Postpartum Renal Cortical Necrosis Is Associated With Atypical Hemolytic Uremic Syndrome in Developing Countries

Abstract

Introduction Pregnancy-related acute kidney injury is the most common cause of renal cortical necrosis (RCN). Atypical hemolytic uremic syndrome (aHUS) as a cause of RCN in pregnant/postpartum is underevaluated. In the current article, we describe a series of cases of pregnancy-related RCN. Methods All cases with acute kidney injury (AKI) in the setting of pregnancy and postpartum state were included. Diagnosis of RCN was made by contrast-enhanced computerized tomography (nonenhancing renal cortex, enhancing medulla, and no excretion of contrast medium) or on a renal biopsy. aHUS was diagnosed in the presence of microangiopathic hemolytic anemia (thrombocytopenia, elevated lactate dehydrogenase with schistocytes on peripheral smear examination, or low haptoglobin). Results A total of 21 (17.5%) patients presented with RCN during pregnancy, all in the postpartum state. Twenty patients (95.2%) showed microangiopathic hemolytic anemia consistent with HUS and 1 (4.8%) patient had biopsy-proven thrombotic microangiopathy. Low complement 3 or activation of an alternate complement pathway was seen in 9 of 15 patients in which it was done. At the end of 6 months, only 2 (9.5%) patients had partial recovery of renal functions, 5 (23.8%) patients died, and 14 remained (66.7%) on hemodialysis. Conclusion The clinical and laboratory features are highly suggestive of aHUS in more than three-fourths of cases with postpartum RCN. Investigations are needed to look for genetic abnormalities in the complement pathway.

Maternal Outcomes of Pregnancy-Related Acute Kidney Injury

“…Pr-AKI was not very common in young mothers as 43 (20%) mothers with Pr-AKI were in the age group up to 20 years. Similar figures 43 (23%) were observed in the age group (21)(22)(23)(24)(25)(26)(27)(28)(29)(30) years. An alarming rise was noted in mothers belonging to the 3 rd group (>30 years) as 124 (57.4 %) belonged to this age group.…”

“…However, outcome figures varied widely in different studies which may be the result of different study designs, population sizes and variable definitions of AKI. [19][20][21][22][23][24] All literature of the world is unanimous on the fact that high morbidity and mortality is associated with Pr-AKI and this issue needs early recognition and prompt management.…”

Pregnancy-related Acute Kidney Injury in Public Hospital in South India: Changing Trends

“…In our study CN was due to puerperal sepsis (52%), PPH (22.9%), abruptio (20.83%), and TMA (4.1%). In a recent study by Ramachandran et al 31 32 developed AKI in early pregnancy and 40.35% in late pregnancy. 3,4 However, like in our study, most cases of PRAKI in recent studies are now seen to occur postpartum.…”

“…23 In our study 72% cases of PRAKI occurred postpartum. In a study in 1970s 31 Chugh et al reported a high maternal mortality (MM) of 30% in their study. 3,4 Maternal mortality has been variously reported in recent Indian studies from 5 to 25% as shown in Table 2.…”

Acute Kidney Injury in Pregnancies Complicated With Preeclampsia or HELLP Syndrome

“…Hypertensive disorders causing AKI can occur throughout the late second to third trimesters (27)(28)(29). As illustrated in Figure 2, the most commonly reported primary causes for PR-AKI are widespread, however these factors are often multifactorial, which can worsen the clinical scenario for the pregnant patient (27)(28)(29)(30)(31)(32)(33)(34)(35)(36)(37)(38)(39)(40)(41)(42)(43). PR-AKI of any etiology can be severe and in some cases can lead to ARF, or the need for renal transplantation, plasma exchange, dialysis or pharmacological treatment (3,44).…”