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Insuffisance rénale aiguë et prééclampsie

Acute renal failure and preeclampsia

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Réanimation

Résumé

L’insuffisance rénale aiguë liée à la grossesse est une complication responsable d’une importante morbimortalité mais dont la fréquence diminue. Cette défaillance résulte de multiples causes dont la prééclampsie (PE) et le HELLP (Hemolysis, elevated liver enzymes, low platelets) syndrome. La PE modifie l’adaptation physiologique rénale lors de la grossesse, en détournant le rôle de facteurs angiogéniques dont le Vascular endothelial growth factor (VEGF), impliqué dans le remodelage vasculaire placentaire afin de permettre le bon développement foetal. De récentes avancées ont permis de mettre en évidence un facteur circulant, le Soluble fms-like tyrosine kinase-1 (sFlT-1), bloquant l’action du VEGF en inhibant sa fixation sur son récepteur à la surface des cellules endothéliales. Il en résulte une ischémie placentaire, la cellule endothéliale glomérulaire en étant la première cible physiopathologique. Le diagnostic précoce de PE a pour but de limiter les séquelles en initiant un traitement rapide. Celui-ci repose sur l’association d’un traitement antihypertenseur pour contrôler la pression artérielle diastolique et d’un remplissage vasculaire. À l’heure actuelle, le seul traitement efficace, notamment en cas d’insuffisance rénale aiguë, reste l’interruption immédiate de la grossesse pour permettre la réversion de l’endothéliopathie glomérulaire. Le suivi à long terme de femmes prééclamptiques a permis de définir cette pathologie comme un facteur de risque à la fois cardiovasculaire et rénal, avec le risque de développer une néphropathie secondaire. Ainsi, la mise en évidence d’une protéinurie au cours de la grossesse nécessite des explorations néphrologiques complémentaires et un suivi à distance de l’accouchement.

Abstract

During pregnancy, acute renal failure is mostly represented by preeclampsia (PE) and HELLP (Hemolysis, elevated liver enzymes, low platelets) syndrome. During PE, several angiogenic factors including the vascular endothelial growth factor (VEGF) present failing functions. Recent studies highlighted the role of the soluble fms-like tyrosine kinase-1, a circulating factor that inhibits VEGF binding to its endothelial receptor, leading to placenta ischemia and acute kidney injury.Astrict control of diastolic blood pressure along with early fluid administration must be quickly started to avoid development of renal failure. To date, medical delivery is indicated in complicated PE and represents the only treatment allowing the reversal of the glomerular endothelopathy. Long-term follow-up of PE women highlights that PE is a cardiovascular risk factor as well as a risk of subsequent nephropathy. In that setting, proteinuria during pregnancy or in the peripartum period indicates additional kidney investigations.

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Authors and Affiliations

  1. Service de réanimation médicale, centre de réanimation, CHRU de Lille, 2 avenue Oscar Lambret, F-59000, Lille, France

    M. Jonard & M. Jourdain

  2. Service de néphrologie, hôpital Claude Huriez, CHRU de Lille, 2 avenue Oscar Lambret, F-59000, Lille, France

    M. Decambron

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  1. M. Jonard
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Correspondence to M. Jonard.

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Jonard, M., Decambron, M. & Jourdain, M. Insuffisance rénale aiguë et prééclampsie. Réanimation 22, 373–381 (2013). https://doi.org/10.1007/s13546-013-0692-9

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