印度南部公立医院与妊娠相关的急性肾损伤：变化趋势。
Pregnancy-related Acute Kidney Injury in Public Hospital in South India: Changing Trends.
机构信息
Professor and Head;Corresponding Author.
Postgraduate.
出版信息
J Assoc Physicians India. 2022 Aug;70(8):11-12. doi: 10.5005/japi-11001-0064.
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.
背景
妊娠相关急性肾损伤（PRAKI）是发展中国家的一个常见问题。
材料与方法
在印度南部一家三级保健医院进行的这项回顾性观察性研究中，我们评估了患有 PRAKI 的女性的母婴和肾脏结局的记录。
结果
在 10 年期间，共有 395 例 PRAKI 患者，占所有急性肾损伤（AKI）的 8.1%。患者的平均年龄为 27 ± 3 岁。共有 176 例（44.5%）患有子痫前期，132 例（33.4%）患有产褥期败血症，76 例（19.2%）有产前或产后出血（APH 30/PPH 46），9 例（2.2%）患有溶血尿毒综合征（HUS）。有 2 例患者存在梗阻。有 3 例患者存在自身免疫性肾小球肾炎，其中 11 例患者存在血小板减少症。在 395 例患者中，有 45 例（11.39%）存在溶血性贫血、肝酶升高和血小板减少（HELLP）综合征，即子痫前期患者中的 25.5%。有 16 例（4.0%）发生胎盘早剥。共有 288 例（72.9%）在产后就诊。对 103 例患者进行了肾脏活检，结果显示 25 例（22.3%）存在斑片状皮质坏死（PCN），23 例（20.3%）存在弥漫性皮质坏死（DCN），20 例（19.4%）存在急性肾小管坏死（ATN），10 例（9.7%）存在急性间质性肾炎（AIN），9 例（8.7%）存在血栓性微血管病（TMA）。有 11 例存在肾小球疾病。有 48 例患者存在皮质坏死（CN），其中 10 例（20.83%）发生胎盘早剥，25 例（52%）发生产褥期败血症，11 例（22.9%）发生产后出血（PPH），2 例（4.1%）发生 TMA。共有 290 例（73.4%）需要透析。约 76%的患者有所改善，而 8.3%的患者进展为终末期肾病（ESRD）。产妇死亡率（MM）为 5%。有 42 例宫内胎儿死亡，30 例新生儿死亡。
讨论
与西方国家相比，发展中国家妊娠相关急性肾损伤更为常见。只有 49%的患者有预约妊娠，即定期接受产前护理。除了子痫前期也是西方国家的主要病因，也是我们研究中 44%的 PRAKI 患者的病因外，败血症（33%）和产妇出血（19%）也是重要的病因。PRAKI 的即刻恢复率为 75%，但约 8%的患者发展为终末期肾病（ESKD），而在西方国家，ESKD 仅发生在约 2%的患者中。
结论
妊娠相关急性肾损伤是母婴发病率和死亡率的重要原因。子痫前期是 PRAKI 最常见的病因，CN 是最常见的组织学病变。适当的产前护理和管理可能会改善妊娠结局。
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