Acute kidney injury e-alerts in pregnancy: rates, recognition and recovery

Abstract

Background Acute kidney injury (AKI) in pregnancy (Pr-AKI) is associated with substantial maternal morbidity and mortality. E-alerts are routinely used for detection of AKI in non-pregnant patients but their role in maternity care has not been explored. Methods All pregnant or postpartum women with AKI e-alerts for AKI Stages 1–3 (Kidney Disease Improving Global Outcomes (KDIGO) criteria) were identified at a tertiary centre >2 years. Two women matched by delivery date for each case were selected as controls. AKI stage, recognition of AKI, pregnancy outcomes, renal recovery, AKI aetiology and risk factors were extracted from electronic patient records. Results 288 of 11 922 (2.4%) women had AKI e-alerts, of which only 118 (41%) were recognized by the obstetric team. Common Pr-AKI causes included infection (48%), pre-eclampsia (26%) and haemorrhage (25%), but no cause was identified in 15% of women. Renal function recovered in 213 (74%) women, but in 47 (17%) repeat testing was not undertaken and 28 (10%) did not recover function. Hypertensive disorders of pregnancy and Caesarean section were associated with increased incidence of Pr-AKI compared with controls. Conclusions Pr-AKI e-alerts were identified in ∼1 in 40 pregnancies. However, a cause for Pr-AKI was not identified in many cases and e-alerts may have been triggered by gestational change in serum creatinine. Pregnancy-specific e-alert algorithms may be required. However, 1 in 10 women with Pr-AKI had not recovered kidney function on repeat testing. Better understanding of long-term impacts of Pr-AKI on pregnancy and renal outcomes is needed to inform relevant Pr-AKI e-alert thresholds.

The predictive value of renal resistance index and plasma cystatin C in pregnancy-related acute kidney injury

“…The incidence of PR-AKI in this study far exceeded that reported in China [12]; in this study, the patients were enrolled on account of presenting with pathological obstetrics, and the incidence was also related to the severity of the patients' condition [26][27][28]. In this study, the APACHE II score was 8 (7-9) in Group B and 10 (8. in Group A.…”

National recommendations to standardise acute kidney injury detection and alerting

“…11 Neither clinical nor laboratory criteria for AKI diagnosis in non-pregnant patients are fully validated in pregnant patients, but one early study has provided some useful data on the validity of them. 17 We asked if other patient groups were excluded and a notable 26% reported yes; with Paediatrics, Primary Care, OPDs, Renal Wards, Renal OPDs and ITUs listed. These additional exclusions were also contrary to the NHSE PSA.…”

“…8,10,11 Blood samples from people receiving dialysis or who are pregnant are exceptions to this recommendation. 8,10,11,17 Where possible, laboratories should develop processes to avoid reporting AKI in these patient populations. The AKI taskforce recognise it may not be feasible for many laboratories to exclude them, therefore exclusion by testrequest location, such as dialysis unit or maternity ward, may be more pragmatic 7 Laboratories must report AKI in both children and adults.…”

Acute Kidney Injury in Pregnancies Complicated by Late-Onset Preeclampsia with Severe Features

“…The significant association between the two cohorts for an increased risk for postpartum hemorrhage and cesarean delivery in women with AKI is not surprising because these are known risk factors for AKI. 22 Said another way, it is likely that the comorbid factor of postpartum hemorrhage contributed to AKI rather than the inverse. Perinatal outcomes were clinically similar and there were no differences in stillbirth or neonatal death rates, although these were relatively rare and our study may not be powered to detect these differences.…”