Pregnancy-related Acute Kidney Injury: A Narrative Review of Epidemiology, Pathophysiology, and Clinical Management

Abstract

Pregnancy-related acute kidney injury (Pr-AKI) is a severe 
complication of obstetric medicine that remains a significant 
cause of maternal and fetal morbidity and mortality. Although 
the burden has declined in many low- and middle-income 
countries (LMICs) following improvements in prenatal and 
obstetric care, its incidence has risen in high-income nations, 
due to older maternal age, the growing prevalence of diabetes 
and chronic hypertension, as well to more sensitive definition 
criteria and improved diagnostic tools. Physiological changes 
during pregnancy can lower the baseline serum creatinine level 
and may delay diagnosis.
This review summarizes current evidence on the epidemiology, 
pathophysiology, etiologic mechanisms, diagnostic difficulties, 
management, and outcomes of Pr-AKI. Globally, the condition 
demonstrates a paradox, i.e., decreasing incidence but persistent 
mortality in LMICs and increasing incidence in developed 
countries. Hypertensive disorders of pregnancy, particularly 
preeclampsia, eclampsia, and the HELLP (hemolysis, elevated 
liver enzymes, and low platelets) syndrome, have become the 
predominant causes worldwide. Distinct trimester-specific 
patterns, overlap with thrombotic microangiopathies and acute 
fatty liver of pregnancy, and the need to balance maternal and 
fetal health make Pr-AKI uniquely complex.
Improving Pr-AKI outcomes requires early recognition, pregnancy
specific diagnostic biomarkers, and coordinated multidisciplinary 
care. Strengthening antenatal surveillance, expanding access 
to renal replacement therapy in resource-limited settings, and 
providing structured postpartum follow-up are essential to 
reducing the global burden of Pr-AKI.