Introduction:
Pregnancy associated acute kidney injury is a critical complication during pregnancy .Prevalence of PrAKI is reported to vary between 5-15% (. ).Causes of AKI during pregnancy are multifactorial from socio economic causes to medical morbidities .Additionally, equity , affordability and accessibility of kidney services remains a major challenge in LMIC , thus impacting the mortality rates. AKI can occur during all the three trimesters , though it was reported to be common in first trimester /postpartum with septic abortion/puerperal sepsis, being most common causes. A paradigm shift in was observed in AKI etiology with pre eclampsia , being the most common cause of AKI than the sepsis.
Methods:
This is case record based study of PrAKI admitted between Jun 2014-Jun 2024.Demographic details and outcomes are noted from case records.
Setting :
Tertiary care teaching public sector hospital
Study population :
Inclusion Criteria:
All those pregnant patients referred for Kidney services
Exclusion Criteria:
Those patients with renal dysfunction due to causes other than AKI were excluded.
Methodology:
Patient records were analyzed for demographic characteristics, obstetric history, and clinical profile on admission.
Dialysis services were given as per the indication. Hemodialysis was provided with single use dialyzer of surface area of 1.3m2. Bedside hemodialysis services were given to all the patients,in maternal intensive care unit, CRRT was the choice of RRT in patients with hemodynamic instability and Multiorgan dysfunction. Other mode of RRT in hemodynamically unstable patients was Peritoneal Dialysis.Patients with multi organ failure were given multi organ support.Patients were delivered as per the obstetric indication.
outcomes assessed are maternal and fetal outcomes, and Renal Recovery.
Results:
There were total of 65000 deliveries during the study time frame. 500 women had PRAKI, thus prevalence of 0.76%.
Majority of the patients are aged between 18 to 35 years, with mean age of 25+4 years .Primigravidae (269/500) were slightly more than half of the group(53.8%).
On analysis of time of occurrence, PrAKI was most common in third trimester and in post partum period (87%),first trimester PrAKI was rare in our group (0.8%).Regarding pregnancy outcome, 273 (54.6%) mothers delivered by caesarean section.
Pre Eclampsia was present in 48% of the group (240/500), preeclampsia with organ involvement of renal failure /liver failure was observed in 161(32%).
On evaluation of causes of AKI, rather than a single cause , AKI was multifactorial Preeclampsia and its associations like Hemorrhage which included both Antepartum causes of placenta previa, abruption and uterine rupture as well as Postpartum causes of uterine atony, retained placenta or accreta and lacerations.followed by Sepsis and its associated complications. However 33.8% patients had both Preeclampsia and Sepsis. Other less common etiologies of AKI were Drugs 36 (7.2%),TMA 7(1.4%), and AFLP6(1.2%).
With regard to laboratory profile, mean Hemoglobin was 9.2+/-2.08g/dl and mean serum creatinine was 3.42+/-2.2mg/dl. Leukocytosis and derranged liver function tests in the form of hyperbilirubinemia, transaminitis were suggestive of the multiorgan involvement which can be attributed to Preeclampsia, and sepsis , as they constituted predominant causes of PrAKI.
Oligoanuria was the most common referral problem from the obstetrics department. On staging of AKI, AKI stage 3 was diagnosed in 71% and AKI stage I ,II were present in 14% , 15% respectively.
Of total of 379 /500 patients in stage 3 AKI, hemodialysis was given to 265 patients (53%), 36 patients (7%) received CRRT services.Main mode of kidney replacement therapy was hemodialysis followed by continuous renal replacement services. Peritoneal dialysis was treatment in 32 patients (6.4%).Hybrid mode of RRT like PD with HD was done in 7 patients(1.4%) and CRRT followed by HD in 14 patients (2.8%).Few patients (32.2%) had multi organ failure , needing organ supports.
On analysis of fetal outcome, live birth occurred in more than half of the mothers( 55%) , while IUD occurred in 225(45%) and preterm babies in 63 mothers(12.6%), respectively.
A total of 257(51%) patients had complete renal recover,120(24%) patients died,However 112 patients had persistent renal dysfunction on discharge and 11 were dialysis dependent.
Our Praki study group had a mortality of 24%( 120 patients).
Elderage,parity status, multiorgan failure with usage of increased organ supports, etiologies of preeclampsia and antepartum haemorrhage and sepsis, were significantly associated with poor survival of Praki.
Conclusions:
1. The prevalence of PrAKI was 0.76% among all Pregnancies
2. The incidence of PrAKI was 1%
3. Etiology of PrAKI is multifactorial, Most common cause being Sepsis and associated complications 43%, followed by Sepsis and associated complications27%.
4. In 21% of patients Sepsis was coexisting with Preeclampsia
5.Factors associated with poor maternal outcomes are Elderage,parity status, multiorgan failure with usage of increased organ supports, etiologies of preeclampsia and antepartum haemorrhage and sepsis.
6. Factors associated with poor fetal oucomes are preeclampsia, multiparity, Abrution.
Limitations:
1.longterm Follow up couldn't be done for the patients
2.Biopsy was done in very few patients.
I have no potential conflict of interest to disclose.
I did not use generative AI and AI-assisted technologies in the writing process.