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