ABSTRACT
Background: Pregnancy-related acute kidney injury (PRAKI) is a common problem in the developing world. Materials and methods: In this retrospective observational study at a tertiary care hospital in South India we evaluated records for the maternal, fetal, and renal outcomes in women with PRAKI. Results: Over a 10-year period, 395 patients of PRAKI were seen constituting 8.1% of all acute kidney injury (AKI). The mean age of patients was 27 ± 3 years. A total of 176 (44.5%) had pre-eclampsia, 132 (33.4%) had puerperal sepsis, 76 (19.2%) had antepartum hemorrhage or postpartum hemorrhage (APH 30/PPH 46), nine (2.2%) had hemolytic uremic syndrome (HUS). Obstruction was seen in two patients. Eleven had underlying glomerulonephritis out of three had lupus nephritis. Forty-five of 395 (11.39%) had hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome, that is, 25.5% of those with pre-eclampsia. Sixteen (4.0%) had placental abruption. A total of 288 (72.9%) presented postpartum. Renal biopsy done in 103 (26%) showed patchy cortical necrosis (PCN) in 25 (22.3%), diffuse cortical necrosis (DCN) in 23 (20.3%), acute tubular necrosis (ATN) in 20 (19.4%), acute interstitial nephritis (AIN) in 10 (9.7%), while nine (8.7%) had thrombotic microangiopathy (TMA). Glomerular disease was seen in 11. Cortical necrosis (CN) was seen in 48 patients of which 10 (20.83%) had abruption placenta, 25 (52%) had puerperal sepsis, 11 (22.9%) had postpartum hemorrhage (PPH), and two (4.1%) had TMA. A total of 290 (73.4%) required dialysis. About 76% improved while 8.3% progressed to end-stage renal disease (ESRD). Maternal mortality (MM) was 5%. There were 42 intrauterine deaths and 30 deaths in the neonatal period. Discussion: Pregnancy-related acute kidney injury in developing countries is more common as compared to the West. Only 49% patients had booked pregnancy, that is, received regular antenatal care. Apart from pre-eclampsia which is also the major cause in the West and was the etiology in 44% of patients with PRAKI in our study, sepsis (33%) and maternal hemorrhage (19%) were also significant. Immediate recovery from PRAKI was 75% however about 8% develop end-stage kidney disease (ESKD) while in the west ESKD occurred in only about 2%. Conclusion: Pregnancy-related acute kidney injury is an important cause of maternal and fetal morbidity and mortality. Pre-eclampsia emerged as the most common cause of PRAKI and CN was the most common histological lesion. Proper antenatal care and management may improve pregnancy outcomes.
ABSTRACT
Group A Streptococcal infection in the throat is responsible for causing initial and recurrent attacks of acute guttate psoriasis (AGP). Up to 70% of these AGP patients go on to develop chronic plaque psoriasis (CPP). We hypothesized that chronic sub-clinical, on-going streptococcal infection might solely be responsible for CPP in a genetically predisposed individual. Rifampin, a useful drug for several types of bacterial infections including Group A Streptococci (GAS) because of its broad spectrum, excellent tissue penetration, low sideeffect profile and its salivary concentrations after oral administration greatly exceeds the minimum inhibitory concentration for most GAS, thus helpful in eradicating pharyngeal carriage of GAS, was considered for long term use in CPP. Fifty patients with moderate to severe CPP were enrolled. Of these 25 were randomly selected to receive rifampin for 36 weeks as a single oral morning dose of 10 mg/kg body weight (approx. patient weighing <50 kg received 450mg per day and patients >50 kg received 600mg per day). Remaining 25 patients received placebo. Rifampin group was further followed-up to one more year. Significant improvement in PASI score was noted from 12 weeks in majority of patients in Rifampin group. Relevant investigations and clinical assessment was done at regular intervals to observe any side effects and check progress of the disease. Data were analyzed statistically using the t-test. As psoriasis is a chronic disorder that waxes and wanes over time, withdrawal of treatments usually is accompanied by relapse of skin manifestations so a follow-up with one year drug-free period was added to verify treatment consistency. Patients tolerated the therapy well.