Hemolysis Elevated Liver Low Platelet Acute Renal Dysfunction syndrome: evidence for a new entity in the critically ill obstetric patient

Introduction

The incidence of HELLP syndrome complicated with acute renal failure (ARF) is unknown because of a paucity of large series dealing with this subject. Recent experimental and clinical investigations indicate that ARF presents a condition that exerts a fundamental impact on the course of disease, the evolution of associated complications and on prognosis independently from the type and severity of the underlying disease.

Objective

To test the pertinence of a new classification of HELLP syndrome derived from the Tennessee Classification [1] and containing renal dysfunction as a prognostic factor.

Patients and methods

A retrospective analysis of the prospectively collected data part of the APRiMo study [2]. Critically ill obstetric patients first managed in tertiary referral maternity care for high-risk pregnancies, then transferred to our independent multidisciplinary ICU. Inclusion criteria: patients that developed HELLP syndrome in prepartum or postpartum. The main outcome of interest was vital status at ICU discharge. Demographic data, obstetric management modalities, diagnosis of ICU admission, SAPS-Obst, APACHE III-J, daily MODS and SOFA scores, and ICU complications were collected. We used the following classification. Complete HELLP syndrome (Class 1): platelets < 100,000/mm³, LDH ≥ 600 UI/l, ASAT ≥ 70 IU/l. Incomplete HELLP syndrome (Class 2): only one or two factors of the aforementioned criteria. B: acute renal dysfunction, with a maximum serum creatinine level between 100 and 200 μmol/l at day 1 of ICU admission. C: ARF, with a maximum serum creatinine level ≥ 200 μmol/l at day 1 of ICU admission. A: no renal dysfunction. Patients presenting with HELLP syndrome could therefore be classified into six different categories.

Results

During the study period January 1996-December 2004, 261 patients developed HELLP syndrome (21.1% mortality) from a database of 640 patients (13.3% overall mortality) (Table 1). In a logistic regression model with renal function represented by three dichotomous variables and HELLP syndrome expressed in a dichotomous manner as follows (Class 1 = 2, Class 2 = 1), B and C are associated with a respective OR concerning mortality of 2.8 and 8.7.

Table 1 (abstract P274)

Discussion and conclusion

Adding renal dysfunction to the HELLP syndrome classification refined the prognosis of patients. Acute renal dysfunction is a strong independent denominator of survival in the critically ill obstetric patient.