Renal Cortical Necrosis in Postpartum Hemorrhage: A Case Series.

Background: Pregnancy-related renal cortical necrosis may lead to end-stage renal disease. Although this obstetric complication had virtually disappeared in high-income countries, we have noted new cases in France over the past few years, all following postpartum hemorrhage. Study Design: Case series. Setting & Participants: We retrospectively identified 18 patients from 5 French nephrology departments who developed renal cortical necrosis following postpartum hemorrhage in 2009 to 2013. Outcomes: Obstetric and renal features, therapeutic measures, and kidney disease outcome were studied. Results: All patients had a severe postpartum hemorrhage (mean blood loss, 2.6 +/- 1.1 [SD] L). Hemodynamic instability and disseminated intravascular coagulation were reported in 5 and 11 patients, respectively. All developed rapid onset of acute kidney injury and required hemodialysis. Diagnosis of renal cortical necrosis was performed 4 to 33 days following delivery. At 6 months postpartum, 8 patients remained dialysis dependent and none recovered normal kidney function. The length of exposure to tranexamic acid treatment was significantly more prolonged in women whose estimated glomerular filtration rate remained < 15 mL/min/ 1.73 m(2) (7.1 +/- 4.8 vs 2.9 +/- 2.4 hours; P = 0.03). Limitations: Retrospective study; small sample size. Conclusions: In the setting of gravid endothelium, the conjunction of disseminated intravascular coagulation with the life-saving use of procoagulant and antifibrinolytic agents (recently implemented in France in a postpartum hemorrhage treatment algorithm) may give rise to a risk for uncontrolled clotting in the renal cortex and hence irreversible partial or diffuse cortical necrosis. Am J Kidney Dis. 68(1): 50-57. (C) 2016 by the National Kidney Foundation, Inc.