|Year : 2016 | Volume
| Issue : 4 | Page : 126-129
Various Presentations of Postpartum Acute Kidney Injury
Vijay Kumar Binwal1, Dilip Ahir2, Thabish Syed2, Meenakshi Rana2, Zara Wani3
1 Department of Nephrology, NIMS, Jaipur, Rajasthan, India
2 Department of Medicine, NIMS, Jaipur, Rajasthan, India
3 Department of Anaesthesia, NIMS, Jaipur, Rajasthan, India
|Date of Web Publication||7-Nov-2016|
Vijay Kumar Binwal
Department of Nephrology, NIMS, Jaipur, Rajasthan
Source of Support: None, Conflict of Interest: None
We report a series of cases with multiple presentations of postpartum acute kidney injury presented to the NIMS Kidney Institute, Jaipur, India.
Keywords: Acute kidney injury, chronic kidney disease, disseminated intravascular coagulation, postpartum hemorrhage, septicemia
|How to cite this article:|
Binwal VK, Ahir D, Syed T, Rana M, Wani Z. Various Presentations of Postpartum Acute Kidney Injury. J Integr Nephrol Androl 2016;3:126-9
| Introduction|| |
Pregnancy-related acute kidney injury (AKI) is a rare but life-threatening complication. The incidence of AKI has sharply declined from 0.5/1000 pregnancies to 1 in 20,000 births in developed countries.  On the other hand, in developing countries, pregnancy is still responsible for 15-20% of AKI mostly due to late referral of pregnancy-related complications. , Pregnancy-related AKI may comprise up to 25% of referrals to dialysis centers in developing countries and is associated with substantial maternal and fetal mortality.  Septic abortion is the most common cause of pregnancy-related AKI in developing countries. , Based on the trimester of pregnancy, acute renal failure (ARF) is divided into three groups, namely, first half, second half, and postpartum ARF. Septic abortion is the most common cause of ARF during the first half of the pregnancy; preeclampsia or abruptio placentae is the causes in the second half of pregnancy while hemolytic-uremic syndrome occurs in the postpartum period.  Obstetric complications are the most common cause (50-70%) of renal cortical necrosis; abruptio placentae, septic abortion, preeclampsia, postpartum hemorrhage (PPH), and puerperal sepsis are the conditions associated with pregnancy and are responsible for renal cortical necrosis.  Blood loss secondary to the abruptio placentae, antepartum hemorrhage, PPH, associated hemolysis, elevated liver enzymes and low platelets syndrome, and disseminated intravascular coagulation (DIC) sets up the stage for injury at a micro level involving a combination of hypercoagulable state, vasoconstriction, impaired release of nitrous oxide, and intravascular thrombosis.  The severity of PPH is often underestimated and even moderate blood loss can have deleterious effects on the kidneys. Therefore, blood should be replaced as early as possible for recovery of the patients.  ARF in pregnancy is associated with a high risk for maternal mortality (9-55%).  Mortality in recent Indian studies is reported as 20%  and 18.5%.  The renal lesions of acute cortical necrosis in obstetric patients with evidence of DIC have been very low. ,,, DIC occurs due to release of tissue thromboplastin in cases of endotoxic shock associated with septic abortion and catecholamines in hemorrhagic shock,  and it is regarded as a prominent feature of PPH;  preeclamptic and eclamptic toxemia have been considered chronic stages of DIC. 
| Case report|| |
In this case series, we compared four different postpartum patients with AKI. The first patient was a 23-year-old pregnant woman with full-term normal delivery (FTND) stillbirth with PPH. Vaginal bleeding continued for 24 h after delivery. On the very 2 nd day after delivery, the patient had anuria, bilateral pedal edema, facial puffiness, and abdominal distension. On routine blood investigation, it was found that the patient had severe anemia with thrombocytopenia and metabolic acidosis (pH - 7.08, sodium bicarbonate - 5 mEq/L). Her hemoglobin (Hb) was 4.4 gm%, total leucocyte counts were 13,400/mm 3 , and platelets were 61,000/mm 3 ; blood urea and serum creatinine were 42 and 2 mg/dL, respectively. Later, 14 whole blood and 4 fresh-frozen plasma transfusion were given in 5-6 days, but her renal function (blood urea - 142 mg/dL, serum creatinine - 7.7 mg/dL) kept deteriorating with time. After 7 days of hospitalization, hemodialysis was done in these patients and with time her renal function improved gradually. Hence, this has been our case of anuria with normal recovery.
The second patient was a 25-year-old pregnant woman, admitted after stillbirth with complaints of oliguria, dyspnea, and bilateral pedal edema following FTND stillbirth. On routine blood investigations, it was found that the patient had septicemia with Hb - 12.9 gm%, total white blood cell (WBC) - 33,600/mm 3 , platelet - 3.08 lakhs/mm 3 , blood urea - 115 mg/dL, and serum creatinine - 2.5 mg/dL which gradually deranged with time. After 3 days on routine blood investigation, it was found that her Hb - 9.4 gm%, total WBC - 46,000/mm 3 , platelet - 144,000/mm 3 , blood urea - 235 mg/dL, and serum creatinine - 4.9 mg/dL with severe metabolic acidosis in arterial blood gas analysis. With the help of routine hemodialysis and the treatment of septicemia for a period of 1½ months, her urine output and blood profile became normal. This is a case of oliguria with delayed recovery.
The third patient was a 23-year-old pregnant woman with missed abortion 2 days back with complaints of oliguria, dyspnea, and generalized edema, gradually progressive over 3 months. On routine blood investigation, the patient had severe anemia with deranged renal function tests with severe metabolic acidosis. Her history reveals that the patient had complaint of dyspnea with bilateral pedal edema, on and off with hypertension since 2011 with history of preeclampsia delivered uneventfully. The patient was on tablet amlodipine 5 mg and atenolol 50 mg irregularly for control of hypertension in the last 3 years. The patient was admitted in the Intensive Care Unit 2 years back (January 2014) for viral fever landing in AKI which improved with intensive medical management; 4 months later, she became pregnant (April 2014); on routine blood investigation, her Hb - 10 gm%, blood urea - 66.2 mg/dL, serum creatinine - 1.8 mg/dL, and blood pressure - 160/110, for which she was referred to a nephrologist who advised her to terminate the pregnancy, but peer pressure forced her to continue pregnancy, but the patient had a missed abortion in May 2014, by that time her blood urea was 97.5 mg/dL and serum creatinine was 2.8 mg/dL. The patient came back in January 2016 with complaints of shortness of breath, nausea, vomiting, and decreased urine output eventually diagnosed as chronic kidney disease (CKD) with Hb - 7 gm%, blood urea - 240 mg/dL, and serum creatinine - 12.7 mg/dL, thus requiring hemodialysis. After stabilizing, she is on maintenance hemodialysis along with antihypertensive treatment being planned for renal transplantation next month.
The fourth patient was a 24-year-old woman presented in emergency with bleeding per vaginal in shock. With the help of history and clinical examination, we diagnosed as the case of septic abortion in multi-organ failure along with DIC. In spite of our best efforts, we could not revive the patients, eventually succumbed within 24 h [Figure 1].
| Discussion|| |
Pregnancy-related ARF is a common occurrence. Puerperal sepsis is the most common etiological factor responsible for pregnancy-related ARF. Postabortion septicemia leading to ARF is still a common complication;  sepsis, thrombocytopenia, PPH, DIC, and liver involvement are associated with maternal mortality while duration of dialysis and anuria is associated with renal survival. In recent years, maternal mortality rate is in decreasing phase, but sepsis is still accounted for majority of deaths. The mortality rate related to postpartum acute kidney injury (PPAKI) in developed countries is <10%,  while in a developing countries, it has decreased to 24.39%. , However, in rural areas like our institute, the mortality rates of PPAKI are beyond imaginable due to poor reporting. Hence, it has become point of interest in studying this disease and its manifestations implicitly.
In our case series, we selected four patients of PPAKI with four different presentations which revealed the importance of aseptic delivery practices and early management of PPH in preventing the poor outcomes. This is in accordance with Goplani et al.'s study of 772 ARF patients in India.  The various presentations of PPAKI are early recovery, delayed recovery, landing in CKDs, and death like our series of four cases which are supported by Gullipalli and Srinivasulu.  Eswarappa et al. highlight the need for provision of quality maternal care and fetal monitoring to decrease the mortality rates of PPAKI in developing countries. 
The following figure [Figure 2] depicts the trend of postpartum acute kidney injury based on serum creatinine values of four different patients as explained below.
|Figure 2: Trend of postpartum acute kidney injury based on serum creatinine values of four different patients as explained below|
Click here to view
Case 1: Case of anuria with normal recovery.
In this patient, serum creatinine was 2 mg/dL with severe metabolic acidosis on presentation. Within 5-6 days, there was gradual increase in serum creatinine level up to 7 mg/dL. After 7 days, the patient was taken for hemodialysis which brought serum creatinine level in decreasing trends up to 1.8 mg/dL, and the patient recovered subsequently with four routine cycles of hemodialysis.
Case 2: Case of oliguria with delayed recovery.
This is a case of septicemia with acute kidney injury. On presentation, the patient's renal function test was deranged with serum creatinine level 2.5 mg/dL which was gradually progressive with time up to 4.9 mg/dL with severe metabolic acidosis within 3 days. Thereafter, the patient was put on routine maintenance hemodialysis on every 3 rd or 4 th day and higher antibiotic for septicemia for about a period of 1½ months which brought serum creatinine level to normal level, and the patient's hematological and biochemical parameters improved gradually.
Case 3: Postpartum acute kidney injury progression to chronic kidney disease.
This is a case of chronic hypertension with missed abortion which landed up into the chronic kidney disease mainly due to carrying of pregnancy with deranged renal function test in spite of warnings by nephrologist. In this patient, serum creatinine was 1.8 mg/dL before 2 years which was gradually deranged with time. After 2 years of routine follow-up, her renal function test was so deranged (serum urea - 12.7 mg/dL) that the patient requires routine hemodialysis for survival. However, the patient is being planned for renal transplantation next month.
Case 4: Septic abortion leading to mortality.
This is a case of septic abortion in multi-organ failure present in disseminated intravascular coagulation. On presentation, her renal function test was deranged (serum urea - 3.2 mg/dL) with severe metabolic acidosis. However, despite all efforts, we could not revive the patient and was succumbed to the diseases.
| Conclusion|| |
PPAKI is one of the most serious conditions leading to increased morbidity and mortality in developing countries like India. It may lead to prolonged hospitalization, permanent kidney damage, and death which add to the sorrow of poor people. Illiteracy, poor antenatal care, unsafe delivery practices, and misguidance from quakes are the common causes for PPAKI. Therefore, there is a need of decentralization of quality services, proper counseling and orientation about disease, careful watch on serial renal function test in suspicious patients, timely action and, if necessary, termination of pregnancy.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]