Abstract
Kidneys may fail post-partum in a number of circumstances due, for example, to post-partum haemorrhage, preeclampsia, amniotic fluid embolism or septic abortion. All these conditions in pregnancy and post partum represent a threat not only to the endothelium but also to the renal tubular epithelium, and as such may lead to rapid and also irreversible impairment of the renal function. This paper is a non-systematic review of the literature and of our experience, in which we discuss the main open issues on kidney disease in pregnancy and following delivery, in particular as regards tubular damage, with the aim to help reasoning on acute kidney injury (AKI) following delivery. The review will emphasize the often under-estimated importance of the tubular epithelium in the peri-partum period and will: (1) describe the main characteristics of the renal tissues around delivery; (2) define pregnancy-related AKI according to recent Kidney Disease/Improving Global Outcome (KDIGO) guidelines; (3) discuss the most common circumstances of post-partum AKI; and (4) describe the input expected from urinalysis, renal imaging and kidney biopsy.
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Abbreviations
- AKI:
-
Acute kidney injury
- ATN:
-
Acute tubular necrosis
- RBP:
-
Retinol-binding protein
- sEng:
-
Soluble endoglin
- s-Flt1:
-
Soluble fms-like tyrosine kinase 1
- TMA:
-
Thrombotic microangiopathy
- VEGF:
-
Vascular endothelial growth factor
References
Maynard SE, Min J-Y, Merchan J, Lim K-H, Li J, Mondal S et al (2003) Excess placental soluble fms-like tyrosine kinase 1 (sFlt1) may contribute to endothelial dysfunction, hypertension, and proteinuria in preeclampsia. J Clin Invest 111(5):649–658
Venkatesha S, Toporsian M, Lam C, Hanai J, Mammoto T, Kim YM et al (2006) Soluble endoglin contributes to the pathogenesis of preeclampsia. Nat Med 12(6):642–649
Eremina V, Jefferson JA, Kowalewska J, Hochster H, Haas M, Weisstuch J et al (2008) VEGF inhibition and renal thrombotic microangiopathy. N Engl J Med 358(11):1129–1136
Eremina V, Sood M, Haigh J, Nagy A, Lajoie G, Ferrara N et al (2003) Glomerular-specific alterations of VEGF-A expression lead to distinct congenital and acquired renal diseases. J Clin Invest 111(5):707–716
Levine RJ, Maynard SE, Qian C, Lim K-H, England LJ, Yu KF et al (2004) Circulating angiogenic factors and the risk of preeclampsia. N Engl J Med 350(7):672–683
Taylor AA, Davison JM (1997) Albumin excretion in normal pregnancy. Am J Obstet Gynecol 177(6):1559–1560
Yoshimatsu J, Matsumoto H, Goto K, Shimano M, Narahara H, Miyakawa I (2006) Relationship between urinary albumin and serum soluble fms-like tyrosine kinase 1 (sFlt-1) in normal pregnancy. Eur J Obstet Gynecol Reprod Biol 128(1–2):204–208
Strevens H, Wide-Swensson D, Hansen A, Horn T, Ingemarsson I, Larsen S et al (2003) Glomerular endotheliosis in normal pregnancy and pre-eclampsia. BJOG Int J Obstet Gynaecol 110(9):831–836
Aukland K, Krog J (1960) Renal oxygen tension. Nature 188:671
Sheikh IA, Shaheen FA (1998) Acute renal failure and HELLP syndrome: a single center’s experience. Saudi J Kidney Dis Transpl Off Publ Saudi Cent Organ Transplant Saudi Arab 9(3):290–293
Abraham KA, Kennelly M, Dorman AM, Walshe JJ (2003) Pathogenesis of acute renal failure associated with the HELLP syndrome: a case report and review of the literature. Eur J Obstet Gynecol Reprod Biol 108(1):99–102
Sibai BM, Villar MA, Mabie BC (1990) Acute renal failure in hypertensive disorders of pregnancy. Pregnancy outcome and remote prognosis in thirty-one consecutive cases. Am J Obstet Gynecol 162(3):777–783
Nelimarkka O, Halkola L, Niinikoski J (1982) Distribution of renal cortical and Medullary tissue oxygenation in hemorrhagic shock. Acta Chir Scand 148(3):213–219
Ibarra-Hernández M, Orozco-Guillén OA, de la Alcantar-Vallín ML, Garrido-Roldan R, Jiménez-Alvarado MP, Castro KB et al (2017) Acute kidney injury in pregnancy and the role of underlying CKD: a point of view from México. J Nephrol 30(6):773–780
Fakhouri F, Deltombe C (2017) Pregnancy-related acute kidney injury in high income countries: still a critical issue. J Nephrol 30(6):767–771
Abstract (2012) Kidney Int Suppl 2(1):6
Odutayo A, Hladunewich M (2012) Obstetric nephrology: renal hemodynamic and metabolic physiology in normal pregnancy. Clin J Am Soc Nephrol CJASN 7(12):2073–2080
Hladunewich MA, Lafayette RA, Derby GC, Blouch KL, Bialek JW, Druzin ML et al (2004) The dynamics of glomerular filtration in the puerperium. Am J Physiol Renal Physiol 286(3):F496-503
Pritchard JA, Cunningham FG, Pritchard SA (1984) The Parkland Memorial Hospital protocol for treatment of eclampsia: evaluation of 245 cases. Am J Obstet Gynecol 148(7):951–963
Frimat M, Decambron M, Lebas C, Moktefi A, Lemaitre L, Gnemmi V et al (2016) Renal cortical necrosis in postpartum hemorrhage: a case series. Am J Kidney Dis Off J Natl Kidney Found
Wong TC (1962) A study on the generalized Shwartzman reaction in pregnant rats induced by bacterial endotoxin. Am J Obstet Gynecol 84:786–797
Apitz K (1934) Die Wirkung bakterieller kulturfiltrate nach umstimmung des gesamten endothels beim kanichen. Virchows Arch 1–33
WOMAN Trial Collaborators (2017) Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet Lond Engl 389(10084):2105–2116
Jeong JY, Kim SH, Sim JS, Lee HJ, Do K-H, Moon MH et al (2002) MR findings of renal cortical necrosis. J Comput Assist Tomogr 26(2):232–236
François M, Tostivint I, Mercadal L, Bellin MF, Izzedine H, Deray G (2000) MR imaging features of acute bilateral renal cortical necrosis. Am J Kidney Dis Off J Natl Kidney Found 35(4):745–748
McKay H, Ducharlet K, Temple F, Sutherland T (2014) Contrast enhanced ultrasound (CEUS) in the diagnosis of post-partum bilateral renal cortical necrosis: a case report and review of the literature. Abdom Imaging 39(3):550–553
Assali NS, Kaplan SA, Fomon SJ, Douglass RA (1953) Renal function studies in toxemia of pregnancy; excretion of solutes and renal hemodynamics during osmotic diuresis in hydropenia. J Clin Invest 32(1):44–51
Lafayette RA, Druzin M, Sibley R, Derby G, Malik T, Huie P et al (1998) Nature of glomerular dysfunction in pre-eclampsia. Kidney Int 54(4):1240–1249
Prakash J, Ganiger VC, Prakash S, Iqbal M, Kar DP, Singh U et al (2018) Acute kidney injury in pregnancy with special reference to pregnancy-specific disorders: a hospital based study (2014–2016). J Nephrol 31(1):79–85
Zeisler H, Llurba E, Chantraine F, Vatish M, Staff AC, Sennström M et al (2016) Predictive value of the sFlt-1:PlGF ratio in women with suspected preeclampsia. N Engl J Med 374(1):13–22
American College of Obstetricians and Gynecologists (2013) Task Force on Hypertension in Pregnancy. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists’ Task Force on Hypertension in Pregnancy. Obstet Gynecol 122(5):1122–1131
Piccoli GB, Cabiddu G, Castellino S, Gernone G, Santoro D, Moroni G et al (2017) A best practice position statement on the role of the nephrologist in the prevention and follow-up of preeclampsia: the Italian study group on kidney and pregnancy. J Nephrol 30(3):307–317
Xiao J, Niu J, Ye X, Yu Q, Gu Y (2013) Combined biomarkers evaluation for diagnosing kidney injury in preeclampsia. Hypertens Pregnancy 32(4):439–449
Sass N, Facca TA, Pereira ARPR., Famá EA, Nishida SK, Moreira SR et al (2012) PP019 The role of renal markers in women with and without preeclampsia: evaluation of urinary excretion of podocytes and proteins. Pregnancy Hypertens 2(3):251–252
Codsi E, Garovic VD, Gonzalez-Suarez ML, Milic N, Borowski KS, Rose CH et al (2017) Longitudinal characterization of renal proximal tubular markers in normotensive and preeclamptic pregnancies. Am J Physiol Regul Integr Comp Physiol 312(5):R773–R778
George JN, Nester CM (2014) Syndromes of thrombotic microangiopathy. N Engl J Med 371(7):654–666
Fakhouri F, Roumenina L, Provot F, Sallée M, Caillard S, Couzi L et al (2010) Pregnancy-associated hemolytic uremic syndrome revisited in the era of complement gene mutations. J Am Soc Nephrol JASN 21(5):859–867
Hecht JL, Ordi J, Carrilho C, Ismail MR, Zsengeller ZK, Karumanchi SA et al (2017) The pathology of eclampsia: an autopsy series. Hypertens Pregnancy 5:1–10
Fakhouri F, Jablonski M, Lepercq J, Blouin J, Benachi A, Hourmant M et al (2008) Factor H, membrane cofactor protein, and factor I mutations in patients with hemolysis, elevated liver enzymes, and low platelet count syndrome. Blood 112(12):4542–4545
Crovetto F, Borsa N, Acaia B, Nishimura C, Frees K, Smith RJH et al (2012) The genetics of the alternative pathway of complement in the pathogenesis of HELLP syndrome. J Matern-Fetal Neonatal Med Off J Eur Assoc Perinat Med Fed Asia Ocean Perinat Soc Int Soc Perinat Obstet 25(11):2322–2325
Fisher KA, Luger A, Spargo BH, Lindheimer MD (1981) Hypertension in pregnancy: clinical-pathological correlations and remote prognosis. Medicine (Baltimore) 60(4):267–276
Slater DN, Hague WM (1984) Renal morphological changes in idiopathic acute fatty liver of pregnancy. Histopathology 8(4):567–581
Kang HM, Ahn SH, Choi P, Ko Y-A, Han SH, Chinga F et al (2015) Defective fatty acid oxidation in renal tubular epithelial cells has a key role in kidney fibrosis development. Nat Med 21(1):37–46
Liban E, Raz S (1969) A clinicopathologic study of fourteen cases of amniotic fluid embolism. Am J Clin Pathol 51(4):477–486
Pritchard JA, Whalley PJ (1971) Abortion complicated by Clostridium perfringens infection. Am J Obstet Gynecol 111(4):484–492
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Villie, P., Dommergues, M., Brocheriou, I. et al. Why kidneys fail post-partum: a tubulocentric viewpoint. J Nephrol 31, 645–651 (2018). https://doi.org/10.1007/s40620-018-0488-0
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DOI: https://doi.org/10.1007/s40620-018-0488-0