H7N9 kills and attacks kidneys

By John Pickering 24/05/2013 10


27% of patients with H7N9 Influenza A died.  This is the finding of a report just released  in the New England Journal of Medicine is a study of 111 of the 132 confirmed cases of H7N9 Influenza A*.

Acute Kidney Injury or “Kidney Attack” was amongst the most common complications.

Of the 111 patients we evaluated, 85 (76.6%) were admitted to an intensive care unit (ICU); of these patients, 54 were directly admitted to the ICU, and 31 were admitted during hospitalization. Moderate-to-severe ARDS [Acute Respiratory Disease Syndrome] was the most common complication (in 79 patients), followed by shock (in 29 patients), acute kidney injury (in 18 patients), and rhabdomyolysis (in 11 patients).

In an analysis in the Appendix to the paper a comparison was made between the 30 patients who had died and 49 who had recovered (others were still in hospital).  100% of those who died had had ARDS compared with 40% of those who recovered.  One third of those who died had Acute Kidney Injury compared with 4% of those who recovered.  From a statistical perspective these numbers illustrate a real difference with a low probability (~ 1-2 out of 1000) of observing such a difference by chance.**

Note, all patients had been in close contact withe live chickens or pigeons within 2 weeks of hospitalisaton.

NEJM 23 May 2013

NEJM 23 May 2013

* Clinical Findings in 111 Cases of Influenza A (H7N9) Virus Infection

Hai-Nv Gao, M.D., Hong-Zhou Lu, M.D., Ph.D., Bin Cao, M.D., Bin Du, M.D., Hong Shang, M.D., Jian-He Gan, M.D., Shui-Hua Lu, M.D., Yi-Da Yang, M.D., Qiang Fang, M.D., Yin-Zhong Shen, M.D., Xiu-Ming Xi, M.D., Qin Gu, M.D., Xian-Mei Zhou, M.D., Hong-Ping Qu, M.D., Zheng Yan, M.D., Fang-Ming Li, M.D., Wei Zhao, M.D., Zhan-Cheng Gao, M.D., Guang-Fa Wang, M.D., Ling-Xiang Ruan, M.D., Wei-Hong Wang, M.D., Jun Ye, M.D., Hui-Fang Cao, M.D., Xing-Wang Li, M.D., Wen-Hong Zhang, M.D., Xu-Chen Fang, M.D., Jian He, M.D., Wei-Feng Liang, M.D., Juan Xie, M.D., Mei Zeng, M.D., Xian-Zheng Wu, M.D., Jun Li, M.D., Qi Xia, M.D., Zhao-Chen Jin, M.D., Qi Chen, M.D., Chao Tang, M.D., Zhi-Yong Zhang, M.D., Bao-Min Hou, M.D., Zhi-Xian Feng, M.D., Ji-Fang Sheng, M.D., Nan-Shan Zhong, M.D., and Lan-Juan Li, M.D.New England Journal of Medicine Online May 22, 2013 DOI: 10.1056/NEJMoa1305584

** something called a multivariate analysis was attempted which trys to take into account correlations between diseases to see which diseases are the major factors.  However, with “only” 30 deaths such an analysis is very limited and I do not think of value in this situation.

Tagged: Acute Kidney Injury, Acute Respiratory Disease Syndrome, AKI, ARDS, Avian influenza, H7N9, Kidney Attack, new england journal of medicine


10 Responses to “H7N9 kills and attacks kidneys”

  • Im guessing here that the doctors in China havent heard about the Allan Smith ,swine flu and mega dose iv vitamin c case. This would have been an ideal time to try as with a 27% death rate orthadox medicine didnt fair to well.However without jumping to conclusions maybe they did try it and it didnt work. I would very much doubt that though. It seems nothing has changed here in NZ as the doctors still have this atitude that they will not give iv vitamin c to paitents for what ever reason. I presume it must be better for the paitent to die then to be injected with an inexpensive vitamin.

  • Hello James, thanks for the comment. A few brief points.
    1. H7N9 is not the same as “Swine flu” (H1N1)
    2. If left untreated – or treated by “back street” Chinese medicinal herbs we do not know what the death rate would be. It may have been much much greater than 27%. However, I agree with the sentiment that 27% is too high and like you I want solutions.
    3. Large doses of antioxidants are regularly used in intensive care units for a variety of conditions (N-acetylcysteine, for example, being one of the most common). Doctors are not afraid to use them. They just do so when their is evidence that they are more likely to do good then harm.
    4. When A (recovery) follows B (dose of something, procedure) it is a starting point for research not for wholesale treatment. Other things happened to Allan Smith other than vitamin C. Eg, moving a patient in the bed can occasionally have a dramatic effect on recovery (or the opposite). I understand this happened to Allan Smith at the same time he received vit C. Unless research is done, we don’t know if moving or Vit C or something else or nothing at all helped him recover. Try this experiment at home… next time you have a cold, drink a glass of warm milk every morning for a week. I can all but guarantee you will get better. Is it because of the milk? Probably not – you were probably going to get better anyway. This is called “regression to the mean.” Research is needed to find out what really works and what is just a random effect.
    5. Sometimes “good ideas” do work, more often then don’t, and occasionally they cause harm. For example, in the ICU patients receive a lot of fluids when they come into ICU. One of the “good ideas” driving this is that it ensures more flow of blood through the kidneys. Recent evidence, including a little of my own research, suggests that quite a few patients receive so much fluid that it causes harm (greater mortality rate in those with high fluid intake). It is a long and complicated process to try and distinguish it this is really the case or if just the “sicker” patients receive more fluid and are more likely to die anyway. Nothing is simple or straightforward in the ICU.
    6. Finally, please do not suggest “it must be better for a patient to die than …”. This is very dishonoring to the thousands of medical practitioners who work their butts off trying to save lives using the very best evidence based medicine they can get their hands on. No way, will they get it right every time, but I know these people well enough to know that they always put the best interests of the patient first.

  • Hi john , some interesting points you made.
    I agree that H1N1 and H7N9 are not the same virus however for a few people the end result is the same ie death. From which i would say is caused by an acute state of scurvy, this could be confirmed with a blood test.
    In the point of dishonoring doctors that was not my intent as there are some exellent doctors working hard to save lives. However from what i have heard Auckland hospital still will not under any circumstance administer vitamin c . Even when there is nothing to lose, ie better off to let the paitent die.
    In the case of Allan Smith yes he was moved or (proned) at the same time as vitamin c was administerd, however after a week on the vitamin c and recoverying a new consultant decided that he didnt believe in the treament and stopped it. From that point on Allan Smith again deteriorated and no amount of proning did any good. It was until a fight from the family to reinstate the vitamin c did Allan then again start to recover. This then happined again when he was taken to waikato hospital. Vitamin c stopped. Again it was the adimistration of vitamin c to treatment he was already getting that put him back on the road to recovery. Not once but three times vitamin c made the difference. The following year the same thing happined to a young Australian women, on ECMO with infected lungs. The hospital was persuaded to give vitamin c and she as allan recovered to the point of being taken off ECMO. This time however the doctors convinced the mother to stop the vitamin c and within a few days she died. I understand nothing is simple or straightforward in the icu however nothin seems to have been learned from this either. How would you feel if your mother, daughter , son etc was in the same situation as Allan Smith . Turn off life support or push for a vitamin that could make the difference between life or death. At this point in time with the Auckland hospitals atitude about vitamin c your loved one would die. ( i truly hope no one ever has to go threw that )
    The evidence is there that shows even small amounts of vitamin c in critical paitents given IV can have a life saving effect.
    http://www.ncbi.nlm.nih.gov/pubmed/17182364
    http://www.ncbi.nlm.nih.gov/pubmed/20689415
    http://www.ncbi.nlm.nih.gov/pubmed/17713412
    I see also vitamin c Study Finds Vitamin C Can Kill Drug-Resistant TB http://www.einstein.yu.edu/news/releases/907/study-finds-vitamin-c-can-kill-drug-resistant-tb/
    For the Auckland hospital to say there is absolutley no evidence that vitamin c does any good is beyond belief in my book

  • “From which i would say is caused by an acute state of scurvy”

    Why? In many fatal cases of H1N1, for example, patients’ deaths have been attributed to what’s known as a cytokine storm (http://www.jidc.org/index.php/journal/article/viewArticle/18/8). Onset is rapid. This is not typical of severe scurvy, which takes around 3 months to develop (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2567249/).

    (Evidence in your first link appears to be from in vitro studies; this is not the same as trials in human patients.)

  • James – from my blog, might be of interest: Reviews & IV vitamin C as treatment for severe pneumonia. BTW, the abstract of your second link suggests that research nothing to do with IV treatments as such. (It leads me to wonder if you’re presenting things you think support IV vitamin C, perhaps copied from a website, without understanding what the research is about.)

    Case examples (like you offer) can’t draw the very firm, generalised conclusions of the kind you present because they can’t control for other things that may have contributed.

    John – I thought to write a short post around that cartoon as media stories on cancer “cures” that prove to be in-vitro claims are a pet peeve of mine. It’s good, eh?

  • Severe scurvy and acute scurvy at the end of the day will end with the same result if not treated. Acute scurvy happens rapidly, the more sick you become the more depleted your vitamin c levels become.
    http://www.ncbi.nlm.nih.gov/pubmed/8625625
    Vitamin c is now a registered drug in Newzealand to treat vitamin c deficiency. This happins to paitents in ICU. The links above are not about clinical trials but to show the importance of vitamin c in the criticaly ill.
    Hospitals should be checking paitents in ICU and treating them as needed.
    As i said before even small doses help with colds and flu
    http://www.ncbi.nlm.nih.gov/pubmed?orig_db=PubMed&term=The+effectiveness+of+vitamin+C+in+preventing+and+relieving+the+symptoms+of+virus-induced+respiratory+infection&cmd=search&cmd_current=

  • Hi James
    Patients do receive Vitamin C in the ICU. Providing appropriate nutritional support is very important and very tricky. It is the subject of many studies. Here is a recent overview of what is provided in NZ: http://www.cicm.org.au/journal/2012/june/ccr_14_2_010612-148.pdf
    The nutritional support given contains vitamin C. Eg, the most common nutritional formulation given “Jevity” contains has a Vit C content of 120% the Recommended Daily Dose in just one serving: http://abbottnutrition.com/brands/products/jevity-1-cal

  • James, you need to distinguish people needing a substance to cope with a deficiency, or a demand for the substance—e.g. the nutritional support John referred to—and the substance being used as a treatment (i.e. when the substance is being used effectively as a drug).

  • The nutritional support in the ICU in regards to vitamin c content maybe ok (or not) for the average healthy people , however this small amount would be used by the body in less than 10 min. As i have said before this can be confirmed with a blood test. The links i have posted have stated this , in one it says that it can take a !000mg a day for a month threw IV before the paitents levels to get even close to normal. Giving vitamin c threw the nasel tube as in the nutritional formulation will do nothing for the paitents vitamin c levels.Can you plese show me evidence that says this is not so.