Urgent-start peritoneal dialysis in a large pediatric STEC-HUS outbreak: Clinical and operational rationale

In September 2023, Calgary, Canada experienced a large point-source outbreak of Shiga toxin-producing Escherichia coli (STEC) infection linked to a centralized kitchen serving daycare centers. More than 200 children presented with bloody diarrhea, and 21 developed hemolytic uremic syndrome (HUS). Nine children required acute kidney replacement therapy (KRT). All were managed with urgent-start peritoneal dialysis (PD) initiated on general pediatric wards. Tenckhoff catheters were inserted by pediatric urologists and PD was initiated approximately 12 h after placement using low initial fill volumes that were escalated as tolerated. Mean PD duration was 10 days (range 4-16). No patients required conversion to extracorporeal KRT, and all patients recovered kidney function with normal estimated glomerular filtration rates by 3 months post-discharge. PD effectively managed solute clearance and acid-base balance while minimizing ultrafiltration, supporting maintenance of intravascular volume, a strategy that was linked to better neurological and kidney outcomes in STEC-HUS. One patient developed culture-negative peritonitis treated with intraperitoneal antibiotics, and the same patient subsequently experienced delayed bowel perforation requiring surgical intervention after PD discontinuation and catheter removal. Neurologic outcomes in two children showed substantial recovery at 3 months evaluation. Our findings demonstrate that urgent-start PD can be implemented in general ward settings rather than in pediatric ICUs, conserving critical care resources during periods of high demand. These results underscore the importance of maintaining PD as a viable KRT modality for children with AKI and ensuring ongoing institutional training, readiness, and infrastructure to support effective deployment during surges or outbreaks.