II. L’étude
II.4. Discussion
II.4.2. Perspectives
Les résultats de cette étude témoignent de l'importance de la détermination préopératoire de la fonction rénale en appliquant des critères de classification consensuels pour l'IRC selon KDIGO avec le DFG, mais également d’autres marqueurs simples comme la protéinurie. De même, la stratification du risque préopératoire et postopératoire pour l'IRA à l'aide de biomarqueurs urinaires pourrait permettre la mise en œuvre de stratégies préventives simples et peu coûteuses pendant la période pré-opératoire qui pourraient prévenir ou atténuer le déclin de la fonction rénale. Mis à part l’albumine urinaire, qui est encore aujourd’hui un marqueur de référence de la MRC, très utile pour le diagnostic précoce et l’évaluation du risque cardiovasculaire chez l’insuffisant rénal chronique, de nouveaux biomarqueurs sanguins et urinaires ont fait l’objet dernièrement d’essais cliniques prometteurs. Ainsi, ils pourraient être utilisés, seuls ou en association, pour améliorer la prise en charge de la MRC et pour détecter plus précocement l’IRA. Parmi eux, nous pouvons citer NGAL, IL-18, KIM-1, NAG et plus récemment Galectin-3 (110,111)
Il semble donc justifié de mettre en place une surveillance en collaboration avec les néphrologues, pour les patients ayant présenté une IRA au décours d’une coronarographie ou d’une chirurgie par pontage, afin de mettre en place des règles de néphroprotection.
Faut-il rallonger le délais coronarographie-chirurgie ? Dans notre étude, le délais coronarographie-chirurgie est de 28j. Les études divergent sur le délai minimal permettant de respecter le rein. En 2018, sur une population de 938 patients, Tecson et al. ont montré que les patients avec NPCI ayant une chirurgie de PAC dans le jour suivant la coronarographie étaient deux fois plus à risque d’évènements cardiovasculaires et d’évènements rénaux à 30jours, par rapport à des patients opérés dans un délais de 5 jours (92).
Conclusion
Lors du parcours d’un patient pris en charge pour pontages aorto-coronaires, celui-ci est confronté à un risque rénal, lors de la coronarographie, puis lors de la chirurgie de pontages.
La survenue d’une insuffisance rénale aigüe a donc un impact significatif sur la mortalité et la survenue d’événements cardio-vasculaires au long cours chez les patients pontés, notamment quand elle survient en post-opératoire. Le pronostic de ces patients s’approche de celui des insuffisants rénaux chroniques.
Les maladies cardiaques et rénales étaient déjà très liées, mais il apparait au travers de notre étude et d’autres travaux sur le sujet, que l’évolution de la fonction rénale pourrait servir de marqueur prédictif solide du devenir de nos patients coronariens. Cela nécessite tout de même la réalisation d’études complémentaires, portant sur les facteurs prédictifs, mais également sur les moyens thérapeutiques à mettre en place dès le diagnostic d’IRA.
Quoi qu’il en soit, la prévention, le dépistage précoce et un suivi assidu alliant néphrologues et cardiologues doit impérativement être mis en place pour ces patients fragiles.
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