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Hyperhydration to Improve Kidney Outcomes in Children with Shiga Toxin-Producing E. coli Infection: a multinational
Stephen B Freedman1, David Schnadower2, Myka Estes3
1Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine, Alberta Childrens Hospital, Alberta Childrens Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada. stephen.freedman@albertahealthservices.ca.
Insights
Hyperhydration may prevent severe kidney injury in children with Shiga toxin-producing E. coli (STEC) infections. This study will test if aggressive fluid expansion reduces major adverse kidney events (MAKE30) compared to conservative management.
Area of Science:
- Pediatric Nephrology
- Infectious Diseases
- Critical Care Medicine
Background:
- Shiga toxin-producing E. coli (STEC) infections can lead to hemolytic uremic syndrome (HUS) in children, a serious condition with high rates of dialysis and mortality.
- Current treatment for STEC infections is supportive, with no established therapies to prevent HUS development.
- Observational studies suggest intravascular volume expansion (hyperhydration) may mitigate end-organ damage, necessitating a rigorous trial.
Purpose of the Study:
- To determine if hyperhydration, compared to conservative fluid management, improves outcomes in children with high-risk STEC infections.
- To assess the efficacy of hyperhydration in reducing major adverse kidney events within 30 days (MAKE30).
- To evaluate the impact of hyperhydration on secondary outcomes, including life-threatening extrarenal complications and HUS development.
Main Methods:
- A pragmatic, embedded, cluster-randomized, crossover trial involving 1040 children across 26 pediatric institutions.
- Comparison of a hyperhydration pathway (200% maintenance fluids, aiming for 10% weight gain/20% hematocrit reduction) versus a conservative fluid management pathway (euvolemia focus).
- Primary outcome: MAKE30 (death, new renal replacement therapy, or persistent kidney dysfunction).
Main Results:
- The study is designed to have 90% power to detect a 5% absolute risk reduction in MAKE30.
- Estimates suggest 10% of children in the conservative pathway will experience the primary outcome.
- Intraclass correlation coefficient (ICC) of 0.11 indicates moderate clustering effect.
Conclusions:
- Hemolytic uremic syndrome (HUS) is a severe illness lacking effective treatment options.
- This pragmatic study aims to provide evidence on whether hyperhydration can decrease HUS-related morbidity in children with high-risk STEC infections.
Background:
Shiga toxin-producing E. coli (STEC) infections affect children and adults worldwide, and treatment remain solely supportive. Up to 15-20% of children infected by high-risk STEC (i.e., E. coli that produce Shiga toxin 2) develop hemolytic anemia, thrombocytopenia, and kidney failure (i.e., hemolytic uremic syndrome (HUS)), over half of whom require acute dialysis and 3% die. Although no therapy is widely accepted as being able to prevent the development of HUS and its complications, several observational studies suggest that intravascular volume expansion (hyperhydration) may prevent end organ damage. A randomized trial is needed to confirm or refute this hypothesis.
Methods:
We will conduct a pragmatic, embedded, cluster-randomized, crossover trial in 26 pediatric institutions to determine if hyperhydration, compared to conservative fluid management, improves outcomes in 1040 children with high-risk STEC infections. The primary outcome is major adverse kidney events within 30 days (MAKE30), a composite measure that includes death, initiation of new renal replacement therapy, or persistent kidney dysfunction. Secondary outcomes include life-threatening, extrarenal complications, and development of HUS. Pathway eligible children will be treated per institutional allocation to each pathway. In the hyperhydration pathway, all eligible children are hospitalized and administered 200% maintenance balanced crystalloid fluids up to targets of 10% weight gain and 20% reduction in hematocrit. Sites in the conservative fluid management pathway manage children as in- or outpatients, based on clinician preference, with the pathway focused on close laboratory monitoring, and maintenance of euvolemia. Based on historical data, we estimate that 10% of children in our conservative fluid management pathway will experience the primary outcome. With 26 clusters enrolling a mean of 40 patients each with an intraclass correlation coefficient of 0.11, we will have 90% power to detect a 5% absolute risk reduction.
Discussion:
HUS is a devastating illness with no treatment options. This pragmatic study will determine if hyperhydration can reduce morbidity associated with HUS in children with high-risk STEC infection.
Trial Registration:
ClinicalTrials.gov NCT05219110 . Registered on February 1, 2022.
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