1. Fluid overload that is refractory to medical therapy and is associated with heart failure or severe hypertension.
2. Hyperkalemia or metabolic acidosis that is refractory to medical management.
3. Severe hyponatremia or hypernatremia that cannot be corrected medically.
4. Symptomatic uremia (drowsiness, nausea and vomiting, irritability) usually seen as BUN exceeds 100 and approaches 150 mg/dL or is rapidly rising at > 30 mg/dL/day.
5. Supportive dialysis for fluid removal to allow adequate nutritional support.
VI. Problem Case Diagnosis. The previously healthy 2-year-old boy had visited a petting zoo 1 week before becoming ill. On admission, he was irritable with hepatosplenomegaly and petechiae. CBC was remarkable for hemoglobin of 8.2 g/dL and platelet count of 50,000/mm3. Urinalysis was positive for blood and protein. E coli O157:H7 was isolated from the heme-positive stool. The child was diagnosed with HUS (acute renal failure, hemolytic anemia, and thrombocytopenia).
VII. Teaching Pearl: Question. What additional organ system may be involved in HUS?
VIII. Teaching Pearl: Answer. CNS is involved in 20-30% of patients with HUS, causing stupor, seizures, cerebral infarct, or coma. Pancreatic insufficiency, myocarditis, and cardiomyopathy can also occur.
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