RENAL DATA FROM THE ARAB WORLD
|Year : 2015 | Volume
| Issue : 3 | Page : 619-624
|Outcome assessment of pregnancy-related acute kidney injury in Morocco: A national prospective study
Nadia Kabbali1, Nabil Tachfouti2, Mohammed Arrayhani1, Mustapha Harandou3, Mounia Tagnaouti4, Yassamine Bentata5, Inass Laouad6, Benyounes Ramdani7, Rabia Bayahia8, Zouhair Oualim9, Tarik Sqalli Houssaini1
1 Nephrology Department, Hassan II University Hospital, Fez, Morocco
2 Epidemiology Department, Faculty of Medicine and Pharmacy, Hassan II University Hospital, Fez, Morocco
3 Intensive Care Unit, Hassan II University Hospital, Fez, Morocco
4 Nephrology Department, Mohammed V Hospital, Tangier, Morocco
5 Nephrology Department, Mohammed VI University Hospital, Oujda, Morocco
6 Nephrology Department, Mohammed VI University Hospital, Marrakech, Morocco
7 Nephrology Department, Ibn Rochd University Hospital, Casablanca, Morocco
8 Nephrology Department, Ibn Sina University Hospital, Rabat, Morocco
9 Nephrology Department, Mohammed V Military Hospital, Rabat, Morocco
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|Date of Web Publication||20-May-2015|
| Abstract|| |
Acute kidney injury (AKI) is a rare but life-threatening complication of pregnancy. The aim of this paper is to study the characteristics of acute AKI in pregnancy and to emphasize on its management modalities in Moroccan hospitals. This is a national prospective study performed over six months from July 1 to December 31 2010 on AKI developing in pregnant patients, both preand post-partum period. Patients with pre-existing kidney disease were excluded from the study. Outcome was considered unfavorable when complete recovery of renal function was not achieved and/or maternal death occurred. Forty-four patients were included in this study. They were 29.6 ± 6 years old and mostly illiterate (70.6%). Most AKI occurred in the post-partum period, with 66% of the cases occurring in those who did not receive antenatal care. The main etiologies were pre-eclampsia (28 cases), hemorrhagic shock (six cases) and septic events (five cases). We noted three cases of acute fatty liver, one case of obstructive kidney injury and one case of lupus nephritis. Hemodialysis was necessary in 17 (38.6%) cases. The outcome was favorable in 29 patients. The maternal mortality rate was 11.4%. Two poor prognostic factors were identified: Age over 38 years and sepsis. AKI is a severe complication of pregnancy in developing countries. Its prevention necessitates the improvement of the sanitary infrastructure and the establishment of the obligatory antenatal care.
|How to cite this article:|
Kabbali N, Tachfouti N, Arrayhani M, Harandou M, Tagnaouti M, Bentata Y, Laouad I, Ramdani B, Bayahia R, Oualim Z, Houssaini TS. Outcome assessment of pregnancy-related acute kidney injury in Morocco: A national prospective study. Saudi J Kidney Dis Transpl 2015;26:619-24
|How to cite this URL:|
Kabbali N, Tachfouti N, Arrayhani M, Harandou M, Tagnaouti M, Bentata Y, Laouad I, Ramdani B, Bayahia R, Oualim Z, Houssaini TS. Outcome assessment of pregnancy-related acute kidney injury in Morocco: A national prospective study. Saudi J Kidney Dis Transpl [serial online] 2015 [cited 2021 Jun 14];26:619-24. Available from: https://www.sjkdt.org/text.asp?2015/26/3/619/157426
| Introduction|| |
Acute kidney injury (AKI) is a rare but lifethreatening complication of pregnancy. The incidence of AKI in pregnancy has been decreasing from one per 2000 pregnancies to one in 20,000 pregnancies in developed countries.  This low incidence can probably be attributed to improved antenatal and perinatal obstetric care. Conversely, the incidence is higher and continues to be a major problem in developing countries, resulting in high maternal mortality. ,
Septic abortion is the most common cause of AKI in early pregnancy, whereas toxemia of pregnancy, hemorrhage and ischemic acute tubular necrosis are the responsible factors during late pregnancy.  Acute fatty liver is an uncommon cause of AKI in pregnancy. It occurs in the third trimester of pregnancy. Puerperal sepsis and thrombotic microangiopathy are mostly seen in the post-partum period.
We undertook this study to investigate the characteristics of pregnancy-related AKI and to evaluate the contributing factors responsible for unfavorable outcome.
| Methods|| |
On initiative of the Moroccan Society of Nephrology, we conducted a national-level prospective study from July 1 to December 31, 2010. All pregnant and post-partum patients (3 months) with pregnancy-related AKI were included in this study. Patients with pre-existing kidney disease before pregnancy were excluded.
For this prospective study, data were collected from a questionnaire that was validated by an expert committee belonging to the Scientific Committee of the Moroccan Society of Nephrology.
We studied different aspects:
- Population: Age, sex, history and antenatal care.
- AKI: Factors such as clinical features, biochemical values, date of occurrence and etiology.
- The maternal renal function outcome.
- The maternal outcome.
Pre-eclampsia was defined by a set of three signs: Hypertension [systolic blood pressure (SBP) ≥140 mm Hg and/or diastolic blood pressure (DBP) ≥90 mm Hg], edema, and proteinuria after 20 weeks of gestation. Eclampsia was defined by the existence of generalized convulsions and/or loss of consciousness occurring during pregnancy or post-partum in preeclampsia. HELLP syndrome (hemolysis, elevated liver enzymes, low platelet count) was defined by the existence of three main features: Hemolysis, elevated liver enzymes and low platelet count. Post-partum is the period beginning immediately after delivery and extending three months.
AKI was defined and classed according to the Risk of renal dysfunction; injury to the kidney; failure of kidney function, loss of kidney function and end-stage kidney disease (ESRD) (RIFLE) criteria based on changes in serum creatinine or changes in urine output, or both.
The RIFLE criteria include three levels of renal dysfunction and two clinical outcomes: "loss" and "end-stage renal disease."
Outcome was considered unfavorable when complete recovery of renal function was not achieved and/or maternal death occurred.
| Statistical Analysis|| |
Descriptive, univariate and multivariate analyses have been conducted in collaboration with the epidemiology laboratory from the Medicine and Pharmacy Faculty of Fez using the EPI Info software. Qualitative variables were expressed as percentages and quantitative variables were expressed as median or mean. The level of significance was set at <0.05.
| Results|| |
Forty-four patients were included from eight Moroccan hospitals between July 1 and December 31. The mean age was 29 years, with an age range from 20 to 42 years. Majority of the patients were mostly illiterate (70.6%). The mean parity rate was 1.83 among these patients. Twenty-five percent of our patients were primigravida and 41% of the cases were from rural areas.
AKI occurred in the postpartum period in 23 cases (52%). 66% of patients doesn't have any medical care during pregnancy. Cesarean sections were performed in 68% of the cases. Patient characteristics are listed in [Table 1].
Hypertension was a common symptom present in 75% of the cases. The mean SBP and DBP was, respectively, 152 ± 38 mm Hg and 89 ± 28 mm Hg. Twenty-four patients (57%) were oliguric. Pulmonary edema was observed in six cases.
Anemia and thrombocytopenia were noted in 33 cases and elevated liver enzymes in 71% of patients.
The stage of AKI according to the RIFLE criteria was as follows: Risk in 16%, injury in 21%, failure in 61% and loss of function in 2% of the cases. The average creatinine was 428 ± 330 μmol/L
Only one percutaneous kidney biopsy was performed 15 days after abortion for an AKI with nephrotic syndrome. It was a lupus nephritis class IV.
Toxemia of pregnancy was the most common cause of AKI (28 cases), followed by septic events (six cases) and pregnancy hemorrhages (five cases). We noted three cases of acute fatty liver, one case of obstructive renal failure and one case of lupus nephritis [Figure 1].
The management of our patients was marked by the use of intravenous fluids in 52.3%, vasoactive drugs in 11% and transfusion in 59% of the cases. Antihypertensive treatment by syringe pump infusion was administered in 45% of the cases, and seven patients received magnesium sulfate to forestall seizures.
Dialysis was required in 17 cases (38.6%), which was intermittent hemodialysis in all the cases.
Complete recovery of renal function was observed in 66% and partial recovery in 23% of the cases. There were five maternal deaths (11.4%): Four from septic shock and one from hemorrhagic shock.
Two prognostic factors were identified: Age >38 years and sepsis [Table 2].
| Discussion|| |
In Morocco, pregnancy-related AKI is a serious complication and causes significant maternal and fetal mortality. It could be attributed to a variety of reasons such as poor prenatal care, difficult road transport, inadequate emergency obstetric care at peripheral hospitals and late referral of women with severe complications such as multi-organ dysfunction and disseminated intravascular coagulation. Indeed, in our study, only 34% of patients had pre-natal care. In our study, pregnancy-related AKI was more frequent during the post-partum period (52%). Similar results have been reported in India,  where AKI occurred during the post-partum in 75.6% of cases, whereas in Pakistan,  the majority of AKI occurred in the 3rd trimester (86%). The mean age of onset of AKI during pregnancy is between 25 and 32 years according to various authors. ,,,, The mean age of our patients was 29.6 years. In our study, age ≥38 years emerged as a factor significantly related to unfavorable outcome (P = 0.01). In the literature, this factor was associated with increased perinatal complications, including premature delivery. 
In our study, the main cause of AKI was preeclampsia (64%). In most retrospective studies, pre-eclampsia/eclampsia were reported to be a major cause of AKI during pregnancy. Erdemoglu et al, Parkash et al and Ventura et al found eclampsia/pre-eclampsia in 75.2%, 35.9% and 47.7% patients, respectively. ,, Puerperal sepsis was the major cause of AKI in Goplani's study,  whereas Khalil et al  observed that 65% of AKI was related to hemorrhage in their study [Table 3] and [Table 4].
Total recovery of renal function was obtained in 66% of the cases, which is similar to the results found in some other studies. Arora et al,  Goplani et al  and Erdemoğlu et al  reported a total recovery of renal function in 42%, 54.3% and 61% patients, respectively.
Currently, maternal mortality due to pregnancy-related AKI represents <10% in Europe and North America, but remains high in the developing countries. , Recent studies in India have shown a maternal mortality rate of around 20%. , In Turkey, this rate was 10.6%.  In Pakistan, Khalil et al  reported a maternal mortality rate of 15% in 2011 compared with 33.3% reported by Chaudhri et al  in 2008.
Moroccan studies noted a variable rate ranging from 9.1% to 25.6%. ,,, In our study, the maternal mortality rate (11.4%) was comparable to the various studies in developing countries, but remains high compared with developed countries. Maternal outcome in the literature is shown in [Table 5].
In our study, perinatal mortality was observed in 15.9% of the cases. Altintepe et al  reported 12%, Drakeley et al  38% and Khalil et al  66.6%. Keeping in mind the potential severity of extreme prematurity, it appears that the immediate care in a neonatal intensive care center, associated with antenatal steroids, has considerably improved the prognosis of newborns. This highlights the importance of early maternal transfer to a referral center. 
The poor prognostic factors found in our study are the advanced age of the patient and sepsis. Other risk factors found in the literature include the use of mechanical ventilation,  home delivery,  disseminated intravascular coagulation,  HELLP syndrome,  anuria  and the number of hemodialysis sessions. ,
In conclusion, pregnancy-related AKI is still a common occurrence in our country. In this study, pre-eclampsia was the most frequent etiology, followed by hemorrhagic shock and sepsis. Advanced age and sepsis were associated with unfavorable outcome.
In this context, prevention is the best and leastexpensive solution. Pre-natal care and greater access to emergency obstetric services, especially in rural areas, could avert pregnancy-related AKI and its consequences. 
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Dr. Nadia Kabbali
Nephrology Department, Hassan II University Hospital, Fez
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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