Clinical Research Of Pregnancy-related Acute Kidney Injury

BackgroundPregnancy-related Acute Kidney Injury(AKI) is a rare but serious complication.Recently, a major decrease in its incidence has been attributed to the improvement ofobstetric diagnosis and treatment technology, the reduction of sepsis abortion and theimproved perinatal care, however, the condition still contributes to significantmaternal adverse outcomes. Hypertensive disorders in pregnancy is apregnancy-specific disease, the pathogenesis and its complications make kidney moreeasily affected, it is the most common cause of pregnancy-related AKI. Severepostpartum hemorrhage is the leading cause of maternal morbidity and mortalityworldwide. A sharp decrease of blood volume within a short time can cause seriouscomplications of hemorrhagic shock, DIC, liver and kidney dysfunction. As one of theimportant cause of maternal adverse outcomes, AKI has always been a concern ofobstetricians, but due to various reasons, the exact incidence of pregnancy-relatedAKI was unknown, and there was still few reports at home and abroad. The purposeof this retrospective study was to review of all cases of pregnancy-related AKI inObstetric Critical Care Center of Guangzhou(The Third Affilated Hospital ofGuangzhou Medical College) in the past eleven years. To investigate thecharacteristics and outcomes of pregnancy-related AKI, moreover, to study theassociated risk factors and clinical outcomes of severe postpartum hemorrhagecomplicated with AKI, and then hoping to give some advice to clinical work for early diagnosis and treatment.ChapterⅠ Clinical data analysis of pregnancy-related acutekidney injuryObjectiveTo study the main etiologies and clinical characteristics of pregnancy-related AKI,and the risk factors of pregnancy-related AKI associated with maternal adverseoutcomes.Materials and MethodsThe study group included209cases with pregnancy-related AKI in Obstetric CriticalCare Center of Guangzhou(The Third Affilated Hospital of Guangzhou MedicalCollege) from August2000to July2011. Main clinical details included genenalcondition, the main etiologies of AKI, clinical characteristics, treatment measures andclinical outcomes were collected from the medical records. The data obtained wereanalyzed using SPSS13.0software package. Measurement data of normal distributionwere expressed as mean±standard deviation and compared using independent samplest-test; measurement data of non-normal distribution were presented as median andinterquartile range (IQR;25th to75th percentiles), using2independent samplesnonparametric tests; cout data were expressed as frequency and rate and comparedusing the chi-square test. Multivariable binary logistic regression analysis wasconducted to investigate risk factors. In all comparisons, a p-value of <0.05wasconsidered statistically significant.Results1. The main etiologies of pregnancy-related AKI included hypertensive disorders inpregnancy(36.8%,77/209), severe obstetric hemorrhage (24.4%,51/209), liver disease(12.4%,26/209), infectious diseases(8.6%,18/209), chronic kidneydisease(7.7%,16/209) and amniotic fluid embolism (6.2%,13/209).2. The severity and clinical outcomes of pregnancy-related AKI:144(68.9%) cases admitted to the ICU, the incidence of MODS was76.1%(159/209). Oliguria wasobserved in84(40.2%) cases, CRRT was given to86(41.1%) cases. The totalmortality was27.8%(58/209), moreover, with the increase of AKI stage, the mortalitywere19.4%(13/67),29.2%(7/24) and32.2%(38/118), respectively.3. Univariate analysis was performed between CRRT group and non-CRRT groupshowed that there was no difference in hypertensive disorders in pregnancy, severeobstetric hemorrhage, liver disease, infectious diseases, chronic kidney disease andamniotic fluid embolism(all P＞0.05). Oliguria/anuria, MODS, ALT, AST, totalbilirubin, direct bilirubin, BUN, CR, serum sodium and RBC between the two groupswere statistically significant (all P <0.05).4. The clinical outcomes of AKI requiring CRRT in obstetric patients:Mortality was observed in30(34.9%) cases,27(31.4%) patients recoveredcompletely,10(11.6%) patients showed partial recovery, and19(22.1%) patientsremained dependent on CRRT or renal function did not improve.The outcomesbetween the two groups were statistically significant(P=0.008).5. Univariate analysis was performed between non-survivors group and survivorsgroup showed that hypertensive disorders in pregnancy, infectious diseases, amnioticfluid embolism, chronic kidney disease, cardiopulmonary resuscitation, systolic bloodpressure, diastolic blood pressure, mean arterial blood pressure, oliguria/anuria,MODS, ALT, AST, total bilirubin, direct bilirubin, BUN, CR, UA, PT, APTT, WBC,HGB and HCT were statistically significant (all P <0.05).6. Multivariable binary logistic regression analysis showed that cardiopulmonaryresuscitation(OR5.846,95%CI1.738-19.660), infectious diseases(OR4.258,95%CI1.059-17.112), MODS(OR1.158,95%CI1.052-1.478), HCT(OR1.154,95%CI1.073-1.241) and PT(OR1.037,95%CI1.010-1.065) were the independent risk factorsassociated with death of pregnancy-related AKI, mean arterial blood pressure(OR0.980,95%CI0.962-0.998) was a protective factor.Conclusion1. The main etiologies of pregnancy-related AKI were hypertensive disorders inpregnancy, severe obstetric hemorrhage, liver disease, infectious diseases, chronic kidney disease and amniotic fluid embolism.2. Pregnancy-related AKI was a rare but serious complication in obstetric patients,with higher incidence of ICU admission and MODS. Mortality was high, moreover,AKIN criteria seem to have association with mortality.3. CRRT was the main treatment of pregnancy-related AKI. The outcomes of CRRTpatients were poor.4. The factors associated with death were presence of cardiopulmonary resuscitation,infectious diseases, MODS, HCT and PT.ChapterⅡ Analysis of the clinical characteristics of severepostpartum hemorrhage complicated withacute kidney injurySectionⅠ Risk factors associated with severe postpartum hemorrhagecomplicated with acute kidney injuryObjectiveTo investigate the clinical characteristics and risk factors of severe postpartumhemorrhage complicated with AKI.Materials and MethodsThe study group included88cases of severe postpartum hemorrhage complicatedwith AKI in Obstetric Critical Care Center of Guangzhou(The Third AffilatedHospital of Guangzhou Medical College) from August2000to July2011, thenretrospectively reviewed165cases of severe postpartum hemorrhage without thecomplication of AKI during the same period as control group (non-AKI group).219cases (86.6%,219/253) were transferred from other hospitals. Main clinical detailsincluding genenal condition, clinical characteristics, the amounts of bleeding andblood transfusion and treatment measures were collected from the medical records.The data obtained were analyzed using SPSS13.0software package. Measurement data of normal distribution were expressed as mean±standard deviation and comparedusing independent samples t-test; measurement data of non-normal distribution werepresented as median and interquartile range (IQR;25th to75th percentiles), using2independent samples nonparametric tests; cout data were expressed as frequency andrate and compared using the chi-square test. Multivariable binary logistic regressionanalysis was conducted to investigate risk factors for severe postpartum hemorrhagecomplicated with AKI. In all comparisons, a p-value of <0.05was consideredstatistically significant.Results1. AKI occurred in88(34.8%,88/253) cases of patients with severe postpartumhemorrhage.2. Univariate analysis was performed between AKI group and non-AKI group showedthat ICU admission, severe preeclampsia/eclampsia/HELLP syndrome, Amniotic fluidembolization, liver disease, placental abruption, cerebrovascular accident, theamounts of bleeding and blood transfusion, MODS, cardiopulmonary resuscitation,mechanical ventilation and dialysis treatment were statistically significant (all P<0.05).3. Independent risk factors for severe postpartum hemorrhage complicated with AKIincluded severe preeclampsia/eclampsia/HELLP syndrome(OR5.077,95%CI2.111-12.211), liver disease(OR3.501,95%CI1.106-11.080), the amount ofbleeding(OR1.000,95%CI1.000-1.000) and blood transfusion(OR1.000,95%CI1.000-1.001), cardiopulmonary resuscitation(OR3.893,95%CI1.274-11.894) andMODS(OR12.110,95%CI4.813-30.465).SectionⅡ Analysis of the risk factors and clinical characteristicsassociated with death of severe postpartum hemorrhagecomplicated with acute kidney injuryObjectiveTo investigate the risk factors and clinical characteristics associated with death ofsevere postpartum hemorrhage complicated with AKI. Materials and MethodsThe study group included88cases of severe postpartum hemorrhage complicatedwith AKI in Obstetric Critical Care Center of Guangzhou(The Third AffilatedHospital of Guangzhou Medical College) from August2000to July2011,78(88.6%,78/88) cases were transferred from other hospitals. Death occurred in25cases, sodivided these patients into non-survivors group(25cases) and survivors group (63cases). Main clinical details including genenal condition, clinical characteristics andtreatment measures were collected from the medical records. The data obtained wereanalyzed using SPSS13.0software package. Measurement data of normal distributionwere expressed as mean±standard deviation and compared using independent samplest-test; measurement data of non-normal distribution were presented as median andinterquartile range (IQR;25th to75th percentiles), using2independent samplesnonparametric tests; cout data were expressed as frequency and rate and comparedusing the chi-square test. Multivariable binary logistic regression analysis wasconducted to investigate risk factors for mortality of severe postpartum hemorrhagecomplicated with AKI. In all comparisons, a p-value of <0.05was consideredstatistically significant.Results1. The severity and clinical outcomes of of severe postpartum hemorrhagecomplicated with AKI: ICU admission and MODS occurred in79.5%(70/88) and92%(81/88) of severe postpartum hemorrhage complicated with AKI, respectively.Most patients of severe postpartum hemorrhage complicated with AKI associated withinadequate perinatal care. The incidence of hysterectomy and CRRT were52.3%and45.5%, respectively. Overall mortality was28.4%(25/88), moreover, with the increaseof AKI stage, the mortality were25%(6/24),27.3%(3/11) and30.2%(16/53),respectively.2. Univariate analysis was performed between non-survivors group and survivorsgroup showed that peripartum hysterectomy, ICU admission, length of hospital stay,amniotic fluid embolization, cerebrovascular accident, cardiopulmonary resuscitation, systolic blood pressure, diastolic blood pressure, mean arterial pressure, BUN, UA、PT、APTT、RBC、HGB and HCT were statistically significant (all P <0.05).3. Multivariable binary logistic regression analysis showed that PT(OR1.053,95%CI1.017-1.090) and RBC(OR4.231,95%CI1.912-9.360) were the independent riskfactors associated with death of severe postpartum hemorrhage complicated with AKI,systolic blood pressure(OR0.972,95%CI0.954-0.991) was the protective factor.Conclusion1. The incidence of severe postpartum hemorrhage complicated with AKI was not low.Mortality was high, moreover, AKIN criteria seem to have association with mortality.2. Severe preeclampsia/eclampsia/HELLP syndrome, liver disease, the amounts ofbleeding and blood transfusion, cardiopulmonary resuscitation and MODS were theindependent risk factors of severe postpartum hemorrhage complicated with AKI.3. PT and RBC were the independent risk factors associated with death of severepostpartum hemorrhage complicated with AKI; systolic blood pressure was theprotective factor.