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Urgent-start peritoneal dialysis in a large pediatric STEC-HUS outbreak: Clinical and operational rationale
Naji Al Dhawi1, Julian P Midgley2, Lorraine A Hamiwka2
1Department of Pediatric Nephrology, Sultan Qaboos University Hospital, Muscat, Oman.
Insights
Urgent-start peritoneal dialysis (PD) effectively treated children with Shiga toxin-producing E. coli (STEC)-induced kidney failure during a Calgary outbreak. This approach, managed on general wards, conserved resources and led to full kidney function recovery.
Area of Science:
- Pediatrics
- Nephrology
- Infectious Disease Epidemiology
Background:
- Calgary experienced a large Shiga toxin-producing Escherichia coli (STEC) outbreak in September 2023, primarily affecting children through a centralized kitchen.
- The outbreak led to over 200 cases of bloody diarrhea and 21 cases of hemolytic uremic syndrome (HUS), with nine children requiring acute kidney replacement therapy (KRT).
Purpose of the Study:
- To evaluate the effectiveness and feasibility of urgent-start peritoneal dialysis (PD) for managing acute kidney injury (AKI) in children during a large STEC outbreak.
- To assess outcomes, including kidney function recovery and neurological status, and the resource implications of using PD on general pediatric wards.
Main Methods:
- Nine children with STEC-induced AKI requiring KRT were managed with urgent-start PD initiated on general pediatric wards.
- Tenckhoff catheters were surgically placed, and PD was commenced approximately 12 hours post-insertion with gradually escalated fill volumes.
- PD management focused on solute clearance, acid-base balance, and minimizing ultrafiltration to maintain intravascular volume.
Main Results:
- All nine children successfully managed with PD on general wards, with a mean PD duration of 10 days.
- No patients required conversion to extracorporeal KRT; all recovered normal kidney function by 3 months post-discharge.
- One patient experienced culture-negative peritonitis and a subsequent delayed bowel perforation. Neurological recovery was substantial in two evaluated children.
Conclusions:
- Urgent-start PD is an effective and resource-conserving KRT modality for pediatric AKI during outbreaks, manageable outside of pediatric ICUs.
- Maintaining PD readiness is crucial for pediatric institutions to effectively manage KRT needs during public health crises.
- PD facilitated favorable kidney and neurological outcomes in STEC-HUS patients by supporting intravascular volume maintenance.
Abstract:
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.
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