Résumé
Peu de temps après leur mise sur le marché, les hydroxyéthylamidons (HEA) se sont imposés comme soluté de remplissage de référence dans beaucoup de pays dont la France. Leur origine naturelle et leur coût moindre que celui de l’albumine ont favorisé leur utilisation. Cependant, le bénéfice d’un remplissage par colloïde par rapport aux cristalloïdes n’a jamais été démontré en réanimation, et des effets secondaires sévères des HEA ont été rapidement décrits chez l’homme. L’évolution des caractéristiques des différentes générations d’HEA afin de réduire leur demivie intravasculaire en diminuant leur poids moléculaire et leur substitution n’a pas permis d’améliorer la tolérance de ces solutions. Plusieurs essais randomisés larges et plusieurs méta-analyses concluent à une toxicité rénale des HEA et même à une surmortalité chez les patients de réanimation, indépendantes des caractéristiques des HEA. Ces données récentes ont justifié la réévaluation du ratio bénéfice/risque des HEA par la Food and Drug Administration (FDA) et l’European Medicines Agency (EMA) dont les conclusions mentionnent que les HEA ne doivent plus être utilisés chez les patients de réanimation. Depuis la description des premières lésions rénales avec les HEA, 20 ans se seront écoulés avant d’interdire leur utilisation en réanimation. Cette mise au point fait la synthèse des données scientifiques sur le bénéfice-risque des HEA et discute les raisons qui ont abouti à un tel délai avant qu’une alerte sanitaire ne soit déclenchée. Il faut, en effet, arriver à tirer les leçons de cette expérience.
Abstract
Shortly after obtaining their market authorization, hydroxyethyl starches (HES) have emerged as the preferred fluid for resuscitation in many countries including France. Its natural origin and a lesser cost than that of albumin have promoted their large use. However, the benefit of colloids over crystalloids has never been demonstrated in the intensive care unit (ICU), and severe side-effects of HES have been rapidly described in humans. By reducing their molecular weight and substitution, the changing characteristics of the different HES generations shorted their intravascular half-life but did not improve the safety of the solutions. Several large randomized trials and meta-analyzes conclude on the renal toxicity of HES and even on a higher mortality in critically ill patients, independently of HES characteristics. These recent data have justified the reevaluation of the benefit-risk ratio of HES by the Food and Drug Administration and the European Medecines Agency. Their conclusions indicate that HES should not be used in critically ill patients. Since the first description of HES-related kidney damages, 20 years have been elapsed before prohibiting their use in the ICU. This literature review discusses the recently published evidences on the benefit-risk ratio of HES and the reasons that led to such a delay before health alert was triggered. We must learn from this experience.
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Schortgen, F. Hydroxyéthylamidons en réanimation. Réanimation 23, 159–166 (2014). https://doi.org/10.1007/s13546-014-0855-3
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DOI: https://doi.org/10.1007/s13546-014-0855-3