypical-EPEC/EAEC clone reported in Brazil.
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Escherichia coli Enteropatógena , Infecciones por Escherichia coli , Brasil/epidemiología , Células Clonales , Diarrea/epidemiología , Diarrea/etiología , Diarrea/microbiología , Brotes de Enfermedades , Escherichia coli Enteropatógena/clasificación , Escherichia coli Enteropatógena/genética , Escherichia coli Enteropatógena/aislamiento & purificación , Escherichia coli Enteropatógena/patogenicidad , Infecciones por Escherichia coli/complicaciones , Infecciones por Escherichia coli/epidemiología , Humanos , Serogrupo , Factores de VirulenciaRESUMEN
OBJECTIVE: To analyze the results of an enhanced laboratory-surveillance protocol for bloody diarrhea aimed at identifying children with Shiga toxin-producing Escherichia coli (STEC) infection early in the course of the disease toward the early identification and management of patients with hemolytic uremic syndrome (HUS). STUDY DESIGN: The study (2010-2019) involved a referral population of 2.3 million children. Stool samples of patients with bloody diarrhea were screened for Shiga toxin (Stx) genes. Positive patients were rehydrated and monitored for hemoglobinuria until diarrhea resolved or STEC-HUS was diagnosed. RESULTS: A total of 4767 children were screened; 214 (4.5%) were positive for either Stx1 (29.0%) or Stx2 (45.3%) or both Stx1+2 (25.7%); 34 patients (15.9%) developed STEC-HUS (0.71% of bloody diarrheas). Hemoglobinuria was present in all patients with HUS. Patients with Stx2 alone showed a greater risk of STEC-HUS (23.7% vs 12.7%) and none of the patients with Stx1 alone developed HUS. During the same period of time, 95 other patients were diagnosed STEC-HUS but were not captured by the screening program (26 had nonbloody diarrhea, 11 came from areas not covered by the screening program, and 58 had not been referred to the screening program, although they did meet the inclusion criteria). At HUS presentation, serum creatinine of patients identified by screening was significantly lower compared with that of the remaining patients (median 0.9 vs 1.51 mg/dL). CONCLUSIONS: Nearly 1% of children with bloody diarrhea developed STEC-HUS, and its diagnosis was anticipated by the screening program for Stx. The screening of bloody diarrhea for Stx is recommended, and monitoring patients carrying Stx2 with urine dipstick for hemoglobinuria is suggested to identify the renal complication as early as possible.
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Diarrea/microbiología , Infecciones por Escherichia coli/diagnóstico , Hemorragia Gastrointestinal/microbiología , Síndrome Hemolítico-Urémico/microbiología , Tamizaje Masivo/métodos , Escherichia coli Shiga-Toxigénica/aislamiento & purificación , Adolescente , Niño , Preescolar , Diagnóstico Precoz , Infecciones por Escherichia coli/complicaciones , Femenino , Hemorragia Gastrointestinal/diagnóstico , Genes Bacterianos , Síndrome Hemolítico-Urémico/diagnóstico , Síndrome Hemolítico-Urémico/epidemiología , Síndrome Hemolítico-Urémico/terapia , Humanos , Lactante , Recién Nacido , Italia , Masculino , Toxinas Shiga/genética , Escherichia coli Shiga-Toxigénica/genética , Resultado del Tratamiento , Adulto JovenAsunto(s)
Diarrea/historia , Diarrea/microbiología , Escherichia coli Enteropatógena , Infecciones por Escherichia coli/complicaciones , Infecciones por Escherichia coli/historia , Diarrea/epidemiología , Diarrea/terapia , Escherichia coli Enteropatógena/clasificación , Escherichia coli Enteropatógena/aislamiento & purificación , Infecciones por Escherichia coli/epidemiología , Infecciones por Escherichia coli/terapia , Salud Global , Historia del Siglo XX , Historia del Siglo XXI , HumanosRESUMEN
BACKGROUND: This study describes the investigation of an outbreak of diarrhea, hemorrhagic colitis (HC), and hemolytic uremic syndrome (HUS) at a daycare center in southeastern Brazil, involving fourteen children, six staff members, six family members, and one nurse. All bacterial and viral pathogens detected were genetically characterized. RESULTS: Two isolates of a strain of enterohemorrhagic Escherichia coli (EHEC) serotype O111:H8 were recovered, one implicated in a case of HUS and the other in a case of uncomplicated diarrhea. These isolates had a clonal relationship of 94% and carried the stx2a and eae virulence genes and the OI-122 pathogenicity island. The EHEC strain was determined to be a single-locus variant of sequence type (ST) 327. EHEC isolates were resistant to ofloxacin, doxycycline, tetracycline, ampicillin, and trimethoprim-sulfamethoxazole and intermediately resistant to levofloxacin and ciprofloxacin. Rotavirus was not detected in any samples, and norovirus was detected in 46.7% (14/30) of the stool samples, three of which were from asymptomatic staff members. The noroviruses were classified as the recombinant GII.4 Sydney [P16] by gene sequencing. CONCLUSION: In this outbreak, it was possible to identify an uncommon stx2a + EHEC O111:H8 strain, and the most recent pandemic norovirus strain GII.4 Sydney [P16]. Our findings reinforce the need for surveillance and diagnosis of multiple enteric pathogens by public health authorities, especially during outbreaks.
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Infecciones por Caliciviridae , Brotes de Enfermedades , Escherichia coli Enterohemorrágica/genética , Infecciones por Escherichia coli , Norovirus/genética , Brasil , Infecciones por Caliciviridae/complicaciones , Infecciones por Caliciviridae/epidemiología , Infecciones por Caliciviridae/microbiología , Infecciones por Caliciviridae/virología , Preescolar , Farmacorresistencia Bacteriana/genética , Escherichia coli Enterohemorrágica/clasificación , Infecciones por Escherichia coli/complicaciones , Infecciones por Escherichia coli/epidemiología , Infecciones por Escherichia coli/microbiología , Infecciones por Escherichia coli/virología , Femenino , Humanos , Lactante , Masculino , Norovirus/clasificaciónRESUMEN
BACKGROUND: Shiga toxin-producing Escherichia coli (STEC) infection is the most common cause of hemolytic uremic syndrome (HUS). Only few studies correlated serotypes and stx genotypes with disease severity. This study aimed to update STEC serotypes, stx genotypes, and virulence factors (eae and ehxA) in a cohort of patients with STEC-HUS and investigate whether they influence the severity of disease. METHODS: In this multicentric study, children hospitalized between 2005 and 2016 with STEC-HUS confirmed by the National Reference Laboratory were included. Serotypes (O157, O145, O121, and others), stx genotypes (stx1a, stx2a, stx2c, stx2d, and others), and virulence factors were analyzed, and their association with dialysis requirement (>10 days); severe neurological, cardiovascular, and/or bowel involvement; and death was assessed. RESULTS: The records of 280 patients were reviewed; 160 females, median age 21 months (IQR18m). STEC O157 was isolated in 206 (73.6%) patients, O145 in 47 (16.8%), O121 in 15 (5.4%), and other serotypes in 12 (4.2%). The stx2a/2c genotype was carried by 179 (63.9%) strains, stx2a by 94 (33.6%), stx1a/stx2a by five (1.8%), and stx1a only by two (0.7%). All strains except six harbored eae and ehxA genes. Fifty-nine (21.1%) patients had severe neurological involvement, 29 (10.4%) severe bowel injury, 14 (5%) cardiovascular involvement, 53 (18.9%) required > 10 days of dialysis, and 12 (4.3%) died. Neither serotypes nor stx genotypes detected were significantly linked to severity. CONCLUSIONS: Serotype O157 and virulence stx2a/2c, eae, ehxA genotype are prevalent in Argentina, and no relationship was found between severity and serotypes and genotypes of STEC detected.
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Infecciones por Escherichia coli , Síndrome Hemolítico-Urémico , Escherichia coli Shiga-Toxigénica , Argentina/epidemiología , Infecciones por Escherichia coli/complicaciones , Infecciones por Escherichia coli/epidemiología , Proteínas de Escherichia coli/genética , Femenino , Genotipo , Síndrome Hemolítico-Urémico/epidemiología , Síndrome Hemolítico-Urémico/etiología , Humanos , Lactante , Masculino , Diálisis Renal , Serogrupo , Escherichia coli Shiga-Toxigénica/genética , Factores de Virulencia/genéticaRESUMEN
OBJECTIVE: To assess the performance of a hemolytic uremic syndrome (HUS) severity score among children with Shiga toxin-producing Escherichia coli (STEC) infections and HUS by stratifying them according to their risk of adverse events. The score has not been previously evaluated in a North American acute care setting. STUDY DESIGN: We reviewed medical records of children <18 years old infected with STEC and treated in 1 of 38 participating emergency departments in North America between 2011 and 2015. The HUS severity score (hemoglobin [g/dL] plus 2-times serum creatinine [mg/dL]) was calculated using first available laboratory results. Children with scores >13 were designated as high-risk. We assessed score performance to predict severe adverse events (ie, dialysis, neurologic complication, respiratory failure, and death) using discrimination and net benefit (ie, threshold probability), with subgroup analyses by age and day-of-illness. RESULTS: A total of 167 children had HUS, of whom 92.8% (155/167) had relevant data to calculate the score; 60.6% (94/155) experienced a severe adverse event. Discrimination was acceptable overall (area under the curve 0.71, 95% CI 0.63-0.79) and better among children <5 years old (area under the curve 0.77, 95% CI 0.68-0.87). For children <5 years, greatest net benefit was achieved for a threshold probability >26%. CONCLUSIONS: The HUS severity score was able to discriminate between high- and low-risk children <5 years old with STEC-associated HUS at a statistically acceptable level; however, it did not appear to provide clinical benefit at a meaningful risk threshold.
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Reglas de Decisión Clínica , Servicio de Urgencia en Hospital , Infecciones por Escherichia coli/diagnóstico , Síndrome Hemolítico-Urémico/diagnóstico , Índice de Severidad de la Enfermedad , Escherichia coli Shiga-Toxigénica , Adolescente , Niño , Preescolar , Infecciones por Escherichia coli/complicaciones , Infecciones por Escherichia coli/mortalidad , Femenino , Síndrome Hemolítico-Urémico/complicaciones , Síndrome Hemolítico-Urémico/mortalidad , Humanos , Lactante , Recién Nacido , Masculino , América del Norte , Pronóstico , Estudios Retrospectivos , Medición de Riesgo , Sensibilidad y EspecificidadRESUMEN
BACKGROUND: Management of acute kidney injury (AKI) in children with hemolytic uremic syndrome induced by a Shiga toxin-producing Escherichia coli infection (STEC-HUS) is supportive; however, 40 to 60% of cases need kidney replacement therapy (KRT). The aim of this study was to analyze procedure complications, especially peritonitis, and clinical outcomes in children with AKI secondary to STEC-HUS treated with acute PD. METHODS: This is a multicenter retrospective study conducted among thirty-seven Argentinian centers. We reviewed medical records of 389 children with STEC-HUS hospitalized between January 2015 and February 2019 that required PD. RESULTS: Complications associated with PD were catheter malfunction (n = 93, 24%), peritonitis (n = 75, 19%), fluid leaks (n = 45, 11.5%), bleeding events (n = 23, 6%), and hyperglycemia (n = 8, 2%). In the multivariate analysis, the use of antibiotic prophylaxis was independently associated with a decreased risk of peritonitis (hazard ratio 0.49, IC 95% 0.29-0.81; p = 0.001), and open-surgery catheter insertion was independently associated with a higher risk (hazard ratio 2.8, IC 95% 1.21-6.82; p = 0.001). Discontinuation of PD due to peritonitis, severe leak, or mechanical complications occurred in 3.8% of patients. No patient needed to be transitioned to other modality of KRT due to inefficacy of the technique. Mortality during the acute phase occurred in 2.8% patients due to extrarenal complications (neurological and cardiac involvement), not related to PD. CONCLUSIONS: Acute PD was a safe and effective method to manage AKI in children with STEC-HUS. Prophylactic antibiotics prior to insertion of the PD catheter should be considered to decrease the incidence of peritonitis.
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Lesión Renal Aguda , Infecciones por Escherichia coli , Síndrome Hemolítico-Urémico , Diálisis Peritoneal , Escherichia coli Shiga-Toxigénica , Lesión Renal Aguda/epidemiología , Lesión Renal Aguda/etiología , Lesión Renal Aguda/terapia , Niño , Infecciones por Escherichia coli/complicaciones , Infecciones por Escherichia coli/epidemiología , Infecciones por Escherichia coli/terapia , Síndrome Hemolítico-Urémico/complicaciones , Síndrome Hemolítico-Urémico/epidemiología , Síndrome Hemolítico-Urémico/terapia , Humanos , Diálisis Peritoneal/efectos adversos , Peritonitis/epidemiología , Peritonitis/etiología , Estudios RetrospectivosRESUMEN
BACKGROUND: Shiga toxin-producing Escherichia coli-associated hemolytic uremic syndrome (STEC-HUS) is the main cause of pediatric acute kidney injury (AKI) in Argentina. Endothelial injury is the trigger event in the microangiopathic process. The host inflammatory response to toxin and E. coli lipopolysaccharide (LPS) is involved in disease pathophysiology. METHODS: This retrospective study describes pediatric STEC-HUS patients with multiorgan involvement at the initial phase of disease. A retrospective study of critically ill HUS patients with evidence of E. coli infection was conducted through a period of 15 years. RESULTS: Forty-four patients 35.4 ± 4.1 months were admitted to the intensive care unit for 21 ± 2 days. Mechanical ventilation was required in 41 patients, early inotropic support in 37, and 28 developed septic shock. Forty-one patients required kidney replacement therapy for 12 ± 1 days. Forty-one patients showed neurological dysfunction. Dilated cardiomyopathy was demonstrated in 3 patients, left ventricular systolic dysfunction in 4, and hypertension in 17. Four patients had pulmonary hemorrhage, and acute respiratory distress syndrome in 2. Colectomy for transmural colonic necrosis was performed in 3 patients. Thirty-seven patients were treated with therapeutic plasma exchange, and 28 patients received methylprednisolone (10 mg/kg for 3 days). Of the surviving 32 patients, neurological sequelae were seen in 11 and chronic kidney failure in 5. CONCLUSIONS: Severe clinical outcome at onset suggests an amplified inflammatory response after exposure to Shiga toxin and/or E. coli LPS. STEC-HUS associated with severe neurological involvement, hemodynamic instability, and AKI requires intensive care and focused therapy.
Asunto(s)
Lesión Renal Aguda , Infecciones por Escherichia coli , Síndrome Hemolítico-Urémico , Escherichia coli Shiga-Toxigénica , Lesión Renal Aguda/etiología , Lesión Renal Aguda/terapia , Niño , Infecciones por Escherichia coli/complicaciones , Infecciones por Escherichia coli/terapia , Síndrome Hemolítico-Urémico/complicaciones , Síndrome Hemolítico-Urémico/terapia , Humanos , Lipopolisacáridos , Estudios Retrospectivos , Toxina ShigaAsunto(s)
Complemento C3/análisis , Infecciones por Escherichia coli/complicaciones , Síndrome Hemolítico-Urémico/sangre , Enfermedades del Sistema Nervioso/epidemiología , Niño , Infecciones por Escherichia coli/sangre , Infecciones por Escherichia coli/inmunología , Infecciones por Escherichia coli/microbiología , Síndrome Hemolítico-Urémico/inmunología , Síndrome Hemolítico-Urémico/microbiología , Humanos , Enfermedades del Sistema Nervioso/inmunología , Curva ROC , Valores de Referencia , Medición de Riesgo/métodos , Escherichia coli Shiga-Toxigénica/inmunologíaRESUMEN
BACKGROUND: Acute gastroenteritis (AGE) is a major cause of morbidity and mortality in children aged less than 5 years in low- and middle-income countries where limited access to potable water, poor sanitation, deficient hygiene, and food product contamination are prevalent. Research on the changing etiology of AGE and associated risk factors in Latin America, including Colombia, is essential to understand the epidemiology of these infections. The primary objectives of this study were to describe etiology of moderate to severe AGE in children less than 5 years of age from Bucaramanga, Colombia, a middle-income country in Latin American, and to identify the presence of emerging E. coli pathotypes. METHODOLOGY/PRINCIPAL FINDINGS: This was a prospective, matched for age, case-control study to assess the etiology of moderate to severe AGE in children less than 5 years of age in Bucaramanga, Colombia, South America. We tested for 24 pathogens using locally available diagnostic testing, including stool culture, polymerase chain reaction, microscopy and enzyme-linked immunoassay. Adjusted attributable fractions were calculated to assess the association between AGE and each pathogen in this study population. The study included 861 participants, 431 cases and 430 controls. Enteric pathogens were detected in 71% of cases and in 54% of controls (p = <0.001). Co-infection was identified in 28% of cases and in 14% of controls (p = <0.001). The adjusted attributable fraction showed that Norovirus GII explained 14% (95% CI: 10-18%) of AGE, followed by rotavirus 9.3% (6.4-12%), adenovirus 3% (1-4%), astrovirus 2.9% (0.6-5%), enterotoxigenic Escherichia coli (ETEC) 2.4% (0.4-4%), Cryptosporidium sp. 2% (0.5-4%), Campylobacter sp. 2% (0.2-4%), and Salmonella sp.1.9% (0.3 to 3.5%). Except for Cryptosporidium, all parasite infections were not associated with AGE. Three emergent diarrheagenic E. coli pathotypes were identified in cases (0.7%), including an enteroaggregative/enterotoxigenic E.coli (EAEC/ETEC), an enteroaggregative/enteropathogenic E.coli (EAEC/EPEC), and an emergent enteroinvasive E. coli with a rare O96:H19. No deaths were reported among cases or controls. CONCLUSIONS/SIGNIFICANCE: Norovirus and rotavirus explained the major proportion of moderate to severe AGE in this study. Higher proportion of infection in cases, in the form of single infections or co-infections, showed association with AGE. Three novel E. coli pathotypes were identified among cases in this geographic region.