Marie Frimat1, Melanie Decambron2, Celine Lebas3, Anissa Moktefi4, Laurent Lemaitre5, Viviane Gnemmi6, Benedicte Sautenet7, François Glowacki8, Damien Subtil9, Mercedes Jourdain10, Agnes Rigouzzo11, Isabelle Brocheriou4, Jean-Michel Halimi7, Eric Rondeau12, Christian Noel8, François Provôt8, Alexandre Hertig12. 1. Service de Néphrologie, Hôpital Claude Huriez, CHU Lille, Université de Lille, Lille, France. Electronic address: marie.frimat@chru-lille.fr. 2. Service de Néphrologie, Hôpital Victor Provo, Roubaix, France. 3. Service de Néphrologie, CH Valenciennes, Valenciennes, France. 4. Service d'Anatomie Pathologique, APHP, Hôpital Tenon, Paris, France. 5. Service de Radiologie, Hôpital Claude Huriez, CHU Lille, Université de Lille, Lille, France. 6. Centre de Biologie et Pathologie, CHU Lille, Université de Lille, Lille, France. 7. Service de Néphrologie, CHU Tours, Tours, France. 8. Service de Néphrologie, Hôpital Claude Huriez, CHU Lille, Université de Lille, Lille, France. 9. Pôle Femme Mère Nouveau-Né, Hôpital Jeanne de Flandre, EA 2694, PRES Université Lille Nord de France, Lille, France. 10. Pôle de Réanimation, CHU Lille, Université de Lille, Lille, France. 11. Anesthésie-Réanimation, APHP, Hôpital Trousseau, Paris, France. 12. APHP, Hôpital Tenon, Urgences Néphrologiques et Transplantation Rénale, Paris, France.
Abstract
BACKGROUND: Pregnancy-related renal cortical necrosis may lead to end-stage renal disease. Although this obstetric complication had virtually disappeared in high-income countries, we have noted new cases in France over the past few years, all following postpartum hemorrhage. STUDY DESIGN: Case series. SETTING & PARTICIPANTS: We retrospectively identified 18 patients from 5 French nephrology departments who developed renal cortical necrosis following postpartum hemorrhage in 2009 to 2013. OUTCOMES: Obstetric and renal features, therapeutic measures, and kidney disease outcome were studied. RESULTS: All patients had a severe postpartum hemorrhage (mean blood loss, 2.6±1.1 [SD] L). Hemodynamic instability and disseminated intravascular coagulation were reported in 5 and 11 patients, respectively. All developed rapid onset of acute kidney injury and required hemodialysis. Diagnosis of renal cortical necrosis was performed 4 to 33 days following delivery. At 6 months postpartum, 8 patients remained dialysis dependent and none recovered normal kidney function. The length of exposure to tranexamic acid treatment was significantly more prolonged in women whose estimated glomerular filtration rate remained <15mL/min/1.73m(2) (7.1±4.8 vs 2.9±2.4 hours; P=0.03). LIMITATIONS: Retrospective study; small sample size. CONCLUSIONS: In the setting of gravid endothelium, the conjunction of disseminated intravascular coagulation with the life-saving use of procoagulant and antifibrinolytic agents (recently implemented in France in a postpartum hemorrhage treatment algorithm) may give rise to a risk for uncontrolled clotting in the renal cortex and hence irreversible partial or diffuse cortical necrosis.
BACKGROUND: Pregnancy-related renal cortical necrosis may lead to end-stage renal disease. Although this obstetric complication had virtually disappeared in high-income countries, we have noted new cases in France over the past few years, all following postpartum hemorrhage. STUDY DESIGN: Case series. SETTING & PARTICIPANTS: We retrospectively identified 18 patients from 5 French nephrology departments who developed renal cortical necrosis following postpartum hemorrhage in 2009 to 2013. OUTCOMES: Obstetric and renal features, therapeutic measures, and kidney disease outcome were studied. RESULTS: All patients had a severe postpartum hemorrhage (mean blood loss, 2.6±1.1 [SD] L). Hemodynamic instability and disseminated intravascular coagulation were reported in 5 and 11 patients, respectively. All developed rapid onset of acute kidney injury and required hemodialysis. Diagnosis of renal cortical necrosis was performed 4 to 33 days following delivery. At 6 months postpartum, 8 patients remained dialysis dependent and none recovered normal kidney function. The length of exposure to tranexamic acid treatment was significantly more prolonged in women whose estimated glomerular filtration rate remained <15mL/min/1.73m(2) (7.1±4.8 vs 2.9±2.4 hours; P=0.03). LIMITATIONS: Retrospective study; small sample size. CONCLUSIONS: In the setting of gravid endothelium, the conjunction of disseminated intravascular coagulation with the life-saving use of procoagulant and antifibrinolytic agents (recently implemented in France in a postpartum hemorrhage treatment algorithm) may give rise to a risk for uncontrolled clotting in the renal cortex and hence irreversible partial or diffuse cortical necrosis.
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