Acute kidney injury in pregnancy and the role of underlying CKD: a point of view from México

Abstract

The incidence of acute kidney injury in pregnancy (P-AKI) in developed countries is significantly lower than in developing ones, where it is estimated to range between 4 and 26%. Mortality in cases of P-AKI requiring dialysis is high, varying from 20 to 80%. In developing countries, clinical decisions are often based on the availability of services and not on needs. Prenatal surveillance in Mexico does not include serum creatinine, limiting the potential for early diagnosis of AKI and CKD and their differential diagnosis. There are few specialized centers for the care of a pregnancy complicated with kidney disease in Mexico. P-AKI superimposed on preexistent, and usually undiagnosed CKD, is common: in Guadalajara 10 out of the 27 patients with Stage 3-5 CKD or nephrotic proteinuria, that were followed in 2013-2015, required renal replacement therapy (RRT) in pregnancy; in the same period in Mexico City out of 18 patients with P-AKI requiring dialysis, 5 remained dialysis dependent, 3 started dialysis in the following year after their pregnancy and only 1 fully recovered renal function. The grim prognosis is exacerbated by the fact that 70% of Mexicans are not reimbursed for dialysis, and pregnancy-related coverage lasts for only 42 days after delivery. Perinatal results are no less troubling, as most patients with P-AKI give birth preterm to small or very small babies. While our data do not allow us to evaluate needs, they do make it possible to define the complexity of the problems faced in the care of P-AKI in Mexico. Early diagnosis of P-AKI and chronic kidney disease (CKD) is needed to protect mothers and children and the country urgently needs programs to enable it to fulfil the World Health Organization's imperative that we "make every mother and child count".

What we do and do not know about women and kidney diseases; questions unanswered and answers unquestioned: reflection on World Kidney Day and International Women’s Day

“…Small babies and preterm babies have highly increased risks of neurological deficits and postnatal complications, especially sepsis [28][29][30][31][32]. The risks may be higher in lowincome countries, since survival and deficit-free survival depend on the provision of postnatal intensive care [20,21]. In the long term, small babies are at risk for the development of diabetes, metabolic syndrome, cardiovascular diseases (CVDs), and CKD in adulthood [33][34][35][36][37].…”

What we do and do not know about women and kidney diseases; questions unanswered and answers unquestioned: Reflection on World Kidney Day and International Woman’s Day

“…Помимо ПЭ различные заболевания и состояния могут приводить к развитию ОПП, ассоцииро-ванного с беременностью. Причины ОПП разли-чаются в зависимости от региона: криминальный септический аборт -главная причина ОПП в стра-нах, где легальные аборты запрещены, тогда как ПЭ, возникшая после искусственного оплодотво-рения, становится ведущей причиной ОПП в раз-витых странах [12,[20][21][22].…”

“…При этой патологии поражение почек, являющихся основной мишенью, развива-ется вследствие нарушения баланса между про-ангиогенными и антиангиогенными факторами, ведущего к массивному эндотелиальному повреж-дению и развитию гипертензии и протеинурии. Заболеваемость ПЭ особенно высока в странах с низким и средним доходом (что, возможно, от-ражает наличие нераспознанных хронических за-болеваний), пик заболеваемости приходится на на-чало и конец репродуктивного периода [12,[20][21][22].…”

“…Маловесные и недоношенные дети подвержены риску неврологического дефицита и постнаталь-ных осложнений, в особенности сепсиса [28][29][30][31][32]. Эти риски могут быть особенно значимыми в стра-нах с низким и средним доходом, поскольку выжи-ваемость и бездефицитная выживаемость сильно зависят от возможности обеспечения интенсивной терапии и ухода в постнатальном периоде [20,21]. Кроме того, маловесные дети имеют повышенный риск отдаленных последствий, таких как развитие диабета, метаболического синдрома, сердечно-со-судистых заболеваний и ХБП во взрослом возрас-те [33][34][35][36][37].…”

What We Do and Do Not Know About Women and Kidney Diseases; Questions Unanswered and Answers Unquestioned: Reflection on World Kidney Day and International Women’s Day

“…2018;7(1):1-11 teinuria, and widespread endothelial damage. The incidence of PE, higher in low-middle income countries (possibly reflecting undiagnosed predisposing diseases), peaks at the extremes of reproductive age for reasons mentioned above [12,[20][21][22].…”