Advertisement

Acute Kidney Injury During Pregnancy

  • Anjali AcharyaEmail author
Chapter

Abstract

PR-AKI is associated with significant fetal and maternal morbidity. Hypertensive disorders of pregnancy and their complications, notably HELLP syndrome, are the leading cause of PR-AKI. In women with existing kidney disease, worsening of renal function during pregnancy is common, and differentiating it from preeclampsia can be a challenge. This poses a dilemma as treatment options are very different in the two conditions, with premature termination of pregnancy or early delivery being indicated in some cases of preeclampsia. Preconception assessment is essential in women with CKD, to determine whether pregnancy may pose an unacceptably high maternal or fetal risk. It provides an opportunity to evaluate disease activity, initiate interventions, and adjust medications to those that are least harmful to the fetus. P-TMA is a clinically challenging cause of PR-AKI. Several breakthroughs in our understanding of different mechanisms underlying P-TMA and preeclampsia have led to better management of these patients.

Keywords

Acute kidney injury during pregnancy Pregnancy and acute kidney injury Acute renal failure in pregnancy Acute fatty liver of pregnancy Acute cortical necrosis Acute tubular necrosis 

References

  1. 1.
    Stratta P, Besso L, Canavese C, et al. Is pregnancy-related acute renal failure a disappearing clinical entity? Ren Fail. 1996;18(4):575–84.PubMedCrossRefPubMedCentralGoogle Scholar
  2. 2.
    Prakash J, Niwas SS, Parekh A, et al. Acute kidney injury in late pregnancy in developing countries. Ren Fail. 2010;32(3):309–13.PubMedCrossRefPubMedCentralGoogle Scholar
  3. 3.
    Liu S, Joseph KS, Bartholomew S, et al. Temporal trends and regional variations in severe maternal morbidity in Canada, 2003 to 2007. J Obstet Gynaecol Can. 2010;32(9):847–55.PubMedCrossRefPubMedCentralGoogle Scholar
  4. 4.
    Mehta RL, Kellum JA, Shah SV, et al. Acute kidney injury network: report of an initiative to improve outcomes in acute kidney injury. Crit Care. 2007;11(2):R31.PubMedPubMedCentralCrossRefGoogle Scholar
  5. 5.
    Levey AS, Becker C, Inker LA. Glomerular filtration rate and albuminuria for detection and staging of acute and chronic kidney disease in adults: a systematic review. JAMA. 2015;313(8):837–46.PubMedPubMedCentralCrossRefGoogle Scholar
  6. 6.
    Mehrabadi A. Obstet Gynecol. 2016;127(5):899–906.PubMedCrossRefPubMedCentralGoogle Scholar
  7. 7.
    Sibai BM, Villar MA, Mabie BC. Acute renal failure in hypertensive disorders of pregnancy. Pregnancy outcome and remote prognosis in thirty-one consecutive cases. Am J Obstet Gynecol. 1990;162(3):777–83.PubMedCrossRefPubMedCentralGoogle Scholar
  8. 8.
    Vikse BE. Pre-eclampsia and the risk of kidney disease. Lancet. 2013;382(9887):104–6.PubMedCrossRefPubMedCentralGoogle Scholar
  9. 9.
    Hildebrand AM, Liu K, Shariff SZ, et al. Characteristics and outcomes of AKI treated with dialysis during pregnancy and the postpartum period. J Am Soc Nephrol: JASN. 2015;26(12):3085–91.PubMedCrossRefPubMedCentralGoogle Scholar
  10. 10.
    Pahwa N, Bharani R, Kumar R. Post-partum acute kidney injury. Saudi J Kidney Dis Transplant Off Publ Saudi Cent Organ Transplant, Saudi Arab. 2014;25(6):1244–7.Google Scholar
  11. 11.
    Godara SM, Kute VB, Trivedi HL, et al. Clinical profile and outcome of acute kidney injury related to pregnancy in developing countries: a single-center study from India. Saudi J Kidney Dis Transplant Off Publ Saudi Cent Organ Transplant, Saudi Arab. 2014;25(4):906–11.Google Scholar
  12. 12.
    Odutayo A, Hladunewich M. Obstetric nephrology: renal hemodynamic and metabolic physiology in normal pregnancy. Clin J Am Soc Nephrol. 2012;7(12):2073–80.PubMedCrossRefPubMedCentralGoogle Scholar
  13. 13.
    Johnson RJ, Kanbay M, Kang DH, Sanchez-Lozada LG, Feig D. Uric acid: a clinically useful marker to distinguish preeclampsia from gestational hypertension. Hypertension. 2011;58(4):548–9.PubMedPubMedCentralCrossRefGoogle Scholar
  14. 14.
    Roberts JM, Bodnar LM, Lain KY, et al. Uric acid is as important as proteinuria in identifying fetal risk in women with gestational hypertension. Hypertension. 2005;46(6):1263–9.PubMedCrossRefPubMedCentralGoogle Scholar
  15. 15.
    Silva GB Jr, Monteiro FA, Mota RM, et al. Acute kidney injury requiring dialysis in obstetric patients: a series of 55 cases in Brazil. Arch Gynecol Obstet. 2009;279(2):131–7.PubMedCrossRefPubMedCentralGoogle Scholar
  16. 16.
    Kamal EM, Behery MM, Sayed GA, Abdulatif HK. RIFLE classification and mortality in obstetric patients admitted to the intensive care unit with acute kidney injury: a 3-year prospective study. Reprod Sci. 2014;21(10):1281–7.PubMedCrossRefPubMedCentralGoogle Scholar
  17. 17.
    Drakeley AJ, Le Roux PA, Anthony J, Penny J. Acute renal failure complicating severe preeclampsia requiring admission to an obstetric intensive care unit. Am J Obstet Gynecol. 2002;186(2):253–6.PubMedCrossRefPubMedCentralGoogle Scholar
  18. 18.
    Gul A, Aslan H, Cebeci A, Polat I, Ulusoy S, Ceylan Y. Maternal and fetal outcomes in HELLP syndrome complicated with acute renal failure. Ren Fail. 2004;26(5):557–62.PubMedCrossRefPubMedCentralGoogle Scholar
  19. 19.
    Haddad B, Barton JR, Livingston JC, Chahine R, Sibai BM. HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome versus severe preeclampsia: onset at < or =28.0 weeks’ gestation. Am. J Obstet Gynecol. 2000;183(6):1475–9.PubMedCrossRefPubMedCentralGoogle Scholar
  20. 20.
    Sibai BM, Ramadan MK, Usta I, Salama M, Mercer BM, Friedman SA. Maternal morbidity and mortality in 442 pregnancies with hemolysis, elevated liver enzymes, and low platelets (HELLP syndrome). Am J Obstet Gynecol. 1993;169(4):1000–6.PubMedCrossRefPubMedCentralGoogle Scholar
  21. 21.
    Selcuk NY, Odabas AR, Cetinkaya R, Tonbul HZ, San A. Outcome of pregnancies with HELLP syndrome complicated by acute renal failure (1989-1999). Ren Fail. 2000;22(3):319–27.PubMedCrossRefPubMedCentralGoogle Scholar
  22. 22.
    Wilcken B, Leung KC, Hammond J, Kamath R, Leonard JV. Pregnancy and fetal long-chain 3-hydroxyacyl coenzyme A dehydrogenase deficiency. Lancet. 1993;341(8842):407–8.PubMedCrossRefPubMedCentralGoogle Scholar
  23. 23.
    Schoeman MN, Batey RG, Wilcken B. Recurrent acute fatty liver of pregnancy associated with a fatty-acid oxidation defect in the offspring. Gastroenterology. 1991;100(2):544–8.PubMedCrossRefPubMedCentralGoogle Scholar
  24. 24.
    Katz AI, Lindheimer MD. Does pregnancy aggravate primary glomerular disease? Am J Kidney Dis. 1985;6(4):261–5.PubMedCrossRefPubMedCentralGoogle Scholar
  25. 25.
    Jones DC, Hayslett JP. Outcome of pregnancy in women with moderate or severe renal insufficiency. N Engl J Med. 1996;335(4):226–32.PubMedCrossRefPubMedCentralGoogle Scholar
  26. 26.
    Fakhouri F, Fremeaux-Bacchi V. Does hemolytic uremic syndrome differ from thrombotic thrombocytopenic purpura? Nat Clin Pract Nephrol. 2007;3(12):679–87.PubMedCrossRefPubMedCentralGoogle Scholar
  27. 27.
    Fakhouri F, Roumenina L, Provot F, et al. Pregnancy-associated hemolytic uremic syndrome revisited in the era of complement gene mutations. J Am Soc Nephrol. 2010;21(5):859–67.PubMedPubMedCentralCrossRefGoogle Scholar
  28. 28.
    Mannucci PM, Canciani MT, Forza I, Lussana F, Lattuada A, Rossi E. Changes in health and disease of the metalloprotease that cleaves von Willebrand factor. Blood. 2001;98(9):2730–5.PubMedCrossRefPubMedCentralGoogle Scholar
  29. 29.
    Verlohren S, Galindo A, Schlembach D, et al. An automated method for the determination of the sFlt-1/PIGF ratio in the assessment of preeclampsia. Am J Obstet Gynecol. 2010;202(2):161.e161–11.CrossRefGoogle Scholar
  30. 30.
    Salmon JE, Heuser C, Triebwasser M, et al. Mutations in complement regulatory proteins predispose to preeclampsia: a genetic analysis of the PROMISSE cohort. PLoS Med. 2011;8(3):e1001013.PubMedPubMedCentralCrossRefGoogle Scholar
  31. 31.
    Shamonki JM, Salmon JE, Hyjek E, Baergen RN. Excessive complement activation is associated with placental injury in patients with antiphospholipid antibodies. Am J Obstet Gynecol. 2007;196(2):167.e161–5.CrossRefGoogle Scholar
  32. 32.
    Redecha P, Tilley R, Tencati M, et al. Tissue factor: a link between C5a and neutrophil activation in antiphospholipid antibody induced fetal injury. Blood. 2007;110(7):2423–31.PubMedPubMedCentralCrossRefGoogle Scholar
  33. 33.
    Qing X, Redecha PB, Burmeister MA, et al. Targeted inhibition of complement activation prevents features of preeclampsia in mice. Kidney Int. 2011;79(3):331–9.PubMedCrossRefPubMedCentralGoogle Scholar
  34. 34.
    Fakhouri F, Jablonski M, Lepercq J, et al. Factor H, membrane cofactor protein, and factor I mutations in patients with hemolysis, elevated liver enzymes, and low platelet count syndrome. Blood. 2008;112(12):4542–5.PubMedCrossRefPubMedCentralGoogle Scholar
  35. 35.
    Acharya A, Brima W, Burugu S, Rege T. Prediction of preeclampsia-bench to bedside. Curr Hypertens Rep. 2014;16(11):491.PubMedCrossRefPubMedCentralGoogle Scholar
  36. 36.
    Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton TM. Infectious diseases society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis. 2005;40(5):643–54.PubMedCrossRefPubMedCentralGoogle Scholar
  37. 37.
    Matlin RA, Gary NE. Acute cortical necrosis. Case report and review of the literature. Am J Med. 1974;56(1):110–8.PubMedCrossRefGoogle Scholar
  38. 38.
    Grams ME, Estrella MM, Coresh J, Brower RG, Liu KD. Fluid balance, diuretic use, and mortality in acute kidney injury. Clin J Am Soc Nephrol. 2011;6(5):966–73.PubMedPubMedCentralCrossRefGoogle Scholar
  39. 39.
    Lindheimer MD, Taler SJ, Cunningham FG. Hypertension in pregnancy. J Am Soc Hypertens. 2010;4(2):68–78.PubMedCrossRefGoogle Scholar
  40. 40.
    Abalos E, Duley L, Steyn DW. Antihypertensive drug therapy for mild to moderate hypertension during pregnancy. Cochrane Database Syst Rev. 2014;2:Cd002252.Google Scholar
  41. 41.
    Magee LA, von Dadelszen P, Rey E, et al. Less-tight versus tight control of hypertension in pregnancy. N Engl J Med. 2015;372(5):407–17.PubMedCrossRefPubMedCentralGoogle Scholar
  42. 42.
    Jim B, Sharma S, Kebede T, Acharya A. Hypertension in pregnancy: a comprehensive update. Cardiol Rev. 2010;18(4):178–89.PubMedCrossRefPubMedCentralGoogle Scholar
  43. 43.
    Katz L, de Amorim MM, Figueiroa JN, Pinto e Silva JL. Postpartum dexamethasone for women with hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome: a double-blind, placebo-controlled, randomized clinical trial. Am J Obstet Gynecol. 2008;198(3):283.e281–8.CrossRefGoogle Scholar
  44. 44.
    Eckford SD, Macnab JL, Turner ML, Plews D, Liston WA. Plasmapheresis in the management of HELLP syndrome. J Obstet Gynaecol. 1998;18(4):377–9.PubMedCrossRefPubMedCentralGoogle Scholar
  45. 45.
    Vesely SK, George JN, Lammle B, et al. ADAMTS13 activity in thrombotic thrombocytopenic purpura-hemolytic uremic syndrome: relation to presenting features and clinical outcomes in a prospective cohort of 142 patients. Blood. 2003;102(1):60–8.PubMedCrossRefPubMedCentralGoogle Scholar
  46. 46.
    Veyradier A, Obert B, Houllier A, Meyer D, Girma JP. Specific von Willebrand factor-cleaving protease in thrombotic microangiopathies: a study of 111 cases. Blood. 2001;98(6):1765–72.PubMedCrossRefPubMedCentralGoogle Scholar
  47. 47.
    Morigi M, Galbusera M, Gastoldi S, et al. Alternative pathway activation of complement by Shiga toxin promotes exuberant C3a formation that triggers microvascular thrombosis. J Immunol. 2011;187(1):172–80.PubMedCrossRefPubMedCentralGoogle Scholar
  48. 48.
    Noris M, Caprioli J, Bresin E, et al. Relative role of genetic complement abnormalities in sporadic and familial aHUS and their impact on clinical phenotype. Clin J Am Soc Nephrol. 2010;5(10):1844–59.PubMedPubMedCentralCrossRefGoogle Scholar
  49. 49.
    Scully M, McDonald V, Cavenagh J, et al. A phase 2 study of the safety and efficacy of rituximab with plasma exchange in acute acquired thrombotic thrombocytopenic purpura. Blood. 2011;118(7):1746–53.PubMedCrossRefPubMedCentralGoogle Scholar
  50. 50.
    Gammill HS, Jeyabalan A. Acute renal failure in pregnancy. Crit Care Med. 2005;33(10 Suppl):S372–84.PubMedCrossRefPubMedCentralGoogle Scholar
  51. 51.
    Holley JL, Reddy SS. Pregnancy in dialysis patients: a review of outcomes, complications, and management. Semin Dial. 2003;16(5):384–8.PubMedCrossRefPubMedCentralGoogle Scholar
  52. 52.
    Kremer Hovinga JA, Vesely SK, Terrell DR, Lammle B, George JN. Survival and relapse in patients with thrombotic thrombocytopenic purpura. Blood. 2010;115(8):1500–11; quiz 1662.PubMedCrossRefPubMedCentralGoogle Scholar
  53. 53.
    Scully M, Starke R, Lee R, Mackie I, Machin S, Cohen H. Successful management of pregnancy in women with a history of thrombotic thrombocytopaenic purpura. Blood Coagul Fibrinolysis. 2006;17(6):459–63.PubMedCrossRefPubMedCentralGoogle Scholar
  54. 54.
    Najar MS, Shah AR, Wani IA, et al. Pregnancy related acute kidney injury: a single center experience from the Kashmir Valley. Indian J Nephrol. 2008;18(4):159–61.PubMedPubMedCentralCrossRefGoogle Scholar
  55. 55.
    Clark SL. Handbook of critical care obstetrics. Boston: Blackwell Scientific Publications; 1994.Google Scholar
  56. 56.
    Dragun D. Acute kidney failure during pregnancy and postpartum. In: Management of acute kidney problems. Heidelberg: Springer; 2010. p. 445–58.CrossRefGoogle Scholar
  57. 57.
    Hladunewich MA, Hou S, Odutayo A, et al. Intensive hemodialysis associates with improved pregnancy outcomes: a Canadian and United States cohort comparison. J Am Soc Nephrol. 2014;25(5):1103–9.PubMedPubMedCentralCrossRefGoogle Scholar
  58. 58.
    Sachdeva M, Barta V, Thakkar J, et al. Pregnancy outcomes in women on hemodialysis: a national survey. Clin Kidney J. 2017;10(2):276–81.PubMedPubMedCentralGoogle Scholar
  59. 59.
    Acharya A, Santos J, Linde B, Anis K. Acute kidney injury in pregnancy—current status. Adv Chronic Kidney Dis. 2013;20(3):215–22.PubMedCrossRefPubMedCentralGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Department of MedicineJacobi Medical CenterBronxUSA

Personalised recommendations