The Changing Landscape of Acute Kidney Injury in Pregnancy from an Obstetrics Perspective
Abstract
1. Introduction
2. Physiological Changes and Kidney Adaptation to Pregnancy
3. The Changing Epidemiological Landscape of Acute Kidney Injury in Pregnancy
4. Challenges in Diagnosis of PR-AKI
5. Principle of Management of PR-AKI
6. Clinical Presentations of PR-AKI
6.1. Bleeding and Hypovolemia
6.2. Infection and Sepsis
6.3. Hypertensive Disorders of Pregnancy
6.4. Haematological/Immune Conditions
7. The Risk of CKD after AKI
8. Conclusions
Author Contributions
Conflicts of Interest
References
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% Change | Pregnant | Postnatal | |||
---|---|---|---|---|---|
1–20 weeks | 20–30 weeks | 30–40 weeks | 1–6 weeks | >6 weeks | |
Odutayo and Hladunewich [17] | |||||
GFR | 37.13 | 38.38 | 39.46 | 24.9 | −0.91 |
ERPF | 41.18 | 29.44 | 10.37 | −5.13 | −7.49 |
FF | −1.89 | 10.68 | 29.26 | 24.8 | −1.59 |
Davison and Dunlop [18] | |||||
GFR | 48.9 | 45.8 | 51.0 | - | - |
ERPF | 67.8 | 64.9 | 44.1 | - | - |
FF | −10.9 | −10.9 | 5.8 | - | - |
Renal Variable | Non-Pregnant Values | Pregnant Values | Values in Pregnancy that Require Further Investigation |
---|---|---|---|
Glomerular filtration rate (GFR) (mL/min) | 106–132 | 130–180 | <115 |
Effective renal plasma flow (ERPF) (mL/min) | 492–696 | 630–1030 | <590 |
Filtration Fraction (FF) (%) | 16.9–24.7 | 15.4–22.8 | <14.0 |
Serum Sodium (mEq/L) | 136–146 | 133–148 | <128 |
Serum Potassium (mEq/L) | 3.5–5.0 | 3.3–5.0 | >5.1 |
Serum Chloride (mEq/L) | 102–109 | 97–109 | >110 |
Serum Bicarbonate (mEq/L) | 27–28 | 20–22 | <20 |
Plasma osmolality (mOsm/kg H2O) | 275–295 | 276–289 | >290 |
pH (arterial) | 7.35–7.45 | 7.40–7.45 | <7.36; >7.45 |
Plasma urate (mg/dL) | 4–6 | 2.5–4 | >5.8 |
Plasma Creatinine (mg/dL, µmol/L) | 0.51–1.02; (45–90) | 0.59–0.87; (52–77) | >0.87 (77) |
Creatinine clearance (mL/min) | 91–130 | 110–150 | <90 |
Blood urea nitrogen (mg/dL) | 13 ± 3 | 8.7 ± 1.5 | >14 |
Urinary glucose (mg/24 h) | 20–100 | >100 | - |
Urinary protein (mg/24 h) | <100–150 | <250–300 | >300 |
Urinary amino acids (g/24 h) | - | ≤2 | >2 |
AKI Classification Systems | |||||
---|---|---|---|---|---|
RIFLE Criteria for Classification/Staging AKI | AKIN Criteria for Classification/Staging AKI | ||||
Stage | GFR Criteria | Urine Output Criteria | Stage | Serum Creatinine Criteria | Urine Output Criteria |
Risk | Increase in SCr ×1.5 or Decrease in GFR > 25% | UO < 0.5 mL/kg/h × 6 h | Stage 1 | Increase in SCr ≥ 0.3 mg/dL or Increase SCr ≥ 1.5–2.0 × | UO < 0.5 mL/kg/h × 6 h |
Injury | Increase in SCr ×2.0 or Decrease in GFR >50% | UO < 0.5mL/kg/h × 12 h | Stage 2 | Increase in SCr > 2.0–3.0 × | UO < 0.5 mL/kg/h × 12 h |
Failure | Increase in SCr × 3.0 or Decrease in GFR >75% or SCr >4.0 mg/dL (acute increase ≥ 0.5 mg/dL) | UO < 0.3mL/kg/h × 24 h or anuria for 12 h | Stage 3 | Increase in SCr > 3 × or Increase of SCr to ≥4.0 mg/dL with an acute increase of at least 0.5 mg/dL | UO < 0.3 mL/kg/h × 24 h or anuria for 12 h |
Loss | Persistent ARF: Complete loss of kidney function for >4 weeks | Patients who receive renal replacement therapy (RRT) are considered to have met the criteria for stage 3 irrespective of the stage they were in at the time of commencement of RRT. | |||
ESKD | End-stage kidney disease for >3 months |
AKI Classification Systems: KDIGO Criteria | ||
---|---|---|
Stage | Serum Creatinine Criteria | Urine Output Criteria |
Stage 1 | Increase in SCr × 1.5–1.9 or Increase in SCr ≥ 0.3 mg/dL | UO < 0.5 mL/kg/h × 6–12 h |
Stage 2 | SCr ≥ 2.0–2.9 times baseline | UO < 0.5 mL/kg/h ≥ 12 h |
Stage 3 | Increase SCr ≥ 3.0 × or Increase in SCr to ≥ 4.0 mg/dL or Initiation of renal replacement therapy (RRT) or In patients < 18 years, decrease in eGFR to <35 mL/min per 1.73 m2 | UO < 0.3 mL/kg/h × ≥24 h or Anuria for ≥ 12 h |
Pre-Renal | Intrinsic Renal | Post-Renal |
---|---|---|
Early Pregnancy | ||
Bleeding—miscarriage | Anticardiolipin antibody syndrome | Renal stones |
Hyperemesis gravidarum | Sepsis (i.e., septic abortion) | Ureteral obstruction |
Ovarian hyperstimulation syndrome | Autoimmune disease | |
Ectopic pregnancy | Glomerulonephritis, interstitial nephritis, lupus nephritis | |
CKD progression | ||
Late Pregnancy | ||
Bleeding—second-trimester miscarriage, placenta praevia, placental abruption | Severe pre-eclampsia, HELLP | Polyhydramnios |
Acute fatty liver of pregnancy | Multifetal gestation | |
HUS/TTP | Large uterine fibroids | |
Pyelonephritis | Ureteral obstruction | |
Chorioamnionitis | Renal stones | |
CKD Progression | ||
Glomerulonephritis, interstitial nephritis, lupus nephritis | ||
Postpartum | ||
Bleeding—uterine atonia, uterine rupture, obstetrical trauma (vulvo-vaginal and perineal tears and lacerations) | Severe pre-eclampsia, HELLP | Renal stones |
HUS | ||
Puerperal sepsis | ||
Glomerulonephritis, interstitial nephritis, lupus nephritis | ||
Nephrotoxic drugs (NSAIDS, antibiotics, proton-pump inhibitors, H2 antagonists) | ||
CKD Progression |
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Vinturache, A.; Popoola, J.; Watt-Coote, I. The Changing Landscape of Acute Kidney Injury in Pregnancy from an Obstetrics Perspective. J. Clin. Med. 2019, 8, 1396. https://doi.org/10.3390/jcm8091396
Vinturache A, Popoola J, Watt-Coote I. The Changing Landscape of Acute Kidney Injury in Pregnancy from an Obstetrics Perspective. Journal of Clinical Medicine. 2019; 8(9):1396. https://doi.org/10.3390/jcm8091396
Chicago/Turabian StyleVinturache, Angela, Joyce Popoola, and Ingrid Watt-Coote. 2019. "The Changing Landscape of Acute Kidney Injury in Pregnancy from an Obstetrics Perspective" Journal of Clinical Medicine 8, no. 9: 1396. https://doi.org/10.3390/jcm8091396
APA StyleVinturache, A., Popoola, J., & Watt-Coote, I. (2019). The Changing Landscape of Acute Kidney Injury in Pregnancy from an Obstetrics Perspective. Journal of Clinical Medicine, 8(9), 1396. https://doi.org/10.3390/jcm8091396