Early Fluid Saves Lives in HUS

Short Attention Span Summary

Early IVF Saves Lives
A recent study in Pediatrics found that early IV fluid for HUS improved both renal and CNS outcomes.  This meta-analysis of 8 studies, over 1500 patients, found that a hematocrit (Hct) > 23% was associated with worse outcomes.  Hct was an indicator of hemoconcentration.  Yes, you read that right - a higher hematocrit was worse in this case.  Clinical dehydration at the time of HUS diagnosis was associated with almost 4 times the odds of death.  IV fluid administration prior to establishing the diagnosis of HUS markedly reduced the risk of needing dialysis.

Spoon Feed
Early IV fluid administration benefited patients with HUS and drastically reduced the odds of oliguria, need for dialysis, and death.  A word of caution (from one who has made mistakes), start slowly - 5 or 10mL/kg bolus - and reassess before giving more fluid.  You don't know if they are already in renal failure and oliguric.  Such patients can easily get volume overloaded, or at least I've heard of this happening to other attending physicians' patients :).


Abstract

JAMA Pediatr. 2016 Nov 28. doi: 10.1001/jamapediatrics.2016.2952. [Epub ahead of print]

Associations Between Hydration Status, Intravenous Fluid Administration, and Outcomes of Patients Infected With Shiga Toxin-Producing Escherichia coli: A Systematic Review and Meta-analysis.

Grisaru S1, Xie J2, Samuel S1, Hartling L3, Tarr PI4, Schnadower D5, Freedman SB6; Alberta Provincial Pediatric Enteric Infection Team.

Author information:

1Section of Pediatric Nephrology, Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada.

2Section of Pediatric Emergency Medicine, Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada.

3Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.

4Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri.

5Division of Emergency Medicine, Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri.

6Alberta Children's Hospital Research Institute, Section of Gastroenterology, Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada7Alberta Children's Hospital Research Institute, Section of Pediatric Emergency Medicine, Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada.

Abstract

Importance:

The associations between hydration status, intravenous fluid administration, and outcomes of patients infected with Shiga toxin-producing Escherichia coli (STEC) remain unclear.

Objective:

To determine the relationship between hydration status, the development and severity of hemolytic uremic syndrome (HUS), and adverse outcomes in STEC-infected individuals.

Data Sources:

MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials via the OvidSP platform, PubMed via the National Library of Medicine, CINAHL Plus with full text, Scopus, Web of Science, ClinicalTrials.gov, reference lists, and gray literature were systematically searched.

Study Selection:

Two reviewers independently identified studies that included patients with hydration status documentation, proven or presumed STEC infection, and some form of HUS that developed. No language restrictions were applied.

Data Extraction and Synthesis:

Two reviewers independently extracted individual study data, including study characteristics, population, and outcomes. Risk of bias was assessed using the Newcastle-Ottawa Scale; strength of evidence was adjudicated using the Grading of Recommendations Assessment, Development, and Evaluation method. Meta-analyses were conducted using random-effects models.

Main Outcomes and Measures:

Development of HUS, complications (ie, oligoanuric renal failure, involvement of the central nervous system, or death), and interventions (ie, renal replacement therapy).

Results:

Eight studies comprising 1511 patients (all children) met eligibility criteria. Unpublished data were provided by the authors of 7 published reports. The median risk-of-bias score was 7.5 (range, 6-9). No studies evaluated the effect of hydration during STEC infections on the risk for HUS. A hematocrit value greater than 23% as a measure of hydration status at presentation with HUS was associated with the development of oligoanuric HUS (OR, 2.38 [95% CI, 1.30-4.35]; I2 = 2%), renal replacement therapy (OR, 1.90 [95% CI, 1.25-2.90]; I2 = 17%), and death (OR, 5.13 [95% CI, 1.50-17.57]; I2 = 55%). Compared with putatively hydrated patients, clinically dehydrated patients had an OR of death of 3.71 (95% CI, 1.25-11.03; I2 = 0%). Intravenous fluid administration up to the day of HUS diagnosis was associated with a decreased risk of renal replacement therapy (OR, 0.26 [95% CI, 0.11-0.60]).

Conclusions and Relevance:

Two predictors of poor outcomes for STEC-infected children were identified: (1) the lack of intravenous fluid administration prior to establishment of HUS and (2) a higher hematocrit value at presentation. These findings point to an association between dehydration and adverse outcomes for children with HUS.

PMID: 27893870 [PubMed - as supplied by publisher]