Vol. 118, October Printed in U .8 A.
THE JOURNAL OF UROLOGY
Copyright © 1977 by The Williams & Vl'ilkins Co.
HEMOLYTIC-UREMIC JOSEPH GIANGIACOMO* From the
uPnrLru1·1pr1.,.
AND
MARC E. VVEBER
of Pediatrics, Cardinal Glennon Memorial Hospital for Children, St. Louis University School of Medicine, St. Louis, Missouri
ABSTRACT
Total cessation of urine formation child with the hemolytic--uremic The metabolic effects of acute ance when indicated,
with ultimate survival is a rare occurrence. Ii was anuric for 27 and renal function careful control of water and until renal function returns. The was maintained on a per cent dextrose and water at 500 cc Urine output totaled cc 24 increased to 87.9 per dL and uvu.-,,_,vv,.,. per dl. count was 78,000 count was 2.5 per cent. was started L5 cent dianeal. Dexarnethasone phosphate, 1.5 and 1.25 gm. administered. The child remained anuric for 27 was cells were
syndrome consists crn''"'""'"' signs of gastrointestinal bleeding, central nervous associated with hematological abnormalcell remains unknown. The persistence of anuria has been considered to be a poor prognostic sign. 1 Ultimate recovery of renal function has not been reported to occur in patients with the who have been 14 days. who was for 27 with function but significant residual 11eu1.·u1L1;,; CASIE RIEPORT
An 18--month-old white was hospitalized elsewhere with a 5-day of u1,,u1crn~a, u11.uc1us: and fever. While in the hospital she 2 generalized ~""""~···~, and received intravenous ampicillin and gentamicin. The after the Convulsions the child 'I/Vas rnsoc,nn-na, and was tranS·· from the urea nitrogen (BUN) 68 dl, hemoglobin 10 gm. per urine during previous 20 hours. The was well developed (10.0 kg.) but comatose. Temperature was 38 degrees rectally, heart rate was 110 ute, blood pressure was 130/92 mm. Hg at 8 breaths per minute with an endotracheal in place. There were multiple the thorax and right arm. The remainder of the cal examination was unremarkable. Hemoglobin was 8.8 gm. dL, white blood count was cells per mm. 3 with per cent stabs and 74 cent and there were many and 1). The count was count was 66,000 per mm.'i. The cerebrospinal fluid contained 9 cells per mm.", 100 cent ,mon,r.c"'''"'."'" 122 mg. per dl. 132 mg. per and 46 cm. water vv~w,u.1-, The serum glutamic ~"'~""w transaminase was serum sodium was 132 L, per 1., chloride 96 per L total carbon dioxide 18.7 per L BUN was 74.8 mg. per dl., serum calcium '112 per L, serum phosphate 4.2 mEq. per L and serum 207 mg. per dL Arterialized capillary pH was 7.32, oxygen pressure 71 mm. and carbon dioxide 38 Cultures of the and cerebrospinal no The chest roentgenogram showed a lobe infiltrate.
DISCUSSION
pancreas,
Accepted for publication April 7, J.977. 3908 W. Rollins, Columbia, Missouri 65201.
* Current address:
FIG. 1. Fragmentation of red blood cells with helmet and burr 675
676
GIANGIACOMO AND WEBER
250 PLATE LETS / 200 mm 3 x 10 3 150 100
OPLlIJtlL_ _ _ _ _ _ _ _ _ _----1
B.U.N.
(mg%)
URINE OUTPUT
I ml /24 hrs I
120 80 40 0 150 100 50 0I
I I I I I I I I I I I I I I I j [ I 1 I I I I I I I I I I l I j I ! 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34
- -- - DAYS
~---Peritoneal Dialysis---~ FIG. 2. Clinical course
Management of the acute renal failure requires monitoring of water and electrolytes, early peritoneal or hemodialysis, when confronted with hyperkalemia, fluid overload and multiple electrolyte imbalances. Blood transfusions may be required because of the progressive anemia.
The use of anticoagulants, particularly heparin, has not been rewarding and indeed may have increased the morbidity and mortality. 2 The rationale for the use offibrinolytic agents, such as streptokinase, was to lyse the microthrombi in the capillaries but it is yet unproved. 3 Aspirin and/or dipyridamole has been used to inhibit platelet function but has had limited use in the hemolytic-uremic syndrome and requires further control studies to establish efficacy. 4 The long-term prognosis is quite variable, with survival ranging from 66 to 85 per cent. A number of patients sustain either permanent renal damage or severe neurologic impairment. However, in our case renal function did improve after 27 days of anuria. REFERENCES
1. Gianantonio, C. A., Vitacco, M., Mendilaharzu, F., Gallo, G. E.
and Sojo, E.T.: The hemolytic-uremic syndrome. Nephron, 11: 174, 1973. 2. Vitacco, M., Sanchez Avalos, J. and Gianantonio, C. A.: Heparin therapy in the hemolytic-uremic syndrome. J. Pediat., 83: 271, 1973. 3. Powell, H. R. and Ekert, H.: Streptokinase and anti-thrombotic therapy in the hemolytic-uremic syndrome. J. Pediat., 84: 345, 1974. 4. Arenson, E. B., Jr. and August, C. S.: Preliminary report: treatment of the hemolytic-uremic syndrome with aspirin: and dipyridamole. J. Pediat., 86: 957, 1975.
THE JOURNAL OF UROLOGY
Copyright © 1977 by The Williams & Vl'ilkins Co.
HEMOLYTIC-UREMIC JOSEPH GIANGIACOMO* From the
uPnrLru1·1pr1.,.
AND
MARC E. VVEBER
of Pediatrics, Cardinal Glennon Memorial Hospital for Children, St. Louis University School of Medicine, St. Louis, Missouri
ABSTRACT
Total cessation of urine formation child with the hemolytic--uremic The metabolic effects of acute ance when indicated,
with ultimate survival is a rare occurrence. Ii was anuric for 27 and renal function careful control of water and until renal function returns. The was maintained on a per cent dextrose and water at 500 cc Urine output totaled cc 24 increased to 87.9 per dL and uvu.-,,_,vv,.,. per dl. count was 78,000 count was 2.5 per cent. was started L5 cent dianeal. Dexarnethasone phosphate, 1.5 and 1.25 gm. administered. The child remained anuric for 27 was cells were
syndrome consists crn''"'""'"' signs of gastrointestinal bleeding, central nervous associated with hematological abnormalcell remains unknown. The persistence of anuria has been considered to be a poor prognostic sign. 1 Ultimate recovery of renal function has not been reported to occur in patients with the who have been 14 days. who was for 27 with function but significant residual 11eu1.·u1L1;,; CASIE RIEPORT
An 18--month-old white was hospitalized elsewhere with a 5-day of u1,,u1crn~a, u11.uc1us: and fever. While in the hospital she 2 generalized ~""""~···~, and received intravenous ampicillin and gentamicin. The after the Convulsions the child 'I/Vas rnsoc,nn-na, and was tranS·· from the urea nitrogen (BUN) 68 dl, hemoglobin 10 gm. per urine during previous 20 hours. The was well developed (10.0 kg.) but comatose. Temperature was 38 degrees rectally, heart rate was 110 ute, blood pressure was 130/92 mm. Hg at 8 breaths per minute with an endotracheal in place. There were multiple the thorax and right arm. The remainder of the cal examination was unremarkable. Hemoglobin was 8.8 gm. dL, white blood count was cells per mm. 3 with per cent stabs and 74 cent and there were many and 1). The count was count was 66,000 per mm.'i. The cerebrospinal fluid contained 9 cells per mm.", 100 cent ,mon,r.c"'''"'."'" 122 mg. per dl. 132 mg. per and 46 cm. water vv~w,u.1-, The serum glutamic ~"'~""w transaminase was serum sodium was 132 L, per 1., chloride 96 per L total carbon dioxide 18.7 per L BUN was 74.8 mg. per dl., serum calcium '112 per L, serum phosphate 4.2 mEq. per L and serum 207 mg. per dL Arterialized capillary pH was 7.32, oxygen pressure 71 mm. and carbon dioxide 38 Cultures of the and cerebrospinal no The chest roentgenogram showed a lobe infiltrate.
DISCUSSION
pancreas,
Accepted for publication April 7, J.977. 3908 W. Rollins, Columbia, Missouri 65201.
* Current address:
FIG. 1. Fragmentation of red blood cells with helmet and burr 675
676
GIANGIACOMO AND WEBER
250 PLATE LETS / 200 mm 3 x 10 3 150 100
OPLlIJtlL_ _ _ _ _ _ _ _ _ _----1
B.U.N.
(mg%)
URINE OUTPUT
I ml /24 hrs I
120 80 40 0 150 100 50 0I
I I I I I I I I I I I I I I I j [ I 1 I I I I I I I I I I l I j I ! 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34
- -- - DAYS
~---Peritoneal Dialysis---~ FIG. 2. Clinical course
Management of the acute renal failure requires monitoring of water and electrolytes, early peritoneal or hemodialysis, when confronted with hyperkalemia, fluid overload and multiple electrolyte imbalances. Blood transfusions may be required because of the progressive anemia.
The use of anticoagulants, particularly heparin, has not been rewarding and indeed may have increased the morbidity and mortality. 2 The rationale for the use offibrinolytic agents, such as streptokinase, was to lyse the microthrombi in the capillaries but it is yet unproved. 3 Aspirin and/or dipyridamole has been used to inhibit platelet function but has had limited use in the hemolytic-uremic syndrome and requires further control studies to establish efficacy. 4 The long-term prognosis is quite variable, with survival ranging from 66 to 85 per cent. A number of patients sustain either permanent renal damage or severe neurologic impairment. However, in our case renal function did improve after 27 days of anuria. REFERENCES
1. Gianantonio, C. A., Vitacco, M., Mendilaharzu, F., Gallo, G. E.
and Sojo, E.T.: The hemolytic-uremic syndrome. Nephron, 11: 174, 1973. 2. Vitacco, M., Sanchez Avalos, J. and Gianantonio, C. A.: Heparin therapy in the hemolytic-uremic syndrome. J. Pediat., 83: 271, 1973. 3. Powell, H. R. and Ekert, H.: Streptokinase and anti-thrombotic therapy in the hemolytic-uremic syndrome. J. Pediat., 84: 345, 1974. 4. Arenson, E. B., Jr. and August, C. S.: Preliminary report: treatment of the hemolytic-uremic syndrome with aspirin: and dipyridamole. J. Pediat., 86: 957, 1975.
