Saudi Journal of Kidney Diseases and Transplantation

: 2017  |  Volume : 28  |  Issue : 1  |  Page : 1--8

The prevalence of pregnancy-related acute renal failure in Asia: A systematic review

Zynab Karimi, Leila Malekmakan, Maryam Farshadi 
 Shiraz Nephro-Urology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran

Correspondence Address:
Leila Malekmakan
Shiraz Nephro-Urology Research Center, Shiraz University of Medical Sciences, Shiraz


Acute renal failure (ARF) is a major complication during pregnancy and is associated with high mortality rate in developing countries. The aim of this study was to report the prevalence of pregnancy-related ARF in Asia. This study is a systematic review Google Scholar, PubMed, and Medline databases were searched for all papers in English on pregnancy related ARF (PR-ARF) in Asian countries that were published between 2010 and 2015 were reviewed. Of all the articles published in that period, 19 were selected - 17 were original articles and two were cases reports. We gathered information on the prevalence of PR-ARF, parity, duration of pregnancy when PR-ARF developed, etiology of PR-ARF, common clinical symptoms, and laboratory findings in PR-ARF.

How to cite this article:
Karimi Z, Malekmakan L, Farshadi M. The prevalence of pregnancy-related acute renal failure in Asia: A systematic review.Saudi J Kidney Dis Transpl 2017;28:1-8

How to cite this URL:
Karimi Z, Malekmakan L, Farshadi M. The prevalence of pregnancy-related acute renal failure in Asia: A systematic review. Saudi J Kidney Dis Transpl [serial online] 2017 [cited 2017 Mar 30 ];28:1-8
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Full Text


Pregnancy-related acute renal failure (PR-ARF) is a rare yet serious problem during pregnancy. Pregnancy per se can cause acute renal failure (ARF) even if the mother had a previously healthy kidney.[1]

Many significant changes occur during a normal pregnancy in comparison to a non-pregnant condition. Increased blood volume, reduced systemic vascular resistance, and other adaptive physiological and anatomic changes that follow in response to pregnancy-related needs affect kidney function, and in some serious cases can cause renal failure.[2] ,[3] These disorders also cause important changes in laboratory parameters such as body fluids, electrolytes, acid-base balance, and kidney function.[4] ,[5] ,[6] It is essential to understand these changes to make a proper interpretation of laboratory and diagnostic studies that are routinely used in the evaluation of kidney disease in pregnant women;[7] this understanding is fundamental for proper management of these unusual disorders.[8] ,[9] In general, disorders causing ARF during early or late pregnancy fall into many categories.[9] Most common causes of ARF in the first trimester are infections (usually septic abortion) or severe nausea and vomiting that can cause initiation of renal disorders such as prerenal uremia, acute tubular necrosis, renal cortical necrosis, and pyelonephritis during early pregnancy.

However, ARF is more prevalent in the later months, and it is usually related to preeclampsia, acute fatty liver, hemolytic uremic syndrome, sepsis, and antepartum hemorrhage (APH), intrapartum or postpartum hemorrhage (PPH).[4] ,[10] From 2010 to 2015, there has been no systematic review study on the prevalence of PR-ARF in Asia. Consequently, our objective was to provide a report on the prevalence of PR-ARF in Asia.


A systematic review was conducted by searching PubMed, Medline database, and Google Scholar to identify all relevant English papers published from 2010-2015 in Asia. Furthermore, the reference lists of all identified papers were reviewed to find other relevant papers that were not found in the database search. All the full texts were reviewed to identify epidemiological studies that fulfilled the following criteria. All observational epidemiological study including case report and original articles which reported the prevalence and mortality rates were included in this review. In this study, patients who had a kidney transplant or had a history of hypertension and kidney disease before pregnancy were excluded and the patients, who were healthy before pregnancy and developed renal failure during pregnancy or after, were included in this study. Of the total 35 papers that we gathered, 19 were within the time frame selected by us and are shown in [Table 1].{Table 1}

We prepared a data sheet that contained; name of author, year of study, name of country, mean age, prevalence, number of pregnancy, duration of pregnancy, causes of PR-ARF, and common clinical and laboratory symptoms.

ARF is a clinical syndrome that indicates an abrupt decline in glomerular filtration rate (GFR) to a sufficient amount to decrease the excretion of nitrogenous waste products (urea and creatinine) and other uremic toxins.[11] PR-ARF was diagnosed on the basis of clinical and laboratory findings. Sudden oliguria (urine <400 mL in 24 h) or anuria or serum creatinine increased above 1.5 mg/dL was defined as ARF.[8] Complete recovery was defined as renal function returning to normal. The partial improvement was defined when serum creatinine decreased below 2 mg/dL, and the patient was not dialysis dependent. Irreversible renal failure was defined when the patient remained dialysis dependent three months after enrollment.[12]


Nineteen papers related to the mentioned time frame in Asia are included as shown in [Table 1].

The prevalence of PR-ARF was between 0.1% in China 21.6% in Bangladesh). In Rahman et al study from Bangladesh done during 2007 to 2008, ARF occurred in the third trimester of pregnancy with average gestational age of 31.4 ± 7.4 weeks. Sepsis (43%) and eclampsia (19%) were identified as the main causes of PR-ARF.[12]

In a study from India, 10 of 57 pregnant women enrolled in the study, developed ARF, 40 after delivery, and seven after abortion. Of all patients, 19.3% developed acute kidney failure in the first trimester, 10.5% in the second, and 70.2% during the puerperium period. Sepsis caused by abortion at the hands of nonspecialists was reported as the most common cause of PR-ARF following abortions. Most of the patients received hemodialysis (HD) or peritoneal dialysis (85%). The death rate of PR-ARF was 28.1%. Forty-one patients survived, of whom 24 recovered fully, five had partial recovery of kidney function, and five received kidney transplants, and there were no follow-ups for nine remaining patients. In the few patients who had renal biopsy patients, renal histopathology revealed acute tubular necrosis and renal cortical necrosis as well as acute interstitial nephritis.[13]

Sivakumar et al reported that out of 1,353 cases with ARF seen between 1999 and 2009, 59 (4.36%) were pregnancy-related (with average age of 25 years). The prevalence rates of ARF during different trimesters pregnancy were as follows: 1.7% in the first trimester, 6.7% in the second trimester, 16.9% in the third trimester, and 74.6% in the postpartum period. 52.3% of all patients required dialysis treatment. Full recovery occurred in 54.2% of patients, 10.2% made a partial recovery, and 23.7% expired. In this study, the most common causes of ARF were septic abortion (47.4%) during the first half, and preeclampsia (30.5%) and placental abruption (18.6%) in the second half of pregnancy.[14]

In another study from India, the prevalence rate of ARF was found to be 8% in the first trimester, 50% in the second, and 42% in the third trimester. Among the most common causes of PR-ARF were puerperal sepsis (40%), pregnancy-induced hypertension (28%), and retained products of conception (42%). Common laboratory findings were 24 h urinary protein (52%), metabolic acidosis (22%), anemia (78%), and leukocytosis (64%). Thirtythree patients required HD.

Godara et al, studied the clinical profiles and outcomes of pregnancy-related to ARF in 57 patients with average age of 26. Oliguria and high serum creatinine levels were the diagnostic markers for the disease. Patients were 56.1 % multigravida and 43.9 % primigravida. From the 57 patients, 59.6 % developed ARF during the puerperal period, and their primary clinical signs were fever, anuria, oliguria, peripheral edema, and vaginal bleeding. The most common causes of PR-ARF were puerperal sepsis (36.6%) and preeclampsia/eclampsia (33.3%). Renal biopsies revealed renal cortical necrosis.[16]

Another study reported that out of 752 patients with ARF, 27 developed it during postpartum. In these cases, plasma creatinine levels had increased significantly during the 2nd and 3rd day after delivery. Sepsis was identified as the main cause. Antepartum and PPH also played an important role such that anemia was among the most significant clinical signs. During hospitalization, 29.6 % of patients needed HD. 18.5 % of patients expired; 80% of which died from sepsis and one patient died from postpartum hemorrhage.[1]

Krishna et al, studied 98 out of the 2890 patients with PR-ARF who visited the nephrology center from 2006 to 2011. The average age was 28 years and all of them required at least once dialysis session. 79.6% of patients were multiparous, and 56.1% developed PR-ARF during their third trimester. Sepsis was reported as the most common cause (56.1%). 18.4% of the subjects expired; sepsis was the cause of mortality in 13 patients, and risk of death was higher in patients with oliguria, sepsis, and involvement of the nervous system. Multiple dialyses were required in 75.5% of cases, and kidney biopsy was performed on 16 patients. Cortical necrosis was observed in eight cases, two cases had cortical necrosis alongside with thrombotic microangiopathy, and in six cases biopsy showed acute tubular necrosis.[17]

Liu et al, reported 22 ARF pregnancy-related cases from 18,589 patients who had visited the nephrology centers from 2004 to 2013. Their average gestational age was 32 weeks, and 20 patients were primiparous; 72.4% experienced renal failure in the third trimester of pregnancy, and 77.3% of the patients were from rural areas and with no regular prenatal care. Hemorrhagic shock (31.8%) and preeclampsia (18.2%) were among the main causes of PR-ARF, and the most significant clinical signs were edema, hypertension, fever, anuria, oliguria, DIC, and increased blood uric acid levels.[18]

From 2006 to 2007, Khanal et al collected information on 50 patients with PR-ARF with an average age of 29 years. 17.5% of patients were multiparous. Most common causes of the disease were antepartum and PPH, preeclampsia/eclampsia. Overall, 50% of the patients became dialysis-dependent; of the remaining 50%, 7%, and 5.5% made a full or partial recovery, respectively.[19]

Rafiq et al studied the hemostatic changes in 40 patients with PR-ARF during one year. The average age of patients was 33. Clinical manifestations included paleness, hemorrhage, fever, anuria, oliguria, petechiae and edema. Diarrhea, vomiting, and APH were identified as the causes of the disease.[20]

In another study, Chaudhri et al examined 345 patients with ARF who visited the nephrology centers during 2009-2010. Of these, 51 patients with average age of 28 had PR-ARF. Out of these patients, 88.2% were multiparous, and 90.2% developed PR-ARF in the third trimester. Sepsis was found to be the most common cause (64.7%). The highest serum creatinine level was 25.9 mg/dL. Metabolic acidosis, thrombocytopenia, sepsis, respiratory alkalosis, hyperkalemia, oliguria, hypotension, and paleness were observed. In this study, 3.9% of patients recovered partially, 7.8% did not recover at all, and 33.3% were lost to follow-up.[21]

Srinil et al, reported on 44 patients with PR-ARF caused by septic abortion 52.2% of the patients were multiparous, and 54.5% had abortion in the first trimester. Most common findings were abdominal pain (36.4%) and vaginal bleeding (36.4%). Fever, anemia, oliguria/anuria, and azotemia were also seen in the patients of whom, 38.6% needed dialysis. The mortality rate among this group was 9%.[22]

Kadimova studied 250 patients with PR-ARF during 2009-2011. 45.8% of the patients developed the disease in the first trimester, 33.3 % in the second, and 20.9% in the third trimester. Acute pyelonephritis, renal hydronephrosis, and eclampsia were the most common causes of PR-ARF.[23]

In a case report by Jeon et al described a 29 year-old woman who developed PR-ARF during the third trimester of her first pregnancy serum creatinine reached a level of 5.1 mg/mL. The symptoms were fever, oliguria, flank pain, nausea and vomiting.[24]

Rashid et al, reported that from the 210 ARF patients who were admitted during 2010 to 2011, 40 had PR-ARF. Of these, 55% were multiparous, 15% developed renal failure in the first trimester, 15% in the second, and 70% in the third trimester or after delivery. In this study IUD, puerperal sepsis, septic abortion, PPH, and DIC were among most common causes of PR-ARF. 85% of the patients received HD; 20% made a full recovery and 32% did not recover at all. Mortality was reported to be 30%.[26]

In a study in Hyderabad, in 56 patients with an average age of 21-30 who entered the study from 2011 to 2011; 27% were primiparous. Eleven percent of the patients developed the disease in the first trimester, 18% in the second, 33 % in the third trimester, and 38% in the puerperal period. Anuria and oliguria were seen. Antepartum and PPH (41%) and septicemia (21%) were the most common causes of PR-ARF. 43% of patients received HD, and 43% made full recovery. Mortality rate was at 43%.[27]


PR-ARF is a life-threatening condition During pregnancy; the kidney goes through anatomical and physiological changes to adapt with the new condition. These changes include increase in kidney size, renal blood flow, GFR, and collecting duct dilation.[28]

During a normal pregnancy, mother's cardiovascular system generally undergoes considerable changes. Blood volume and red blood cell mass increase up to 50%. Systemic vascular resistance decreases thus increases cardiac output by 30%. This cardiovascular adaptability has profound effects on renal hemodynamics which result in change of normal renal laboratory values.[3] ,[29] Changes in renal function consist of an increase in effective renal blood flow (5%) and as a result glomerular filtration rate (30%) and finally a decrease in serum creatinine levels (30%).[6] Renal plasma flow increases by 5%-70% and reaches up to 85% by the second trimester. After fertilization, GFR increases constantly, it exceeds 25% in the 4th week of pregnancy and reaches 65% by the 13th week. Renal hemodynamic changes are visible by the end of the first trimester.

Due to increase in GFR and glomerular basement membrane permeability, urinary protein excretion increases by two-fold.[2] Renal plasma flow increases up to 85% during the second trimester of pregnancy. These changes are caused by vasodilator agents such as nitric oxide and relaxing synthesis or aldosterone resistance, which leads to increase in cardiac output and vasodilation of afferent and efferent arterioles.[4] While up to 300 mg of proteinuria per day is considered normal during pregnancy, higher levels of protein excretion could be a sign of deterioration of the disease or initiation of kidney disease or the development of preeclampsia, especially after the 20th week of pregnancy. In general, abnormal protein levels before the 20th week are an indicator of intrinsic renal disease as opposed to pregnancy-related ones. In nonpregnant women, urinary protein excretion can be evaluated, using the protein/creatinine ratio; but this might not be accurate during pregnancy, therefore, an accurate 24-h measurement of urine protein is necessary.[7]

PR-ARF still remains a serious problem in developing countries. Various studies were performed between 2010 and 2015 in Asia, presented the epidemiological characteristics (prevalence, structure, causes and general dynamics) of kidney disease in pregnant women. Most of these studies have identified sepsis and antepartum/PPH as the main causes of PR-ARF, and most of the patients were in need of treatment with HD. These studies showed that patients who were not under prepregnancy and prenatal care were more prone to the disease. Therefore, we can reduce its prevalence by promoting prenatal care. Hence, we can reduce the rate of mortality to a minimum by early and accurate diagnosis during pregnancy.


The Vice-Chancellery of Research and Technology of Shiraz University of Medical Sciences financially supported this study. The authors would like to thank the Research Consultation Center (RCC) of Shiraz University of Medical Sciences for their invaluable assistance in editing this article.

Conflict of interest: None declared.


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