Overview of Postpartum Acute Renal Failure
Postpartum acute renal failure is a renal disease in pregnancy with oliguria or even anuria and rapid deterioration of renal function as the main manifestations, also known as idiopathic postpartum acute renal failure and postpartum hemolytic uremic syndrome. This disease occurs from the first day to several months after delivery, and is rarely seen in late pregnancy. It is characterized by oliguric or anuric acute renal failure with microangiopathic hemolytic anemia occurring in the postpartum period.
Etiology
The etiology of the disease is unclear. The disease may be associated with significant microangiopathic hemolytic anemia and disorders of the bleeding and coagulation systems, with pathologic changes similar to those seen in hypertensive disorders of pregnancy, primarily vasospasm, endothelial damage, platelet aggregation and depletion, fibrin deposition, and end-organ ischemia. Changes such as hyperplasia and swelling of glomerular capillary endothelial cells, fibrinoid necrosis of capillary collaterals, and microthrombosis, which are the same as those seen in thrombotic microangiopathy, are seen.
Symptoms
Acute postpartum renal failure is characterized by an uneventful pregnancy and delivery, with no risk factors for renal failure, but the onset of influenza-like symptoms from the first day to several months postpartum, with oliguria, anuria, nausea, vomiting, lumbago, and jaundice of varying severity and elevated blood pressure. It may be accompanied by microangiopathic hemolytic anemia or consumptive coagulation abnormalities such as pallor, vomiting, diarrhea, and bloody stools. Some patients have cardiovascular and central nervous system damage such as lethargy, coma, seizures, cardiac enlargement, congestive heart failure, thrombotic thrombocytopenic purpura, etc. Such symptoms do not parallel the degree of renal failure.
Examination
1. Laboratory examination
(1) Routine blood test may show a decrease in hemoglobin and platelet count.
(2) Urine routine examination can see hemoglobinuria, hemoglobinuria can be seen when accompanied by jaundice, a large number of proteins and tubular, red blood cells full of field of vision.
(3) Renal function tests show a sharp increase in blood creatinine and urea nitrogen.
(4) Water, electrolyte and acid-base balance examination can see acidosis, elevated blood potassium, etc..
(5) Coagulation function examination of fibrinogen <1g/L, prolongation of prothrombin and prothrombin time, increased fibrin degradation products.
2. Imaging examination
Ultrasound examination shows that both kidneys are normal size or enlarged, and the stone sign or ureteral compression can be seen in the case of obstruction.
3.Histopathologic examination
Renal puncture biopsy can see glomerular capillary endothelial cell hyperplasia and swelling, capillary collaterals fibrinoid necrosis, microthrombosis and other changes. However, since the patient has a tendency to bleed, this examination should be done with caution.
Diagnosis
The diagnosis is made on the basis of the patient’s history of pregnancy and postpartum, the clinical manifestations of oliguria or even anuria and hemolytic anemia or consumptive coagulation abnormality, combined with laboratory tests such as abnormal renal function and hemoglobinuria seen in the urine routine. The presence of other causes of acute kidney injury such as preeclampsia, severe placental abruption, acute fatty liver of pregnancy, hemolysis combined with high liver enzymes and low platelet syndrome, postpartum hemorrhage, and intrauterine infections should also be identified, and the disease should be diagnosed with suspicion if no etiology is found.
Differential diagnosis
1. Amniotic fluid embolism
Amniotic fluid embolism often occurs after rupture of fetal membranes or excessive contractions, manifested by acute respiratory and circulatory failure, disseminated intravascular coagulation and secondary acute renal failure, and most often occurs within a few days after delivery.
2. Gestational hypertension
Gestational hypertension mainly occurs in pregnancy, with hypertension, proteinuria and edema as the main symptoms, rarely occurs hemolytic anemia, according to the symptoms and laboratory examination without hemolytic anemia can be identified.
3. Placental abruption
Placental abruption is characterized by persistent abdominal pain and vaginal bleeding before or during labor, and the diagnosis can be confirmed after delivery.
Treatment
Postpartum acute renal failure should be diagnosed early and treated as soon as possible. Actively search for the causative factors and treat the primary disease. Strengthen the support and symptomatic treatment, reasonable dilatation, diuresis, protection of renal function, correction of water, electrolyte disorders and acid-base balance imbalance, prevention of infections, to be antispasmodic, sedative, hypotensive. Depending on the condition, large-dose transfusion of fresh frozen plasma, fresh blood products, intravenous injection of immunoglobulin, glucocorticoid shock and other therapies can be taken to alleviate the condition. If the condition is serious, with anuria, oliguria, with sodium retention, electrolyte disorders, hemodialysis, continuous hemofiltration should be carried out in time, and plasmapheresis should be carried out in severe cases. If it occurs in late pregnancy, pregnancy should be terminated in time.
Questions you may be concerned about
Postpartum acute renal failure
Postpartum acute renal failure requires drug treatment, and in severe cases, dialysis is needed.
1. Drug treatment: Postpartum acute renal failure needs to actively search for the primary disease and use drugs according to the primary disease. In addition, drugs such as furosemide are needed to dilate and diuretic, captopril and valsartan are needed to protect renal function and maintain water, electrolyte and acid-base balance.
2. Dialysis treatment: mainly including hemodialysis and peritoneal dialysis, dialysis treatment can remove metabolic wastes and water, maintain electrolyte and acid-base balance.
Patients with postpartum acute renal failure are recommended to go to regular hospitals for timely consultation and standardized treatment under the guidance of doctors.
Prognosis
Postpartum acute renal failure is a critical clinical condition with a poor prognosis, 2/3 of the patients will die or need chronic dialysis, and only a few patients can recover their renal function. Early diagnosis and treatment can improve the prognosis.
Nursing care
Patients with postpartum acute renal failure should be closely monitored for vital signs, renal function, water, electrolyte and acid-base balance should be checked regularly, fluid intake and output should be monitored, urine output should be recorded, and diet should be limited to water, salt, potassium and phosphorus, and sufficient calories should be supplied.