Original article
Postdiarrhoeal haemolytic uraemic syndrome without thrombocytopenia
Síndrome urémico hemolítico asociado a diarrea sin trombocitopenia
Alejandro Balestraccia,
, Ismael Toledoa, Luciana Meni Battagliaa, Leonardo de Lillob, Natalia Moreb, Gabriel Caoc, Caupolican Alvaradoa
Corresponding author
a Unidad de Nefrología, Hospital General de Niños Pedro de Elizalde, Ciudad Autónoma de Buenos Aires, Argentina
b Departamento de Pediatría, Hospital General de Niños Pedro de Elizalde, Ciudad Autónoma de Buenos Aires, Argentina
c División de Patología, Hospital General de Niños Pedro de Elizalde, Ciudad Autónoma de Buenos Aires, Argentina
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Leonardo de Lillo, Natalia More, Gabriel Cao, Caupolican Alvarado" "autores" => array:7 [ 0 => array:4 [ "nombre" => "Alejandro" "apellidos" => "Balestracci" "email" => array:1 [ 0 => "abalestracci@yahoo.com.ar" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Ismael" "apellidos" => "Toledo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Luciana" "apellidos" => "Meni Battaglia" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Leonardo" "apellidos" => "de Lillo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "Natalia" "apellidos" => "More" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 5 => array:3 [ "nombre" => "Gabriel" "apellidos" => "Cao" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 6 => array:3 [ "nombre" => "Caupolican" "apellidos" => "Alvarado" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Unidad de Nefrología, Hospital General de Niños Pedro de Elizalde, Ciudad Autónoma de Buenos Aires, Argentina" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Pediatría, Hospital General de Niños Pedro de Elizalde, Ciudad Autónoma de Buenos Aires, Argentina" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "División de Patología, Hospital General de Niños Pedro de Elizalde, Ciudad Autónoma de Buenos Aires, Argentina" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Síndrome urémico hemolítico asociado a diarrea sin trombocitopenia" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1634 "Ancho" => 1155 "Tamanyo" => 319872 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Findings from the renal histology of one child with diarrhoea-positive haemolytic uraemic syndrome with no thrombocytopenia. (A) Renal glomeruli with capillary dilatation and mesangiolysis (white arrow). Haematoxylin and eosin, 400×. (B) Immunofluorescence showed fibrin thrombi in some glomeruli (white arrow), 400×.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Diarrhoea-positive haemolytic uraemic syndrome (D+ HUS) is one of the main causes of acute kidney injury in children.<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">1,2</span></a> It is mediated by Shiga toxin-producing <span class="elsevierStyleItalic">Escherichia coli</span> (STEC), which causes direct endothelial damage inducing platelet aggregation and thrombus formation that occlude the microvasculature of vital organs such as the kidneys.<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">1,2</span></a> The diagnosis of D+ HUS is based on the presence of a prodrome of diarrhoea associated with microangiopathic haemolytic anaemia, thrombocytopenia and acute kidney injury.<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">1–3</span></a> On rare occasions, the thrombocytopenia may be transient and therefore undetected by laboratory tests.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">4</span></a> Because there is scarce information on the clinical characteristics of children with D+ HUS with no thrombocytopenia, the aim of this study is to describe the clinical course of a series of patients with this particularity.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Patients and methods</span><p id="par0010" class="elsevierStylePara elsevierViewall">We reviewed the medical records of all hospitalised children diagnosed with D+ HUS at the Pedro de Elizalde General Children's Hospital between 2000 and 2016 to identify those without thrombocytopenia. Then, the following variables were extracted from the medical records selected: age, gender, time elapsed between the first symptom and diagnosis of D+ HUS, signs and symptoms of the prodromal phase, blood count on admission (white blood cell and platelet counts, haematocrit and haemoglobin), minimum platelet count and the percentage of decrease in relation to the initial value, maximum serum creatinine and severity of acute kidney injury, number of red blood cell transfusions received, need for and days of dialysis, presence of severe extrarenal manifestations and/or hypertension, and isolation of the aetiological agent. In addition, follow-up time after the acute stage and renal status at the time of the last check-up was recorded.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The study was approved by our institution's research and ethics committees.</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Definitions</span><p id="par0020" class="elsevierStylePara elsevierViewall">D+ HUS is defined as the presence of diarrhoea associated with thrombocytopenia (<150,000<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">3</span>), acute microangiopathic haemolytic anaemia (haemoglobin <3rd percentile for age and gender with the presence of schistocytes in a peripheral blood smear, a negative Coombs’ test and an increase in lactate dehydrogenase) and kidney failure expressed by haematuria and proteinuria with or without elevated creatinine relative to ages.<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">1–3</span></a> Cases with no thrombocytopenia were considered to be when no test during hospitalisation showed a platelet count<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>150,000<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">3</span>, but which met the rest of the criteria.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">5</span></a> Platelet counts in all cases were determined by automated methods and later confirmed by paediatric haematologists at our hospital who directly viewed the peripheral blood smears.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The aetiological diagnosis was based on the identification of STEC or Shiga toxin in faeces and/or positive antibodies to polysaccharides of the most common STEC serotypes.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">6</span></a> Given that Argentina not only has the highest global incidence of D+ HUS but also that the aetiological identification in our setting varies between 32% and 54%, cases that showed a prodrome of diarrhoea, even with no pathogen detected, were also considered STEC-mediated.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">6,7</span></a> Patients with familial or recurrent HUS and cases associated with specific causes, such as deregulation of the complement system, AIDS, drugs and pneumococcal infection, were excluded.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">8</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The presence of neurological manifestations, such as decreased alertness, seizures or coma, and intestinal manifestations, such as intussusception, perforation or ischaemic colitis, were considered to be serious extrarenal involvement.<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">9–11</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Readings on the blood pressure monitor of systolic and/or diastolic blood pressure greater than the 95th percentile for age, height and gender according to the reference values were considered to be cases of hypertension.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">12</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The indications for dialysis were anuria >24<span class="elsevierStyleHsp" style=""></span>h, untreatable electrolyte disturbances and hypervolaemia.<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">13,14</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Creatinine was measured with the Jaffe reaction, and glomerular filtration rate (eGFR) was estimated by the Schwartz formula, using the maximum creatinine value.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">15</span></a> The severity of the acute kidney injury was stratified according to paediatric RIFLE criteria <span class="elsevierStyleItalic">(risk</span> decrease in eGFR<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>25%; <span class="elsevierStyleItalic">injury</span><span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>50%; and <span class="elsevierStyleItalic">failure</span><span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>75%), assuming a baseline eGFR of 100<span class="elsevierStyleHsp" style=""></span>ml/min/1.73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> because, as is usually the case with children with acute kidney injury, the renal function before admission was not known.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">16</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Diuresis<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>ml/kg/h<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">17</span></a> was considered to be a normal urine output.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Haematuria was considered if there were more than 5 RBCs per field (with ×400 magnification) in centrifuged fresh urine.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">18</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Proteinuria was determined by means of a test strip; the presence of 1+ or more on the colourimetric scale was considered a positive result.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">18</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Statistical analysis</span><p id="par0065" class="elsevierStylePara elsevierViewall">A descriptive analysis of the variables collected was performed; continuous variables were expressed, according to the distribution type (Shapiro–Wilk test), as the median (interval) or mean (standard deviation), and categorical variables were expressed as the frequency of distribution. The statistical analysis was performed using Statistix, ver. 7 (IBM version; Analytical Software, Tallahassee, FL, United States).</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Results</span><p id="par0070" class="elsevierStylePara elsevierViewall">From 2000 to 2016, 161 children with D+ HUS were admitted to our hospital, 9 of whom were identified with no thrombocytopenia (prevalence of 5.6%).</p><p id="par0075" class="elsevierStylePara elsevierViewall">The median age at diagnosis was 17 months (7–32), and the duration of the prodrome period was 15 days (7–21). Four patients showed no decrease in platelet count compared with the value on admission, and the remaining 5 had a mean decrease of 30<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>17%; but all had values greater than 150,000<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">3</span> throughout hospitalisation. The median number of red blood cell transfusions was 1 (0–2), and no patient had severe extrarenal involvement and/or hypertension. Regarding the severity of kidney failure based on the paediatric RIFLE criteria, in 3 cases there was no acute kidney injury (although haematuria and proteinuria were present as a sign of kidney disease), 2 cases fell under the <span class="elsevierStyleItalic">risk</span> category, 2 under <span class="elsevierStyleItalic">injury</span> and 2 under <span class="elsevierStyleItalic">failure</span>. Eight patients had normal diuresis and one young girl had anuria and severe kidney failure (creatinine 8.1<span class="elsevierStyleHsp" style=""></span>mg/dl on admission) and required peritoneal dialysis. She had no history of kidney disease nor had she received drugs during the prodromal phase; her C3 (89<span class="elsevierStyleHsp" style=""></span>mg/dl) and C4 (20<span class="elsevierStyleHsp" style=""></span>mg/dl) levels were normal, and no bacterial or viral agents were detected in her blood. Likewise, the test for Shiga toxin and the faecal culture were negative. An ultrasound revealed normal-sized hyperechogenic kidneys. Given the absence of thrombocytopenia, together with the severity of the kidney failure and the lack of aetiological identification, a kidney biopsy was performed that confirmed the diagnosis of thrombotic microangiopathy. The main findings from the biopsy were as follows: thickening and disruption of the glomerular capillary walls; focal mesangiolysis and aneurysmal dilatation of the glomerular capillaries; patchy acute tubular necrosis; and interstitial oedema involving less than 5% of the sample. The arteries and arterioles showed no changes. Fibrin thrombi were identified by immunofluorescence (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). She needed 7 days of dialysis and 2 red blood cell transfusions during hospitalisation, and was discharged in good clinical condition and with her kidney function improving progressively (creatinine 1.19<span class="elsevierStyleHsp" style=""></span>mg/dl). During the outpatient follow-up, she had a positive result for polysaccharide antibodies to <span class="elsevierStyleItalic">Escherichia coli</span> O145, and her kidney function was stabilised (creatinine 0.3<span class="elsevierStyleHsp" style=""></span>mg/dl). <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the patients’ demographic and clinical characteristics, and <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the laboratory findings during the acute phase.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">After discharge, the patients were followed for 2 years (1.5–4), and all had a normal eGFR, no proteinuria or haematuria and normal blood pressure.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Discussion</span><p id="par0085" class="elsevierStylePara elsevierViewall">The presence of thrombocytopenia is a distinctive sign of D+ HUS; however, it may be transient and therefore go undetected.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">4</span></a> There is limited information on the prevalence of D+ HUS with no thrombocytopenia, and the course of the disease in these patients has not been described in detail. In a cohort of 102 patients with D+ HUS, Schifferli et al.<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">19</span></a> found that 7 (6.8%) had no thrombocytopenia, a prevalence similar to that seen by Siegler et al.<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">20</span></a> (6%) in 157 cases (89% with prodrome of diarrhoea). Similarly, in our series of 161 children, the prevalence of lack of thrombocytopenia was 5.6%. These results differed from those seen by Giménez Llort et al.,<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">21</span></a> who noted a lower prevalence (one case in 51 children, or 2%), and from that reported by Ardissino et al.,<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">22</span></a> who found this condition in 11% of their cases; although it should be clarified here that in the latter study, this percentage corresponds to patients with platelet counts<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>150,000<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">3</span> on admission, but this does not specify whether they later declined during the course of the disease. Finally, in Argentina, in 254 children with bloody diarrhoea, López et al.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">5</span></a> found that 6 developed HUS and 14 had “incomplete forms” (they did not meet 3 diagnostic criteria), with 3 showing no thrombocytopenia, i.e. the missing criterion. The case reported by Meier et al. is interesting; it concerns a child with diarrhoea due to STEC, who developed microangiopathic anaemia with no kidney impairment or thrombocytopenia. The authors speculated that Shiga toxin may cause direct damage to the erythrocyte membrane as a possible explanation for such a case.<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">23</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">To the best of our knowledge, this is the first case-series to specifically describe the disease's course in patients with D+ HUS with no thrombocytopenia. The median age of the group studied (17 months) is consistent with that of children who meet all the diagnostic criteria.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">6</span></a> It should be noted that the median time between the first symptom and the diagnosis (15 days) was longer than usual (the median is approximately 7 days).<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">24</span></a> Late diagnosis may explain the absence of thrombocytopenia; it is possible that the children studied here presented with transient thrombocytopenia, but that at the time of the laboratory tests the rebound of the platelet count was detected.<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">24</span></a> Moreover, no patients showed a decrease of less than 150,000<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">3</span>, nor were there sudden reductions in platelet counts compared with the baseline values (the mean decrease was 30%). Late diagnosis may also have been responsible for the low rate of isolation of STEC in stools in our patients,<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">3</span></a> which was only possible in 3 of 9 cases, although the isolation rate is within the norm in our setting.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">6,7</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">In D+ HUS, platelet counts are commonly normalised before kidney function is recovered; in fact, the time to reaching a count<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>150,000<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">3</span> was proposed as an indirect marker that the microangiopathic process has resolved.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">8</span></a> Accordingly, it has been postulated that these late cases with no thrombocytopenia are usually mild.<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">24</span></a> Our results confirm this assumption: no patient presented with serious extrarenal involvement, and, although the severity of acute kidney injury varied, 8 of 9 cases maintained adequate diuresis with no need for dialysis, i.e. a lower rate than previously reported in children with D+ HUS.<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">13,14,25</span></a> In addition, no patient had any signs of renal sequelae at the last check-up.</p><p id="par0100" class="elsevierStylePara elsevierViewall">In conclusion, the prevalence of D+ HUS with no thrombocytopenia was 5.6% and most cases were mild; however, since one patient required dialysis, it is worth noting that the normalisation of platelet counts is not always an accurate marker that the disease has resolved. Additionally, our results show that the time when D+ HUS cases present with normal platelet counts is usually long after the first intestinal symptoms, and a high rate of diagnostic suspicion is therefore necessary.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflicts of interest</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors declare that they have no potential conflicts of interest related to the contents of this article.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres912448" "titulo" => "Abstract" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Patients and methods" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec892043" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres912447" "titulo" => "Resumen" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Antecedentes" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivo" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Pacientes y métodos" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec892042" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Patients and methods" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Definitions" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Statistical analysis" ] ] ] 6 => array:2 [ "identificador" => "sec0025" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0030" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-07-19" "fechaAceptado" => "2016-12-10" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec892043" "palabras" => array:4 [ 0 => "Haemolytic uraemic syndrome" 1 => "Non-thrombocytopenia" 2 => "<span class="elsevierStyleItalic">Escherichia coli</span>" 3 => "Children" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec892042" "palabras" => array:4 [ 0 => "Síndrome urémico hemolítico" 1 => "Atrombocitopenia" 2 => "<span class="elsevierStyleItalic">Escherichia coli</span>" 3 => "Niños" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Thrombocytopenia is a hallmark of postdiarrhoeal haemolytic uraemic syndrome (D+ HUS), although it can be transient and therefore undetected. There is scarce information regarding the prevalence and the course of the disease in children with D+ HUS without thrombocytopenia.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To determine the prevalence of D+ HUS without thrombocytopenia and to describe the clinical characteristics of a series of children with this condition.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Patients and methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The medical records of patients with D+ HUS hospitalised between 2000 and 2016 were reviewed to identify those without thrombocytopenia (>150,000<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">3</span>). Demographic, clinical and laboratory parameters of the selected cases were collected and descriptively analysed.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Nine cases (5.6%) without thrombocytopenia were identified among 161 patients hospitalised during the study period. Median age at diagnosis was 17 months (7–32) and median prodromal symptom duration was 15 days (7–21). Eight patients maintained normal urine output while the remaining one required dialysis. No patient presented with severe extrarenal compromise and/or hypertension.</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The prevalence of non-thrombocytopenic D+ HUS was 5.6% and most cases occurred with mild forms of the disease; however, the need for dialysis in one of them indicated that normalisation of platelet count is not always an accurate marker for disease remittance. Our results also confirm that the time of onset of D+ HUS in patients without thrombocytopenia is usually delayed with respect to the initial intestinal symptoms; thus, heightened diagnostic suspicion is necessary.</p></span>" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Patients and methods" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Antecedentes</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La presencia de trombocitopenia es una marca distintiva del síndrome urémico hemolítico asociado a diarrea (SUH D+); sin embargo, puede ser transitoria y, por lo tanto, no ser detectada. Existe limitada información sobre la prevalencia y el curso de la enfermedad en niños con SUH D+ sin trombocitopenia.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivo</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Determinar la prevalencia de SUH D+ sin trombocitopenia y describir las características clínicas de una serie de niños con esta particularidad.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Pacientes y métodos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Fueron revisadas las historias clínicas de los pacientes con SUH D+ internados entre 2000 y 2016 para identificar a aquellos sin trombocitopenia (><span class="elsevierStyleHsp" style=""></span>150.000<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">3</span>). De los casos seleccionados se recolectaron las variables demográficas, clínicas y de laboratorio, las cuales fueron analizadas descriptivamente.</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">De 161 pacientes internados durante el periodo de estudio se identificaron 9 sin trombocitopenia (5,6%). La mediana de la edad al diagnóstico fue de 17 meses (7-32) y la de la duración del periodo prodrómico, de 15 días (7-21). Ocho pacientes mantuvieron diuresis normal y uno requirió diálisis. Ningún paciente presentó compromiso extrarrenal severo y/o hipertensión arterial.</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusiones</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">La prevalencia de SUH D+ sin trombocitopenia fue del 5,6% y la mayoría de los casos fueron leves; sin embargo, el requerimiento de diálisis en uno de ellos señala que la normalización del recuento de plaquetas no siempre es un marcador preciso de resolución de la enfermedad. Nuestros resultados también confirman que el momento de presentación de los pacientes con SUH D+ sin trombocitopenia está usualmente alejado de los primeros síntomas intestinales, por lo que es necesario un alto índice de sospecha diagnóstica.</p></span>" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Antecedentes" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivo" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Pacientes y métodos" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Balestracci A, Toledo I, Meni Battaglia L, de Lillo L, More N, Cao G, et al. Síndrome urémico hemolítico asociado a diarrea sin trombocitopenia. Nefrologia. 2017;37:508–514.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1634 "Ancho" => 1155 "Tamanyo" => 319872 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Findings from the renal histology of one child with diarrhoea-positive haemolytic uraemic syndrome with no thrombocytopenia. (A) Renal glomeruli with capillary dilatation and mesangiolysis (white arrow). Haematoxylin and eosin, 400×. (B) Immunofluorescence showed fibrin thrombi in some glomeruli (white arrow), 400×.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">F: female; M: male; BP: blood pressure; RBCT: red blood cell transfusion; Stx: Shiga toxin.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Case \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Age (months) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Gender (F/M) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Duration of prodromal phase (days) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Symptoms of prodromal phase \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">RBCT (number) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Dialysis (days) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Serious extrarenal involvement \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Maximum BP (mmHg) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Aetiology \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bloody diarrhoea<br>Pallor \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">95/50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Escherichia coli</span> O157:H7 and Stx2 in stools \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bloody diarrhoea<br>Fever<br>Pallor \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">90/60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bloody diarrhoea<br>Fever<br>Pallor \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">85/60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Diarrhoea with no blood<br>Pallor \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">90/60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bloody diarrhoea<br>Pallor \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">85/50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Diarrhoea with no blood<br>Vomiting \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">95/50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">Escherichia coli</span> O157:H7 and Stx2 in stools \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Abdominal pain<br>Diarrhoea with no blood<br>Fever<br>Pallor \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">90/60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Stx2 in stools \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Diarrhoea with no blood<br>Pallor \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">90/50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Polysaccharide antibodies to <span class="elsevierStyleItalic">Escherichia coli</span> O145 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bloody diarrhoea \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">80/50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1535972.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Demographic and clinical characteristics of children with diarrhoea-positive haemolytic uraemic syndrome with no thrombocytopenia.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">eGFR: estimated glomerular filtration rate; WBC: white blood cells; Hb: haemoglobin; Ht: haematocrit; LDH: lactate dehydrogenase.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Case \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Proteinuria \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Red blood cells in urine \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">WBC on admission (mm<span class="elsevierStyleSup">3</span>) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Ht (%) on admission \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Hb (g/dl) on admission \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Platelets on admission (mm<span class="elsevierStyleSup">3</span>) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Minimum platelet count (m<span class="elsevierStyleSup">3</span>) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Maximum LDH (IU/l) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Maximum creatinine (mg/dl) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Minimum eGFR (ml/min/1.73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+++ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6900 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">599,000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">599,000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1340 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">109 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+++ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10–15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13,700 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">309,000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">309,000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1200 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">56 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">++ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8–10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27,200 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">350,000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">151,000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1560 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">++ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10–15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12,000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">374,000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">374,000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1180 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.34 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">90 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+++ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15,800 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">199,000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">153,000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1845 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6–8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8500 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">435,000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">388,000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1500 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.66 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">65 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+++ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11,200 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">374,000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">278,000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1460 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">81 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+++ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15–20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13,300 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">570,000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">360,000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1494 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14,800 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">250,000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">250,000 \t\t\t\t\t\t\n \t\t\t\t</td><td 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 5 | 12 |
| 2024 October | 30 | 37 | 67 |
| 2024 September | 54 | 33 | 87 |
| 2024 August | 60 | 76 | 136 |
| 2024 July | 33 | 32 | 65 |
| 2024 June | 61 | 42 | 103 |
| 2024 May | 50 | 43 | 93 |
| 2024 April | 45 | 42 | 87 |
| 2024 March | 39 | 40 | 79 |
| 2024 February | 30 | 49 | 79 |
| 2024 January | 38 | 41 | 79 |
| 2023 December | 19 | 36 | 55 |
| 2023 November | 37 | 51 | 88 |
| 2023 October | 45 | 44 | 89 |
| 2023 September | 30 | 46 | 76 |
| 2023 August | 27 | 53 | 80 |
| 2023 July | 37 | 29 | 66 |
| 2023 June | 33 | 36 | 69 |
| 2023 May | 50 | 43 | 93 |
| 2023 April | 34 | 32 | 66 |
| 2023 March | 46 | 31 | 77 |
| 2023 February | 39 | 28 | 67 |
| 2023 January | 38 | 43 | 81 |
| 2022 December | 67 | 37 | 104 |
| 2022 November | 49 | 39 | 88 |
| 2022 October | 64 | 42 | 106 |
| 2022 September | 73 | 39 | 112 |
| 2022 August | 43 | 52 | 95 |
| 2022 July | 40 | 56 | 96 |
| 2022 June | 41 | 54 | 95 |
| 2022 May | 48 | 31 | 79 |
| 2022 April | 64 | 52 | 116 |
| 2022 March | 83 | 50 | 133 |
| 2022 February | 50 | 43 | 93 |
| 2022 January | 65 | 42 | 107 |
| 2021 December | 94 | 37 | 131 |
| 2021 November | 65 | 32 | 97 |
| 2021 October | 67 | 48 | 115 |
| 2021 September | 80 | 47 | 127 |
| 2021 August | 50 | 47 | 97 |
| 2021 July | 37 | 60 | 97 |
| 2021 June | 55 | 35 | 90 |
| 2021 May | 65 | 55 | 120 |
| 2021 April | 118 | 47 | 165 |
| 2021 March | 61 | 54 | 115 |
| 2021 February | 68 | 41 | 109 |
| 2021 January | 41 | 20 | 61 |
| 2020 December | 36 | 17 | 53 |
| 2020 November | 41 | 15 | 56 |
| 2020 October | 30 | 24 | 54 |
| 2020 September | 38 | 18 | 56 |
| 2020 August | 45 | 17 | 62 |
| 2020 July | 34 | 13 | 47 |
| 2020 June | 53 | 20 | 73 |
| 2020 May | 82 | 22 | 104 |
| 2020 April | 61 | 21 | 82 |
| 2020 March | 67 | 14 | 81 |
| 2020 February | 44 | 25 | 69 |
| 2020 January | 52 | 27 | 79 |
| 2019 December | 77 | 24 | 101 |
| 2019 November | 110 | 16 | 126 |
| 2019 October | 61 | 13 | 74 |
| 2019 September | 59 | 9 | 68 |
| 2019 August | 43 | 20 | 63 |
| 2019 July | 51 | 19 | 70 |
| 2019 June | 43 | 16 | 59 |
| 2019 May | 39 | 17 | 56 |
| 2019 April | 50 | 26 | 76 |
| 2019 March | 43 | 31 | 74 |
| 2019 February | 30 | 23 | 53 |
| 2019 January | 39 | 20 | 59 |
| 2018 December | 221 | 36 | 257 |
| 2018 November | 444 | 18 | 462 |
| 2018 October | 391 | 21 | 412 |
| 2018 September | 183 | 21 | 204 |
| 2018 August | 224 | 18 | 242 |
| 2018 July | 110 | 13 | 123 |
| 2018 June | 124 | 19 | 143 |
| 2018 May | 171 | 21 | 192 |
| 2018 April | 141 | 15 | 156 |
| 2018 March | 141 | 9 | 150 |
| 2018 February | 177 | 9 | 186 |
| 2018 January | 82 | 9 | 91 |
| 2017 December | 107 | 7 | 114 |
| 2017 November | 42 | 14 | 56 |
| 2017 October | 58 | 21 | 79 |
| 2017 September | 2 | 0 | 2 |
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