Best supportive care and therapeutic plasma exchange with or without eculizumab in Shiga-toxin-producing E. coli O104:H4 induced haemolytic-uraemic syndrome: an analysis of the German STEC-HUS registry.

BACKGROUND: May 22nd marks the beginning of a Shiga-toxin-producing Escherichia coli (STEC) O104:H4 outbreak in Northern Germany. By its end on 27 July, it had claimed 53 deaths among 2987 STEC and 855 confirmed haemolytic-uraemic syndrome (HUS) cases. METHODS: To describe short-term effectiveness of best supportive care (BSC), therapeutic plasma exchange (TPE) and TPE with eculizumab (TPE-Ecu) in 631 patients with suspected HUS treated in 84 hospitals in Germany, Sweden and the Netherlands using the web-based registry of the DGfN (online since 27 May). RESULTS: Of 631 entries, 491 fulfilled the definition of HUS (median age 46 years; 71% females). The median (inter-quartile range) hospital stay was 22 (14-31) days. Two hundred and eighty-one (57%) patients underwent dialysis and 114 (23%) mechanical ventilation. Fifty-seven patients received BSC, 241 TPE and 193 TPE-Ecu. Treatment strategy was dependent on disease severity (laboratory signs of haemolysis, thrombocytopenia, peak creatinine level, need for dialysis, neurological symptoms, frequency of seizures) which was lower in BSC than in TPE and TPE-Ecu patients. At study endpoint (hospital discharge or death), the median creatinine was lower in BSC [1.1 mg/dL (0.9-1.3)] than in TPE [1.2 mg/dL (1.0-1.5), P < 0.05] and TPE-Ecu [1.4 mg/dL (1.0-2.2), P < 0.001], while need for dialysis was not different between BSC (0.0%, n = 0), TPE (3.7%; n = 9) and TPE-Ecu (4.7%, n = 9). Seizures were absent in BSC and rare in TPE (0.4%; n = 1) and TPE-Ecu (2.6%; n = 5) patients. Total hospital mortality in HUS patients was 4.1% (n = 20) and did not differ significantly between the TPE and TPE-Ecu groups. CONCLUSIONS: Despite frequent renal impairment, advanced neurological disorders and severe respiratory failure, short-term outcome was better than expected when compared with previous reports. Within the limitations of a retrospective registry analysis, our data do not support the notion of a short-term benefit of Ecu in comparison to TPE alone in the treatment of STEC-HUS. A randomized trial comparing BSC, TPE and Ecu seems to be prudent and necessary prior to establishing new treatment guidelines for STEC-HUS.

Prognostic value of troponin T, troponin I, and CK-MBmass in patients with chronic renal failure.

BACKGROUND: In patients with chronic renal failure undergoing long-term hemodialysis, ischemic heart disease accounts for up to 50% of mortality. Cardiac troponins T (TnT) and I (TnI) are frequently elevated in this patient group, but data on the prognostic relevance of these markers, especially TnI, are controversial. The aim of this study was to investigate the prognostic power of a new, sensitive TnI assay in comparison with TnT and other cardiac markers. PATIENTS AND METHODS: 104 ambulatory and in-hospital patients (41 women, median age: 65 years, interquartiles: 48-72.5 years; 63 men, median age: 63 years, interquartiles: 51.3-72.5 years) undergoing long-term hemodialysis were investigated. Patients were followed up for 6 months for all kinds of fatal events and nonfatal cardiac events. Serum levels of cardiac TnT, two TnI assays (ACS:180 and Stratus II), CK (creatine kinase), and CK-MB were measured pre- and post-dialysis. RESULTS: Pre- and post-dialysis results were not different for TnT and TnI, while CK and CK-MB levels were significantly lower post-dialysis. Elevated (pre-)dialysis levels were found in 65.7% of patients for TnT (> 0.1 microg/l), in 32.4% for TnI (ACS:180, > 0.15 microg/l), in 2.9% for TnI (Stratus II, > 0.4 microg/l), in 5.7% for CK (> 170 U/l), and in 2.8% for CK-MB (> 1.0 microg/l). 6-month events were observed in 42 patients (40.4%; 20 fatal, 22 nonfatal). The relative risk for 6-month events was calculated to be 16.0-fold for TnT and 8.5-fold for a known coronary heart disease, while both TnI and CK-MB did not predict 6-month events independently. CONCLUSIONS: TnT and a known coronary heart disease are relevant, independent risk factors in patients with chronic renal failure undergoing long-term hemodialysis.