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Hemolytic Uremic Syndrome

Typical Hemolytic-Uremic Syndrome


Presentation

Hemolytic uremic syndrome usually begins with diarrhea and vomiting that contains blood. In addition, to these the following signs and symptoms are also present:

In the later stages, affected individuals may also experience seizures, though this is very rare.

Easy Bruising
  • A week later, he presents to the ER with jaundice, abdominal pain, and easy bruising. Lab results come back with low platelet count, anemia, and increased creatinine. A peripheral blood shows schistocytes. He is started on IV hydration.[step2.medbullets.com]
Anemia
  • It is characterized by hemolytic anemia (anemia, hemolytic); thrombocytopenia; and acute renal failure Use Additional ICD-9-CM Volume 2 Index entries containing back-references to 283.11 :[icd9data.com]
  • Postpartum hemolytic uremic syndrome (PHUS) is a severe thrombotic microangiopathy (TMA) that is clinically characterized by hemolytic anemia, renal dysfunction, and low platelet levels after childbirth.[ncbi.nlm.nih.gov]
  • Typical management of STEC-HUS patients relies on supportive care of electrolyte and water imbalance, anemia, hypertension and renal failure.[ncbi.nlm.nih.gov]
  • Overhydration, hypertension, anemia, or dyselectrolytemias sometimes cause cardiovascular impairment in childhood hemolytic-uremic syndrome.[ncbi.nlm.nih.gov]
  • Abstract The hemolytic–uremic syndrome (HUS) is characterized by microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury (AKI).[ncbi.nlm.nih.gov]
Fever
  • Fever, tachycardia, a rising white blood cell count, and abdominal pain out of proportion to examination are key findings for which physicians should be vigilant.[ncbi.nlm.nih.gov]
  • METHODS: Thirty-two patients infected with enterohemorrhagic Escherichia coli O104:H4 (HUS: n 23; non-HUS: n 9) were retrospectively screened for anti-Stx2 IgM/IgG and matched with clinical data regarding HUS development, fever, superinfection, dialysis[ncbi.nlm.nih.gov]
  • At the fifth month of follow-up, the patient was diagnosed with acute B-cell lymphoblastic leukemia with fever, bone pain, hepatosplenomegaly, and pancytopenia.[ncbi.nlm.nih.gov]
  • Some individuals with TTP may have neurological symptoms and fever.[healthcommunities.com]
  • When fever and CNS manifestations coexist, the distinction between HUS and thrombotic thrombocytopenic purpura (TTP) can be difficult. Epidemiology HUS has been characterized as either epidemic/endemic (or prodromal) or sporadic (nonprodromal).[doi.org]
Pallor
  • However, eight days post delivery, the patient developed severe nausea and vomiting followed by hematuria, spontaneous bruising, marked pallor, icteric sclera, and lethargy.[ncbi.nlm.nih.gov]
  • Symptoms Symptoms of HUS include bloody diarrhea, vomiting, anemia, blood in urine, decreased urinary output, fatigue, lethargy, confusion, pallor, irritability, edema and fever.[symptoma.com]
  • […] factors use of antimotility agents in EHEC diarrhea use of antibiotics in EHEC diarrhea Presentation Symptoms prodromal gastrointestinal illness abdominal pain bloody diarrhea nausea vomiting fatigue (anemia) oliguria/anuria (renal failure) Physical exam pallor[step2.medbullets.com]
  • Symptoms Signs and symptoms of HUS can include: Bloody diarrhea Decreased urination or blood in the urine Abdominal pain, vomiting and occasionally fever Pallor Small, unexplained bruises or bleeding from the nose and mouth Fatigue and irritability Confusion[mayoclinic.org]
Pediatric Disorder
  • Rekha Hans, Satya Prakash, Ratti Ram Sharma and Neelam Marwaha, Role of therapeutic apheresis in pediatric disorders, Pediatric Hematology Oncology Journal, 10.1016/j.phoj.2016.11.002, 1, 3, (63-68), (2016). James B. Mowry, Emmanuel A.[doi.org]
Malaise
  • On day 15, after the beginning of plasma exchange, the patient suffered a sudden malaise with neck pain. Circulatory arrest associated was identified with pulse rate under 25/min.[doi.org]
Severe Clinical Course
  • Moreover, a shorter period between the onset of diarrhea and a diagnosis of D   HUS indicated a more severe clinical course or long-term sequelae, and it should be considered as a risk factor for poor prognosis.[ncbi.nlm.nih.gov]
Diarrhea
  • Diarrhea-associated hemolytic uremic syndrome (HUS) is characterized by acute kidney injury with microangiopathic hemolytic anemia and thrombocytopenia with a diarrhea prodrome, typically caused by Shiga-like toxin-producing Escherichia coli.[ncbi.nlm.nih.gov]
  • OBJECTIVES: To clarify the clinical characteristics and long-term outcomes of patients with diarrhea-associated hemolytic uremic syndrome (D   HUS) with a particular focus on time course.[ncbi.nlm.nih.gov]
  • The most common form of the syndrome (D HUS) occurs in healthy young children ( 6 mo to 5 y of age) and is preceded by watery diarrhea that can evolve to hemorrhagic colitis.[ncbi.nlm.nih.gov]
  • Eleven of 45 attendees with diarrhea had positive tests (stool culture or shiga-like toxin assay) for E. coli O157:H7. Two of these 11 (18%) progressed to hemolytic uremic syndrome.[dx.doi.org]
Vomiting
  • However, eight days post delivery, the patient developed severe nausea and vomiting followed by hematuria, spontaneous bruising, marked pallor, icteric sclera, and lethargy.[ncbi.nlm.nih.gov]
  • Hemolytic uremic syndrome usually begins with diarrhea and vomiting that contains blood.[symptoma.com]
  • Four days earlier, she had suffered from gastroenteritis (non-bloody diarrhea and vomiting without fever).[ncbi.nlm.nih.gov]
  • These early symptoms can include diarrhea (which is often bloody), stomach cramps, mild fever, or vomiting that results in dehydration and reduced urine.[en.wikipedia.org]
  • Symptoms of HUS include vomiting and diarrhea (often bloody), weakness , lethargy, and bruising (purpura).[medicinenet.com]
Abdominal Pain
  • Fever, tachycardia, a rising white blood cell count, and abdominal pain out of proportion to examination are key findings for which physicians should be vigilant.[ncbi.nlm.nih.gov]
  • The abdominal pain accompanied by failure kidney is a suspicious symptom to develop this disorder.[ncbi.nlm.nih.gov]
  • The patient had a past history of abdominal pain, bloody diarrhea, and acute renal failure.[ncbi.nlm.nih.gov]
  • A 50-year-old female, after presenting with diarrhea and abdominal pain, developed pancolitis, acute renal failure, and thrombocytopenia. The patient underwent total abdominal colectomy.[doi.org]
  • Additionally, abdominal pain and tenderness could mimic appendicitis or an acute abdomen.[aafp.org]
Nausea
  • However, eight days post delivery, the patient developed severe nausea and vomiting followed by hematuria, spontaneous bruising, marked pallor, icteric sclera, and lethargy.[ncbi.nlm.nih.gov]
  • Nausea and vomiting is present in approximately half of the patients. Most patients recover in 7-10 days, but some (6%) go on to have HUS. This is most likely to happen in children and the elderly.[medicinenet.com]
  • Adverse Reactions The most frequently reported adverse reactions in the PNH randomized trial ( 10% overall and greater than placebo) are: headache, nasopharyngitis, back pain, and nausea.[alexion.com]
  • Some of the signs and symptoms of aHUS include: confusion; diarrhea, nausea and vomiting; shortness of breath; fatigue; heart symptoms and kidney symptoms. Certain lab tests can help your doctor determine if you may have aHUS.[enerca.org]
  • Among those on Soliris, the most common adverse events included high blood pressure (hypertension), diarrhea, headache, anemia, vomiting, nausea, upper respiratory and urinary tract infections, and a decrease in white blood cells (leukopenia).[medicalnewstoday.com]
Food Poisoning
  • Abstract A food-poisoning outbreak due to enterohemorrhagic Escherichia coli (EHEC) occurred in Toyama, Japan.[ncbi.nlm.nih.gov]
  • CONTACT OUR LAWYERS ABOUT AN HUS FOOD POISONING LAWSUIT[youhavealawyer.com]
  • This type of E. coli can be found in undercooked meat and is one of the causes of restaurant-related food poisoning outbreaks.[hopkinsmedicine.org]
  • It can be found in undercooked meat and other foods; and is one of the causes of food recalls and restaurant-related food poisoning outbreaks. This accounts for almost 90% of HUS in children.[medicinenet.com]
Hypertension
  • Overhydration, hypertension, anemia, or dyselectrolytemias sometimes cause cardiovascular impairment in childhood hemolytic-uremic syndrome.[ncbi.nlm.nih.gov]
  • Patient 1: A 74-year-old male with resected adenocarcinoma of the pancreas started adjuvant treatment with GEM, but after 5 months GEM was discontinued due to acute kidney injury and severe hypertension.[ncbi.nlm.nih.gov]
  • Superimposed preeclampsia and HELLP syndrome were diagnosed after the establishment of nephrotic range proteinuria, hypertension and recurrence of hemolysis.[ncbi.nlm.nih.gov]
  • Anemia, edema, oliguria, hemoglobinuria and hypertension were the most common manifestations. Thrombocytopenia, hyponatremia, hypocalcemia, hyperkalemia, metabolic acidosis, increased fibrinogen and hypocomplementemia were found in most patients.[ncbi.nlm.nih.gov]
  • […] of Miami, Miami, FL; and 2 Division of Nephrology and Hypertension, Albany Medical College, Albany, NY.[journals.lww.com]
Tachycardia
  • Fever, tachycardia, a rising white blood cell count, and abdominal pain out of proportion to examination are key findings for which physicians should be vigilant.[ncbi.nlm.nih.gov]
  • At that time, she exhibited moderate dehydration, pallor, drowsiness, and a generalized seizure of 10 to 15 min duration, tachycardia, tender and tense abdominal wall, and a history of oligoanuria for the last 48 h. Blood pressure was 128/67 mm Hg.[doi.org]
  • Blood cultures were drawn and an antibiotic was given based on a body temperature of 38.9 C and tachycardia. The patient was started at 4 g piperacillin-tazobactam 3 times per day intravenously (i.v.). The cultures did not show any bacterial growth.[bmcresnotes.biomedcentral.com]
  • His heart has a regular rhythm with tachycardia and a grade II/VI vibratory systolic ejection murmur at the left sternal border without radiation. No heaves, lifts, thrills, rubs, or gallops are present. His lungs are clear with good aeration.[hawaii.edu]
Jaundice
  • A week later, he presents to the ER with jaundice, abdominal pain, and easy bruising. Lab results come back with low platelet count, anemia, and increased creatinine. A peripheral blood shows schistocytes. He is started on IV hydration.[step2.medbullets.com]
  • […] the following signs and symptoms are also present: Stools contain blood Fever Lethargy Passing out blood in urine or very less urinary output Weakness Irritability Confusion Pain in the abdomen Development of swelling in the arms, feet and face Pallor Jaundice[symptoma.com]
  • In addition to the usual signs of anemia, the patient may also exhibit jaundice. hemolytic component a degree of extravascular hemolysis in association with other types of anemia. hemolytic disease of the newborn see alloimmune hemolytic anemia of the[medical-dictionary.thefreedictionary.com]
  • .  LATER SYMPTOMS: • Bruising • Decreased consciousness • Low urine output • No urine output • Pallor • Seizures -- rare • Skin rash that looks like fine red spots (petechiae) • Yellow skin (jaundice) 10.[slideshare.net]
Petechiae
  • Physical examination is significant for petechiae on his legs and diffuse abdominal tenderness to palpation. Lab-work shows BUN 72 mg/dL, creatinine 8.1 mg/dL, and platelet count 10,000. PT and PTT are within normal limits.[medbullets.com]
  • […] diarrhea use of antibiotics in EHEC diarrhea Presentation Symptoms prodromal gastrointestinal illness abdominal pain bloody diarrhea nausea vomiting fatigue (anemia) oliguria/anuria (renal failure) Physical exam pallor (anemia) jaundice (hemolysis) petechiae[step2.medbullets.com]
  • In addition, petechia, purpura, and/or active bleeding are uncommon features of HUS, despite the significant low platelet count.[clinicaladvisor.com]
  • .  LATER SYMPTOMS: • Bruising • Decreased consciousness • Low urine output • No urine output • Pallor • Seizures -- rare • Skin rash that looks like fine red spots (petechiae) • Yellow skin (jaundice) 10.[slideshare.net]
  • […] per dL (60 g per L) is common and requires red blood cell transfusion. 2 Ninety-two percent of patients with hemolytic uremic syndrome develop thrombocytopenia, which results from entrapment of platelets in the organs. 2 Clotting times are normal, and petechiae[aafp.org]
Extrapyramidal Symptoms
  • Patient 49: MRI findings at day 3 in a 3-year-old girl with severe coma, pyramidal and extrapyramidal symptoms, and cortical blindness suspected on day 15 of evolution.[doi.org]
Oliguria
  • CONCLUSIONS: The age of onset younger than 2 years, oliguria/anuria more than 1 week, and associated with extrarenal complications were predictive factors of poor prognosis.[ncbi.nlm.nih.gov]
  • Risk of a complicated course/poor outcome was strongly associated with oliguria (p   0.000006) and hypertension (p   0.00003) at presentation.[ncbi.nlm.nih.gov]
  • The diarrhea precedes the hemolysis and thrombocytopenia by 5 to 7 days; oliguria/anuria follows several days later. Although the pathogenesis is unknown, available evidence strongly suggests that endothelial cell damage is necessary.[ncbi.nlm.nih.gov]
  • […] vegetables animals at petting zoos Risk factors use of antimotility agents in EHEC diarrhea use of antibiotics in EHEC diarrhea Presentation Symptoms prodromal gastrointestinal illness abdominal pain bloody diarrhea nausea vomiting fatigue (anemia) oliguria[step2.medbullets.com]
  • (also called verocytotoxin because it damages Vero cells in culture) Main cause of childhood acute renal failure Usually infants and young children, may occur at any age Symptoms : sudden onset of influenza, bleeding (hematemesis or melena), severe oliguria[pathologyoutlines.com]
Dark Urine
  • You have bloody or dark urine or bowel movements. You have questions or concerns about your condition or care. When should I seek immediate care or call 911? You are urinating less than usual or not at all. You have diarrhea and vomiting.[drugs.com]
  • . • KIDNEY DIALYSIS • PLASMA EXCHANGE • PLATELET TRANSFUSIONS • RED BLOOD CELL TRANSFUSIONS: Low RBCs result in chills, fatigue, short of breath, rapid heart rate, yellow skin and dark urine.[slideshare.net]
  • Two days later, he developed increasing fatigue, and noted dark urine and jaundiced skin and sclerae. There was no history of recent travel or diarrhoea. His dietary history was unremarkable.[doi.org]

Workup

The following diagnostic procedures would be done to confirm HUS:

  • Blood tests are carried out to study platelet count, level of creatinine and RBC count. Low levels of RBCs, low platelet count and elevated levels of creatinine all point towards onset of HUS.
  • Peripheral blood smear examination by microscopy will reveal schistocytes as a marker of hemolysis among red blood cells in HUS [8].
  • Stool sample will be analyzed to check for presence of bacteria and further analysis would also be done to determine the pathogenic strain.
  • Urine analysis would determine the presence of blood and protein in urine.
  • A urine protein test is also a necessity to evaluate the levels of protein excreted in urine.

In addition to the above mentioned tests, other tests include a kidney biopsy and blood clotting tests for differential diagnosis.

Burr Cell
  • ., schistocytes, burr cells, or helmet cells) on peripheral blood smear, AND Renal injury (acute onset) evidenced by either hematuria, proteinuria, or elevated creatinine level (i.e., greater than or equal to 1.0 mg/dL in a child aged less than 13 years[wwwn.cdc.gov]
  • Title Other Names: HUS; Acute renal failure, thrombocytopenia, and microangiopathic hemolytic anemia associated with distorted erythrocytes ('burr cells') Categories: Hemolytic uremic syndrome (HUS) is a disorder that usually occurs when an E. coli bacterial[rarediseases.info.nih.gov]
  • cells, helmet cells Increased L-lactate dehydrogenase level Leukocytosis Negative Coombs’ test Proteinuria on urinalysis Reticulocyte count moderately elevated Stool culture positive for Shiga toxin–roducing Escherichia coli O157:H7 Thrombocytopenia:[aafp.org]
Decreased Platelet Count
  • This leads to platelet activation, endothelial cell damage, and white blood cell activation, leading to systemic TMA, which manifests as decreased platelet count, hemolysis, damage to multiple organs, and ultimately, death.[en.wikipedia.org]
  • platelet count Elevated blood urea nitrogen (BUN) and creatinine due to decreased kidney function Blood and protein in urine Presence of shiga toxin-producing E. coli in stool samples Treatment for hemolytic uremic syndrome Due to its severity, HUS is[davita.com]
Coombs Negative Hemolytic Anemia
  • BACKGROUND: Hemolytic uremic syndrome is characterized by acute renal failure, thrombocytopenia, and Coombs-negative hemolytic anemia.[ncbi.nlm.nih.gov]
  • Blood chemistry showed Coombs-negative hemolytic anemia (hemoglobin level 5.5 g/dl) with red blood cell fragmentation and thrombocytopenia (72 10 3 /μl). Serum haptoglobin was Figure 1 ).[dx.doi.org]
Haptoglobin Decreased
Creatinine Increased
  • Increased serum creatinine The condition results when the bacteria lodge in the digestive tract and produce toxins that can enter the bloodstream.[rarediseases.info.nih.gov]
Escherichia Coli 0157:H7
  • HUS and TTP Associated with Escherichia Coli 0157:H7. Emerg Med News. 2004. Ruggenenti P, Remuzzi G. Treatment of adult hemolytic-uremic syndrome. Adv Nephrol Necker Hosp. 2000. 30:83-94. [Medline]. Safdar N, Said A, Gangnon RE, Maki DG.[emedicine.medscape.com]
  • A continuing assessment of risk factors for the development of Escherichia coli 0157:H7-associated hemolytic uremic syndrome. Clin Nephrol 1994 ;42: 85 - 89 27. Cimolai N, Morrison BJ, Carter JE.[dx.doi.org]
Colitis
  • Colitis Colitis Colitis Pancreatic colitis[jaoa.org]
  • The most common form of the syndrome (D HUS) occurs in healthy young children ( 6 mo to 5 y of age) and is preceded by watery diarrhea that can evolve to hemorrhagic colitis.[ncbi.nlm.nih.gov]
  • Shiga toxin (Stx)-producing enterohemorrhagic Escherichia coli O157:H7 has become a global threat to public health, as a primary cause of a worldwide spread of hemorrhagic colitis complicated by diarrhea-associated hemolytic uremic syndrome (HUS), a disorder[ncbi.nlm.nih.gov]
  • Pathology confirmed ischemic colitis with scattered mesenteric microthrombi. Due to mental and respiratory decline, she remained intubated. Continuous venovenous hemodialysis was initiated.[doi.org]
  • Shiga toxin-producing Escherichia Coli (STEC) infection cause a spectrum of clinical sings ranging from asymptomatic carriage to non-bloody diarrhea, hemorrhagic colitis, HUS and death.[ncbi.nlm.nih.gov]

Treatment

Patients with HUS require immediate hospitalization. The following are the treatment methods administered to stabilize the condition of the patient:

  • Transfusions of red blood cells and platelets.
  • Plasma exchange [9]
  • Dialysis is done as there is acute renal failure. It is a temporary treatment method which is carried out until the kidney restores its normal functioning. If there is severe damage to the kidney or signs of chronic failure are noticed then kidney transplant may be necessary.
  • Patient is given medications such as corticosteroids.
  • Antibiotics may only be used when HUS patients are undergoing septicemia [10].

Prognosis

The prognosis of HUS is very favorable when appropriate treatment regime is initiated. About 70 – 80% children completely recover after treatment. Recovery period in children is faster as compared to adults.

Complications

The possible complications of HUS include the following:

Etiology

Infections caused by E. coli O157:H7 lead to development of HUS [2]. Such a strain of E. coli causes gastrointestinal infections which precipitate by diarrhea and vomiting in affected children. In addition, other potent strains of E. coli like O111:H8, O103:H2, and O104:H4 have also been linked to HUS [3]. In adults, HUS is known to be triggered by the following factors:

  • Medications like quinine [4], chemotherapy drugs, anti-platelet medications and immunosuppresants can cause HUS.
  • Pregnant women are more prone to develop HUS [5].
  • Individuals with infectious diseases such as H1N1 influenza A virus and HIV/AIDS are likely to suffer from HUS [6]. 
  • Heredity can also play foul in causation of specific type of HUS known as atypical hemolytic uremic syndrome

Epidemiology

Incidence of HUS peaks during the summer season and majorly affects children. It has been estimated that in United States, for children below 5 years of age, the prevalence of HUS per year has been recorded to be 6.1 cases per 100,000 population.

Sex distribution
Age distribution

Pathophysiology

Hemolytic uremic syndrome is classified under two categories on the basis of its causative agent: Typical HUS and atypical HUS. In the former category, the development of the disease occurs due to toxins produced by E. coli O157:H7 and in the atypical variety, infections are not the cause. It can occur either due to genetic defect or can be sporadic in nature.

Once the pathogenic bacteria E. coli O157:H7 gains entry into the body, it produces Shiga toxin which binds with the epithelial cells lining the gut. Following this event, series of unfavorable reactions are triggered that cause destruction of red blood cells. The destroyed red blood cells then clog the filtering system in the kidney causing acute renal failure. This may further be aggravated by the loss of vascular endothelial growth factor (VEGF) in autoimmune diseases resulting to renal microvascular angiopathies [7].

Prevention

Food borne cases of HUS can be prevented by following certain simple steps to avoid falling prey to these illnesses. They include:

  • Appropriately cook raw meat and avoid consumption of such high risk foods on open food stalls.
  • Raw food should not share the same platform with cooked food. Keep them separately.
  • Hands should be thoroughly washed prior to cooking and eating.
  • It is also necessary to wash and disinfect all raw produce before cooking them.
  • Sanitization of the cooking surface prior to cooking should be done.

Summary

Hemolytic uremic syndrome (HUS) is a disease that causes sudden kidney failure due to destruction of the red blood cells (RBCs). The kidney failure is a temporary condition and functioning of the kidneys gets normal after rigorous treatment regime.

HUS remains to be the most common cause of acute renal failure in children [1]. Children who contract Escherichia coli (E. coli) infection fall prey to HUS. The disease usually begins with bloody diarrhea and finally causes destruction of the red blood cells that eventually block the filtering system. Such a condition causes sudden kidney failure. With prompt diagnosis and appropriate treatment regime, majority of the children completely recover from the condition.

Patient Information

Definition

Hemolytic uremic syndrome (HUS) is characterized by acute renal failure due to destruction of red blood cells usually as a result of severe infection due to E coli O157:H7. Such a condition commonly strikes the children; however it can also affect adults. Contaminated raw produce, water and uncooked meat products are the source of infections.

Cause

HUS occurs due to gastrointestinal infection caused by pathogenic strain of E. coli. In addition, other causes include certain medications, infectious diseases that affect the immune system and heredity factors.

Symptoms

Symptoms of HUS include bloody diarrhea, vomiting, anemia, blood in urine, decreased urinary output, fatigue, lethargy, confusion, pallor, irritability, edema and fever.

Diagnosis

Blood tests to detect levels of RBCs, platelets and total blood count forms the preliminary diagnostic procedures for detecting HUS. Urine analysis and stool culture are some of the additional tests that are done for confirming the disease condition.

Treatment

Patient is hospitalized immediately to ease the signs and symptoms. Acute renal failure is treated through temporary dialysis and the patient is also given transfusions of platelets and red blood cells.

References

Article

  1. Siegler RL. Management of hemolytic-uremic syndrome. J Pediatr. Jun 1988; 112(6):1014-20.
  2. Tarr PI, Gordon CA, Chandler WL. Shiga-toxin-producing Escherichia coli and haemolytic uraemic syndrome. Lancet. Mar 19-25 2005; 365(9464):1073-86.
  3. Frank C, Werber D, Cramer JP, et al. Epidemic profile of Shiga-toxin-producing Escherichia coli O104:H4 outbreak in Germany. N Engl J Med. Nov 10 2011; 365(19):1771-80.
  4. Kojouri K, Vesely SK, George JN. Quinine-associated thrombotic thrombocytopenic purpura-hemolytic uremic syndrome: frequency, clinical features, and long-term outcomes. Ann Intern Med. Dec 18 2001; 135(12):1047-51.
  5. Wang YQ, Wang J, Jiang YH, Ye RH, Zhao YY. A case of severe preeclampsia diagnosed as post-partum hemolytic uremic syndrome.Chin Med J (Engl). 2012; 125(6):1189-92 (ISSN: 0366-6999)
  6. Rhee H, Song SH, Lee YJ, Choi HJ, Ahn JH. Pandemic H1N1 influenza A viral infection complicated by atypical hemolytic uremic syndrome and diffuse alveolar hemorrhage. Clin Exp Nephrol. 2011; 15(6):948-52 
  7. Eremina V, Jefferson JA, Kowalewska J, et al. VEGF inhibition and renal thrombotic microangiopathy. N Engl J Med. Mar 13 2008; 358(11):1129-36.
  8. Burns ER, Lou Y, Pathak A. Morphologic diagnosis of thrombotic thrombocytopenic purpura. Am J Hematol. Jan 2004; 75(1):18-21.
  9. Lapeyraque AL, Wagner E, Phan V, et al. Efficacy of plasma therapy in atypical hemolytic uremic syndrome with complement factor H mutations. Pediatr Nephrol. Aug 2008; 23(8):1363-6.
  10. McGannon CM, Fuller CA, Weiss AA. Different classes of antibiotics differentially influence Shiga toxin production. Antimicrob Agents Chemother. Sept 2010; 54(9):3790-3798.

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Last updated: 2018-06-21 22:03