The changing face of pregnancy-related acute kidney injury from eastern part of India: A hospital-based, prospective, observational study

Risk factors and fetomaternal outcome in pregnancy-related acute kidney injury

Introduction

Pregnancy-related acute kidney injury (PRAKI) is acute kidney injury (AKI) occurring during pregnancy, labor, and postpartum period. AKI is defined as suddenly impaired kidney function with the retention of nitrogenous and other waste products. In high population country like India, not all deliveries are done tertiary care. Even not all are registered one if delivery is conducted at a hospital setup. The majority of patients are being managed by available obstetrician at local places. Early diagnosis and timely management of complications related to pregnancy are very important to avoid PRAKI. We aim to study maternal risk factors and fetomaternal outcome in PRAKI.

Materials and Methods

A prospective study is conducted between 2021 and 2022 in the Department of Obstetrics and Gynaecology, VMMC, and Safdarjung Hospital, New Delhi. For antenatal and delivered women up to 6 weeks, 50 patients were recruited according to KDIGO (Kidney Disease International Global Outcomes) criteria. Patients were followed with CBC, serum electrolytes, serial KFT, urine input/output monitoring, and USG-KUB. Dialysis was done if indicated. Complete renal recovery was considered if S.Cr ≤1.0 mg/dl within 6 weeks of diagnosis of AKI. For statistical significance, a P value of less than 0.05 was considered.

Results

The majority of patients were unbooked, 21-25 years of age, and belonged to lower socioeconomic status (54%). Risk factors were: preeclampsia (28%), puerperal sepsis (24%), PPH (20%), abruption (14%), pyelonephritis (4%), acute gastroenteritis (4%), gestational hypertension with superimposed preeclampsia (2%), antepartum eclampsia (2%), and thrombotic microangiopathy (2%). Hemodialysis is required in 23 (46%). Complete renal recovery was seen in 40 (80%) and partial renal recovery in 3 (6%). Maternal mortality was 14% and causes were: puerperal sepsis (57%), preeclampsia with severe features with MODS (29%), and antepartum eclampsia with hepatorenal failure (14%). Fetal outcome: 76% live birth, 24% intrauterine death, and 16% early neonatal death.

Conclusion

Most common risk factors for PRAKI are preeclampsia followed by puerperal sepsis and PPH where all are preventable causes.

Access to Nephrology Care for Pregnancy-Related Acute Kidney Injury in Low- and Lower-Middle-Income Countries: A Perspective

Pregnancy-related acute kidney injury (AKI) is a major public health problem with substantial maternal and fetal morbidity and mortality. Women with pregnancy-related AKI require immediate access to nephrology care to prevent deleterious kidney and health outcomes. Patients with pregnancy-related AKI in low-income and lower-middle-income countries experience disparities in access to comprehensive nephrology care for many reasons. In this perspective, we highlight the burden of pregnancy-related AKI and explore the challenges among different low-income and lower-middle-income countries. The lack of adequate nephrology workforce and infrastructure for kidney health care represents a fundamental component of the problem. A shortage of nephrologists hampers the care of patients with pregnancy-related AKI leading to poor outcomes. The lack of diagnostic tools and therapeutic options, including kidney replacement therapy, impedes the implementation of effective management strategies. International efforts are warranted to empower women to get the right services and support at the right time. Dedicated preventive and early care programs are urgently needed to decrease the magnitude of pregnancy-related AKI, a complication under-represented in the literature.

Coping, wellbeing, and psychopathology during high-risk pregnancy: A systematic review

OBJECTIVE

Complications during pregnancy can negatively impact the physical and psychological wellbeing of mothers. This systematic review aimed to synthesise evidence which has examined the impact of high-risk conditions developed during pregnancy on women's coping, wellbeing, and symptoms of psychopathology.

DATA SOURCES

Medline (Ovid), PsycINFO (ProQuest), Scopus, Web of science, AMED (Ebsco), CINAHL (Ebsco) and ProQuest databases were searched in May 2021 with no restrictions on publication date.

STUDY SELECTION

English-language literature was reviewed to identify 31 articles.

DATA EXTRACTION

Fifteen articles examined Gestational Diabetes Mellitus (GDM: 48%), nine examined multiple high-risk pregnancy conditions (29%), four examined Hypertensive disorders of pregnancy, Preeclampsia (PE: 13%), two did not specify the condition examined (7%), and one examined Pregnancy-Related Acute Kidney Injury (PR-AKI: 3%). The most common study design was quantitative, non-randomised, and survey-based.

DATA SYNTHESIS

Twenty-seven articles (87%) reported a high-risk pregnancy resulted in decreased wellbeing and ability to cope, and increased symptoms of psychopathology. The remaining four articles (13%) reported no difference in wellbeing or psychopathology outcomes for women experiencing high-risk compared to healthy pregnancies. Moreover, hypertensive disorders and GDM were associated with ineffective submissive or avoidant coping, reduced wellbeing, and quality-of-life, and exacerbated symptoms of anxiety and depression.

CONCLUSION

High-risk pregnancy negatively impacts coping, wellbeing, and psychopathology, and preventive and supportive interventions to mitigate this should focus on empowering women to feel optimistic and in control of their pregnancy. A holistic and culturally sensitive approach is recommended, where pregnant women (and their partners or support people) are involved in healthcare decisions, thus promoting wellbeing, coping, satisfaction, and improved treatment outcome.

Etiology of Pregnancy-related Acute Kidney Injury among Obstetric Patients in India: A Systematic Review

Background

Pregnancy-related acute kidney injury (PRAKI) is an important cause of fetomaternal mortality and morbidity in developing countries. We undertook a systematic review to identify the causes of PRAKI among obstetric patients in India.

Materials and methods

We systematically searched PubMed, MEDLINE, Embase, and Google Scholar using appropriate search terminology between 1 January 2010 to 31 December 2021. Studies reporting the etiology of PRAKI among obstetric patients (pregnant and within 42 days postpartum) in India were included for evaluation. Studies done in any other geographical location besides India were excluded. We also excluded studies done in any one trimester or any specific subgroup of patients [e.g., postpartum acute kidney injury (AKI), postabortal AKI]. A five-point questionnaire was used to assess the risk of bias in included studies. The results were synthesized as per preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines.

Results

A total number of 7 studies with 477 participants were included for analysis. All were single-center descriptive observational studies either done in tertiary care public or private hospitals. Sepsis (mean, 41.9%; median, 49.4%; and range, 6-56.1%) was the most common cause of PRAKI followed by hemorrhage (mean, 22.1%; median, 23.5%; and range, 8.3-38.5%) and pregnancy-induced hypertension (mean, 20.9%; median, 20.7; and range, 11.5-39%). Among these seven studies, five were of moderate quality, one was of high quality, and another one was of low quality. Our study is limited due to the lack of consensus definition of PRAKI in literature and heterogeneity in reporting methods. Our study highlights the need for a structured reporting format for PRAKI to understand the true disease burden and take control measures.

Conclusion

There is a moderate quality of evidence to suggest that sepsis followed by hemorrhage and pregnancy-induced hypertension are the commonest causes of PRAKI in India.

How to cite this article

Gautam M, Saxena S, Saran S, Ahmed A, Pandey A, Mishra P, et al. Etiology of Pregnancy-related Acute Kidney Injury among Obstetric Patients in India: A Systematic Review. Indian J Crit Care Med 2022;26(10):1141-1151.

Pregnancy-Associated Acute Kidney Injury in Low-Resource Settings: Progress Over the Last Decade

Despite immense global effort, the maternal mortality rate in low-resource settings remains unacceptably high. Globally, this reflects the grave inequalities in access to health and reproductive services. Pregnancy-associated acute kidney injury (PRAKI) is an independent risk factor for mortality. The reported incidence of PRAKI in low- and middle-income countries is higher than that of high-income countries (4%-26% versus 1%-2.8%, respectively). Hypertensive disorders are now the leading cause of PRAKI in many regions, followed by hemorrhage and sepsis. PRAKI in low-resource settings carries a high mortality for both mother and child. Outcome studies suggest that PRAKI is associated with residual kidney dysfunction and may lead to dialysis dependence. This can be a death sentence in many regions with limited kidney replacement therapy. This review will summarize data on PRAKI on the African, Latin American, and Asian continents over the past decade. It will include the progress in published data, mortality, and treatment interventions and provide recommendations for the next decade.