Acute kidney injury (acute renal failure) in pregnancy
- Phyllis August, MD, MPH
Phyllis August, MD, MPH
- Ralph A Baer, MD Professor of Research in Medicine
- Director, Hypertension Center
- Division of Nephrology & Hypertension
- Weill Cornell Medical College
- Section Editors
- Charles J Lockwood, MD, MHCM
Charles J Lockwood, MD, MHCM
- Section Editor — Obstetrics
- Senior Vice President, USF Health
- Dean, Morsani College of Medicine
- Professor, Obstetrics and Gynecology
- University of South Florida
- Paul M Palevsky, MD
Paul M Palevsky, MD
- Section Editor — Renal Failure
- Professor of Medicine
- University of Pittsburgh
- VA Pittsburgh Healthcare System
Acute kidney injury (AKI) is the abrupt loss of kidney function, resulting in the retention of urea and other nitrogenous waste products and in the dysregulation of extracellular volume and electrolytes. The term, AKI, has largely replaced acute renal failure (ARF), reflecting the recognition that smaller declines in kidney function that do not result in overt organ failure are of substantial clinical relevance and are associated with increased morbidity and mortality.
Pregnancy-related AKI can be caused by any of the disorders leading to AKI in the general population. There are also, however, pregnancy complications characteristic of each trimester that can be associated with kidney injury [1,2]. This topic reviews causes of AKI that are most commonly encountered during pregnancy. Causes of AKI in the general population are discussed elsewhere. (See "Diagnostic approach to the patient with subacute kidney injury in an outpatient setting", section on 'Major causes and pathogenesis of kidney disease'.)
Nephrolithiasis during pregnancy is discussed elsewhere. (See "Nephrolithiasis during pregnancy".)
AKI is defined by the abrupt loss of kidney function. Several consensus definitions of AKI have been developed for use in the general population in order to provide a uniform, quantitative definition of AKI. These include the RIFLE and Acute Kidney Injury Network (AKIN) definitions and the Kidney Disease: Improving Global Outcomes (KDIGO) modifications of the AKIN definition. (See "Diagnostic approach to the patient with subacute kidney injury in an outpatient setting", section on 'Major causes and pathogenesis of kidney disease'.)
However, it is not clear that the consensus criteria for AKI are useful in pregnancy. This is because, during pregnancy, glomerular filtration rate (GFR) increases significantly (by approximately 50 percent), resulting in a lower baseline serum creatinine compared with similarly healthy, nonpregnant individuals (see "Renal and urinary tract physiology in normal pregnancy", section on 'Increase in GFR'). Most obstetricians do not routinely check the serum creatinine either prior to or early in pregnancy. Thus, seemingly "normal" serum creatinine levels (eg, 0.7 to 0.9 mg/dL) may represent significant increases from baseline, which may not be appreciated at the time of presentation.
- Krane NK. Acute renal failure in pregnancy. Arch Intern Med 1988; 148:2347.
- Grünfeld JP, Pertuiset N. Acute renal failure in pregnancy: 1987. Am J Kidney Dis 1987; 9:359.
- Nwoko R, Plecas D, Garovic VD. Acute kidney injury in the pregnant patient. Clin Nephrol 2012; 78:478.
- Najar MS, Shah AR, Wani IA, et al. Pregnancy related acute kidney injury: A single center experience from the Kashmir Valley. Indian J Nephrol 2008; 18:159.
- Kamal EM, Behery MM, Sayed GA, Abdulatif HK. RIFLE classification and mortality in obstetric patients admitted to the intensive care unit with acute kidney injury: a 3-year prospective study. Reprod Sci 2014; 21:1281.
- Umans JG. Obstetric nephrology: preeclampsia--the nephrologist's perspective. Clin J Am Soc Nephrol 2012; 7:2107.
- Fakhouri F, Vercel C, Frémeaux-Bacchi V. Obstetric nephrology: AKI and thrombotic microangiopathies in pregnancy. Clin J Am Soc Nephrol 2012; 7:2100.
- Drakeley AJ, Le Roux PA, Anthony J, Penny J. Acute renal failure complicating severe preeclampsia requiring admission to an obstetric intensive care unit. Am J Obstet Gynecol 2002; 186:253.
- Acharya A, Santos J, Linde B, Anis K. Acute kidney injury in pregnancy-current status. Adv Chronic Kidney Dis 2013; 20:215.
- Sibai BM, Ramadan MK, Usta I, et al. Maternal morbidity and mortality in 442 pregnancies with hemolysis, elevated liver enzymes, and low platelets (HELLP syndrome). Am J Obstet Gynecol 1993; 169:1000.
- McCrae KR, Samuels P, Schreiber AD. Pregnancy-associated thrombocytopenia: pathogenesis and management. Blood 1992; 80:2697.
- McMinn JR, George JN. Evaluation of women with clinically suspected thrombotic thrombocytopenic purpura-hemolytic uremic syndrome during pregnancy. J Clin Apher 2001; 16:202.
- Martin JN Jr, Blake PG, Perry KG Jr, et al. The natural history of HELLP syndrome: patterns of disease progression and regression. Am J Obstet Gynecol 1991; 164:1500.
- Sibai BM, Villar MA, Mabie BC. Acute renal failure in hypertensive disorders of pregnancy. Pregnancy outcome and remote prognosis in thirty-one consecutive cases. Am J Obstet Gynecol 1990; 162:777.
- McDonald SD, Han Z, Walsh MW, et al. Kidney disease after preeclampsia: a systematic review and meta-analysis. Am J Kidney Dis 2010; 55:1026.
- George JN. Clinical practice. Thrombotic thrombocytopenic purpura. N Engl J Med 2006; 354:1927.
- George JN. How I treat patients with thrombotic thrombocytopenic purpura: 2010. Blood 2010; 116:4060.
- Bresin E, Rurali E, Caprioli J, et al. Combined complement gene mutations in atypical hemolytic uremic syndrome influence clinical phenotype. J Am Soc Nephrol 2013; 24:475.
- Noris M, Caprioli J, Bresin E, et al. Relative role of genetic complement abnormalities in sporadic and familial aHUS and their impact on clinical phenotype. Clin J Am Soc Nephrol 2010; 5:1844.
- Fakhouri F, Roumenina L, Provot F, et al. Pregnancy-associated hemolytic uremic syndrome revisited in the era of complement gene mutations. J Am Soc Nephrol 2010; 21:859.
- Levy GG, Nichols WC, Lian EC, et al. Mutations in a member of the ADAMTS gene family cause thrombotic thrombocytopenic purpura. Nature 2001; 413:488.
- Noris M, Remuzzi G. Atypical hemolytic-uremic syndrome. N Engl J Med 2009; 361:1676.
- Dashe JS, Ramin SM, Cunningham FG. The long-term consequences of thrombotic microangiopathy (thrombotic thrombocytopenic purpura and hemolytic uremic syndrome) in pregnancy. Obstet Gynecol 1998; 91:662.
- Mannucci PM, Canciani MT, Forza I, et al. Changes in health and disease of the metalloprotease that cleaves von Willebrand factor. Blood 2001; 98:2730.
- Vesely SK, George JN, Lämmle B, et al. ADAMTS13 activity in thrombotic thrombocytopenic purpura-hemolytic uremic syndrome: relation to presenting features and clinical outcomes in a prospective cohort of 142 patients. Blood 2003; 102:60.
- Martin JN Jr, Bailey AP, Rehberg JF, et al. Thrombotic thrombocytopenic purpura in 166 pregnancies: 1955-2006. Am J Obstet Gynecol 2008; 199:98.
- Weiner CP. Thrombotic microangiopathy in pregnancy and the postpartum period. Semin Hematol 1987; 24:119.
- Ezra Y, Rose M, Eldor A. Therapy and prevention of thrombotic thrombocytopenic purpura during pregnancy: a clinical study of 16 pregnancies. Am J Hematol 1996; 51:1.
- Mokrzycki MH, Rickles FR, Kaplan AA, Kohn OF. Thrombotic thrombocytopenic purpura in pregnancy: successful treatment with plasma exchange. Case report and review of the literature. Blood Purif 1995; 13:271.
- Vesely SK, Li X, McMinn JR, et al. Pregnancy outcomes after recovery from thrombotic thrombocytopenic purpura-hemolytic uremic syndrome. Transfusion 2004; 44:1149.
- Castro MA, Fassett MJ, Reynolds TB, et al. Reversible peripartum liver failure: a new perspective on the diagnosis, treatment, and cause of acute fatty liver of pregnancy, based on 28 consecutive cases. Am J Obstet Gynecol 1999; 181:389.
- Usta IM, Barton JR, Amon EA, et al. Acute fatty liver of pregnancy: an experience in the diagnosis and management of fourteen cases. Am J Obstet Gynecol 1994; 171:1342.
- Ibdah JA, Yang Z, Bennett MJ. Liver disease in pregnancy and fetal fatty acid oxidation defects. Mol Genet Metab 2000; 71:182.
- Black RM. Vascular diseases of the kidney. In: Pathophysiology of Renal Disease, 2nd ed., Rose BD (Ed), McGraw-Hill, New York 1987. p.349.
- Matlin RA, Gary NE. Acute cortical necrosis. Case report and review of the literature. Am J Med 1974; 56:110.
- Ali A, Ali MA, Ali MU, Mohammad S. Hospital outcomes of obstetrical-related acute renal failure in a tertiary care teaching hospital. Ren Fail 2011; 33:285.
- Prakash J, Vohra R, Wani IA, et al. Decreasing incidence of renal cortical necrosis in patients with acute renal failure in developing countries: a single-centre experience of 22 years from Eastern India. Nephrol Dial Transplant 2007; 22:1213.
- Frimat M, Decambron M, Lebas C, et al. Renal Cortical Necrosis in Postpartum Hemorrhage: A Case Series. Am J Kidney Dis 2016; 68:50.
- Shultz PJ, Raij L. Endogenously synthesized nitric oxide prevents endotoxin-induced glomerular thrombosis. J Clin Invest 1992; 90:1718.
- Thompson C, Verani R, Evanoff G, Weinman E. Suppurative bacterial pyelonephritis as a cause of acute renal failure. Am J Kidney Dis 1986; 8:271.
- Sharma P, Thapa L. Acute pyelonephritis in pregnancy: a retrospective study. Aust N Z J Obstet Gynaecol 2007; 47:313.
- Fried AM. Hydronephrosis of pregnancy: ultrasonographic study and classification of asymptomatic women. Am J Obstet Gynecol 1979; 135:1066.
- Brandes JC, Fritsche C. Obstructive acute renal failure by a gravid uterus: a case report and review. Am J Kidney Dis 1991; 18:398.
- Lattuada A, Rossi E, Calzarossa C, et al. Mild to moderate reduction of a von Willebrand factor cleaving protease (ADAMTS-13) in pregnant women with HELLP microangiopathic syndrome. Haematologica 2003; 88:1029.
- Preeclampsia with or without HELLP
- Thrombotic thrombocytopenic purpura or hemolytic uremic syndrome
- Acute fatty liver of pregnancy
- Renal cortical necrosis
- Acute pyelonephritis
- Urinary tract obstruction
- Postpartum AKI associated with nonsteroidal anti-inflammatory drugs
- DIAGNOSTIC APPROACH AND DIFFERENTIAL DIAGNOSIS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS