Acute kidney injury in pregnancy

Acute kidney injury requiring dialysis in pregnancy and postpartum: Case series and literature review

INTRODUCTION

The occurrence of acute kidney injury (AKI) during pregnancy is a rare event but is associated with higher maternal-fetal morbidity and mortality, particularly when dialysis is required.

METHODS

This is a retrospective observational study from a single center to evaluate pregnant women with AKI undergoing hemodialysis and followed by the nephrology team in charge of in-hospital patient visits at UNIFESP-EPM between 2005 and 2019.

RESULTS

The characteristics of 10 pregnant women who required hemodialysis during the study period were analyzed, with a mean age of 31.4 years, and the majority were primiparous (57.1 %). The etiologies of AKI were preeclampsia (50 %) or sepsis (50 %). All patients in the AKI group underwent hemodialysis in the postpartum period. The mortality rate was 40 %, and all other pregnant women were discharged without the need for dialysis. The live birth rate was 60 %, with 66.7 % of premature births.

CONCLUSIONS

Pregnant women with AKI requiring dialysis presented renal dysfunction in the postpartum period due to obstetric complications or infectious conditions. In our sample, there was a high mortality rate of 40 %. However, all surviving pregnant women showed at least partial recovery of renal function and were discharged without the need for dialysis. Fetal outcomes included a lower rate of live births and a higher rate of prematurity compared to the general population.

Clinical characteristics and prognosis of pregnancy-related acute kidney injury: a case series study

OBJECTIVE

Acute kidney injury (AKI) seriously affects the health of both pregnant women and fetuses. This study aimed to investigate the clinical characteristics and prognosis of pregnancy-related AKI (PR-AKI).

METHODS

This case series study enrolled pregnant women with PR-AKI admitted to the surgical intensive care unit of Xinhua Hospital affiliated to Shanghai Jiaotong University School of Medicine between January 2010 and December 2020.

RESULTS

Thirty-one PR-AKI patients were enrolled with a mean age of 29.16 ± 4.97 years. Seventeen pregnant women (54.84%) had complete recovery of renal function, 5 (16.13%) had partial recovery of renal function, 2 (6.45%) patients had no renal function improvement, and 7 (22.58%) died. Among the 31 patients with 35 fetuses, 25 (80.6%) pregnant women had poor fetal outcomes, including 5 cases of stillbirths, 5 neonatal asphyxia, 18 premature births, 10 low birth weight, and 8 deficient birth weight infants. Compared to cases with good fetal outcomes, cases with poor fetal outcomes had significantly shorter gestational weeks (39.26 ± 1.53 vs. 31.62 ± 5.50, P = 0.002), lower platelet count (217.13 ± 122.87 vs. 90.24 ± 84.88, P = 0.005), lower hemoglobin (94.19 ± 13.21 vs. 74.48 ± 20.78, P = 0.036), higher blood urea nitrogen (11.87 ± 4.28 vs. 19.47 ± 10.98, P = 0.013), and higher uric acid (262.41 ± 167.00 vs. 586.87 ± 144.52, P < 0.001).

CONCLUSIONS

The maternal renal function of women with PR-AKI might improve after treatment, but occurrence rates of adverse fetal outcomes were still high.

Pregnancy-Related Acute Kidney Injury: Do We Know What to Do?

Pregnancy-related AKI is a global health problem and is associated with a higher risk of both maternal and fetal morbidity and mortality. Risk factors for developing AKI during pregnancy include older age, history of preeclampsia, and comorbidities like diabetes. Hyperemesis gravidarum is a common cause of AKI during the first trimester, and conditions such as preeclampsia, acute fatty liver disease of pregnancy, thrombotic thrombocytopenic purpura, hemolytic uremic syndrome, and placental abruption are important causes of AKI later in the pregnancy. Diagnosis of pregnancy-related AKI is challenging due to the lack of standard criteria and overlap of clinical manifestations among different etiologies. Timely diagnosis of pregnancy-related AKI is instrumental. Specific treatment includes steroids and immunosuppressive therapy for glomerulonephritis, prompt delivery for severe preeclampsia and acute fatty liver of pregnancy, plasmapheresis for thrombotic thrombocytopenic purpura, and eculizumab for the atypical hemolytic uremic syndrome. Due to the high complexity, management of pregnancy-related AKI should be performed by a multidisciplinary team consisting of a nephrologist, obstetrician, and neonatologist.

Acute kidney injury during pregnancy in kidney transplant recipients

Pregnancy-related acute kidney injury (AKI) is a public health problem and remains an important cause of maternal and fetal morbidity and mortality. The incidence of pregnancy-related AKI has increased in developed countries due to increase in maternal age and higher detection rates. Pregnancy in women with kidney transplants is associated with higher adverse outcomes like preeclampsia, preterm births, and allograft dysfunction, but limited data exist on causes and outcomes of pregnancy-related AKI in the kidney transplant population. Diagnosis of AKI during pregnancy remains challenging in kidney transplant recipients due to lack of diagnostic criteria. Management of pregnancy-related AKI in the kidney transplant population requires a multidisciplinary team consisting of transplant nephrologists, high-risk obstetricians, and neonatologists. In this review, we discuss pregnancy-related acute kidney injury in women with kidney transplants, etiologies, pregnancy outcomes, and management strategies. This article is protected by copyright. All rights reserved.

Pr-AKI: Acute Kidney Injury in Pregnancy – Etiology, Diagnostic Workup, Management

Despite significant improvements in inpatient and outpatient management, pregnancy-related acute kidney injury (Pr-AKI) remains an important risk factor for early and late maternal and fetal morbidity and mortality. There is a discrepancy between the incidence of Pr-AKI in developing and in developed countries, with the former experiencing a decrease and the latter an increase in Pr-AKI in recent decades. Whereas septic and hemorrhagic complications predominated in the past, nowadays hypertensive disorders and thrombotic microangiopathy are the leading causes of Pr-AKI. Modern lifestyles and the availability and widespread use of in-vitro fertilization techniques in industrialized countries have allowed more women of advanced age to become pregnant. This has led to a rise in the percentage of high-risk pregnancies due to the disorders and comorbidities inherent to or accompanying aging, such as diabetes, arterial hypertension and preexisting chronic kidney disease. Last but not least, the heterogeneity of symptoms, the often overlapping clinical and laboratory characteristics and the pathophysiological changes related to pregnancy make the diagnosis and management of Pr-AKI a difficult and challenging task for the treating physician. In addition to general supportive management strategies such as volume substitution, blood pressure control, prevention of seizures or immediate delivery, each disease entity requires a specific therapy to reduce maternal and fetal complications. In this review, we used the current literature to provide a summary of the physiologic and pathophysiologic changes in renal physiology which occur during pregnancy. In the second part, we present common and rare disorders which lead to Pr-AKI and provide an overview of the available treatment options.

Bilateral serous retinal detachment in a patient with atypical presentation of preeclampsia due to HELLP syndrome

Exudative retinal detachment (ERD) is a rare complication that occurring in 1% of patients with preeclampsia, its incidence is increased when it is associated with HELLP syndrome. Preeclampsia is defined by the development of arterial hypertension and proteinuira occurs after 20 weeks of gestation until postpartum. HELLP syndrome (low platelets, hemolysis and elevated liver enzymes) is a severe form of preeclampsia. ERD in preeclampsia is related to choroidal ischaemia, in the vast majority of the cases associated with hypertensive retinopathy. However, it has been proposed that the combination of hypertension with a microangiopathic hemolysis, hipercoagulability and hypoalbuminemia are the main factors contributing to the development of ERD. Its treatment includes a rapid resolution of labor to reverse ocular manifestations and prevent visual sequels. We describe the case of a pregnant woman with atypical preeclampsia who, in the postpartum of a cesarean, presented an ERD concomitantly with a HELLP syndrome.

Bilateral serous retinal detachment in a patient with atypical presentation of preeclampsia due to HELLP syndrome

Exudative retinal detachment (ERD) is a rare complication that occurring in 1% of patients with preeclampsia, its incidence is increased when it is associated with HELLP syndrome. Preeclampsia is defined by the development of arterial hypertension and proteinuira occurs after 20 weeks of gestation until postpartum. HELLP syndrome (low platelets, hemolysis and elevated liver enzymes) is a severe form of preeclampsia. ERD in preeclampsia is related to choroidal ischaemia, in the vast majority of the cases associated with hypertensive retinopathy. However, it has been proposed that the combination of hypertension with a microangiopathic hemolysis, hipercoagulability and hypoalbuminemia are the main factors contributing to the development of ERD. Its treatment includes a rapid resolution of labor to reverse ocular manifestations and prevent visual sequels. We describe the case of a pregnant woman with atypical preeclampsia who, in the postpartum of a cesarean, presented an ERD concomitantly with a HELLP syndrome.

SGLT2 inhibitor empagliflozin monotherapy alleviates renal oxidative stress in albino Wistar diabetic rats after myocardial infarction induction

Acute kidney injury (AKI) is a sudden insult of the kidney that happens within a short period of time, which is associated with poor prognosis in diabetic patients with myocardial infarction (MI). Subclinical AKI is a condition in which tubular damage biomarkers [Neutrophil gelatinase-associated lipocalin (NGAL) and kidney injury molecule-1(KIM-1)] are positive even in the absence of elevated serum creatinine. Recent studies reported that SGLT-2 inhibitors could protect against subclinical AKI in diabetic patients by elevating the level of β-Hydroxybutyric acid (βOHB). This study aims to examine the reno-protective potential of empagliflozin (EMPA) against MI associated AKI in diabetic rats. Eighty Albino Wistar rats were divided into: (1) nondiabetic sham group (CS), (2) nondiabetic + myocardial infarction group (CM), (3) diabetic + myocardial infarction group (DM) and (4) diabetic + myocardial infarction + empagliflozin group (DME). At the end of the experiment, blood samples and kidneys were collected for biochemical analysis, histopathological, and immunohistochemical studies. After induction of myocardial infarction, there was a significant decrease in serum creatinine and NGAL levels in DME. After EMPA administration, mesangial matrix index and glomerular area were lowered in DME if compared to DM group. As a marker for tubular injury, we used anti-NGAL and anti-KIM-1 immunohistochemistry. Strong positive reaction was noticed in DM group if compared to DME group which showed weak positive reaction. Levels of renal mRNAs [NGAL; KIM-1; Nox-2,4; TLR-2,4; MyD88; TNF- α and IL-1 β, 18] in DME group were reduced significantly compared to DM group. In conclusion, empagliflozin can protect against subclinical acute kidney injury in diabetic albino Wistar rats after myocardial infarction induction, which could improve the clinical outcome of SGLT-2 inhibitors in diabetic patients.

Acute Kidney Injury in Pregnancy

Acute kidney injury in pregnancy is a public health problem and a significant cause of maternal and fetal morbidity and mortality. The incidence of pregnancy-related acute kidney injury has increased in the developed countries, theorized to be the result of an increase in pregnancies in advanced maternal age, and continues to remain higher in developing countries owing to inadequate antenatal care. While hyperemesis gravidarum is a common cause of pregnancy-related acute kidney injury during the first trimester, complications such as preeclampsia, hemolysis, elevated liver enzymes, and low platelet count syndrome, acute fatty liver disease of pregnancy, thrombotic thrombocytopenic purpura, and hemolytic uremic syndrome are important causes of acute kidney injury later in the pregnancy. Diagnosis of pregnancy-related acute kidney injury can be difficult owing to lack of diagnostic criteria and overlapping clinical features between various causes. General measures to treat pregnancy-related acute kidney injury include identification of the underlying cause of kidney injury, intravenous fluid resuscitation, timely initiation of dialysis if needed, and prompt fetal delivery, if necessary. Specific treatment includes steroid and immunosuppressive therapy for glomerulonephritis; prompt delivery for severe preeclampsia, hemolysis, elevated liver enzymes, and low platelet count syndrome, and acute fatty liver of pregnancy; and plasmapheresis and eculizumab for thrombotic microangiopathies such as thrombotic thrombocytopenic purpura and atypical hemolytic uremic syndrome.