Gebelikte Akut Böbrek Yetmezliği ve Trombotik Mikroanjiopatilere Yaklaşım
Özet
Gebelik sırasında veya sonrasında ortaya çıkan akut böbrek yetmezliği (ABY), maternal-fetal mortaliteye yol açabilen ciddi bir sağlık sorunudur. Gebelikte böbrek uzunluğu, hacmi ve kan hacmi artarken, sistemik vasküler direnç azalır; bu fizyolojik değişiklikler serum kreatinin, üre ve ürik asit düzeylerinde düşüşe neden olur. Bu adaptasyonlar sebebiyle gebelikte ABY'nin erken teşhisi zorlaşmaktadır. Postpartum ABY kriterleri KDIGO'ya göre 48 saat içinde serum kreatinin düzeyinde ani artış veya idrar çıkışında azalma ile tanımlanır. Gelişmiş ülkelerde preeklampsi, HELLP sendromu ve trombotik mikroanjiopati (TMA) en yaygın nedenlerken, gelişmekte olan ülkelerde doğum sonu kanama ve enfeksiyonlar öne çıkar. TMA grubu bozukluklar arteriyol ve kapillerlerde yaygın trombüs oluşumu, hemolitik anemi ve trombositopeni ile karakterizedir. Bu kapsamda yer alan TTP tedavisinde acil plazmaferez ve steroid uygulanırken, kompleman düzenleyici gen mutasyonlarından kaynaklanan aHUS tedavisinde ekulizumab tercih edilir. Ayrıca gebeliğin akut yağlı karaciğeri (AFLP) ve lupus nefriti de ABY'ye yol açabilen nadir durumlardandır. Pr-ABY yönetimi; intravenöz sıvı resüsitasyonu, magnezyum toksisitesine karşı dikkatli olunması, nefrotoksik ilaçlardan kaçınılması ve multidisipliner bir yaklaşım ile fetüsün hızlıca doğurtulmasını gerektirir.
Acute kidney injury (AKI) emerging during or after pregnancy is a serious health problem that can lead to maternal-fetal mortality. During pregnancy, renal length, volume, and blood volume increase, while systemic vascular resistance decreases; these physiological changes cause a drop in serum creatinine, urea, and uric acid levels. Due to these adaptations, early diagnosis of AKI in pregnancy becomes difficult. Postpartum AKI criteria are defined by KDIGO as a sudden increase in serum creatinine within 48 hours or a decrease in urine output. While preeclampsia, HELLP syndrome, and thrombotic microangiopathy (TMA) are the most common causes in developed countries, postpartum hemorrhage and infections stand out in developing countries. TMA group disorders are characterized by widespread thrombus formation in arterioles and capillaries, hemolytic anemia, and thrombocytopenia. In this context, urgent plasmapheresis and steroids are applied in the treatment of TTP, whereas eculizumab is preferred in the treatment of aHUS caused by complement-regulatory gene mutations. Additionally, acute fatty liver of pregnancy (AFLP) and lupus nephritis are rare conditions that can lead to AKI. Pr-AKI management requires intravenous fluid resuscitation, caution against magnesium toxicity, avoidance of nephrotoxic drugs, and rapid delivery of the fetus through a multidisciplinary approach.
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