WHY ARE PREGNANT INDIVIDUALS WITH AKI DYING? AND WHAT CAN WE DO TO SAVE THEM? - RESULTS FROM A PROSPECTIVE COHORT SUTDY

Introduction:

Pregnancy-associated acute kidney injury [PRAKI] continues to be a significant cause of maternal and fetal adverse outcomes in the developing world. This prospective study aims to evaluate the predictors of maternal mortality and long-term maternal outcomes in a tertiary referral center from western India at the patient, provider, and policymaker’s level.

Methods:

Consecutive patients presenting with PRAKI were enrolled prospectively from April 2021 to December 2024 and were followed up for 6 months post-partum. Primary outcome was maternal mortality within 42 days postpartum. Clinical and social predictors of maternal mortality were analyzed using univariate and multivariate analysis. Key secondary outcomes were fetal/neonatal survival, kidney function and hypertension at discharge, at 3 months and 6 months post-partum.

Results:

The study enrolled 231 patients with PRAKI, of which 52 (22.5%) had expired. The mean age was 27.4 ± 3.8 years. 96% had institutional delivery. The most common cause of maternal mortality was puerperal sepsis (48.5%), followed by obstetric hemorrhage (44.5%) and preeclampsia (39%).

Primary outcome

Patient level factors– Patients who died were more likely to have underlying comorbidities (p = 0.002), have unplanned pregnancies (p = 0.00), have higher Sequential Organ Failure Assessment (SOFA) Score at day 0 and day 3 of admission (p 0.028), require blood transfusion (p = 0.04) and inotropes (p = 0.012).

Provider and Policymaker level factors – Social determinants of maternal mortality were delayed presentation after symptom onset (p= 0.00), referral from more than one medical facility (p =0.01), and patient residence outside Mumbai (p= 0.02). 100% of patients had out-of-pocket expenses during admission despite being covered under the Janani Suraksha Yojana (government scheme for perinatal coverage). Two women succumbed due to lack of access to a dialysis facility post-discharge.

After multivariate adjustments, higher SOFA scores on day 3, delayed presentation after symptom onset, and referral from more than one medical facility independently predicted maternal mortality.

Secondary Outcomes

Preterm delivery was seen in 64% of pregnancies. Birth weight was < 2.5 kgs in the majority of neonates. Only 52.1% of pregnancies lead to a living child one month post-partum. Complete renal recovery at discharge was seen in 42.5%. At the last follow-up available, 8.1% of individuals developed chronic kidney disease. 

Conclusions:

PRAKI continues to have high rates of maternal and fetal mortality. Higher SOFA scores, delayed presentation, and lack of access to optimum care at primary and secondary levels (leading to multiple referrals) independently predicted maternal deaths. Based on the results of this study, reforms are suggested at patient, provider, and policymaker levels to eliminate this preventable cause of mortality (Figure 1).

I have no potential conflict of interest to disclose.

I did not use generative AI and AI-assisted technologies in the writing process.