Pregnancy-related Acute Kidney Injury in Public Hospital in South India: Changing Trends

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.

Risk of live kidney donation--Indian perspective.

INTRODUCTION: Live kidney donation is an established form of organ donation but carries the risk of an unnecessary surgery in a normal individual for the benefit of the recipient. Long term effects of nephrectomy have not been studied in Indian donors so far. AIM: The aim of this pilot study was to review the effects of kidney donation on morbidity (renal function, BP and proteinuria), psychosocial outcome and mortality. MATERIAL AND METHODS: Fifty donors who had nephrectomy 3 months to 20 years prior formed the material of this study. Medical history (donor age at nephrectomy, duration post-nephrectomy, family history), physical examination including anthropometry and systolic and diastolic blood pressure (SBP and DBP) measurement pre and post nephrectomy were recorded. Evaluation of renal function included pre and post-nephrectomy urinalysis, determination of microalbuminuria, serum creatinine, blood urea, 24 hr urinary protein and creatinine estimation and calculation of creatinine clearance. Renal length was measured by ultrasonography. Quality of life (QOL) was assessed by a standard questionnaire. Donors with co-morbidities not related to nephrectomy were excluded from the analysis. Data was statistically analyzed. RESULTS: Twenty two donors (44%) were males and 28 (56%) females. Parents constituted the majority 39 (78%); 10 were siblings (20%) and 1 was a spousal donor. The mean age at donation was 41.26 +/- 8.12 years (25-54.16 years). Since kidney donation a mean time interval of 63 months (3-264 months) had elapsed. There was a mean rise of 9.96 mm Hg in SBP and 7.18 mm Hg in DBP. Hypertension was noted in 23(46%). 20 donors (40%) developed microalbuminuria (MAU) post nephrectomy and 7 (14%) developed overt proteinuria (> 300 mg/day). Mean GFR pre and post nephrectomy was 102.74 +/- 6.91 ml/min and 74.54 +/- 14.64 ml/min with a mean reduction of 28.2 +/- 13.57 ml/min. There was no significant change in serum creatinine after donation (0.97 +/- 0.09 mg/dl vs 1.22 +/- 0.82 mg/dl). There was an increase in renal length of 1.14 +/- 0.73 cm. None of the donors regretted donation. CONCLUSION: This pilot study reaffirms the safety of live kidney donation. There was a fall in GFR with consequent increase in renal length postnephrectomy. The long-term implications of the minimal increase in proteinuria and rise in blood pressure need to be evaluated in larger cohort of donors over a longer period of time. This study underscores the need for initiating a donor registry to achieve this objective.

Sodium transporters in kidney role in health and disease.

Sodium is an important cation and has an important role in BP regulation and ECF balance. Kidney plays an important role in sodium balance. Almost 99% of filtered sodium is reabsorbed. The absorption occurs via sodium transporters located in the various segments of the nephron. Each of these transporters has unique features and is blocked by a specific diuretic. The activating and inactivating mutations of these transporters are associated with important clinical syndromes. The understanding of these transporters and their mutations is essential for proper diagnosis and management of syndromes associated with the defects of these transporters. Also the knowledge of sodium transporters helps in understanding the role of kidney in pathogenesis of hypertension and pharmacodynamics of diuretic action.