| Abstract|| |
Acute kidney injury (AKI) is one of the most challenging and serious complications of pregnancy. We present our experience on the clinical profile and outcome of 57 patients with pregnancy-related AKI, of a total of 580 patients with AKI seen during the study period. This is a prospective single-center study in a civil hospital conducted from January to December 2010. The most common age group of the study patients was 20-25 years; 43.8% of the patients had received antenatal care. AKI was observed in the puerperium (n = 34), early pregnancy (n = 10) and late pregnancy (n = 13). The cause of AKI included puerperal sepsis (63.1%), pregnancy-induced hypertension (PIH) (33.33%), post-abortion (22.80%), ante-partum hemorrhage (APH) (14%) and post-partum hemorrhage (PPH) (8%). Complete, partial and no renal recovery was observed in 52.64%, 21.05% and 26.31% of the patients, respectively. Low platelet count and plasma fibrinogen and high bilirubin, D-dimer and activated partial throm-boplastin time were observed more commonly in patients with partial recovery. Of the 57 patients, 50 received hemodialysis, three received peritoneal dialysis and seven patients were managed conservatively. A total of 13 patients developed cortical necrosis that was associated with sepsis in six, PPH and pre-eclampsia/eclampsia in three patients each and APH in one. Nine patients died, and the cause of death was septicemia in four, pre-eclampsia in three and APH and PPH in one patient each. In our study, puerperal sepsis was the most common etiological factor for pregnancy-related AKI. Prolonged oliguria or anuria were bad prognostic factors for renal recovery. Sepsis, thrombocytopenia, disseminated intra-vascular coagulation and liver involvement were associated with increased mortality.
|How to cite this article:|
Godara SM, Kute VB, Trivedi HL, Vanikar AV, Shah PR, Gumber MR, Patel HV, Gumber VM. Clinical profile and outcome of acute kidney injury related to pregnancy in developing countries: A single-center study from India. Saudi J Kidney Dis Transpl 2014;25:906-11
|How to cite this URL:|
Godara SM, Kute VB, Trivedi HL, Vanikar AV, Shah PR, Gumber MR, Patel HV, Gumber VM. Clinical profile and outcome of acute kidney injury related to pregnancy in developing countries: A single-center study from India. Saudi J Kidney Dis Transpl [serial online] 2014 [cited 2017 Jul 24];25:906-11. Available from: http://www.sjkdt.org/text.asp?2014/25/4/906/135215
| Introduction|| |
Acute kidney injury (AKI) is one of the most challenging and serious complications of pregnancy. The reported incidence of obstetric AKI in the developed countries is 1-2.8%, while in developing countries it is 9-25%.  AKI that requires dialysis is rare in developed countries, with an incidence of 1:20,000 or less, of all gestations. , The incidence of pregnancy-related AKI in developing countries like India is up to 25%, and this has not changed significantly and continues to remain an important medical problem.  AKI in pregnancy bears a high risk of development of bilateral renal cortical necrosis and, consequently, of chronic renal failure. Obstetric complications constitute the most common cause of renal cortical necrosis (50- 70%). ,, Abruptio placenta, septic abortion, eclamptic toxemia, post-partum hemorrhage (PPH) and puerperal sepsis are the pregnancy-related situations responsible for causing renal cortical necrosis.  We present our experience on the clinical profile and outcome of pregnancy-related AKI in 57 patients.
| Patients and Methods|| |
We carried out a prospective single-center study from January to December 2010 during which period 580 patients with AKI were admitted at our institute. A total of 68 pregnant individuals had AKI. Of these, 11 had evidence of renal disease prior to pregnancy and were excluded; thus, 57 patients with pregnancy-related AKI were studied. Diagnosis of AKI was based on the presence of oliguria (urine output <400 mL/d) and/or mounting azotemia [serum creatinine (SCr) >2 mg/dL].
Exclusion criteria included the following: Evidence of renal disease of any cause prior to pregnancy, history of hypertension or diabetes before gestation, history of renal stone disease, renal scarring on ultrasonography, elevated serum creatinine and presence of small-sized kidneys prior to gestation. Detailed history, clinical examination and investigations were carried out on all patients. Each patient underwent proper obstetric examination and removal of products of conception was performed as and when required. Specific details on the mode of delivery, need for blood transfusion(s) and surgical intervention were collected. Renal biopsy was performed if a patient was oliguric or required dialysis for longer than three weeks. Hemo-dialysis (HD) or peritoneal dialysis (PD) was performed according to standard indications. Patients who became dialysis independent with good urine output and renal function were discharged and followed-up every fortnight for three months. Complete renal recovery was defined as SCr of <1.4 mg/dL, partial renal recovery was defined as SCr >1.4 mg/dL with no need for maintenance dialysis and no renal recovery was defined as need for permanent renal replacement therapy. Patients were classified according to age group as 20-25, 26-30, 31-35 and 36-40 years. Early and late pregnancy indicated the first and last trimesters, respectively.
| Results|| |
Out of the 580 patients with AKI seen during the study period, 57 (9.82%) had pregnancy-related AKI and were included in the present study. The mean age of the study patients was 26.4 ± 5.1 years and the most common age group affected was 20-25 years. Only 25 patients (43.8%) had received antenatal care, 23 patients (40.4%) had home delivery/abortion and 34 patients (59.6%) had hospital delivery. Of the study patients, 32 (56.14%) were multi-gravida and 25 (43.86%) were primigravida. Majority of the study patients (n = 34; 59.64%) presented with AKI in the puerperal period, while 10 patients (17.54%) presented in early pregnancy and 13 patients (22.80%) presented in late pregnancy. The clinical features at presentation included fever (82.45%), edema (82.45%), breathlessness (73.68%), oliguria (64.9%), vaginal bleeding (33.33%), anuria (21%), altered level of consciousness (19.2%) and convulsions (14%). Patients had more than one presenting symptom in association with decreased or no urine output.
The etiology of AKI in the study patients included post-abortion sepsis (n = 9; 15.7%), hemorrhage in early pregnancy (n = 5; 8.7%), ante-partum hemorrhage (APH) (n = 8; 14%), PPH (n = 5; 8.7%), pre-eclampsia/eclampsia (n = 19; 33.3%), puerperal sepsis (n = 36; 63.1%), malaria (n = 3; 5.2%) and disseminated intra-vascular coagulation (DIC) (n = 5; 8.7%). Some patients had more than one causative factor for AKI.
The interval between the onset of AKI and referral to our institute varied from 1 to 30 days, with a mean of 6.86 days. The mean pre-dialysis blood urea was 129 ± 49 mg/dL (range 40-229 mg/dL) and serum creatinine was 6.5 ± 2.5 mg/dL (range 2.2-16.22 mg/dL). The duration of oliguria/anuria before onset of the diuretic phase during hospitalization was 12.8 ± 6.4 days (range 3-30 days). The mean serum potassium was 4.3 ± 0.8 mmol/L (range 2.7-6.3 mmol/L). All patients received medical therapy for infection in addition to dialysis, if required. The mean number of dialysis sessions required per patient was 6.9 (range 0-20), each of 4 h duration. Fifty patients received HD; three patients received PD initially due to hemodyna-mic instability and were subsequently shifted to HD and seven patients were treated conservatively; all seven recovered completely without dialysis. All patients underwent detailed gynecological evaluation and ultrasonography. Evacuation of retained products of conception was carried out in eight patients, and one patient required hysterectomy for uncontrolled uterine bleeding. Of the 57 study patients, nine expired (15.78%); complete renal recovery was seen in 30 patients (52.64%), partial recovery in 12 patients (21.05%) and no recovery was seen in 15 patients (26.31%). Comparison of laboratory parameters and their effect on outcome in the study patients is shown in [Table 1].
|Table 1: Comparison of laboratory parameters in the study patients with pregnancy-related acute kidney|
injury and their effect on outcome.
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There were 12 patients with total anuria; of them, only one patient had complete recovery and five patients did not recover and remained dialysis dependent. The other six patients (50% of anuric AKI) had partial renal recovery and were dialysis independent. The etiology of AKI in the study patients included acute tubular necrosis (ATN) (n = 40), commonly associated with septicemia (n = 28), pre-eclampsia (n = 14), APH (n = 7) and PPH (n = 2), singly or in association. Cortical necrosis was seen in 13 patients (22.81%), and was seen more commonly in late pregnancy (11 of 13 cases, i.e. 84.62%) as compared with only two cases in early pregnancy. Causes of late pregnancy cortical necrosis included eclampsia (n = 4), intra-uterine death (IUD) (n = 3) puerperal sepsis (n = 2), APH (n = 1) and PPH (n = 1).
Nine patients (15.79%) expired. Cause of death included septicemia (n = 4; 44.44%), pre-eclampsia (n = 3; 33%), APH (n = 1) and PPH (n = 1). Fetal mortality was seen in 28 cases (49.12%); common causes included pre-eclam-psia (n = 11; 57%), APH (n = 7), PPH (n = 3; 60%) and septicemia (n = 7; 47.2%). We observed that 87.5% of the cases with APH and 60% of the cases with PPH had fetal loss. Postnatal deaths were most commonly associated with maternal sepsis (40%) and PPH (40%), whereas IUD was more commonly associated with pre-eclampsia and APH. Common organisms grown on blood culture included E. coli (n = 12), Pseudomonas (n = 7) and Klebsiella (n = 5).
Renal biopsy was performed in 21 patients (36.84%) and revealed cortical necrosis in 13 patients, ATN in four patients and one each with focal and segmental glomerulosclerosis, membranoproliferative glomerulonephritis, membranous glomerulonephritis and acute tubulo-interstitial nephritis.
Analysis of individual dependent variables, using a Bonferroni adjusted alfa level of 0.01, showed that there was no contribution of duration of oliguria, hemoglobin level, blood urea and SCr (P = 0.629, 0.266, 0.224 and 0.637, respectively) toward mortality. Renal recovery was significantly associated with duration of oliguria (P = 0.001). All statistical analyses were performed using SPSS version 12.
| Discussion|| |
The reported incidence of pregnancy-related AKI is 5-40%. ,,,,,,,,, Observations of various studies indicate that this incidence is decreasing in both developed and developing countries, but the decrease is less in developing countries. ,,,,,,,,,,,,,,,, The reason for this decrease in incidence is due to the prevention of pregnancy-related complications such as septic abortion, early and more effective treatment of pre-eclampsia and performing selective timely lower segment cesa-rian section. In our study, the mean age of the patients was 26.4 years while in the studies of Grunfeld et al  and Chugh et al,  the mean age was 28.4 and 29.5 years, respectively. Our study patients had a slightly lower mean age, which may be due to the lower age at marriage. Chugh et al  reported in 1976 that 43 patients (59.7%) developed AKI in early pregnancy and 29 (40.35%) in late pregnancy. In the present study, renal failure due to abortion was seen in 13 patients (22.8%), while in the study of Chugh et al  renal failure due to abortion was seen in almost half of the total group; this difference could be due to more patients receiving ante-natal care now than earlier. However, even in recent years, more than half of the pregnant ladies do not follow antenatal care; in this study, 37 patients (64.9%) had not received any type of antenatal care. In the study of Chugh et al,  31.9% of the patients were anuric, 55.6% were oliguric and 12.5% were non-oliguric; similar observations were noted in our study. Maternal mortality is reported to be 14-32% in other studies. ,,, In the present study, maternal mortality (15.78%) was lesser than the report of Chugh et al (30%); this may be due to the lesser incidence of septic abortion (22%) and early institution of hemodialysis in our patients (85%).
In our study, the interval between onset of renal failure and referral to our institute varied from one to 30 days, with a mean of 6.86 days. The mean serum creatinine was 6.54 mg% in the present study, which was less compared with 15.4 mg/dL in the study by Chugh et al.  This could be due to early referral. Most of our patients (85.96%) received hemodialysis because this is the preferred mode of dialysis in patients with AKI at our center, unless contraindicated. In the present study, cortical necrosis was seen more commonly in late pregnancy (11 of 13 cases, i.e. 84.62%) as compared with only two cases in early pregnancy. However, other workers have shown that the incidence of cortical necrosis is equal in both early and late pregnancy. 
In the study of Chugh et al,  25% of the eclampsia group had cortical necrosis and mortality was high (75%). In their study, the incidence of APH was 6.94%; 80% of these patients had cortical necrosis and mortality was 100%. In the PPH group, 16.7% had cortical necrosis and mortality was 50%. In the group with puerperal sepsis, 33.3% had cortical necrosis and mortality was 44.4%. In the study by Jai Prakash et al,  APH was seen in only 3.17% of the patients; none had cortical necrosis, while among patients with PPH, 20% had cortical necrosis. In the study by Grunfeld et al,  among patients with PPH, 50% had cortical necrosis, while there was no maternal mortality in this group.
In our study, fetal loss was seen in 28 cases (49.12%). Post-natal deaths were associated more commonly with maternal sepsis (40%) and PPH (40%), while intra-uterine death was more common in patients with pre-eclampsia and APH. A study from Casablanca has reported fetal death in 5.5% and maternal mortality in 9.1% of their patients.  In our study, septic shock and PIH were the most common causes of maternal mortality, similar to other studies.  ,  Erdemoglu et al  reported on 75 women with pregnancy-related AKI. The age range was 21-46 years, and 36% of the cases were seen in the post-partum period. Pregnancy-related AKI was caused by sepsis in 14.6%, toxemia of pregnancy in 75.2%, hemorrhage in 12% and postabortion sepsis in 14.6% of the cases. Dialysis was needed in 33.3% of the patients, and the maternal mortality rate was 10.6%. Arora et al  reported that the leading causes of pregnancy-related AKI among the 57 cases studied were sepsis (33.3%), hemorrhage (28.1%) and hypertensive disorders (26.3%). Najar et al  in their study on 569 cases of pregnancy-related AKI reported that septic abortion (50%), APH (15%), toxemia of pregnancy (15%), acute gastroenteritis (7.5%), PPH (5%), acute pyelonephritis (5%) and post-partum AKI (2.5%) were the common causes. Dialysis was needed in 60% of the cases, and the mortality rate was 20%. Sivakumar et al  reported on 59 patients with pregnancy-related AKI, which was seen in the post-partum period in 74.57%, in the third trimester in 16.94%, in the second trimester in 6.77% and in the first trimester in 1.69% of the cases. Puerperal sepsis was the major cause of AKI in their study.
| Conclusions|| |
Pregnancy-related AKI is a common medical problem, and puerperal sepsis seems to be the most common etiological factor along with the occurrence of pre-eclampsia, APH and PPH. Prolonged oliguria or total anuria are bad prognostic factors.
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Vivek B Kute
Department of Nephrology and Clinical Transplantation, Institute of Kidney Diseases and Research Centre - Dr. H. L. Trivedi Institute of Transplantation Sciences Civil Hospital Campus, Asarwa, Ahmedabad 380016, Gujarat