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Master Thesis

Perturbations rénales chez le patient traumatisé crânien : approche physiopathologique

Abstract : Augmented renal clearance in critically ill trauma patients: a pathophysiologic approach using renal vascular index. Background: in critically ill trauma patients, augmented renal clearance (ARC) is common and may result in subtherapeutic antibiotic exposure. The aim of the present study was to explore the relationship between creatinine clearance (CrCL), cardiac output (CO) and renal Doppler vascular index (RVI) in order to assess the potential mechanisms driving ARC in this population. Methods: this study involves a retrospective review of a prospectively collected database of every trauma patients consecutively admitted to a 25- bed Surgical and Trauma Intensive Care Unit (ICU) over a 3-month period. Were included every trauma patients who underwent cardiac and renal ultrasound measurements over three consecutive days during their initial ICU management. ARC was defined by a 24-hr urinary measured CrCL > 130 ml/min. RESULTS: Thirty patients, contributing for 86 coupled physiologic data, were retrospectively analyzed. There was an inverse correlation between CrCL and RVI values (ρ = -0.501; p < 0.0001). The best threshold value for RVI to predict ARC was 0.65 (sensibility 76% [62 – 86]; specificity 72% [56 - 84]). There was only a slight correlation between CrCL and CO values (ρ = 0.219; p = 0.05). There was no statistical correlation between RVI and MAP (ρ = - 0.09; p = 0.41), whether in patients with or without ARC. Conclusion: the combination of an inhibition of arteriolar vascular tone coupled with an increased cardiac output in patients with a greater physiological reserve should been accepted as the leading mechanism for ARC. Salt wasting syndrome in the brain-damaged patients: a pathophysiologic approach using sodium balance and urinary biochemical analysis. Purpose: to explore the underlying mechanisms leading to the occurrence of hyponatremia and enhanced urinary sodium excretion in brain- damaged patients using sodium balance and urinary biochemical analysis. Methods: we conducted a retrospective analysis of a local database prospectively collected in 60 brain trauma patients without chronic renal dysfunction. Metabolic and hemodynamic parameters were averaged over three consecutive periods over the first seven days after admission. The main outcome investigated in this study was the occurrence of at least one episode of hyponatremia. Results: over the study period, there was a prompt decrease in sodium balance (163 ± 193 vs. -12 ± 154 mmol/day, p < 0.0001) and free water clearance (-0.7 ± 0.7 vs. -1.8 ± 2.3 ml/min, p < 0.0001). The area under the ROC curves for sodium balance in predicting the occurrence of hyponatremia during the next period was 0.81 [95% CI: 0.64 – 0.97]. Variables associated with averaged urinary sodium excretion were sodium intake (R2 = 0.26, p < 0.0001) and fractional excretion of urate (R2 = 0.15, p = 0.009). Urinary sodium excretion was also higher in patients with sustained augmented renal clearance over the study period (318 ± 106 vs. 255 ± 135 mmol/day, p = 0.034). Conclusion: the decreased vascular volume resulting from a negative sodium balance is a major precipitating factor of hyponatremia in brain- damaged patients. Predisposing factors for enhanced urinary sodium excretion were high sodium intake, high fractional excretion of urate and augmented renal clearance over the first seven days after ICU admission.
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https://dumas.ccsd.cnrs.fr/dumas-02863724
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Alexandre Lannou. Perturbations rénales chez le patient traumatisé crânien : approche physiopathologique. Sciences du Vivant [q-bio]. 2020. ⟨dumas-02863724⟩

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