| Abstract|| |
Acute renal failure (ARF) is a serious medical complication during pregnancy, and, in the post-partum period, is associated with significant maternal morbidity and mortality as well as fetal loss. The objective of our study is to find the etiology and maternal outcome of ARF during pregnancy. The study was conducted at the Obstetrics and Gynecology Department of the Institute of Kidney Disease and Research Center, Ahmedabad, India from January 2009 to January 2011. Fifty previously healthy patients who developed ARF, diagnosed on oliguria and serum creatinine >2 mg%, were included in the study. Patients with a known history of renal disease, diabetes and hypertension were excluded from the study. All patients were followed-up for a period of six months. Patient records, demographic data, urine output on admission and preceding history of antepartum hemorrhage (APH), post-partum hemorrhage (PPH), septicemia, operative interventions and retained product of conception were noted and need for dialysis was considered. Patients were thoroughly examined and baseline biochemical investigations and renal and obstetrical ultrasound were performed on each patient and bacterial culture sensitivity on blood, urine or vaginal swabs were performed in selected patients. The age range was 19-38 years (mean 26 ± 3.8). The first trimester, second trimester and puerperal groups comprised of four (8%), 25 (50%) and 21 patients (42%), respectively. Hemorrhage was the etiology for ARF in 15 (30%), APH in ten (20%) and PPH in five (10%) patients. Eleven (22%) patients had lower segment cesarian section (LSCS) while 36 (78%) patients had normal vaginal delivery. In 20 (40%) patients, puerperal sepsis was the etiological factor, while pre-eclampsia, eclampsia and HELLP syndrome accounted for 18 (36%) patients. Two (4%) patients had disseminated intravascular coagulation on presentation while one (2%) patient was diagnosed with hemolytic uremic syndrome. Maternal mortality was 12% (n = 6). Of the 38 (88%) surviving patients, 21 (42%) had complete recovery of renal function, eight (16%) patients had partial and 15 (30%) patients required dialysis on a long-term basis. ARF in pregnancy is associated with poor maternal and renal outcome if not detected and treated in time.
|How to cite this article:|
Aggarwal RS, Mishra VV, Jasani AF, Gumber M. Acute renal failure in pregnancy: Our experience. Saudi J Kidney Dis Transpl 2014;25:450-5
|How to cite this URL:|
Aggarwal RS, Mishra VV, Jasani AF, Gumber M. Acute renal failure in pregnancy: Our experience. Saudi J Kidney Dis Transpl [serial online] 2014 [cited 2017 Mar 26];25:450-5. Available from: http://www.sjkdt.org/text.asp?2014/25/2/450/128621
| Introduction|| |
Acute renal failure (ARF) is a challenging medical complication during pregnancy. Despite decreasing incidence, mortality  and morbidity of ARF associated with pregnancy remains high. Management requires knowledge of the renal physiologic changes occurring in pregnancy and the relevant diagnoses, both pregnancy-specific and those that may coincidental^ occur with pregnancy. Ideal medical care of these patients need a multi-disciplinary approach considering maternal and fetal risks and timely specialist involvement.
Renal disease may develop de novo during pregnancy. The usual causes are pregnancy induced hypertension (PIH), new-onset glomerulonephritis or interstitial nephritis, lupus nephritis or ARF. Rarely, obstructive uropathy develops as a result of stone disease or large uterine myoma that has increased in size during pregnancy.
The incidence of pregnancy-related ARF in the developed countries is 1-2.8%, whereas in the developing countries this is about 4.2-15%. ,, Renal failure in pregnancy has a bi-modal distribution, one peak occurring during the 7 th and 8 th weeks of pregnancy mostly as a result of hyperemesis gravidarum and a second peak occurring during the 32 nd and 36 th weeks of pregnancy.  Based on the trimester of pregnancy, ARF is divided into three groups, viz. first half, second half and post-partum ARF. Septic abortion is the most common cause of ARF during the first half of pregnancy; preeclampsia or abruptio placenta are the causes in the second half of pregnancy while hemolytic uremic syndrome occurs in the postpartum period.  Renal cortical necrosis (RCN) remains a dreaded complication of obstetrical related ARF. It carries high morbidity and mortality in South East Asia, ranging from 23% and 26% , to 93.3%.  Its diagnosis can be suspected from history, clinical presentation, persistent oliguria/anuria on admission and dialysis dependency. However, renal biopsy remains the diagnostic tool as it not only confirms renal cortical necrosis but also differentiates it from acute tubular necrosis (ATN), which has better prognosis.
| Materials and Methods|| |
Fifty patients who were healthy previously and had developed ARF, diagnosed on oliguria (urine output <400 mL/day) and serum creatinine >2 mg%, were included in the study. Patients were followed-up for a period of six months. Patient records, demographic data, urine output on admission and preceding history of antepartum hemorrhage (APH), postpartum hemorrhage (PPH), septicemia, operative interventions and retained product of conception were noted and need for dialysis was considered. Obstetrical patients with a known history of glomerulonephritis, systemic lupus erythematosis (SLE), hereditary nephritis, known diabetes and hypertension were excluded from the study.
Patients were thoroughly examined and baseline biochemical investigations, e.g. hemoglobin, creatinine, serum electrolytes, fibrinogen degradation products, 24-h urinary protein and renal and obstetrical ultrasound, were performed on each patient and bacterial culture sensitivity on blood, urine or vaginal swabs were performed in selected patients. Percentages were calculated for qualitative variables, i.e. causes of ARF, mortality, morbidity and outcome in the form of complete recovery, partial recovery, demise and non-recovery. Full recovery was defined as return of renal functions to normal. Partial recovery was defined as patients with impaired renal functions but not requiring dialysis. End-stage renal disease was defined as patients with impaired renal functions for more than three months and requiring dialysis.
| Results|| |
The patient age ranged from 19 to 38 years, with a mean age of 26 ± 3.8 years, mean gravidity 3.5 ± 2.14 and mean parity 2.2 ± 1.1 at mean gestational age of 30 ± 3.6 weeks. Mean urine output on admission was 250 ± 50 mL. Twenty-one patients (42%) were in the puerperium, four (8%) patients were in the first trimester and 25 (50%) patients were in the second and third trimesters [Table 1].
Among these 50 cases, 15 (30%) patients had hospital deliveries, 35 (70%) patients delivered at home, of which ten (20%) deliveries were assisted by lady health visitors (LHVs) and 25 (50%) deliveries were conducted by Dais [Table 2]. Among them, 11 patients (22%) had cesarean section, 35 patients (70%) had vaginal delivery and three (6%) patients had septic abortion.
In the first trimester, one patient had ARF due to hyperemesis gravidarum and three patients had septic abortion. In the second and third trimesters, 14 patients had PIH, one patient had eclampsia and one patient had urinary tract infection with septicemia as the causative factors for ARF. Puerpereal sepsis was found in 20 patients. Hemorrhage was the etiology of ARF in 15 patients, six patients (12%) had abruptio placentae, four patients (8%) had placenta previa and five patients (10%) had a history of PPH [Table 3].
At the time of admission, the mean creatinine was 6.75 ± 3.71 mg/dL and mean hemoglobin was 7.5 ± 0.3 gm% in 78% of the patients [Table 4].
Hemodialysis was required by 33 (66%) patients during the hospital stay and 17 (34%) patients were treated conservatively. Only eight patients (16%) were dialysis independent with some degree of renal impairment whereas 15 patients (30%) were dialysis dependent. Twenty-one patients (42%) had fully recovered renal functions on follow-up [Table 5].
| Discussion|| |
ARF is a syndrome characterized by rapid decline in glomerular filtration rate (GFR) and retention of nitrogenous waste products such as blood urea nitrogen and creatinine.  The hemodynamic changes affecting renal blood flow are coincident with and partially causative of some of the general cardiovascular changes of pregnancy.  Very early decreases in peripheral vascular resistance in pregnancy are due in a large part to decreased renal vascular resistance that may be related to the effects of maternal hormones such as relaxin and progesterone. There are also changes in GFR and renal plasma flow. Both increase during the first half of pregnancy and subsequently level off, with increases on the order of 40-65% for GFR and 50-85% for renal plasma flow. These changes explain the decreases in serum creatinine levels that are seen throughout gestation. , Blood loss secondary to abruptio placenta, APH, PPH, associated HELLP: (Hemolysis, Elevated Liver enzymes Low Platelet count) syndrome and disseminated intravascular coagulation (DIC) sets up the stage for injury at a micro level involving a combination of hypercoagulable state, vasoconstriction, impaired release of nitrous oxide (NO) and intravascular thrombosis. 
In recent years, there has been a marked decline in the incidence of ARF associated with pregnancy in developed countries; currently, cases that are severe enough to require dialysis occur in fewer than one in 20,000 pregnancies, although complications with transient mild to moderate GFR decrease occur in approximately one in 8000 deliveries. Although obstetrical ARF is also on decline in developed countries, it is still one of the main causes of ARF in the developing countries. 
The rate of septic abortion as the reason of ARF was 33.3% in 1980-85 and decreased to 6.3% in 1989-97.  Post-abortal sepsis in India was reported to be 59.7% in 1976  and, in a recent study published in 2008 was 20%,  whereas in the current study three of 50 (6%) patients had septic abortion.
ARF in pregnancy is associated with a high risk for maternal mortality (9-55%).  Mortality in recent Indian studies was reported as 20%  and 18.5%.  Maternal mortality in some recent studies from Pakistan [Akhter et al (2004)] was 18%,  from Hassan et al (2007) was 16.2%  and from Munib et al (2008) was 12.5%.  In our study, maternal outcome showed a maternal mortality of 6/50 (12%).
In our study, puerpural sepsis was the most common etiological factor (40%) encountered in ARF. In our study, 4% of the patients had DIC, 20% had APH and 10% had PPH as etiological factors. Preeclampsia, eclampsia and HELLP syndrome accounted for 34% of the patients. Renal failure is unusual even with severe cases of preeclampsia, unless there is significant bleeding with hemodynamic instability or marked DIC or HELLP syndrome.  Goplani et al2 have concluded that, in 61.42% of the patients, puerperal sepsis was the most common etiological factor leading to ARF, while 32.85% of the patients had DIC on presentation. Hemorrhage as the etiology for ARF was present in 38.56% of the patients, APH in 14.28% and PPH in 24.28% of patients. Preeclampsia, eclampsia and HELLP syndrome accounted for 28.57% of patients with pregnancy-related ARF. Post-abortal sepsis as a precipitating event for ARF was present in 20% of the patients. This was very much consistent with the current study.
On follow-up, of 44 (88%) surviving patients, 15 (30%) patients were dialysis dependent while 29 (58%) patients had complete recovery of renal function. Dialysis dependency is invariably associated with chronic renal disease. Our study is in good agreement with the study of Hassan et al,  who concluded that of the 36 (83.7%) surviving patients, 18 (41.4%) had complete recovery of renal function, 12 (27.9%) had partial recovery and six (13.9%) required chronic dialysis. Hemorrhage was the etiology for ARF in 25 (58.1%), APH in eight (18.6%) and PPH in 16 (37.2%) patients. In 12 (27.9%) patients, puerperal sepsis was the etiological factor, while four (9.3%) patients had DIC on presentation. Pre-eclampsia, eclampsia and HELLP syndrome accounted for five (11.6%) patients, while one (2.3%) patient was diagnosed with hemolytic uremic syndrome and another one was diagnosed as ARF secondary to hypotension produced by hyper-emesis gravidarum.
It is crucial for physicians caring for these patients to have a broad knowledge of physiologic alterations in the renal system in pregnancy to apply the best evidence-based diagnostic and therapeutic strategies for these disease processes and to consider both maternal and fetal effects of disease and therapy. Prompt diagnosis of high-risk individuals and timely referral to tertiary medical care facilities is needed for good outcome.
Disclosure: Financial support: None.
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Department of Nephrology and Clinical Transplantation, IKDRC-ITS, Civil Hospital Campus, Asarwa, Ahmedabad 380016, Gujarat
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]