The changing landscape of Postpartum Acute Kidney Injury in the Indian subcontinent- sepsis is not always the culprit!

Pregnancy-related AKI (PRAKI) in associated with significant morbidity and mortality in

otherwise young, healthy women. With increasing age during pregnancy, higher prevalence

of non-communicable diseases like Diabetes, Hypertension and Obesity, use of artificial

reproduction technologies and multifetal gestation, this cohort is highly prone for Acute

Kidney Injury. Till about 5-10 years ago, the most common etiology of Postpartum AKI

(PPAKI) was attributed to sepsis. However, in recent times, there is a change in the

etiopathogenesis of this entity with a paradigm shift towards glomerular diseases and

thrombotic microangiopathy.

This was a single centre, retrospective study done during a

period of 10 years- 2013-2022. The aim of our study was to assess the prognostic factors

determining the renal recovery and factors associated with dialysis-dependency in patients

with PPAKI in North India. Outcome variables of renal recovery and mortality were assessed.

A total of 276 patients were included. They were divided into 2 groups based on 2 time

periods- 2013-2017 and 2018-2022. Overall number of cases were 57% vs 43% highlighting

decreasing incidence of PPAKI in recent times. There was no difference in age, parity and

mode of delivery between the 2 groups. In the earlier group, there was higher prevalence of

AKI after 1st trimester pregnancy termination, which may be attributed to septic abortions

and unhygienic practices (11.3% vs 0.9%,p<0.001). 125 patients underwent kidney biopsy-

most common histopathological finding was Patchy cortical necrosis (48.8%) , Acute tubular

necrosis (20.2%); Thrombotic microangiopathy (12%); Glomerulonephritis (10.8%);

Diffuse global glomerulosclerosis (5%) and Tubulointerstitial nephritis (3.2%). 40.6% patients

had dialysis dependency with no correlation to age, parity, gestational age. Presence of

oligoanuria, high Lactate dehydrogenase, schistocytes on peripheral blood smear, low C3 and

C4, ANCA positivity, dialysis dependency at admission, advanced renal failure (eGFR <30)

at presentation and cortical necrosis were predictors of dialysis-dependency and non-recovery

of renal function at discharge. Overall mortality was 13%, with highest being in-hospital and

within 3 months of discharge (6.5% + 5.4%).

There is a changing spectrum with shift from septic abortions and puerperal sepsis to TMA

and glomerular diseases causing PPAKI highlighting improvement in obstetric practices. In

our study, presence of oligoanuria, high LDH, schistocytes on smear, low C3 and C4, ANCA

positivity, dialysis dependency at presentation with advanced renal failure (eGFR <30) and

cortical necrosis were found to be associated with poor renal recovery and dialysis-

dependency. Postpartum AKI was associated with overall mortality of 13% and poor renal

recovery.