Incidence of Pregnancy Related-Acute Kidney Injury and Urological Co-Morbidities in Morbidly Adherent Placenta: A Potential Challenge to AKI-0by25 Initiative

Pregnancy related-acute kidney injury (PR-AKI) and urological complications are potentially preventable causes of maternal morbidity and mortality. An in-depth knowledge of their risk in various maternal conditions can assist in getting closer to the ambitious target of zero preventable death from AKI, by 2025. The aim of the current research was to study the incidence of acute kidney injury and urological complications in morbidly adherent placenta (MAP), a rare maternal condition now being increasingly encountered worldwide, due to increasing incidence of cesarean deliveries. This was a prospective study, done over a period of four years. Pregnant patients with morbidly adherent placenta, with normal baseline renal function and no past history of renal disease or diabetes were included in the study after obtaining a written informed consent. Patients with pre-eclampsia/eclampsia and history of urological surgery in the past were excluded. Baseline parameters (demographic, antenatal and perinatal parameters) and operative details (obstetric, urological, and hemostatic procedures) were recorded in detail for each patient. Outcome parameters, including acute kidney injury (Acute Kidney Injury Network criteria), urological complications, and maternal outcome were studied during the peri-operative and post-operative period, daily, till the end of the hospital stay and followed up weekly for six weeks after delivery. Patients with AKI were compared to those without AKI and those needing a urological intervention were compared to those without urological complications. All statistical calculations were done using SPSS 21 with P value < 0.05 considered as significant. A total of 5475 deliveries were conducted during the study period, out of which 64 patients had adherent placenta (incidence 12.8 per 1000 deliveries; 31-accreta, 13-increta, 20-percreta), none needing exclusion. Furthermore, AKI occurred in 39.1% of patients (nMAP-AKI = 25), most of them had mild AKI (AKIN-1 in 11 patients), with severe AKI (AKIN-2, 3) in 10.9% (nAKIN-2 = 9, nAKIN-3 = 5) and one required two sessions of slow low efficacy dialysis. On univariate analysis, AKI was higher in placenta percreta (P = 0.021, RR -2.34), urological injuries (0.001, RR 2.86), and higher blood loss (P = 0.001). On multivariate analysis, placenta percreta was independently associated with higher incidence of AKI (P = 0.049). Urological involvement/injuries requiring intervention were seen in 22 patients (nMAP-Ur = 22) with significantly higher incidence in placenta previa (P = 0.023, RR1.62) and placenta percreta (P = 0.000, RR 17.18), and patients undergoing hysterectomy (P = 0.000, RR -2.01) on univariate analysis, but on multivariate analysis, placenta percreta was found to be the most significant factor (P = 0.017). Significantly higher number of MAP-Ur had AKI (15/22, P = 0.001, RR -2.87, 95% CI 1.55 - 5.28). Acute Kidney Injury and urological injuries significantly increased the need for intensive care and days of hospital stay. At the end of six weeks follow-up all AKI patients had complete recovery of renal function and no urinary leak or vesico-vaginal fistula was seen in urologically intervened patients. No maternal mortality was seen. There is an alarmingly high incidence of pregnancy-related acute kidney injury and urological complications in adherent placentation, posing a great threat to their worldwide improving statistics. Awareness of this condition among renal fraternity and its multidisciplinary management can significantly improve maternal renal and overall prognosis