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

Abstract

Pregnancy-related acute kidney injury (pAKI), preeclampsia (PE), and the hypertensive disorders of pregnancy are closely related conditions, which are, in turn, frequently linked to pre-existing and often non-diagnosed chronic kidney disease (CKD). The current literature and research mainly underline the effects of pregnancy complications on the offspring; this review strongly emphasizes the maternal health as well. These conditions not only negatively affect pregnancy outcomes, but have a relevant effect on the future health of affected mothers and their children. Therefore, dedicated diagnostic and follow-up programs are needed, for optimizing materno-foetal health and reducing the impact of pregnancy-related problems in the mothers and in the new generations. This narrative review, performed on the occasion of the 2018 World Kidney Day dedicated to women’s health, focuses on three aspects of the problem. Firstly, the risk of AKI in the hypertensive disorders of pregnancy (the risk is the highest in developing countries; however PE is the main cause of pregnancy related AKI worldwide). Secondly, the effect of AKI and the hypertensive disorders of pregnancy on the development of CKD in the mother and offspring: long-term risks are increased; the entity and the trajectories are still unknown. Thirdly, the role of CKD in the pathogenesis of AKI and the hypertensive disorders of pregnancy: CKD is a major risk factor and the most important element in the differential diagnosis; pregnancy is a precious occasion for early diagnosis of CKD. Higher awareness on the importance of AKI in pregnancy is needed to improve short and long term outcomes in mothers and children.

Acute Kidney Injury in Pregnancies Complicated With Preeclampsia or HELLP Syndrome

“…Development of a uniform diagnostic criteria and refining of animal models will help advance our knowledge and understanding of the clinical implications of acute renal injury during pregnancy. Additionally, as work continues to identify the best nutritional diets, health plans and safe therapeutics to prophylactically administer during pregnancy to women with hypertensive and TMA disorders (114)(115)(116) we can also hope to see a decrease in fetal and maternal mortality and morbidity.…”

Preeclampsia: A Diagnosis-Nondiagnosis That Is Too Easily Made: The Case of Primary Hyperaldosteronism

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After decades in which the major medical textbooks reported with slightly different wordings that preeclampsia (PE) in pregnancy is a transitory kidney disease ultimately cured when the mother delivers, we are finally acknowledging that PE is neither always transitory nor systematically cured and that it may be both the herald of future diseases of the kidney and the cardiovascular system and the epiphenomenon of an underlying disease, as the interesting and well-presented case series published here demonstrates [1][2][3]. While the number of systematic reviews, large-population studies, and long-term registry data are multiplying and most of them conclude with a generic statement that future studies, actions, and programs are needed, few if any changes are taking place in real-life clinical practice [4].The result of this dangerous combination of minimalism (PE is a self-healing disorder), lack of interdisciplinary collaboration (the pragmatic obstetrician holding that "nephrologists make things too complicated," while the cultivated nephrologist retorts that "obstetricians oversimplify"), short-sightedness, and common alibis (no time to see all these women after a PE episode, someone else should do it …) is that women who have already had a stressful and occasionally life-threatening episode of PE lose a precious occasion to receive a timely diagnosis of a potentially curable disease.The series reported here is a clear example of how pregnancy is a valuable but often missed occasion for diagnosis of a potentially serious disease: of the 14 patients described, only 3 were diagnosed as having primary hyperaldosteronism within 1 year from the discovery of hypertension, while in 8 the interval was 5 years or more (up to 12 years). Perhaps even more interestingly, hypertension was diagnosed (or first appeared) in preg-

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“…After decades in which the major medical textbooks reported with slightly different wordings that preeclampsia (PE) in pregnancy is a transitory kidney disease ultimately cured when the mother delivers, we are finally acknowledging that PE is neither always transitory nor systematically cured and that it may be both the herald of future diseases of the kidney and the cardiovascular system and the epiphenomenon of an underlying disease, as the interesting and well-presented case series published here demonstrates [1][2][3]. While the number of systematic reviews, large-population studies, and long-term registry data are multiplying and most of them conclude with a generic statement that future studies, actions, and programs are needed, few if any changes are taking place in real-life clinical practice [4].…”

Acute kidney injury during pregnancy leads to increased sFlt-1 and sEng and decreased renal T regulatory cells in pregnant rats with HELLP syndrome

“…Disorders of pregnancy such as preeclampsia, HELLP (hemolysis, elevated liver enzyme, low platelet) syndrome, and thrombotic microangiopathies are among the primary contributors to the development of acute kidney injury (AKI) during pregnancy [ 1 , 2 ]. Despite the once declining rates of AKI during pregnancy (PR-AKI), the incidence of PR-AKI or the early postpartum period has recently seen a resurgence with rates ranging as high as 20% depending on the geographic location of the high-risk pregnancy [ 3 , 4 ]. Increased maternal age at the time of pregnancy, and increased provider awareness and detection of renal injury and existence of multiple maternal comorbidities such as diabetes have all been proposed to contribute to the increase in PR-AKI [ 5 , 6 ].…”