Plasma exchange therapy may be a key tool for treating diarrhea-associated haemolytic uraemic syndrome (HUS), according to one of the first investigations after this summers Escherichia coli outbreak in Europe. HUS is usually a rare but life threatening complication that was observed in several cases in the outbreak. The discoveries are reported in an article published Online First by The Lancet, written by Dr Martin Tepel and Dr Kjell Titlestad, Odense University Hospital, Denmark, and colleagues.
In May, 2011, primarily centered in Germany but also in other countries an E. coli outbreak (serotype O104:H4) caused major health problems, causing over 40 deaths while several others experienced severe kidney damage due to HUS. Some studies have indicated HUS has been more common in this outbreak than previously.
The investigation evaluated plasma exchange treatment in four women and a man, aged between 44 and 70 years. All presented with bloody diarrhea-associated HUS at Odense University Hospital, Denmark. Based on platelet count and lactate dehydrogenase concentration, the diagnosis was completed in hours. Yet, verification of the E. coli serotype took several days. After diagnosis, each patient had the equivalent of their total body plasma exchanged each day.
They discovered that the longer the time before plasma exchange treatment started, the longer it took to have effect. Symptoms of HUS (low platelet count, high lactate dehydrodgenase concentration, and low blood filtration rate through the kidneys), were removed with plasma exchange. All patients were discharged within one week of starting treatment.
The researchers conclude:
“Our study was able to assess the benefit of plasma exchange in a large outbreak of haemolytic uraemic syndrome; such assessment might be difficult in a randomized controlled trial because of the rarity of the disease. Early plasma exchange might ameliorate the course of diarrhoea-associated haemolytic uraemic syndrome in adults, but this finding should be verified in randomized controlled trials.”
In a joined statement, Dr Piero Ruggenenti and Professor Giuseppe Remuzzi, Mario Negri Institute for Pharmacological Research, Bergamo, and Azienda Ospedaliera Ospedali Riuniti di Bergamo, Bergamo, Italy, say that as well as plasma exchange, add-on treatment with eculizumab (a monoclonal antibody) could have been considered, but that during the German outbreak results with this add-on therapy were inconsistent.
They conclude:
“At present, early plasma exchange, with or without eculizumab, remains the cornerstone of treatment. Whether early treatment with carbapenems or antimicrobals that are electively effective against extended-spectrum β-lactamaseproducing E coli (eg, fosfomycin) could help to prevent progression from enterocolitis to haemolytic uraemic syndrome might merit formal investigation.”
Written by Grace Rattue