Targeting kidney injury, fluid loss, and electrolytes may reduce Ebola deaths

Last Updated: 2015-08-21

By Joan Stephenson PhD

NEW YORK (Reuters Health) - Patients with Ebola virus disease have more extensive kidney damage and electrolyte imbalance even in early stages of the illness than previously recognized, according to research conducted in Sierra Leone.

However, addressing these problems through aggressive management of hypovolemia with intravenous fluid and targeted electrolyte support is likely to reduce deaths, researchers reported.

The observational cohort study included 118 evaluable patients (mean age 26) admitted to the Kerry Town Ebola treatment center between December 8, 2014, and January 9, 2015. Only patients with Ebola virus disease previously confirmed at other centers and who had blood results within 24 hours of admission were included.

At admission, researchers documented each patient's clinical presentation and collected blood samples for reverse-transcriptase-polymerase chain reaction (RT-PCR) confirmation of the diagnosis and for hematological and biochemical analysis in an on-site laboratory. Primary outcome was discharge from the center, which is operated by Save the Children International.

"Previously, treatment has been quite basic, including oral rehydration and pain management," lead author Dr. Luke Hunt, of Save the Children International, told Reuters Health by email. "We wanted to see if there was a role for more advanced supportive care, including intravenous fluid therapy and measurement of electrolytes."

About 35% of the patients died (41 of 118), noted the researchers in a report online August 11 in The Lancet Infectious Diseases.

Most of the patients (71%) presented with stage 2 disease (featuring diarrhea, and/or vomiting or abdominal pain) or stage 3 disease (which also includes hemorrhage, shock, neurological involvement, or signs of organ failure).

About 59% of the patients had severe hepatitis and 50% had acute kidney injury. Incidence of kidney failure did not differ significantly by clinical stage; 29% (9 of 31) of patients admitted with stage 1 disease had kidney failure.

About 33% had abnormal serum potassium and 21% had increased C-reactive protein levels. Hematological abnormalities included thrombocytopenia in 45% of patients, granulocytosis in 42%, and raised hematocrit in 15%.

Multivariate analysis indicated that the strongest risk factors for mortality include low RT-PCR cycle threshold (indicating a high viral load) and severe acute kidney injury, with odds ratios of 6.72 (p=0.013) and 5.84 (p=0.033), respectively.

"We were surprised to see how common kidney failure was in these patients, occurring in over 50% of cases," said Dr. Hunt. "Previously, this was thought to be due to dehydration, though our results indicate that the virus may cause direct damage to the kidneys."

In an accompanying editorial, Dr. John S. Schieffelin, of Tulane University School of Medicine in New Orleans, and Dr. Shevin T. Jacob, of the University of Washington in Seattle, wrote the researchers' finding that as many patients had hyperkalemia as hypokalemia suggests that electrolyte replacement "should not be approached with a one-size-fits-all algorithm."

Being able "to monitor electrolytes and other laboratory tests is crucial to being able to provide safe and effective care of all patients with Ebola in an Ebola treatment center," they noted.

"The study adds significant information to the knowledge base of how to treat Ebola patients," Dr. Amesh Adalja, a spokesperson for the Infectious Diseases Society of America, told Reuters health by email.

"The most important finding is that acute kidney injury, which is potentially preventable through aggressive supportive care, is a major driver of death," Dr. Adalja said. "This finding should change practice, providing more rationale for emphasizing that as simple an intervention as fluid resuscitation be started promptly to forestall the development of kidney injury."

The authors declared no competing interests.

SOURCE: http://bit.ly/1IYAgqU and http://bit.ly/1EDMSTt

Lancet Infect Dis 2015