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2017 ; 27
(4
): 258-270
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Acute Kidney Injury in Pregnancy-specific Disorders
#MMPMID28761227
Prakash J
; Ganiger VC
Indian J Nephrol
2017[Jul]; 27
(4
): 258-270
PMID28761227
show ga
The incidence of acute kidney injury in pregnancy (P-AKI) has declined
significantly over the last three decades in developing countries. However, it is
still associated with significant fetomaternal mortality and morbidity. The
diagnosis of P-AKI is based on the serum creatinine increase. The usual formulas
for estimating glomerular filtration rate (GFR) are not validated in this
population. The incidence of P-AKI with respect to total AKI cases has decreased
in the last three decades from 25% in 1980s to 9% in 2000s at our centre. During
the first trimester of gestation, AKI develops most often due to septic abortion
or hyperemesis gravidarum. Septic abortion related AKI with respect to total AKI
decreased from 9% to 5% in our study. Prevention of unwanted pregnancy and
avoidance of septic abortion are keys to eliminate abortion associated AKI in
early pregnancy. However, we have not seen AKI on account of hyperemesis
gravidarum over a period of 33 years at our center. In the third trimester, the
differential diagnosis of AKI in association with pregnancy specific conditions
namely preeclampsia/HELLP syndrome, acute fatty liver of pregnancy and thrombotic
microangiopathies of pregnancy (P-TMA) is more challenging, because these 3
conditions share several clinical features of thrombotic microangiopathy which
makes the diagnosis very difficult on clinical grounds. It is imperative to
distinguish these conditions to make appropriate therapeutic decisions.
Typically, AFLP and HELLP syndrome improve after delivery of the fetus, whereas
plasma exchange is the first-line treatment for pregnancy associated thrombotic
microangioathies (P-TMA). We observed that preclampsia/eclampsia is the most
common cause of AKI in late third trimester and postpartum periods followed by
puerperal sepsis and postpartum hemorrhage. Pregnancy-associated thrombotic
microangiopathies (aHUS/TTP) and AFLP are rare causes of AKI during pregnancy in
developing countries.