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Year : 2008  |  Volume : 18  |  Issue : 1  |  Page : 17--21

Pregnancy-related acute renal failure: A single-center experience

KR Goplani1, PR Shah1, DN Gera1, M Gumber1, M Dabhi1, A Feroz1, K Kanodia2, S Suresh3, AV Vanikar4, HL Trivedi1,  
1 Department of Nephrology, Institute of Kidney Disease and Research Centre and Dr HL Trivedi Institute of Transplantation Sciences, Civil Hospital, Asarwa, Ahmedabad, Gujarat, India
2 Department of Pathology, Institute of Kidney Disease and Research Centre and Dr HL Trivedi Institute of Transplantation Sciences, Civil Hospital, Asarwa, Ahmedabad, Gujarat, India
3 Sundaram Hospital, Chennai, Tamil Nadu, India
4 Department of Pathology and Immunology, Institute of Kidney Disease and Research Centre and Dr HL Trivedi Institute of Transplantation Sciences, Civil Hospital, Asarwa, Ahmedabad, Gujarat, India

Correspondence Address:
K R Goplani
Department of Nephrology, Smt. G.R. Doshi and Smt. K.M. Mehta Institute of Kidney Disease and Research Centre (IKDRC), Dr HL Trivedi Institute of Transplantation Sciences (ITS), Civil Hospital, Asarwa, Ahmedabad, Gujarat
India

Abstract

Pregnancy-related acute renal failure (ARF) is a common occurrence and is associated with substantial maternal and fetal mortality. It also bears a high risk of bilateral renal cortical necrosis. We conducted this study to evaluate the contributing factors and to assess the frequency of cortical necrosis. In this prospective study, of the 772 patients with ARF admitted at our institute between January 2004 and May 2006, 70 had ARF associated with pregnancy complications. ARF was diagnosed by documenting oliguria (urine output <400 ml/d) or mounting azotemia in the presence of normal urine output. (serum creatinine >2 mg%). Renal biopsy was performed if a patient was found to be oliguric or required dialysis support at the end of three weeks. The incidence of pregnancy-related ARF was 9.06%. Approximately 20% cases occurred due to postabortal complications in early pregnancy and 80% following complications in late pregnancy. Puerperal sepsis was the most common etiological factor in 61.42% of the patients. Preeclampsia accounted for 28.57% of ARF. Two-thirds of patients recovered with dialysis and supportive care. The incidence of biopsy proven renal cortical necrosis was 14.8% (10 of the 70 patients). The incidence of renal cortical necrosis was 28.57% in the early pregnancy group and 10.71% in the late pregnancy group. Postabortal sepsis was the most common precipitating event for renal cortical necrosis. Maternal mortality was 18.57%. Sepsis accounted for a majority of deaths (61.53%). Pregnancy-related ARF is common in western India. Puerperal sepsis is the most frequent etiological factor. Renal cortical necrosis is common and postabortal sepsis was the most common precipitating event. Sepsis accounted for a majority of maternal mortality.

How to cite this article:
Goplani K R, Shah P R, Gera D N, Gumber M, Dabhi M, Feroz A, Kanodia K, Suresh S, Vanikar A V, Trivedi H L. Pregnancy-related acute renal failure: A single-center experience.Indian J Nephrol 2008;18:17-21

How to cite this URL:
Goplani K R, Shah P R, Gera D N, Gumber M, Dabhi M, Feroz A, Kanodia K, Suresh S, Vanikar A V, Trivedi H L. Pregnancy-related acute renal failure: A single-center experience. Indian J Nephrol [serial online] 2008 [cited 2021 Apr 11 ];18:17-21
Available from: https://www.indianjnephrol.org/text.asp?2008/18/1/17/41283

Full Text

 Introduction



Pregnancy-related acute renal failure (ARF) may comprise up to 25% of the referrals to dialysis centers in developing countries and is associated with substantial maternal and fetal mortality. [1]

In recent years, there has been a marked decline in the incidence of ARF associated with pregnancy; currently, cases that are severe enough to require dialysis occur in fewer than 1 in 20,000 pregnancies, although complications with transient mild to moderate glomerular filtration rate (GFR) decrease occur in approximately 1 in 8000 deliveries. The rate of septic abortion as the reason of the ARF was 33.3% in 1980-85 and has decreased to 6.3% in 1989-97. [2]

ARF in pregnancy is associated with a high risk for maternal mortality (9-55%). [3]

All factors that can cause ARF in a nonpregnant woman can theoretically cause renal failure in a pregnant woman, including volume depletion, bleeding and sepsis. Based on the stage of pregnancy, pregnancy-related ARF is divided into three groups, viz, first half, second half and postpartum ARF. Unskilled and septic abortion are the most common cause of ARF during the first half of pregnancy. During the second half, ARF is most commonly associated with preeclampsia or abruptio placentae. Postpartum renal failure is a specific entity and may be considered as a form of hemolytic-uremic syndrome occurring in the postpartum period.

ARF in pregnancy bears a high risk of bilateral renal cortical necrosis and consequently of chronic renal failure. Renal cortical necrosis is an uncommon entity and accounts for only 2% of all cases of ARF. Obstetric complications are the most common (50-70%) cause of renal cortical necrosis; abruptio placentae, septic abortion, preeclampsia, postpartum hemorrhage and puerperal sepsis are the conditions associated with pregnancy, and are responsible for renal cortical necrosis. [4]

The management of ARF following septic abortion or in the puerperium is similar to that of ARF in nonpregnant subjects, an exception being that hemorrhage may be concealed. This fact is often underestimated and even moderate blood loss can have deleterious effects on the kidneys. Therefore, blood should be replaced early. [5]

We undertook this study to evaluate the contributing factors responsible for pregnancy-related ARF, assess the frequency of cortical necrosis and acute tubular necrosis and factors contributing to their development.

 Materials and Methods



Between January 2004 and May 2006, 772 patients with ARF were admitted at the Institute Of Kidney Diseases and Research Centre and Institute Of Transplantation Sciences.

A total of 92 patients with ARF were pregnant. Of these, 22 patients had the evidence of renal disease prior to pregnancy and were excluded; hence, 70 patients with pregnancy-related ARF were studied.

Pregnant women who were healthy previously and had developed ARF were diagnosed in oliguria (Urine output 2 mg%).

Exclusion criteria were the following:

Evidence of renal disease prior to pregnancy (glomerulonephritis, renal insufficiency from any cause)History of hypertension or diabetes before gestationHistory of renal stone diseasesRenal scarring on ultrasonographySmall size of the kidneysElevated serum creatinine prior to gestation

Thus, women with no history of oliguria or renal disease prior to gestation, normal-sized kidneys on ultrasound and no urological complication were included in the present study.

Detailed history, clinical examination and investigations were performed in all patients. Each patient underwent complete obstetric examination and removal of products of conception was performed as and when required. Specific inquiries were conducted regarding the mode of delivery, need for blood transfusion and surgical intervention. Renal biopsy was performed if a patient was oliguric or required dialysis at the end of three weeks.

Hemodialysis or peritoneal dialysis was performed according to standard indications.

Patients who became dialysis independent with good urine output and renal function were discharged and followed-up every fortnight for three months.

Statistical analysis was performed with unpaired t test. P P P Escherichia coli , Klebsiella and Pseudomonas . Of the six patients with positive blood culture, four died (66.6%).

 Discussion



The incidence of pregnancy-related ARF in the developed countries is 1-2.8%. In the developing countries, the incidence is still remains at 9-25%, mostly due to late referral of pregnancy-related complications. In the present study, the incidence is 9.06%, which is similar to the results found in other literatures from India. [6],[7] The reason of the lower incidence in the developed countries is the prevention of the pregnancy complications and early and more effective treatment of preeclampsia. Septic abortion is not observed any more in developed countries. [3]

In the present study, 20% of the cases were due to postabortal complications in the early pregnancy, while 80% were in late pregnancy. This is in contrast with a previous study conducted in India in which 59.7% of patients were reported to have developed ARF in early pregnancy. [8] This appears to be due to the legalization of abortion.

In our study, the incidence of cortical necrosis was 14.28%, while it was 23.8% in another study previously conducted in India. [6] However, this rate is still higher than other causes of ARF which is [9] The incidence of renal cortical necrosis was 28.57% in early pregnancy and 10.71% in late pregnancy. The higher incidence is probably due to late diagnosis and referral of complications related to dilatation and evacuation. In another study conducted in India, [9] the incidence was nearly equal in the early (20.5%) and late (29%) pregnancies. This is in contrast to the western countries where postabortal ARF leading to renal cortical necrosis is rare (1.5%). [10]

In our study, the maternal mortality was 18.57%, while in a previous study conducted in India, it was approximately 30%. [11] Kumar et al . recently reported a maternal mortality rate of 24%. [7] This appears to be the result of aseptic delivery practices and early management of antepartum and postpartum hemorrhages.

 Conclusion



Pregnancy-related ARF is a common occurrence. Puerperal sepsis was the most common etiological factor responsible for pregnancy-related ARF. ARF due to postabortal sepsis is still a common complication. The incidence of biopsy-proven renal cortical necrosis is high with postabortal sepsis accounting for a significant number. Sepsis, thrombocytopenia, DIC and liver involvement were associated with maternal mortality. While the duration of dialysis and anuria was associated with renal survival. Maternal mortality is decreasing but sepsis is still accounted for a majority of deaths.

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