| Abstract|| |
Acute kidney injury (AKI) in pregnancy is associated with significant maternal morbidity and mortality. Several studies from worldwide have shown different frequencies of the causes of pregnancy-related AKI (PRAKI). The present study aimed to provide local data on frequency of causes of PRAKI. A total of 111 pregnant women using nonprobability consecutive sampling technique, with the age group of 18–45 years, admitted with the diagnosis of PRAKI were included in the study. The information regarding age, duration of pregnancies, serum creatinine levels, and outcome variables (complications) were collected from each patient. Effect modifiers were controlled by stratification. The mean age was 29.90 ± 5.40 years. Out of 111 cases, 10 (9%) developed AKI in the 1st trimester, 12 (10.8%) in the 2nd trimester, 13 (11.7%) cases in the 3rd trimester, and rest of the 76 (68.4%) cases were of the postpartum period. The etiology of PRAKI was multifactorial in several patients. The frequencies of complication leading to AKI were observed individually. The results showed that 21 (18.9%) had antepartum hemorrhage, 41 (36.9%) postpartum hemorrhage, 33 (29.7%) puerperal sepsis, 11 (9.9%) preeclampsia, 13 (11.7%) eclampsia, 11 (9.9%) hemolysis, elevated liver enzymes, and low-platelet count syndrome, 7 (6.3%) hemolytic uremic syndrome, and 5 (4.5%) had hyperemesis gravidarum. The results of the present study showed no statistically significant association of age with the individual complications with P >0.05. AKI during pregnancy was mostly due to prerenal causes. The most common cause was postpartum hemorrhage followed by puerperal sepsis and antepartum hemorrhage.
|How to cite this article:|
Haroon F, Dhrolia MF, Qureshi R, Imtiaz S, Ahmed A. Frequency of pregnancy-related complications causing acute kidney injury in pregnant patients at a tertiary care hospital. Saudi J Kidney Dis Transpl 2019;30:194-201
|How to cite this URL:|
Haroon F, Dhrolia MF, Qureshi R, Imtiaz S, Ahmed A. Frequency of pregnancy-related complications causing acute kidney injury in pregnant patients at a tertiary care hospital. Saudi J Kidney Dis Transpl [serial online] 2019 [cited 2019 Mar 23];30:194-201. Available from: http://www.sjkdt.org/text.asp?2019/30/1/194/252910
| Introduction|| |
Acute kidney injury (AKI) represents a challenging clinical condition when it occurs during pregnancy. The worldwide incidence of pregnancy-related AKI (PRAKI) has decreased markedly in the past from 20% to 40% in 1960 to <10% in the 80s through the legalization of abortion and improvement of antenatal and obstetric care. Whereas the incidence of PRAKI has decreased in developed countries to only 1%–2.8% following the disappearance of septic abortion and a better perinatal care by 90s,, PRAKI is still frequent in developing countries; and its incidence there varies considerably from one country to the other and within the same country, from one region to the other. In this context, PRAKI represents 6%–36% of all adult cases of AKI.,
Limited access to prenatal care and to abortion services is the main reason for the high incidence of PKAKI in the developing world, and in other similar populations. Data from South Asia suggest that PRAKI continues to account for 10% of total AKI cases and that mortality rates remain as high as 20%., In an inner-city population in Atlanta, a low renal recovery rate of approximately 50% raises concerns about access to care in certain populations even in the United States.
PRAKI makes up about 25% of referrals for dialysis in a tertiary care center and is associated with substantial maternal and fetal mortality. Coincident with declines of PRAKI in the developed world, there has been little change in the overall mortality and long-term morbidity rates. From the 1950s through the 1990s, overall mortality rates have ranged from 0-30% with no clear trend over time.  Longterm prognosis has also remained fairly consistent over time, with full renal recovery rates of 60%–90%.,
Caring for women diagnosed with AKI is a real challenge for nephrologists and their medical team. Cases of AKI specific to pregnancy exhibit a tripartite distribution: AKI of the first trimester associated with gravidic vomiting and medically unsupervised septic abortions, AKI of the third trimester which occurs mainly in the context of hypertensive disorders, and postpartum AKI which is secondary to septic states and thrombotic microangiopathies. Preeclampsia in its classical form is not usually accompanied by AKI. It is in severe forms of preeclampsia that AKI is frequent, or in the presence of an additional obstetric complication, such as abruptio placentae, hemolysis, elevated liver enzymes, and low-platelet count (HELLP) syndrome and disseminated intravascular coagulation (DIC). Recovery of renal function is the rule, occurring in 60%–90% of cases. Acute tubular necrosis (ATN) is the most common condition with a good prognosis compared to other pathology such as severe eclampsia, HELLP syndrome, and DIC where the glomerular involvement is preeminent.
In addition to the estimated impact of PRAKI in previously healthy patients, it is well-known that in women with underlying chronic renal dysfunction (baseline serum creatinine >1.4 mg/dL), there is a significantly increased risk of pregnancy-related loss of renal function (43%), and an estimated 10% of patients experience rapid deterioration in renal function.
Several studies from worldwide have shown different frequencies of the causes of renal failure in pregnancy. In recent studies from India, sepsis was the most common etiological factor (41.7%–63.1%)., Studies from other parts of the world show thrombotic microangiopathies, HELLP syndrome, and preeclampsia as the common causes. Previous study from Pakistan showed antepartum hemorrhage in 25.71%, eclampsia in 17.14%, DIC in 14.28%, and sepsis in 11.42%.
To limit the overall incidence of disease, primary prevention through improved access to prenatal care is the key. On the other hand, affecting mortality and long-term renal recovery is the focus of acute care for these patients, since early and appropriate management can prevent or limit irreversible change.
The aim of this study was to find out the current pattern of pregnancy-related etiological factors of renal dysfunction in our local population. It will help us to determine the frequency of different pregnancy-related conditions which cause AKI. The results of this study can give future recommendations to manage these conditions.
| Materials and Methods|| |
A total of 111 patients of PRAKI aged between 18 to 45 years, who were admitted at the Department of Nephrology, Jinnah Postgraduate Medical Center, Karachi were included in this study. This was a cross-sectional study and samples were collected on the nonprobability consecutive sampling technique. The study was conducted from August 19, 2015, to February 18, 2016. The purpose and benefit of the study were explained to the patient and written informed consent was obtained. The data were collected by preformed structure performa.
The confounding factors were controlled by excluding patients with known history of renal disease, hypertension, or diabetes mellitus before pregnancy.
The information regarding age(years), duration of pregnancies(1st, 2nd, 3rd, and postpartum), serum creatinine levels and outcome variables (antepartum hemorrhage, postpartum hemorrhage, puerperal sepsis, preeclampsia, eclampsia, HELLP syndrome, hemolytic uremic syndrome (HUS), and hyperemesis gravidarum from each patient was collected.
| Statistical analysis|| |
Data were analyzed using Statistical Package for Social Sciences (SPSS) version 21.0 (IBM Corp. Armonk, NY, USA) Qualitative data, duration of pregnancy and outcome variable (antepartum hemorrhage, postpartum hemorrhage, puerperal sepsis, preeclampsia, eclampsia HELLP syndrome, HUS, and hyperemesis gravidarum) were expressed as frequency and percentage. Quantitative data (age and serum creatinine) were calculated as mean and standard deviation. Age of the patient was then be classified into three groups (<25 years, 25–30 years, >30 years). Stratification of the outcome variable (antepartum hemorrhage, postpartum hemorrhage, puerperal sepsis, preeclampsia, eclampsia HELLP syndrome, HUS, and hyperemesis gravidarum) was done with regard to age groups.
| Results|| |
A total of 111 pregnant women of age 18 to 45 years, diagnosed with AKI secondary to pregnancy-related complications presented during pregnancy or after delivery (within 6 weeks period of puerperium) were included in the study to determine the frequency of different pregnancy-related conditions responsible for AKI. Descriptive statistics were calculated using SPSS version 21. Stratification was done to see the effect of modifiers on the outcome. Chi-square test was applied poststratification and P ≤0.05 was considered as statistically significant.
The results showed that the mean age was 29.90 ± 5.40 years. The distribution of age is presented in [Figure 1]. The mean serum creatinine was 5.79 ± 1.88 mg/dL [Figure 2].
|Figure 2: Histogram presenting distribution of serum creatinine (mg/dL) (n = 111).|
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Out of 111 cases, 10 (9%) developed AKI in 1st tri-mester, 12 (10.8%) in the 2nd trimester, 13 (11.7%) cases in the 3rd trimester, and rests of the 76 (68.4%) cases were of postpartum period [Table 1].
The etiology of AKI was multifactorial in several patients. The frequencies of complication leading to AKI were observed individually. The results showed that 21 (18.9%) had antepartum hemorrhage, 41 (36.9%) postpartum hemorrhage, 33 (29.7%) puerperal sepsis, 11 (9.9%) preeclampsia, 13 (11.7%) eclampsia, 11 (9.9%) HELLP syndrome, seven (6.3%) HUS, and five (4.5%) had hyperemesis gravidarum [Figure 3]. Of patients with preeclampsia and eclampsia, 11 (45.8%) patients had concomitant HELLP syndrome and three (12.5%) had concomitant HUS. Of patient with antepartum/postpartum hemorrhage, 17 (27.4%) had concomitant sepsis.
|Figure 3: Bar chart presenting the frequency of complications leading to acute kidney injury.|
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Stratification with respect to age was done to observe effect of this modifier on outcomes i.e., complications. The results of the study showed no statistically significant association of age with the individual complications with P >0.05 [Table 2].
|Table 2: Association of age (years) with the pregnancy-related complications causing acute kidney injury.|
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| Discussion|| |
AKI in pregnancy follows a bimodal distribution. There are peaks in the first trimester (related to unregulated and/or septic abortion) and the late third trimester (related to obstetric complications) leading to cortical necrosis in 3%–20%,, maternal mortality in 6–25, and fetal mortality in 60% of the cases. AKI due to sepsis has fallen significantly relative to the incidence secondary to obstetric complications (e.g., abruption placentae, amniotic fluid embolism, and postpartum hemorrhage) in developed countries. In developing countries, the incidence of PRAKI is still high, mainly due to the lack of education and antenatal care.,
AKI in pregnancy is a common medical problem in our region. Delay in diagnosis and late referral is associated with increased mortality. AKI is usually multifactorial in pregnancy and s factors can influence the outcome of AKI.
In the third world countries, pregnancy still causes 20% of the AKI related maternal mortality., All the factors that can cause AKI in a nonpregnant woman can theoretically cause AKI in a pregnant woman. Important causes in pregnancy include causes such as hyperemesis gravidarum, uterine hemorrhage, abruption placentae, acute pyelonephritis, septic abortion, and renal cortical necrosis.
The endothelial cell injury is the starting point with subsequent vasospasm, platelet activation, unbalanced prostacyclin-thromboxane ratio, and decreased release of endothelium-derived relaxing factor, playing central role in the pathogenesis of several disorders such as preeclampsia, hemolysis, HELLP syndrome, thrombotic thrombocytopenic purpura, HUS, acute fatty liver of pregnancy, and acute renal failure.
The incidence of PRAKI has decreased in developed countries over the past 60 years from one in 3000 in the mid-20th century to 1 in 20,000. However, PRAKI still comprises 25% of referrals to dialysis center in developing countries. Septic abortion as a cause of PRAKI decreased from 33.3% to 6.3%; however, it still remains the common cause of PRAKI in developing countries. Worldwide, one of the major causes of sepsis leading to PRAKI is illegal abortion. At least 5% of women undergoing illegal abortions become gravely ill.
Puerperal sepsis and postpartum hemorrhage are the leading causes of ATN in the postpartum period.  Renal cortical necrosis, a rare and irreversible cause of AKI, accounts for about 2% of all cases of AKI; and 50%–70% of these cases are associated with complications of pregnancy.
A transient decline in glomerular filtration rate with pregnancy-associated complications is not uncommon. It occurs once in 8000 deliveries while PRAKI requiring dialysis occurs in approximately one in 20,000 pregnancies. Recent studies have shown that patients in the risk and injury groups on RIFLE criteria of AKI had a good outcome as compared to the failure group.
A recent study conducted in India in 2015, showed 98/2890 (3.39%) suffering from PRAKI during the study period. Out of these patients, 15 patients (15.3%) developed PRAKI in the first trimester of pregnancy, 28 (28.57%) in the second trimester, and 55 (56.12%) in the third trimester of pregnancy. The most common cause was sepsis. Twenty-five (25.51%) developed sepsis after abortion by local village practitioners or traditional birth attendants, 7 (7.14%) after medical termination of pregnancy at primary health centers, and 23 (23.46%) had puerperal sepsis. Twenty-three (23.46%) developed PRAKI following antepartum and postpartum hemorrhage, 14 (14.28%) after preeclampsia/eclampsia, four (4.08%) after hemolysis, elevated liver enzymes and low-platelet (HELLP) syndrome, and two (2.02%) had postpartum HUS.
In a Moroccan study, PRAKI was more frequent in the 3rd trimester (61%) and 22% in the postpartum. Another study conducted in Pakistan in 2011, showed that out of 3285 admissions in the obstetric ward, 35(1.0655%) had PRAKI problems. Out of 35 women, 31.42% had postpartum hemorrhage. Antepartum hemorrhage was found in 25.71%, eclampsia in 17.14%, DIC in 14.28%, and sepsis in 11.42%.
Keeping the observed studies in mind, our results mostly correlated with the studies from both India and Pakistan. Out of the patients admitted to the nephrology ward with PRAKI, 10 (9.0%) were in the first trimester, 12 (0.8%) in the second trimester, 13 (11.7%) in the third trimester and 76 (68.5%) in the postpartum stage. Out of these patients, the most frequent pregnancy-related problem in this study was postpartum hemorrhage 41 (36.9%) followed by puerperal sepsis in 33 (29.7%) of patients and the third most common problem faced by the pregnant mothers was antepartum hemorrhage in 21 (18.9%). Besides these the other PRAKI problems in our study cohort were eclampsia in 13 (11.7%) patients, preeclampsia in 11 (9.9%) patients, HELLP syndrome also in 11 (9.9%) patients, HUS in seven (6.3%) patients, and hyper emesis gravidarum in five (4.5%) patients.
Data from Pakistan on PRAKI are very sparse; although, this is a very serious health issue. Karachi has the maximum healthcare facilities as compared to the rest of the country so the problem in other less privileged areas need more attention, where it is expected to be much higher than the main cities of the country because of multiple factors, such as social trends of Dai assisted home deliveries, poverty, remote, under-manned and under-equipped district headquarter hospitals, the high parity, because of religious belief of not following the family planning practices. The root cause of the problem seems to be either lack of facilities or lack of access to the available healthcare facilities.
| Limitations of the study|| |
The main limitations of the present study include a single-center experience and non-randomized study design. One of the limitations of this study is that it was conducted with small sample size and in urban environment; therefore, the results might not be generalizable to populations of the whole country. The study is conducted at nephrology ward so the cases with early PRAKI (Risk or Injury in RIFLE criteria) could be missed.
| Ethical issues|| |
Principles laid down by the Helsinki decalration were observed. All participants were duly informed and made their free choice to join the study. Formal written informed consent was obtained from the patients.
| Conclusion|| |
The present study showed that AKI during pregnancy was mostly due to prerenal causes.
Most of the patients were in the postpartum period followed by the patients with 3rd trimester. The most common cause was postpartum hemorrhage followed by puerperal sepsis and antepartum hemorrhage. These factors can be prevented with good antenatal care and education. Any patient with PRAKI should be referred early for prompt diagnosis and timely nephrological intervention. Ideal care for women with AKI in pregnancy or postpartum requires a multidisciplinary approach that may include maternal-fetal medicine, critical care medicine, nephrology, and neonatology specialists.
Conflict of interest:
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Murtaza F Dhrolia
Department of Nephrology, The Kidney Centre Postgraduate Training Institute, Karachi 75530
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]