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Saudi Journal of Kidney Diseases and Transplantation
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CASE REPORT Table of Contents   
Year : 2010  |  Volume : 21  |  Issue : 4  |  Page : 715-719
H1N1 in dialysis units: Prevention and management


Kanoo Kidney Centre, Department of Nephrology, Dammam Medical Complex, Dammam, Saudi Arabia

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Date of Web Publication26-Jun-2010
 

   Abstract 

Dialysis patients are at increased risk of contracting influenza A H1N1 and deve­loping serious illness. Increasing the awareness of dialysis patients and continuous education and training of medical staff on early recognition and management of influenza A H1N1 can help in saving the life of patients. Antiviral drugs and influenza vaccines are effective in providing ade­quate immunity in dialysis patients with strict implementation of infection control policies and procedures can help in preventing and controlling the dissemination of influenza A H1N1 in dia­lysis units. We report a case of a patient who presented with HINI influenza and developed acute kidney injury during his hospitalization and his course with disease.

How to cite this article:
Karkar A, Abdelrahman M, Jasim MR, AlOyouni W. H1N1 in dialysis units: Prevention and management. Saudi J Kidney Dis Transpl 2010;21:715-9

How to cite this URL:
Karkar A, Abdelrahman M, Jasim MR, AlOyouni W. H1N1 in dialysis units: Prevention and management. Saudi J Kidney Dis Transpl [serial online] 2010 [cited 2019 Aug 25];21:715-9. Available from: http://www.sjkdt.org/text.asp?2010/21/4/715/64657

   Introduction Top


Following the recent world threat of avian in­fluenza that has been originated in Asia, a new epidemic of acute respiratory infections caused by influenza A (H1N1) virus emerged in Mexico in April 2009 and soon spread to the United States and the rest of the world. [1],[2] In­fluenza A virus strains are assigned an H (or hemagglutinin) number and an N (or neurami­nidase) number based on which forms of these two proteins the strain contains on its surface. [3] The structure of these proteins differs from strain to strain due to rapid genetic mutation in the viral genome. [4] The hemagglutinin gene of this 2009 pandemic H1N1 virus (2009 H1N1) belongs to the classical swine lineage, which was first introduced into swine populations around 1918. [3],[4],[5]

H1N1 has a unique combination of genes from different swine lineages that has not been identified previously in either swine or human populations, [7],[8] and it is antigenically and gene­tically distinct from hemagglutinins of contem­porary human seasonal influenza H1N1 virus. [6],[7],[8],[9]

The clinical presentation is variable and non­specific, and ranges from self-limited febrile illness to sever pneumonia. Emergency war­ning signs that need urgent medical attention include severe or persistent vomiting, short­ness of breath, pain or pressure in the chest or abdomen, sudden dizziness and confusion. [10] Diagnosis of the 2009 H1N1 virus is con­firmed by a qualitative positive RT-PCR test from a properly obtained nasal and/or throat swabs. [11],[12]

The risk factors of severe H1N1 illness in­clude young age, obesity, pregnancy and chro­nic medical conditions such as cardiovascular diseases, diabetes mellitus, bronchial asthma and chronic renal failure. However, immune deficient patients are also at increased risk of developing severe or life threatening disease. [7]


   Case Report Top


A 43-year-old male technician who lived with 40 other residents in a camp, presented to the emergency room on 06 August 2009 with a 5-day history of progressive rise in tempe­rature, cough, runny nose, sore throat, head­ache, body aches, fatigue, shortness of breath and chest pain, which increases on coughing or taking deep breath. Few inhabitants of his camp had mild cough but no fever. The patient and his camp mates had no history of recent travel abroad, and had no past history of any major medical illness or drug intake.

On physical examination the patient's tempe­rature was 39.5΀C, regular pulse rate 90 beats/ min, blood pressure 133/75 mmHg, respiratory rate 30/min, O 2 saturation 95% and body weight 85 kg. His throat examination showed conges­tion and there were bilateral crackles on chest auscultation, but no other positive findings were detected on the rest of physical exa­mination.

The throat and nasopharyngeal swabs were obtained on admission and tested positive for influenza-A H1N1 (2009 H1N1) by molecular pathology that included RNA extraction and cDNA extraction for real time-polymerase chain reaction. Chest X-ray revealed bilateral pulmonary infiltration. A diagnosis of commu­nity acquired pneumonia due to H1N1 virus was entertained, and the patient was admitted in an isolated room and started on oseltamivir 75 mg twice daily and broad spectrum anti­biotics. However, the patient's symptoms pro­gressed rapidly and within few hours of admi­ssion he developed respiratory failure, which necessitate intubation and assisted ventilation using high flow oxygen in an isolated nega­tively pressured room in the intensive care unit (ICU).

Three days following admission the patient developed generalized convulsions, where brain CT scan revealed hypodense areas in bilateral basal ganglia. His convulsions were controlled with phenytoin and diazepam. However, the pa­tient developed severe nosocomial sepsis due to Acinetobacter central line infection. The cul­ture and sensitivity of nasal swabs and chest secretions revealed multi-drug resistant Acine­tobacter baumanii sensitive to tigecycline and colistin. He was covered with multiple antimi­crobial agents including vancomycin, colistin, imipenem and tazocine according to clinical response and blood/secretions culture and sen­sitivity reports. Urine culture and sensitivity re­vealed Candida albicans urinary tract infec­tion which was sensitive to voriconazole.

Subsequently, the patient developed acute kid­ney injury, which was evident by oligo-anuria and rapid rise in serum urea (55, 153 and 227 mg/dL) and creatinine (1.3, 3.5 and 7.5 mg/dL), hyperkalemia (K + 6.2 mmol/dL) with severe metabolic acidosis (pH 7.2 and HCO 3 17.7). The associated hypotension (BP ≤ 90/50 mmHg) and hemodynamic instability of the patient ne­cessitated initiation of continuous renal repla­cement therapy (CRRT) on the 3rd day after admission, which was continued for 180 hours over the subsequent 18 days till the hemody­namic status of the patient was stabilized with­out the need for inotropic support. The osel­tamivir dose was adjusted accordingly and continued for five days. Repeated throat and nasal swabs performed on the 18 th day of ad­mission were negative for H1N1. After 3 weeks of stay in the hospital, the patient showed a significant clinical recovery of pneumonia, and it was possible to wean him off the ventilator. His renal function showed a significant im­provement with progressive increase in urine output (initially up to 480 mL/24hr, 1100, 1600, 1900 and 2600 mL/24hr) and stabilization of serum urea (84 mg/dL) and creatinine (2.2 mg/ dL). During the following few days the patient made complete recovery of renal function, and he was shifted to the medical ward and subse­quently discharged after one month of hospita­lization.

During the patient's admission to the hospital, all the infection control policies and proce­dures were strictly applied, and all precautions were taken to avoid transmission of H1N1 virus.


   Discussion Top


Despite the early presentation with the expec­ted common mild signs and symptoms of viral influenza, this reported case demonstrates the clinical evolvement into the possible worse scenario of the H1N1 flu. The deterioration of clinical condition was rapidly progressive and led to multi-organ failure. This includes severe and life threatening pneumonia, [13] which re­quired intubation and ventilation, and acute kid­ney injury that necessitated continuous renal replacement therapy with high medical atten­tion in the intensive care unit. The risk of life threatening scenario of 2009 H1N1 influenza is increased with young age, obesity, pregnan­cy, chronic medical conditions and decreased immunity. [7] Our patient was obese (body mass index of 35), but had no history of cardio­vascular disease, diabetes mellitus, bronchial asthma or chronic kidney disease and he was not immune compromised or taking any drugs/ medications.

The early suspicion, recognition, and diagno­sis of H1N1 in this patient has largely con­tributed to early intervention and management that resulted in full recovery. This reflects the increased awareness of medical and nursing staff that has been achieved by continuous education, repeated presentations and distribu­tion of educational materials about signs and symptoms besides ways of early detection and diagnosis of 2009 H1N1. Furthermore, the H1N1 educational program reinforced the im­portance of taking all precautions and pre­ventive measures and strict implementation of infection control policies and procedures, in order to avoid contamination and dissemina­tion of infection, which prevented other patients and involved medical staff from contracting the 2009 H1N1 flu.

Acute kidney injury is expected in patients with sepsis and multi-organ failure, and early intervention with renal replacement therapy is crucial for stabilization of clinical condition and in achieving favorable outcome. [14],[15] CRRT in the form of hemofiltration or hemodiafiltra­tion has been shown to provide more hemo­dynamic stability, than classic hemodialysis, in critically ill patients in ICU; [16],[17] though it might not have survival benefit over daily intermittent renal replacement therapy. [18] How­ever, CRRT modality can be performed in an isolated room, where isolation of such patients is necessary, using a portable CRRT machine with disposable devices and sterilized dialysate and reconstitution fluids without the need of treated water or transferring patient to hemodia­lysis section, thereby avoiding exposure of other susceptible hemodialysis patients to H1N1 virus and the possibility of cross infection. Our patient received continuous hemodiafiltration over 180 hours which resulted in stabilization of his hemodynamic status, fluid balance, la­boratory parameters and achievement of full renal function recovery.

Finally, prophylaxis with influenza vaccina­tion reduces the frequency of influenza-like illness [19] and is associated with a lower risk of hospitalization and death in renal patients. [20] Two recent studies have described the effec­tiveness of two vaccines (adjuvanted and non­ adjuvanted) against the 2009 H1N1. [21],[22] It has recently been shown, in a large prospective study, that influenza vaccination (against H1N1 and H3N2) confers high seroprotection (81%­87%) in hemodialysis, [23] and peritoneal dialysis patients, [24] which is similar to healthy volun­teers and where booster dose does not improve seroprotection rate, and seroresponse rates are not influenced by nutritional status, dialysis a­dequacy or uremic toxins. [23] Therefore, vacci­nation against 2009 H1N1 virus can help in protecting dialysis patients or at least minimize the severity of 2009 H1N1 infection. [24],[25] Vac­cination of health care providers, who are po­tential transmitters of influenza to others, is also important. [26] It remains, however, that im­plementation of infection control policies and procedures constitutes an essential part in pro­tection against 2009 H1N1 and in particular in immune compromised patients. [27],[28],[29],[30]

Antiviral drugs (neuralminidase inhibitors) are effective in treating or reducing the se­verity of signs and symptoms of the 2009 H1N1. [25]

 
   References Top

1.Novel Swine-Origin Influenza A (H1N1) Virus Investigating Team. Emergence of a novel swine­origin influenza A (H1N1) virus in humans. N Engl J Med 2009;360:2605-15.  Back to cited text no. 1      
2.Khan K, Arino J, Hu W, et al. Spread of a novel influenza A (H1N1) virus via global airline transportation. N Engl J Med 2009;361: 212-4.  Back to cited text no. 2  [PUBMED]    
3.Zimmer SM, Burke DS. Historical perspective­emergence of influenza A (H1N1) viruses. N Engl J Med 2009;361:279-85.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]  
4.Morens DM, Taubenberger JK, Fauci AS. The persistent legacy of the 1918 influenza virus. N Engl J Med 2009;361:225-9.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]  
5.Shinde V, Bridges CB, Uyeki TM, et al. Triple­reassortant swine influenza A (H1) in humans in the United States. N Engl J Med 2009;360: 2616-25.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]  
6.Nelson MI, Viboud C, Simonsen L, et al. Mul­tiple reassortment events in the evolutionary history of H1N1 influenza virus since 1918. PLOS Pathog 2008;4(2):e1000012.  Back to cited text no. 6      
7.Belshe RB. The origins of pandemic influenza lessons from the 1918 virus. N Engl J Med 2005; 353:2209-11.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]  
8.Trifonov V, Khiabanian H, Rabadan R. Geo­graphic dependence, surveillance, and origins of the 2009 influenza A (H1N1) Virus. N Engl J Med 2009;361:115-9.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]  
9.Baden LR, Drazen JM, Kritek PA, et al. H1N1 influenza A disease-information for health professionals. N Engl J Med 2009;360;252-67.  Back to cited text no. 9      
10.http://www.cdc.gov/h1n1flu/identifying patients. htm Interim guidance for clinicians on iden­tifying and caring for patients with swine­origin influenza A (H1N1) virus infection. 4 May, 2009.  Back to cited text no. 10      
11.Faix DJ, Sherman SS, Waterman SH. Rapid­test sensitivity for novel swine-origin influenza A (H1N1) virus in humans. N Engl J Med 2009;361:728-9.  Back to cited text no. 11  [PUBMED]    
12.CDC protocol of real time RT-PCR for influenza A (H1N1). WHO. http://www.who. int/csr/resources/publications/swineflu/CDCRe al timeRTPCR-SwineH1Assay 2009.  Back to cited text no. 12      
13.Ng WF, To KF, Lam WW, Ng TK, Lee KC. The comparative pathology of severe acute respiratory syndrome and avian influenza A subtype H5N1. Hum Pathol 2006;37:381-90.  Back to cited text no. 13  [PUBMED]  [FULLTEXT]  
14.Forni LG, Hilton PJ. Continuous hemofiltra­tion in the treatment of acute renal failure. N Eng J Med 1997;336:1303-9.  Back to cited text no. 14      
15.Cho KC, Himmelfarb J, Paganini, et al. Sur­vival by dialysis modality in critically ill patients with acute kidney injury. J Am Soc Nephrol 2006;17:3232-8.  Back to cited text no. 15      
16.John S, Griesbach D, Baumgartel M, et al. Effects of continuous hemodialysis on syste­mic haemodynamics and splanchnic regional perfusion in septic shock patients: a prospec­tive, randomized clinical trial. Nephrol Dial Transplant 2001;16:320-7.  Back to cited text no. 16      
17.Marenzi G, Lauri G, Grazi M, Assanelli E, Campodonico J, Agostoni P. Circulatory res­ponse to fluid overload removal by extractor­poreal ultra-filtration in refractory congestive heart failure. J Am Coll Cardiol 2001;38:963­8.  Back to cited text no. 17  [PUBMED]  [FULLTEXT]  
18.Lins RL, Elseviers MM, van der Niepen P, et al. Intermittent versus continuous renal re­placement therapy for acute kidney injury patients admitted to the intensive care unit: results of a randomized clinical trial. Nephrol Dial Transplant 2009;24:512-8.  Back to cited text no. 18  [PUBMED]  [FULLTEXT]  
19.Bhandari S, Farr M, Sellars L. Influenza vaccination in renal patients. Nephrol Dial Transplant 1995;10:912-3.  Back to cited text no. 19      
20.Gilbertson DT, Unruh M, Mcbean AM, et al. Influenza vaccine delivery and effectiveness in end-stage renal disease. Kidney Int 2003;63: 738-43.  Back to cited text no. 20  [PUBMED]  [FULLTEXT]  
21.Clark TW, Pareek M, Hoschler K, et al. Trial of influenza A (H1N1) 2009 monovalent MF59­adjuvanted vaccine - preliminary report. N Engl J Med 2009;361:1-11.  Back to cited text no. 21      
22.Greenberg ME, Lai MH, Hartel GF, et al. Response after one dose of a monovalent influenza A (H1N1) 2009 vaccine - preli­minary report. N Engl J Med 2009;361:1-10.  Back to cited text no. 22      
23.Scharpe J, Peetermans WE, Vanwalleghem J, et al. Immunogenicity of a standard trivalent influenza vaccine in patients on long-term hemodialysis: an open-label trial. Am J Kidney Dis 2009;54:77-85.  Back to cited text no. 23      
24.Hancock K, Veguilla V, Lu X, et al. Cross­reactive antibody responses to the 2009 pan­demic H1N1 influenza virus. N Engl J Med 2009;361:1-8.  Back to cited text no. 24      
25.Couch RB. Prevention and treatment of in­fluenza. N Engl J Med 2000;343(24):1778-87.  Back to cited text no. 25      
26.Carman WF, Elder AG, Wallace LA, et al. Effects of influenza vaccination of health-care workers on mortality of elderly people in long­term care: a randomized controlled trial. Lancet 2000;355:93-7.  Back to cited text no. 26  [PUBMED]  [FULLTEXT]  
27.Novel H1N1 (swine flu) and you. http://www. cdc.gov/h1n1flu/ga.htm. 2009.  Back to cited text no. 27      
28.Interim additional guidance for infection con­trol for care of patients with confirmed, pro­bable, or suspected novel influenza A (H1N1) virus infection in outpatient hemodialysis. http://www.cdc.gov/1n1flu/guidance/hemodialysis centers.htm.  Back to cited text no. 28      
29.Interim guidance for infection control for care of patients with confirmed or suspected novel influenza A (H1N1) virus infection in a health care setting 2009. http://www.cdc.gov/ h1n1 flu/guidelines infection control.htm.  Back to cited text no. 29      
30.Shine KI, Rogers B, Goldfrank LR. Novel H1­N1 influenza and respiratoy protection for health care workers. N Engl J Med 2009;361(19): 1823-5.  Back to cited text no. 30      

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Correspondence Address:
Ayman Karkar
Department of Nephrology, Kanoo Kidney Centre, P.O. Box 11825, Dammam 31463
Saudi Arabia
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PMID: 20587878

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    Abstract
    Introduction
    Case Report
    Discussion
    References
 

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