Back
Haemorrhage, hypertension and sepsis cause 75% of maternal deaths in Sierra Leone, and globally, and commonly lead to Acute Kidney Injury, which is associated with high rates of maternal and fetal morbidity and mortality (6 to 52%). Most deaths and serious morbidity are preventable with early detection, enabling targeted management. However, challenges in laboratory infrastructure in low and middle income settings often leads to late or missed pregnancy AKI diagnoses. In a large prospective observational study in South Africa our group found that 15% (237/1547) of pregnant women admitted with hypertensive disorders had AKI, relative risk of death was 6.2% (95% CI 2.2-17) and 50% had persistent abnormal renal function, which is associated with development of CKD, cardiovascular disease and four fold greater risk of pre-eclampsia in future pregnancies. Sierra Leone has no studies of pregnancy AKI to date. Understanding the scale of the problem is an essential ‘first step’ in order to develop tailored detection and management strategies for evaluation in future studies. We aimed to determine prevalence of pregnancy AKI in a high risk obstetric population admitted to a tertiary maternity unit in Freetown, Sierra Leone.
Women were eligible for the study if they were pregnant or up to six weeks’ postpartum, and triggering amber or red lights on the CRADLE vital signs alert device indicating either hypertension or shock. Women were consented for inclusion and venous creatinine sampling was offered at three timepoints (study entry, 6 to 8 hours, 24 hours) to identify pregnancy AKI. Results were available to clinical staff and women were managed as per routine management pathways. Demographic information was collected and mean and median creatinine values and proportion of women with AKI (defined as women with a creatinine value of 77umol/l and/ or an increase or decrease in creatinine of 26umol/l or 50%) were calculated.
835 women underwent venous creatinine sampling between 13th February and 25th April 2023, either once (n=811, 97.1%), twice (n=601, 71.9%) or three times (n=123, 14.7%). Mean age was 26 years, and the median creatinine value was 69 (61.9 to 79.5). 272/835 (32.6%) of women had pregnancy AKI diagnosed by venous creatinine testing.
A third of women were found to have pregnancy AKI (or undiagnosed CKD). Under normal clinical conditions in this setting all of these cases would have gone undetected given challenges in accessing laboratory testing, with associated risks of both short and long term complications. Point-of-care creatinine testing facilitates early detection, and management, without the need for complex, expensive laboratory infrastructure, and has revolutionised access to antenatal testing for malaria, syphilis, TB and HIV, but is a novel strategy in the context of pregnancy AKI. We are currently conducting a follow-up study to evaluate the feasibility of point-of-care creatinine testing, combined with a co-created pregnancy AKI teaching package for clinicians. We were unable to determine chronic kidney disease status in our cohort of women who did not have serial creatinine samples, which was a limitation of our study, so we will collect ‘baseline’ creatinine samples in a subset of study participants attending antenatal clinic, and postnatal creatinine samples to explore CKD burden in this setting.