Diarrhoea-associated haemolytic uraemic syndrome and Shiga toxin-producing Escherichia coli infections in New Zealand children: Clinical features and short-term complications from a 23-year cohort study.

BACKGROUND: Diarrhoea-associated haemolytic uraemic syndrome (D+HUS) is an important cause of acute kidney injury (AKI) in young children and it is most commonly associated with Shiga toxin-producing Escherichia coli (STEC). Gastrointestinal infections caused by STEC have been increasing in New Zealand over the past two decades, but little is known regarding the acute and short-term outcomes of New Zealand children who develop D+HUS. AIM: To describe the clinical characteristics, complications and short-term outcomes of New Zealand children with D+HUS identified between 1 January 1998 and 31 December 2020. METHODS: The New Zealand Paediatric Surveillance Unit sends out a monthly survey to all practising paediatricians regarding conditions under active surveillance. Paediatricians caring for a child aged 0-15 years of age with D+HUS over the prior month were requested to report their patient. Reporting clinicians were then contacted by the principal investigator and sent a questionnaire requesting patient clinical and laboratory information. RESULTS: Two hundred and twenty-six children had D+HUS; median age 2.8 years (interquartile range 1.7-4.9). Acute dialysis was required in 128/226 (56.2%) of children for a median of 9 days (range 1-38). Children with shorter diarrhoeal prodrome, higher neutrophil count and haemoglobin had a longer duration of dialysis. Seizures occurred in 31/226 (13.7%) and were not associated with a greater HUS severity score. Acute mortality was 1.3%, all resulting from thrombotic microangiopathic cerebral injury. CONCLUSION: D+HUS is a major cause of AKI in previously healthy young children. Earlier recognition of STEC infections in young children may reduce the need for dialysis and other extra-renal complications. The New Zealand incidence of acute dialysis, other major complications and mortality are consistent with other reported studies.

Barriers to pre-emptive kidney transplantation in New Zealand children.

AIM: Pre-emptive kidney transplantation (PKT) is generally considered the optimal treatment for kidney failure as it minimises dialysis-associated morbidity and mortality and is associated with improved allograft survival. This study aimed to determine rates of paediatric PKT in New Zealand, identify barriers to PKT and consider potential interventions to influence future rates of pre-emptive transplantation. METHODS: Children commencing kidney replacement therapy between 2005 and 2017 in New Zealand were included. Descriptive analysis considered those referred late (referral <3 months prior to kidney replacement therapy initiation) or early based on referral timing to paediatric nephrology. Additional analysis compared characteristics of children receiving dialysis versus pre-emptive transplant as their first mode of kidney replacement therapy. RESULTS: PKT occurred in 15 of 90 children (17%). One-third of all patients were referred late. No late referrals received a pre-emptive transplant. Pre-emptively transplanted children were referred younger (median age 0.49 years), lived in less deprived areas, were more likely to have congenital anomalies of the kidney and urinary tract and none were Maori or Pasifika ethnicity. CONCLUSIONS: Late referral, higher deprivation levels and Maori and Pasifika ethnicity confer a greater risk of not receiving pre-emptive transplantation. Improved education amongst health professionals about recognition of paediatric chronic kidney disease and the importance of timely referral to paediatric nephrology is recommended to reduce rates of late referral. A modified approach including enhanced culturally appropriate support for those diagnosed with chronic kidney disease during transplant evaluation should be pursued to improve equity.