MAPPING THE LANDSCAPE; ETIOLOGICAL PATTERNS AND CLINICAL OUTCOMES OF POSTPARTUM ACUTE KIDNEY INJURY PATIENTS PRESENTING TO TERTIARY CARE HOSPITAL, PESHAWAR, PAKISTAN

 

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MAPPING THE LANDSCAPE; ETIOLOGICAL PATTERNS AND CLINICAL OUTCOMES OF POSTPARTUM ACUTE KIDNEY INJURY PATIENTS PRESENTING TO TERTIARY CARE HOSPITAL, PESHAWAR, PAKISTAN

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Annum Riaz
Ahmed
Annum Riaz Ahmed annum.riaz020@gmail.com Khyber Teaching Hospital Nephrology Department Peshawar Pakistan *
Ali Raza meetdoctorali@gmail.com Khyber Teaching Hospital Nephrology Department Peshawar Pakistan -
Aimal Khan dr.aimalkhan1@gmail.com Khyber Teaching Hospital Nephrology Department Peshawar Pakistan -
Rabia Khan Khalil rabiakhankhalil@gmail.com Khyber Teaching Hospital Nephrology Department Peshawar Pakistan -
Asma Khan Khalil drasmakhankhalil@gmail.com Northwest Teaching And General Hospital Medicine Department Peshawar Pakistan -
Mehak Zaidi mehakzaidi1992@gmail.com Khyber Teaching Hospital Nephrology Department Peshawar Pakistan -
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Postpartum Acute Kidney Injury (PPAKI) is a critical obstetric complication which significantly contributes to the maternal welfare and the morbidity and mortality rate. Globally, the incidence of pregnancy-related AKI has declined in developed countries due to improved prenatal surveillance, widespread institutional deliveries, and prompt obstetric interventions. However, in South Asia and Sub-Saharan Africa, PPAKI still accounts for 5–20% of all hospital-reported AKI cases. In Pakistan, PPAKI remains underreported despite its multi-factorial etiologies including postpartum hemorrhage, sepsis, pre-eclampsia/eclampsia, and hemolytic uremic syndrome. Most available data is either from single-center reports or limited case series, making it difficult to develop data backed reports and evidence-based guidelines for prevention and subsequent disease management. This study aims to evaluate the etiological spectrum with clinical presentations, renal support needs and short-term outcomes of patients diagnosed with PPAKI at the Nephrology Division, Tertiary care, at Khyber Teaching Hospital (KTH), Peshawar, Pakistan.

A cross-sectional study was conducted from January 2025 to June 2025 at Nephrology division at Khyber Teaching Hospital, Peshawar. The representative sample included postpartum women, diagnosed with Acute Kidney Injury (AKI) based on KDIGO criteria within six weeks of delivery. Patients with preexisting chronic kidney disease or with failure to follow-up were excluded from the study. Data was collected using structured proforma covering demographic characteristics, obstetric history, AKI etiology, clinical features, laboratory findings, dialysis requirement, and renal outcomes. SPSS v25.0 was used for statistical analysis and categorical variables were presented as frequencies and percentages whereas continuous variables were expressed as mean ± standard deviation

Among 84 listed patients, the mean age was 28.7 ± 5.6 years. 65.5% patients were multiparous, and 78.6% had delivered at home or peripheral centers. The predominant etiologies in descending order were postpartum hemorrhaging (32.1%), puerperal sepsis (28.6%), preeclampsia/eclampsia (21.4%), and hemolytic uremic syndrome (10.7%). Symptoms being oliguria was observed in 28.1% of cases. Treatments involved a total of 64.3% renal replacement therapy, primarily hemodialysis. Complete renal recovery was observed in 61.9% patients, partial recovery in 19.0%. And 11.9% of the cases progressed to acute kidney disease. Maternal mortality was 7.1%, with most deaths attributed to septic shock and multi organ failure.

Table 1 illustrates majority of patients (57.1%) were aged between 25–34 years, with 65.5% being multiparous. A significant proportion (78.6%) had delivered at home or peripheral health centers, reflecting limited access to tertiary obstetric care. Vaginal delivery was more common (66.7%) than cesarean section. Alarmingly, 61.9% of patients had no or irregular antenatal care, and more than half (56%) developed AKI within 3 days postpartum, indicating an acute and early onset pattern often linked to preventable obstetric complications.


Figure 1 illustrates the etiological distribution of postpartum acute kidney injury (PPAKI) in the study population. Postpartum hemorrhage was the leading cause, accounting for 32.1% of cases, followed closely by puerperal sepsis (28.6%) and preeclampsia/eclampsia/HELLP (21.4%). Less frequent causes included hemolytic uremic syndrome (10.7%), acute fatty liver of pregnancy, and other rare etiologies (3.6% each). These findings highlight the predominance of preventable obstetric complications in the pathogenesis of PPAKI, emphasizing the urgent need for early recognition and timely management.

Figure 2 shows that clinical features of PPAK. Oliguria, defined as urine output less than 400 mL in 24 hours, was the most common presenting symptom, observed in 28.1% of cases. This was followed closely by edema, seen in 25.8% of patients, indicating significant fluid retention. Hypertension (systolic blood pressure >140 mmHg) was reported in 17.6% of the cohort, suggesting a potential link with hypertensive disorders of pregnancy such as preeclampsia. Fever or signs of sepsis were present in 14.9%, emphasizing the role of infectious etiologies in the pathogenesis of PPAKI. Anuria and neurological symptoms were less frequently encountered, accounting for 7.2% and 6.3% of cases, respectively, and were likely reflective of more severe systemic involvement or multiorgan dysfunction. These findings highlight the importance of early recognition of volume and blood pressure abnormalities in the clinical assessment of PPAKI.


Figure 3 revealed that serum creatinine was markedly elevated at 4.9 ± 1.8 mg/dL, indicating significant renal impairment. Mean hemoglobin levels were 8.4 ± 1.6 g/dL, reflecting moderate anemia, which is common in postpartum AKI. Thrombocytopenia was observed with a mean platelet count of 134 ± 52 ×10⁹/L, especially in cases associated with HELLP syndrome and sepsis. Liver function was also mildly deranged, with a mean ALT level of 58 ± 25 U/L, suggestive of hepatic involvement in some patients.



This study highlights that postpartum acute kidney injury (PPAKI) remains a significant contributor to maternal morbidity and mortality in our region, with a predominance of preventable causes such as postpartum hemorrhage, sepsis, and hypertensive disorders of pregnancy.  Integration of nephrology consultation and recommendation into maternal health program in real time can lead to early diagnosis, effective management and prevention leading to reducing the incidence and severity of PPAKI in underdeveloped countries.

Kewords