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Saudi Journal of Kidney Diseases and Transplantation
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EDITORIAL Table of Contents   
Year : 2000  |  Volume : 11  |  Issue : 4  |  Page : 537-542
An Update on the Hemolytic Uremic Syndrome


Department of Pediatrics, The Children’s Hospital of Philadelphia and the University of Pennsylvania, Philadelphia, Pennsylvania, USA

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How to cite this article:
Kaplan BS. An Update on the Hemolytic Uremic Syndrome. Saudi J Kidney Dis Transpl 2000;11:537-42

How to cite this URL:
Kaplan BS. An Update on the Hemolytic Uremic Syndrome. Saudi J Kidney Dis Transpl [serial online] 2000 [cited 2014 Apr 24];11:537-42. Available from: http://www.sjkdt.org/text.asp?2000/11/4/537/36639
Recent major outbreaks in several parts of the world of  Escherichia More Details coli enteritis with subsequent development of hemolytic uremic syndrome (HUS), continue to draw attention to this important public health problem. In August 1998, Time Magazine featured Escherichia coli, as the killer germ on its front cover and there are many reports about this problem in the medical literature and lay media in recent years. HUS is not a notifiable disease in every state of the United States. However, although 63 cases of post-diarrheal HUS were reported to the National Center for Infectious Diseases for the first 36 weeks of 1999, it is estimated that there are about 1000 new cases of HUS in the United States each year. The purpose of this review is to present recent developments in the understanding of HUS and to re-emphasize the fact that HUS differs in important respects from thrombotic thrombocytopenic purpura (TTP).

Shiga toxin-associated HUS (Stx HUS)

The term Stx HUS is more precise than D+, typical or post-diarrheal HUS. Stx HUS follows infection with shiga toxin-producing bacteria that include Escherichia coli (STEC) and  Shigella dysenteriae Scientific Name Search e type 1. Stx HUS is a post-infectious, multi-system syndrome defined by acute onset of hemolytic anemia with fragmented erythrocytes, thrombo­cytopenia and renal injury. [1]

There is still an unfortunate inclination on the part of nephrologists and hematologists in internal medicine to 'diagnose' TTP in adult patients who have Stx HUS. Any patient, who develops acute onset of hemolytic anemia with fragmented erythro­cytes, thrombocytopenia and renal injury, following an episode of bloody diarrhea, whether a child or an adult, whether there is a fever or not, and whether or not there is central nervous system involvement, has HUS and not TTP. This cannot be stressed strongly enough because of the implications for treatment and prognosis.

Stx HUS usually follows gastroenteritis with bloody diarrhea but occasionally can occur with non-bloody diarrhea and may rarely complicate a urinary tract infection. Stx HUS must be anticipated in any patient with bloody diarrhea. It must be suspected in any patient with diarrhea whose urine volume does not increase when adequate hydration is restored, or who becomes pale or edematous during or after an episode of bloody diarrhea. It must also be suspected in any patient who has seizures during or after bloody diarrhea. Stx HUS occurs in all ages but mainly between six months and four years. Slightly more females are affected. It occurs mainly in summer, as sporadic cases and in epidemics. Epidemics have been caused by ingestion of under­cooked ground meat contaminated with Escherichia coli 0157:H7. Ground meat must be cooked to a temperature of more than 68°C (155°F). HUS also follows ingestion of contaminated fruit, vegetables, water, apple cider, milk-containing products, and many different kinds of undercooked and prepared meats. Affected cases must be reported to the appropriate health department and contacts that develop diarrhea must be evaluated medically. The incubation period is one to ten days. Five to 15% of children with Escherichia coli 0157:H7 gastrointestinal infections are at risk for HUS. Antibiotics increase the risk of developing Stx HUS after Escherichia coli 0157:H7 infection. [2] Among 71 children with Escherichia coli O157:H7 diarrhea, HUS developed in five of nine who were treated with antibiotics (56 percent). In contrast, HUS developed in only five of the 62 children who had not been treated with antibiotics (8 percent). [2] Similarly, antimotility agents should not be used to treat suspected Escherichia coli 0157:H7 gastroenteritis. The importance of washing hands, cooking meat well, avoiding contamination of food by uncooked meat, and eating only pasteurized dairy products, cannot be over­ emphasized. In addition, toddlers with diarrhea must be prevented from attending day-care schools and swimming in pools.

New observations, and references, on the pathogenesis of Stx HUS can be found in references 3 and 4. STEC colonize the intestine, produce Stx1 and Stx2, and these translocate across the intestinal epithelium. Stx1 and 2 have A and B subunits. The A subunit has N-glycanase activity and the five B subunits bind to the globo­triaosylceramide (Gb3) receptor. It is not known whether Stx is released in single or multiple waves. Stx-induced endothelial cell damage still appears to be the central event in the pathogenesis of renal dysfunction and injury in Stx HUS. Glomerular endothelial cells become swollen and detach from the underlying basement membrane. As a result of the injury there are abnormalities in the procoagulant and anticoagulant functions of the endothelial cells. Cytokines and lipopolysaccharide amplify Stx sensitivity. Stx stimulates the procoagulant, thromboxane A2. Activation of human endothelium by tissue necrosis factor (TNF) or IL-1 after exposure to Stx, increases Gb3 synthesis, and increases the expression of functional Gb3 receptor.

Endothelial cells are not the only targets for Stx in the kidney. Other renal cells have receptors for Stx and are damaged by this toxin. Stx directly injures human proximal tubular cells in vitro. Distal renal tubular cells express Gb3 and undergo apoptosis after exposure to Stx. Stx1 and Stx2 were found in tubular epithelial cells of a patient with Stx HUS. Gb3 is expressed on cultured human mesangial cells and it is noteworthy that these cells are also injured in patients with Stx HUS. The damage varies from mild cellular edema to severe mesangiolysis. Inhibition of protein synthesis by Stx1 is potentiated by preincubation of the cells with IL-1 or TNF-alpha. These cytokines activate chemokine genes and result in lethal toxic injury. Recent studies show that human glomerular epithelial cells (human GEC) express Gb3 and are susceptible to the toxic effects of Stx1. [5] The effects of Stx1 are amplified by exposure to pro­inflammatory IL-1, TNF, LPS and butyrate. In summary, Stx has toxic effects on renal arteriolar and glomerular endothelial cells, aortic, and brain endothelial cells, mesangial cells, proximal and distal renal tubular epithelial cells, monocytes, astrocytoma cells, lung epithelial cells, glomerular epithelial cells and direct effects on polymorphonuclear cells. Erythrocytes and platelets may also have receptors for Stx.

Stx HUS is a multi-system disease that can affect the gastrointestinal tract, kidneys, blood, brain, pancreas, liver, heart and lungs. The serious immediate consequences include colonic gangrene, acute renal failure, minor to severe cerebral impairment, and transient or permanent diabetes mellitus. Acute hepatic injury, cardiac failure or adult respiratory distress syndrome is less often seen. Conservative treatment with appropriate use of peritoneal or hemodialysis, maintenance of fluid and electrolyte balances, careful control of hypertension, and judicious use of blood transfusions has reduced the acute mortality rate from as high as 30% to below 3%. Platelet infusions should not be given unless there is active bleeding or a surgical procedure is required. There are no advantages for the use of fresh frozen plasma, plasmapheresis, anti­coagulants or anti-platelet agents. Trials on the use of Synsorb Pk to prevent HUS or to reduce its effects are still in progress. [6]

Renal biopsies are rarely indicated. The diagnosis of colonic gangrene and the prevention and treatment of central nervous system injury remain areas of major difficulty. Few children with Stx HUS progress to chronic dialysis or require renal transplantation. [7] The outcome in elderly adults remains more guarded, in part because of co-morbid conditions. Most patients who have normal serum creatinine concentrations, normal blood pressures and no proteinuria a year after the acute episode, have an excellent long-term prognosis. [8] Long-term serious sequelae are surprisingly infrequent and include chronic renal failure, diabetes mellitus, cholecystitis, [9] and very rarely, central nervous system impairment. Less serious renal sequelae include mild to moderate reductions in glomerular filtration rate, proteinuria, and hypertension. Post­transplant recurrences of Stx HUS are extremely rare and there is no contra­indication to using inhibitors of calci­neurin. [10]

Idiopathic HUS

Idiopathic (atypical or non-diarrhea­associated) HUS is a heterogeneous yet distinct subgroup of the HUS that differs from diarrhea-associated HUS on epide­miologic, clinical, laboratory, histologic, and prognostic grounds. [11] Some of these patients have hypocomplementemia with low Factor H concentrations and the pathogenesis may be linked to disorders of complement. [12],[13] Treatment can be extremely difficult because of severe hypertension, parental anxiety about the possibility of recurrences, and course that is often indolent. Plasmapheresis, although unproven, is still recommended. Post­transplant recurrences are frequent. Using a living-related kidney and calcineurin antagonists increase the chances of a recurrence, whereas pretransplant neph­rectomies may reduce the possibility of a recurrence [14] .

Autosomal recessive and autosomal dominant inheritance of HUS

A diagnosis of autosomal recessive or autosomal dominant HUS cannot be made in the absence of a positive family history. [15] However, it must be suspected in patients who have idiopathic HUS especially if there is hypocomplementemia and a Factor H deficiency. In the recessive form there are no recognized precipitating events, and no sex or race preferences. Most affected individuals have been infants and children, but adults are not exempt. In occasional patients there may be complete resolution, in some there may be several episodes of HUS, and HUS may recur before and/or after renal transplantation. [16]

Pregnancy may be a precipitating event in the dominant form in which adults are affected more often than children; there is no sex or race preference. [17] Complete recovery is uncommon. The pathogenesis of the inherited forms of HUS is being elucidated with new insights into the possible role of Factor H deficiency and evidence of linkage to the Factor H locus on chromosome 1. [18],[19] There is no specific treatment but fresh frozen plasma infusions and plasmapheresis are indicated for inherited cases. The prognosis is dismal for renal and poor for patient survival. The timing of a renal transplant presents problems, but it is advisable to wait for six to twelve months between the occurrence of HUS and the transplant. The patient must be free from all evidence of active disease. Although the use of a living-related donor presents a problem, there are no definite guidelines. There are also no hard data in regard to the use of cyclosporin A or oral contraceptives. Pregnancy may increase the likelihood of recurrences. Genetic counseling is particularly difficult if the patient is the first affected individual in the family.

Thrombotic thrombocytopenic purpura (TTP)

It has become abundantly clear that Stx HUS differs fundamentally from TTP in regard to etiology, pathogenesis and outcome. Therefore, the term HUS/TTP is best avoided because it confuses the approach to diagnosis, treatment and outcome. An increasing body of evidence demonstrates perturbations in the function of von Willibrand factor (vWf) proteases in TTP. [20] Two different defects have been demon­strated. Patients with acute TTP had a severe deficiency of vWf-cleaving protease caused by inhibitory activity against the protease. [21] No deficiency was detected in patients in TTP who were in remission. The inhibitors were IgG antibodies and the resultant deficiency of this protease may have a role in the pathogenesis of platelet thrombosis in TTP. [21] Patients with familial forms of TTP lacked vWf-cleaving protease activity but had no inhibitor. [22] These findings are in contrast to those in HUS where patients with inherited HUS had normal or slightly decreased levels of activity of vWf-cleaving protease during the acute episode. [23] Furthermore, in vitro proteolytic degradation of vWf by the protease was normal in all patients with inherited HUS and non-inherited HUS. [23],[24]

Therefore, non-familial TTP appears to result from an inhibitor of vWf-cleaving protease, whereas the familial form seems to be caused by a constitutional deficiency of the protease. Furthermore, patients with TTP have a deficiency of vWf-cleaving protease, whereas patients with HUS have normal activity of this protease. [22],[23] The ability of plasmapheresis to remove auto­antibodies to the vWf-cleaving protease provides the first solid rationale for this treatment in some patients with TTP.

Recent studies have demonstrated that TTP may be caused by the antiplatelet agents ticlopidine [24] and clopidogrel. [25] Auto­antibodies to the vWF metalloproteinase were demonstrated in patients who developed ticlopidine-associated TTP; this led to the same type of vWF abnormalities observed in patients with idiopathic acute TTP. The findings suggest that failure to process large and unusually large vWF multimers in vivo caused binding of vWF to platelets, systemic platelet thrombosis, and TTP.[26]

 
   References Top

1.Kaplan BS, Meyers KE, Schulman SL. The pathogenesis and treatment of hemo-lytic uremic syndrome. J Am Soc Nephrol 1998;9:1126-33.  Back to cited text no. 1    
2.Wong CS, Jelacic S, Habeeb RL, Watkins SL, Tarr PI. The risk of the hemolytic­uremic syndrome after antibiotic treatment of Escherichia coli O157:H7 infections. N Engl J Med 2000;342:1930-6.  Back to cited text no. 2    
3.Kaplan BS. Shiga toxin induced tubular injury in hemolytic uremic syndrome. Kidney Int 1998;54:648-9.  Back to cited text no. 3    
4.Meyers KE, Kaplan BS. Many cell types are shiga toxin targets. Kidney Int 2000; 57:2650-1.  Back to cited text no. 4    
5.Hughes AK, Stricklett PK, Schmid D, Kohan DE. Cytotoxic effect of shiga toxin-1 on human glomerular epithelial cells. Kidney Int 2000;57:2350-9.  Back to cited text no. 5    
6.Armstrong GD, Rowe PC, Goodyer P, et al. A phase I study of chemically synthesized verotoxin (Shiga-like toxin) Pk-trisac­charide receptors attached to chromosorb for preventing hemolytic-uremic syndrome. J Infect Dis 1995;171:1042-5.  Back to cited text no. 6    
7.Meyers KW, Schulman SL, Kaplan BS. Principles of the treatment of Shigatoxin­associated hemolytic uremic syndrome: Pay meticulous attention to detail, and do no harm. In Kaper JB, O'Brien A, eds. Escherichia coli 0157:H7 and other Shiga­Toxin-Producing Escherichia coli strains. Am Soc Microbiol 1998;364-373.  Back to cited text no. 7    
8.Milford DV, White RH, Taylor CM. Prognostic significance of proteinuria one year after onset of diarrhea-associated hemolytic-uremic syndrome. J Pediatr 1991;118:191-4.  Back to cited text no. 8    
9.Brandt JR, Joseph MW, Fouser LS, et al. Cholelithiasis following Escherichia coli O157:H7-associated hemolytic uremic syndrome. Pediatr Nephrol 1998;12:222-5.  Back to cited text no. 9    
10.Bassani CE, Ferraris J, Gianantonio CA, Ruiz S, Ramirez J. Renal transplantation in patients with classical haemolytic- uraemic syndrome. Pediatr Nephrol 1991;5:607-11.  Back to cited text no. 10    
11.Fitzpatrick MM, Walters MD, Trompeter RS, Dillon MJ, Barratt TM. Atypical (non­diarrhea-associated) hemolytic-uremic syndrome in childhood. J Pediatr 1993; 122:532-37.  Back to cited text no. 11    
12.Rougier N, Kazatchkine MD, Rougier JP, et al. Human complement factor H deficiency associated with hemolytic uremic syndrome. J Am Soc Nephrol 1998;9:2318-26.  Back to cited text no. 12    
13.Noris M, Ruggenenti P, Perna A, et al. Hypocomplementemia discloses genetic predisposition to hemolytic uremic syndrome and thrombotic thrombo­cytopenic purpura: role of factor H abnormalities. Italian Registry of Familial and Recurrent Hemolytic Uremic Syndrome/Thrombotic Thrombocytopenic Purpura. J Am Soc Nephrol 1999;10:281-93.  Back to cited text no. 13    
14.Ducloux D, Rebibou JM, Semhoun-Ducloux S, et al. Recurrence of hemolytic-uremic syndrome in renal transplant recipients: a meta-analysis. Transplan-tation 1998;65:1405-7.  Back to cited text no. 14    
15.Mattoo TK, Mahmood MA, Al-Harbi MS, Mikail I. Familial, recurrent hemolytic­uremic syndrome. J Pediatr 1989;114:814-6.  Back to cited text no. 15    
16.Kaplan BS, Papadimitriou M, Brezin JH, Tomlanovich SJ, Zulkharnain. Renal transplantation in adults with autosomal recessive inheritance of hemolytic uremic syndrome. Am J Kidney Dis 1997;30:760-5.  Back to cited text no. 16    
17.Kaplan BS, Leonard M. Autosomal dominant hemolytic uremic syndrome: variable phenotypes and transplantation. Pediatr Nephrol 2000;14:464-8.  Back to cited text no. 17    
18.Warwicker P, Donne RL, Goodship JA, et al. Familial relapsing haemolytic uraemic syndrome and complement factor H deficiency. Nephrol Dial Transplant 1999; 14:1229-33.  Back to cited text no. 18    
19.Ying L, Katz Y, Schlesinger M, et al. Complement factor H gene mutation associated with autosomal recessive atypical hemolytic uremic syndrome. Am J Hum Genet 1999;65:1538-46.  Back to cited text no. 19    
20.Moake JL. Moschcowitz, multimers, and metalloproteinase. N Engl J Med 1998; 339:1629-31.  Back to cited text no. 20    
21.Tsai HM, Lian EC. Antibodies to von Willebrand factor-cleaving protease in acute thrombotic thrombocytopenic purpura. N Engl J Med 1998;339:1585-94.  Back to cited text no. 21    
22.Furlan M, Robles R, Galbusera M, et al. von Willebrand factor-cleaving protease in thrombotic thrombocytopenic purpura and the hemolytic-uremic syndrome. N Engl J Med 1998;339:1578-84.  Back to cited text no. 22    
23.Gerritsen HE, Turecek PL, Schwarz HP, Lammle B, Furlan M. Assay of von Willebrand factor (vWF)-cleaving protease based on decreased collagen binding affinity of degraded vWF: a tool for the diagnosis of thrombotic thrombocytopenic purpura (TT). Thromb Haemost 1999; 82:1386-9.  Back to cited text no. 23    
24.Bennett CL, Davidson CJ, Raisch DW, Weinberg PD, Bennett RH, Feldman MD. Thrombotic thrombocytopenic purpura associated with ticlopidine in the setting of coronary artery stents and stroke prevention. Arch Intern Med 1999; 159:2524-8.  Back to cited text no. 24    
25.Bennett CL, Connors JM, Carwile JM, et al. Thrombotic thrombocytopenic purpura associated with clopidogrel. N Engl J Med 2000;342:1773-7.  Back to cited text no. 25    
26.Tsai HM, Rice L, Sarode R, Chow TW, Moake JL. Antibody inhibitors to von Willebrand factor metalloproteinase and increased binding of von Willebrand factor to platelets in ticlopidine-associated thrombotic thrombocytopenic purpura. Ann Intern Med 2000;132:794-9.  Back to cited text no. 26    

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Correspondence Address:
Bernard S Kaplan
The Children’s Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, Pennsylvania, 19104
USA
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