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

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.

Causes and outcome of pregnancy related acute kidney injury

Objective

To determine frequencies of causes and renal outcomes of pregnancy related acute kidney injury.

Method

This descriptive case series study was conducted in Nephrology unit of a tertiary care hospital of Peshawar, from 1st August 2021 to 31st July 2022.A total of 100 patients with acute kidney injury secondary to obstetric conditions were enrolled via non-probability consecutive sampling technique. While patients with pre-existing renal disease, those with renal stones, or having bilateral small kidneys on ultrasound were excluded from the study. Patients were followed till 12 weeks postpartum period. Underlying obstetrical causes and outcome at 12 weeks postnatal period were determined.

Results

The mean age of sample of 100 cases was 29.29 ± 6.45. Mean serum creatinine at presentation was 6.5± 3.13. Majority of patient, 89% were multigravidas. Seventy eight percent patients required hemodialysis. Primary postpartum hemorrhage remained the commonest underlying cause of pregnancy related acute kidney injury in this study. The frequency of persistent renal failure in Pr-AKI (pregnancy related acute kidney injury) in this study was 14%. In about 66% of cases complete recovery occurred. All the underlying obstetrical causes, when adjusted for age, gravidity, place and mode of delivery, had no association with persistent renal failure.

Conclusion

Primary postpartum hemorrhage is the predominant cause of pregnancy related acute kidney injury. By the end of 12 weeks postpartum, two third patients recover completely from pregnancy related acute renal injury.

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.

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.