Pregnancy-related Acute Kidney Injury in Public Hospital in South India: Changing Trends.

Abstract

Pregnancy-related acute kidney injury (PRAKI) is a common problem in the developing world. In this retrospective observational study at a tertiary care hospital in South India we evaluated records for the maternal, fetal, and renal outcomes in women with PRAKI. Over a 10-year period, 395 patients of PRAKI were seen constituting 8.1% of all acute kidney injury (AKI). The mean age of patients was 27 ± 3 years. A total of 176 (44.5%) had pre-eclampsia, 132 (33.4%) had puerperal sepsis, 76 (19.2%) had antepartum hemorrhage or postpartum hemorrhage (APH 30/PPH 46), nine (2.2%) had hemolytic uremic syndrome (HUS). Obstruction was seen in two patients. Eleven had underlying glomerulonephritis out of three had lupus nephritis. Forty-five of 395 (11.39%) had hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome, that is, 25.5% of those with pre-eclampsia. Sixteen (4.0%) had placental abruption. A total of 288 (72.9%) presented postpartum. Renal biopsy done in 103 (26%) showed patchy cortical necrosis (PCN) in 25 (22.3%), diffuse cortical necrosis (DCN) in 23 (20.3%), acute tubular necrosis (ATN) in 20 (19.4%), acute interstitial nephritis (AIN) in 10 (9.7%), while nine (8.7%) had thrombotic microangiopathy (TMA). Glomerular disease was seen in 11. Cortical necrosis (CN) was seen in 48 patients of which 10 (20.83%) had abruption placenta, 25 (52%) had puerperal sepsis, 11 (22.9%) had postpartum hemorrhage (PPH), and two (4.1%) had TMA. A total of 290 (73.4%) required dialysis. About 76% improved while 8.3% progressed to end-stage renal disease (ESRD). Maternal mortality (MM) was 5%. There were 42 intrauterine deaths and 30 deaths in the neonatal period. Pregnancy-related acute kidney injury in developing countries is more common as compared to the West. Only 49% patients had booked pregnancy, that is, received regular antenatal care. Apart from pre-eclampsia which is also the major cause in the West and was the etiology in 44% of patients with PRAKI in our study, sepsis (33%) and maternal hemorrhage (19%) were also significant. Immediate recovery from PRAKI was 75% however about 8% develop end-stage kidney disease (ESKD) while in the west ESKD occurred in only about 2%. Pregnancy-related acute kidney injury is an important cause of maternal and fetal morbidity and mortality. Pre-eclampsia emerged as the most common cause of PRAKI and CN was the most common histological lesion. Proper antenatal care and management may improve pregnancy outcomes.