Access to Nephrology Care for Pregnancy-Related Acute Kidney Injury in Low- and Lower-Middle-Income Countries: A Perspective

Abstract

Pregnancy related acute kidney injury (AKI) is a major public health problem with substantial maternal and fetal morbidity and mortality. Women with pregnancy-related AKI require immediate access to nephrology care to prevent deleterious kidney and health outcomes. Patients with pregnancy-related AKI in low- and lower-middle-income countries experience disparities in access to comprehensive nephrology care for many reasons. In this perspective, we highlight the burden of pregnancy-related AKI and explore the challenges among different low- and lower-middle-income countries. The lack of adequate nephrology workforce and infrastructure for kidney healthcare represents a fundamental component of the problem. Shortage of nephrologists hampers the care of patients with pregnancy-related AKI leading to poor outcomes. The lack of diagnostic tools and therapeutic options including kidney replacement therapy impedes the implementation of effective management strategies. International efforts are warranted to empower women to get the right services and support at the right time. Dedicated preventive and early care programs are urgently needed to decrease the magnitude of pregnancy-related AKI, a complication under-represented in the literature. Pregnancy related acute kidney injury (AKI) is a major public health problem with substantial maternal and fetal morbidity and mortality. Women with pregnancy-related AKI require immediate access to nephrology care to prevent deleterious kidney and health outcomes. Patients with pregnancy-related AKI in low- and lower-middle-income countries experience disparities in access to comprehensive nephrology care for many reasons. In this perspective, we highlight the burden of pregnancy-related AKI and explore the challenges among different low- and lower-middle-income countries. The lack of adequate nephrology workforce and infrastructure for kidney healthcare represents a fundamental component of the problem. Shortage of nephrologists hampers the care of patients with pregnancy-related AKI leading to poor outcomes. The lack of diagnostic tools and therapeutic options including kidney replacement therapy impedes the implementation of effective management strategies. International efforts are warranted to empower women to get the right services and support at the right time. Dedicated preventive and early care programs are urgently needed to decrease the magnitude of pregnancy-related AKI, a complication under-represented in the literature. Inviting the world to dream, the United Nations (UN) in 2012 launched the unprecedented sustainable development goals for global consultation under the banner “the world we want”. The ambitious sustainable development goals emphasized health as a core goal for international efforts aiming at sustaining healthier human lives. The world has realized that health challenges can no longer be addressed by the health sector acting alone and special emphasis should be given to reducing global inequalities1Marmot M. Bell R. The Sustainable Development Goals and Health Equity.Epidemiology. 2018; 29Crossref PubMed Scopus (59) Google Scholar. Health equity is a societal goal justifiable on moral grounds. An access to comprehensive health care service is a global human right, however, most people living in low-income and lower-middle income countries are deprived of this right2Tannor E.K. Nlandu Y.M. Elrggal M.E. Kidney Health for All–Bridging the gap to better kidney care in Africa.African Journal of. 2022; Google Scholar,3Elrggal M.E. et al.Disparities in Access to Kidney Transplantation in Developing Countries.Transplantation. 2021; 105: 2325-2329Crossref PubMed Scopus (0) Google Scholar. Women in these countries are particularly vulnerable due to a number of factors, including pregnancy and childbirth related issues, often not controlling economic resources, and being culturally disadvantaged4Murembe N. et al.Context matters in understanding the vulnerability of women: perspectives from southwestern Uganda.Arch. Public Health. 2021; 79: 4Crossref PubMed Scopus (0) Google Scholar. The lack of adequate perinatal care and inappropriate management of obstetric complications might contribute to devastating morbidities such as pregnancy-related AKI5Shalaby A.S. Shemies R.S. Pregnancy-related acute kidney injury in the African continent: where do we stand? A systematic review.Journal of Nephrology. 2022; : 1-15Google Scholar. Pregnancy-related AKI is a major public health problem with substantial maternal and fetal morbidity and mortality, characterized by an abrupt decline of kidney function during pregnancy and puerperium 6Gaber T.Z. et al.Acute kidney injury during pregnancy and puerperium: an Egyptian hospital-based study.Journal of Nephrology. 2021; 34: 1611-1619Crossref PubMed Scopus (6) Google Scholar, 7Bentata Y. Housni B. Mimouni A. Azzouzi A. Abouqal R. Acute kidney injury related to pregnancy in developing countries: etiology and risk factors in an intensive care unit.Journal of nephrology. 2012; 25: 764-775Crossref PubMed Scopus (0) Google Scholar, 8Hildebrand A.M. et al.Characteristics and outcomes of AKI treated with dialysis during pregnancy and the postpartum period.Journal of the American Society of Nephrology. 2015; 26: 3085-3091Crossref PubMed Google Scholar, 9Ferreira D.P. et al.Pregnancy-related acute kidney injury: mortality and survival of patients treated at a maternal intensive care unit.Journal of Nephrology. 2020; 33: 1361-1367Crossref PubMed Scopus (7) Google Scholar. Women with or at risk of pregnancy-related AKI should receive optimum care to prevent maternal and fetal morbidity and mortality5Shalaby A.S. Shemies R.S. Pregnancy-related acute kidney injury in the African continent: where do we stand? A systematic review.Journal of Nephrology. 2022; : 1-15Google Scholar. Potential disparities between high-income countries and low- and lower-middle-income countries are due to the unavailability of healthcare resources including medications, medical equipment, trained professionals, dialysis infrastructure, and transportation facilities. These translate into delayed diagnosis which subsequently hinders the appropriate and timely management of pregnancy-related AKI 10Cerdá J. Bagga A. Kher V. Chakravarthi R.M. The contrasting characteristics of acute kidney injury in developed and developing countries.Nat. Clin. Pract. Nephrol. 2008; 4: 138-153Crossref PubMed Scopus (165) Google Scholar,11Ponce D. Balbi A. Acute kidney injury: risk factors and management challenges in developing countries.Int. J. Nephrol. Renovasc. Dis. 2016; 9: 193-200Crossref PubMed Scopus (40) Google Scholar. Complications related to pregnancy and childbirth are estimated to cause the death of about half a million women each year, of which 99 percent occur in low- and middle-income countries12Duley L. The global impact of pre-eclampsia and eclampsia.Semin. Perinatol. 2009; 33: 130-137Crossref PubMed Scopus (1806) Google Scholar. Significant efforts are urgently needed to decrease the magnitude of this problem. In this Perspective, we describe the disparities in access to health care for women with pregnancy-related AKI among different low- and lower-middle-income countries in the world (Figure 1). We asked representative nephrologists from a selection of low- and lower-middle-income countries to provide evidence-based answers, if available, to four questions regarding their countries; 1- the prevalence of pregnancy-related AKI; 2- the etiology, risk factors and outcomes for pregnancy-related AKI ; 3- the availability of trained nephology workforce; and 4- the availability of diagnostic and therapeutic tools to detect and treat pregnancy-related AKI. Our review includes ten countries; eight African and two South-Eastern countries, classified based on their gross national income (GNI) per capita as presented by the World Bank’s classification: 3 low-income countries (Zambia, Democratic Republic of Congo (DRC), and Somalia), and 7 lower-middle-income countries (Egypt, Ghana, Cameroon, Zimbabwe, Nigeria, India, and Pakistan) (Table 1). Our aim is to achieve a better understanding of pregnancy-related AKI and its outcomes in low- and lower-middle-income countries, which is a complication under-represented in the literature.Table 1Comparison between participating countries in availability of PRAKI cases registry, nephrology workforce, availability of routine diagnostic tests, kidney biopsy and kidney replacement therapy modalitiesCameroonDRCEgyptGhanaIndiaNigeriaPakistanSomaliaZambiaZimbabweRegistryn/areportsreportsn/aavailablereportsn/an/an/an/aWorkforce pmp*1.10.321.60.471.860.752.20.320.520.33Routine diagnostic toolsAvailablenot routinely availableavailableavailable in major citiesavailableavailableavailableavailable in tertiary hospitalsavailable at tertiary, secondary and first levelavailable at tertiary centersBiopsyLM only, but rareLM onlyavailableavailableavailable in all urban areas, restricted in rural areasIn areas with available nephrologistsavailableNot availableNot availableavailable in privateKRTHD available, in 8/10 regions (9 public, 4 private)HD, PD available but costly and unevenly distributedHD onlyHD in 9/16 regions (strictly out of pocket). PD available but infrequentHD is the primary modality available in all urban and few rural areas; PD acceptance is scarce due to financial constraintsHD available in urban only and costly; Acute PD is available in some tertiary centers but rarely used for PR-AKIHD available majorly in urban areas; PD available but infrequentHD onlyHD available in 7/10 regions; PD available in 2 regionsHD onlyKRT: Kidney replacement therapy, HD: hemodialysis, PD: peritoneal dialysis, LM: light microscopy, PR-AKI, pregnancy-related acute kidney injury* Nephrology workforce, n/a: not available Open table in a new tab KRT: Kidney replacement therapy, HD: hemodialysis, PD: peritoneal dialysis, LM: light microscopy, PR-AKI, pregnancy-related acute kidney injury* Nephrology workforce, n/a: not available Identifying the burden of pregnancy-related AKI in each country is the initial step in problem solving, followed by exploring risk factors in each region and the disparities in access to care. Provision of solutions as per the need of each country will eventually lead to improved outcomes. Unfortunately, the data about incidence and prevalence of pregnancy-related AKI in low- and lower-middle-income countries are scarce5Shalaby A.S. Shemies R.S. Pregnancy-related acute kidney injury in the African continent: where do we stand? A systematic review.Journal of Nephrology. 2022; : 1-15Google Scholar. Most low- and lower-middle-income countries lack studies reporting the national incidence of pregnancy-related AKI. Among the countries contributing to this report, only India has a national reported incidence of pregnancy-related AKI and its related outcomes. India reported a decline in pregnancy-related AKI requiring dialysis from 15% in the period (1982-1991) to 10% (1992-2002), and a concurrent decrease in maternal mortality from 20% to 6.4%13Prakash, J. et al. Acute Renal Failure in Pregnancy in a Developing Country: Twenty Years of Experience. Renal Failure vol. 28 309–313 Preprint at https://doi.org/10.1080/08860220600583658 (2006).Google Scholar. After 2010, the reported incidence of pregnancy-related AKI in India ranges from 4% to 10%14Gopalakrishnan, N. et al. Acute kidney injury in pregnancy—a single center experience. Renal Failure vol. 37 1476–1480 Preprint at https://doi.org/10.3109/0886022x.2015.1074493 (2015).Google Scholar, 15Bharani, R., Kumar, R. & Pahwa, N. Post-partum acute kidney injury. Saudi Journal of Kidney Diseases and Transplantation vol. 25 1244 Preprint at https://doi.org/10.4103/1319-2442.144259 (2014).Google Scholar, 16Kute, V. et al. Clinical profile and outcome of acute kidney injury related to pregnancy in developing countries: A single-center study from India. Saudi Journal of Kidney Diseases and Transplantation vol. 25 906 Preprint at https://doi.org/10.4103/1319-2442.135215 (2014).Google Scholar. One of the largest centers from Pakistan reported that 25.6% (n=1441) of patients who presented with AKI were experiencing pregnancy-related AKI in the period from 1990 to 201417Naqvi, R., Ahmed, E., Sheikh, R. & Rizvi, A. Obstetrical acute kidney injury: 25 years’ experience from nephrology care unit in Pakistan. OAlib 02, 1–7 (2015).Google Scholar. Other countries like Egypt6Gaber T.Z. et al.Acute kidney injury during pregnancy and puerperium: an Egyptian hospital-based study.Journal of Nephrology. 2021; 34: 1611-1619Crossref PubMed Scopus (6) Google Scholar,18Emara, A., Bichari, W., El-Salam, M. A. & El-Said, A. E.-H. Acute kidney injury secondary to obstetric complications in the third trimester of pregnancy and the puerperium. Journal of The Egyptian Society of Nephrology and Transplantation vol. 22 44 Preprint at https://doi.org/10.4103/jesnt.jesnt_27_21 (2022).Google Scholar,19Elshinnawy, H. A., H. A. M. & A. Y. of Pregnancy related AKI in Egyptian factors and An International Journal of vol. Preprint at Scholar, Pregnancy-related acute kidney injury requiring dialysis as an of maternal morbidity at a tertiary center in J. 2018; PubMed Scopus (0) Google Scholar, et al.Pregnancy-related acute kidney injury: and outcomes in a tertiary in J. Kidney Dis. PubMed Scopus (6) Google Scholar, A.M. et among pregnancy related acute kidney injury A single center experience in J. Nephrol. 2016; 26: PubMed Scopus (6) Google and A. et al. Acute kidney injury is a of mortality in a study from the Democratic Republic of Nephrology vol. Preprint at a few single center on the incidence and outcomes of pregnancy-related AKI; however, these do not provide the national burden of pregnancy-related AKI in each The early of risk factors of pregnancy-related AKI is a step outcomes and from that lack of adequate care to the development of pregnancy-related AKI. obstetric and were the of pregnancy-related AKI in maternal and fetal mortality were T.Z. et al.Acute kidney injury during pregnancy and puerperium: an Egyptian hospital-based study.Journal of Nephrology. 2021; 34: 1611-1619Crossref PubMed Scopus (6) Google Scholar,18Emara, A., Bichari, W., El-Salam, M. A. & El-Said, A. E.-H. Acute kidney injury secondary to obstetric complications in the third trimester of pregnancy and the puerperium. Journal of The Egyptian Society of Nephrology and Transplantation vol. 22 44 Preprint at https://doi.org/10.4103/jesnt.jesnt_27_21 (2022).Google Scholar,19Elshinnawy, H. A., H. A. M. & A. Y. of Pregnancy related AKI in Egyptian factors and An International Journal of vol. Preprint at Scholar. In study that the risk factors for pregnancy-related AKI perinatal fetal and Other to and with R., Ahmed, E., Sheikh, R. & Rizvi, A. Obstetrical acute kidney injury: 25 years’ experience from nephrology care unit in Pakistan. OAlib 02, 1–7 (2015).Google Scholar. The risk factors, and were with pregnancy-related AKI in a study in et and the Development of Acute Kidney in J. Health. 2022; PubMed Scopus Google Scholar. In India, for about of pregnancy-related AKI in a study from in M. et al. Pregnancy related acute kidney injury: A single center experience from the Journal of Nephrology vol. Preprint at Scholar. In has an prevalence of pre-eclampsia in women of which might contribute to the incidence of pregnancy-related AKI J. of Among Women of in J. Scholar. An from that postpartum and the major of pregnancy-related AKI, leading to dialysis in about of R. & M. Pregnancy related acute in Scholar. A systematic review including African studies the of pregnancy-related AKI in countries which are obstetric and substantial if their and A.S. Shemies R.S. Pregnancy-related acute kidney injury in the African continent: where do we stand? A systematic review.Journal of Nephrology. 2022; : 1-15Google Scholar. The availability of nephrology workforce is the initial step in comprehensive nephrology care for patients with kidney including pregnancy-related AKI. are disparities in the of the nephrology workforce in low- and lower-middle-income countries, on the nephrology healthcare a single between and do M.E. The global nephrology and Kidney 2016; 9: PubMed Google Scholar. has the number of nephrologists per million in the E.K. Nlandu Y.M. Elrggal M.E. Kidney Health for All–Bridging the gap to better kidney care in Africa.African Journal of. 2022; Google Scholar, with no or a of in most of the low- and lower-middle-income countries of the including Ghana, and as as which represents of the countries in M.E. The global nephrology and Kidney 2016; 9: PubMed Google Scholar. The of nephrology workforce is the in with nephrologists M.E. The global nephrology and Kidney 2016; 9: PubMed Google et nephrology and a sustainable kidney care International 2018; PubMed Scopus (0) Google Scholar. for Pakistan has nephrologists a of India has of the with only about nephrologists per million J. & V. India. vol. Preprint at Scholar. is to that this of nephrologists hampers the care of patients with pregnancy-related AKI leading to poor outcomes. of patients with pregnancy-related AKI in areas where nephrologists are or require optimum to and prevent pregnancy-related AKI healthcare of the of AKI et al. reported a gap between and among healthcare AKI, in their in the of and factors with acute kidney injury in African A review of the J. Nephrol. 2022; Scopus Google Scholar. about of healthcare with an experience of 7 a understanding of the and of AKI, were of at risk for AKI. is in developing countries. of to and detect kidney complications early can lead to timely of women developing kidney complications has as a contributing to poor outcomes of pregnancy-related AKI A. et al. The of pregnancy-related acute kidney injury from of A Saudi Journal of Kidney Diseases and Transplantation vol. Preprint at Scholar. to be given to and early care of pregnancy-related et and kidney on world kidney 2018; PubMed Scopus Google Scholar, care and with of a and of kidney in the routine for patients has by the nephrology et to routine pregnancy a for the of patients with in PubMed Scopus Google Scholar. is in women who experience pregnancy programs should women with of pregnancy-related AKI and of pregnancy for early diagnosis of programs aiming at the and of maternal health care should be to early and of women at risk to nephrology particularly in burden countries; however, the lack of resources impedes the implementation of preventive and diagnosis of women with for pregnancy-related AKI and in of should occur contribute to and delayed is efforts should be to the of healthcare regarding the optimum women at risk of pregnancy-related AKI should be to a this the Egyptian of nephrology and is an national at and for early of women at risk for pregnancy-related AKI to nephrology The includes a of and which aim to health care and appropriate care for women at risk for pregnancy-related AKI during pregnancy women with that represents a to the and women with kidney during pregnancy or should be early to a or an obstetric nephrology service Women with are particularly vulnerable to pregnancy-related AKI, and women with kidney should an pregnancy and puerperium. women with or of of that the kidney as kidney and who are kidney should from care for the and to these The of tools to and treat women with pregnancy-related AKI is for outcomes. These diagnostic and dialysis Unfortunately, the availability of diagnostic and like kidney is in most low- and lower-middle-income countries. a global do not routinely for and during care A study in that only of patients with pre-eclampsia J. of at a in A J. 2021; Google Scholar. The are only routinely available at tertiary care in and and about two of secondary in E.K. M. V. of kidney in of secondary in the of Journal of 2021; 4Crossref Google Scholar. diagnostic and kidney are available is a in from rural and and India to tests, and kidney biopsy facilities. the number of to kidney is in kidney to a decline in the incidence of from in 1990 to in India the J. et incidence of in patients with acute in developing countries: a experience of 22 from PubMed Scopus Google Scholar. Women with pregnancy-related AKI require kidney replacement therapy The availability of represents a problem for patients living in developing countries. per has in out of ten regions to tertiary In Zimbabwe, peritoneal dialysis is not available to AKI, and is the primary modality of in and public The dialysis prevalence in is patients per million R. L. N. in A J. Kidney Dis. 2022; PubMed Scopus (0) Google Scholar. the to dialysis is in has that of patients with AKI requiring dialysis in are not due to lack of & The of acute kidney injury in a tertiary in A J. Nephrol. Scholar. has and center for acute PD which to the and PD to with AKI. In Nigeria, PD is only available rarely for women with pregnancy-related AKI requiring centers are in urban only, and many patients the of is a substantial need for dialysis the which the management of patients with pregnancy-related AKI requiring et on available for acute kidney injury in the African Development and are we for by in Scopus Google Scholar. In only centers are in the and is a and the two are PD is not available in The and of dialysis services Democratic Republic of the Congo has the of dialysis et of in the Democratic Republic of the A study in two 2020; PubMed Scopus Google Scholar. et reported that only of patients with AKI requiring access to A. et al. Acute kidney injury is a of mortality in a study from the Democratic Republic of Nephrology vol. Preprint at Scholar. In Ghana, is the modality of for AKI. PD is used by A study by et al. that out of the regions in access and patients with pregnancy-related AKI who require dialysis, patients living in regions need to the which lead to and poor outcomes. to is the of dialysis The of in is between per which for the the national health is to for the of dialysis for AKI, this is not and to of replacement therapy services in 2015; PubMed Scopus (0) Google Scholar. In most patients are treated in tertiary all the studies were at where diagnostic and therapeutic such as kidney and are T.Z. et al.Acute kidney injury during pregnancy and puerperium: an Egyptian hospital-based study.Journal of Nephrology. 2021; 34: 1611-1619Crossref PubMed Scopus (6) Google Scholar,18Emara, A., Bichari, W., El-Salam, M. A. & El-Said, A. E.-H. Acute kidney injury secondary to obstetric complications in the third trimester of pregnancy and the puerperium. Journal of The Egyptian Society of Nephrology and Transplantation vol. 22 44 Preprint at https://doi.org/10.4103/jesnt.jesnt_27_21 (2022).Google Scholar,19Elshinnawy, H. A., H. A. M. & A. Y. of Pregnancy related AKI in Egyptian factors and An International Journal of vol. Preprint at Scholar. is the primary modality in the of PD is due to the of the the need for trained healthcare and the lack of a national to M. et al. in Journal of the International Society for vol. Preprint at Scholar. is no adequate data regarding the of dialysis has estimated that the number of dialysis in dialysis in Y. M. & Preprint at (2022).Google Scholar. these centers are to provide dialysis services only for patients requiring for the health Egyptian for each Y. M. & Preprint at (2022).Google Scholar, the is not that for patients with requiring AKI, and each center its which or not be by the or In India, the most dialysis modality available is PD is restricted to the sector patients on PD in V. et al. The of nephrology in Kidney International vol. Preprint at Scholar. A in estimated the number of centers in India to be among all 28 and eight V. et al. The of nephrology in Kidney International vol. Preprint at Scholar. is in access to with most centers in urban areas and few in rural India. to in the about of patients to to access in A. J. et al. Renal and their risk factors in India representative from the The Health vol. Preprint at Scholar. to the financial burden related to the of hinders access to care for women who are M. et and outcomes for patients in 2018; PubMed Scopus Google Scholar. A has reported in where is the most available modality of all in urban Unfortunately, living in rural areas are to receive these are public and centers in urban areas of Nephrology services in PubMed Scopus Google Scholar. The of to the financial burden of the which hampers access to care. In a single of to in an of per the reported income in Pakistan is A. the most dialysis modality for 2021; Google Scholar. these in is for and health in developing countries to the incidence of pregnancy-related AKI, obstetric care by early of women with or at risk of pregnancy-related AKI, provide diagnostic and therapeutic tools for adequate management of these and of health care services with trained nephrologists (Figure In India, for the initial decline in the incidence of pregnancy-related AKI to which to a in the incidence of J. et al. Acute Renal Failure in Pregnancy in a Developing Country: Twenty Years of Experience. Renal Failure vol. 28 309–313 Preprint at https://doi.org/10.1080/08860220600583658 (2006).Google Scholar. of obstetric including better management of and early and management of to the decline in incidence of pregnancy-related AKI. lack of lack of has reported in to to of patients with pregnancy-related AKI in V. et al. Clinical profile and outcome of acute kidney injury related to pregnancy in developing countries: A single-center study from India. Saudi Journal of Kidney Diseases and Transplantation vol. 25 906 Preprint at https://doi.org/10.4103/1319-2442.135215 (2014).Google A. et al. The of pregnancy-related acute kidney injury from of A Saudi Journal of Kidney Diseases and Transplantation vol. Preprint at J. et al. Acute kidney injury in pregnancy with special to a based study Journal of Nephrology vol. Preprint at Scholar. Pregnancy-related AKI is a major public health the of and their particularly women living in developing countries. Potential disparities between high-income countries and low- and lower-middle-income countries do due to healthcare resources, nephrology workforce and An access to comprehensive health care is a global human right and health equity should be to the sustainable development should be given to resources and to healthcare resources in and lower-middle income countries. International and should a to empower women in these countries to get the right service and support at the right time.

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