Acute Kidney Injury in Pregnancy: The Need for Higher Awareness. A Pragmatic Review Focused on What Could Be Improved in the Prevention and Care of Pregnancy-Related AKI, in the Year Dedicated to Women and Kidney Diseases.

Giorgina Piccoli,Mona Alrukhaimi,Alejandra Orozco Guillen,Gianfranca Cabiddu,Rossella Attini,Gloria Ashuntantang,Gulliermo Garcia-Garcia,Zhi-Hong Liu,Philip Li,Margarita Ibarra Hernandez,Elena Zakharova,Bianca Covella,Adeera Levin

doi:10.3390/jcm7100318

Abstract

Pregnancy-related acute kidney injury (pAKI), preeclampsia (PE), and the hypertensive disorders of pregnancy are closely related conditions, which are, in turn, frequently linked to pre-existing and often non-diagnosed chronic kidney disease (CKD). The current literature and research mainly underline the effects of pregnancy complications on the offspring; this review strongly emphasizes the maternal health as well. These conditions not only negatively affect pregnancy outcomes, but have a relevant effect on the future health of affected mothers and their children. Therefore, dedicated diagnostic and follow-up programs are needed, for optimizing materno-foetal health and reducing the impact of pregnancy-related problems in the mothers and in the new generations. This narrative review, performed on the occasion of the 2018 World Kidney Day dedicated to women’s health, focuses on three aspects of the problem. Firstly, the risk of AKI in the hypertensive disorders of pregnancy (the risk is the highest in developing countries; however PE is the main cause of pregnancy related AKI worldwide). Secondly, the effect of AKI and the hypertensive disorders of pregnancy on the development of CKD in the mother and offspring: long-term risks are increased; the entity and the trajectories are still unknown. Thirdly, the role of CKD in the pathogenesis of AKI and the hypertensive disorders of pregnancy: CKD is a major risk factor and the most important element in the differential diagnosis; pregnancy is a precious occasion for early diagnosis of CKD. Higher awareness on the importance of AKI in pregnancy is needed to improve short and long term outcomes in mothers and children.

Highlights

Acute kidney injury (AKI) is still an enormous unsolved health-care problem worldwide [1–3]
Even though in the past AKI was generally considered to be an all-or-nothing situation, in which complete reversal was the rule in surviving patients, this condition is known to be associated with future risk for chronic kidney disease (CKD), hypertension, and cardiovascular diseases [14–18]
It is likely that Pregnancy-related AKI (p-AKI) increases the risk of CKD, which is already higher after PE, for reasons still to be fully elucidated; as previously mentioned, as podocyte loss is a hallmark of PE, this suggests the cause is permanent glomerular damage

Summary

Introduction

Acute kidney injury (AKI) is still an enormous unsolved health-care problem worldwide [1–3]. Even though in the past AKI was generally considered to be an all-or-nothing situation, in which complete reversal was the rule in surviving patients, this condition is known to be associated with future risk for chronic kidney disease (CKD), hypertension, and cardiovascular diseases [14–18]. This pragmatic definition is clinically relevant (maternal PE is usually, but not uniformly milder); the definition of maternal disease is elusive, and the equation early = placental = severe; late = maternal = mild is imperfect and may be misleading This is a promising approach, with the advantage of simplicity and of employing numeric values, and is possibly more objective; there is no agreement on how best to test for the condition: cut-points are not univocal, the levels and the ratio between factors may change over time and the availability of the tests is limited.

Pathologic Findings

Conclusions

14. Trends in Maternal Mortality