Hemolytic-uremic syndrome medical therapy: Difference between revisions

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==Overview==
==Overview==
The mainstay of therapy for [[Hemolytic-uremic syndrome|hemolytic uremic syndrome]] [[Hemolytic-uremic syndrome|(HUS)]] is supportive therapy. [[Antibiotic therapy]] is not recommended among patients with [[Hemolytic-uremic syndrome|HUS]]. Hydration and [[intravenous]] ([[IV]]) [[isotonic]] [[Saline (medicine)|saline]] replacment decrease the risk of [[hemolytic-uremic syndrome]] [[HUS|(HUS)]]. Patients with [[Hemolytic-uremic syndrome|HUS]] who have significant clinical bleeding or who require an invasive [[procedure]] should receive [[platelet]] [[transfusions]].
==Medical Therapy==
==Medical Therapy==
Treatment is generally supportive with [[dialysis]] as needed.  [[Platelet]] [[blood transfusion|transfusion]] may actually worsen outcome.
*The mainstay of therapy for [[Hemolytic-uremic syndrome|HUS]] is supportive [[therapy]] and almost all cases of [[HUS]] are self-limited.<ref>{{Cite journal
| author = [[Silviu Grisaru]]
| title = Management of hemolytic-uremic syndrome in children
| journal = [[International journal of nephrology and renovascular disease]]
| volume = 7
| pages = 231–239
| year = 2014
| month =
| doi = 10.2147/IJNRD.S41837
| pmid = 24966691
}}</ref> However any patient suspected of [[Hemolytic-uremic syndrome|HUS]] should be referred to a kidney center or [[nephrology]] unit or be managed in an [[Intensive care medicine|intensive care unit]].
*[[Antibiotic therapy]] is not  recommended among patients with E. coli O157:H7 infection. This increases the risk of [[Hemolytic-uremic syndrome|HUS]]. However there are some antibiotics that decrease the risk of [[Hemolytic-uremic syndrome|HUS]] such as [[quinolones]].<ref>{{Cite journal
  | author = [[C. S. Wong]], [[S. Jelacic]], [[R. L. Habeeb]], [[S. L. Watkins]] & [[P. I. Tarr]]
| title = The risk of the hemolytic-uremic syndrome after antibiotic treatment of Escherichia coli O157:H7 infections
| journal = [[The New England journal of medicine]]
| volume = 342
| issue = 26
| pages = 1930–1936
| year = 2000
| month = June
| doi = 10.1056/NEJM200006293422601
| pmid = 10874060
}}</ref><ref>{{Cite journal
| author = [[Nasia Safdar]], [[Adnan Said]], [[Ronald E. Gangnon]] & [[Dennis G. Maki]]
| title = Risk of hemolytic uremic syndrome after antibiotic treatment of Escherichia coli O157:H7 enteritis: a meta-analysis
| journal = [[JAMA]]
| volume = 288
| issue = 8
| pages = 996–1001
| year = 2002
| month = August
| pmid = 12190370
}}</ref><ref>{{Cite journal
| author = [[G. Z. Panos]], [[G. I. Betsi]] & [[M. E. Falagas]]
| title = Systematic review: are antibiotics detrimental or beneficial for the treatment of patients with Escherichia coli O157:H7 infection?
| journal = [[Alimentary pharmacology & therapeutics]]
| volume = 24
| issue = 5
| pages = 731–742
| year = 2006
| month = September
| doi = 10.1111/j.1365-2036.2006.03036.x
| pmid = 16918877
}}</ref><ref>{{Cite journal
| author = [[Paul N. Goldwater]] & [[Karl A. Bettelheim]]
| title = Treatment of enterohemorrhagic Escherichia coli (EHEC) infection and hemolytic uremic syndrome (HUS)
| journal = [[BMC medicine]]
| volume = 10
| pages = 12
| year = 2012
| month = February
| doi = 10.1186/1741-7015-10-12
| pmid = 22300510
}}</ref>
*Heparin, [[Antiplatelet drug|anti-platelet]] agents, [[immunoadsorption,]] [[thrombomodulin]] ([[rhTM]]).<ref>{{cite journal|doi=10.1097/INF.0b013e31823096a8.}}</ref>
*[[Fosfomycin]] should be started within 48-72 hours of the patient's presentation of HUS.<ref>{{Cite journal
| author = [[K. Ikeda]], [[O. Ida]], [[K. Kimoto]], [[T. Takatorige]], [[N. Nakanishi]] & [[K. Tatara]]
| title = Effect of early fosfomycin treatment on prevention of hemolytic uremic syndrome accompanying Escherichia coli O157:H7 infection
| journal = [[Clinical nephrology]]
| volume = 52
| issue = 6
| pages = 357–362
| year = 1999
| month = December
| pmid = 10604643
}}</ref>
*[[Empiric therapy|Empiric]] [[antibiotic]] [[therapy]] such as [[cephalosporins]] for invasive [[Pneumococcal infections|pneumococcal]] disease should be used following culture results.
*[[Recombinant]] [[human]] [[soluble]] [[thrombomodulin]] (rTM)<ref>{{Cite journal
| author = [[Yukihiko Kawasaki]], [[Kazuhide Suyama]], [[Atsushi Ono]], [[Tomoko Oikawa]], [[Shinichiro Ohara]], [[Yuichi Suzuki]], [[Nobuko Sakai]] & [[Mitsuaki Hosoya]]
| title = Efficacy of recombinant human soluble thrombomodulin for childhood hemolytic uremic syndrome
| journal = [[Pediatrics international : official journal of the Japan Pediatric Society]]
| volume = 55
| issue = 5
| pages = e139–e142
| year = 2013
| month = October
| doi = 10.1111/ped.12165
| pmid = 24134770
}}</ref> is a novel [[medicine]] that use to treat children with [[Hemolytic-uremic syndrome|HUS]].<ref name=":0">{{Cite journal
| author = [[Takashi Honda]], [[Shohei Ogata]], [[Eri Mineo]], [[Yukako Nagamori]], [[Shinya Nakamura]], [[Yuki Bando]] & [[Masahiro Ishii]]
| title = A novel strategy for hemolytic uremic syndrome: successful treatment with thrombomodulin alpha
| journal = [[Pediatrics]]
| volume = 131
| issue = 3
| pages = e928–e933
| year = 2013
| month = March
| doi = 10.1542/peds.2012-1466
| pmid = 23382444
}}</ref><ref>{{Cite journal
| author = [[Lindsay S. Keir]], [[Stephen D. Marks]] & [[Jon Jin Kim]]
| title = Shigatoxin-associated hemolytic uremic syndrome: current molecular mechanisms and future therapies
| journal = [[Drug design, development and therapy]]
| volume = 6
| pages = 195–208
| year = 2012
| month =
| doi = 10.2147/DDDT.S25757
| pmid = 22888220
}}</ref><ref>{{Cite journal
| author = [[Marina Noris]] & [[Giuseppe Remuzzi]]
| title = Hemolytic uremic syndrome
| journal = [[Journal of the American Society of Nephrology : JASN]]
| volume = 16
| issue = 4
| pages = 1035–1050
| year = 2005
| month = April
| doi = 10.1681/ASN.2004100861
| pmid = 15728781
}}</ref>
*[[Eculizumab]] is used to treat atypical [[Hemolytic-uremic syndrome|HUS]].<ref>{{Cite journal
| author = [[Rawaa Ebrahem]], [[Salam Kadhem]] & [[Quoc Truong]]
| title = Treatment of Atypical Hemolytic-Uremic Syndrome in the Era of Eculizumab
| journal = [[Cureus]]
| volume = 9
| issue = 3
| pages = e1111
| year = 2017
| month = March
| doi = 10.7759/cureus.1111
| pmid = 28439485
}}</ref>
===[[Hemolytic-uremic syndrome|HUS]]===


In severe cases or when there is diagnostic uncertainty between HUS and [[Thrombotic thrombocytopenic purpura|TTP]], [[plasmapheresis]] is the treatment of choice.
*  '''Acute kidney injury'''
**  First discontinue medicines that have [[renal]] [[toxicity]].<ref>{{Cite journal
| author = [[Mini Michael]], [[Elizabeth J. Elliott]], [[Jonathan C. Craig]], [[Greta Ridley]] & [[Elisabeth M. Hodson]]
| title = Interventions for hemolytic uremic syndrome and thrombotic thrombocytopenic purpura: a systematic review of randomized controlled trials
| journal = [[American journal of kidney diseases : the official journal of the National Kidney Foundation]]
| volume = 53
| issue = 2
| pages = 259–272
| year = 2009
| month = February
| doi = 10.1053/j.ajkd.2008.07.038
| pmid = 18950913
}}</ref>
**  Fluid replacement is the mainstay of treatment.<ref>{{Cite journal
| author = [[Mini Michael]], [[Elizabeth J. Elliott]], [[Greta F. Ridley]], [[Elisabeth M. Hodson]] & [[Jonathan C. Craig]]
| title = Interventions for haemolytic uraemic syndrome and thrombotic thrombocytopenic purpura
| journal = [[The Cochrane database of systematic reviews]]
| issue = 1
| pages = CD003595
| year = 2009
| month = January
| doi = 10.1002/14651858.CD003595.pub2
| pmid = 19160220
}}</ref>
**  Maintain adequate [[hydration]] and<nowiki/>  [[electrolyte]]<nowiki/>s during infection by ample fluid ther<nowiki/>apy effects on short and long-term disease outcomes.<ref>{{Cite journal
| author = [[Gianluigi Ardissino]], [[Francesca Tel]], [[Ilaria Possenti]], [[Sara Testa]], [[Dario Consonni]], [[Fabio Paglialonga]], [[Stefania Salardi]], [[Nicolo Borsa-Ghiringhelli]], [[Patrizia Salice]], [[Silvana Tedeschi]], [[Pierangela Castorina]], [[Rosaria Maria Colombo]], [[Milena Arghittu]], [[Laura Daprai]], [[Alice Monzani]], [[Rosangela Tozzoli]], [[Maurizio Brigotti]] & [[Erminio Torresani]]
| title = Early Volume Expansion and Outcomes of Hemolytic Uremic Syndrome
| journal = [[Pediatrics]]
| volume = 137
| issue = 1
| year = 2016
| month = January
| doi = 10.1542/peds.2015-2153
| pmid = 26644486
}}</ref>
**  Indications for [[dialysis]] in children with<nowiki/> [[Hemolytic-uremic syndrome|HUS]] are similar to those in children with other forms of [[acute kidney injury]] ([[Acute kidney injury|AKI]]).<ref>{{Cite journal
| author = [[Jennifer G. Jetton]], [[Louis J. Boohaker]], [[Sidharth K. Sethi]], [[Sanjay Wazir]], [[Smriti Rohatgi]], [[Danielle E. Soranno]], [[Aftab S. Chishti]], [[Robert Woroniecki]], [[Cherry Mammen]], [[Jonathan R. Swanson]], [[Shanty Sridhar]], [[Craig S. Wong]], [[Juan C. Kupferman]], [[Russell L. Griffin]] & [[David J. Askenazi]]
| title = Incidence and outcomes of neonatal acute kidney injury (AWAKEN): a multicentre, multinational, observational cohort study
| journal = [[The Lancet. Child & adolescent health]]
| volume = 1
| issue = 3
| pages = 184–194
| year = 2017
| month = November
| doi = 10.1016/S2352-4642(17)30069-X
| pmid = 29732396
}}</ref>
*  '''Anemia'''
**  Transfuse packed [[Red blood cell|red blood cells]]<nowiki/>[[Red blood cell|ls]] ([[RBC]]):<ref>{{Cite journal
| author = [[J. R. Brandt]], [[L. S. Fouser]], [[S. L. Watkins]], [[I. Zelikovic]], [[P. I. Tarr]], [[V. Nazar-Stewart]] & [[E. D. Avner]]
| title = Escherichia coli O 157:H7-associated hemolytic-uremic syndrome after ingestion of contaminated hamburgers
| journal = [[The Journal of pediatrics]]
| volume = 125
| issue = 4
| pages = 519–526
| year = 1994
| month = October
| pmid = 7931869
}}</ref>
***  Hemoglobin <6 g/dL
***  Hematocrit < 18
**  Transfusion should be done slowly and patients should be obsereved close<nowiki/>ly.
**  Monitor the plasma [[potassium]] to prevent [[hyperkalemia]].
**  Maintain a goal Hgb level after transfiution of between 8-9 g/dL<nowiki/>.
**  Do no<nowiki/>t try to normalize the hemoglobin as it may lead to heart failur<nowiki/>e, [[pulmonary edema]] and<nowiki/> [[hypertension]] due to <nowiki/>volume overload.<ref>{{Cite journal
| author = [[B. S. Kaplan]], [[P. D. Thomson]] & [[J. P. de Chadarevian]]
| title = The hemolytic uremic syndrome
| journal = [[Pediatric clinics of North America]]
| volume = 23
| issue = 4
| pages = 761–777
| year = 1976
| month = November
| pmid = 792781
}}</ref>
**  Patients who undergo hemodialysis, [[transfusions]] sh<nowiki/>ould be given during [[dialysis]] to minimize the risks of [[hypervolemia]]<nowiki/> and [[hyperkalemia]].<ref>{{Cite journal
| author = [[Hoon Young Choi]] & [[Sung Kyu Ha]]
| title = Potassium balances in maintenance hemodialysis
| journal = [[Electrolyte & blood pressure : E & BP]]
| volume = 11
| issue = 1
| pages = 9–16
| year = 2013
| month = June
| doi = 10.5049/EBP.2013.11.1.9
| pmid = 23946760
}}</ref>
*  '''Thrombocytopenia'''
** Patients w<nowiki/>ith [[Hemolytic-uremic syndrome|HUS]] who are noted to have significant clinical [[bleeding]] or who require an [[Invasive (medical)|invasive]] [[procedure]] should receive [[platelet]] [[transfusions]]<ref>{{Cite journal
| author = [[Phillip I. Tarr]], [[Carrie A. Gordon]] & [[Wayne L. Chandler]]
| title = Shiga-toxin-producing Escherichia coli and haemolytic uraemic syndrome
| journal = [[Lancet (London, England)]]
| volume = 365
| issue = 9464
| pages = 1073–1086
| year = 2005
| month = March
| doi = 10.1016/S0140-6736(05)71144-2
| pmid = 15781103
}}</ref>


Antibiotic treatment of O157:H7 colitis may stimulate further verotoxin production and thereby increase the risk of HUS.<ref>http://www.emedicine.com/EMERG/topic238.htm</ref>  
* '''Hypertension'''
** At the first [[Indication (medicine)|indication]] of [[hypertension]] [[Fluid|fluids]] should be restricted. [[Dialysis]] is more effective than [[Diuretic|diuretics]].
** [[Calcium channel blocker|Calcium channel blockers]] should be used as the initial choice of [[antihypertensive agents]] and after this phase [[antihypertensive therapy]] should be changed to [[ACE inhibitor|ACE inhibitors]] in patients who appear to have long-term renal [[sequelae]].<ref>{{Cite journal
  | author = [[Phillip I. Tarr]], [[Carrie A. Gordon]] & [[Wayne L. Chandler]]
  | title = Shiga-toxin-producing Escherichia coli and haemolytic uraemic syndrome
  | journal = [[Lancet (London, England)]]
  | volume = 365
  | issue = 9464
  | pages = 1073–1086
  | year = 2005
  | month = March
  | doi = 10.1016/S0140-6736(05)71144-2
  | pmid = 15781103
  }}</ref>
 
*  '''[[Neurologic dysfunction]]'''
** Patients with serious [[neurologic]] [[dysfunction]] should undergo brain [[imaging]] performed to assess [[CNS]] involvement.<ref>{{Cite journal
| author = [[Andreas Greinacher]], [[Sigrun Friesecke]], [[Peter Abel]], [[Alexander Dressel]], [[Sylvia Stracke]], [[Michael Fiene]], [[Friedlinde Ernst]], [[Kathleen Selleng]], [[Karin Weissenborn]], [[Bernhard M. W. Schmidt]], [[Mario Schiffer]], [[Stephan B. Felix]], [[Markus M. Lerch]], [[Jan T. Kielstein]] & [[Julia Mayerle]]
| title = Treatment of severe neurological deficits with IgG depletion through immunoadsorption in patients with Escherichia coli O104:H4-associated haemolytic uraemic syndrome: a prospective trial
| journal = [[Lancet (London, England)]]
| volume = 378
| issue = 9797
| pages = 1166–1173
| year = 2011
| month = September
| doi = 10.1016/S0140-6736(11)61253-1
| pmid = 21890192
}}</ref>[[Seizure|Seizures]] are treated with [[Antiepileptic drugs|antiepileptic agents]].<ref>{{Cite journal
| author = [[Mini Michael]], [[Elizabeth J. Elliott]], [[Greta F. Ridley]], [[Elisabeth M. Hodson]] & [[Jonathan C. Craig]]
| title = Interventions for haemolytic uraemic syndrome and thrombotic thrombocytopenic purpura
| journal = [[The Cochrane database of systematic reviews]]
| issue = 1
| pages = CD003595
| year = 2009
| month = January
| doi = 10.1002/14651858.CD003595.pub2
| pmid = 19160220
}}</ref>


:*Plasma exchange daily until LDH normal and platelets stable
:*Renal pathology may not entirely resolve (no data on continued plasma exchange after platelets and markers of hemolysis have resolved)
:*Average 7-16 exchanges required to induce remission
:*Caution plasmapheresis-associated thrombocytopenia (more with certain instruments)
:*Cryopoor plasma exchange not better than regular FFP
==References==
==References==
{{reflist|2}}
{{Reflist|2}}
 
{{WH}}
{{WH}}
{{WS}}
{{WS}}
[[Category:Disease]]
 
[[Category:Nephrology]]
[[Category:Nephrology]]
[[Category:Hematology]]
[[Category:Hematology]]
[[Category:Mature chapter]]
[[Category:Syndromes]]

Latest revision as of 02:35, 21 December 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sogand Goudarzi, MD [2]

Overview

The mainstay of therapy for hemolytic uremic syndrome (HUS) is supportive therapy. Antibiotic therapy is not recommended among patients with HUS. Hydration and intravenous (IV) isotonic saline replacment decrease the risk of hemolytic-uremic syndrome (HUS). Patients with HUS who have significant clinical bleeding or who require an invasive procedure should receive platelet transfusions.

Medical Therapy

HUS

References

  1. ↑ Silviu Grisaru (2014). "Management of hemolytic-uremic syndrome in children". International journal of nephrology and renovascular disease. 7: 231–239. doi:10.2147/IJNRD.S41837. PMID 24966691.
  2. ↑ C. S. Wong, S. Jelacic, R. L. Habeeb, S. L. Watkins & P. I. Tarr (2000). "The risk of the hemolytic-uremic syndrome after antibiotic treatment of Escherichia coli O157:H7 infections". The New England journal of medicine. 342 (26): 1930–1936. doi:10.1056/NEJM200006293422601. PMID 10874060. Unknown parameter |month= ignored (help)
  3. ↑ Nasia Safdar, Adnan Said, Ronald E. Gangnon & Dennis G. Maki (2002). "Risk of hemolytic uremic syndrome after antibiotic treatment of Escherichia coli O157:H7 enteritis: a meta-analysis". JAMA. 288 (8): 996–1001. PMID 12190370. Unknown parameter |month= ignored (help)
  4. ↑ G. Z. Panos, G. I. Betsi & M. E. Falagas (2006). "Systematic review: are antibiotics detrimental or beneficial for the treatment of patients with Escherichia coli O157:H7 infection?". Alimentary pharmacology & therapeutics. 24 (5): 731–742. doi:10.1111/j.1365-2036.2006.03036.x. PMID 16918877. Unknown parameter |month= ignored (help)
  5. ↑ Paul N. Goldwater & Karl A. Bettelheim (2012). "Treatment of enterohemorrhagic Escherichia coli (EHEC) infection and hemolytic uremic syndrome (HUS)". BMC medicine. 10: 12. doi:10.1186/1741-7015-10-12. PMID 22300510. Unknown parameter |month= ignored (help)
  6. ↑ . doi:10.1097/INF.0b013e31823096a8. Check |doi= value (help). Missing or empty |title= (help)
  7. ↑ K. Ikeda, O. Ida, K. Kimoto, T. Takatorige, N. Nakanishi & K. Tatara (1999). "Effect of early fosfomycin treatment on prevention of hemolytic uremic syndrome accompanying Escherichia coli O157:H7 infection". Clinical nephrology. 52 (6): 357–362. PMID 10604643. Unknown parameter |month= ignored (help)
  8. ↑ Yukihiko Kawasaki, Kazuhide Suyama, Atsushi Ono, Tomoko Oikawa, Shinichiro Ohara, Yuichi Suzuki, Nobuko Sakai & Mitsuaki Hosoya (2013). "Efficacy of recombinant human soluble thrombomodulin for childhood hemolytic uremic syndrome". Pediatrics international : official journal of the Japan Pediatric Society. 55 (5): e139–e142. doi:10.1111/ped.12165. PMID 24134770. Unknown parameter |month= ignored (help)
  9. ↑ Takashi Honda, Shohei Ogata, Eri Mineo, Yukako Nagamori, Shinya Nakamura, Yuki Bando & Masahiro Ishii (2013). "A novel strategy for hemolytic uremic syndrome: successful treatment with thrombomodulin alpha". Pediatrics. 131 (3): e928–e933. doi:10.1542/peds.2012-1466. PMID 23382444. Unknown parameter |month= ignored (help)
  10. ↑ Lindsay S. Keir, Stephen D. Marks & Jon Jin Kim (2012). "Shigatoxin-associated hemolytic uremic syndrome: current molecular mechanisms and future therapies". Drug design, development and therapy. 6: 195–208. doi:10.2147/DDDT.S25757. PMID 22888220.
  11. ↑ Marina Noris & Giuseppe Remuzzi (2005). "Hemolytic uremic syndrome". Journal of the American Society of Nephrology : JASN. 16 (4): 1035–1050. doi:10.1681/ASN.2004100861. PMID 15728781. Unknown parameter |month= ignored (help)
  12. ↑ Rawaa Ebrahem, Salam Kadhem & Quoc Truong (2017). "Treatment of Atypical Hemolytic-Uremic Syndrome in the Era of Eculizumab". Cureus. 9 (3): e1111. doi:10.7759/cureus.1111. PMID 28439485. Unknown parameter |month= ignored (help)
  13. ↑ Mini Michael, Elizabeth J. Elliott, Jonathan C. Craig, Greta Ridley & Elisabeth M. Hodson (2009). "Interventions for hemolytic uremic syndrome and thrombotic thrombocytopenic purpura: a systematic review of randomized controlled trials". American journal of kidney diseases : the official journal of the National Kidney Foundation. 53 (2): 259–272. doi:10.1053/j.ajkd.2008.07.038. PMID 18950913. Unknown parameter |month= ignored (help)
  14. ↑ Mini Michael, Elizabeth J. Elliott, Greta F. Ridley, Elisabeth M. Hodson & Jonathan C. Craig (2009). "Interventions for haemolytic uraemic syndrome and thrombotic thrombocytopenic purpura". The Cochrane database of systematic reviews (1): CD003595. doi:10.1002/14651858.CD003595.pub2. PMID 19160220. Unknown parameter |month= ignored (help)
  15. ↑ Gianluigi Ardissino, Francesca Tel, Ilaria Possenti, Sara Testa, Dario Consonni, Fabio Paglialonga, Stefania Salardi, Nicolo Borsa-Ghiringhelli, Patrizia Salice, Silvana Tedeschi, Pierangela Castorina, Rosaria Maria Colombo, Milena Arghittu, Laura Daprai, Alice Monzani, Rosangela Tozzoli, Maurizio Brigotti & Erminio Torresani (2016). "Early Volume Expansion and Outcomes of Hemolytic Uremic Syndrome". Pediatrics. 137 (1). doi:10.1542/peds.2015-2153. PMID 26644486. Unknown parameter |month= ignored (help)
  16. ↑ Jennifer G. Jetton, Louis J. Boohaker, Sidharth K. Sethi, Sanjay Wazir, Smriti Rohatgi, Danielle E. Soranno, Aftab S. Chishti, Robert Woroniecki, Cherry Mammen, Jonathan R. Swanson, Shanty Sridhar, Craig S. Wong, Juan C. Kupferman, Russell L. Griffin & David J. Askenazi (2017). "Incidence and outcomes of neonatal acute kidney injury (AWAKEN): a multicentre, multinational, observational cohort study". The Lancet. Child & adolescent health. 1 (3): 184–194. doi:10.1016/S2352-4642(17)30069-X. PMID 29732396. Unknown parameter |month= ignored (help)
  17. ↑ J. R. Brandt, L. S. Fouser, S. L. Watkins, I. Zelikovic, P. I. Tarr, V. Nazar-Stewart & E. D. Avner (1994). "Escherichia coli O 157:H7-associated hemolytic-uremic syndrome after ingestion of contaminated hamburgers". The Journal of pediatrics. 125 (4): 519–526. PMID 7931869. Unknown parameter |month= ignored (help)
  18. ↑ B. S. Kaplan, P. D. Thomson & J. P. de Chadarevian (1976). "The hemolytic uremic syndrome". Pediatric clinics of North America. 23 (4): 761–777. PMID 792781. Unknown parameter |month= ignored (help)
  19. ↑ Hoon Young Choi & Sung Kyu Ha (2013). "Potassium balances in maintenance hemodialysis". Electrolyte & blood pressure : E & BP. 11 (1): 9–16. doi:10.5049/EBP.2013.11.1.9. PMID 23946760. Unknown parameter |month= ignored (help)
  20. ↑ Phillip I. Tarr, Carrie A. Gordon & Wayne L. Chandler (2005). "Shiga-toxin-producing Escherichia coli and haemolytic uraemic syndrome". Lancet (London, England). 365 (9464): 1073–1086. doi:10.1016/S0140-6736(05)71144-2. PMID 15781103. Unknown parameter |month= ignored (help)
  21. ↑ Phillip I. Tarr, Carrie A. Gordon & Wayne L. Chandler (2005). "Shiga-toxin-producing Escherichia coli and haemolytic uraemic syndrome". Lancet (London, England). 365 (9464): 1073–1086. doi:10.1016/S0140-6736(05)71144-2. PMID 15781103. Unknown parameter |month= ignored (help)
  22. ↑ Andreas Greinacher, Sigrun Friesecke, Peter Abel, Alexander Dressel, Sylvia Stracke, Michael Fiene, Friedlinde Ernst, Kathleen Selleng, Karin Weissenborn, Bernhard M. W. Schmidt, Mario Schiffer, Stephan B. Felix, Markus M. Lerch, Jan T. Kielstein & Julia Mayerle (2011). "Treatment of severe neurological deficits with IgG depletion through immunoadsorption in patients with Escherichia coli O104:H4-associated haemolytic uraemic syndrome: a prospective trial". Lancet (London, England). 378 (9797): 1166–1173. doi:10.1016/S0140-6736(11)61253-1. PMID 21890192. Unknown parameter |month= ignored (help)
  23. ↑ Mini Michael, Elizabeth J. Elliott, Greta F. Ridley, Elisabeth M. Hodson & Jonathan C. Craig (2009). "Interventions for haemolytic uraemic syndrome and thrombotic thrombocytopenic purpura". The Cochrane database of systematic reviews (1): CD003595. doi:10.1002/14651858.CD003595.pub2. PMID 19160220. Unknown parameter |month= ignored (help)

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