Pregnancy-Related AKI in South Asia: Etiology, Practice Patterns, Outcomes, and System Barriers

To the Editor:

Pregnancy-related acute kidney injury (PrAKI) remains an important cause of maternal and fetal morbidity, with a disproportionately high burden in low- and middle-income countries.1, 2, 3 Despite remarkable changes in obstetric care across South Asia, regional data on its etiologic spectrum, management practices, and outcomes remain limited. We conducted a multinational survey of 234 nephrologists from India (n = 106), Pakistan (n = 75), Nepal (n = 24), Bangladesh (n = 22), Sri Lanka (n = 5), and Maldives (n = 2) to understand clinician-reported PrAKI etiologies, diagnostic and treatment practices, outcomes, and barriers to care. Detailed country-wise findings are provided in Table 1. The survey highlights an evolving spectrum of PrAKI in South Asia. Septic abortion–associated acute kidney injury, historically an important cause, was reported to account for <10% of PrAKI by most respondents, whereas puerperal sepsis, obstetric hemorrhage, and hypertensive disorders remained important contributors. However, diagnostic capacity has not evolved uniformly with this changing spectrum. ADAMTS13 testing was reported to be available to only 9.4% of respondents in India, 14.7% in Pakistan, 4.2% in Nepal, and none in Bangladesh, whereas full thrombotic microangiopathy (TMA) genetic evaluation was reported to be performed in > 25% of cases by only 32.1%, 8.0%, 4.2%, and 0%, respectively. Although hemodialysis was universally available, access to disease-specific therapy remained limited; eculizumab was reported to be available by only 40% of respondents in India, 25.3% in Pakistan, 13.6% in Bangladesh, and 8.3% in Nepal, with actual use substantially lower. Reported outcomes were suboptimal. Clinician-reported median estimated complete renal recovery was only 40%–50%. Chronic kidney disease progression in >25% of survivors was reported by 44.6% and 44.0% of respondents from India and Pakistan, respectively, whereas end-stage kidney disease progression >10% was reported by 42.9% and 53.3%, respectively. Delayed presentation and referral were the most frequently identified barriers across countries. Adverse fetal outcomes also remained substantial with median reported rates ranging from 10% to 25%.

Table 1.

Country-wise comparison of clinician-perceived estimates of etiologies, diagnostic practices, management, outcomes, and barriers in pregnancy-related acute kidney injury

Variable	India (n = 106)	Pakistan (n = 75)	Bangladesh (n = 22)	Nepal (n = 24)	P-value
Etiologies (Clinician-perceived estimates)
Septic abortion–related AKI burden
<10% of PrAKI cases (%)	79 (75)	43 (57.3)	18 (81.8)	18 (75)	0.47
10%–25% of PrAKI cases (%)	25 (23.5)	17 (22.7)	3 (13.6)	5 (20.8)	0.12
26%–50% of PrAKI cases (%)	2 (1.8)			1 (4.2)	-
Median estimated burden of puerperal sepsis–related AKI (Clinician-perceived estimates)	26%–50%	10%–25%	10%–25%	10%–25%	0.34
Hemorrhage-related AKI (%), median (IQR)	20.0 (10.0–30.0)	12.5 (1.0–37.5)	0.3 (0.1–10.0)	12.5 (3.6–35.0)	0.21
Preeclampsia/HELLP (%), median (IQR)	25.0 (10.0–50.0)	10.0 (1.2–27.6)	0.2 (0.1–10.0)	12.5 (6.2–20.0)	<0.001
TTP (%), median (IQR)	5.0 (1.0–10.0)	5.0 (1.0–10.0)	0.1 (0.0–4.4)	1.5 (0.1–10.0)	0.013
aHUS (%), median (IQR)	6.2 (1.1–10.0)	2.5 (1.0–10.0)	0.1 (0.0–2.5)	0.5 (0.0–6.2)	<0.001
Glomerular diseases (%), median (IQR)	5.0 (2.1–10.0)	5.0 (1.0–10.0)	0.4 (0.1–10.0)	12.5 (10.0–25.0)	0.008
Obstructive uropathy (%), median (IQR)	2.8 (1.0–5.0)	3.0 (0.8–10.0)	0.8 (0.1–6.9)	2.5 (0.6–10.0)	0.685
Investigations and diagnostic practices, n/N (%)
Routine hematological parameters and kidney function test	100%	100%	100%	100%	NA
Complement levels available	102/106 (96.2)	62/75 (82.7)	11/22 (50.0)	18/24 (75.0)	0.001
ADAMTS13 available	10/106 (9.4)	11/75 (14.7)	0/22 (0.0)	1/24 (4.2)	<0.001
Genetic testing panel used	37/106 (34.9)	4/75 (5.3)	2/22 (9.0)	3/24 (12.5)	<0.001
Complement functional markers performed in >25% cases	61/106 (57.5)	30/75 (40.0)	4/22 (18.2)	7/24 (29.2)	0.004
Full TMA genetic work-up performed in >25% cases	34/106 (32.1)	6/75 (8.0)	0/22 (0.0)	1/24 (4.2)	<0.001
Treatment and follow-up, n/N (%)
PD used in >5% of cases	9/106 (8.5%)	10/75 (13.3)	1/22 (4.5)	0/24 (0.0)	0.203
HD facilities available	100%	100%	100%	100%	NA
Eculizumab available in country	42/106 (39.6)	19/75 (25.3)	3/22 (13.6)	2/24 (8.3)	<0.001
Eculizumab usable in >25% of indicated patients	15/106 (14.2)	5/75 (6.7)	0/22 (0.0)	0/24 (0.0)	0.054
Plasmapheresis available	106/106 (100.0)	58/75 (77.3)	6/22 (27.3)	19/24 (79.2)	<0.001
Routine post-discharge follow-up	100/106 (94.3)	72/75 (96.0)	16/22 (72.7)	22/24 (91.7)	0.004
Reported outcomes, n/N (%)
Reported CKD progression > 25%	47/106 (44.3)	33/75 (44.0)	5/22 (22.7)	4/24 (16.7)	0.029
Reported ESKD progression > 10%	45/106 (42.5)	40/75 (53.3)	5/22 (22.7)	6/24 (25.0)	0.017
Reported adverse fetal outcomes > 25%	35/106 (33)	29/75 (38.7)	3/22 (13.6)	6/24 (25.0)	0.135
Full renal recovery, median (IQR), %	40 (25–75)	40 (25–75)	40 (25–75)	50 (25–75)	0.08
CKD progression, median (IQR), %	25 (10–50)	25 (10–50)	20 (10–40)	20 (10–25)	0.04
ESKD progression, median (IQR), %	10 (5–25)	12 (5–25)	7–10 (5–15)	7–10 (5–15)	0.02
Adverse fetal outcomes, median (IQR), %	25 (10–30)	22 (10–30)	10 (5–20)	20 (10–30)	<0.001
Barriers, n/N (%)
Delayed referral/late presentation	42 (39.6)	24 (32)	7 (31.8)	9 (37.5)	0.92
financial constraints	18 (17)	7 (9.3)	5 (22.7)	5 (20.8)	0.43
Lack of awareness/education	16 (15.1)	9 (12)	5 (22.7)	4 (16.7)	0.12
Health care system and infrastructure	10 (9.4)	12 (16)	2 (9.1%)	4 (16.7)	0.42
Obstetric–nephrology coordination	8 (7.5)	14 (18.7)	2 (9.1%)	1 (4.2)	0.03
Antenatal care gaps	6 (5.7)	6 (8)	-	1 (4.2)	0.31
Other factors	6 (5.7)	3 (4)	1 (4.5%)	-	0.31

AKI, acute kidney injury; aHUS, atypical hemolytic uremic syndrome; CKD, chronic kidney disease; ESKD, end-stage kidney disease; HD, hemodialysis; IQR, interquartile range; PD, peritoneal dialysis; PrAKI, pregnancy-related AKI; TMA, thrombotic microangiopathy; TTP, thrombotic thrombocytopenic purpura.

Data in the table are not directly measured patient-level event rates, these represent clinician-perceived estimates based on respondents’ clinical experience.

The reported outcomes in our survey were broadly consistent with previously published literature.^1,4,5 In a recent systematic review from India, 12.8%–35% of women progressed to chronic kidney disease and up to 30% remained dialysis-dependent. Similarly, a global meta-analysis reported 72.5% complete renal recovery, 8.5% dialysis dependence, and 2.4% progression to end-stage kidney disease, whereas another systematic review identified hypertensive disorders, obstetric hemorrhage, and sepsis as the predominant etiologies of PrAKI. The lower complete renal recovery reported by our respondents (40%–50%) may reflect the restriction of survey participants in tertiary referral centers, where more severe, renal replacement therapy-requiring, and complex PrAKI cases are more commonly managed. Supplementary Figure S1 shows some key suggestions to improve PrAKI care in low- and middle-income countries and/or low-income countries. The spectrum of PrAKI in South Asia reflects a changing landscape in which progress in maternal health care coexists with persistent gaps in PrAKI care. The decline in septic abortion–related acute kidney injury reflects important progress in maternal health care; however, the persistent burden of preventable kidney injury, delayed recognition, and poor long-term outcomes highlights the substantial work that remains.

Disclosure

All the authors declared no competing interests.

Supplementary Material

Supplementary File (PDF)

Supplementary Methods. Supplementary Results. Figure S1. Some key suggestions to improve PrAKI care in LMICs/LICs.