THE CLINICAL SPECTRUM OF POSTPARTUM ACUTE RENAL INSUFFICIENCY

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Abstract
Much of the controversy concerning management of renal insufficiency stems from failure to appreciate the full clinical spectrum of the disease. These considerations are illustrated by 18 obstetrical patients who developed acute renal insufficiency. Abruptio placentae, abortions, infections, and intravascular hemolysis were the specific etiologies. Group I included 6 patients who were managed conservatively with no mortality and oliguria from 1 to 10 (Mean - 4.7) days. Group II included 10 patients with oliguria ranging from 8 to 32 (Mean - 16.3) days. All had hyperkalemia, and marked azotemia with an average BUN of 223 mg.%. Fourteen dialyses with a Kolff artificial kidney were used in this group and the overall mortality was 50%. One patient survived 23 days of oliguria with 2 dialyses. Group III consisted of 2 patients who died in 4 days with overwhelming complications, i.e., cardiac arrest, shock, and gastric hemorrhage. The main indications for dialyses were (1) Significant uncontrollable hyperkalemia, (2) A fulminating uremic syndrome, (3) Some combination of the two. Final arbiter was clinical judgement. The principal com-plications were fluid balance problems, hematologic abnormalities, and infection. All patients transferred from other hospitals were overhydrated. The weight loss with diuresis ranged from 12 to 40 lb. An analysis of the reasons for overhydration is presented. Hematologic abnormalities included anemia, leuko-cytosis, and complex coagulation defects. All patients in Group II became infected. Paracolon and A. aerogenes were the most common organisms in the urine. Staphylococcus and paracolon septicemias were seen. Discussion centers on the necessity for considering acute renal insufficiency not only in terms of the duration of oliguria but also in the magnitude of the catabolic response to precipitating injury. The obstetrical patient is the target of catabolic factors including involuting tissues, major surgery, sepsis, and hemolysis. Obstetrical patients therefore illustrate the clinical spectrum which acute renal insufficiency presents from the mildest forms to the fulminating and frequently fatal type.

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