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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE  
Year : 2018  |  Volume : 29  |  Issue : 4  |  Page : 837-845
Characteristics and outcome of postpartum acute kidney injury requiring dialysis: A single-center experience from North India


1 Department of Nephrology, Sawai Man Singh Medical College, Jaipur, Rajasthan, India
2 Department of Pathology, Sawai Man Singh Medical College, Jaipur, Rajasthan, India

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Date of Submission20-Dec-2017
Date of Decision23-Jan-2018
Date of Acceptance01-Feb-2018
Date of Web Publication28-Aug-2018
 

   Abstract 

Postpartum acute kidney injury (AKI) is one of the serious complications of pregnancy and is associated with high mortality and morbidity. We conducted this study to determine the characteristics and outcome of the most severe form of postpartum AKI requiring dialysis. This prospective, observational study was conducted in Sawai Man Singh Medical College, Jaipur. All postpartum female suffering from AKI requiring dialysis between July 2014 and December 2016 were included in the study. Demographic, clinical and laboratory data of the patients were recorded. Outcome variables included survival at hospital discharge and estimated glomerular filtration rate (eGFR) at three months of follow-up. Sixty (88.2%) out of 68 women admitted with postpartum AKI required dialysis. The mean age was 26.5 ± 4.3 years and the majority (80%) had institutional delivery. The mean sequential organ failure assessment (SOFA) score was 8.0 ± 2.9. Puerperal sepsis (n = 37, 61.6%), preeclampsia (n = 21, 35%), and antepartum hemorrhage (n = 14, 23.3%) were the most common obstetric complication associated with postpartum AKI. Maternal mortality was 28.3%. Higher SOFA score (P = 0.015, odds ratio [OR]: 1.99, confidence interval [CI]: 1.14–3.45) and diagnosis of sepsis (P = 0.048, OR: 26.3, CI: 1.03–678.3) were the independent predictors of mortality. Out of 37 patients who were followed up at three months, 51.3% had eGFR <60 mL/min/1.73 m2. Duration of anuria (in days) was the only independent predictor of (eGFR <60 mL/min/1.73 m2 at three months of follow-up (P = 0.029, OR: 1.2, CI: 1.02–1.46). Postpartum AKI requiring dialysis was associated with high mortality. More than half of the survivors had eGFR <60 mL/min/1.73 m2 on follow-up highlighting the need of appropriate follow-up.

How to cite this article:
Tanwar RS, Agarwal D, Gupta RK, Rathore V, Beniwal P, Joshi P, Malhotra V. Characteristics and outcome of postpartum acute kidney injury requiring dialysis: A single-center experience from North India. Saudi J Kidney Dis Transpl 2018;29:837-45

How to cite this URL:
Tanwar RS, Agarwal D, Gupta RK, Rathore V, Beniwal P, Joshi P, Malhotra V. Characteristics and outcome of postpartum acute kidney injury requiring dialysis: A single-center experience from North India. Saudi J Kidney Dis Transpl [serial online] 2018 [cited 2019 Nov 17];29:837-45. Available from: http://www.sjkdt.org/text.asp?2018/29/4/837/239663

   Introduction Top


The incidence of pregnancy-related acute kidney injury (PR-AKI) varies from 1 in 20,000 in developed countries[1] to 1 in 56 in developing countries[2] and may account for 8.3%-18% of AKI admitted to hospitals[3],[4] and 15% of the referrals to dialysis centers in developing countries.[5] Although there is a decrease in the incidence of obstetric AKI with improved obstetric care,[3] PR-AKI still remains a therapeutic challenge.

The common causes of PR-AKI are potentially preventable obstetric complications such as sepsis, hemorrhage, and toxemia of pregnancy.[3] With improvement in antenatal care and legalization of abortion, majority of the PR-AKI are now reported in late pregnancy and puerperium,[3] with postpartum AKI contributing up to 26%–70% of PRAKI.[6],[7],[8],[9] The severest form of postpartum AKI requiring dialysis is often associated with significant mortality and short-term morbidity[3],[6],[7],[8],[9] as well as increased risk of developing chronic kidney disease.[10],[11] However, the outcomes of post-partum AKI requiring dialysis from developing countries are scarcely studied.[8],[9],[10],[11] Therefore, characteristics and outcomes of postpartum AKI requiring dialysis is worth studying.

We undertook this study to investigate the characteristics of postpartum AKI and to determine its outcome.


   Subjects and Methods Top


Study center

This prospective study was carried out in the Department of Nephrology, Sawai Man Singh (SMS) Medical College, a tertiary care teaching institute situated in the North Indian city of Jaipur. It has a well-established nephrology department with peritoneal dialysis, hemo-dialysis, and renal transplant unit. Obstetric care is mainly provided by two associated hospitals, namely Mahila Chikitsalaya and Zenana Hospital attached to SMS medical college. Obstetric patients suffering from renal injury are referred to the Department of Nephrology for further management.

Study subject

The study included all patients with post-partum (<12 weeks after delivery) AKI referred to our center from July 2014 to December 2016 who required dialysis. The need and modality of dialysis were determined by the treating nephrologist based on standard indications of dialysis.

Patients with underlying renal disease before pregnancy, hypertension before pregnancy, presence of renal stone, renal scarring, or small size kidney on ultrasonography were excluded from the study.

Data collection

Demographic, clinical, and laboratory data of the patients were obtained by interviewing the patients and reviewing the medical records and were recorded in a standard proforma. Specific inquiries were conducted with regard to the mode of delivery, symptomatology, and surgical interventions.

Sequential organ failure assessment (SOFA) score was calculated based on physiological data, which included the most abnormal values in the first 24 h of hospital admission.[12]

Outcome

The primary outcome was survival at hospital discharge. The secondary outcome was estimated glomerular filtration rate (eGFR) at three months of follow-up after discharge. eGFR was calculated by chronic kidney disease-epidemiology collaboration formula.[13] For comparison, patients were divided into two groups based on eGFR at three months of follow-up: Group 1 (eGFR >60 mL/min/1.73 m2) and Group 2 (eGFR <60 mL/min/1.73 m2).

Renal biopsy

Renal biopsy was performed by a trained nephrologist under ultrasound guidance. The need and the timing of renal biopsy were determined by the treating nephrologist. Typically, renal biopsy was performed if the diagnosis was uncertain or when there was inadequate recovery at the end of three weeks.


   Statistical Analysis Top


Continuous variables are presented as mean ± standard deviation or median and interquartile range (IQR) and compared using Student's t- test or Mann-Whitney U-test, where appropriate. Categorical variables are presented as proportions and compared using Pearson's Chi-square test. Multivariate logistic regression was performed to identify variables independently associated with the outcomes. All variables with a P ≤0.25 on univariate analysis were included in multivariate analysis. The statistical analysis was performed using the Statistical Package for Social Sciences version 20.0 (IBM Corp., Armonk, NY). P <0.05 was considered statistically significant.


   Results Top


Out of 531 patients admitted with AKI during the study period, 68 (12.8%) had postpartum AKI. Sixty women with postpartum AKI (88.2%) who underwent dialysis were included in the study. The mean age of the study population was 26.5 ± 4.3 years. Twenty-five patients (41.7%) were primigravida. Forty-eight patients (80.0%) had institutional delivery. Seventeen (28.3%) patients delivered by lower section cesarean section. The mean SOFA score was 8.0 ± 2.9 [Table 1].
Table 1: Characteristics of the study population and its association with survival.

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Outcome

Seventeen women died during the hospital admission. The maternal mortality was 28.3%. The median time from admission to death was 4 (1.5–14.0) days. Of 43 survivors 6 (13.9%) patients did not turn up for follow-up. Nearly 37 (86.0%) patients were followed at three months after discharge. Eleven (29.7%) patients had eGFR more than 90 mL/min/1.73 m2, seven (18.9%) had eGFR between 60–89 mL/min/1.73 m2, 11 (29.7%) had eGFR between 30–59 mL/min/1.73 m2, five (13.5%) had eGFR between 15 and 29 mL/min/1.73 m2 while three (8.1%) had eGFR <15 mL/min/ 1.73 m2. Two (5.4%) patients continued to require dialysis at three months of follow-up [Figure 1].
Figure 1: Outcomes of postpartum acute kidney injury requiring dialysis.

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Clinical characteristics of the study population and its association with survival

Oliguria (n = 39, 65%) and anuria (n = 13, 21.7%) were commonly present at admission. Other common clinical features were edema, dyspnea, fever, and encephalopathy. Nearly 19 (31.7%) required vasoactive support at admission while nine (15.0%) patients required mechanical ventilation. Fifty-four (90.0%) patients received hemodialysis, 25 (41.7%) received peritoneal dialysis while 19 (31.7%) had received both modalities of dialysis [Table 1].

Nearly 53 (88.3%) patients were anemic (defined as hemoglobin <10.0 g/dL), 45 (75.0%) had thrombocytopenia (defined as platelets count <100,000/mm3), and nine (15%) had hyperkalemia (defined as serum potassium >5.5 mEq/L).

The most common pregnancy-related complication contributing to AKI was puerperal sepsis (n = 37, 61.6%), followed by preeclampsia (n = 21, 35%), antepartum hemorrhage (n = 14, 23.3%), intrauterine death (n = 14, 23.3%), and postpartum hemorrhage (n = 7, 11.7%). Two patients had thrombotic microangiopathy while two patients had malaria and one had dengue hemorrhagic fever. Those who died had higher mean SOFA score (9.9 ± 3.2 vs. 7.1 ± 2.2, P = 0.001), and were more likely to have puerperal sepsis (82.3% vs. 53.4%, P = 0.038).

Multivariate logistic regression analysis revealed higher SOFA score [P = 0.015, odds ratio (OR): 1.99, confidence interval (CI): 1.14-3.45] and diagnosis of puerperal sepsis (P = 0.048, OR: 26.3, CI: 1.03–678.3) as an independent predictor of mortality.

Clinical characteristics of the study population and its association with estimated glomerular filtration rate at three months

Thirty-seven patients who followed up at three months were divided into two groups based on eGFR. Group 1 had eGFR >60 mL/ min/1.73 m2 at three months of follow-up while group 2 had eGFR <60 mL/min/1.73 m2. The median duration of oliguria (urine output <400 mL/24 h) was significantly higher among those who had eGFR less than 60 mL/min/ 1.73 m2 (10 days, IQR 6–18) as compared to those who had eGFR more than 60 mL/min/ 1.73 m2 (5 days, IQR: 4–7.25) (P = 0.029) [Table 2].
Table 2: Characteristics of the survivors and its association with renal outcomes at three months of follow-up.

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On multivariate logistic regression analysis, longer duration of oliguria was the only independent predictor of GFR <60 mL/min/m2 (P = 0.029, OR: 1.2, CI: 1.02–1.46).

Renal biopsy

Renal biopsy was performed in 11 (18.3%) patients, six patients had evidence of cortical necrosis, two patients had acute tubular necrosis, two patients had thrombotic microangiopathy and another patient's biopsy was inadequate for opinion.


   Discussion Top


A very high percentage of women suffering from postpartum AKI required dialysis in our study. This probably is due to referral bias as patient with the most severe form of renal injury are being referred to our center. PR-AKI requiring dialysis seems to be rare event in high-income countries.[1],[7] A recent population-based retrospective cohort study from Canada found out an incidence PR-AKI requiring dialysis to be 1:10,000, almost half of them (53.7%) being postpartum AKI.[7] However single-center experiences, of nephrology units from low-income countries, are more or less similar to ours [Table 3]. Godara et al reported dialysis requirement in 87.7% of their cohort of PR-AKI most of whom had presented in puerperium.[14]
Table 3: Recent studies on pregnancy-related acute kidney injury.

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The most common maternal complication associated with AKI was puerperal sepsis, followed by toxemia of pregnancy and ante-partum hemorrhage. In contrast, literature from high-income countries reports preeclampsia as the most common maternal complication associated with PR-AKI with incidence of sepsis being 0%–18%.[7],[15],[16] High incidence of sepsis despite the majority of delivery being institutional (80%) is a cause for concern and calls for improvement in aseptic practices during delivery. Other studies from India too reports puerperal sepsis as the commonest cause of PR-AKI and postpartum AKI [Table 3].[2],[3],[5],[8],[9],[10],[11]

The maternal mortality in our cohort was 28.3%. The high maternal mortality is in contrast to reported mortality of 0%–4.3% from high-income countries[1],[7] and is consistent with other Indian studies [Table 3].[6],[8],[10] SOFA score and diagnosis of sepsis were the two independent predictors of mortality in our study. SOFA score has been found to be a good predictor of maternal mortality in other studies as well.[17],[18] The higher mortality in our cohort may be due to higher severity of illness at admission as reflected by high SOFA score. Similarly, puerperal sepsis has been found to be a predictor of mortality in a Brazilian study.[19]

Nineteen (51.3%) patients had eGFR <60 mLl/min/1.73 m2 while two (5.4%) patients remained dialysis dependent. The percentage of patients remaining dialysis dependent following PR-AKI has been reported to be 2.5%–18.5% [Table 3].[10],[20] Almost half of those who followed up at three months had eGFR <60 mL/min/1.73 m2. This fact highlights the need of appropriate follow-up for the patients suffering from postpartum AKI requiring dialysis. While, we have reported the outcome at three months as estimated GFR, most of the other studies have reported outcome as dialysis dependence, partial recovery, and complete recovery, with varying definition [Table 3]. Duration of oliguria (in days) was the only predictor of eGFR <60 mL/min/1.73 m2 at three months of follow-up.

Fourteen percent (n = 6) patients were lost to follow-up, which was one of the major limitation of our study. Another major limitation was unavailability of baseline serum creatinine, because of which possibility of women with progressive kidney disease being included in the study is not ruled out despite extensive exclusion criteria.

To conclude, postpartum AKI requiring dialysis is associated with high maternal mortality and almost half of the survivors had eGFR <60 mL/min/1.73m2 at three months of follow-up. Puerperal sepsis, preeclampsia, and antepartum hemorrhage were the most common maternal complication associated with postpartum AKI. The severity of diseases at admission as assessed by SOFA score and diagnosis of sepsis were predictors of maternal mortality, while days of anuria predicted eGFR <60 mL/min/1.73 m2 at three months of follow-up.

Conflict of interest: None declared.

 
   References Top

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Stratta P, Besso L, Canavese C, et al. Is pregnancy-related acute renal failure a disappearing clinical entity? Ren Fail 1996;18: 575-84.  Back to cited text no. 1
    
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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. 2
    
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Prakash J, Pant P, Prakash S, et al. Changing picture of acute kidney injury in pregnancy: Study of 259 cases over a period of 33 years. Indian J Nephrol 2016;26:262-7.  Back to cited text no. 3
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Chugh KS, Sakhuja V, Malhotra HS, Pereira BJ. Changing trends in acute renal failure in third-world countries – Chandigarh study. Q J Med 1989;73:1117-23.  Back to cited text no. 5
    
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Makusidi AM, Liman HM, Yakubu A, et al. Hemodialysis among pregnancy related acute kidney injury patients: A single center experience in North-Western Nigeria. Indian J Nephrol 2016;26:340-2.  Back to cited text no. 6
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Hildebrand AM, Liu K, Shariff SZ, et al. Characteristics and outcomes of AKI treated with dialysis during pregnancy and the post-partum period. J Am Soc Nephrol 2015;26: 3085-91.  Back to cited text no. 7
    
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Eswarappa M, Madhyastha PR, Puri S, et al. Postpartum acute kidney injury: A review of 99 cases. Ren Fail 2016;38:889-93.  Back to cited text no. 8
    
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Arora N, Mahajan K, Jana N, Taraphder A. Pregnancy-related acute renal failure in Eastern India. Int J Gynaecol Obstet 2010;111 : 213-6.  Back to cited text no. 9
    
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Vincent JL, Moreno R, Takala J, et al. The SOFA (Sepsis-related organ failure assessment) score to describe organ dysfunction/failure. On behalf of the working group on sepsis-related problems of the European society of intensive care medicine. Intensive Care Med 1996;22: 707-10.  Back to cited text no. 12
    
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Levey AS, Stevens LA, Schmid CH, et al. A new equation to estimate glomerular filtration rate. Ann Intern Med 2009;150:604-12.  Back to cited text no. 13
    
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Godara SM, Kute VB, Trivedi HL, et al. 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.  Back to cited text no. 14
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Jonard M, Ducloy-Bouthors AS, Boyle E, et al. Postpartum acute renal failure: A multicenter study of risk factors in patients admitted to ICU. Ann Intensive Care 2014;4:36.  Back to cited text no. 15
    
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Mehrabadi A, Liu S, Bartholomew S, et al. Hypertensive disorders of pregnancy and the recent increase in obstetric acute renal failure in Canada: Population based retrospective cohort study. BMJ 2014;349:g4731.  Back to cited text no. 16
    
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Jain S, Guleria K, Suneja A, Vaid NB, Ahuja S. Use of the sequential organ failure assessment score for evaluating outcome among obstetric patients admitted to the Intensive Care Unit. Int J Gynaecol Obstet 2016;132: 332-6.  Back to cited text no. 17
    
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Najar MS, Shah AR, Wani IA, 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. 20
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Correspondence Address:
Dr. Vinay Rathore
Department of Nephrology, Sawai Man Singh Medical College, Jaipur - 302 004, Rajasthan
India
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DOI: 10.4103/1319-2442.239663

PMID: 30152420

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