Contribution de la biopsie rénale en réanimation

L'impact de la ponction biopsie rénale sur la prise en charge thérapeutique des patients en réanimation n'a pas été clairement étudié. Il s'agit d'une étude rétrospective réalisée entre 2000 et 2011 dans cinq unités de réanimation. Cinquante six patients ayant au moins une défaillance d'organe autre que rénale, définie par un score SOFA ( Sequential Organ Failure Assessment) >=3 à l'admission en réanimation et chez qui une ponction biopsie rénale a été réalisée durant leur séjour en réanimation ont été inclus. Les prélèvements furent obtenus par voie percutanée (N=55) ou par voie transjugulaire (N=1). Les scores SAPS II (Simplified Acute Physiology Score II) et SOFA moyen à l'admission étaient de 52+-19 et 10.3+-3.6 respectivement. La mortalité en réanimation était de 23%. Le délai médian entre l'admission et la réalisation de la ponction biopsie rénale était de 9 jours [5-21]. Les indications de la biopsie rénale étaient une insuffisance rénale aigue persistante (N=32), une protéinurie glomérulaire (N=14), une suspicion de maladie systématique (N=18), de microangiopathie thrombotique (N=14) ou de néphrite tubulointerstitielle (N=6). Les diagnostics histologiques sont dans les 54 cas analysables, une nécrose tubulaire aigue (N=26), une glomérulonéphrite (N=14), une néphrite vasculaire aigue (N=11), une néphrite interstitielle aigue (N=6) et une maladies de dépôts (N=3). La ponction biopsie rénale a eu un impact thérapeutique chez 40 patients : 23 ont reçu un nouveau traitement, 13 ont eu une préparation aux techniques d'épuration extra rénale. Sept patients ont eu une complication hémorragique dont une d'évolution fatale. La ponction biopsie rénale a un impact majeur sur la prise en charge thérapeutique des patients en réanimation. Des études prospectives doivent être réalisées pour définir les groupes de patients qui bénéficieraient de cette procédure avec un risque minime.CLERMONT FD-BCIU-Santé (631132104) / SudocSudocFranceF

Membranous Nephropathy and Intrarenal Extramedullary Hematopoiesis in a Patient With Myelofibrosis

International audienc

Renal artery thrombosis induced by COVID-19

International audienc

Immunoallergic interstitial nephritis secondary to denosumab

International audienc

Bile Cast Nephropathy Caused by Obstructive Cholestasis

International audienc

Ischemia reperfusion injury in kidney transplantation

International audienceAbstract Rationale: Kidney transplantation is considered the best treatment for patients with end stage renal disease. Ischemia- reperfusion injury (IRI) is an evitable event after deceased donor transplantation and influences short term and long term graft outcome. Few data on IRI's histology in the setting of kidney transplantation are available in the literature despite its frequency and its severity. Patient concerns: A 64-year-old patient was admitted for his 1st kidney transplantation. There were no pre-existing immunization. The surgery proceeded without complications; with cold ischemia estimated at 37 h 50 min and warm ischemia at 44 min. The immunosuppression protocol was as follows: induction by thymoglobulins, mycophelonate mofetil, corticosteroids. Few hours after transplantation, the patient remained anuric and the biological assessment highlighted in addition to renal failure, hyperlactatemia at 5 mmol/L and a high increase in lactate deshydrogenase (LDH) at 5239 U/L. An abdominopelvic angio-scanner was performed urgently to eliminate the hypothesis of thrombosis of the artery or vein of the graft. A kidney biopsy was performed the day after the transplant and revealed massive lesions of acute tubular necrosis including apoptosis, autophagy-associated cell death, and necrosis. Microvascular dysfunction with increased vascular permeability and endothelial cell inflammation were also present. Activation of coagulation is represented by thrombi in the lumens of the glomerular capillaries. Diagnosis: The diagnosis was ischemia reperfusion injury responsible for delayed graft function (DGF). Interventions: Immunosuppressive regimen was delayed use of calcineurin inhibitors, mycophenolate mofetil, and corticosteroids. Outcomes: At 1 year post transplant, the patient has a renal autonomy with a graft function stable and physiological proteinuria. Lessons: The main clinical consequences of IRI in kidney transplant are DGF, acute and chronic graft rejection, and chronic graft dysfunction. Reducing IRI is one of the most relevant challenge in kidney transplantation

Hyalinose segmentaire et focale collapsante secondaire au cytomégalovirus : à propos d’un cas

International audienc

Diagnostic yield and therapeutic impact of open lung biopsy in the critically ill patient.

Open lung biopsy (OLB) is a rare procedure in intensive care units (ICUs) for therapeutic management of acute respiratory failure (ARF). The purpose of this study was to analyze the diagnostic yield, therapeutic contribution and complications of OLB in ICU patients with ARF of unclear etiology, including acute respiratory distress syndrome (ARDS) and ARDS mimics.Retrospective study conducted in a 10-bed ICU over a 13-year period. Patients undergoing OLB for ARF with undiagnosed infiltrates on CT scan were included. ARDS was defined according to Berlin criteria, and ARDS mimics as a condition looking like ARDS except for the presence of a known cause. OLB was contributive when the OLB findings yielded a specific diagnosis resulting in a change in the patients' treatment or management.Forty six patients were included (sex ratio = 2.5, median and [interquartile range] age = 69 [59-77] years, and admission SAPS II = 42 [33-50]. ARF corresponded to ARDS in 22 patients and to ARDS mimics in 16. OLB yielded 61 diagnoses in 45 patients including diffuse alveolar damage (N = 21), lung fibrosis (N = 18), and organizing pneumonia (N = 11). OLB was contributive in 37 patients (80%), including 13/16 ARDS mimickers. The main contributions of OLB were the introduction or maintenance of steroids (N = 32) and discontinuation of antibiotics (N = 9). In 4 patients OLB resulted directly in the decision to forgo life-sustaining treatment. OLB complications occurred in 16 patients (35%), in one case associated with fatal outcome.OLB can play a useful role in the management of ICU patients with ARF of undetermined origin, including ARDS mimickers. Further studies should be done to identify the groups of ICU patients likely to benefit from the procedure with minimum risk