Hemorrhagic Fever With Renal Failure Syndrome Treatment & Management

Updated: Oct 04, 2018
  • Author: Rajendra Bhimma, MBChB, MD, PhD, DCH (SA), FCP(Paeds)(SA), MMed(Natal); Chief Editor: Craig B Langman, MD  more...
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Treatment

Medical Care

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. [10] 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. [11, 12]

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.

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Surgical Care

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.

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Consultations

Consultation with the following specialists are indicated as needed:

  • Pediatric nephrologist

  • Pediatric infectious disease specialist

  • Pediatric critical care specialist

  • Pediatric surgeon

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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.

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Activity

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

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