Pregnancy-associated acute kidney injury as an important driver of chronic kidney disease in females in developing countries: A systematic review

Abstract

Introduction: Pregnancy-related AKI (PR-AKI), has profound maternal and fetal implications, including high mortality and long-term risks such as the development of chronic kidney disease (CKD). This systematic review aims to evaluate the burden of CKD owing to PR-AKI cases during follow-up in developing countries, particularly India.

Methods: A systematic search of PubMed, Embase, and Cochrane databases was performed for Indian studies published between 2000 and June 2024. We included cross-sectional, retrospective, and prospective cohort studies that reported the incidence of PR-AKI, subsequent CKD, and dialysis dependency in Indian cohorts during follow-up. Details of etiology of PRAKI, and adverse fetal and maternal outcomes were also recorded. Only studies that provided follow-up kidney outcomes were considered.

Results: A total of 25 studies comprising 2,306 participants were included in the analysis. The incidence of PR-AKI ranged from 1 to 12% across different studies. Sepsis was the most common cause of PR-AKI, accounting for up to 78% of cases, followed by hypertensive disorders, obstetric haemorrhage, and tropical etiologies. Hemodialysis was required in 20-85% of patients. CKD development during follow-up was observed in 12.8-35% of cases, with up to 30% remaining dialysis-dependent. Maternal mortality ranged from 2.5 to 34%, while perinatal mortality reached as high as 67.3%. Pre-term delivery rates varied between 13.9% and 58%.

Conclusions: Up to one-third of PR-AKI patients may develop CKD and remain dialysis-dependent during follow-up. PR-AKI significantly impacts both maternal and fetal morbidity and mortality. Early prevention and prompt management by healthcare professionals are critical to improving outcomes in PR-AKI. Pregnancy-related acute kidney injury (PR-AKI) significantly affects maternal and fetal health, leading to high mortality and long-term complications such as chronic kidney disease (CKD). This systematic review, focusing on developing countries like India, evaluated the burden of CKD due to PR-AKI patients. The review analyzed Indian studies published between 2000 and June 2024, including 25 studies with 2,306 participants. PR-AKI incidence ranged from 1 to 12%, with sepsis being the leading cause in up to 78% of cases, followed by hypertensive disorders, obstetric hemorrhage, and tropical fevers. RRT was needed in 20-85% of patients, and 12.8-35% developed CKD during follow-up, with up to 30% remaining dialysis-dependent. Maternal mortality varied from 2.5 to 34%, while perinatal mortality reached 67.3%. The study emphasizes the critical need for early prevention timely intervention and need for long-term follow-up to reduce the high morbidity and mortality rates associated with PR-AKI.

Keywords: Chronic kidney disease (CKD) hemolysis; Elevated liver enzymes and low platelets (HELLP); Pre-eclampsia Thrombotic microangiopathy and Dialysis; Pregnancy-related acute kidney injury.

Fig. 1

Prisma flowchart

Fig. 2

Kidney biopsy findings in cases of Pregnancy-related acute kidney injury

Fig. 3

Summary of the article

Fig. 4

Etiology of pregnancy-associated acute kidney injury

Fig. 5

Key causes of pregnancy-related acute kidney injury categorized by the stage of pregnancy. ATN: Acute tubular necrosis, ACN Acute cortical necrosis, AKI; Acute kidney injury, Acute cortical necrosis, PE: Preeclamptic toxemia, HELLP: Hemolysis, elevated liver enzymes, low platelets; AFLP: Acute fatty liver of pregnancy; APS: Antiphospholipid antibody syndrome, TMA: Thrombotic microangiopathy, TTP Thrombotic thrombocytopenic purpura, aHUS Atypical hemolytic uremic syndrome, POC: Product of conception