Abstract

Introduction: Obstetric Acute Renal Failure (ARF) is a serious, life-threatening complication for both mother and fetus. It is preventable, as it is often linked to a delay or poor management of a given complication. In Kayes, there are no data on the prevalence of obstetric ARF, hence the interest of this study, which aimed to describe the socio-clinical, paraclinical and evolutionary characteristics of this entity of renal failure at the Fousseyni DAOU Hospital in Kayes.

Materials and methods: This was a descriptive, prospective, cross-sectional study conducted from January 1 to December 31, 2023. All patients hospitalized in the gynecology-obstetrics department, the intensive care unit and the nephrology unit for ARF during or after pregnancy in the postpartum period were included.

Results: From January 1 to December 31, 2023, we recorded 42 cases of obstetric ARF out of 1427 hospitalizations, representing a prevalence of 2.94%. Patients in the 20-35 age bracket accounted for 71.4% (30) of cases, with an average age of 26.61 years, and extremes of 17 and 42 years. Housewives accounted for 90.5% (38 cases), followed by students 4.7% (2 cases). They had no schooling (64.3%), primary education (33.4%) and secondary education (2.4%). Multiparous women were the most represented at 42.8%, with an average parity of 2.4. Multigestation represented 14 cases or 33.3%. Pre-eclampsia was the most common reason for hospitalization, accounting for 30.9%. Patients in their third trimester of pregnancy accounted for 85.7%. Headache, dizziness and fever were the main symptomatological manifestations, at 71.4%, 64.3% and 33.3% respectively. Creatinine levels ranged from 200 to 400 µmol/l in 45.3% of cases, with a mean value of 400.28 µmol/l. Hemoglobin levels were between 7.1 and 10 g/dl in 42.8% of cases, with an average of 8.44g/dl and extremes of 3 and 13.80g/dl. The most frequent etiology was pre-eclampsia, at 57.1%. Acute renal failure occurred in the postpartum period, 2^nd trimester and first trimester in 87.5% (36 cases), 9.5% (4ca) and 4.8% (2 cases) respectively. The patients had given birth vaginally in 78% of cases, and by Caesarean section in 22% (6 cases). The indication for caesarean section was RetroPlacental Haematoma (RPH), eclampsia and uterine rupture in respectively 5 cases (62.5%), 2 cases (25%) and 1 case (12.5%). The evolution was marked by total recovery of renal function in 27 cases (63.4%), death in 8 cases (19%), discharge against medical advice in 5 cases (11.9%). At fetal level, we recorded 18 (42.9%) live births, 15 (35.7%) stillbirths, 6 (14.3%) in utero deaths and 3 (7.1%) spontaneous abortions.

Conclusion: Obstetric acute renal failure is common in our practice. Pre-eclampsia and eclampsia are the most common causes of obstetric ARF due to vasculo-renal complications.

Keywords

Urinary Tract Infection; Urosepsis; Acute Kidney Injury; Pyelonephritis; Antihypertensives; Ppis

Introduction

Acute Renal Failure (ARF) during pregnancy encompasses all causes of acute impairment of renal function, which can occur at any time between the beginning and end of pregnancy. It is a serious complication, potentially life-threatening for both mother and fetus [1,2]. It is preventable, as it is often the result of delayed or poor management of a given complication.

Diagnosis of ARF is based on increased serum creatinine levels, often caused by a variety of factors [3]. The causes of ARF in pregnancy can be classified into three categories: pre-renal, intrarenal and post-renal [4]. However, there is a lack of standardization in the diagnosis of ARF in clinical practice, due to variability in the criteria and methods used [4]. The management of pregnancy-related ARF should be carried out by a multidisciplinary team, including an obstetrician and a neonatologist [5]. Obstetric ARF is relatively rare in developed countries, with an incidence of between 1 and 2.8%. This dramatic reduction in obstetric ARF reflects the virtual disappearance of post-abortal ARF, and more careful monitoring of the perinatal period [6]. In developing countries, however, it remains frequent, with rates ranging from 4.2% to 15% [7]. It is associated with significant maternal-fetal morbidity and mortality, constituting a real public health problem [8].

In the USA, the incidence of pregnancy-associated ARF has increased recently, from 0.04% in 2006 to 0.12% in 2015, with an overall rate of 0.08% [9]. In Niger, the prevalence of obstetric ARF was 14.95% at the Issaka Gazoby maternity hospital in Niamey in November 2016 [10]. In Mali, in the nephrology department of the CHU du point G, this prevalence was 1.85% between January 2017 and December 2018 [11]. It was 6.03% in 2023 in the medicine and haemodialysis department of Sikasso hospital [12].

In Kayes, there are no data on the prevalence of obstetric AKI, hence the interest of this study, which aimed to describe the socio-clinical, paraclinical and evolutionary characteristics of this renal failure entity at the Fousseyni DAOU Hospital in Kayes.

Materials and Methods

This was a cross-sectional, monocentric, descriptive, prospective study from January 1 to December 31, 2023. All patients hospitalized in the gynecology-obstetrics department, the intensive care unit or the nephrology unit for ARF occurring during or after pregnancy in the post-partum period were included.

Patients whose records could not be retrieved, patients hospitalized outside the study period and patients hospitalized for chronic renal failure and pregnancy were not included in the study.

Data were collected on an individualized survey form from obstetric records, delivery registers and medical records.

The variables studied were:

- quantitative: patient’s age; age of pregnancy; Blood Pressure (BP); gestational age; parity; level of education.

- qualitative: marital status; medical and surgical history; obstetrical history; profession; reason for consultation; pathology diagnosed.

Biological tests:

- Complete Blood Count (CBC), reticulocyte count, schizocyte count, creatininemia, uremia, uricemia, LDH, haptoglobin, total and conjugated bilirubin, transaminases.

- Complete blood and urine ionograms.

- 24-hour proteinuria to check for glomerular damage.

- Cytobacteriological study of urine (CBSU) for urinary tract infection, microscopic hematuria, hematuric or leukocytic cylinder or asymptomatic bacteriuria.

- Serology for HIV, AgHbs, HCV, AAN, GE.

Imaging: Abdominal ultrasound was requested to assess the size and morphology of the kidneys and excretory tracts.

Operational definitions

- Acute Renal Failure (ARF)

Oliguria: diuresis less than 500 ml/24H,

- anuria: diuresis less than 100 ml/24H,

- polyuria: diuresis greater than 2ml/kg/H.

- disseminated intravascular coagulopathy (DIC) is defined by the presence of thrombocytopenia of less than 100 - 103/mm³, a drop in fibrinogen of less than 3g/L, fibrin degradation products of more than 40m/dl, and a prolongation of overall times: TQ and TCA of 1.5 to 2 times;

- HELLP syndrome as defined by Weinstein [13,14]: hemolysis: increase in indirect bilirubin with drop in hemoglobin, hepatic cytolysis: glutamic-oxaloacetic transaminase greater than 72 IU/L and thrombocytopenia less than 100 - 103 /mm³.

- Pregnancy-Induced Hypertension (PIH) is defined as Systolic Blood Pressure (SBP) greater than or equal to 140mmHg and/or Diastolic Blood Pressure (DBP) greater than or equal to 90mmHg occurring after the 20^th week of amenorrhea and disappearing before the 6^th week post partum.

- Pre-eclampsia is defined by the association of GVHD and proteinuria in excess of 300mg/24h.

- Severe pre-eclampsia is pre-eclampsia associated with at least one of the following signs:

• Severe hypertension (SBP greater than 160mmHg and/or DBP greater than 110mmHg),

• Renal impairment (oliguria less than 500ml/24h, or creatinine level greater than 135µmol/l or proteinuria greater than 5g/l),

• Acute pulmonary edema,

• Persistent epigastric bar pain,

• HELLP syndrome,

• Neurological disorders (phosphene, headache, polykineticosteotendinous reflexes) or eclampsia,

• Retroplacental hematoma or fetal repercussions (growth retardation).

-Eclampsia: tonic-clonic convulsive seizure occurring in a hypertensive context of pregnancy.

-The indication for hemodialysis was based on : Pulmonary acute edema (POA) refractory to diuretic therapy, hyperkalemia greater than 6.5, anuria greater than 24h, severe metabolic acidosis (< 12mmol/l) with no margin for correction by bicarbonate infusion, uremic syndrome (encephalopathy, pericardial friction, hemorrhagic syndrome, coma).

Patients were monitored on an outpatient basis by nephrologists and gynecologists. Follow-up was weekly, with monitoring of renal function and blood ionograms.

Data entry and Analysis

Data entry was performed using Microsoft Office World 2016 software. Statistical data processing and analysis were performed using SPSS 20.0 software.

Ethical Considerations

The study complied with the ethical standards of our institution’s research committee. Each patient and/or family was informed of the objectives of the study, the use of data for research purposes and the anonymity of the data collected. Informed verbal consent was obtained.

Results

From January 1 to December 31, 2023, we recorded 42 cases of obstetric ARF out of 1,427 hospitalizations, representing a prevalence of 2.94%. Patients in the 20-35 age bracket accounted for 71.4% (30) of cases, with an average age of 26.61 years, and extremes of 17 and 42 years (Tables 1-3). Housewives accounted for 90.5% (38 cases), followed by students 4.7% (2 cases), shopkeepers and accountants with 2.4% each. They were married, single, divorced and widowed in 88%, 4.8%, 4.8% and 2.4% of cases respectively. Patients had no schooling (64.3%), primary education (33.4%) and secondary education (2.4%). Multiparous women were the most represented at 42.8%, with an average parity of 2.4. Multigestations accounted for 14 cases or 33.3%, and patients in their third trimester of pregnancy represented 85.7% (Table 4). Patients came from community health centers in 17 cases (40.5%), reference health centers in 14 cases (33.3%), doctor’s surgeries in 5 cases (11.9%), self-referrals in 4 cases (9.5%) and private clinics in 2 cases (4.8%). Pre-eclampsia was the most common reason for hospitalization, accounting for 30.9% (Table 5). Headache, dizziness and fever were the main symptomatological manifestations, at 71.4%, 64.3% and 33.3% respectively (Table 6).

Stage AK	Creatinine*	Diuresis
1	Increase >26 μmol/L (3 mg/L) in 48 hours or >50 % in 7 days	<0.5 ml/kg/h for 6-12 hrs
2	Creatinine x 2	<0.5 ml/kg/h ≥ 12 hrs
3	Creatinine x 3 Or creatinine >354 μmol/L (40 mg/L) in the absence of prior value or need for dialysis	<0.3 ml/kg/h ≥ 24 hours or anuria ≥ 12 h

Table 1: Universal definition of acute renal failure according to KDIGO (Kidney Disease Improving Global Outcome 2012) [13].

	Woman	Pregnantwoman	Men
Normal	Hb 11-12g/dl	Hb 10-10,9g/dl	Hb 11-13g/dl
Moderate	Hb 8-10,9g/dl	Hb 7-9,9g/dl	Hb 8-10,9g/dl
Severe	Hb<8g/dl	Hb<7g/dl	Hb<8g/dl

Table 2: WHO definition of anemia and its severity.

Age range (year)	Work force	Percentage
20-35	30	71,4
Less than or equal to 19	7	16,7
More than 35	5	11,9
Total	42	100

Table 3: Breakdown by age group.

Gyneco-obstetricalfeatures		Workforce	Percentage
Gestite	Primigeste	12	28,6
	Paucigeste	10	23,8
	Multigeste	14	33,3
	Large multigeste	6	14,3
Parity	Multipare	16	42,8
	Primipare	13	31
	Pauci pare	10	23,8
	Nullipare	1	2,4
Age of pregnancy	Thirdtrimester	36	85,7
	Second trimester	4	9,5
	First trimester	2	4,8

Table 4: Breakdown of patients by obstetrical characteristics.

Motif d’hospitalisation	Workforce	Percentage
Preeclampsia	13	30,9
Eclampsia	11	26,2
RPH	7	16,7
Lowerlimbweakness	3	7,1
Anemiacaused by IPPH	3	7,1
HELLP syndrome	1	2,4
Ruptureduterus	1	2,4
Septicshock	1	2,4
Severe malaria	1	2,4
Endometritis	1	2,4
Total	42	100

Table 5: Breakdown by reason for hospitalization.
*IPPH: immediate postpartum hemorrhage. *RPH: retro-placental hematoma.

Symptom	Workforce	Percentage
Headache	30	71,4
Vertigo	27	64,3
Fever	14	33,3
Epigastralgia	13	30,9
Oliguria	9	21,4
Anuria	7	16,7
Vomiting	6	14,3
Asthenia	6	14,3
Phosphenes	2	4,8
Anorexia	1	2,4
Tinnitus	1	2,4

Table 6: Breakdown of symptoms found.

Arterial hypertension was found in 61.7% of patients. According to the WHO 2003 classification, it was respectively grade 3, 2, 1 and isolated systolic in 13 cases (31.7%); 12 cases (29.3%); 3 cases (7.3%) and 1 case (2.4%). Oliguria and anuria were present in 22 cases (52.4%) and 5 cases (11.9%). The main physical signs were edema of the lower limbs in 24 cases (57.1%), pulmonary crepitus rales in 17 cases (40.5%) and conjunctival pallor in 14 cases (33.3%) (Table7). Creatinine levels ranged from 200 to 400 µmol/l in 45.3% of cases, with a mean value of 400.28 µmol/l (Table 8). Patients with uraemia (n=32) below 18 mmol/l accounted for 68.8% (22 cases), and above 30 mmol/l in 4 patients. Hemoglobin levels ranged from 7.1 to 10 g/dl in 42.8% of patients, with a mean of 8.44 g/dl and extremes of 3 and 13.80 g/dl (Table 9). Anemia was normocytic in two out of three patients, with thrombocytopenia in 69% and hyperleukocytosis in 73.8%.

Physical signs	Workforce	Percentage
Edema of the lower limbs	24	57,1
Crackling rail	17	40,5
Conjunctivalpallor	14	33,3
Convulsion	11	26,2
Abdominal pain on palpation	10	21,8
Decreasedvesicularmurmur	9	21,4
Ascites	9	21,4
jaundice	7	16,7
Pericardial friction	4	9,5
Extracellulardehydrationfolds	1	2,4
Uremicfrostbite	1	2,4
Hepatomegaly	1	2,4

Table 7: Distribution of patients according to signs on physical examination.

Creatininemia (µmol/l)	Workforce	Percentage
201-400	19	45,3
401 and more	14	33,3
121-200	9	21,4
Total	42	100

Table 8: Distribution of patients according to creatinine level at admission.

Hemoglobin level (g/dl)	Workforce	Percentage
7,1 à 10	18	42,8
Lessthan 7	13	31
12,1 à 14	7	16,7
10,1 à 12	4	9,5
Total	42	100

Table 9: Distribution by hemoglobin level.

Transaminases were increased in 18 cases (42.9%) for ASAT and ALAT. Hyponatremia was found in 8 patients (24.2%), with hyperkalemia in 5 cases. Urinary tract infections were found in 23 patients, with Escherichia coli and Staphylococcus in 5 cases each. 24-hour proteinuria (n=30) was massive (>3g), moderate (1-3g) and minimal (<1g) in 19 (63.4%), 9 (30%) and 1 (3.3%) patients respectively. The kidneys were of normal size, echogenic and well differentiated in 87.5%, 70.8% and 75% respectively. Acute renal failure was observed in the postpartum period, 2^nd trimester and first trimester in 87.5% (36 cases), 9.5% (4 cases) and 4.8% (2 cases) respectively.

The most frequent etiology was pre-eclampsia, accounting for 57.1% (Table 10). Its severe form was frequent in the 20-35 age group (Table 11). The patients had given birth vaginally in 78% of cases, and by Caesarean section in 22% (6 cases). The indication for Caesarean section was Retro-Placental Hematoma (RPH), eclampsia and uterine rupture in 5 cases (62.5%), 2 cases (25%) and 1 case (12.5%) respectively. Isogroupisorhesus whole blood transfusion was performed in 28 patients (66.7%). The number of bags transfused was 1-3 bags in 16 patients (38.1%) and more than 3 bags in 12 patients (28.6%). The anti-hypertensives used were calcium antagonists alone in 26 cases (61.9%), or a combination of calcium antagonists and central anti-hypertensives in 10 cases (23.8%). Furosemide was used in 30 patients (71.4%). Antibiotics used were beta-lactams in 28 cases (66.7%) and quinolones in 5 cases (11.9%). Hemodialysis was performed in 5 (12%) patients, indicated by persistent anuria in 3 cases, uremic coma in 1 case and diuretic-refractory PAO in 1 case. The evolution was marked by total recovery of renal function in 27 cases (63.4%), death in 8 cases (19%), discharge against medical advice in 5 cases (11.9%) and chronic renal failure in 2 cases (4.8%). Maternal deaths were related to PAO (3 cases), hyperkalemia (2 cases), uremia (2 cases) due to inaccessibility of replacement therapy, and septic shock (1 case). At fetal level, we recorded 18 (42.9%) live births, 15 (35.7%) stillbirths, 6 (14.3%) in utero deaths and 3 (7.1%) spontaneous abortions.

Etiologicaldiagnosis	Workforce	Percentage
Severepre-eclampsia	24	57,1
retro-placental hematoma	7	16,7
Immediate postpartum hemorrhage	5	11,9
Severedehydration	3	7,1
Septicshock	2	4,8
Severe malaria	1	2,4
Total	42	100

Table 10: Distribution of patients by etiology of obstetric AKI.

Etiology	Age (year)			Total
	Inferior 20	20-35	Superior 35
Severepre-eclampsia	1	11	1	13
Eclampsia	3	6	2	11
retro-placental hematoma	1	5	1	7
Immediate postpartum hemorrhage	1	2	1	4
Vomiting	1	2	0	3
Septicshock	0	2	0	2
Uterine rupture	0	1	0	1
Malaria	0	1	0	1
Total	7	30	5	42

Table 11: Relationship between age group and etiology.

Discussion

During the study period, we recorded 1,427 hospitalizations, including 42 cases of acute renal failure, representing a prevalence of 2.94%. This result is higher than that reported by Fofana AS et al [15] in 2019 in the nephrology department of the Point G Hospital, i.e. 2.08%, and lower than those obtained in Niger at the Gazoby ISSAKA maternity hospital [10] in 2016 and at the Sikasso hospital by KOITA M [12] in 2023, in the order of 14.95% and 6.03%. This difference could be explained by the selection criteria, but also by the recruiting department. In Morocco, it was 2.49% at the hospital IBN Roch in Casablanca [16]. This complication is currently extremely rare in developed countries, whereas it accounted for a quarter of all acute renal failures in the 1940s-1950s [1], illustrating the efforts made and the results achieved in preventing this type of renal failure.

The 20-35 age group was the most affected, accounting for 71.4%. The average age was 26.6 years, with extremes of 17 and 42 years. In Mali, Tounkara AA, et al. [17] in 2016 and FOFANA AS et al. [15] in 2019 reported a mean age of 25.9 and 27.31 ± 5.49 years respectively. The mean age in Niger [10] and Morocco [16] was 25.21 ± 5.14 and 28 ± 7years respectively, comparable to our results. On the other hand, Lemrabott, et al. in Mauritania and Mahfoudh et al. in Tunisia found a mean age of 32 and 37.8 years respectively [18,19]. This could be explained by the fact that this age bracket corresponds to the period of high genital activity and fertility in women.

Patients with no schooling accounted for 64.3%, and 79% of them lived in rural areas. The study carried out at the Issaka GAZOBY maternity hospital in Niger [10] reported 62.5% of uneducated patients, and 45% came from rural areas. This predominance of non-education was reported by KOITA M [12] in 2023, i.e. 82.1%, and 64.3% of them lived in rural areas around the town of Sikasso. This could be explained by the low literacy rate of these women, who are unaware of the danger signs of pregnancy, and their late recourse to health care, favored by the absence of prenatal follow-up and home delivery assisted by traditional matrons in precarious medical conditions.

73.8% of patients were referred by community health centers and Referral Health Centers in the Kayes region. The gynecology-obstetrics department was the only referral department in the region with the presence of resuscitators and nephrologists. In the nephrology department of the Point G Hospital, 71% of patients came from the gynecology department of the same structure [15].

Clinical symptoms were dominated by headache, dizziness, hyperthermia and epigastralgia, in 71.4%, 64.3%, 33.3% and 30.9% of cases respectively. KOITA M [12] found nausea, vomiting and hyperthermia in 39.3%, 39.3% and 28.6% of cases respectively. In the series by Fatimetou Abdelkader, et al. [20], the main functional signs were dyspnea, headache and vomiting, with proportions of 34.31%, 29.41% and 11.76% respectively.

Multiparous women were the most represented, at 42.8%, with an average parity of 2.4. Primigravida represented 25% of patients, with an average gestation of 4.03 and extremes of 1 and 12 gestation [17]. In the ZMM Tondi study in Niger, primiparous women accounted for 53.1% [10]. Similar results have been reported in the literature [21,22]. Physical examination revealed edema of the lower limbs (57.1%), pulmonary crepitus rales (40.5%) and conjunctival pallor (33.3%). KOITA M [12] found conjunctival pallor 89.3%, IMO 60.7% and pericardial friction 21.4%. In Niger [10], 37.5% oedematous syndrome was observed. At the Nouakchott national hospital, FatimetouAbdelkader et al. [20] found edema of the lower limbs in 68.62% of patients, followed by hypertension (66.66%), paleness of the mucous membranes (63.72%) and tachycardia (38.23%).

Oliguria was observed in 52.4% of patients, anuria in 11.9%. Diuresis was preserved in 35.7%. This result is comparable with that of ZMM Tondi’s series [10], in which oliguria was observed in 40.5% and anuria in 3.12% of patients.

Hypertension was present in 70.7% of our patients. This result is similar to those reported by Konaté S [11] and Tounkara AA [17], with frequencies of 70% and 92.7% respectively.

The physiological increase in Glomerular Filtration Rate (GFR) in pregnant women lowers creatinine levels by 0.4-0.5mg/dl, which may mask early impairment of renal function. The 2008 expert recommendations define a pathological threshold in pregnant women for a plasma creatinine value in excess of 10mg/l [23]. The mean plasma creatinine was 400.9 µmol/l, with extremes of 125 and 1042 µmol/l, and ranged from 201 - 400µmol/l in 45.3% of patients. These results are lower than those reported by KOITA M [12], who reported creatinine levels of 800 µmol/l in 60.7% of cases, with a mean value of 941.93 µmol/l, and by other authors [22,24-26]. This difference may be due to the rapid referral of patients, 73.8% of whom came from health centers in the town or district of Kayes, and to the rapid call-up of the nephrology team by the department’s gynaeco-obstetricians.

Blood urea levels above certain thresholds constitute a severity criterion for ARF, and a level of over 3g/l is often correlated with uremic encephalopathy, constituting an indication for Emergency Extra-Renal Cleansing (EER) [27]. In our series, urea levels were below 1.08g/l (18 mmol/l) in 68.8% of cases. This relatively low urea level, compared with other authors [22,28], may be explained by the low plasma creatinine levels and the use of ERT in our series.

Hyperkalemia was present in 15.2% of patients. Other authors [6,11] had obtained respectively 13% and 16.7% hyperkalemia in their series. This can be explained by the reduced capacity of the kidneys to filter and excrete potassium via the urine during ARF, as well as the rhabdomyolys is caused by iterative convulsions during attacks of preeclampsia and eclampsia.

Anemia was present in 2/3 of patients (73.9%), with a mean hemoglobin level of 8.44g/dl. In the study by KOITA M [12], anemia was observed in 92.9% with a mean hemoglobin level of 6.9g/dl. This may be due to the difference between our etiologies. Other authors [10,11,17,19] have reported lower mean levels than our series, respectively 7.12g/dl; 7.3g/dl; 6.43 g/dl and 6.18+/- 2.21g/dl. This anemia is due to several etiologies, essentially hemorrhagic childbirth and mechanical hemolysis in the context of HELLP syndrome or thrombotic micro angiopathy, which often aggravate the deficiency anemia common in our region [28].

On CBSU, Escherichia coli was isolated from 5 patients (21.7%), as were Staphylococci (21.7%). This high frequency of Escherichia coli in pregnancy has been reported by other authors [29-31]. It is thought to be related to urinary stasis, which results from hormonemediated ureteral dilatation and hypoperistalsis, and the pressure of the expanding uterus against the ureters.

The postpartum period was the most frequent period of onset of ARF, accounting for 85.7% of cases. The same trend was observed in the study by KOITA M [12], with a lower frequency than ours, i.e. 67.9% of cases. This could be explained by the fact that, in our study, assessment was most often carried out in the post-partum period, and that cases of acute renal failure in the first trimester either resolved spontaneously or were managed in secondary health centers.

Severe pre-eclampsia was the most frequent etiology, accounting for 57.1% of cases. This result is in line with the literature, which identifies pre-eclampsia as the main etiology of obstetric ARF. In the series by ZMM Tondi et al. [10], eclampsia and pre-eclampsia accounted for 68.75% of the etiologies of obstetric ARF. Some authors [11,17] found pre-eclampsia in 28.57% and 43%. In the USA, it affects 7.5% of women during pregnancy, with an incidence of 15% of acute renal failure [32].

The place of delivery was hospital in 64.2%, community health centers in 16.7% and home in 11.9%. This result differs from that of KOITA M [12] in 2023, where the place of delivery was the referral health center (59.3%), the hospital (29.6%). Kerma et al. [20] found that 87.5% of deliveries took place in a medical facility. This difference can be explained by the fact that our patients were referred directly to the hospital.

Two out of three patients (78%) had undergone vaginal delivery. In the series [11,12,33], vaginal delivery was found in 53.3%, 55.6% and 46.9% respectively.

Caesarean section was performed in 22%, compared with 36.7% and 50.1% reported by Konaté S [11] in 2020 and Ibrahim F [33] in 2023. In our study, the main indication for Caesarean section was HRP (62.5%), followed by eclampsia (25%). In Niger [10], the main indication for Caesarean section was eclampsia (58%) and in Sikasso KOITA M [12] in 2023 found eclampsia to be 58.4%. These results can be explained by the fact that HRP and eclampsia are the major complications of severe pre-eclampsia that can endanger the fetomaternal prognosis.

Stillbirths and in utero deaths accounted for 35.7% and 14.3% respectively. In Niger, ten fetal deaths in utero out of 32 deliveries [10].

Hemodialysis, which remains the most widely used method of replacement therapy for ARF [34,35], was used in 5 (12%) patients, with 3 to 4 weekly sessions on a double-lumen femoral or jugular catheter. Indications for dialysis were, in order of frequency: anuria (60%), uremic coma (20%) and refractory PAO (20%). Dialysis was performed in 39 patients (38.2%) in the series by Fatimetou Abdelkader, et al in Nouakchott [20].

Blood transfusion was performed in 66.7% of cases. This was the case in 71.56% of patients in the series by Fatimetou M, et al. [20]. This reflects the frequency of severe, poorly tolerated anemias often requiring blood transfusions.

Furosemide and calcium channel blockers were the most widely used antihypertensive agents, 71.43% and 61.90% respectively. The same finding was observed in studies by Arora, et al. [36] and Aggarwal, et al. [6]. Although furosemide is widely used to boost diuresis and overcome the oliguric stage of ARF, it does nothing to speed up recovery of renal function or reduce maternal mortality and the need for hemodialysis [35]. Its use may even be dangerous, as it induces forced diuresis, which may lead to renal hypoperfusion as a result of hypovolemia [37]. Hemodialysis, however, remains the most widely used method of replacement therapy for AKI [35].

Recovery of renal function was observed in 27 patients (64.3%). Two (2) cases (4.8%) had progressed to chronicity. The maternal mortality rate was 19.05%. It was 9.8% and 13.8% in the series by Fatimetou M, et al [20] and M. Miguil, et al [16] and 9.8% in the series by M. Miguil, et al. [16]. The factors involved in this mortality are:

- Etiology of AKI: eclampsia is associated with a poor prognosis [38];

- The type of renal lesions: cortical necrosis has a poor prognosis: mortality is 93.3% versus 16.6% for acute tubular necrosis in an Indian series. The background to AKI in India is certainly a factor (vasculitis, Takayasu’s disease, etc.) [39,40].

PAO, hyperkalaemia and uraemic coma were the most frequent causes of death: 37.5%, 25% and 25% respectively. These deaths occurred in a context of inaccessibility to dialysis due to shortages of dialysis inputs or breakdowns in water treatment at the only public dialysis center in the region, located 615 km from the country’s capital. The most common complications and causes of death were PAO and haemorrhagic syndrome [10,23].

The average hospital stay was 12.6 days, with extremes of 2 and 87 days. Long hospital stays were associated with extra-renal complications, decubitus-related pressure sores and stroke. Some authors have reported a mean hospital stay of 19.17 days and 11.4 ± 6.2 days [16,23] higher than ours.

Study Limitation

Incomplete or incomplete renal workup due to the low socioeconomic status of our patients and the high cost of examinations. Difficult, if not impossible, access to renal biopsy did not allow us to explore glomerular lesions found in moderate to abundant proteinurics.

Conclusion

Obstetric acute renal failure is still common in developing countries. Pre-eclampsia and eclampsia are the most common causes of obstetric ARF due to vasculo-renal complications. It remains a major challenge requiring a multidisciplinary approach. Access to replacement therapies, such as hemodialysis, plays a key role in reducing the significant morbidity and mortality associated with this condition.

Conflict of Interest

None.

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Article Information

Article Type: RESEARCH ARTICLE

Citation: Magara Samaké M, Fofana AS, Sy S, Yattara H, Traoré R, et al. (2025) Obstetric Acute Renal Insufficiency at the Fousseyni Daou Hospital in Kayes, Mali. Int J Nephrol Kidney Fail 11(2): dx.doi.org/10.16966/2380-5498.253

Copyright: © 2025 Magara S, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Publication history: 

Received date: 20 Mar, 2025

Accepted date: 12 Apr, 2025

Published date: 22 May, 2025