وصف
Acute kidney damage (AKI) in pregnancy is a major contributor to morbidity and mortality in both the mother and the fetus. Preeclampsia, hemolysis, elevated liver enzymes, low platelet count (HELLP) syndrome, acute fatty liver disease of pregnancy, thrombotic thrombocytopenic purpura, and hemolytic uremic syndrome are among the complications that can lead to pregnancy-related acute kidney injury (AKI) later in the pregnancy. Hyperemesis gravidarum is a common cause of pregnancy-related AKI during the first trimester. A kidney biopsy should be explored when the laboratory evaluation for AKI is non-diagnostic, as a definitive diagnosis will aid to facilitate proper therapy, outweighing the hazards of biopsy. Diagnosis of pregnancy-related AKI is difficult because there are no established diagnostic criteria. Finding the underlying cause of kidney damage and administering intravenous fluid are general treatments for acute kidney injury (AKI) during pregnancy.
ملخص
- Acute kidney injury (AKI) in pregnancy is a complex condition due to the need to manage two lives, requiring a deep understanding of both physiological and pathological processes specific to pregnancy. Challenges persist in the validation of AKI definitions, leading to potential problems in diagnosis and management. Early detection is crucial, with risk factors including older maternal age, comorbidities like diabetes and pre-eclampsia, and socioeconomic status affecting access to adequate healthcare facilities.
- Pregnancy-associated AKI requiring dialysis has decreased in recent years, but remains a significant concern, particularly as it relates to maternal mortality. The causes of AKI vary by trimester, with hyperemesis gravidarum and septic abortion being common in the first trimester. Glomerulonephritis, UTI, pre-eclampsia, HELLP syndrome, and acute fatty liver of pregnancy can occur across trimesters. Pathophysiological mechanisms include increased inflammatory mediators, oxidative stress, and impaired blood-brain barrier function.
- Pre-renal AKI is often caused by hemorrhage, hypovolemic shock, sepsis, and congestive heart failure, while intrinsic renal causes include acute tubular necrosis, renal cortical necrosis, thrombotic microangiopathies, HELLP syndrome, pre-eclampsia, and acute fatty liver. Post-renal causes involve mechanical obstruction. Fetal outcomes can be negatively affected, resulting in preterm birth, low birth weight, and fetal growth restriction.
- Preeclampsia, defined by hypertension and proteinuria after 20 weeks of gestation, can impact various organs due to reduced vascular tone and changes in prostacyclin metabolism. Severe preeclampsia involves higher blood pressure, significant proteinuria, oliguria, and potential complications like thrombocytopenia, TTP, or HELLP syndrome. HELLP syndrome, characterized by hemolysis, elevated liver enzymes, and low platelets, requires timely delivery as the primary intervention, along with magnesium sulfate for seizure prophylaxis and potential platelet transfusion.
- Diagnosis of AKI in pregnancy involves urine routine analysis, metabolic and coagulation profiles, sonography to assess kidney size and hydronephrosis, and complement levels in specific cases. The RIFLE, AKIN, and KDIGO classifications lack validation for pregnancy. While biomarkers like NGAL are available, their clinical utility for early AKI detection is debated. Renal biopsy may be considered in difficult cases following consultation with a nephrologist.
- Management of AKI in pregnancy focuses on addressing the underlying cause, optimizing hydration while avoiding overload, and managing complications like hyperkalemia with potassium binders. Loop diuretics should be used cautiously to avoid dehydration. Treatment options vary depending on the etiology, including antibiotics for infections, delivery for pre-eclampsia and HELLP syndrome, plasma exchange for TTP, and eculizumab for atypical hemolytic uremic syndrome. Immunosuppressive drugs require careful consideration of their side effect profiles and potential risks to the fetus.
نموذج شهادة
حول المتحدثين
Dr. Shrikant Sahasrabudhe
Head of the Department, Critical Care & Pulmonology, KIMS Manavata Hospital, Nashik
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