Haemolysis, elevated liver enzymes and low platelets: Diagnosis and management in critical care

A thirty-year-old pregnant woman was admitted to hospital with headache and gastrointestinal discomfort. She developed peripheral oedema and had an emergency caesarean section following an episode of tonic-clonic seizures. Her delivery was further complicated by postpartum haemorrhage and she was admitted to the Intensive Care Unit (ICU) for further resuscitation and seizure control which required infusions of magnesium and multiple anticonvulsants. Despite haemodynamic optimisation she developed an acute kidney injury with evidence of liver damage, thrombocytopenia and haemolysis. Haemolysis, Elevated Liver enzymes and Low Platelets (HELLP) syndrome, a multisystem disease of advanced pregnancy which overlaps with pre-eclampsia, was diagnosed. HELLP syndrome is associated with a range of complications which may require critical care support, including placental abruption and foetal loss, acute kidney injury, microangiopathic haemolytic anaemia, acute liver failure and liver capsule rupture. Definitive treatment of HELLP is delivery of the fetus and in its most severe forms requires admission to the ICU for multiorgan support. Therapeutic strategies in ICU are mainly supportive and include blood pressure control, meticulous fluid balance and possibly escalation to renal replacement therapy, mechanical ventilation, neuroprotection, seizure control, and management of liver failure-related complications. Multidisciplinary input is essential for optimal treatment.

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Eculizumab, a novel potential treatment for acute kidney injury associated with preeclampsia/HELLP syndrome

BMJ Case Reports ◽

10.1136/bcr-2018-228709 ◽

2019 ◽

Vol 12 (9) ◽

pp. e228709 ◽

Cited By ~ 11

Author(s):

Hatem Elabd ◽

Mennallah Elkholi ◽

Lewis Steinberg ◽

Anjali Acharya

Keyword(s):

Acute Kidney Injury ◽

Renal Replacement Therapy ◽

Replacement Therapy ◽

Complement Activation ◽

Hellp Syndrome ◽

Kidney Injury ◽

Complement Protein ◽

Igg Antibody ◽

Elevated Liver Enzymes

The kidney is one of the major organs affected in preeclampsia. There is evidence suggesting a role for excessive complement activation in the pathogenesis of preeclampsia. We describe a case of preeclampsia with severe features, including HELLP syndrome (hemolysis, elevated liver enzymes, low platelets) and acute kidney injury (AKI) that developed following caesarian section. The patient required renal replacement therapy. A trial of daily plasma exchange was not effective. The patient received a single dose of eculizumab, a humanised monoclonal IgG antibody that binds to complement protein C5. One week post administration of eculizumab, there was significant improvement in haematologic, hepatic and renal function. Blood pressure had normalised and renal replacement therapy was discontinued. The use of eculizumab may have contributed to recovery of kidney function further supporting the role of complement activation in the pathogenesis of preeclampsia and associated AKI.

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Pregnancy Related Acute Kidney Injury at a Tertiary Care Center in Nepal

Nepal Journal of Obstetrics and Gynaecology ◽

10.3126/njog.v10i1.13195 ◽

2015 ◽

Vol 10 (1) ◽

pp. 43-47

Author(s):

P Paudyal ◽

N Pradhan ◽

KDB Bista ◽

S Rawal

Keyword(s):

Acute Kidney Injury ◽

Hospital Stay ◽

Postpartum Period ◽

Hellp Syndrome ◽

Tertiary Care ◽

Kidney Injury ◽

Severe Preeclampsia ◽

University Teaching ◽

Study Patient ◽

Elevated Liver Enzymes

Aims: This was performed to study the characteristics of Pregnancy Related Acute Kidney Injury (PRAKI), its management and outcome in patients at a tertiary level referral centre. Methods: A hospital based prospective observational study was conducted in Tribhuvan University Teaching Hospital (TUTH) over a period of 18 months. All patients diagnosed with PRAKI were included in the study. Patient profiles in terms of age, parity, gestational age were studied along with time of occurrence of PRAKI, preceding event, etiology, management and maternal outcome. Descriptive and univariate analyses were conducted and qualitative variables were expressed as percentages while quantitative variables as means. Results: There were fifteen cases of PRAKI during the study period with incidence of 2.1 per 1000 deliveries. The average age was 25.23± 3.8 years and 9(60%) were primipara. Fourteen (93.3%) developed PRAKI in the postpartum period with 10(66.6%) cases following Lower Segment Caesarian Section (LSCS). The commonest etiology of PRAKI was severe preeclampsia/ Hemolysis, Elevated Liver enzymes, Low Platelet (HELLP) syndrome and pregnancy hemorrhages each consisting 4(26.6%) cases. The stage of Acute Kidney Injury (AKI) according to RIFLE (Risk, Injury, Failure, Loss, ESRD-End Stage Renal Disease) criteria was as follows: risk in 1(6.6%), injury in 3(20%) and failure in 11(73.3%) cases. Hemodialysis was necessary in 12(80%) cases while 3 cases (20%) improved with medical management only. The average duration of hospital stay was 25.2±14.7 days and 7(46.6%) needed ICU admission. Twelve (80%) cases recovered completely while two patients were dialysis dependent at the time of evaluation. There was one death. Conclusions: PRAKI occurred mainly in the postpartum period with severe preeclampsia/HELLP syndrome and hemorrhages as the most common causes. It is associated with high maternal morbidity, prolonged hospital stay and even mortality. Multidisciplinary team management is essential.

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Acute kidney injury associated with preeclampsia or hemolysis, elevated liver enzymes, and low platelets syndrome

Pregnancy Hypertension ◽

10.1016/j.preghy.2019.11.010 ◽

2020 ◽

Vol 19 ◽

pp. 94-99 ◽

Cited By ~ 2

Author(s):

Sarah Novotny ◽

Nicole Lee-Plenty ◽

Kedra Wallace ◽

Wondwosen Kassahun-Yimer ◽

Aswathi Jayaram ◽

...

Keyword(s):

Acute Kidney Injury ◽

Liver Enzymes ◽

Kidney Injury ◽

Elevated Liver Enzymes

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Faculty Opinions recommendation of Acute kidney injury and acute-on-chronic liver failure classifications in prognosis assessment of patients with acute decompensation of cirrhosis.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.725855163.793510689 ◽

2015 ◽

Author(s):

Tilman Sauerbruch

Keyword(s):

Acute Kidney Injury ◽

Liver Failure ◽

Kidney Injury ◽

Chronic Liver ◽

Chronic Liver Failure ◽

Acute Decompensation

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Renal replacement therapy in critical care in patients with acute kidney injury

Nihon Toseki Igakkai Zasshi ◽

10.4009/jsdt.51.141 ◽

2018 ◽

Vol 51 (2) ◽

pp. 141-148

Author(s):

Shigeo Negi ◽

Daisuke Koreeda ◽

Masaki Higashiura ◽

Takuro Yano ◽

Sou Kobayashi ◽

...

Keyword(s):

Acute Kidney Injury ◽

Critical Care ◽

Renal Replacement Therapy ◽

Replacement Therapy ◽

Kidney Injury

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Clinical characteristics and prognosis of postpartum acute kidney injury

Journal of International Medical Research ◽

10.1177/0300060520988388 ◽

2021 ◽

Vol 49 (2) ◽

pp. 030006052098838

Author(s):

Hong Shu ◽

Fang Nie

Keyword(s):

Acute Kidney Injury ◽

Clinical Characteristics ◽

Survival Rates ◽

Kidney Injury ◽

Renal Recovery ◽

Replacement Treatment ◽

Elevated Liver Enzymes ◽

Recovery Times ◽

Low Platelet Count ◽

Lost To Follow Up

Objective To investigate the clinical characteristics and prognoses of patients with postpartum acute kidney injury (PPAKI). Methods We retrospectively reviewed the clinical presentations, laboratory examinations, treatments, and outcomes of patients with PPAKI admitted to our hospital from January 2013 to December 2017. We then analyzed the clinical characteristics and prognoses of the mothers and their infants. Results Of 37 patients diagnosed with PPAKI, 26 (70.3%) received treatment in the intensive care unit, mainly for hemolysis, elevated liver enzymes, low platelet count (HELLP) syndrome (28/37, 75.7%), pre-eclampsia (26/37, 70.3%), and postpartum hemorrhage (22/37, 59.5%). Twenty patients required renal replacement treatment (RRT), but renal recovery times were similar in the RRT and non-RRT groups. Renal function recovered completely in 30 patients (81.1%) and partially in one patient (2.7%), and was not re-examined in two patients (5.4%). Three patients (8.1%) were lost to follow-up. Only one patient (2.7%) remained dialysis-dependent, and no maternal deaths occurred. The preterm birth, low birth weight, and infant survival rates were 70.7% (29/41), 68.3% (28/41), and 78.0% (32/41), respectively. Conclusion RRT does not reduce renal recovery time compared with non-RRT. Overall, the prognoses of both mothers and their fetuses are good following treatment for PPAKI.

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