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Despite all the research published in the last three decades on screening and prevention of preeclampsia (PE), this condition remains one of the main causes of maternal and perinatal morbidity and mortality, both in low and high-income countries. It affects 2-8% of all pregnancies, being responsible for one out of five maternal deaths and 15% of all premature deliveries1. An ideal screening test requires identification of women at high-risk of developing severe and early-onset forms of the disease, a high detection rate (DR) with an acceptable false-positive rate (FPR), and the availability of an effective preventive measure2.

Resume Le dosage de l'excretion urinaire d'albumine (EUA) peut se faire sur un echantillon urinaire sur les premieres urines du matin, sur les urines de 24 heures ou sur prelevement urinaire minute. Les valeurs definissant la microalbuminurie sont : urines de 24 heures : 30–300 mg/24 h ; echantillon urinaire : 20–200 mg/ml ou 30–300 mg/g creatinine urinaire ou 2,5–25 mg/mol (chez l'homme), ou 3,5–35 mg/mol (chez la femme) creatinine urinaire ; echantillon urinaire minute : 20–200 μg/min. La place du dosage semi-quantitatif (bandelettes) n'est pas clairement definie. La microalbuminurie est consideree comme un reflet d'une atteinte generalisee de l'endothelium, mais ce n'est pas demontre. Chez le sujet diabetique La microalbuminurie est un marqueur independant de risque cardiovasculaire (CV), renal et de mortalite totale chez les diabetiques de type 1 et 2. L'augmentation de l'EUA au cours du temps est un marqueur de risque CV et renal chez le diabetique de type 1 ; sa regression est associee a une regression de ces risques. Chez le sujet non diabetique La microalbuminurie est un marqueur independant de risque CV, de risque de diabete, d'alteration de la fonction renale et de mortalite totale. Elle est un marqueur de risque de developper une hypertension arterielle chez le sujet normotendu et un marqueur de risque d'evolution defavorable, ou de deces au cours de cancers et de lymphomes. L'elevation ou la persistance d'une EUA elevee au cours du temps est associee a un pronostic pejoratif chez certains hypertendus. La mesure d'EUA peut etre recommandee chez certains hypertendus ayant un ou deux facteurs de risque CV associes dont le risque CV semble mal evalue ou ayant une hypertension arterielle (HTA) refractaire : la microalbuminurie indique ici un risque CV eleve et incite a assurer un controle tensionnel strict. Il y a peu d'etudes chez les sujets non hypertendus et non diabetiques ; elles suggerent globalement que la microalbuminurie est un facteur de comorbidite et de mauvais pronostic comme chez les sujets hypertendus ou diabetiques. En prevention secondaire, la microalbuminurie est un marqueur de risque independant, mais n'a pas de retombees therapeutiques specifiques. Il n'est pas recommande de rechercher systematiquement une microalbuminurie chez le sujet non hypertendu, non diabetique, sans antecedent de maladie renale. Il est recommande d'effectuer une surveillance de la fonction renale annuelle (excretion urinaire d'albumine creatininemie et estimation du debit de filtration glomerulaire) chez les sujets microalbuminuriques. Therapeutique Chez tout patient ayant une microalbuminurie : reduction ponderale et de l'apport sode excessif ( chez le diabetique , prescription d'un inhibiteur de l'enzyme de conversion (diabete de type 1) ou d'un antagoniste des recepteurs de l'angiotensine 2 (diabete de type 2) a dose suffisante en premiere intention. Les diuretiques thiazidiques ont un effet synergique avec les bloqueurs du systeme renine angiotensine sur la reduction de l'EUA ; chez le non diabetique , les cinq grandes classes d'antihypertenseurs (IEC, ARA2, diuretiques, antagonistes calciques, betabloquants) sont utilisables en premiere intention.

Aspirin is used in pregnant women in order to obviate the imbalance of prostanoids caused by a defective placentation, and also to counteract the widespread thrombotic tendency related to endothelial dysfunction. After a series of controlled trials which showed a very consistent effect of aspirin t prevent preeclampsia and fetal growth retardation, several recent large trials have cast the doubt, and even unbelief. Their results are analyzed in an explicative way. Discrepancies seem largely related to either studying very low-risk populations, or strong differences in aspirin dosage and/or term of introduction. In the last few years, several works have shown the critical importance of an early treatment, and also of a measurable biologic effect, which requires larger dosages than those used in the most recent trials. The doubt largely remains as for the adequate indications of this treatment. New data in the physiology of placentation suggest that it would be logical to give aspirin as early as the first wave of throphoblastic invasion. The effect of so an early treatment need to be evaluated. The search for early markers should be pursued. The combination of aspirin and heparin is under investigation. Finally, other ways of prevention, such as anti-oxidants, are also being studied.

Hypertension and diabetes mellitus are strongly associated conditions from epidemiologic, genetic, and pathophysiologic points of view. The prevalence of hypertension is high in patients with diabetes, and, conversely, many patients with essential hypertension are glucose intolerant. Proteinuria appears in 40-50% of patients with insulin-dependent diabetes mellitus and 20-30% of patients with non-insulin-dependent diabetes mellitus. Progressive renal failure occurs in 30-40 and 3-8% of patients, respectively, hypertension being a leading factor in its rate of progression. In various animal experiments, ACE inhibitors are able to prevent proteinuria and glomerular sclerosis, presumably by lowering transglomerular capillary pressure. In the diabetic human, ACE inhibitors are powerful antihypertensive drugs, devoid of metabolic side effects. Clinical studies indicate that ACE inhibitors reduce proteinuria and possibly slow the rate of decline in renal function. Such an effect is not observed with beta-blockers. Large-scale studies are needed to confirm this very important hypothesis.

The efficacy of low-dose aspirin in preventing fetal growth retardation was tested in a randomised, placebo-controlled, double-blind trial. A secondary aim was to find out whether dipyridamole improves the efficacy of aspirin. 323 women at 15-18 weeks' amenorrhoea were selected at twenty-five participating centres on the basis of fetal growth retardation and/or fetal death or abruptio placentae in at least one previous pregnancy. They were randomly allocated to groups receiving placebo, 150 mg/day aspirin, or 150 mg/day aspirin plus 225 mg/day dipyridamole, for the remainder of the pregnancy. In the first phase of the trial all actively treated patients (n = 156) were compared with the placebo group (n = 73). Mean birthweight was significantly higher in the treated than in the placebo group (2751 [SD 670] vs 2526 [848] g; difference 225 g [95% CI 129-321 g], p = 0.029) and the frequency of fetal growth retardation in the placebo group was twice that in the treated group (19 [26%] vs 20 [13%]; p less than 0.02). The frequencies of stillbirth (4 [5%] vs 2 [1%]) and abruptio placentae (6 [8%] vs 7 [5%]) were also higher in the placebo than in the treated group. The benefits of aspirin treatment were greater in patients with two or more previous poor outcomes than in those with only one. In the second analysis, of aspirin only (n = 127) vs aspirin plus dipyridamole (n = 119), no significant differences were found. There was no excess of maternal or neonatal side-effects in the aspirin-treated patients.

Resume Nous avons etudie, chez 16 patients hypertendus essentiels, les effets sur l'hemodynamique renale d'un traitement d'un mois par une combinaison fixe de captopril (50 mg) et d'hydrochlorothiazide (25 mg). La pression arterielle systolique et diastolique a diminue de maniere significative. Il n'y a pas eu de variation significative du poids corporel, du volume plasmatique, des taux d'hormone antidiuretique et d'aldosterone plasmatique. L'elevation de l'activite renine plasmatique est conforme a ce que l'on pouvait attendre avec ce type de traitement. Sur l'ensemble des patients, les clairances de l'inuline et du PAH ne se sont pratiquement pas modifiees. Nous avons separe les patients en 2 groupes: le groupe 1 comprenait les patients (n = 5) dont la clairance de l'inuline etait initialement elevee > 120 ml/min (133 ± 15 ml/min), le groupe 2 les patients (n = 11) dont la clairance de l'inuline initiale etait normale ou basse

Urinary albumin excretion (UAE) may be assayed on a morning urinary sample or a 24 h-urine sample. Values defining microalbuminuria are: 1) 24-h urine sample: 30-300 mg/24 h; 2) morning urine sample: 20-200 mg/ml or 30-300 mg/g creatinine or 2.5-25 mg/mmol creatinine (men) or 3.5-35 mg/mmol (women); 3) timed urine sample: 20-200 mug/min. The optimal use of semi-quantitative urine test-strip is not clearly defined. It is generally believed that microalbuminuria reflects a generalized impairment of the endothelium; however, no definite proof has been obtained in humans.Microalbuminuria is a marker of increased risk of cardiovascular (CV) and renal morbidity and mortality in type 1 and type 2 diabetic subjects. The increase in UAE during follow-up is associated with greater CV and renal risks in type 1 and type 2 diabetic subjects; its decrease during follow-up is associated with lower risks. IN NON-DIABETIC SUBJECTS: Microalbuminuria is a marker of increased risk for diabetes mellitus, deterioration of renal function, CV morbidity and all-cause mortality. It is a marker of increased risk for the development of hypertension in normotensive subjects, and is associated with unfavorable outcome in patients with cancer and lymphoma. Persistence of elevated UAE during follow-up is associated with poor outcome in some hypertensive subjects. Measurement of UAE may be recommended in hypertensive medium-risk subjects with 1 or 2 CV risk factors in whom CV risk remains difficult to assess, and in those with refractory hypertension: microalbuminuria indicates a high CV risk and must lead to strict control of arterial pressure. Studies focused on microalbuminuria in non-diabetic non-hypertensive subjects are limited; most of them suggest that microalbuminuria predicts CV complications and deleterious outcome. Subjects with a history of CV or cerebrovascular disease have an even greater CV risk if microalbuminuria is present than if it is not; however, in all cases, therapeutic intervention must be aggressive regardless of whether microalbuminuria is present or not. It is not recommended to measure UAE in non-diabetic non-hypertensive subjects in the absence of history of renal disease. Monitoring of renal function (UAE, serum creatinine and estimation of GFR) is recommended annually in all subjects with microalbuminuria.In patients with microalbuminuria, weight reduction, sodium restriction (6 g per day), smoking cessation, strict glucose control in diabetic subjects, strict arterial pressure control are necessary; in diabetic subjects: use of maximal doses of angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) are recommended; ACEI/ARB and thiazides have synergistic actions on arterial pressure and reduction of UAE; in non-diabetic subjects, any of the five classes of anti-hypertensive medications (ACEI, ARB, thiazides, calcium channel blockers or beta-blockers) can be used.

Calves were subjected to experimental hypoxia from 0.5 to 4 h after birth. The plasma level of immunoreactive gastric inhibitory polypeptide was higher (P less than 0.05) than in control calves during hypoxia and 2 and 7 h later. However, the gastrin level was not lower during treatment and was higher (P less than 0.05) 3, 6, and 13 h later. Hypoxia could have changed circulating levels or degradation rates of these peptides and could have delayed abomasal emptying.

We followed 325 pregnancies in 131 patients with known renal disease. Perinatal death was of increased frequency (8–10 %), contrary to growth retardation and spontaneous abortion. Pre-existing blood pressure and serum creatinin were the main determinants of pregnancy outcome.

Umblical blood flow velocity was studied in 55 pregnant, chronically hypertensive patients, during variations of beta-blocking therapy. There was a highly significant positive correlation between in SBP and variations in diastolic flow velocity.

941 patients were evaluated at least 3 months after an hypertensive pregnancy. 318 of them (34 %) were hypertensive and 183 were treated at once. 142 patients normotensive at first evaluation were followed up for 1 to 14 years, 12,6 % of them became hypertensive within this time.

Of 221 patients with « pure preeclampsia , 137 had at least one subsequent pregnancy. This one was normal in only 28% of patients, and this did not improve in further pregnancies. Fetal growth retardation occured in 11% of second pregnancies and fetal death in 6%. 28% of patients appeared in the few subsequent years to have either hypertension or renal disease.

1. High plasma immunoreactive calcitonin concentrations were observed in ten of eleven patients with acute renal failure, particularly in the oliguric phase. 2. Immunoreactive calcitonin decreased progressively with time, independently of recovery of renal function. 3. Radioimmunoassay curves obtained with serial dilutions of plasma from these patients were parallel to or superimposed upon those obtained with calcitonin standards.