Predicting Hemolytic Uremic Syndrome and Renal Replacement Therapy in Shiga Toxin–producing Escherichia coli–infected Children

Abstract

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 aged <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 (all shown as odds ratio [OR] with 95% confidence interval [CI]) of HUS included younger age (0.77 [.69–.85] per year), leukocyte count ≥13.0 × 103/μL (2.54 [1.42–4.54]), higher hematocrit (1.83 [1.21–2.77] per 5% increase) and serum creatinine (10.82 [1.49–78.69] per 1 mg/dL increase), platelet count <250 × 103/μL (1.92 [1.02–3.60]), lower serum sodium (1.12 [1.02–1.23 per 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 (OR, 0.70 [95% CI, .54–.90]). RRT predictors (all shown as OR [95% CI]) included female sex (2.27 [1.14–4.50]), younger age (0.83 [.74–.92] per year), lower serum sodium (1.15 [1.04–1.27] per mmol/L decrease), higher leukocyte count ≥13.0 × 103/μL (2.35 [1.17–4.72]) and creatinine (7.75 [1.20–50.16] per 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.