Acute Renal Failure (Acute Kidney Injury) in Pregnancy



Acute renal failure (ARF or acute kidney injury [AKI]) in pregnancy is characterized by a rapid decrease in the glomerular filtration rate (GFR) over a matter of minutes or days. It may result from many of the same causes that occur in nonpregnant women. However, there are specific conditions in pregnancy that may precipitate ARF [1]. Understanding the causes of renal functional deterioration in pregnancy is important in arriving at a rational differential diagnosis and initiating appropriate treatment. In pregnancy, development of ARF is a major clinical challenge because it affects both mother and fetus. Management options, therefore, need to take both maternal and fetal well-being into consideration. Prevention, early recognition, and appropriate therapeutic decisions are imperative in improving maternal and perinatal outcomes. ARF in pregnancy is a complex entity, requiring a multidisciplinary approach with the nephrologist playing an important role.


Acute Renal Failure Renal Replacement Therapy Acute Kidney Injury Continuous Renal Replacement Therapy Thrombotic Thrombocytopenic Purpura 


  1. 1.
    Krane NK. Acute renal failure in pregnancy. Arch Intern Med. 1988;148(11):2347.CrossRefPubMedGoogle Scholar
  2. 2.
    Stratta P, Besso L, Canavese C, Grill A, Todros T, Benedetto C, et al. Is pregnancy-related acute renal failure a disappearing clinical entity? Ren Fail. 1996;18:575–84.CrossRefPubMedGoogle Scholar
  3. 3.
    Prakash J, Kumar H, Sinha DK, Kedalaya PG, Pandey LK, Srivastava PK, et al. Acute renal failure in pregnancy in a developing country: twenty years of experience. Ren Fail. 2006;28:309–13.CrossRefPubMedGoogle Scholar
  4. 4.
    Prakash J, Tripathi K, Pandey LK, Sahai S, Usha, Srivastava PK. Spectrum of renal cortical necrosis in acute renal failure in eastern India. Postgrad Med J. 1995;71:208–10.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Kumar KS, Krishna CR, Siva Kumar V. Pregnancy related acute renal failure. J Obstet Gynecol India. 2006;56:308–10.Google Scholar
  6. 6.
    Goplani KR, Shah PR, Gera DN, et al. Pregnancy-related acute renal failure: a single-center experience. Indian J Nephrol. 2008;18(1):17–21.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    August P, George JN. Acute kidney injury (acute renal failure) in pregnancy. Lockwood CJ, Palevsky PM, editors. In: UpToDate. Waltham: UpToDate; 2014. Accessed 14 Nov 2014.Google Scholar
  8. 8.
    Machado S, Figueiredo N, Borges A, et al. Acute kidney injury in pregnancy: a clinical challenge. J Nephrol. 2012;25(01):21–30.CrossRefGoogle Scholar
  9. 9.
    Chugh KS, Singhal PC, Sharma BK. ARF of obstetric origin. J Obstet Gynecol. 1976;108:253–61.Google Scholar
  10. 10.
    Prakash J, Tripathi K, Pandey LK, Gadela SR, Usha. Renal cortical necrosis in pregnancy related acute renal failure. J Indian Med Assoc. 1996;94:227–9.PubMedGoogle Scholar
  11. 11.
    Report of the ACOG Task Force on Hypertension in Pregnancy. Obstet Gynecol. 2013;122(5).Google Scholar
  12. 12.
    Leeman L, Fontaine P. Hypertensive disorders of pregnancy. Am Fam Physician. 2008;78(1):93–100.PubMedGoogle Scholar
  13. 13.
    Lafayette RA, Druzin M, Sibley R, et al. Nature of glomerular dysfunction in pre-eclampsia. Kidney Int. 1998;54:1240.CrossRefPubMedGoogle Scholar
  14. 14.
    Sibai BM, Ramadan MK. Acute renal failure in pregnancies complicated by hemolysis, elevated liver enzymes, and low platelets. Am J Obstet Gynecol. 1993;168:1682.CrossRefPubMedGoogle Scholar
  15. 15.
    Picinni P, Gallo G. Diagnosis and management of HELLP syndrome. In: Ronco C, Bellomo R, Kellum J, editors. Critical care nephrology. 2nd ed. Philadelphia: Saunders; 2009. p. 337–40.Google Scholar
  16. 16.
    Baxter JK, Weinstein L. HELLP syndrome: the state of the art. Obstet Gynecol Surv. 2004;59(12):838–45.CrossRefPubMedGoogle Scholar
  17. 17.
    Haram K, Svendsen E, Abildgaard U. The HELLP syndrome: clinical issues and management: a Review. BMC Pregnancy Childbirth. 2009;9(1):8. 65.Google Scholar
  18. 18.
    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.CrossRefPubMedGoogle Scholar
  19. 19.
    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.CrossRefPubMedGoogle Scholar
  20. 20.
    Sibai BM. Diagnosis, controversies, and management of the syndrome of hemolysis, elevated liver enzymes, and low platelet count. Obstet Gynecol. 2004;103(5 Pt 1):981–91.CrossRefPubMedGoogle Scholar
  21. 21.
    Castro MA, Fassett MJ, Reynolds TB, et al. Reversible peripartum liver failure: a new perspective on the diagnosis, treatment, and cause of acute fatty liver of pregnancy, based on 28 consecutive cases. Am J Obstet Gynecol. 1999;181:389.CrossRefPubMedGoogle Scholar
  22. 22.
    Santana L, Hernández Medina E, O’Shanahan G, Sánchez-Palacios M. Acute renal failure in acute fatty liver of pregnancy: apropos of a case. Nefrologia. 2005;25(4):453–4.PubMedGoogle Scholar
  23. 23.
    Koroshi A, Babameto A. Acute renal failure during acute fatty liver of pregnancy. Nephrol Dial Transplant. 2002;17(6):1110–2.CrossRefPubMedGoogle Scholar
  24. 24.
    Guntupalli SR, Steingrub J. Hepatic disease and pregnancy: an overview of diagnosis and management. Crit Care Med. 2005;33(10 Suppl):S332–9.CrossRefPubMedGoogle Scholar
  25. 25.
    Nelson DB, Yost NP, Cunningham FG. Acute fatty liver of pregnancy: clinical outcomes and expected duration of recovery. Am J Obstet Gynecol. 2013;209:456.e1.CrossRefGoogle Scholar
  26. 26.
    Fakhouri F, Frémeaux-Bacchi V. Does hemolytic uremic syndrome differ from thrombotic thrombocytopenic purpura? Nat Clin Pract Nephrol. 2007;3(12):679–87.CrossRefPubMedGoogle Scholar
  27. 27.
    George J. The thrombotic thrombocytopenic purpura and hemolytic uremic syndrome: evaluation, management and long-term outcomes experience of the Oklahoma TTP-HUS registry, 1989–2007. Kidney Int. 2009;112:S52–4.CrossRefGoogle Scholar
  28. 28.
    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.CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Drakely 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;186:253–6.CrossRefGoogle Scholar
  30. 30.
    Prakash J, Niwas SS, Parekh A, et al. Acute kidney injury in late pregnancy in developing countries. Ren Fail. 2010;32(3):309–13.CrossRefPubMedGoogle Scholar
  31. 31.
    Kellum JA, Lameire N. Diagnosis, evaluation, and management of acute kidney injury: a KDIGO summary (Part 1). Crit Care. 2013;17:204.CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Podymow T, August P. Update on the use of antihypertensive drugs in pregnancy. Hypertension. 2008;51:960–9.CrossRefPubMedGoogle Scholar
  33. 33.
    Visintin C, Mugglestone MA, Almerie MQ, Nherera LM, James D, Walkinshaw S. Management of hypertensive disorders during pregnancy: summary of NICE guidance. BMJ. 2010;341:c2207.CrossRefPubMedGoogle Scholar
  34. 34.
    Vidaeff AC, Carroll MA, Ramin SM. Acute hypertensive emergencies in pregnancy. Crit Care Med. 2005;33:S307–12.CrossRefPubMedGoogle Scholar
  35. 35.
    Magee LA, Cham C, Waterman EJ, Ohlsson A, von Dadelszen P. Hydralazine for treatment of severe hypertension in pregnancy: meta-analysis. BMJ. 2003;327:955–60.CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Chandiramani M, Shennan A. Hypertensive disorders of pregnancy: a UK-based perspective. Curr Opin Obstet Gynecol. 2008;20:96–101.CrossRefPubMedGoogle Scholar
  37. 37.
    Machado S, Figueiredo N, Borges A, et al. Acute kidney injury in pregnancy: a clinical challenge. J Nephrol. 2012;25:19–30.CrossRefPubMedGoogle Scholar
  38. 38.
    Acharya A, Santos J, Linde B, Anis K. Acute kidney injury in pregnancy-current status. Adv Chronic Kidney Dis. 2013;20:215–22.CrossRefPubMedGoogle Scholar
  39. 39.
    Tanhehco YC, Berns JS. Red blood cell transfusion risks in patients with end-stage renal disease. Semin Dial. 2012;25:539–44.CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Jungers P, Chauveau D. Pregnancy in renal disease. Kidney Int. 1997;52:871–85.CrossRefPubMedGoogle Scholar
  41. 41.
    Barraclough K, Leone E, Chiu A. Renal replacement therapy for acute kidney injury in pregnancy. Nephrol Dial Transplant. 2007;22:2395–7.CrossRefPubMedGoogle Scholar
  42. 42.
    Davison JM, Dunlop W. Renal hemodynamics and tubular function normal human pregnancy. Kidney Int. 1980;18:152–61.CrossRefPubMedGoogle Scholar
  43. 43.
    Sturgiss SN, Dunlop W, Davison JM. Renal haemodynamics and tubular function in human pregnancy. Baillieres Clin Obstet Gynaecol. 1994;8:209–34.CrossRefPubMedGoogle Scholar
  44. 44.
    Bagon JA, Vernaeve H, De Muylder X, Lafontaine JJ, Martens J, Van Roost G. Pregnancy and dialysis. Am J Kidney Dis. 1998;31:756–65.CrossRefPubMedGoogle Scholar
  45. 45.
    Gangji AS, Windrim R, Gandhi S, Silverman JA, Chan CT. Successful pregnancy with nocturnal hemodialysis. Am J Kidney Dis. 2004;44:912–6.CrossRefPubMedGoogle Scholar
  46. 46.
    Okundaye I, Abrinko P, Hou S. Registry of pregnancy in dialysis patients. Am J Kidney Dis. 1998;31:766–73.CrossRefPubMedGoogle Scholar
  47. 47.
    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;25:1103–9.CrossRefPubMedPubMedCentralGoogle Scholar
  48. 48.
    Krane NK, Hamrahian M. Pregnancy: kidney diseases and hypertension. Am J Kidney Dis. 2007;49:336–45.CrossRefPubMedGoogle Scholar
  49. 49.
    Davenport A. Peritoneal dialysis in acute kidney injury. Perit Dial Int. 2008;28:423–4; author reply 424.PubMedGoogle Scholar
  50. 50.
    Briones-Garduno JC, Diaz de Leon-Ponce MA, Rodriguez-Roldan M, Briones-Vega CG, Torres-Perez J. Peritoneal dialysis in obstetric patients. Cir Cir. 2006;74:15–20.PubMedGoogle Scholar
  51. 51.
    Hou S. Modification of dialysis regimens for pregnancy. Int J Artif Organs. 2002;25:823–6.PubMedGoogle Scholar
  52. 52.
    Fieghen HE, Friedrich JO, Burns KE, et al. The hemodynamic tolerability and feasibility of sustained low efficiency dialysis in the management of critically ill patients with acute kidney injury. BMC Nephrol. 2010;11:32.CrossRefPubMedPubMedCentralGoogle Scholar
  53. 53.
    Hill JB, Yost NP, Wendel GDJ. Acute renal failure in association with severe hyperemesis gravidarum. Obstet Gynecol. 2002;100:1119–21.PubMedGoogle Scholar
  54. 54.
    Blackwell SC, Redman ME, Tomlinson M, et al. Labor induction for the preterm severe pre-eclamptic patient: is it worth the effort? J Matern Fetal Med. 2001;10:305–11.CrossRefPubMedGoogle Scholar
  55. 55.
    Gammill HS, Jeyabalan A. Acute renal failure in pregnancy. Crit Care Med. 2005;33(10 Suppl):S372–84.CrossRefPubMedGoogle Scholar
  56. 56.
    Bushnell C, Chireau M. Preeclampsia and stroke: risks during and after pregnancy. Stroke Res Treat. 2011;2011:858134.PubMedPubMedCentralGoogle Scholar
  57. 57.
    Dennis AT, Solnordal CB. Acute pulmonary oedema in pregnant women. Anaesthesia. 2012;67:646–59.CrossRefPubMedGoogle Scholar
  58. 58.
    Churchill D, Duley L, Thornton JG, Jones L. Interventionist versus expectant care for severe pre-eclampsia between 24 and 34 weeks’ gestation. Cochrane Database Syst Rev. 2013;(7):CD003106.Google Scholar
  59. 59.
    Group TETC. Which anticonvulsant for women with eclampsia? Evidence from the Collaborative Eclampsia Trial. Lancet. 1995;345:1455–63.CrossRefGoogle Scholar
  60. 60.
    Chugh KS, Jha V, Sakhuja V, Joshi K. Acute renal cortical necrosis–a study of 113 patients. Ren Fail. 1994;16:37–47.CrossRefPubMedGoogle Scholar
  61. 61.
    Esplin MSM, Branch DW. Diagnosis and management of thrombotic microangiopathies during pregnancy. Clin Obstet Gynecol Ambul Gynecol. 1999;42:360–7.CrossRefGoogle Scholar
  62. 62.
    Rock G, Shumak KH, Buskard MA, et al. Comparison of plasma exchange with plasma infusion in the treatment of thrombotic thrombocytopenic purpura. Canadian Apheresis Study Group. N Engl J Med. 1991;325:393–7.CrossRefPubMedGoogle Scholar
  63. 63.
    Fakhouri F, Vercel C, Fremeaux-Bacchi V. Obstetric nephrology: AKI and thrombotic microangiopathies in pregnancy. Clin J Am Soc Nephrol. 2012;7:2100–6.CrossRefPubMedGoogle Scholar
  64. 64.
    Kremer Hovinga JA, Vesely SK, Terrell DR, Lammle B, George JN. Survival and relapse in patients with thrombotic thrombocytopenic purpura. Blood. 2010;115:1500–11; quiz 1662.CrossRefPubMedGoogle Scholar
  65. 65.
    Gall B, Yee A, Berry B, et al. Rituximab for management of refractory pregnancy-associated immune thrombocytopenic purpura. J Obstet Gynaecol Can. 2010;32:1167–71.CrossRefPubMedGoogle Scholar
  66. 66.
    Chakravarty EF, Murray ER, Kelman A, Farmer P. Pregnancy outcomes after maternal exposure to rituximab. Blood. 2011;117:1499–506.CrossRefPubMedGoogle Scholar
  67. 67.
    Kaplan M. Eculizumab (Alexion). Curr Opin Investig Drugs. 2002;3:1017–23.PubMedGoogle Scholar
  68. 68.
    Mache CJ, Acham-Roschitz B, Fremeaux-Bacchi V, et al. Complement inhibitor eculizumab in atypical hemolytic uremic syndrome. Clin J Am Soc Nephrol. 2009;4:1312–6.CrossRefPubMedPubMedCentralGoogle Scholar
  69. 69.
    Legendre CM, Licht C, Muus P, et al. Terminal complement inhibitor eculizumab in atypical hemolytic-uremic syndrome. N Engl J Med. 2013;368:2169–81.CrossRefPubMedGoogle Scholar
  70. 70.
    Kelly R, Arnold L, Richards S, et al. The management of pregnancy in paroxysmal nocturnal haemoglobinuria on long term eculizumab. Br J Haematol. 2010;149:446–50.CrossRefPubMedGoogle Scholar
  71. 71.
    Clark SL. Handbook of critical care obstetrics. Boston: Blackwell Scientific Publications; 1994.Google Scholar
  72. 72.
    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.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer India 2016

Authors and Affiliations

  1. 1.Department of Obstetrics and GynaecologyE V Kalyani Medical FoundationChennaiIndia
  2. 2.Department of MedicineSundaram Medical Foundation, Dr. Rangarajan Memorial HospitalChennaiIndia

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