Incidence, risk factors, and outcomes associated with pregnancy-related acute kidney injury in northwest Nigeria

Incidence, risk factors, and outcomes associated with pregnancy-related acute kidney injury in northwest Nigeria | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 16 May 2025 V1 Latest version Share on Incidence, risk factors, and outcomes associated with pregnancy-related acute kidney injury in northwest Nigeria Authors : Aisha M. Nalado [email protected] , Rayyan M. Garba , Fatimah I. Tsiga-Ahmed , Aishatu L. Adamu , Usman Bashir , Bala Waziri , Zubaida F. Ladan , … Show All … , Halima Kabir , Hafsat U. Ibrahim , Sherifah Sheriff , Aisha A. Galadanci , Zainab D. Ahmed , Hadiza Galadanci , Aliyu Abdu , Mansur A. Ramalan , C. William Wester , and Muktar H. Aliyu Show Fewer Authors Info & Affiliations https://doi.org/10.22541/au.174738259.97974391/v1 245 views 168 downloads Contents Abstract Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Objective The study aimed to evaluate the incidence, risk factors, and maternal-fetal outcomes of patients with PRAKI. Design Prospective cross-sectional observational study. Setting Nigeria Population Prgnant women attending anenatal clinic and labour ward of two referal hosiptal in Nigeria. Methods Study conducted among 841 women admitted to the Obstetrics and Gynecology wards of two large referral hospitals in Nigeria, between 1 st October 2022 and 30 th March 2023. Multivariate logistic regression analysis was performed to determine independent predictors of PRAKI. Main Outcome Measures Multivariate logistic regression analysis was performed to determine independent predictors of PRAKI. Results The mean age ± standard deviation (SD) of respondents was 27.8 ± 6.7 years. The prevalence of PRAKI was 11.4%, with the majority (55.2%) being in KDIGO stage 1. The most common risk factors for PRAKI were pre-eclampsia (24%), postpartum hemorrhage (16.7%), sepsis (15.6%), and eclampsia (14.6%). The overall maternal and perinatal mortality rates were 7.4 % and 21.9 %, respectively. PRAKI was independently associated with the use of traditional medications (adjusted odds ratio, aOR =1.94; 95% CI: 1.18, 3.18), history of pregnancy-induced hypertension (aOR = 2.61; 95% CI: 1.49-4.59), and an established diagnosis of hypertension (aOR = 2.53; 95% CI: 1.42, 4.50). Conclusion PRAKI is common in women presenting for care in our setting and is associated with significant maternal and perinatal mortality. The important risk factors for development of PRAKI in our study population include hypertensive disorders of pregnancy, established diagnosis of hypertension, postpartum hemorrhage, and sepsis. Incidence, risk factors, and outcomes associated with pregnancy-related acute kidney injury in northwest Nigeria Aisha M. Nalado 1 , Rayyan M. Garba 2 , Fatimah I. Tsiga-Ahmed 2 , Aishatu L. Adamu 2 , Usman Bashir 2 , Bala Waziri 3 , Zubaida F. Ladan 4 , Halima Kabir 4, , Hafsat U. Ibrahim 4 , Sherifah Sheriff 5 , Aisha A. Galadanci 6 , Zainab D. Ahmed 7 , Hadiza S. Galadanci 7 , Aliyu Abdu 1 , Mansur A. Ramalan 1 , C. William Wester 9-10 , Muktar H. Aliyu 9,11 1 Department of Medicine, Bayero University, Kano & Aminu Kano Teaching Hospital, Kano Nigeria 2 Department of Community Medicine, Bayero University, Kano & Aminu Kano Teaching Hospital, Kano Nigeria 3 Department of Medicine, Renal Unit, Ibrahim Babangida Specialist Hospital, Minna, Nigeria 4 Department of Paediatrics, Bayero University, Kano &Aminu Kano Teaching Hospital, Kano, Nigeria 5 Department of Chemical Pathology, Bayero University, Kano, Nigeria 6 Department of Haematology, Bayero University, Kano, Nigeria 7 Department of Obstetrics & Gynecology, Bayero University, Kano, Nigeria 8 Africa Center of Excellence for Population Health and Policy, Bayero University Kano, Kano, Nigeria 9 Vanderbilt Institute for Global Health (VIGH), Nashville, Tennessee, USA 10 Vanderbilt University Medical Center (VUMC), Department of Medicine, Division of Infectious Diseases, Nashville, Tennessee, USA 11 Vanderbilt University Medical Center (VUMC), Department of Health Policy, Nashville, Tennessee, USA Address all correspondence to: Aisha M. Nalado, MBBS, PhD Department of Medicine Bayero University Kano Kano, Nigeria [email protected] Objective The study aimed to evaluate the incidence, risk factors, and maternal-fetal outcomes of patients with PRAKI. Design Prospective cross-sectional observational study. Setting Nigeria Population Prgnant women attending anenatal clinic and labour ward of two referal hosiptal in Nigeria. Methods Study conducted among 841 women admitted to the Obstetrics and Gynecology wards of two large referral hospitals in Nigeria, between 1 st October 2022 and 30 th March 2023. Multivariate logistic regression analysis was performed to determine independent predictors of PRAKI. Main Outcome Measures Multivariate logistic regression analysis was performed to determine independent predictors of PRAKI. Results The mean age ± standard deviation (SD) of respondents was 27.8 ± 6.7 years. The prevalence of PRAKI was 11.4%, with the majority (55.2%) being in KDIGO stage 1. The most common risk factors for PRAKI were pre-eclampsia (24%), postpartum hemorrhage (16.7%), sepsis (15.6%), and eclampsia (14.6%). The overall maternal and perinatal mortality rates were 7.4 % and 21.9 %, respectively. PRAKI was independently associated with the use of traditional medications (adjusted odds ratio, aOR =1.94; 95% CI: 1.18, 3.18), history of pregnancy-induced hypertension (aOR = 2.61; 95% CI: 1.49-4.59), and an established diagnosis of hypertension (aOR = 2.53; 95% CI: 1.42, 4.50). Conclusion PRAKI is common in women presenting for care in our setting and is associated with significant maternal and perinatal mortality. The important risk factors for development of PRAKI in our study population include hypertensive disorders of pregnancy, established diagnosis of hypertension, postpartum hemorrhage, and sepsis. Keywords: Pregnancy, Acute kidney Injury, Risk factors 0 Introduction Acute kidney injury (AKI) is a global public health problem that affects approximately 13 million people annually, with more than 2 million people dying from the condition and/or its complications (1, 2). Pregnancy increases the risk of AKI by 51% (3, 4). Pregnancy-related acute kidney injury (PRAKI) is a life-threatening complication of pregnancy, characterized by an abrupt decline in kidney function during pregnancy and the immediate puerperium. PRAKI is associated with substantial maternal and fetal morbidity and mortality and increases the likelihood of progression to end-stage kidney disease (3, 5-7). The burden of PRAKI is greater in low- and middle-income countries (LMICs) than in high-income settings.(8) The reported incidence of PRAKI in LMICs is higher than that of high-income countries (4%-26% versus 1%-2.8%, respectively)(8-10). The incidence of PRAKI in sub-Saharan Africa is ~ 1 per 1,000 deliveries, accounting for 5%–27% of all cases of AKI among adults in Africa, which is 20–100-fold higher when compared to rates in high-income settings (3, 11). The incidence of PRAKI in northern Nigeria is estimated to be as high as 25.3% (12). PRAKI is preventable and treatable but remains a significant contributor to maternal mortality in resource-constrained settings like Nigeria. In addition, despite imposing a significant burden on healthcare systems throughout the African continent, PRAKI remains under-studied, underreported, and often overlooked (3, 13). Moreover, key risk factors for PRAKI, such as eclampsia, antepartum and postpartum hemorrhage, and puerperal sepsis, continue to predominate in developing countries (6). Further, assessing the risk of adverse pregnancy and kidney outcomes related to PRAKI is challenging due to the limited sample sizes of published data to date. Thus, this study aimed to evaluate the incidence, risk factors, and maternal-fetal outcomes of patients with PRAKI. 2.0 Materials and Methods 2.1 Study Design and Setting This is a prospective multicenter study conducted at the Obstetrics and Gynecology units of Murtala Muhammad Specialist Hospital (MMSH) and Aminu Kano Teaching Hospital (AKTH) in Kano, Nigeria, between 1 st October 2022 and 30 th March 2023. The two hospitals serve as tertiary referral facilities for more than 13 million residents of Kano and neighboring states in northern Nigeria. 2.2 Study Participants Study participants included pregnant women with gestational age greater than 20 weeks or within 6 weeks of delivery and hospitalized at the two hospitals. We excluded women with known kidney disease, hypertension, and/or diabetes mellitus prior to pregnancy, history of kidney stones, renal scarring or small size of the kidneys on ultrasound imaging, and known elevated serum creatinine (SCr) greater than 0.8 mg/dL prior to gestation (14). 2.3 Study Procedures Trained research assistants used a standardized data sheet to record patients’ sociodemographic information, clinical details, and laboratory measurements. The recorded demographic and clinical parameters included age, marital status, occupation, gravidity, parity, gestational age at presentation, booking status, vital signs, obstetrical history, medication usage, history of consuming local herbs or potential nephrotoxins, symptoms indicative of kidney dysfunction, co-morbid medical conditions, and past medical history. Ten mL of whole blood and urine samples were obtained from the eligible participants. The blood samples were used to assess baseline serum electrolytes, urea, and creatinine at the time of presentation or upon admission. Follow-up measurements including serum electrolytes, urea, and creatinine were conducted at 48 hours and 7 days after admission. For patients identified with PRAKI, subsequent monitoring involved serial measurements of serum electrolytes, urea, and creatinine twice weekly for an additional two weeks. Short term renal outcome was categorized as complete recovery, partial recovery, or irreversible kidney injury. Complete recovery of kidney function was defined as normalization of serum creatinine or serum creatinine returning to <1.5 times the baseline creatinine level. Partial improvement was defined as when serum creatinine is decreased below 2 mg/dL, and the patient is dialysis-dependent. Irreversible renal failure was defined as when the patient remains dialysis-dependent after 7 days. AKI was defined according to the Kidney Disease Improving Global Outcomes (KDIGO) criteria as an increase in serum creatinine by 26.5 μmol/L (0.3 mg/dl) within 48 hours, or a 50% increase in serum creatinine from the baseline within 7 days, or urine volume < 0.5 ml/kg/hour for 6 hours (15). Participants had urinary output monitoring. Acute kidney injury was staged for severity according to KDIGO staging criteria as follows: (16) • KDIGO Stage 1: Characterized by an increase in serum creatinine (SCr) to 1.5-1.9 times the baseline creatinine level or an increase in SCr by 26.5 μmol/L (0.3 mg/dL) • KDIGO Stage 2: An increase in SCr to 2.0-2.9 times the baseline creatinine level • KDIGO Stage 3: The most severe stage, where there is an increase in serum creatinine to ≥ 354 µmol/L (≥ 4 mg/dL) or 3 times the baseline creatinine level Hypertensive disorders of pregnancy were defined based on the guidelines of the American College of Obstetricians and Gynecologists (17). Gestational hypertension was defined as the development of high blood pressure (systolic blood pressure ≥ 140 mmHg or diastolic blood pressure ≥ 90 mmHg) after 20 weeks of gestation in a female who previously had normal blood pressure levels (18). Preeclampsia was diagnosed when gestational hypertension is accompanied by either proteinuria (urine dipstick for protein ≥ 1+ or a urine protein-to-creatinine ratio (uPCR) of 0.3 or higher), or signs of end-organ damage (18). Eclampsia was identified when a woman with preeclampsia experiences new onset grand mal seizures or unexplained loss of consciousness (19). 2.4 Ethical Considerations The study was approved by the Health Research Ethics Committees of Murtala Muhammad Specialist Hospital (NHREC/17/2018), and Aminu Kano Teaching Hospital (EC/3570). Individual written consent was obtained at the sites by trained research assistants. Statistical analysis Numerical data that followed a normal distribution were presented as means ± standard deviations (SDs), while non-normally distributed data were presented as medians and interquartile ranges. Categorical data were expressed as frequencies and percentages. To compare continuous variables between study participants who developed PRAKI and those who did not, an independent t-test or Wilcoxon rank-sum test was used. Proportion comparisons were conducted using Pearson’s or Fisher’s exact tests. Logistic regression models were employed to determine independent predictors of PRAKI, maternal mortality, and perinatal death. A stepwise regression strategy with a backward selection procedure was applied to fit the multiple regression models. Initially, all potential predictor variables were included, and variables with p -values exceeding the pre-specified threshold of 0.20 were subsequently removed. A priori covariates that were biologically plausible to be associated with the study outcomes were included in the model, even if their p -values were greater than 0.20. A p-value less than 0.05 was considered statistically significant with a 95% confidence interval. All analyses were performed using SPSS Version 22 (IBM Corp., Armonk, NY). 0 Results Out of the 1,047 respondents recruited for the study, only 841 consented and participated in the study, giving a participation rate of 80.3%. The mean age of the respondents was 27.8 ± 6.7 years. Table 1 : Participants’ sociodemographic characteristics, PRAKI status, and maternal/perinatal mortality, Kano, Nigeria Age (years) 18 - 24 297 35.3 25 – 29 161 19.1 30 – 34 193 22.9 ≥ 35 190 22.6 Occupation Full time homemaker 26 3.1 Civil Servant 35 4.2 Business 780 92.7 Household Monthly Income (NGN) < 30,000 742 88.2 ≥ 30,000 99 11.8 PRAKI Diagnosis No 745 88.6 Yes 96 11.4 PRAKI Staging Stage 1 53 55.2 Stage 2 17 17.7 Stage 3 26 27.1 Risk Factors for PRAKI Antepartum hemorrhage 6 6.3 Eclampsia 14 14.6 Use of herbal medications 4 4.1 Other 12 12.5 Pregnancy-induced hypertension (PIH) 6 6.3 Postpartum hemorrhage (PPH) 16 16.7 Preeclampsia 23 24 Sepsis 15 15.6 HIV/AIDS No 779 92.6 Yes 62 7.4 Maternal death No 751 89.3 Yes 90 10.7 Perinatal death No 657 78.1 Yes 184 21.9 APH- Antepartum hemorrhage PIH-Pregnancy induced hypertension PPH-Postpartum hemorrhage. The majority of the respondents (35.3%) were 18 – 24 years of age, 92.7% were involved in some form of trade or business, with about 88% of them earning less than Nigeria’s minimum wage of 30,000 Naira (equivalent to approximately 20 USD) per month ( Table 1 ). Approximately 11.4% of the respondents were diagnosed with PRAKI, with the majority of them (55.2%) having Stage 1 disease. The most common risk factor for development of PRAKI was preeclampsia (24%), followed by postpartum hemorrhage (16.7%), and sepsis/eclampsia (~ 15%). The prevalence of HIV was 7.4% among the respondents. Approximately 7.4% of mothers in the study died, while 21.9% reported a perinatal death. \sout, with a maternal mortality rate of 7.4% and perinatal mortality rate of 21.9%. Table 2 : Socio-demographic characteristics and medical history of respondents by PRAKI status, Kano, Nigeria (n=96) (n=745) Age (years) 18 - 24 11 (3.7) 286 (96.3) <0.001* 25 – 29 18 (11.2) 143 (88.8) 30 – 34 20 (10.4) 173 (89.6) ≥ 35 47 (24.7) 143 (75.3) Ethnicity Hausa 94 (11.9) 697 (88.1) 0.532 Yoruba 0 (0.0) 9 (100) Igbo 0 (0.0) 18 (100) Others 2 (8.6) 21 (91.3) Maternal occupation Housewife 3 (11.5) 23 (88.5) 0.495 Civil Servant 1 (2.9) 34 (97.1) Business 92 (11.8) 688 (88.2) Household monthly income < 30,000 83 (11.2) 659 (88.8) 0.567 ≥ 30,000 13 (13.1) 86 (86.9) HIV/AIDS Positive 6 (9.7) 56 (90.3) 0.836 Negative 90 (11.6) 689 (88.4) Diabetes mellitus Yes 2 (20.0) 8 (80.0) 0.319 No 94 (11.3) 737 (88.7) Known hypertensive Yes 66 (22.0) 234 (78.0) <0.001* No 30 (5.5) 511 (94.5) Pregnancy-induced hypertension Yes 61 (26.2) 172 (73.8) <0.001* No 35 (5.8) 573 (94.2) Sickle cell disease Yes 2 (11.8) 15 (88.2) 1 No 94 (11.4) 730 (88.6) On prescribed medications (for HTN and DM) Yes 6 (9.4) 58 (90.6) 0.593 No 90 (11.6) 687 (88.4) Traditional Medication Use Yes 59 (17.9) 271 (82.1) <0.001* No 37 (7.2) 474 (92.8) History of prior abortion No 74 (10.9) 607 (89.1) 0.302 Yes 22 (13.8) 138 (86.3) History of stillbirth No 83 (11.8) 622 (88.2) 0.457 Yes 13 (9.6) 123 (90.4) History of eclampsia Yes 3 (10.0) 27 (90.0) 1 No 93 (11.5) 718 (88.5) History of preeclampsia Yes 5 (12.8) 34 (87.2) 0.795 No 91 (11.3) 711 (88.7) Booking status Booked 78 (12.1) 567 (87.9) 0.262 Not booked 18 (9.2) 178 (90.8) Multiple Gestation Yes 0 (0.0) 53 (100) 0.007* No 96 (12.2) 692 (87.8) Proteinuria Yes 66 (12.1) 478 (87.9) 0.376 No 30 (10.1) 267 (89.9) Eclampsia Yes 39 (13.9) 241 (86.1) 0.105 No 57 (10.2) 504 (89.8) Mode of Delivery Spontaneous vaginal delivery 58 (12.0) 424 (88.0) 0.646 Cesarian section 38 (10.7) 317 (89.3) Assisted delivery 0 (0.0) 4 (100) *Statistically significant at 5% level of significance. On bivariate analysis, we found age to be statistically significantly associated with PRAKI (p0.05). Being a known hypertensive, having pregnancy induced hypertension and using traditional medications were also significantly associated with PRAKI (<0.001), Table 2 . However, diagnoses of HIV/AIDS, diabetes mellitus and using prescribed medications (for hypertension and diabetes) were not found to be statistically significantly associated with PRAKI after bivariate analyses. Multiple gestation was statistically significantly associated with PRAKI ( p =0.007) – all the cases of PRAKI occurred in mothers with singleton pregnancies. History of abortion, stillbirth, pre-eclampsia, and eclampsia, having proteinuria, and mode of delivery were not significantly associated with the development of PRAKI ( p >0.05). Table 3: Mortality of respondents by HIV Status and PRAKI stage, Kano, Nigeria Stage 1 Positive 0 (0.0) 0 (0.0) 0 (100) Negative 23 (88.5) 3 (11.5) 26 (100) Stage 2 Positive 2 (100) 0 (0.0) 2 (100) Negative 12 (80.0) 3 (20.0) 15 (100) Stage 3 Positive 4 (100) 0 (0.0) 4 (100) Negative 44 (89.8) 5 (10.2) 49 (100) The proportion of participants who died was slightly higher among persons with HIV than those who were HIV-negative, but this difference was not statistically significant (11.3% vs. 10.7%, p = 0.504). Mortality was very high among patients with stage 2 and 3 PRAKI, regardless of HIV status ( Table 3 ). All the HIV-positive participants with stage 2 and 3 PRAKI died. None of the six patients that died of PRAKI and HIV had Stage1PRAKI. Table 4 : Independent predictors of PRAKI among participants using multivariate logistic regression, Kano, Nigeria (n=745) (n=96) aOR Lower Upper Use of traditional medications No 474 (92.8) 37 (7.2) Ref Ref Yes 271 (82.1) 59 (17.9) 1.94 1.18 3.18 0.009 Pregnancy-induced hypertension No 573 (94.2) 35 (5.8) Ref Ref Yes 172 (73.8) 61 (26.2) 2.61 1.49 4.59 0.001 Known hypertensive No 511 (94.5) 30 (5.5) Ref Ref Yes 234 (78.0) 66 (22.0) 2.53 1.42 4.5 0.002 Maternal age (years) <0.001 18 - 24 286 (96.3) 11 (3.7) Ref Ref 25 – 29 143 (88.8) 18 (11.2) 0.14 0.07 0.29 <0.001 30 – 34 173 (89.6) 20 (10.4) 0.69 0.36 1.33 0.267 ≥ 35 143 (75.3) 47 (24.7) 0.5 0.27 0.92 0.027 Multiple gestation Yes 53 (100) 0 (0.0) Ref Ref No 692 (87.8) 96 (12.2) 1 0 1 0.997 Adjusted for use of traditional medication, PIH, being hypertensive, age and multiple gestation. Following multivariate analysis ( Table 4 ), we found the use of traditional medication, history of having pregnancy-induced hypertension (PIH), established diagnosis of hypertension, and maternal age to be independent predictors of PRAKI. Respondents who used traditional medications were twice as likely to have PRAKI compared to those who did not use traditional concoctions (aOR =1.94; 95% CI: 1.18, 3.18, p =0.009). Similarly, women with a history of PIH and those with known hypertension had an approximate three-fold higher odds of developing PRAKI relative to those who did not have hypertensive disorders (aOR = 2.61; 95% CI: 1.49, 4.59, p =0.001) and (aOR = 2.53; 95% CI: 1.42, 4.50, p =0.001), respectively. In addition, women who were between 25 and 29 years of age and those ≥ 35 years of age had lower odds of having PRAKI compared to those between 18-24 years of age (aOR = 0.14; 95% CI: 0.07, 0.29, p <0.001) and (aOR=0.50; 95% CI: 0.27, 0.92, p <0.001), respectively. 4.0 Discussion 4.1 Main finding Previously, the comparison of epidemiological data regarding the prevalence of PRAKI was difficult due to the absence of a consensus definition of AKI during pregnancy. The present study, derived from one of the largest national cohorts among a general population of pregnant women in Nigeria, identified a PRAKI prevalence rate of 11.4%. This rate is significantly higher than the PRAKI prevalence rate of 0.03% and 0.02%, reported in population-based studies conducted in Canada and the U.S. (20-22). The difference between our findings and the Canadian and U.S. studies can be attributed to variations in the study populations. In the U.S. cohorts, most study participants had known risk factors for AKI, whereas the Canadian study had patients with and without risk factors for AKI, similar to our study cohort. In addition, the discrepancy may be influenced by differences in the quality of, and access to obstetric care between countries, with Canada’s healthcare infrastructure more advanced compared to Nigeria’s. 4.1 Strengths and Limitations The strengths of this study include the large sample size and prospective design that allowed short-term outcomes to be assessed; similar studies were predominantly retrospective and had relatively small sample sizes. Our use of the KDIGO staging criteria to stage the severity of AKI is another strength. Our study has several limitations. First, we utilized an accepted definition of AKI based on serum creatinine levels that have not been specifically validated for use in pregnancy; hence mild cases of AKI could have been missed due to the physiologic effect of creatinine in pregnancy. Second, considering our short-term follow-up of one week, the long-term outcomes of PRAKI may have been underestimated, and patients who have progressed to end-stage kidney disease could have been missed. To address this limitation, we suggest studies with longer follow-up periods of three months and increasing awareness among healthcare providers and pregnant women. Third, our study was conducted among pregnant women with no risk factors for PRAKI, in two large urban centers. This may have underestimated the true incidence rate of PRAKI and limit the generalizability of our findings. 4.2 Interpretation Consistent with our findings, other studies conducted in resource-constrained settings have reported high incidence and prevalence rates of PRAKI (23). For example, studies conducted in India showed incidence proportions for PRAKI ranging from 5% to 20%, (24, 25), Brazil showed a prevalence rate of 27.8% (5) while studies from Africa reported that obstetrical conditions accounted for 5% to 27% of cases of AKI (11), with incidence rates that were 20–100 times higher than in high-income countries (11, 26). The wide range of reported incidence and prevalence rates of PRAKI can be due to several factors, including the lack of a standardized definition for AKI across studies, variations in study populations, and differences in study design. It is noteworthy that there are no consensus diagnostic criteria for PRAKI in the literature, and results from different studies depend on the criteria used to diagnose AKI in the general population. In this study, pregnancy induced hypertension accounted for nearly 27% of cases within our cohort, followed by postpartum hemorrhage and sepsis. These findings align with reports from other studies (8, 27). The observed shift from septic abortion as the leading cause of PRAKI in resource-constrained settings can be attributed to global advancements in obstetrical care and improved accessibility to antimicrobial agents for the timely management of sepsis (28) These improvements likely contributed to a decrease in the incidence of septic abortion-related PRAKI cases, highlighting the positive impact of enhanced healthcare practices and availability of necessary interventions. In this study, the prevalence of herbal medicine use was 17.9% among participants with PRAKI, and we found a statistically significant association between the use of local herbs and an increased risk of AKI. Although various combinations of herbs are used during pregnancy, studies relating to their safety on both the mother and the fetus are sparse (29, 30). The importance of toxic AKI caused by indigenous medications has been highlighted in studies from sub-Saharan Africa and parts of Asia (29, 31, 32).High concentration of herbal toxins may, lead to direct injury to tubular cells. Other mechanisms include renal ischemia caused by volume loss or a hemodynamic instability(31). A serious sequela of PRAKI is maternal and perinatal mortality. We found maternal death occurred in 10.7% of PRAKI mothers, and a perinatal death rate of 21.9%. The etiology of fetal death is likely due to the underlying cause of PRAKI, especially preeclampsia, eclampsia, and infection. Previous studies in this context have reported maternal mortality and perinatal mortality similar to our findings (6, 30, 33, 34). Early recognition and prompt management of PRAKI are of paramount importance in reducing adverse outcomes, especially in resource-constrained setttings where patients pay out of pocket for basic health care delivery. Further efforts to improve antenatal and perinatal care are needed to decrease the burden of PRAKI. 4.3 Conclusions In summary, we found PRAKI to be common among pregnant women presenting for care at two large referral hospitals in northern Nigeria. The majority of PRAKI cases were attributable to hypertensive disorders of pregnancy, postpartum hemorrhage, chronic hypertension and sepsis. Further research is needed to understand the etiology of PRAKI and develop effective preventive measures against this major cause of maternal and fetal morbidity and mortality. Acknowledgments The study was partly supported by the African Centre for Excellence and Population Health (ACEPHAP) Fogarty International Center and the National Institute of Alcohol Abuse and Alcoholism of the U.S. National Institutes of Health (D43TW011544). The content is solely the responsibility of the authors and does not necessarily represent the official position of the U.S. National Institutes of Health. Author contributions. Dr AM Nalado: Conceived the study, participated in the statistical analysis and interpretation. She drafted the initial manuscript and agreed with the final manuscript for publication Rayyan M. Garb: Participated in the study conception, oversaw the haematological analysis, contributed to the interpretation of the results, read and contributed intellectually to the initial manuscript. He approved the final manuscript for submission Fatimah I. Tsiga-Ahmed: Participated substantially in the study conception, contributed to the interpretation of the results, read and contributed intellectually to the manuscript. She approved the final manuscript for submission. Aishatu L. Adamu 2 : Participated in the study conception, read and contributed intellectually to the manuscript, contributed to the interpretation of the results. He approved the final manuscript for submission. Bala Wazir: Conducted the statistical analysis, interpreted the results, read and contributed intellectually to the manuscript. He approved the manuscript for submission. Zubaida F. Ladan: Participated in the study conception, oversaw the haematological analysis, contributed to the interpretation of the results, read and contributed intellectually to the initial manuscript. He approved the final manuscript for submission Halima Kabir: Participated substantially in the study conception, contributed to the interpretation of the results, read and contributed intellectually to the manuscript. She approved the final manuscript for submission. Hafsat Ibrahim: Participated in the study conception, read and contributed intellectually to the manuscript, contributed to the interpretation of the results. He approved the final manuscript for submission. Hadiza S Galadanci: Conducted the statistical analysis, interpreted the results, read and contributed intellectually to the manuscript. He approved the manuscript for submission. C. William Wester and Muktar H Aliyu: Contributed substantially to the study conception and design, contributed substantially to the interpretation of results, read and contributed intellectually to the manuscript. 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Herb-drug interactions. The Lancet. 2000;355(9208):1019-20. 33. Mahesh E, Puri S, Varma V, Madhyastha P, Bande S, Gurudev K. Pregnancy-related acute kidney injury: An analysis of 165 cases. Indian journal of nephrology. 2017;27(2):113. 34. Arora N, Mahajan K, Jana N, Taraphder A. Pregnancy-related acute renal failure in eastern India. International Journal of Gynecology & Obstetrics. 2010;111(3):213-6. Information & Authors Information Version history V1 Version 1 16 May 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords epidemiology epidemiology: general gynaecology epidemiology: general obstetric epidemiology: perinatal pre-eclampsia: basic science Authors Affiliations Aisha M. Nalado [email protected] Bayero University View all articles by this author Rayyan M. Garba Bayero University View all articles by this author Fatimah I. Tsiga-Ahmed Bayero University View all articles by this author Aishatu L. Adamu Bayero University View all articles by this author Usman Bashir Bayero University View all articles by this author Bala Waziri Ibrahim Badamasi Babangida Specialist Hospital View all articles by this author Zubaida F. Ladan Bayero University View all articles by this author Halima Kabir Bayero University View all articles by this author Hafsat U. Ibrahim Bayero University View all articles by this author Sherifah Sheriff Bayero University View all articles by this author Aisha A. Galadanci Bayero University View all articles by this author Zainab D. Ahmed SUNY Downstate Health Sciences University Department of Obstetrics & Gynecology View all articles by this author Hadiza Galadanci Bayero University View all articles by this author Aliyu Abdu Bayero University View all articles by this author Mansur A. Ramalan Bayero University View all articles by this author C. William Wester Vanderbilt Institute for Global Health View all articles by this author Muktar H. 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