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      Incidence, aetiology and outcomes of obstetric-related acute kidney injury in Malawi: a prospective observational study

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          Abstract

          Background

          Obstetric-related acute kidney injury (AKI) is thought to be a key contributor to the overall burden of AKI in low resource settings, causing significant and preventable morbidity and mortality. However, epidemiological data to corroborate these hypotheses is sparse. This prospective observational study aims to determine the incidence, aetiology and maternal-fetal outcomes of obstetric-related AKI in Malawi.

          Methods

          Women greater than 20 weeks gestation or less than 6 weeks postpartum admitted to obstetric wards at a tertiary hospital in Blantyre, Malawi, and at high-risk of AKI were recruited between 21st September and 11th December 2015. All participants had serum creatinine tested at enrolment; those with creatinine above normal range (> 82 μmol/L) underwent serial measurement, investigations to determine cause of kidney injury, and were managed by obstetric and nephrology teams. AKI was diagnosed and staged by Kidney Disease Improving Global Outcomes (KDIGO) criteria. Primary outcomes were the incidence proportion and aetiology of AKI. Secondary outcomes were in-hospital maternal mortality, need for dialysis, renal recovery and length of stay; in-hospital perinatal mortality, gestational age at delivery, birthweight and Apgar score.

          Results

          354 patients were identified at risk of AKI from the approximate 2300 deliveries that occurred during the study period. Three hundred twenty-two were enrolled and 26 (8.1%) had AKI (median age 27 years; HIV 3.9%). The most common primary causes of AKI were preeclampsia/eclampsia ( n = 19, 73.1%), antepartum haemorrhage ( n = 3, 11.5%), and sepsis ( n = 3, 11.5%). There was an association between preeclampsia spectrum and AKI (12.2% AKI incidence in preeclampsia spectrum vs. 4.3% in other patients, p = 0.015). No women with AKI died or required dialysis and complete renal recovery occurred in 22 (84.6%) cases. The perinatal mortality rate across all high-risk admissions was 13.8%. AKI did not impact on maternal or fetal outcomes.

          Conclusions

          The incidence of AKI in high-risk obstetric admissions in Malawi is 8.1% and preeclampsia was the commonest cause. With tertiary nephrology and obstetric care the majority of AKI resolved with no effect on maternal-fetal outcomes. Maternal-fetal outcomes in Sub-Saharan Africa may be improved with earlier detection of hypertensive disease in pregnancy.

          Electronic supplementary material

          The online version of this article (10.1186/s12882-018-0824-6) contains supplementary material, which is available to authorized users.

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          Most cited references23

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          Notice

          SECTION I: USE OF THE CLINICAL PRACTICE GUIDELINE This Clinical Practice Guideline document is based upon the best information available as of February 2011. It is designed to provide information and assist decision-making. It is not intended to define a standard of care, and should not be construed as one, nor should it be interpreted as prescribing an exclusive course of management. Variations in practice will inevitably and appropriately occur when clinicians take into account the needs of individual patients, available resources, and limitations unique to an institution or type of practice. Every health-care professional making use of these recommendations is responsible for evaluating the appropriateness of applying them in the setting of any particular clinical situation. The recommendations for research contained within this document are general and do not imply a specific protocol. SECTION II: DISCLOSURE Kidney Disease: Improving Global Outcomes (KDIGO) makes every effort to avoid any actual or reasonably perceived conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the Work Group. All members of the Work Group are required to complete, sign, and submit a disclosure and attestation form showing all such relationships that might be perceived or actual conflicts of interest. This document is updated annually and information is adjusted accordingly. All reported information is published in its entirety at the end of this document in the Work Group members' Biographical and Disclosure Information section, and is kept on file at the National Kidney Foundation (NKF), Managing Agent for KDIGO.
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            International Society of Nephrology's 0by25 initiative for acute kidney injury (zero preventable deaths by 2025): a human rights case for nephrology.

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              Chronic kidney disease in pregnancy.

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                Author and article information

                Contributors
                cooke.wr@gmail.com
                ulla.hemmila@fimnet.fi
                alisoncraik@ymail.com
                chimwemwemandula@yahoo.com
                ppmvula@gmail.com
                amsusa@medcol.mw
                gavin_dreyer@hotmail.com
                rhysdrevans@gmail.com , rhys.evans@ucl.ac.uk
                Journal
                BMC Nephrol
                BMC Nephrol
                BMC Nephrology
                BioMed Central (London )
                1471-2369
                2 February 2018
                2 February 2018
                2018
                : 19
                : 25
                Affiliations
                [1 ]ISNI 0000 0004 0598 3456, GRID grid.415487.b, Department of Internal Medicine, , Queen Elizabeth Central Hospital, ; Blantyre, Malawi
                [2 ]ISNI 0000 0000 9007 4476, GRID grid.416094.e, Department of Obstetrics and Gynaecology, , Royal Berkshire Hospital, ; Craven Road, Reading, RG1 5AN UK
                [3 ]ISNI 0000 0004 0598 3456, GRID grid.415487.b, Department of Obstetrics and Gynaecology, , Queen Elizabeth Central Hospital, ; Blantyre, Malawi
                [4 ]ISNI 0000000121901201, GRID grid.83440.3b, University College London Centre for Nephrology, Royal Free Hospital, ; Pond Street, London, NW3 2QG UK
                [5 ]ISNI 0000 0004 0581 2008, GRID grid.451052.7, Department of Nephrology, , Bart’s Health NHS Trust, ; London, UK
                Article
                824
                10.1186/s12882-018-0824-6
                5797378
                29394890
                471e7ba8-235d-455b-a4ba-ff968c954f88
                © The Author(s). 2018

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 28 March 2017
                : 21 January 2018
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/501100000683, Royal Society of Tropical Medicine and Hygiene;
                Funded by: FundRef http://dx.doi.org/10.13039/501100000682, Royal College of Obstetricians and Gynaecologists;
                Award ID: Eden Travelling Fellowship
                Categories
                Research Article
                Custom metadata
                © The Author(s) 2018

                Nephrology
                acute kidney injury,acute renal failure,global health,sub-saharan africa,pregnancy,preeclampsia

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