Hemorrhagic Fever With Renal Failure Syndrome Treatment & Management

Treatment depends on the stage of the disease and on the patient's hydration status and hemodynamic condition. The most essential step in managing hemorrhagic fever with renal failure syndrome (HFRS) is maintaining the patient's circulatory and hemodynamic status.

During active illness, maintaining fluid and electrolyte balance is mandatory. Early and effective fluid therapy is the cornerstone of managing renal failure. Most patients recover with supportive care. The indications for various medications are based on the patient's specific requirements during the different stages of the disease process.

The use of vasoactive agents and intravenous albumin during periods of shock is helpful. Excessive administration of fluids can lead to extravasation caused by capillary leak, especially during the febrile and hypotensive stages.

Consider the use of diuretics, such as furosemide, when the patient has volume overload and oliguria. Consider renal replacement therapy if the patient has no response to diuretics and if he or she has other features, such as fluid overload, hyperkalemia, and acidosis that increases azotemia and is associated with oliguria or anuria.

The possibility of the sudden appearance of life-threatening GI bleeding is always present. In that case, blood transfusions and the use of H₂ receptor antagonists are indicated as general emergency procedures. In the case of disseminated intravascular coagulation (DIC), fresh plasma infusions, plasma exchange treatment, or both are administered but are not always effective.

Results of one prospective placebo-controlled trial suggested that intravenous ribavirin decreased the severity and mortality of hemorrhagic fever with renal failure syndrome in China. ^[15] In contrast, 30 patients with Hantavirus pulmonary syndrome (HPS) who received investigational open-label intravenous ribavirin tolerated it well. Furthermore, treatment was accompanied by drug-induced anemia, which required transfusion, and no clear evidence of benefit was obtained. Differences in dosing schedules did not account for the contrasting responses, and the rapidity with which the disease progressed may have cause the lack of response in the patients with HPS.

Ribavirin is not approved for intravenous use in the United States, pending further ongoing studies. If ribavirin is used during the early part (febrile phase) of the illness, it reduces viremia and the severity of the illness. Ribavirin has been used in two outbreaks of HPS in the United States, but in both trials it did not improve outcome since patients were enrolled at advanced stages of cardiopulmonary edema by the time treatment was initiated. ^{[16, 17]}

Antihypertensives are indicated in patients with hypertension, which is usually present during the oliguric phase of the illness.

Dialysis is indicated if the patient has prolonged oliguria with no response to medical treatment and if renal failure is rapid deteriorating with worsening fluid and electrolyte abnormalities.

If the clinical presentation involves extravasation of plasma in the abdomen (suggestive of acute abdomen and subsequent development of paralytic ileus), the patient probably needs surgical evaluation and, occasionally, exploratory laparotomy. Renal rupture, which rarely occurs, requires surgical management.

A pediatric nephrologist should perform renal biopsy, if indicated, after taking all precautions. The patient's hemodynamic status and coagulation status should be stable before the biopsy is performed.

Consultation with the following specialists are indicated as needed:

• Pediatric nephrologist

• Pediatric infectious disease specialist

• Pediatric critical care specialist

• Pediatric surgeon

Diet

A low-sodium diet with restriction of fluid during the oliguric phase, followed by liberal intake of fluid in the diuretic phase, is recommended.

Activity

Bed rest during the acute phase of the illness is recommended.

Further outpatient care

Recovery takes 0-3 months from the acute phase of the illness, usually beginning in the middle of the second week. The diuretic phase may last from a few days to weeks, and close monitoring for electrolyte imbalances and signs of dehydration is needed. Patient education regarding electrolyte imbalances and signs of dehydration is imperative. Follow-up care is needed as often as warranted.

The convalescent phase lasts for 3-6 months. Glomerular clearances usually normalize, and the concentration ability of the renal tubules steadily improves. Follow-up should be conducted on a weekly basis, until the clearance normalizes, and then on a monthly basis.

Long-term follow-up care is important, especially because hypertension and proteinuria have been reported on long-term follow-up.

Patients with hypertension, residual neurologic defects, concentration defects in the renal tubules, or persistent proteinuria should be followed on a regular basis.

Further inpatient care

Patients with hemorrhagic fever with renal failure syndrome (HFRS) who have established oliguric renal failure must be carefully monitored for water, electrolyte, and acid-base imbalance, which must be promptly corrected. Vasoactive agents should be used in patients with shock after correction of volume deficit. In cases with pulmonary edema, the use of forced diuresis by administration of furosemide, vigorous ultrafiltration, or continuous arteriovenous hemofiltration can be lifesaving.

Transfer

Early referral to a tertiary center is essential to prevent complications and decrease morbidity and mortality.

Human habits can increase incidence of the disease; hence, basic preventive measures are required, including the following:

• Proper storing of food and avoiding contamination by rats

• Taking precautions during work or travel in farms contaminated with rodents

• Avoiding camping in grain fields

• Avoiding stocking straw stacks outside houses

• Avoiding sleeping outside homes

The development of an inexpensive, safe, efficacious, and multivalent vaccine against this group of viruses will be the most effective form of prevention in endemic regions. However, the high genetic and antigenic diversity of the pathogenic hantaviruses, coupled with the sporadic nature of the disease outbreaks, pose considerable challenges for the development of effective preventative vaccines.