Pregnancy-related acute kidney injury in the African continent: where do we stand? A systematic review

Access to Care During Pregnancy for Patients With Chronic Kidney Disease and Kidney Failure in Latin America: A State of the Art with an International Comparison

Access to kidney care is a problem in Latin America, similar to many other low- to medium-income countries. Uneven access and deep discrepancies in quality of care beset this large part of the world that encompasses North America (Mexico) and Central and South America. Access to kidney care during pregnancy can be seen as a marker of overall achievements and needs in nephrology. We suggest that this issue should be systematically considered and compared across settings when health care systems are evaluated. If this were done, pregnancy would be in the spotlight, and this would increase awareness of the problems that need to be dealt with and could guide interventions to improve kidney care in young women. This review discusses some epidemiological and clinical issues, as well as barriers to optimal care of pregnancy in patients with chronic kidney disease encountered in Mexico and other Latin American countries, contextualized with a brief overview on barriers and challenges in other continents.

Outcomes of pregnancy-related acute kidney injury: A retrospective study in the obstetric critical care unit at Kenyatta National Hospital 2020 to 2023

Pregnancy-related acute kidney injury (PrAKI) is defined as a rapid decline in kidney function in the pregnancy or puerperal period that can result in life-threatening organ dysfunction. This study aimed to investigate socio-demographic features of critically ill women with pregnancy-related acute kidney injury as well as their maternal and foetal outcomes. Retrospective analysis of data in patients with pregnancy-related kidney injury in the obstetric critical care unit at a public tertiary referral centre in Kenya between February 2020-2023. Of the 266 patient files reviewed, pregnancy-related acute kidney was found in 203 patients. The main predisposing factors for acute kidney injury were hypertensive disorders in pregnancy (64.1%), obstetric haemorrhage (38.4%) and sepsis (36.5%). According to KDIGO (Kidney Disease Improving Global Outcomes) criteria, 44 patients presented in stage 1 (21.7%), 58 in stage 2 and 101 in stage 3 (49.8%). Patients with KDIGO stage 3 had a higher risk of high SOFA (Sequential Organ Failure Assessment) score (p =< 0.001), longer ICU stay (p = 0.008) and longer duration on ventilation (p = 0.010). Seventy-six patients underwent dialysis (37.4%). Recovery of renal function was complete in 91 patients (44.8%), partial in 41 (20.2%) with dependence on dialysis seen in 23 (23.6%). Forty-eight patients died (23.6%). Risks associated with mortality were mechanical ventilation (p = 0.001) and inotropic support (p =< 0.001) with statistically significant higher mean SOFA scores in those who died versus those who survived (12.6 ± 3.8 p =< 0.001 vs 8.6 ± 3.2). The incidence of PrAKI is still underestimated in the Kenyan setting with the majority of the patients presenting with advanced renal injury. These patients are at higher risk of adverse maternal morbidity and mortality in the critical care setting.

Performance of Serum Neutrophil-Gelatinase Associated Lipocalin (NGAL) in the Diagnosis of Pregnancy-Related Acute Kidney Injury (PRAKI) in Delta, State Nigeria: A Prospective Study

BACKGROUND

Pregnancy-related acute kidney injury (PRAKI) is associated with poor maternal and perinatal outcomes if not promptly recognized. Diagnosis of PRAKI is currently based on serum creatinine, which delays diagnosis and, inevitably, treatment.

AIMS

To determine the performance of serum NGAL in the diagnosis of PRAKI among women in the peripartum period and determine the normal serum NGAL levels in nonpregnant women.

METHODS

A prospective study involving 162 pregnant women who presented in labor in two hospitals in Delta State and 150 nonpregnant controls. Serum creatinine and NGAL were assayed using blood samples collected from study participant at 0, 6, 12, 24, and 48 hours and 7 days postdelivery. Diagnosis of PRAKI was based on both serum creatinine and NGAL. The diagnostic performance of NGAL was determined by performing a receiver operation curve and determining the area under the curve (AUC).

RESULTS

The prevalence of AKI using creatinine-based KDIGO criteria was 22.2% and 50% using serum NGAL. The optimal diagnostic accuracy for serum NGAL was at the 12th hour, using a cut off of 142 ng/dl determined by Youden's index. The reference range for nonpregnant women was 12.77 - 135.67 ng/dl. The sensitivity and specificity of serum NGAL at a cut off 142 ng/ml were 77.2% and 75.4% (AUC = 0.79), respectively while using 135.67 ng/ml (upper limit determined from nonpregnant women) as cut-off, sensitivity was 77.78% and specificity was 70.63%.

CONCLUSION

Serum NGAL is a promising marker for early diagnosis of PRAKI with high sensitivity and specificity.

Prevalence and trends of pregnancy-related acute kidney injury in sub-Saharan Africa: a systematic review and meta-analysis

BACKGROUND

Pregnancy-Related Acute Kidney Injury (PRAKI) is an important contributor to maternal-fetal morbidity and mortality. The burden of PRAKI in sub-Saharan Africa is not well documented. We conducted a systematic literature review and meta-analysis to estimate the prevalence of PRAKI in sub-Saharan Africa.

METHODS

We systematically searched the literature published between January 2000 and May 2024 on PubMed, Embase, Scopus, and African Journals Online. We used a random-effects model to derive the pooled prevalence estimates and analysed trends in prevalence using weighted meta-regression. We assessed the quality of the included studies using the Joanna Briggs Institute critical appraisal tool and evaluated the presence of publication bias using Begg's rank correlation and Egger's test.

RESULTS

Thirteen studies satisfied the inclusion criteria, with a total sample size of 5273 individuals, ranging between 46 and 1547 across the studies. The pooled prevalence of PRAKI was 15.6% (95% CI 11.5-20.1%) with significant heterogeneity in prevalence rates (heterogeneity chi-square: 179.2, p < 0.001, I2: 93.4%). We observed an increase in the trend of PRAKI at a rate of 0.8% per year, with insufficient evidence of a difference in prevalence over the years (p = 0.119).

CONCLUSION

Our findings show a high prevalence of PRAKI and suggest a rising trend in the prevalence of PRAKI within sub-Saharan Africa. Future studies should investigate interventions to improve access to, and the quality of, antenatal care services to reduce maternal-fetal morbidity and mortality.

Frequency of adverse perinatal outcomes in patients with pregnancy related acute renal (kidney) injury in a tertiary care hospital

Background & Objective

Pregnancy related acute kidney injury (Pr-AKI) is coupled with adverse feto-maternal outcomes. Adverse perinatal outcome comprising of still births, intrauterine growth retardation, neonatal deaths are indicators of severity of underlying obstetrical conditions ending on Pr-AKI. These perinatal outcomes can also serve as potential predictors for long term outcomes of Pr-AKI. Our study aimed to determine frequencies of adverse perinatal outcomes and to evaluate adverse perinatal outcome as predictor for persistent renal injury in patients with pregnancy induced acute renal injury (Pr-AKI).

Method

A descriptive case series including 100 women with Pr-AKI, was conducted in a tertiary care hospital of Peshawar from 1st August 2021 to 31st July 2022. Included patients were followed for three months period, from their date of delivery. Adverse perinatal outcome included stillbirths, and early neonatal deaths.

Results

The mean age of study sample was 29.20±6.40. The pre dominant etiology for Pr-AKI was primary postpartum hemorrhage, occurring in 52% women. Still births were seen in 48% cases, while early neonatal deaths were seen in 7% cases. Adverse perinatal outcome had statistically significant association with persistent renal failure (p-0.01). Other factors having statistically significant association with persistent renal injury (PRF) were multiparity and cesarean births. (p<0.05) Association of adverse perinatal outcome with persistent renal injury persisted on multivariate logistic regression. a OR 6.14; CI 1.15-32.29, p-0.033.

Conclusion

Almost half of the cases with Pr-AKI have still births. Still birth in patients with Pr-AKI is associated with persistent renal injury at 12 weeks follow up period.

Factors Associated with Maternal Morbidity in Patients with Eclampsia in Three Obstetric Intensive Care Units: A Retrospective Study

(1) Introduction. Eclampsia is a rare complication that can occur during pregnancy and has a significant impact on maternal and neonatal outcomes. The aim of this study was to investigate the risk factors associated with significant maternal morbidity after an eclamptic seizure. (2) Methods. An observational retrospective study was performed in three maternity hospitals in Romania between 2015 and 2023 and included pregnant patients diagnosed with eclampsia. Clinical and paraclinical data were investigated, and the impact of several risk factors was assessed using multiple logistic regression analysis. The results were reported as risk ratios (RRs) and 95% confidence intervals (Cis). (3) Results. A total of 104 patients with preeclampsia, of whom 23 experienced eclamptic seizures, were included in this study. A total of 82.6% of the patients diagnosed with eclampsia experienced a form of significant morbidity (stroke, PRES syndrome, or any organ failure/dysfunction). Our regression analysis revealed that advanced maternal age (RR: 12.24 95% CI: 4.29-36.61, p = 0.002), the presence of thrombotic disorders (RR: 9.17, 95% CI: 3.41-23.70, p = 0.03), obesity (RR: 4.89, 95% CI: 0.78-18.15, p = 0.036), and smoking status (RR: 2.18, 95% CI: 0.13- 6.51, p = 0.042) significantly increase the risk of maternal comorbidities. (4) Conclusions. Careful monitoring of pregnant patients, adequate weight control during pregnancy, and correct anticoagulation of individual patients could reduce the extent of postpartum comorbidities that can result from an eclamptic seizure.

Acute kidney injury in critically ill obstetric patients: Incidence and role of neutrophil gelatinase-associated lipocalcin - A prospective observational cohort study

Background and Aims

Data focussing on acute kidney injury (AKI) in obstetric patients admitted to the intensive care unit (ICU) are scarce and even more so regarding the role of neutrophil gelatinase-associated lipocalcin (NGAL) in detecting AKI or predicting outcomes in these patients. Hence, we aim to evaluate the incidence of AKI in obstetric ICU patients and validate the role of urinary and serum NGAL in predicting the onset of AKI and mortality.

Methods

This prospective observational cohort included 45 obstetric patients admitted in ICU, excluding those with prior renal dysfunction. Serum creatinine and urine output were monitored for the occurrence of AKI during the ICU stay. The outcome of the patient (survival or death) in the ICU and hospital was recorded, and serum and urinary NGAL were determined at the time of ICU admission.

Results

AKI occurred in 32 [71.1%; 95% confidence interval (CI): 55.4%, 86.8%] patients during their ICU stay. Serum NGAL showed an area under receiver operating characteristic curve (AUROCC) of 0.630 (95% CI: 0.417, 0.842) (P = 0.231) for AKI and 0.486 (95% CI: 0.295, 0.676) (P = 0.883) for ICU mortality. Urinary NGAL showed AUROC = 0.472 (95% CI: 0.285, 0.660) (P = 0.772) to predict AKI and 0.430 (95% CI: 0.268, 0.652) (P = 0.684) for ICU mortality.

Conclusions

AKI is common amongst critically ill obstetric ICU patients. However, serum and urinary NGAL cannot be advocated to discriminate between patients with or without AKI or between survivors and non-survivors in critically ill obstetric patients.

Risk factors and outcomes associated with pregnancy-related acute kidney injury in a high-risk cohort of women in Nigeria

INTRODUCTION

Despite a decline in developed countries, pregnancy-related acute kidney injury (PRAKI) remains a significant contributor to maternal mortality and adverse fetal outcomes in resource-constrained settings. Little is known about the impact of pregnancy-related acute kidney injury in Nigeria. Therefore, this study aimed to assess the incidence and maternal-fetal outcomes associated with pregnancy-related acute kidney injury among a cohort of high-risk women in Nigeria.

METHODS

This prospective multicenter study included women at high risk of acute kidney injury, who were more than 20 weeks pregnant or within 6 weeks postpartum and admitted to the Obstetrics and Gynecology units of two large public hospitals between September 1, 2019, and July 31, 2022. Acute kidney injury was defined and classified using the Kidney Disease Improving Global Outcomes (KDIGO) criteria.

RESULTS

A total of 433 women, with mean age (± standard deviation) of 28 ± 6 years, were included in the evaluation. Pregnancy-related acute kidney injury occurred in 113 women (26.1%; 95% confidence interval [CI]: 21.1%-30.2%). The leading cause was preeclampsia (n = 57; 50.1%); 19 women died (4.4%), with 17 deaths (15%) occurring in the PRAKI group. Increasing severity of pregnancy-related acute kidney injury was independently associated with maternal mortality: adjusted odds ratio (aOR) for KDIGO stage 2 = 4.40; 95% CI 0.66-29.34, p = 0.13, and KDIGO stage 3 aOR = 6.12; 95% CI 1.09-34.34, p = 0.04. The overall perinatal mortality was 15% (n = 65), with 28 deaths (24.8%) occurring in the PRAKI group. Pregnancy-related acute kidney injury was also associated with an increased risk of perinatal mortality, aOR = 2.23; 95 CI 1.17-4.23, p = 0.02.

CONCLUSIONS

The incidence of pregnancy-related acute kidney injury was high, and significantly associated with maternal and perinatal mortality. The leading causes were hypertensive disorders of pregnancy.

Incidence of Pregnancy-Related Acute Kidney Injury in a Low Resource Setting: A Prospective Study

Background

Pregnancy-related acute kidney injury (PRAKI) is a common cause of AKI globally. The incidence and burden of PRAKI are still high in low and middle-income countries (LMICs) especially in Africa due to limited access to optimal obstetric care, late diagnosis, and referral. The study aimed to determine the incidence and aetiologies of PRAKI among women in the peripartum period in two government hospitals in Nigeria.

Methodology

This was a prospective study where serum creatinine was measured among pregnant women presenting in labour at 0-hour, 6 hour, 12 hour, 24 hour, 48 hour and 7 days post-delivery. AKI was defined using the Kidney Disease Improving Global Outcome criteria. Binary logistic regression was used to determine predictors of PRAKI.

Results

The mean age of the 162 pregnant women who completed the study was 30.05±1.28 years. The incidence of AKI use was 22.2%. The aetiologies of PRAKI were obstetric haemorrhage (66.7%), eclampsia (19.4%), and sepsis (13.9%). Seventeen (47.2%) patients had Stage 1 PRAKI, 12 (33.3%) had Stage 2 PRAKI, while seven (19.4%) had Stage 3 PRAKI. Factors significantly associated with PRAKI were parity (p=<0.001), caesarean section (p=<0.001), excess blood loss (p=<0.001), and prolonged duration of labour (p=0.002).

Conclusion

PRAKI occurred in 1 out 5 pregnant women in the peripartum period. Obstetric haemorrhage, sepsis, and eclampsia which are preventable or treatable are common major aetiologies of PRAKI. PRAKI is more associated with multi-parity, caesarean delivery, haemorrhage, and prolonged duration of labour. Optimal ante-natal care, health education, and prompt diagnosis and management of obstetric complications will reduce the incidence in Nigeria.