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.

Focal and segmental glomerulosclerosis: does prognosis vary with the variants?

Focal and segmental glomerulosclerosis (FSGS) is a clinicopathological entity. The following five FSGS variants: Collapsing, cellular, glomerular tip, peri-hilar and not otherwise specified (NOS) are recognized, which may have prognostic value. The aim of this study was to highlight the clinical course and outcome in the different pathological variants of FSGS and to evaluate the predictive risk factors of end-stage renal disease (ESRD). It was a retrospective analysis of biopsy-proven primary FSGS patients who presented over a period of three years. The data were collected from the clinical and biopsy records of the Nephrology Unit. There were 116 patients with biopsy-proven FSGS. The frequency of occurrence of FSGS among all cases of the nephrotic syndrome seen in our unit was 35.47%. NOS was the most common pathological variant (62.2%), followed by peri-hilar (11.2%), cellular (9.4%) and glomerular tip (7.7%), and the least common variant was collapsing (4.3%). Majority of patients with collapsing, NOS and glomerular tip variants had nephrotic range proteinuria. However, the amount of proteinuria was highest in the glomerular tip and collapsing variants. A higher percentage of patients with the collapsing and cellular variants had renal failure at the time of presentation. A higher rate of tubular and interstitial changes was seen in the collapsing and cellular variants. The collapsing and cellular variants showed lower response rate and higher rates of ESRD, while the glomerular tip lesion had the highest remission rate and the lowest rate of ESRD. Poor prognostic factors for ESRD in FSGS were initial renal insufficiency, severe tubulo-interstitial change, initial nonresponsiveness to steroids and collapsing histopathological variant. Our study suggests that histopathological classification of FSGS is of paramount importance in the management and in predicting the prognosis.

Hair dye ingestion--an uncommon cause of acute kidney injury.

INTRODUCTION: Dye containing paraphenylene diamine is not an uncommon cause of renal failure in South India. However, there are very few published reports on renal lesions associated with hair dye ingestion. MATERIAL AND METHODS: We studied 30 consecutive cases (24 males and 6 females) of hair dye induced renal failure seen at our department. All the patients were aged between 18 to 40 years (26.9 +/- 4.95 years). RESULTS: The quantity of dye consumed ranged between 50-100 ml (79.5 +/- 22.45). All patients presented with oliguria and fluid overload. Dyspnea was seen in 24 (80%) while 10 (33.33%) had hypertension. Encephalopathy and seizures were seen in 10 (33.3%). None of the patients had evidence of hemolysis, hematological abnormalities or skin rash. Three patients had elevated SGPT (340 IU/l) which returned to base line after 2 weeks while creatinine phosphokinase (CPK) was elevated in 6(20%) patients. The oliguric phase lasted from 1 to 3 weeks and serum creatinine normalized in 21 (70%) patients. Renal biopsy done in 15 patients (done antemortem in 10 and postmortem in 5) showed evidence of acute tubular necrosis (ATN) in 8, acute interstitial nephritis (AIN) in 7 patients. All patients received dialytic support. Eight (26.6%) patients succumbed. CONCLUSION: Hair dye is an unusual but important cause of acute kidney injury. The commonest renal lesions are acute tubulointerstitial damage. Respiratory and hemodynamic supportive therapy is essential for recovery.