Home About us Current issue Back issues Submission Instructions Advertise Contact Login   

Search Article 
  
Advanced search 
 
Saudi Journal of Kidney Diseases and Transplantation
Users online: 194 Home Bookmark this page Print this page Email this page Small font sizeDefault font size Increase font size 
 


 
Table of Contents   
RENAL DATA FROM ASIA - AFRICA  
Year : 2014  |  Volume : 25  |  Issue : 2  |  Page : 450-455
Acute renal failure in pregnancy: Our experience


1 Department of Nephrology and Clinical Transplantation, Institute of Kidney Diseases and Research Center, Dr. H. L. Trivedi Institute of Transplantation Sciences, Ahmedabad, India
2 Department of Obstetrics and Gynecology, Institute of Kidney Diseases and Research Center, Dr. H. L. Trivedi Institute of Transplantation Sciences, Ahmedabad, India

Click here for correspondence address and email

Date of Web Publication11-Mar-2014
 

   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 Oct 22];25:450-5. Available from: http://www.sjkdt.org/text.asp?2014/25/2/450/128621

   Introduction Top


Acute renal failure (ARF) is a challenging medical complication during pregnancy. Des­pite decreasing incidence, mortality [1] 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%. [2],[3],[4] 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. [4] 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. [2] 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% [6],[7] to 93.3%. [8] 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 Top


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 Top


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].
Table 1: General characteristics of the patients.

Click here to view


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.
Table 2: Assistance offered during deliveries.

Click here to view


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].
Table 3: Causes of pregnancy-related acute renal failure.

Click here to view


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].
Table 4: Laboratory parameters of patients on admission.

Click here to view


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].
Table 5: Maternal outcome.

Click here to view



   Discussion Top


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. [6] The hemodynamic changes affecting renal blood flow are coincident with and partially cau­sative of some of the general cardiovascular changes of pregnancy. [8] 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. [3],[4] 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. [7]

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. [8]

The rate of septic abortion as the reason of ARF was 33.3% in 1980-85 and decreased to 6.3% in 1989-97. [9] Post-abortal sepsis in India was reported to be 59.7% in 1976 [10] and, in a recent study published in 2008 was 20%, [2] 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%). [11] Morta­lity in recent Indian studies was reported as 20% [12] and 18.5%. [2] Maternal mortality in some recent studies from Pakistan [Akhter et al (2004)] was 18%, [13] from Hassan et al (2007) was 16.2% [14] and from Munib et al (2008) was 12.5%. [15] 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. [4] 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, [14] 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.

 
   References Top

1.Gammill HS, Jeyabalan A. Acute renal failure in pregnancy. Crit Care Med 2005;33(10 Suppl):S372-84.  Back to cited text no. 1
    
2.Goplani KR, Shah PR, Gera DN, et al. Preg­nancy related acute renal failure: A single center experience. Indian J Nephrol 2008; 18: 17-21.  Back to cited text no. 2
[PUBMED]  Medknow Journal  
3.Sunil Kumar K, Ramakrishna C, Sivakumar V. Pregnancy related acute renal failure. J Obstet Gynecol India 2006;56:308-10.  Back to cited text no. 3
    
4.Chugh KS. Etiopathogenesis of acute renal failure in the tropics. Ann Natl Acad Med Sci (India) 1987;23:88-99.  Back to cited text no. 4
    
5.Prakash J, Tripathi K, Malhotra V, Kumar O, Srivastava PK. Acute renal failure in eastern India. Nephrol Dial Transplant 1995;10:2009-12.  Back to cited text no. 5
    
6.Thadhani R, Pascual M, Bonventre J. Acute renal failure. N Engl J Med 1996;334:1448-60.  Back to cited text no. 6
    
7.Nisescrt S, Dribusch E, Bellmann O, Kauhausen H. Disorders of liver function, thrombopenia and hemodialysis in a special clinical form of hypertension in pregnancy (the so-called HELLP syndrome) Geburtshilfe Frauenheilkd 1989.  Back to cited text no. 7
    
8.Conrad K, Lindheimer M. Renal and cardio­vascular alterations. In: Chesley's Hyperten­sive Disorders in Pregnancy. Lindheimer M, ed. Stamford, CT: Appleton & Lange; 1999. p. 263-326.  Back to cited text no. 8
    
9.Selcuk NY, Tonbul HZ, San A, Odabas AR. Changes in frequency of acute renal failure in pregnancy (1980-1997). Ren Fail 1998;20:513-17.  Back to cited text no. 9
    
10.Chugh KS, Singhal PC, Sharma BK. ARF of obstetric origin. J Obstet Gynecol 1976;108: 253-61.  Back to cited text no. 10
    
11.Altintepe, Gezginc K, Tonbul HZ, et al. Etio­logy and prognosis in 36 acute renal failure cases related to pregnancy in central Anatolia. Eur J Gen Med 2005;2:110-3.  Back to cited text no. 11
    
12.Najar MS, Shah AR, Wani LA, et al. Preg­nancy related acute kidney injury: A single center experience from the Kashmir Valley. Indian J Nephrol 2008;18:159-61.  Back to cited text no. 12
[PUBMED]  Medknow Journal  
13.Akhtar A, Zaffar S, Mehmood A, Nisar A. Obstetrical acute renal failure from frontier province: A 3 years prospective study. J Postgrad Med Inst 2004;18:109-17.  Back to cited text no. 13
    
14.Hassan I, Junejo AM, Dawani ML. Etiology and outcome of acute renal failure in preg­nancy. J Coll Physicians Surg Pak 2009; 19: 714-7.  Back to cited text no. 14
    
15.Munib S, Khan SJ. Outcomes of pregnancy related acute renal failure. Rawal Med J 2008; 33:189-92.  Back to cited text no. 15
    

Top
Correspondence Address:
Manoj Gumber
Department of Nephrology and Clinical Transplantation, IKDRC-ITS, Civil Hospital Campus, Asarwa, Ahmedabad 380016, Gujarat
India
Login to access the Email id


DOI: 10.4103/1319-2442.128621

PMID: 24626025

Rights and Permissions



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

Top
   
 
 
    Similar in PUBMED
    Search Pubmed for
    Search in Google Scholar for
    Email Alert *
    Add to My List *
* Registration required (free)  
 


 
    Abstract
   Introduction
    Materials and Me...
   Results
   Discussion
    References
    Article Tables
 

 Article Access Statistics
    Viewed2336    
    Printed43    
    Emailed0    
    PDF Downloaded933    
    Comments [Add]    

Recommend this journal