Pr-AKI: Acute Kidney Injury in Pregnancy – Etiology, Diagnostic Workup, Management

Abstract

Despite significant improvements in inpatient and outpatient management, pregnancy-related acute kidney injury (Pr-AKI) remains an important risk factor for early and late maternal and fetal morbidity and mortality. There is a discrepancy between the incidence of Pr-AKI in developing and in developed countries, with the former experiencing a decrease and the latter an increase in Pr-AKI in recent decades. Whereas septic and hemorrhagic complications predominated in the past, nowadays hypertensive disorders and thrombotic microangiopathy are the leading causes of Pr-AKI. Modern lifestyles and the availability and widespread use of in-vitro fertilization techniques in industrialized countries have allowed more women of advanced age to become pregnant. This has led to a rise in the percentage of high-risk pregnancies due to the disorders and comorbidities inherent to or accompanying aging, such as diabetes, arterial hypertension and preexisting chronic kidney disease. Last but not least, the heterogeneity of symptoms, the often overlapping clinical and laboratory characteristics and the pathophysiological changes related to pregnancy make the diagnosis and management of Pr-AKI a difficult and challenging task for the treating physician. In addition to general supportive management strategies such as volume substitution, blood pressure control, prevention of seizures or immediate delivery, each disease entity requires a specific therapy to reduce maternal and fetal complications. In this review, we used the current literature to provide a summary of the physiologic and pathophysiologic changes in renal physiology which occur during pregnancy. In the second part, we present common and rare disorders which lead to Pr-AKI and provide an overview of the available treatment options.

Association between Clustering of Cardiometabolic Risk Factors and Chronic Kidney Disease: Findings from the China Health and Retirement Longitudinal Study

“…While the overall prevalence of diabetes-related complications has declined, the incidence of renal failure is on the rise in diabetic patients [41,43,44]. In individuals with MetS, an in ammatory state triggered by insulin resistance accelerates CKD progression by elevating proin ammatory adipokines and decreasing anti-in ammatory adipokines in the plasma [45]. In addition, dyslipidemia, caused by abnormal lipid metabolism, further worsens renal microvascular damage by promoting atherosclerosis [46].…”

Assessment of Kidney Impairment and Related Risk Factors in Pregnant Women Attending the University Center for Public Health and Rango Health Centers in the Southern Province of Rwanda

“…[11] The pathophysiological basis of PR-AKI depends on local factors such as legality of abortion, exposure to infectious diseases such as malaria and HIV, adequacy of infrastructure for obstetric care, preeclampsia and local contact with nephrotoxins. [12] Racial/ethnic differences have been reported to exist in the incidence of PR-AKI with black women having over 40% higher risk compared to white women. [13] Additional risk factors of PR-AKI include older age, history of pre-eclampsia, lower socioeconomic status and a history of diabetes mellitus.…”

“…[13] Additional risk factors of PR-AKI include older age, history of pre-eclampsia, lower socioeconomic status and a history of diabetes mellitus. [12] Furthermore, PR-AKI has a profound impact on future health by increasing the risk of developing hypertension, CKD and cardiovascular diseases. [12] Monitoring renal function in pregnant women is therefore crucial in reducing the rate of adverse events, both in women with pre-existing kidney disease and those who develop kidney disease during pregnancy.…”

“…[12] Furthermore, PR-AKI has a profound impact on future health by increasing the risk of developing hypertension, CKD and cardiovascular diseases. [12] Monitoring renal function in pregnant women is therefore crucial in reducing the rate of adverse events, both in women with pre-existing kidney disease and those who develop kidney disease during pregnancy. Determining the incidence of PR-AKI has however, remained difficult because of lack of validated criteria.…”

“…Furthermore, kidney function assessment is not routinely conducted during ante natal care in women considered to be at low risk of kidney function impairment. [12] The incidence of PR-AKI in low-and middleincome countries (LMIC) is reported to be compared to high income countries (4%-26% versus 1%-2.8%, respectively). [14] The incidence of PR-AKI is however, declining in LMIC, due to improved antenatal care with such decreases reported in India and China where prevalences decreased from 15% in the 1980's to about 1.5% in 2010.…”