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Saudi Journal of Kidney Diseases and Transplantation
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BRIEF COMMUNICATION  
Year : 2014  |  Volume : 25  |  Issue : 6  |  Page : 1244-1247
Post-partum acute kidney injury


1 Department of Nephrology, Sri Aurobindo Medical College and Post Graduate Institute, Indore, Madhya Pradesh, India
2 Central Research Laboratory, Sri Aurobindo Medical College and Post Graduate Institute, Indore, Madhya Pradesh, India

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Date of Web Publication10-Nov-2014
 

   Abstract 

To determine the risk factors, course of hospital stay and mortality rate among women with post-partum acute kidney injury (AKI), we studied (of 752 patients with AKI admitted to a tertiary care center during the study period between November 2009 and August 2012) 27 (3.59%) women with post-partum AKI. The data regarding age, parity, cause of renal failure, course of hospital stay and requirement of dialysis were recorded. Sepsis was the major cause (70.3%) of post-partum AKI. Other causes included disseminated intravascular coagulation (55.5%), pre-eclampsia/eclampsia (40.7%), ante- and post-partum hemorrhage (40.7% and 22.2%) and hemolytic anemia and elevated liver enzymes and low platelet count syndrome (29.6%); most patients had more than one cause of AKI. We found a very high prevalence (18.5%) of cortical necrosis in our study patients. A significant correlation was also found between the creatinine level on admission and the period of onset of disease after delivery. In conclusion, several factors are involved in causing post-partum AKI in our population, and sepsis was the most common of them.

How to cite this article:
Pahwa N, Bharani R, Kumar R. Post-partum acute kidney injury. Saudi J Kidney Dis Transpl 2014;25:1244-7

How to cite this URL:
Pahwa N, Bharani R, Kumar R. Post-partum acute kidney injury. Saudi J Kidney Dis Transpl [serial online] 2014 [cited 2019 Nov 14];25:1244-7. Available from: http://www.sjkdt.org/text.asp?2014/25/6/1244/144259

   Introduction Top


Post-partum acute kidney injury (AKI) is a challenging health problem in pregnant wo­men, especially in the developing countries. The incidence of AKI requiring dialysis com­plicating pregnancy is approximately one in 20,000 births in industrialized countries. In contrast, pregnancy is still responsible for 15-20% of total AKI cases in the various developing countries. [1],[2],[3]

Pre-eclampsia-eclampsia, post-partum hemor­rhage, hemolytic anemia and elevated liver enzymes and low platelet count (HELLP) syn­drome and puerperal sepsis and disseminated intra-vascular coagulation (DIC) are consi­dered to be the major causes of post-partum AKI. [4] Although the incidence of AKI has decreased sharply in the past 40 years in deve­loped countries, it is still a common problem in the developing countries.

The aim of our study was to identify the causes of post-partum AKI and the outcome of these cases in terms of morbidity and mor­tality.


   Materials and Methods Top


We retrospectively studied all the post-partum patients with AKI admitted in a tertiary care center at Indore between November 2009 and August 2012. AKI was defined and classified according to the risk, injury, failure, loss and end-stage renal failure (RIFLE) criteria, which are based on changes in serum creatinine or changes in urine output or both. Post-partum phase was defined as the period that begins immediately after delivery and extends up to 3 months.

Obstetric records including parity data, preg­nancy-related disorders such as pre-eclampsia, eclampsia, HELLP syndrome, puerperal sep­sis, other infections, and delivery information (route of delivery and associated complications) were recorded. Pre-eclampsia was defined by a set of three signs including hypertension, ede­ma and proteinuria after 20 weeks of gesta­tion. HELLP syndrome was defined as exis­tence of three main features: Hemolysis, ele­vated liver enzymes and low platelets. DIC was defined as coagulation of blood in small blood vessels with bleeding that resulted from the consumption of coagulation proteins and platelets.

The post-partum course was also reviewed, with specific attention to post-partum compli­cations and timing of recovery of kidney func­tion.


   Results Top


Of 752 patients with AKI admitted to a ter­tiary care center during the study period, 27 (3.59%) women had post-partum AKI. The mean age of the patients was 26.7 ± 4.2 years. The mean parity of the women was 1.78 ± 1.1 (range: 1-6). Of the women with post-partum AKI, 66.7% required cesarean delivery, whereas 14.8% had obstructed labor.

Puerperal sepsis occurred in 19 (70.3%) pa­tients, and among these 14 had cesarean deli­veries; two had obstructed labor and three had delivered their child at home by unskilled per­sons called "Dai." Sepsis was the most common cause of post-partum AKI. In the remai­ning eight (29.7%) patients, the causes of AKI included pre-eclampsia/eclampsia (40.7%), DIC (55.5%), antepartum hemorrhage (40.7%), post-partum hemorrhage (22.2%), hemolytic uremic syndrome (33.3%), HELLP syndrome (29.6%) and urinary tract infection (18.5%); some patients had more than one cause of AKI.

In eight (29.6%) post-partum AKI patients, there was retained placenta in the uterus as revealed by ultrasonography findings, whereas abdominal hematoma was observed in five (18.5%) patients.

The symptoms of post-partum AKI were observed within an average of 1.2 ± 1.8 days of delivery. Creatinine levels were increased to a maximum of 8.71 ± 2.5 mg/dL. We found a significant correlation of the number of days after delivery with creatinine levels on admission (r = 0.681, P = 0.000) and their maximum levels (r = 0.413, P = 0.032). D Dimer values, indicators of DIC, were in­creased in 23 patients. The mean hospital stay of the patients was 18.4 ± 14.4 days.

During the hospital stay, 25 (92%) patients required hemodialysis; of these, 17 (68%) pati­ents required more than five sessions of hemodialysis. Five patients (20%) had irreversible kidney injury and three (60%) of them were transplanted. One patient did not require hemodialysis as of early recovery, while one pa­tient died early before the start of hemodialysis because of development of multiple organ failure.

Anemia was a common feature in all the pati­ents, and 24 (88%) patients required blood transfusion with a mean of 4.2 ± 2.9 units, of whom 21 (87%) patients required more than three units of blood transfusion. Two patients died early and one patient did not require blood transfusion.

Of the 22 (81.5%) patients who survived, 11 (40. 7%) had complete recovery of renal func­tion, six (22.2%) had partial recovery and two (7.4%) required chronic dialysis, whereas three (11.1%) had required renal transplant.

Renal biopsies were performed in patients who did not recover or required chronic dia­lysis. Biopsy reports indicate the presence of cortical necrosis in five (18.5%) cases.

Mortality occurred in five (18.5%) patients, of which sepsis accounted for four (80%) cases whereas post-partum hemorrhage occurred in one woman who died after two days of admission.


   Discussion Top


The incidence of pregnancy-related AKI in developed countries is 1-2.8%. In developing countries, the incidence still remains at 9- 25%, mostly due to late referral for pregnancy-related complications. [5] In our study, the inci­dence of post-partum AKI was 3.59%.

Puerperal sepsis was the most common etiology of AKI in the Indian subcontinent in several studies. [6],[7],[8] The high incidence of puer­peral sepsis is mainly due to caesarian section and obstructed labor deliveries by unskilled professionals at primary health care centers in rural areas and late referral to tertiary care centers. Sepsis was more common in preg­nancy with retained placenta in the uterus.

Sepsis accounted for post-partum AKI in 70.3% of our study patients. Similar to our observation, Goplani et al [6] noted puerperal sepsis as the most common (61%) etiology of post-partum AKI in their study. Kumar et al [9] reported puerperal sepsis in 29% of patients with post-partum AKI. However, Ansari et al [7] reported puerperal sepsis in 31% of AKI pa­tients during pregnancy. Riedemann et al reported that AKI occurs in 19% of patients with moderate sepsis, in 23% with severe sepsis and in 51% of patients with septic shock. [10] Patients with sepsis present genera­lized vasodilation, which causes renal hypoperfusion and, consequently, renal failure. [11]

It is generally accepted that pre-eclampsia does not lead to AKI in the absence of other disease processes (hematoma, hemodynamic instability, infection) despite increasing evi­dence suggesting the association between pre-eclampsia and renal injury. [12] In our study, ten of the 11 women with pre-eclampsia had subs­tantial comorbid conditions or obstetric com­plications that could have contributed to AKI.

Post-partum hemorrhage and antepartum hemorrhage were responsible for AKI in 60.9% of non-septic patients in our study. Similar to our observation, hemorrhage was the dominant cause of post-partum AKI in the studies by Naqvi et al (58%), Ansari et al (38%) and Alexopoulos et al (38 %). In con­trast, Kumar et al [9] and Prakash et al [13] observed that hemorrhage of pregnancy constitutes 17% and 18.8% of post-partum AKI, respectively.

Mortality of patients with post-partum AKI seems to be high in the developing countries. Overall, maternal mortality in our study was 18.5%, which is comparable with other recent studies from the Indian subcontinent. [3],[7],[9],[13],[14] Previously, mortality was very high (55.3%) due to late referral, frequent sepsis and high incidence of bilateral diffuse cortical necrosis. [1] The reason for the lower incidence of post-partum AKI in the developed countries is the prevention of pregnancy-related complications through excellent ante-natal care and early and more effective treatment of pre-eclampsia. In our present study, the mortality rate was 18.5%. The combination between AKI and sepsis was associated with a mortality of around 70%. [15] Silva et al studied 128 critically ill patients with AKI and reported that high mortality was observed among patients with sepsis (82% vs. 48%). [15] In our study, four of five (80%) patients died due to sepsis.

AKI in pregnancy is associated with a high risk of bilateral renal cortical necrosis and, consequently, of chronic renal failure. Renal cortical necrosis is an uncommon entity and accounts for only 2% of all the cases of AKI. [13] Obstetric complications such as abruptio pla­centae, septic abortion, pre-eclampsia, post-partum hemorrhage and puerperal sepsis are responsible for renal cortical necrosis in 50- 70% of the cases. In our study, the incidence of cortical necrosis was 18.5%, while it was 23.8% and 14.3% in two different studies previously conducted in India. [6],[8]

In conclusion, post-partum AKI is a common problem in our population. Puerperal sepsis is the most common etiological factor respon­sible for the post-partum AKI. Increased in­volvement of specialties in the care of preg­nant women and improved intra- and post­operative management of cases are advised to reduce the post-partum acute injury, thereby reducing the maternal mortality.


   Acknowledgment Top


The authors are thankful to Dr. Vinod Bhandari, Chairman, Sri Aurobindo Institute of Medical Sciences, Indore for providing infrastructure facilities to carry out this study.

Conflict of interest: None

 
   References Top

1.
Chugh KS, Singhal PC, Sharma BK, et al. Acute renal failure of obstetric origin. Obstet Gynecol 1976;48:642-6.  Back to cited text no. 1
    
2.
Prakash J, Singh RG, Tripathi K, et al. Acute renal failure in pregnancy. J Obstet Gynaecol India 1985;35:233-8.  Back to cited text no. 2
    
3.
Naqvi R, Akhtar F, Ahmed E, et al. Acute renal failure of obstetrical origin during 1994 at one centre. Ren Fail 1996;18:681-3.  Back to cited text no. 3
    
4.
Prakash J. The kidney in pregnancy: A journey of three decade. Indian J Nephrol 2012;22:159-67.  Back to cited text no. 4
[PUBMED]  Medknow Journal  
5.
Gammill HS, Jeyabalan A. Acute renal failure in pregnancy. Crit Care Med 2005;33(10 Suppl):S372-84.  Back to cited text no. 5
    
6.
Goplani KR, Shah PR, Gera DN, et al. Pregnancy related acute renal failure: A single centre experience. Indian J Nephrol 2008;18:7-21.  Back to cited text no. 6
    
7.
Ansari MR, Laghari MS, Solangi KB. Acute renal failure in pregnancy: One year obser­vational study at Liaquat University Hospital, Hyderabad. J Pak Med Assoc 2008; 58:61-4.  Back to cited text no. 7
    
8.
Prakash J, Niwas SS, Parekh A, et al. Acute kidney injury in late pregnancy in developing countries. Ren Fail 2010;32:309-13.  Back to cited text no. 8
    
9.
Kumar KS, Krishna CR, Kumar VS. Pregnancy related acute renal failure. J Obstet Gynaecol India 2006;56:308-10.  Back to cited text no. 9
    
10.
Riedemann NC, Guo RF, Ward PA. The enigma of sepsis. J Clin Invest 2003;112:460-7.  Back to cited text no. 10
    
11.
Schrier RW, Wang W. Acute renal failure and sepsis. N Engl J Med 2004;351:159-69.  Back to cited text no. 11
    
12.
Vikse BE, Irgens LM, Leivestad T, Skjcerven R, Iversen BM. Preeclampsia and risk of end stage renal disease. N Engl J Med 2008;359:800-9.  Back to cited text no. 12
    
13.
Prakash J, Tripathi K, Pandey LK, Gadela SR, Usha. Renal cortical necrosis in pregnancy related acute renal failure. J Indian Med Assoc 1996;94:227-9.  Back to cited text no. 13
    
14.
Rani PU, Narayen G, Anuradha. Changing trends in pregnancy related acute renal failure. J Obstet Gynecol India 2002;52:36-8.  Back to cited text no. 14
    
15.
Silva Junior GB, Daher Ede F, Mota RM, Menezes FA. Risk factors for death among critically ill patients with acute renal failure. Sao Paulo Med J 2006;124:257-63.  Back to cited text no. 15
    

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Correspondence Address:
Dr. Rajesh Bharani
Department of Nephrology, Sri Aurobindo Medical College and Post Graduate Institute, Indore, Madhya Pradesh
India
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DOI: 10.4103/1319-2442.144259

PMID: 25394442

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    Abstract
   Introduction
    Materials and Me...
   Results
   Discussion
   Acknowledgment
    References
 

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