Department of Nephrology and Kidney Transplantation, University Hospital of Nancy, Vandoeuvre-les-Nancy, France.
Sorbonne Université, Urgences Néphrologiques et Transplantation Rénale, Assistance Publique-Hôpital de Paris (APHP), Hôpital Tenon, Paris, France.
Nephrol Dial Transplant. 2020 Sep 1;35(9):1538-1546. doi: 10.1093/ndt/gfz025.
Among the severe complications of preeclampsia (PE), acute kidney injury (AKI) is problematic if features of thrombotic microangiopathy (TMA) are present. Although a haemolysis enzyme liver low-platelets syndrome is considerably more frequent, it is vital to rule out a flare of atypical haemolytic and uraemic syndrome (aHUS). Our objective was to improve differential diagnosis procedures in post-partum AKI.
A total of 105 cases of post-partum AKI, admitted to nine different regional French intensive care units from 2011 to 2015, were analysed. Analysis included initial and final diagnosis, renal features, haemostasis and TMA parameters, with particular focus on the dynamics of each component within the first days following delivery. A classification and regression tree (CART) was used to construct a diagnostic algorithm.
AKI was attributed to severe PE (n = 40), post-partum haemorrhage (n = 33, including 13 renal cortical necrosis) and 'primary' TMA (n = 14, including 10 aHUS and 4 thrombotic thrombocytopenic purpura). Congruence between initial and final diagnosis was low (63%). The dynamics of haemoglobin, haptoglobin and liver enzymes were poorly discriminant. In contrast, the dynamic pattern of platelets was statistically different between primary TMA-related AKI and other groups. CART analysis independently highlighted the usefulness of platelet trajectory in the diagnostic algorithm. Limitations of this study include that only the most severe cases were included in this retrospective study, and the circumstantial complexity is high.
Trajectory of platelet count between admission and Day 3 helps to guide therapeutic decisions in cases of TMA-associated post-partum AKI. Our study also strongly suggests that during the post-partum period, there may be a risk of transient, slowly recovering TMA in cases of severe endothelial injury in women without a genetic mutation known to induce aHUS.
子痫前期（PE）的严重并发症中，如果存在血栓性微血管病（TMA）特征，急性肾损伤（AKI）则成问题。虽然溶血酶肝血小板减少症综合征更为常见，但排除非典型溶血尿毒综合征（aHUS）的发作至关重要。我们的目的是改进产后 AKI 的鉴别诊断程序。
分析了 2011 年至 2015 年期间来自法国九个不同地区的九个重症监护病房的 105 例产后 AKI 病例。分析包括初始和最终诊断、肾脏特征、止血和 TMA 参数，特别关注产后最初几天内每个成分的动态。使用分类回归树（CART）构建诊断算法。
AKI 归因于严重的 PE（n=40）、产后出血（n=33，包括 13 例肾皮质坏死）和“原发性”TMA（n=14，包括 10 例 aHUS 和 4 例血栓性血小板减少性紫癜）。初始和最终诊断之间的一致性低（63%）。血红蛋白、触珠蛋白和肝酶的动态变化没有很好的区分力。相比之下，原发性 TMA 相关 AKI 和其他组之间血小板的动态模式在统计学上存在差异。CART 分析独立强调了血小板轨迹在诊断算法中的有用性。本研究的局限性包括，该回顾性研究仅纳入了最严重的病例，而且情况非常复杂。
入院至第 3 天血小板计数的变化有助于指导 TMA 相关产后 AKI 的治疗决策。我们的研究还强烈表明，在产后期间，在没有已知会引发 aHUS 的基因突变的情况下，严重内皮损伤的女性可能存在 TMA 短暂、缓慢恢复的风险。
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