Acute Kidney Injury in Pregnancy: The Changing Landscape for the 21st Century

Abstract

Pregnancy-related acute kidney injury (Pr-AKI) remains a large public health problem, with decreasing incidences in developing countries but seemingly increasing incidences in the United States and Canada. These epidemiologic changes are reflective of the advances in medical and obstetric care, as well as changes in underlying maternal risk factors. The risk factors associated with advanced maternal age, such as hypertension, diabetes, chronic kidney disease, and those associated with reproductive technologies such as multiple gestations, are increasing. Traditional causes of Pr-AKI, such as septic abortions and puerperal sepsis, have been replaced by hypertensive diseases, such as preeclampsia and thrombotic microangiopathies comprising thrombotic thrombocytopenic purpura (TTP) and atypical hemolytic uremic syndrome (aHUS). In this review, we discuss the global impact of Pr-AKI on maternal and fetal outcomes, the predominant etiologies, and key clinical features to distinguish diagnoses, such as preeclampsia/hemolysis elevated liver function test and low platelet (HELLP) syndrome, acute fatty liver disease of pregnancy (AFLP), and other thrombotic microangiopathies. New insights into the pathogenesis of preeclampsia, TTP/aHUS, and AFLP that have unearthed possible therapeutic targets are summarized. We also delve into special consideration needed to give to pyelonephritis and postobstructive causes of Pr-AKI. With each diagnosis, we offer the latest treatment recommendations, such as the positive reports from the use of eculizumab to treat aHUS. In the end, we hope to arm the clinician with the best tools to understand and address this morbid problem that does not seem to be disappearing.

Pregnancy protects the kidney from acute ischemic injury

“…In developing countries, the situation is worse and can reach 70 cases per 10 000 deliveries (Morocco). Though, for now, it has positive dynamics: for example, while in India in 1980 AKI was diagnosed in 15% of hospitalized pregnant patients, it dropped to 1.5% in 2010; similar numbers were reported for China 4 . Kidney injury during pregnancy is associated with comorbid conditions and outcomes 5 .…”

Acute Kidney Injury in Pregnancy: The Need for Higher Awareness. A Pragmatic Review Focused on What Could Be Improved in the Prevention and Care of Pregnancy-Related AKI, in the Year Dedicated to Women and Kidney Diseases

“…The major predictors for acute pregnancy-related complications are Class III and IV lupus nephritis, a previous history of renal flares, longer disease, hypocomplementemia, antiphospholipid syndrome (APS), and the presence of antiphospholipid antibodies [ 132 , 133 , 134 , 135 , 136 ]. In this context, high titres and triple positivity for antiphospholipid antibodies, previous thrombosis and the presence of a lupus anticoagulant are associated with a higher risk of severe maternal and foetal complications, both in primary and secondary APS, and in catastrophic APS (CAPS) the most severe form of the syndrome [ 136 , 137 , 138 , 139 , 140 , 141 , 142 ]. Conversely, the occurrence of the HELLP syndrome in a patient with APS should raise the suspicion that CAPS will shortly be manifested [ 139 , 141 , 142 , 143 ].…”

“…In this context, high titres and triple positivity for antiphospholipid antibodies, previous thrombosis and the presence of a lupus anticoagulant are associated with a higher risk of severe maternal and foetal complications, both in primary and secondary APS, and in catastrophic APS (CAPS) the most severe form of the syndrome [ 136 , 137 , 138 , 139 , 140 , 141 , 142 ]. Conversely, the occurrence of the HELLP syndrome in a patient with APS should raise the suspicion that CAPS will shortly be manifested [ 139 , 141 , 142 , 143 ].…”

Acute kidney injuries induced by thrombotic microangiopathy following severe hemorrhage in puerperants: A case series and literature review

“…TTP is a rare, life-threatening TMA characterized by a severe de ciency in ADAMTS-13 (A Disintegrin And Metalloprotease with ThromboSpondin type 1 domain 13) [29]. Pregnancy is a known trigger of TTP [1][2][3][30][31][32]. However, TTP was excluded by normal ADAMTS13 in these three patients [33], and complement-mediated thrombotic microangiopathy (C-TMA) also known as atypical hemolytic-uremic syndrome was considered.…”