Acute kidney injury during pregnancy and puerperium: a retrospective study in a single center

Characteristics and outcome of pregnancy-related acute kidney injury in a teaching hospital in a low-resource setting: a five-year retrospective review

BACKGROUND

Pregnancy-related kidney injury contributes to a high burden of acute kidney injury in low-resource settings and causes maternal and perinatal morbidity and mortality. Few studies have examined the impact of acute kidney injury in resource-limited countries, with very limited research on pregnancy-specific disorders in Ethiopia. This study aimed to determine the characteristics of pregnancy-related acute kidney injury, outcomes and associated factors.

METHODS

A retrospective study was conducted to evaluate the clinical profile and maternal-fetal outcome of pregnancy-related acute kidney injury at Ayder Comprehensive Specialized Hospital in Tigray, Ethiopia, from January 1, 2017, to December 31, 2021. Maternal and fetal outcomes were analyzed using descriptive statistics. Multivariate logistic regression was used to determine the association between the dependent and independent variables.

RESULTS

Of 27,350 mothers who delivered at Ayder Comprehensive Specialized Hospital between January 1, 2017, and December 31, 2021, a total of 187 women developed pregnancy-related acute kidney injury, a prevalence rate of 68 per 100,000 births. Preeclampsia, sepsis and pre-renal causes due to dehydration and hemorrhage were the most common causes of pregnancy-related acute kidney injury in this study. Hemodialysis was needed in 8.6% (n = 16) of patients. Of the 187 pregnancy-related acute kidney injuries, 143 (76.5%) recovered completely and 30 (16%) partially. The mortality rate was 7.5%. Preexisting chronic kidney disease (AOR = 30.13; 95% CI: 2.92, 310.84), use of vasoactive agents (AOR = 5.77; 95% CI: 1.47, 22.67), increase in creatinine per unit (AOR = 1.65; 95% CI: 1.11, 2.45) and complications related to acute kidney injury (AOR = 5.26; 95% CI: 1.73, 16.00) were determinants of the composite endpoints (partial renal recovery and death).

CONCLUSIONS

This study emphasizes acute kidney injury in resource-limited settings is a significant cause of maternal and fetal morbidity and mortality. The vast majority of patients with pregnancy-related acute kidney injury recovered completely from kidney injury. The main causes of pregnancy-related acute kidney injury were preeclampsia, sepsis and pre-renal associated with hemorrhage and dehydration. Preexisting renal disease, use of vasopressors, increase in creatinine per unit and complications associated with acute kidney injury were determining factors for concomitant fetomaternal mortality. Appropriate preventive strategies during prenatal care and prompt treatment are needed for pregnancy-related acute kidney injury.

Anesthetic Considerations and Outcomes in Amniotic Fluid Embolism: A Retrospective Study over a 15-Year Period

(1) Background: A rare and unexpected consequence of childbirth, labor, or the immediate postpartum period is amniotic fluid embolism (AFE). This study aims to identify AFE cases during or immediately after birth from anesthetic management perspectives. Secondary goals include assessing patient clinical features, obstetric care techniques, birth outcomes, and case survival. (2) Methods: A retrospective observational study assessed AFE patients hospitalized in three Romanian clinical institutions from October 2007 to April 2023. Based on the Society of Maternal-Fetal Medicine (SMFM) criteria, we diagnosed 11 AFE patients. (3) Results: AFE occurred in eight cases (73%) during peripartum, two (18%) within 30 min after placental delivery, and 1 (9%) during a scheduled cesarean surgery. Only one of six cardiorespiratory arrest patients responded to external cardiac massage, while the other five (83%) needed defibrillation. The patients received, on average, five units of red blood cells, six of fresh frozen plasma, and two of activated platelets. Six patients (55%) received factor VIIa infusions. Maternal mortality was 36.3%. Six neonates (75%) needed neonatal resuscitation, and two (25%) died on the second and third days. (4) Conclusions: AFE management necessitates a multidisciplinary approach and the incorporation of advanced life support techniques to optimize outcomes for both the mother and newborn.

Acute Kidney Injury in Pregnancy: A Prospective Study

INTRODUCTION

When acute kidney damage occurs during pregnancy, it poses a difficult clinical problem. One of the main causes of maternal and fetal morbidity and death is pregnancy-related acute kidney injury (AKI), a significant obstetric complication characterized by a fast deterioration in renal function and several subsequent clinical problems. The objective of the study is to analyze the etiological factors, clinical manifestations, and maternal and fetal outcomes of AKI during pregnancy.

MATERIALS AND METHODS

This prospective observational research involved patients hospitalized in the General Medicine and Obstetrics and Gynecology departments at Indira Gandhi Institute of Medical Sciences, Patna, for a year (October 2021 to September 2022) due to obstetric difficulties resulting in acute renal damage.

RESULTS

The study included 62 patients with a mean age of 25.08±4.25 years. The majority of patients in our study were aged 18-25 years (38, 61.3%), followed by 26-30 years (19, 30.6%) and >30 years (5, 8.1%). The majority of patients in our study were non-booked (52, 83.9%) and presented as emergency cases, whereas 10 (16.1%) patients had booked. In addition, 34 (54.8%) patients were primigravida, while 28 (45.1%) were multigravida. There were 25 patients in their third trimester (40.3%), 19 who were postpartum (30.6%), 10 who were post-abortion (16.1%), and eight in their second trimester (12.9%). Upon admission, the majority of the patients showed signs of oliguria, accounting for 45 cases (72.6%). This was followed by nine cases of abnormal kidney function (14.5%) and eight cases of anuria (12.9%). Among the other symptoms, fever was observed in 25 cases (40.32%), whereas breathlessness increased to 15 cases (24.19%), edema was present in 14 cases (22.58%), vomiting and altered sensorium were observed in four cases (6.45%), abdominal pain was observed in three cases (4.83%), and burning micturition was observed in two cases (3.22%). The most common causes of AKI in pregnancy in the present study were puerperal sepsis (18 cases, 29.0%), followed by preeclampsia/eclampsia (14 cases, 22.6%), hemorrhagic shock (10 cases, 16.1%), septic abortion (six cases, 9.7%), hyperemesis gravidarum (four cases, 6.5%), acute fatty liver of pregnancy (three cases, 4.8%), disseminated intravascular coagulation (three cases, 4.8%), drug-induced sepsis (two cases, 3.2%), and urosepsis (two cases, 3.2%). Modes of delivery in this study were normal vaginal delivery (32 cases, 51.6%), lower segment cesarean section (21 cases, 33.9%), dilation and evacuation (seven cases, 11.3%), and total hysterectomy (two cases, 3.2%). Hemodialysis was performed in 39 patients (62.9%), and 51 (82.3%) received blood transfusions. The mean systolic and diastolic BP (mmHg) were 111.37±22.60 and 71.40±18.88, respectively. Maternal outcome data revealed that 48 (77.4%) women had fully recovered, eight (12.9%) had not recovered, 43 (69.4%) were lost to follow-up, and two (3.2%) had died. Neonatal outcomes in the present study were as follows: live birth, 43 (69.4%); abortion, eight (12.9%); intrauterine death of the fetus, five (8.1%); and neonatal mortality, six (9.7%).

CONCLUSION

The diagnosis and treatment of AKI during pregnancy is a significant challenge for the treating physician because of the pathophysiological changes that occur during pregnancy, the variability of symptoms, and the fact that clinical and laboratory features may occasionally overlap.

A Retrospective Study on Clinical Outcomes of Pregnancy-Related Acute Kidney Injury Patients at a South Indian Tertiary Care Hospital

Introduction Acute kidney injury (AKI) significantly contributes to maternal morbidity and mortality in developing nations. In a retrospective study conducted at our tertiary care center in collaboration between the Department of Nephrology and the Department of Obstetrics and Gynecology, we investigated patients admitted with pregnancy-related acute kidney injury (PR-AKI) under the following parameters: incidence, etiology, and maternal outcomes. Methods We evaluated 70 patients admitted with PR-AKI from May 2016 to August 2020. A thorough evaluation was carried out for these patients. The results were analyzed for the association of mortality with the etiology of PR-AKI and the dialysis requirement. Results The mean age among the PR-AKI patients was 24.56 ± 4.2 years. During the study period, there were 33,403 deliveries, consisting of 20,126 vaginal deliveries, and 13,277 were performed via a lower segment cesarean section (LSCS). Seventy patients developed AKI, with an incidence of 2.9 per 1,000 deliveries. The various etiologies included sepsis in 54 cases (74.3%), preeclampsia/eclampsia in 44 (62.85%), LSCS in 27 (38.6%), abruptio placentae in 11 (15.7%), postpartum hemorrhage (PPH) in 11 (15.7%), post-abortion in eight (11.4%), and hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome in seven (10.46%). The number of patients in various stages of AKI was noted as one in Stage I, 22 in Stage II, and 47 in Stage III. The odds ratio of death in the abruptio placentae was 0.73 (95% CI: 0.08-6.72), whereas among those with PPH, it was 1.96 (95% CI: 0.34-11.29). The odds ratio of death among patients with LSCS was 0.50 (95% CI: 0.09-2.64). Out of the total, 34 patients (48.6%) required renal replacement therapy (RRT) provided as intermittent hemodialysis. In total, there were eight deaths (11.3%). The odds ratio of death in dialysis patients was 1.89 (95% CI: 0.42-8.54). Perinatal mortality was 32.9%, whereas total perinatal mortality among all patients was 3.5%. The odds ratio of perinatal mortality among those with AKI was 13.29 (95% CI: 8.05-21.96) with p < 0.0001. Conclusion Our study demonstrates that sepsis was the most common cause of PR-AKI, which can be attributed to a lack of antenatal and postnatal care. Other causes included preeclampsia, LSCS, and hemorrhage. The present study also shows that a significant association exists between PR-AKI and perinatal mortality. The requirement of RRT in AKI predicts a less favorable prognosis.

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.

Incidence of acute kidney injury during pregnancy and its prognostic value for adverse clinical outcomes: A systematic review and meta-analysis

BACKGROUND

Acute kidney injury (AKI) that develops during pregnancy results from pregnancy-induced hypertension, hemorrhage, and sepsis, associated with morbidity and mortality in the fetus and mother. This meta-analysis was conducted to evaluate the incidence of pregnancy-related AKI (PR-AKI) and adverse clinical outcomes.

METHODS

PubMed and Scopus were systematically searched for studies published between 1980 and 2021. We included cross-sectional, retrospective, and prospective cohort studies that reported the incidence of PR-AKI as well as adverse fetal and maternal clinical outcomes. A random-effects model meta-analysis was performed to generate summary estimates.

RESULTS

The meta-analysis included 31 studies (57,529,841 participants). The pooled incidence of PR-AKI was 2.0% (95% confidence interval [CI] 1.0-3.7). Only 49.3% of patients received antenatal care. The most common cause of PR-AKI was preeclampsia (36.6%, 95% CI 29.1-44.7). The proportion of patients requiring hemodialysis was 37.2% (95% CI 26.0-49.9). More than 70% of patients had complete recovery of renal function, while 8.5% (95% CI 4.7-14.8) remained dependent on dialysis. The pooled mortality rate of PR-AKI was 12.7% (95% CI 9.0-17.7). In addition, fetal outcomes were favorable, with an alive birth rate of 70.0% (95% CI 61.2-77.4). However, the rate of abortion and/or stillbirth was approximately 25.4% (95% CI 18.1-34.4), and the rate of intrauterine death was 18.6% (95% CI 12.8-26.2).

CONCLUSIONS

Although the incidence of PR-AKI is not high, this condition has a high impact on morbidity and mortality in both fetal and maternal outcomes. Early prevention and treatment from health care professionals are needed in PR-AKI, especially in the form of antenatal care and preeclampsia medication.

Renal Outcomes of Pregnancy-Related Acute Kidney Injury: a Single Centre Experience in India

Objective:This study aimed to investigate the incidence, clinical characteristics, and outcomes of acute kidney injury (AKI) during pregnancy in Indian population. Materials and methods:A prospective observational study was conducted in pregnant patients admitted to Pt. B.D. Sharma PGIMS, Rohtak, Haryana, India. Acute kidney injury was assessed using Risk, Injury, Failure, Loss of function, and End-stage renal disease (RIFLE) criteria. Patients were analyzed on the basis of demographic data, detailed history, clinical examination, and laboratory investigations. The primary outcome was maternal renal outcome, including return to normal renal function and progression to chronic kidney disease (CKD). The secondary outcomes included the mode of delivery, complications of pregnancy, intensive care unit (ICU) admission, and maternal death. Results:A total of 51 patients with an average age of 29.5 years were included in the present study. About 49.9% of subjects had severe anemia and 41.2% were primigravida. The main cause of AKI was pre-eclampsia and postpartum hemorrhage. There was a marked improvement in renal outcome with 33 patients having complete renal recovery and six patients developed CKD was observed during three months follow-up period. The peaked median value of blood urea was 62.0 mg% in patients with normal renal function, 178.5 mg% in those with CKD and 120.0 mg% in expired patients (P=0.001). A statistically significant change in serum potassium (P=0.010) and creatinine levels (P<0.001) was observed during the follow-up period. Liver enzymes, including serum glutamic oxaloacetic transaminase and serum glutamic pyruvic transaminase, were high in all patients at the time of admission, but decreased to normal on follow-up. Conclusion:Our study indicates that pregnancy-related AKI patients present with multiorgan complications and many of them require mechanical ventilation and renal replacement therapy. Most of these patients have poor outcome. Hence, the management of pregnancy-related AKI presents a challenge that requires proper evaluation of causative factors to facilitate appropriate treatment.

Feto-maternal outcome of pregnancy related acute kidney injury in a North Indian population

BACKGROUND

Acute kidney injury (AKI) is a serious complication in pregnancy, resulting in significant maternal and fetal morbidity/mortality. The aim of this study was to evaluate the magnitude of pregnancy-related AKI (PRAKI) in a North Indian population, and its contributing factors.

MATERIALS AND METHODS

This prospective study was carried out at the department of obstetrics and gynecology in collaboration with the nephrology unit and internal medicine department at King George Medical University from June 2019 to October 2020. After informed consent and ethical clearance, a total of 150 PRAKI women were enrolled, and 98 women were subjected to renal replacement therapy as per Kidney Disease Improving Global Outcomes 2012 guideline and were followed for 3 months for renal and fetomaternal outcome.

RESULTS

There was a high incidence (1.02%) of AKI during pregnancy and puerperium. Majority (57.3%) of the women were aged 26-30 years, and 93.3% had institutional deliveries. About 49% of the women suffering from PRAKI were multipara, and most were identified in the postpartum period (82%). Hypertensive disorder of pregnancy (48%), puerperal sepsis (45%), and hemorrhage (34%) were the associated causes for PRAKI. Stillbirth/intrauterine death (IUD) was higher in Stage II (53.8%) and Stage III AKI (37.7%) (none in Stage I AKI). The majority of the neonates were born with a birth weight of ≤2500 g irrespective of the stages of AKI. Preterm deliveries were significantly higher in Stage II AKI (53.8%) than in Stage I (33.3%) and Stage III (20.0%). Thirty-seven cases of PRAKI were managed conservatively, while 98 required dialysis. Complete recovery occurred in 27.3% and partial renal recovery in 31.3%. However, 3.3% progressed to chronic kidney disease, 34% expired, and 4% were lost to follow-up. High maternal mortality of 30.1% was observed in those dialyzed.

CONCLUSION

AKI is associated with fetal growth restriction and preterm deliveries. Stillbirth/IUD is higher in Stage II and Stage III AKI.

Maternal-Perinatal Variables in Patients with Severe Preeclampsia Who Develop Acute Kidney Injury

Introduction: At present, we are witnessing an increase in preeclampsia, especially the most severe forms, which are associated with an increased risk of maternal-perinatal morbidity and mortality. As a severity criterion, acute kidney injury (AKI) has been associated with a worse prognosis, and for this reason, the maternal and perinatal variables associated with AKI in patients with severe preeclampsia (SP) were analysed in this study. Methods: An observational, retrospective, single-centre study of patients with SP treated at a tertiary hospital between January 2007 and December 2018 was conducted. The case criteria based on the criteria established by the ACOG Practice Guidelines for Gestational Hypertension and Preeclampsia. AKI is considered when serum creatinine exceeds 1.1 mg/dL in a pregnant woman with previously normal renal function. In patients with existing chronic kidney disease (CKD), it is referred to as AKI if the baseline serum creatinine increases by 1.5 fold. Pregestational, gestational and postpartum variables were analysed up to 12 weeks postpartum using univariate and multivariate logistic regression analysis. Results: During the study period, 76,828 births were attended, and 303 pregnant women were diagnosed with SP. The annual incidence of SP increased gradually throughout the study period, reaching 1.79/100 births/year in 2018. Acute kidney injury (AKI) occurred in 24.8% of the patients. The multivariate analysis revealed an increased association with a history of previous CKD, the use of assisted reproductive techniques and caesarean section. Uric acid and thrombotic microangiopathy (TMA) had a high correlation with AKI. Indications for caesarean section are associated with AKI in SP. Regarding perinatal outcomes in cases of AKI, there was a higher percentage of neonates who required foetal lung maturation with steroids and an increased need for NICU admission. No case of maternal death was recorded; however, an increase in neonatal mortality was found among patients who did not develop AKI. After 12 weeks postpartum, 72 patients were referred to the nephrology consultation for persistent hypertension, proteinuria or renal failure. Conclusions: In preeclampsia, AKI is a common complication, especially among patients with a history of CKD, those who became pregnant using assisted reproduction techniques and those who delivered via caesarean section. The perinatal impact of AKI is mainly centred on a higher rate of NICU admission and a lower mortality rate. Among biochemical and haematological markers, the uric acid level prior to renal failure has a direct and significant correlation with the risk of AKI, as does the development of TMA in patients with preeclampsia. Therefore, the monitoring of renal function in cases of preeclampsia should be strict, and referral for a nephrology consultation may be necessary in some cases.

Association between proteinuria and placental pathology in preeclampsia: A retrospective study

Introduction:

Preeclampsia develops due to placental insufficiency and systemic proinflammatory and antiangiogenic mediator release, with ensuing systemic endothelial dysfunction. Nephrotic-range proteinuria appears to be associated with worse pregnancy outcomes. The relationship between differing degrees of proteinuria and the severity of placental alterations has not been studied.

Methods:

This is a single-centre retrospective comparison of 150 singleton pregnancies complicated by preeclampsia and varying degrees of proteinuria. Maternal demographic, obstetrical and fetal outcome data were obtained from chart review. The placental histologic evaluations were performed by a placental pathologist blinded to all other clinical information.

Results:

Preeclamptic women with massive proteinuria had evidence of more severe maternal vascular malperfusion lesions. The severity of the lesions was progressive through mild, moderate and massive proteinuria. Women with massive proteinuria had a higher incidence of renal dysfunction and severe hypertension, and had earlier preterm deliveries compared to preeclamptic women with mild and moderate proteinuria (p < 0.05).

Conclusion:

Preeclampsia with more severe proteinuria is associated with a higher prevalence of placental maternal vascular malperfusion.

Risk of Acute Kidney Injury After Hypertensive Disorders of Pregnancy: A Population-Based Cohort Study

RATIONALE & OBJECTIVE

Even though studies have demonstrated a relationship between hypertensive disorders of pregnancy (HDPs) and chronic kidney disease, there are limited data on the risk of acute kidney injury (AKI) following HDPs. We examined the risk of AKI following the occurrence of HDPs.

STUDY DESIGN

Retrospective population-based cohort study.

SETTING & PARTICIPANTS

Pregnant women in Ontario, Canada, aged 14-50 years, who delivered at ≥20 weeks' gestation between April 1, 2002, and March 31, 2015.

EXPOSURE

Preeclampsia, gestational hypertension, or neither.

OUTCOMES

The primary outcome was AKI with receipt of dialysis (AKI-D) ≥90 days after delivery. The main secondary outcome was AKI based on a hospitalization with a diagnostic code for AKI ≥90 days after delivery.

ANALYTICAL APPROACH

Time-dependent Cox proportional and cause-specific hazards models were used to evaluate the relationship between HDP and outcomes of interest. Models were adjusted for baseline and time-varying covariates.

RESULTS

Our cohort comprised 1,142,656 women and 1,826,235 deliveries, of which 1.7% were associated with gestational hypertension and 4.4% with preeclampsia. After a mean follow-up of 6.7 years, there were 322 episodes of AKI-D (0.41 per 10,000 person-years) and 1,598 episodes of AKI based on diagnostic codes (2.04 per 10,000 person-years). After adjustment, neither preeclampsia nor gestational hypertension was associated with AKI-D. Preeclampsia was associated with AKI (HR, 1.22 [95% CI, 1.03-1.45]), but gestational hypertension was not.

LIMITATIONS

Retrospective design and possible unmeasured confounding. Cases of HDPs and AKI may have been undetected.

CONCLUSIONS

Preeclampsia was a risk factor for AKI occurring ≥90 days after delivery. Our findings suggest the potential importance of obtaining a pregnancy history as part of a comprehensive risk profile for acute kidney disease and suggest that women with a history of HDP may benefit from monitoring of kidney function.

Acute kidney injuries induced by thrombotic microangiopathy following severe hemorrhage in puerperants: a case series and literature review

BACKGROUND

Acute kidney injury in puerperants is generally caused by acute tubular necrosis and occasionally by thrombotic microangiopathy (TMA) following post-partum hemorrhage. However, TMA leads to worse clinical outcomes and is rarely reported in the literature. Therefore, this study aimed to evaluate the pathological mechanism behind the development of TMA in puerperants to improve the diagnosis and treatment of this condition.

METHODS

Three patients diagnosed with severe postpartum hemorrhage and TMA from 2014 to 2017 at a nephrology center were retrospectively investigated.

RESULTS

All patients had severe hemorrhage during delivery with a mean blood loss, 4.0 L (range, 2.7-5.0 L). AKI developed rapidly in these patients and was treated with hemodialysis. Following treatment, the mean volume of packed red blood cells was 2.3 L (range, 1.2-3.6 L), and the mean volume of resuscitation fluid was 3.7 L (range, 3.5-4.0 L). All patients had renal biopsy specimens with typical TMA and ATN changes on light microscopy. Two patients required a hysterectomy while another two patients received respiratory support. Only one patient received plasma exchange. None of the patients had recovered normal kidney function by the final follow-up (26-61 months), with two patients having stage 3 chronic kidney disease, and one patient having an end-stage renal disease requiring maintenance hemodialysis.

CONCLUSION

Severe postpartum hemorrhage could lead to TMA, in addition to the common finding of ATN. Renal histology revealed that poor renal outcomes could be attributed to TMA coexisting with ATN. The potential mechanism was ischemia-reperfusion, which was followed by endothelial cell injury and activation of the alternative complement pathway.

Pregnancy-related acute kidney injury at high altitude: a retrospective observational study in a single center

Background

Pregnancy-related acute kidney injury (Pr-AKI) is associated with maternal and fetal morbidity and mortality. There are few studies focusing on Pr-AKI at high altitude in the literature.

Objectives

to investigate the incidence, etiology, clinical features and maternal-fetal outcomes of Pr-AKI in women living at high altitude.

Methods

6,512 pregnant women attending the Department of Obstetrics & Gynecology at local hospital from January 2015 to December 2018 were screened for Pr-AKI. Patients with serum creatinine above normal range(> 70umol/L) then underwent assessment to confirm the diagnosis of Pr-AKI. AKI was diagnosed and staged based on Kidney Disease Improving Global Outcomes(KDIGO) guideline. Individuals meeting the Pr-AKI criteria were recruited. Their clinical data were recorded and retrospectively analyzed.

Results

Pr-AKI was identified in 136/6512(2.09 %) patients. Hypertensive disorders of pregnancy(HDP) was the leading cause of Pr-AKI(35.3 %). 4(2.9 %) women died and the majority(86.1 %) had recovered renal function before discharge. Fetal outcomes were confirmed in 109 deliveries with gestational age ≥ 20 weeks. Pre-term delivery occurred in 30(27.3 %) cases and perinatal deaths in 17(15.5 %). The rate of low birth weight infant(LBWI) and intrauterine growth restriction(IUGR) was 22.0 and 10.9 % respectively. 16(14.5 %) infants were admitted to NICU after birth. Patients with HDP had a higher cesarean rate(56.3 %). More IUGR(25.0 %) and LBWI(37.8 %) were observed in their infants with a higher risk of admission to NICU(22.0 %). High altitude might have an adverse impact on HDP-related Pr-AKI patients with earlier terminated pregnancy and more stillbirth/neonatal death. Logistic regression models indicated that uncontrolled blood pressure, high altitude and advanced AKI were associated with adverse fetal outcomes in HDP-related Pr-AKI patients.

Conclusions

Pr-AKI was not rare in high-altitude regions and caused severe fetal morbidities and mortalities. Uncontrolled blood pressure, high altitude and advanced AKI were all risk factors for adverse fetal outcomes in Pr-AKI patients, especially for those with hypertensive disorders of pregnancy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-021-02418-7.

Acute kidney injury e-alerts in pregnancy: rates, recognition and recovery

BACKGROUND

Acute kidney injury (AKI) in pregnancy (Pr-AKI) is associated with substantial maternal morbidity and mortality. E-alerts are routinely used for detection of AKI in non-pregnant patients but their role in maternity care has not been explored.

METHODS

All pregnant or postpartum women with AKI e-alerts for AKI Stages 1-3 (Kidney Disease Improving Global Outcomes (KDIGO) criteria) were identified at a tertiary centre >2 years. Two women matched by delivery date for each case were selected as controls. AKI stage, recognition of AKI, pregnancy outcomes, renal recovery, AKI aetiology and risk factors were extracted from electronic patient records.

RESULTS

288 of 11 922 (2.4%) women had AKI e-alerts, of which only 118 (41%) were recognized by the obstetric team. Common Pr-AKI causes included infection (48%), pre-eclampsia (26%) and haemorrhage (25%), but no cause was identified in 15% of women. Renal function recovered in 213 (74%) women, but in 47 (17%) repeat testing was not undertaken and 28 (10%) did not recover function. Hypertensive disorders of pregnancy and Caesarean section were associated with increased incidence of Pr-AKI compared with controls.

CONCLUSIONS

Pr-AKI e-alerts were identified in ∼1 in 40 pregnancies. However, a cause for Pr-AKI was not identified in many cases and e-alerts may have been triggered by gestational change in serum creatinine. Pregnancy-specific e-alert algorithms may be required. However, 1 in 10 women with Pr-AKI had not recovered kidney function on repeat testing. Better understanding of long-term impacts of Pr-AKI on pregnancy and renal outcomes is needed to inform relevant Pr-AKI e-alert thresholds.

Association of D-dimers with acute kidney injury in pregnant women: a retrospective study

Objective

This study was performed to determine the association of D-dimers measured at the time of admission with the development of acute kidney injury (AKI) in pregnant women.

Methods

We retrospectively analyzed the data of 625 women who developed AKI and 628 normal pregnant women admitted to our hospital from January 2014 to December 2018. The primary endpoint of the study was the development of AKI in pregnant women, and the secondary endpoint was the development of dialysis and death in women with AKI. Univariate and multivariate analyses were conducted.

Results

The D-dimer concentration was significantly higher in patients with than without pregnancy-related AKI (PR-AKI). Multivariate logistic regression showed that a D-dimer concentration of >1108 ng/mL was an independent predictor of PR-AKI. The area under the curve of the D-dimer concentration as a prognostic indicator of PR-AKI was 0.652 (95% confidence interval, 0.622–0.683), that for patients with PR-AKI undergoing dialysis was 0.819 (95% confidence interval, 0.709–0.928), and that for patients who died was 0.828 (95% confidence interval, 0.670–0.986).

Conclusion

The D-dimer concentration is significantly associated with the development of AKI in pregnant patients and may increase the risk of dialysis and death in women with AKI.

Factors associated with acute kidney injury during delivery or the postpartum period: A case control study

INTRODUCTION

To investigate the incidence of risk factors associated with acute kidney injury(AKI) occurring during the intrapartum or the immediate postpartum period.

MATERIAL AND METHODS

A retrospective case control study in a tertiary UK hospital of pregnant women identified with AKI in labour or in the postpartum period between July 2019 and June 2020 was carried out. Women identified with pregnancy related AKI (pr-AKI) in labour or postpartum were compared with a matched cohort of women with no evidence of pr-AKI, using multiple regression analysis.

RESULTS

In 4600 births, 71 women with pr-AKI and 142 control women were identified. The antenatal and intrapartum risk factors strongly associated with pr-AKI were pre-eclampsia, prolonged ruptured membranes, delivery by emergency caesarean section and greater blood loss at delivery (all p < 0.001 in multivariable regression).

CONCLUSION

Pr-AKI is relatively common, occurring in 1.5 % of our cohort. Women who are overweight, have prolonged rupture of the membranes, an emergency caesarean section and/or a postpartum haemorrhage are at greatest risk. Clinicians should be check renal function before prescribing non-steroidal medication for postpartum pain relief if there are risk factors for AKI.

Evaluation of Risk and Prognosis Factors of Acute Kidney Injury in Patients With HELLP Syndrome During Pregnancy

Hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome complicated with acute renal failure (AKI) is an important cause of maternal mortality and morbidity. The present retrospective study aims to identify risk and prognosis factors that are associated with AKI in patients with HELLP syndrome during pregnancy. A total of 110 pregnant HELLP patients with or without AKI from an 8-year period were studied. 65 of the patients were diagnosed with AKI based on the Kidney Disease Outcomes Quality Initiative criteria. Levels of the lowest hemoglobin and highest serum creatinine and bleeding incidence were identified as independent risk factors for AKI onset. Infection and serum creatinine level were identified as independent risk factors for maternal mortality. In addition, we also found that these factors were significantly different in AKI patients of different severity. The overall complete recovery rate was 67.7% (44 out of 65) for patients with AKI. The overall death rate was 4.5% (5 out of 110), where one of the patient was from the non-AKI group and the other four were from the AKI group. Our results provide valuable indications for clinical doctors during their diagnosis, treatment, and monitoring of recovery status in HELLP patients complicated with AKI.

Community-Acquired AKI in Asia: An Update

Community-acquired acute kidney injury (CA-AKI) is the dominant form of AKI encountered in developing countries in Asia. Economic disparities, variations in access to health care services, geographic conditions, environmental risk factors, and sociocultural circumstances shape the causes and outcomes of CA-AKI. Infections, drugs, plant and chemical toxins, envenomations, and obstetric complications are common causes of CA-AKI. Previously healthy young individuals who often work outdoors in fields or farms are exposed to a wide variety of work-related or environmental risk factors for CA-AKI. Improving disease definitions, better data, and evolving host-pathogen interactions have changed disease descriptions and presentations over the past 20 years. Among infections, although the incidence of malaria has decreased, the number of cases with dengue and scrub typhus have increased sharply. The recognition of AKI in relation to Plasmodium knowlesi, Plasmodium vivax, scrub typhus, and leptospirosis in areas not traditionally considered at risk, association of infections with the future development of chronic kidney disease, and the role of complement dysregulation in infection-associated AKI are important new findings. Snake-bite-related toxic envenomation continues to be an important cause of AKI in some counties and is a neglected public health problem. On the other hand, significant decreases in the incidence of AKI related to acute diarrheal illness or obstetric causes are signs of hope. Coordinated efforts between administrative stakeholders, society, and health care delivery services at all levels have the potential to propel research and improve outcomes in CA-AKI.

COVID-19 Pandemic and Pregnancy in Kidney Disease

Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is a rapidly spreading pandemic. Owing to changes in the immune system and respiratory physiology, pregnant women are vulnerable to severe viral pneumonia. We review the clinical course, pregnancy outcomes, and management of women with COVID-19 in pregnancy with a focus on those with kidney involvement. Current evidence does not show an increased risk of acquiring SARS-CoV-2 during pregnancy and the maternal course appears to be similar to nonpregnant patients. However, severe maternal disease can lead to complex management challenges and has shown to be associated with higher incidence of preterm and caesarean births. The risk of congenital infection with SARS-CoV-2 is not known. All neonates must be considered as high-risk contacts and should be screened at birth and isolated. Pregnant women should follow all measures to prevent SARS-CoV-2 exposure and this fear should not compromise antenatal care. Use of telemedicine, videoconferencing, and noninvasive fetal and maternal home monitoring devices should be encouraged. High-risk pregnant patients with comorbidities and COVID-19 require hospitalization and close monitoring. Pregnant women with COVID-19 and kidney disease are a high-risk group and should be managed by a multidisciplinary team approach including a nephrologist and neonatologist.

Pre-eclampsia is associated with later kidney chronic disease and end-stage renal disease: Systematic review and meta-analysis of observational studies

OBJECTIVES

To assess whether there is a risk of kidney disease during the postpartum period of women who had preeclampsia (PE).

STUDY DESIGN

Observational trials were searched in the PubMed, Science Direct, Clinical trials, Cochrane, LILACS and Web of Science databases. The data extracted from the studies were systematized, and the risk of bias was evaluated for each of them. Meta-analyses were performed with studies that evaluated chronic kidney disease (CKD) and end-stage renal disease (ESRD), pooling the natural logarithms of the adjusted risk measures and the confidence intervals of each study in a random effects model.

RESULTS

Of the 4149 studies evaluated, 35 articles were included in the review, of which 3 of the CKD and 6 of the ESRD presented the necessary outcomes to compose the meta-analysis. A formal registration protocol was included in the PROSPERO database (number: CRD42019111821). There was a statistically significant difference between the development of CKD (hazard ratio (HR): 1.82, confidence interval to 95% (95% CI): 1.27-2.62, P < 0.01) and ESRD (HR: 3.01, confidence interval to 95% (95% CI): 1.92-4.70, P < 0.01) in postpartum women affected by PE.

CONCLUSIONS

PE was considered a risk factor for the onset of CKD and ESRD in the postpartum period. Thus, more research is needed to clarify the underlying mechanisms of this association, and to assist in determining the most appropriate and effective clinical conduct to prevent and/or treat such complications.

Acute Kidney Injury in Pregnancies Complicated With Preeclampsia or HELLP Syndrome

Acute kidney injury that occurs during pregnancy or in the post-partum period (PR-AKI) is a serious obstetric complication with risk of significant associated maternal and fetal morbidity and mortality. Recent data indicates that the incidence of PR-AKI is increasing, although accurate calculation is limited by the lack of a uniform diagnostic criteria that is validated in pregnancy. Hypertensive and thrombotic microangiopathic disorders of pregnancy have been identified as major contributors to the burden of PR-AKI. As is now accepted regarding preeclampsia, HELLP syndrome and atypical hemolytic uremic syndrome, it is believed that PR-AKI may have long-term renal, cardiovascular and neurocognitive consequences that persist beyond the post-partum period. Further research regarding PR-AKI could be advanced by the development of a pregnancy-specific validated definition and classification system; and the establishment of refined animal models that would allow researchers to further elucidate the mechanisms and sequelae of the disorder.

Restrictive versus Liberal Fluid Therapy for Post-Cesarean Acute Kidney Injury in Severe Preeclampsia: a Pilot Randomized Clinical Trial

OBJECTIVES

The aim of this study was to determine whether a restrictive compared to a liberal fluid therapy will increase postoperative acute kidney injury (AKI) in patients with severe preeclampsia.

METHODS

A total of 46 patients (mean age, 32 years; standard deviation, 6.8 years) with severe preeclampsia were randomized to liberal (1500 ml of lactated Ringer's, n=23) or restrictive (250 ml of lactated Ringer's, n=23) intravenous fluid regimen during cesarean section. The primary outcome was the development of a postoperative renal dysfunction defined by AKI Network stage ≥1. Serum cystatin C and neutrophil gelatinase-associated lipocalin (NGAL) were evaluated at postoperative days 1 and 2. ClinicalTrials.gov: NCT02214186.

RESULTS

The rate of postoperative AKI was 43.5% in the liberal fluid group and 43.5% in the restrictive fluid group (p=1.0). Intraoperative urine output was higher in the liberal (116 ml/h, IQR 69-191) than in the restrictive fluid group (80 ml/h, IQR 37-110, p<0.05). In both groups, serum cystatin C did not change from postoperative day 1 compared to the preoperative period and significantly decreased on postoperative day 2 compared to postoperative day 1 (p<0.05). In the restrictive fluid group, NGAL levels increased on postoperative day 1 compared to the preoperative period (p<0.05) and decreased on postoperative day 2 compared to postoperative day 1 (p<0.05).

CONCLUSION

Among patients with severe preeclampsia, a restrictive fluid regimen during cesarean section was not associated with increased postoperative AKI.

Pregnancy-Related Acute Kidney Injury in Preeclampsia: Risk Factors and Renal Outcomes

Preeclampsia is a common cause of acute kidney injury (AKI) in low- and middle-income countries, but AKI incidence in preeclampsia, its risk factors, and renal outcomes are unknown. A prospective observational multicenter study of women admitted with preeclampsia in South Africa was conducted. Creatinine concentrations were extracted from national laboratory databases for women with maximum creatinine of ≥90 μmol/L (≥1.02 mg/dL). Renal injury and recovery were defined by Kidney Disease Improving Global Outcomes creatinine criteria. Predefined risk factors, maternal outcomes, and neonatal outcomes were compared between AKI stages. Of 1547 women admitted with preeclampsia 237 (15.3%) met AKI criteria: 6.9% (n=107) stage 1, 4.3% (n=67) stage 2, and 4.1% (n=63) stage 3. There was a higher risk of maternal death (n=7; relative risk, 4.3; 95% CI, 1.6-11.4) and stillbirth (n=80; relative risk, 2.2; 95% CI, 1.8-2.8) in women with AKI compared with those without. Perinatal mortality was also increased (89 of 240; 37.1%). Hypertension in a previous pregnancy was the strongest predictor of AKI stage 2 or 3 (odds ratio, 2.24; 95% CI, 1.21-4.17). Renal recovery rate reduced with increasing AKI stage. A third of surviving women (76 of 230 [33.0%]) had not recovered baseline renal function by discharge. Approximately half (39 of 76; 51.3%) of these women had no further creatinine testing post-discharge. In summary, AKI was common in women with preeclampsia and had high rates of associated maternal and perinatal mortality. Only two-thirds of women had confirmed renal recovery. History of a previous hypertensive pregnancy was an important risk factor.

Neuropsychiatric symptoms as the only acute manifestation of a stroke in the left hemisphere. Case report

We report the case of a 60-year-old female patient with a history of hypertension and dyslipidemia, who suddenly presented with a clinical picture of emotional lability, disorientation, complex visual hallucinations and persecutory delusions. There were no associated neurological findings in her initial physical examination. At a local hospital she was initially diagnosed with late-onset bipolar disorder and a manic episode with psychotic features, then referred to the mental health unit, where nuclear magnetic resonance (NMR) imaging of the brain revealed an acute ischemic stroke in the territory of the left posterior cerebral artery (PCA) with haemorrhagic reperfusion to the occipital cortex. Complete and spontaneous resolution of her clinical condition was achieved after approximately 15 days.

Renal histopathology of prolonged acute kidney injury in HELLP syndrome: a case series and literature review

PURPOSE

Acute kidney injury (AKI) is a severe complication of hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome. However, renal pathological investigation of AKI in this syndrome has rarely been reported. We aimed to evaluate the renal pathological changes of persistent AKI and its relationship with renal outcomes in HELLP syndrome.

METHODS

Women with HELLP syndrome who had a renal biopsy because of persistent AKI were investigated. The cases describing renal pathology of AKI in HELLP syndrome reported in PubMed were also reviewed.

RESULTS

Among the 41 patients diagnosed with AKI complicated by HELLP syndrome, 6 patients had renal biopsy. Four of these patients had anuria and required renal replacement therapy. Renal histopathology showed thrombotic microangiopathy (TMA) that coexisted with acute tubular necrosis (ATN) (3), acute renal cortical necrosis (ARCN) (1), and glomerular disease (2). Two patients who had ARCN and ATN with TMA lesions developed chronic renal dysfunction. Ten cases reported in the literature showed ATN (4), TMA (1), TMA with ATN (1), ARCN (2) and mesangial proliferative glomerulonephritis (1). All of them required temporary renal replacement therapy. Two patients developed chronic renal dysfunction including one patient with ARCN.

CONCLUSIONS

ATN was the most common finding for persistent AKI in HELLP syndrome. Patients with ARCN or TMA with ATN may have the potential to develop chronic renal dysfunction. Renal biopsy should be performed in patients with prolonged AKI to determine the renal prognosis and guide the appropriate treatment.

Acute kidney injury in patients with HELLP syndrome

PURPOSE

To evaluate the risk factors and renal prognosis of acute kidney injury (AKI) in patients with hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome.

METHODS

Women with HELLP syndrome over a 15-year period at Peking Union Medical College Hospital, China, were retrospectively studied.

RESULTS

A total of 108 patients with HELLP syndrome were included. Fifty-two (48.1%) patients were diagnosed with AKI (median serum creatinine, 139.72 µmol/L; range, 89.00-866.00); 11 (21.2%) required hemodialysis. The AKI group had significantly more multiparity (p = 0.034), hemorrhage > 400 mL (p = 0.027), severe systolic hypertension ≥ 160 mmHg (p = 0.005), infection (p < 0.001), and low hemoglobin (p = 0.002) than non-AKI patients. Multivariate logistic regression showed that infection (OR 36.441, 95% CI 3.819-347.732, p = 0.002), severe systolic hypertension (OR 5.295, 95% CI 1.795-15.620, p = 0.003), and low hemoglobin (OR 0.960, 95% CI 0.932-0.988, p = 0.006) were independent risk factors for AKI. Six patients with AKI died (mortality rate: 11.5%); no death occurred among patients without AKI. In addition to infection (OR 16.268, CI 1.334-198.385, p = 0.029) and eclampsia (OR 69.895, CI 2.834-1723.910, p = 0.009), elevated serum creatinine (OR 1.006, CI 1.001-1.011, p = 0.031) was an independent predictor of maternal mortality. Renal function in 43 (82.7%) patients completely recovered. Two (3.8%) patients developed chronic renal dysfunction after 1 to 2 years of follow-up.

CONCLUSIONS

Elevated creatinine was an independent predictor of maternal mortality in HELLP syndrome. AKI severely affects renal prognosis and mortality in pregnant women. The occurrence of AKI was related to infection, severe hypertension, and renal ischemia.

Epidemiology of acute kidney injury in hospitalized pregnant women in China

Background

Epidemiologic data of acute kidney injury (AKI) during pregnancy is lacking in China. This study aims to determine the effect of pregnancy on the risk of AKI among hospitalized women of childbearing age, and to describe the incidence, risk factors and outcomes of AKI in hospitalized pregnant women in China.

Methods

We previously conducted a nationwide, multi-centered cohort of hospitalized patients from 25 hospitals in China during 1/1/2013 to 31/12/2015. Women of childbearing age (14–50 year) who had at least two serum creatinine tests within any 7-day window were selected as analysis set. Patient-level data were obtained from the electronic hospitalization information system and laboratory databases. AKI events were identified according to the creatinine criteria of Kidney Disease Improving Global Outcomes.

Results

Among 110,873 women of childbearing age, pregnant women (n = 10,920) had a 51% higher risk of AKI than non-pregnant women (n = 99,953). Community acquired and hospital acquired AKI occurred in 3.6% (n = 393) and 3.7% (n = 402) of the pregnant women, respectively, giving rise to an overall AKI incidence of 7.3%. While, hospital coding would have identified less than 5% of AKI episodes. The top three risk factors of AKI during pregnancy, ranked in order of decreasing population attributable fractions were pregnancy-induced hypertension syndrome (21.1%), acute fatty liver (13.5%), and chronic kidney disease (6.2%).

Conclusion

AKI in pregnancy is associated with increased maternal mortality rate, longer length of stay and higher daily cost. AKI is a common and severe complication during pregnancy in China.

Electronic supplementary material

The online version of this article (10.1186/s12882-019-1255-8) contains supplementary material, which is available to authorized users.

Cystatin C as a novel predictor of preterm labor in severe preeclampsia

Background

The most common cause of acute kidney injury (AKI) in pregnancy is preeclampsia. Serum cystatin C (CysC) is a potential biomarker of early kidney damage as its levels are not disturbed by volume status changes in pregnancy, and serum CysC levels could serve as a replacement for conventionally used creatinine. In this study, we investigated the serum levels of CysC in severe preeclampsia cases and the associations between CysC levels and poor obstetric outcomes.

Methods

Our cohort included severe preeclampsia patients with a normal serum creatinine level. Creatinine was measured to calculate estimated glomerular filtration rate (eGFR) based on the Cockcroft and Gault, Modification of Diet in Renal Disease Study (MDRD), and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations, while CysC was measured to calculated eGFR based on a CysC-based equation. We then evaluated the correlations between serum CysC level, eGFR, and obstetric outcomes.

Results

Twenty-six patients were evaluated of which 38.5% delivered preterm and 30.8% had low-birth weight babies. Unlike creatinine-based eGFR and CysC-based eGFR, serum CysC demonstrate significant negative correlation with gestational age. Receiver operating characteristic curve analysis indicated that serum CysC is a potential biomarker of preterm delivery with a cut-off serum level of 1.48 mg/L with 80% sensitivity and 75% specificity.

Conclusion

GFR estimation using CysC is likely to be inaccurate in pregnancy. However, we found a significant correlation between preterm delivery and serum CysC level. Our results suggest that serum CysC level has the potential to predict preterm delivery in severe preeclampsia patients.

Characteristics and Outcome of Obstetric Acute Kidney Injury in Pakistan: A Single-center Prospective Observational Study

Introduction

Acute kidney injury (AKI) continues to be a cause of increased morbidity and mortality in pregnant women. While studies have been conducted on the incidence and etiology of this complication, the outcomes of obstetric AKI have not been extensively investigated. The primary focus of this prospective observational study was to analyze the risk factors, etiologies as well as maternal and fetal outcomes of AKI in pregnant females in Pakistan.

Methods

A total of 56 patients with obstetric AKI were recruited. Patients were followed for a period of three months postpartum. The diagnosis and staging of AKI were based on the classification of the Acute Kidney Injury Network (AKIN).

Results

Fifteen patients were lost to follow-up and were excluded from the study. The mean age of the remaining 41 patients was 26±6 years. Twenty-two (54%) patients were multigravida, and 19 (46%) were primigravida. Twenty (48%) patients did not receive any antenatal care, 13 (31%) were visited by a traditional birth attendant, and only eight (19%) had adequate antenatal care by a gynecologist. Out of 41 patients, seven (17%) presented before 28 weeks, and 34 (83%) patients presented after 28 weeks of gestation. Four (10%) patients were found to be in stage I, four (10%) in stage II, and 33 (80%) patients in stage III AKI during hospitalization. The causes of AKI included sepsis in 32 (78%), intrauterine death in 24 (60%), postpartum hemorrhage in 17 (41%), shock in 15 (36%), pre-eclampsia/eclampsia in seven (17%), and coagulopathy in three (7%) patients. Twenty-eight (68.3%) patients received hemodialysis during the hospital stay. Three-month follow-up showed complete resolution of AKI in 14 (34.2%) patients, partial resolution in seven (17%), end-stage renal disease in 10 (24.4%), and death in 10 (24.4%) patients.

Conclusion

The present study indicates that a vast majority of patients with obstetric AKI require dialysis. Residual renal dysfunction and end-stage renal disease were common at the three-month follow-up. Incidentally, sepsis and intrauterine death were the leading causes in this study population. Increased awareness and appropriate obstetrical care may have a significantly positive impact on decreasing the morbidity and mortality in these patients.

Unmasking and successful management of light chain deposition disease of kidney in pregnancy: a complex case, mirroring the complex needs of pregnancy with kidney disease in India

Pregnancy offers a precious window of opportunity to diagnose previously undetected or new onset kidney diseases in emerging countries like India, where access to medical, educational and health care facilities are not equitably distributed across varied sections of society. We report a case of a 33 year-old primi gravida who had a successful pregnancy following what was initially considered to represent preeclampsia at 38 weeks of gestation, in whom a subsequent kidney biopsy for persistence of pregnancy-related acute kidney injury (Pr-AKI) revealed light chain deposition disease (LCDD). The etiological evaluation of LCDD led to the detection of an underlying plasma cell dyscrasia which was treated effectively with chemotherapy and autologous stem cell transplant. In this report, we explore the hitherto uncharted pathophysiological relationship between LCDD and pregnancy-related kidney injury by transmission electron microscopic (TEM) studies of endothelial injury in this setting, and underscore the benefits of medical care in a multidisciplinary environment which yielded gratifying results in preservation of maternal kidney health and fetal outcome.

Acute Kidney Injury in Pregnancy: The Changing Landscape for the 21st Century

Pregnancy-related acute kidney injury (Pr-AKI) remains a large public health problem, with decreasing incidences in developing countries but seemingly increasing incidences in the United States and Canada. These epidemiologic changes are reflective of the advances in medical and obstetric care, as well as changes in underlying maternal risk factors. The risk factors associated with advanced maternal age, such as hypertension, diabetes, chronic kidney disease, and those associated with reproductive technologies such as multiple gestations, are increasing. Traditional causes of Pr-AKI, such as septic abortions and puerperal sepsis, have been replaced by hypertensive diseases, such as preeclampsia and thrombotic microangiopathies comprising thrombotic thrombocytopenic purpura (TTP) and atypical hemolytic uremic syndrome (aHUS). In this review, we discuss the global impact of Pr-AKI on maternal and fetal outcomes, the predominant etiologies, and key clinical features to distinguish diagnoses, such as preeclampsia/hemolysis elevated liver function test and low platelet (HELLP) syndrome, acute fatty liver disease of pregnancy (AFLP), and other thrombotic microangiopathies. New insights into the pathogenesis of preeclampsia, TTP/aHUS, and AFLP that have unearthed possible therapeutic targets are summarized. We also delve into special consideration needed to give to pyelonephritis and postobstructive causes of Pr-AKI. With each diagnosis, we offer the latest treatment recommendations, such as the positive reports from the use of eculizumab to treat aHUS. In the end, we hope to arm the clinician with the best tools to understand and address this morbid problem that does not seem to be disappearing.