Renal Manifestations in Pregnancy-Associated Thrombotic Microangiopathy (TMA)

Renal Manifestations in Pregnancy-Associated Thrombotic Microangiopathy (TMA) | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Renal Manifestations in Pregnancy-Associated Thrombotic Microangiopathy (TMA) Li Zhan, Zhao Ban, Fang Fang, Li Tianhui, Zhao Yanfeng, Wang Yan, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8195195/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Objective This study investigates the characteristics of pregnancy-related thrombotic microangiopathy (TMA) and its renal manifestations, with a focus on factors that affect renal prognosis. Methods Clinical data, renal involvement, treatment regimens, and prognosis were collected for patients diagnosed with pregnancy-related TMA who were admitted to the Nephrology Department of the National Center of Geriatrics at Beijing Hospital from 2014 to 2023. Results Eight clinically and/or pathologically diagnosed cases of pregnancy-related TMA were identified. The average age was (32.12 ± 5.14) years, and the onset of TMA during pregnancy occurred at an average of (28.75 ± 8.73) weeks. Common peripartum symptoms included abdominal pain, placental abruption, and postpartum hemorrhage. Causes of TMA included pre-eclampsia (PE) in 6 cases, among which 1 case was complicated by systemic lupus erythematosus (SLE) and 1 case by malignant hypertension, and atypical hemolytic uremic syndrome (aHUS) in 2 cases. Laboratory findings revealed significantly elevated levels of LDH and D-dimer, with platelet counts at (93.63 ± 86.39)×10 9 /l and hemoglobin at (75.75 ± 33.36) g/l. Renal manifestations showed varying degrees of proteinuria and hematuria in all 8 patients, with 6 patients experiencing different degrees of renal impairment and 2 patients showing no renal function impairment. The highest serum creatinine recorded was (366.58 ± 275.06) umol/l, with 2 cases of aHUS patients requiring renal replacement therapy and 4 patients (2 cases of aHUS patients, 1 case of PE patient, and 1 case of PE combined with SLE patient.) needing plasma exchange treatment (≥ 1time). Among the 6 patients who underwent renal biopsy, 50% exhibited glomerular capillary endothelial cell swelling (83.3%), capillary lumen opening disparity (66.7%), small vessel endothelial cell swelling (66.7%), or brush border loss of renal tubules (66.7%). Four cases of patients had electron microscopy results: 1 case showed endothelial cell proliferation and segmental widening of the basal membrane's loose layer; 1 case showed a large number of fragmented red blood cells within the capillary loops; and 2 cases did not exhibit typical TMA electron microscopy findings. Comparisons between aHUS and PE groups revealed significant differences in serum creatinine levels and the proportion of patients requiring renal replacement therapy (P < 0.05). Patients with aHUS tended to develop the condition later in pregnancy and also had lower platelet counts. Prognosis results showed that 1 patient remained on hemodialysis, 1 patient came off dialysis, 1 patient was discharged automatically, and 3 patients exhibited a significant decrease in serum creatinine upon discharge among the 6 patients with kidney function impairment. Conclusion Pregnancy-related TMA mostly manifests in mid to late pregnancy, with PE being the most common cause and renal manifestations primarily presenting as proteinuria, hematuria, and acute renal failure. Furthermore, patients with pregnancy-related aHUS tend to develop the condition later in pregnancy, experience more severe renal function impairments, have lower platelet levels, and require renal replacement therapy at a higher rate. Once diagnosed with aHUS as the cause of pregnancy-related TMA, promptly terminating the pregnancy and actively engaging in plasma exchange treatment may improve prognosis. Pregnancy Acute Kidney Injury (AKI) Thrombotic Microangiopathy (TMA) Plasma Exchange (PE) Background Pregnancy-associated thrombotic microangiopathy (TMA) is rare but acute, severe, and can affect multiple organs; kidney damage in particular often leads to acute renal failure. Common causes of TMA include severe preeclampsia (sPE)/HELLP syndrome, thrombotic thrombocytopenic purpura (TTP), and atypical hemolytic uremic syndrome (aHUS), which can overlap, making early diagnosis difficult. Prognosis is influenced by various factors, and delayed treatment results in poor outcomes for kidneys and the rest of the body, severely affecting both mothers and fetuses. This study reviews pregnancy-associated TMA cases to analyze characteristics, kidney manifestations, and prognosis, and to enhance diagnostic awareness and capabilities and identify factors that affect prognosis. Methods Study design and study population Study Population: Hospitalized patients diagnosed with pregnancy-associated thrombotic microangiopathy (TMA) in the Department of Nephrology, National Center of Gerontology, Beijing Hospital from January, 2014 to December ,2023. Inclusion criteria included:Age ≥ 18 years, female; Pregnant at the time of diagnosis; TMA confirmed clinically and/or by renal biopsy. Exclusion criterion included Autoimmune hemolytic anemia. Clinical Data: Collected data included basic patient information (age, gestational age, perinatal symptoms, blood pressure at onset, past TMA history, TMA etiology), laboratory parameters (platelet count, hemoglobin (HGB), lactate dehydrogenase (LDH), coagulation profile), renal manifestations (proteinuria, hematuria, serum creatinine (peak and pre-discharge levels), renal pathology), treatment regimens, and renal/systemic prognosis. This study was approved by the institutional ethics committee of Beijing Hospital (2025BJYYEC-KY296-01). This study was carried out in accordance with the code of ethics of the World Medical Association Declara- tion of Helsinki.This study was approved by the Ethics Review Committee of Beijing Hospital with a waiver of informed consent. Statistical Methods: Normally distributed continuous variables were expressed as mean ± SD, and nonnormally distributed variables as median (interquartile range). Categorical data were presented as rates and percentages. Comparisons between two groups for normally distributed data were made using t-tests, and between multiple groups using ANOVA. Comparisons for nonnormally distributed data were made using the Mann-Whitney U test, and categorical data were analyzed using the chi-squared test. All statistical analysis was performed using SPSS 26.0. Results 1. Clinical and Laboratory Characteristics of Pregnancy-Associated TMA Patients The average age was (32.12 ± 5.14) years old, and average gestational time was (28.75 ± 8.73) weeks. Perinatal symptoms included abdominal pain, placental abruption, and postpartum hemorrhage, which occurred in 4 cases (50%). Hypertension occurred in 6 cases (75%). Patients also presented with manifestations of malignant hypertension such as headache, dizziness, and blurred vision. None of the patients had a previous history of thrombotic microangiopathy (TMA). Etiologies of TMA consisted of 6 cases of preeclampsia (PE), among which 1 case had active systemic lupus erythematosus (SLE) complicated with PE, and 1 had malignant hypertension complicated with PE; 2 cases of atypical hemolytic uremic syndrome (aHUS). The platelet count was (93.63 ± 86.39)×10 9 /l, hemoglobin (HGB) was (75.75 ± 33.36) g/l, and lactate dehydrogenase (LDH) was (100.57 ± 895.48) U/L. Complement 3 (C3) was (0.81 ± 0.28) g/l, and complement 4 (C4) was (0.16 ± 0.08) g/l. In 1 aHUS patient, the level of factor H decreased, the factor H antibody was negative (-), and the screening of TMA-related genes revealed heterozygous point mutations in the C3 gene and heterozygous point mutations in the complement factor I (CFI) gene. See Table 1 . Table 1 Baseline Characteristics and Clinical Manifestations of Pregnancy-associated TMA Patients Patient ID Age Gestational age Perinatal symptoms TMA Past Medical History TMA etiology BP PLT (*10 9 /l) HGB (g/l) LDH (U/l) C3 (g/l) C4 (g/l) D-dimer (mg/l) Adam13/Factor-H Autoantibody 1 36 38 + 1 postpartum hemorrhage 0 aHUS N 33 41 NA 0.53 0.13 7.63 (-) (-) 2 23 38 lower abdominal pain, placental abruption, fetal death 0 aHUS Y 24 64 2369 0.81 0.11 17.49 (-) /FH↓ (-) 3 36 27 + 6 lower abdominal pain, placental abruption 0 PE Y 30 68 1265 0.7 0.06 2.34 (-) (-) 4 31 33 lower abdominal pain, placental abruption 0 PE Y 123 77 875 1.38 0.28 13.11 NA ANA1:40 5 35 26 NA 0 PE/SLE Y 14 40 1941 0.5 0.15 5.64 NA ANA1:320 6 31 33 + 5 nausea and vomiting, dizziness, blurred vision 0 MH/PE Y 84 65 360 0.89 NA 0.75 NA (-) 7 27 22 asymptomatic 0 PE Y 230 121 99 0.69 0.14 NA (-) 8 38 12 asymptomatic 0 PE༟ N 211 130 137 0.95 0.28 NA (-) 2.Renal Clinical and Pathological Features of Pregnancy-Associated TMA Renal clinical features : All 8 patients had proteinuria (24h urine protein: 2.9 ± 1.3 g) and hematuria. PE patients had a higher 24h proteinuria (3.2 ± 1.4 g) than aHUS patients (2.2 ± 0.3g). Six patients had acute kidney injury (serum creatinine: 366.58 ± 275.06 µmol/L), and two had normal renal function. Four patients (2 aHUS, 1 PE, 1 PE with SLE) received plasma exchange (≥ 1 session), with 2 aHUS patients also undergoing renal replacement therapy. Plasma exchange started (2 ± 1.4 days) after TMA onset. See Table 2 . Table 2 Renal Manifestations and Treatment Strategies in Pregnancy-Related TMA Patients Patient ID Urine protein–creatinine ratio, g/g or Urinary protein excretion hematuria sCr (max) Histology on kidney biopsy (light microscope) Histology on kidney biopsy (electron microscope) sCr (discharge) Renal Replacement Therapy PE 1 2468mg/Cr Y 618 12 glomeruli, In 9 glomeruli, there was a reduction in the number of glomerular cell nuclei, with coagulative necrosis. The remaining glomeruli showed endothelial cell swelling. The endothelial cells in the interlobular arteries were swollen, with mucoid material deposition beneath the endothelium and resulting luminal narrowing. This is consistent with thrombotic microangiopathy (TMA), accompanied by glomerular necrosis (9/12). 2 glomeruli were examined. The capillary loops were markedly dilated, with numerous fragmented red blood cells causing obstruction. There were no obvious electron-dense deposits in the basement membrane or mesangial area. The basement membrane was not thickened, and there was no significant widening beneath the endothelial cells. The renal tubular epithelial cells showed increased lysosomes. These findings are consistent with intracapillary hemolytic changes. 372 Y 1 2 1967mg/Cr Y 730 15 glomeruli were examined. One glomerulus showed global sclerosis, and one glomerulus exhibited a large-cell crescent. Endothelial cells were swollen, and the capillary loops were barely open. Focal hyaline thrombus formation was observed. The small arteries showed endothelial cell swelling with luminal narrowing, and red-stained material deposits were visible locally. These findings are consistent with thrombotic microangiopathy (TMA) NA 237 Y 4 3 1446mg/Cr N 218 13 glomeruli were examined. Endothelial cells were proliferated and swollen, with basement membrane wrinkling and poor capillary loop patency. Some small vessel walls showed thickening. These findings are consistent with thrombotic microangiopathy (TMA) NA 110 N 6 4 4.5g/24h Y 570.6 31 glomeruli were examined. Endothelial cell proliferation and thickening of the basement membrane were observed, with pseudo-double track formation visible. Some small vessel endothelial cells were swollen, and the vessel walls were thickened. These findings are consistent with thrombotic microangiopathy (TMA), accompanied by acute tubular injury. 2 glomeruli were examined. There was mild proliferation of mesangial cells and matrix. Segmental endothelial cell proliferation was observed, with segmental widening of the loose layer within the basement membrane. Segmental fusion of podocyte foot processes was present, and no definite electron-dense deposits were seen. The renal tubular epithelium showed increased lysosomes, with some loss of microvilli. The renal interstitium showed no significant lesions. In combination with light microscopy findings, this is consistent with thrombotic microangiopathy (TMA) renal injury accompanied by acute tubular injury. 149 N 0 5 NA Y 131 NA NA 68 N 1 6 4.29/24h Y 540 NA NA 501 N 0 7 1.39/24h Y 55 20 glomeruli were examined. One glomerulus showed global sclerosis. The endothelial cells were swollen, and the capillary loops were barely open. These findings are consistent with renal changes of thrombotic microangiopathy (TMA). 1 glomerulus was examined. There was mild proliferation of glomerular mesangial cells and matrix, with a small amount of electron-dense deposits in the mesangial area. The glomerular basement membrane was mostly thinned, with segmental lamellar changes. Most of the podocyte foot processes were fused. The renal epithelium showed vacuolar degeneration. The renal interstitium showed no significant lesions. Alport syndrome should be considered in the differential diagnosis. 55 N 0 8 3.97g/24h N 70 51 glomeruli were examined. Eight glomeruli showed global sclerosis. The walls of small blood vessels were thickened, with deposition of eosinophilic (red-stained) material. These findings are consistent with renal damage due to thrombotic microangiopathy (TMA), accompanied by small vessel lesions. 2 glomeruli were examined. There was mild to moderate proliferation of glomerular mesangial cells and matrix, with a small amount of electron-dense material deposition in the mesangial area. The basement membrane showed diffuse homogeneous thickening. Segmental fusion of podocyte foot processes was present. The renal tubular epithelium exhibited increased lysosomes, and the renal interstitium showed no significant lesions. These findings are consistent with diabetic nephropathy 70 N 0 Renal pathological features Six of eight patients had renal biopsy results. Light microscopy showed glomerular capillary endothelial cell swelling (83.3%), poor capillary loop openness (66.7%), small vessel endothelial cell swelling (66.7%), and tubular brush border loss (66.7%) in most patients. One patient had glomerular coagulative necrosis, and half the patients had interstitial edema, cellular infiltration, or fibrosis. Immunofluorescence showed nonspecific immune complex and C3 deposition. Electron microscopy results from four patients revealed endothelial cell proliferation and basal membrane widening in one, numerous fragmented RBCs in capillary loops in another, and no typical TMA features in the remaining two. See Tables 2 and 3 . Table 3 Renal Biopsy Pathological in Pregnancy-Associated TMA Patient glomerular lesion tubular lesion renal interstitial lesion renal vascular lesion immunofluorescence capillary lumen opening disparity capillary endothelial cell swelling Hyaline thrombus formation glomerulosclerosis Coagulative necrosis Cellular crescents brush border loss of renal tubules Tubular cell proliferation Interstitial edema interstitial fibrosis Interstitial cellular infiltration endothelial cell proliferation Luminal narrowing 1 (+) (+) (-) 0 (+) 0 (+) (-) (-) (-) (+) (+) (+) (-) 2 (+) (+) (+) 1/15 (-) 1/15 (+) (+) (+) (-) (+) (+) (+) IgA(++); IgG(+), kappa(++), lambda(+) 3 (+) (+) (-) 0 (-) 0 (+) (-) (+) (+) (-) (-) (-) (-) 4 (-) (+) (-) 0 (-) 0 (+) (-) (+) (-) (+) (+) (-) IgM(++), C3(+) 7 (+) (+) (-) 1/20 (-) 0 (-) (-) (-) (+) (-) (+) (-) C3(+) 8 (-) (-) (-) 8/51 (-) 0 (-) (-) (-) (+) (-) (-) (-) IgA(+), IgM(++), C3(+) Total 66.7% 83.3% 16.7% 50.0% 16.7% 16.7% 66.7% 16.7% 50.0% 50.0% 50.0% 66.7% 33.3% 3.Treatment and Prognosis of Pregnancy-Associated TMA Treatment Both aHUS patients received plasma exchange and renal replacement therapy. One received 4 plasma exchanges, with Scr dropping to 237 µmol/L and dialysis discontinued. The other had 1 plasma exchange but still required dialysis. Among 6 PE patients, 2 (1 PE with SLE, 1 PE alone) received plasma exchange, and none needed renal replacement therapy. Prognosis : For PE patients, renal function improved post-pregnancy termination (average Scr decrease of 57.2 ± 14.5%), with most recovering well; 2 had localized renal TMA. Prognosis was poor for aHUS patients: 1 had a hysterectomy, no renal recovery, and remained on dialysis; the other experienced fetal demise but partial renal recovery and dialysis discontinuation. See Table 2 . 4.Analysis of Disease Severity among Different Etiological Groups of Pregnancy-Associated TMA Comparison between aHUS and PE groups in pregnancy-associated TMA showed that aHUS patients had significantly higher serum creatinine levels and renal replacement therapy rates (P < 0.05). aHUS patients tended to have later gestational age at onset and lower platelet count than PE patients. No significant differences were found in other indicators. See Table 4 . Table 4 Comparison of Clinical Manifestations Between aHUS and PE Groups in Pregnancy-Associated TMA TMA (n = 8) aHUS(n = 2) PE (n = 6) P-value Age 32.12 ± 5.14 29.50 ± 9.19 33.00 ± 4.05 0.68 Gestational age 28.75 ± 8.73 37.50 ± 0.70 32.83 ± 5.00 0.07 HTN Rate 6/8 1/2 5/6 0.46 PLT (*109/l) 93.63 ± 86.39 28.50 ± 6.36 117.17 ± 89.78 0.06 HGB (g/l) 75.75 ± 33.36 52.50 ± 16.26 86.33 ± 33.76 0.13 LDH (U/L) 100.57 ± 895.48 2369 779.50 ± 727.43 NA D-dimer(mg/l) 7.82 ± 6.42 12.56 ± 6.97 5.46 ± 5.49 0.36 hematuria 6/8 2/2 4/6 0.53 sCr(umol/l) 366.58 ± 275.06 674.00 ± 79.20 264.10 ± 232.94 0.01 C3 (g/l) 0.81 ± 0.28 0.67 ± 0.20 0.85 ± 0.30 0.41 C4 (g/l) 0.16 ± 0.08 0.12 ± 0.01 0.18 ± 0.10 0.36 Proportion of RRT 2/8 2/2 0/6 0.04 Proportion of PE 4/8 2/2 2/6 0.43 sCr(discharge) 195.25 ± 163.63 304.50 ± 67.50 171.16 ± 69.88 0.22 Discussion Pregnancy-associated TMA is a rare but critical illness and is a key cause of severe obstetric complications. Its pathogenesis is endothelial injury that varies by etiology. The incidence rates for pregnancy-associated TMA are: preeclampsia (PE) 1/20, thrombotic thrombocytopenic purpura (TTP) 1/200,000, and atypical hemolytic uremic syndrome (aHUS) 1/25,000. In our study, PE accounted for 6/8 cases and aHUS for 2/8, with no TTP cases. PE is a common cause of pregnancy-associated TMA, often occurring in mid-to-late pregnancy with frequent hypertension. Pregnancy-associated TMA typically arises in mid-to-late pregnancy or postpartum, presenting with abdominal pain, vaginal bleeding, placental abruption, hypertension, proteinuria, hematuria, and variable renal dysfunction. Clinical manifestations and prognoses differ by etiology. For example, PE-related TMA often improves post-pregnancy termination with a favorable prognosis. In contrast, TTP and aHUS-related TMAs have more pronounced thrombocytopenia and severe renal damage, especially aHUS, which may progress despite pregnancy termination, necessitating early etiological diagnosis and specific treatment. TMA is a syndrome with diverse etiologies (hereditary and acquired), characterized by microangiopathic hemolytic anemia, thrombocytopenia, and organ involvement from platelet thrombi in microvasculature. Pregnancy-associated TMA broadly refers to TMA that occurs in pregnant patients. Diagnosis requires confirming TMA and determining the cause as PE, TTP, and aHUS, three distinct etiologies of pregnancy-associated TMA, have different treatments and prognoses. PE often progresses from hypertensive disorders of pregnancy to renal damage and TMA. Measuring serum soluble fms-like tyrosine kinase-1/placental growth factor ratios aids PE diagnosis, and prompt pregnancy termination improves PE-related TMA prognosis. TTP-related pregnancy-associated TMA is rare (1/17,000–200,000 pregnancies), with more significant thrombocytopenia and milder renal injury. Plasma exchange with hormone therapy is the first choice for treatment. Finally, aHUS-related pregnancy-associated TMA may be triggered by pregnancy, with underlying complement system gene abnormalities causing unchecked complement activation and microvascular endothelial damage. A French database study found 19% of TMA with acute kidney injury cases were pregnancy-triggered. Fadi Fakhouri et al., using a global aHUS registry, found similar complement abnormalities in pregnancy and nonpregnancy-related aHUS, supporting complement-mediated pathogenesis. In our study, one aHUS patient had decreased H factor and TMA-related gene mutations, indicating complement system involvement. Pregnancy may trigger aHUS in those with pre-existing complement abnormalities. Accurate etiological diagnosis of pregnancy-associated TMA is challenging. Our study used clinical features, autoimmune markers, post-pregnancy termination TMA changes, ADAMTS13 activity, complement H factor, and genetic testing for diagnosis, though some patients had delayed confirmation. Pregnancy-associated TMA primarily affects the kidneys, causing hematuria, proteinuria, and acute renal failure. Renal pathology typically shows glomerular and vascularendothelial swelling, with half having interstitial damage, and immunofluorescence usually reveals nonspecific deposits. Few prior systematic analyses of renal biopsy pathology in pregnancy-associated TMA exist, due to high biopsy risks in pregnant patients and inadequate communication with nephrologists. Renal impairment severity correlates with TMA etiology. aHUS patients have higher initial serum creatinine and higher rates of renal replacement therapy. PE patients often improve post-pregnancy termination, with some suffering no renal damage. aHUS patients have worse renal recovery than PE patients, but timely plasma exchange can hasten renal function improvement. Our study suggests that if, three days post-pregnancy termination, thrombocytopenia persists and renal function doesn’t improve, TTP/aHUS or PE combined with TTP/aHUS should be suspected. Early plasma exchange can enhance overall and renal prognoses, with more exchanges correlating with better outcomes. Given the unavailability of eculizumab, plasma exchange was used in our study and it improved patient outcomes. PE combined with TTP/aHUS is possible, so early combined plasma exchange and pregnancy termination may benefit patients with unclear etiology. Treatment varies by etiology. PE/HELLP syndrome requires prompt pregnancy termination, even before 28 weeks’ gestation, combined with plasma exchange if needed, while monitoring platelet and LDH recovery. Pregnancy-associated aHUS treatment options include plasma exchange (not always effective) and anti-C5 monoclonal antibody (eculizumab) to inhibit complement activation. Studies show plasma exchange alone doesn’t reduce the risk of end-stage renal disease, however. For pregnancy-associated TTP, plasma exchange is preferred. Early pregnancy TTP cases may consider timely termination, and mid-to-late pregnancy cases may undergo plasma exchange with close fetal monitoring. If plasma exchange fails, prompt termination is advised. In our study, two pregnancy-associated aHUS patients received plasma exchange without anti-C5 monoclonal antibodies, but we recommend adding this test for better diagnosis and treatment. In conclusion, pregnancy-associated TMA is a complex, critical condition that requires multidisciplinary collaboration. Nephrologists play a key role in diagnosis and treatment given the significant renal involvement. Recommendations for standardized management include: enhancing TMA recognition and diagnostic awareness, improving etiological diagnostic capabilities, and implementing tailored treatment strategies. Combined plasma exchange and pregnancy termination is advocated to ensure maternal safety. Declarations Acknowledgements Not applicable. Authors’ contributions LZ and MYH designed the study. LZ, LTH, ZYF, WY, and HJ performed data Collection. LZ , FF and ZB analyzed the data. LZ and MYH drafted and revised the paper. All authors approved the fnal manuscript as submitted. Funding This research was supported by National High Level Hospital Clinical Research Funding ( BJ-2022-105、BJ-2024-194); All funding bodies had no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript. Availability of data and materials The data used to support the fndings of this study are available from the corresponding author upon reasonable request. Ethics approval and consent to participate This study was approved by the institutional ethics committee of Beijing Hospital (2025BJYYEC-KY296-01) . This study was carried out in accordance with the code of ethics of the World Medical Association Declaration of Helsinki. This study was approved by the Ethics Review Committee of Beijing Hospital with a waiver of informed consent. Consent for publication Not applicable. Competing interests The authors have no confict of interest to declare References Zununi, Vahed, et al. Thromb microangiopathy Dur pregnancy Microvascular Res. 2021;138:10422. Gupta M, et al. Thrombotic microangiopathies of pregnancy: Differential diagnosis. Pregnancy Hypertens. 2018;12:29–34. Inkeri Lokki A, Heikkinen-Eloranta J, et al. Pregnancy induced TMA in severe preeclampsia results from complement-mediated thromboinflammation. Hum Immunol. 2021;82:371–8. Scully M, et al. Thrombotic thrombocytopenic purpura and atypical hemolytic uremic syndrome microangiopathy in pregnancy. Semin Thromb Hemost. 2016;42(7):774–9. Megha, Gupta et al. january. Pregnancy-Associated Atypical Hemolytic Uremic Syndrome. obstetrics & gynecology vol. 135, no.1, 2020. Fremeaux-Bacchi V, Fakhouri F, Garnier A, et al. Genetics and outcome of atypical hemolytic uremic syndrome: a nationwide French series comparing children and adults. Clin J Am Soc Nephrol. 2013;8:554. Fadi, Fakhouri, et al. Pregnancy-triggered atypical hemolytic uremic syndrome (aHUS): a Global aHUS. Registry Anal J Nephrol. 2021;34:1581–90. Fadi, Fakhouri et al. Management of thrombotic microangiopathy in pregnancy and postpartum: report from an international working group.Blood 5 november 2020 | volume 136, number 19. Eslick R, McLintock C. Managing ITP and thrombocytopenia in pregnancy. Platelets. 2020;31(3):300–6. Neave L, Scully M. Microangiopathic hemolytic anemia in pregnancy. Transfus Med Rev. 2018;32(4):230–6. Marie Scully. How to evaluate and treat the spectrum of TMA syndromes in pregnancy Hematology 2021 ASH Education Program 545–551. Reese JA, Peck JD, Deschamps DR, et al. Platelet counts during pregnancy. N Engl J Med. 2018;379(1):32–43. Vahed SZ. Yalda Rahbar Saadat,Mohammadreza Ardalan. Thrombotic microangiopathy during pregnancy. Microvasc Res 2021 Nov:138:104226. 10.1016/j.mvr.2021.104226 Additional Declarations No competing interests reported. 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15:53:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8195195/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8195195/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":98422319,"identity":"1044d193-adc5-4867-b102-1e09864684fa","added_by":"auto","created_at":"2025-12-17 16:30:50","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":45414,"visible":true,"origin":"","legend":"","description":"","filename":"RenalManifestationsinPregnancyAssociatedThromboticMicroangiopathyTMAlizhanBMCnephrology.docx","url":"https://assets-eu.researchsquare.com/files/rs-8195195/v1/f9a94fbfe5112ac5f0797071.docx"},{"id":97926903,"identity":"ba172310-b529-4874-a7a5-64e4e8684850","added_by":"auto","created_at":"2025-12-10 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21:55:17","extension":"html","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":123115,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8195195/v1/4778d06899d49a6e52151a45.html"},{"id":98622397,"identity":"4c3eb6d3-35d5-4304-b0ca-8f6c34534179","added_by":"auto","created_at":"2025-12-19 16:53:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1001357,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8195195/v1/796e2d1e-effd-4a92-b763-f95e37d5b19a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Renal Manifestations in Pregnancy-Associated Thrombotic Microangiopathy (TMA)","fulltext":[{"header":"Background","content":"\u003cp\u003ePregnancy-associated thrombotic microangiopathy (TMA) is rare but acute, severe, and can affect multiple organs; kidney damage in particular often leads to acute renal failure. Common causes of TMA include severe preeclampsia (sPE)/HELLP syndrome, thrombotic thrombocytopenic purpura (TTP), and atypical hemolytic uremic syndrome (aHUS), which can overlap, making early diagnosis difficult. Prognosis is influenced by various factors, and delayed treatment results in poor outcomes for kidneys and the rest of the body, severely affecting both mothers and fetuses. This study reviews pregnancy-associated TMA cases to analyze characteristics, kidney manifestations, and prognosis, and to enhance diagnostic awareness and capabilities and identify factors that affect prognosis.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e \u003cb\u003eStudy design and study population\u003c/b\u003e \u003c/p\u003e \u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eStudy Population: Hospitalized patients diagnosed with pregnancy-associated thrombotic microangiopathy (TMA) in the Department of Nephrology, National Center of Gerontology, Beijing Hospital from January, 2014 to December ,2023. Inclusion criteria included:Age\u0026thinsp;\u0026ge;\u0026thinsp;18 years, female; Pregnant at the time of diagnosis; TMA confirmed clinically and/or by renal biopsy. Exclusion criterion included Autoimmune hemolytic anemia.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eClinical Data: Collected data included basic patient information (age, gestational age, perinatal symptoms, blood pressure at onset, past TMA history, TMA etiology), laboratory parameters (platelet count, hemoglobin (HGB), lactate dehydrogenase (LDH), coagulation profile), renal manifestations (proteinuria, hematuria, serum creatinine (peak and pre-discharge levels), renal pathology), treatment regimens, and renal/systemic prognosis. This study was approved by the institutional ethics committee of Beijing Hospital (2025BJYYEC-KY296-01). This study was carried out in accordance with the code of ethics of the World Medical Association Declara- tion of Helsinki.This study was approved by the Ethics Review Committee of Beijing Hospital with a waiver of informed consent.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eStatistical Methods: Normally distributed continuous variables were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, and nonnormally distributed variables as median (interquartile range). Categorical data were presented as rates and percentages. Comparisons between two groups for normally distributed data were made using t-tests, and between multiple groups using ANOVA. Comparisons for nonnormally distributed data were made using the Mann-Whitney U test, and categorical data were analyzed using the chi-squared test. All statistical analysis was performed using SPSS 26.0.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e \u003cb\u003e1. Clinical and Laboratory Characteristics of Pregnancy-Associated TMA Patients\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe average age was (32.12\u0026thinsp;\u0026plusmn;\u0026thinsp;5.14) years old, and average gestational time was (28.75\u0026thinsp;\u0026plusmn;\u0026thinsp;8.73) weeks. Perinatal symptoms included abdominal pain, placental abruption, and postpartum hemorrhage, which occurred in 4 cases (50%). Hypertension occurred in 6 cases (75%). Patients also presented with manifestations of malignant hypertension such as headache, dizziness, and blurred vision. None of the patients had a previous history of thrombotic microangiopathy (TMA). Etiologies of TMA consisted of 6 cases of preeclampsia (PE), among which 1 case had active systemic lupus erythematosus (SLE) complicated with PE, and 1 had malignant hypertension complicated with PE; 2 cases of atypical hemolytic uremic syndrome (aHUS). The platelet count was (93.63\u0026thinsp;\u0026plusmn;\u0026thinsp;86.39)\u0026times;10\u003csup\u003e9\u003c/sup\u003e/l, hemoglobin (HGB) was (75.75\u0026thinsp;\u0026plusmn;\u0026thinsp;33.36) g/l, and lactate dehydrogenase (LDH) was (100.57\u0026thinsp;\u0026plusmn;\u0026thinsp;895.48) U/L. Complement 3 (C3) was (0.81\u0026thinsp;\u0026plusmn;\u0026thinsp;0.28) g/l, and complement 4 (C4) was (0.16\u0026thinsp;\u0026plusmn;\u0026thinsp;0.08) g/l. In 1 aHUS patient, the level of factor H decreased, the factor H antibody was negative (-), and the screening of TMA-related genes revealed heterozygous point mutations in the C3 gene and heterozygous point mutations in the complement factor I (CFI) gene. See Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline Characteristics and Clinical Manifestations of Pregnancy-associated TMA Patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"15\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c14\" colnum=\"14\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c15\" colnum=\"15\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient ID\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGestational age\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePerinatal symptoms\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTMA\u003c/p\u003e \u003cp\u003ePast Medical History\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTMA etiology\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBP\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePLT\u003c/p\u003e \u003cp\u003e(*10\u003csup\u003e9\u003c/sup\u003e/l)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eHGB\u003c/p\u003e \u003cp\u003e(g/l)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eLDH\u003c/p\u003e \u003cp\u003e(U/l)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003eC3\u003c/p\u003e \u003cp\u003e(g/l)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c12\"\u003e \u003cp\u003eC4\u003c/p\u003e \u003cp\u003e(g/l)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c13\"\u003e \u003cp\u003eD-dimer\u003c/p\u003e \u003cp\u003e(mg/l)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c14\"\u003e \u003cp\u003eAdam13/Factor-H\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c15\"\u003e \u003cp\u003eAutoantibody\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" 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colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27\u0026thinsp;+\u0026thinsp;6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003elower abdominal pain, placental abruption\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1265\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e2.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003elower abdominal pain, placental abruption\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e123\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e875\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e1.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e13.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003eANA1:40\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePE/SLE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1941\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e5.64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003eANA1:320\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33\u0026thinsp;+\u0026thinsp;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003enausea and vomiting, dizziness, blurred vision\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMH/PE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e360\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e0.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c13\"\u003e \u003cp\u003e0.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003easymptomatic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e230\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e121\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e0.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003easymptomatic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePE༟\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e211\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e130\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e137\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e0.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003e2.Renal Clinical and Pathological Features of Pregnancy-Associated TMA\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eRenal clinical features\u003c/b\u003e: All 8 patients had proteinuria (24h urine protein: 2.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3 g) and hematuria. PE patients had a higher 24h proteinuria (3.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4 g) than aHUS patients (2.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.3g). Six patients had acute kidney injury (serum creatinine: 366.58\u0026thinsp;\u0026plusmn;\u0026thinsp;275.06 \u0026micro;mol/L), and two had normal renal function. Four patients (2 aHUS, 1 PE, 1 PE with SLE) received plasma exchange (\u0026ge;\u0026thinsp;1 session), with 2 aHUS patients also undergoing renal replacement therapy. Plasma exchange started (2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4 days) after TMA onset. See Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRenal Manifestations and Treatment Strategies in Pregnancy-Related TMA Patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient ID\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUrine protein\u0026ndash;creatinine ratio, g/g or Urinary protein excretion\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ehematuria\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003esCr\u003c/p\u003e \u003cp\u003e(max)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eHistology on kidney biopsy (light microscope)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eHistology on kidney biopsy (electron microscope)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003esCr\u003c/p\u003e \u003cp\u003e(discharge)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eRenal Replacement Therapy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003ePE\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2468mg/Cr\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e618\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12 glomeruli, In 9 glomeruli, there was a reduction in the number of glomerular cell nuclei, with coagulative necrosis. The remaining glomeruli showed endothelial cell swelling. The endothelial cells in the interlobular arteries were swollen, with mucoid material deposition beneath the endothelium and resulting luminal narrowing. This is consistent with thrombotic microangiopathy (TMA), accompanied by glomerular necrosis (9/12).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e2 glomeruli were examined. The capillary loops were markedly dilated, with numerous fragmented red blood cells causing obstruction. There were no obvious electron-dense deposits in the basement membrane or mesangial area. The basement membrane was not thickened, and there was no significant widening beneath the endothelial cells. The renal tubular epithelial cells showed increased lysosomes. These findings are consistent with intracapillary hemolytic changes.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e372\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1967mg/Cr\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e730\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15 glomeruli were examined. One glomerulus showed global sclerosis, and one glomerulus exhibited a large-cell crescent. Endothelial cells were swollen, and the capillary loops were barely open. Focal hyaline thrombus formation was observed. The small arteries showed endothelial cell swelling with luminal narrowing, and red-stained material deposits were visible locally. These findings are consistent with thrombotic microangiopathy (TMA)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e237\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1446mg/Cr\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e218\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13 glomeruli were examined. Endothelial cells were proliferated and swollen, with basement membrane wrinkling and poor capillary loop patency. Some small vessel walls showed thickening. These findings are consistent with thrombotic microangiopathy (TMA)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e110\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.5g/24h\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e570.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e31 glomeruli were examined. Endothelial cell proliferation and thickening of the basement membrane were observed, with pseudo-double track formation visible. Some small vessel endothelial cells were swollen, and the vessel walls were thickened. These findings are consistent with thrombotic microangiopathy (TMA), accompanied by acute tubular injury.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e2 glomeruli were examined. There was mild proliferation of mesangial cells and matrix. Segmental endothelial cell proliferation was observed, with segmental widening of the loose layer within the basement membrane. Segmental fusion of podocyte foot processes was present, and no definite electron-dense deposits were seen. The renal tubular epithelium showed increased lysosomes, with some loss of microvilli. The renal interstitium showed no significant lesions. In combination with light microscopy findings, this is consistent with thrombotic microangiopathy (TMA) renal injury accompanied by acute tubular injury.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e149\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e131\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.29/24h\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e540\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e501\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.39/24h\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20 glomeruli were examined. One glomerulus showed global sclerosis. The endothelial cells were swollen, and the capillary loops were barely open. These findings are consistent with renal changes of thrombotic microangiopathy (TMA).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e1 glomerulus was examined. There was mild proliferation of glomerular mesangial cells and matrix, with a small amount of electron-dense deposits in the mesangial area. The glomerular basement membrane was mostly thinned, with segmental lamellar changes. Most of the podocyte foot processes were fused. The renal epithelium showed vacuolar degeneration. The renal interstitium showed no significant lesions. Alport syndrome should be considered in the differential diagnosis.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.97g/24h\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e51 glomeruli were examined. Eight glomeruli showed global sclerosis. The walls of small blood vessels were thickened, with deposition of eosinophilic (red-stained) material. These findings are consistent with renal damage due to thrombotic microangiopathy (TMA), accompanied by small vessel lesions.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e2 glomeruli were examined. There was mild to moderate proliferation of glomerular mesangial cells and matrix, with a small amount of electron-dense material deposition in the mesangial area. The basement membrane showed diffuse homogeneous thickening. Segmental fusion of podocyte foot processes was present. The renal tubular epithelium exhibited increased lysosomes, and the renal interstitium showed no significant lesions. These findings are consistent with diabetic nephropathy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eRenal pathological features\u003c/strong\u003e \u003cp\u003eSix of eight patients had renal biopsy results. Light microscopy showed glomerular capillary endothelial cell swelling (83.3%), poor capillary loop openness (66.7%), small vessel endothelial cell swelling (66.7%), and tubular brush border loss (66.7%) in most patients. One patient had glomerular coagulative necrosis, and half the patients had interstitial edema, cellular infiltration, or fibrosis. Immunofluorescence showed nonspecific immune complex and C3 deposition. Electron microscopy results from four patients revealed endothelial cell proliferation and basal membrane widening in one, numerous fragmented RBCs in capillary loops in another, and no typical TMA features in the remaining two. See Tables\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRenal Biopsy Pathological in Pregnancy-Associated TMA\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"15\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c14\" colnum=\"14\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c15\" colnum=\"15\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"6\" nameend=\"c7\" namest=\"c2\"\u003e \u003cp\u003eglomerular lesion\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003etubular lesion\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c12\" namest=\"c10\"\u003e \u003cp\u003erenal interstitial lesion\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c14\" namest=\"c13\"\u003e \u003cp\u003erenal vascular lesion\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c15\"\u003e \u003cp\u003eimmunofluorescence\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ecapillary lumen opening disparity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecapillary endothelial cell swelling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHyaline thrombus formation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eglomerulosclerosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCoagulative necrosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCellular crescents\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ebrush border loss of renal tubules\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eTubular cell proliferation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eInterstitial edema\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003einterstitial fibrosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eInterstitial cellular infiltration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eendothelial cell proliferation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003eLuminal narrowing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1/15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1/15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003eIgA(++); IgG(+), kappa(++), lambda(+)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003eIgM(++), C3(+)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1/20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003eC3(+)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8/51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e(+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e(-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003eIgA(+), IgM(++), C3(+)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e50.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e16.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e16.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e66.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e16.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e50.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e50.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e50.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e66.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e33.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003e3.Treatment and Prognosis of Pregnancy-Associated TMA\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eTreatment\u003c/strong\u003e \u003cp\u003eBoth aHUS patients received plasma exchange and renal replacement therapy. One received 4 plasma exchanges, with Scr dropping to 237 \u0026micro;mol/L and dialysis discontinued. The other had 1 plasma exchange but still required dialysis. Among 6 PE patients, 2 (1 PE with SLE, 1 PE alone) received plasma exchange, and none needed renal replacement therapy.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003ePrognosis\u003c/b\u003e: For PE patients, renal function improved post-pregnancy termination (average Scr decrease of 57.2\u0026thinsp;\u0026plusmn;\u0026thinsp;14.5%), with most recovering well; 2 had localized renal TMA. Prognosis was poor for aHUS patients: 1 had a hysterectomy, no renal recovery, and remained on dialysis; the other experienced fetal demise but partial renal recovery and dialysis discontinuation. See Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cb\u003e4.Analysis of Disease Severity among Different Etiological Groups of Pregnancy-Associated TMA\u003c/b\u003e \u003c/p\u003e \u003cp\u003eComparison between aHUS and PE groups in pregnancy-associated TMA showed that aHUS patients had significantly higher serum creatinine levels and renal replacement therapy rates (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). aHUS patients tended to have later gestational age at onset and lower platelet count than PE patients. No significant differences were found in other indicators. See Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of Clinical Manifestations Between aHUS and PE Groups in Pregnancy-Associated TMA\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTMA (n\u0026thinsp;=\u0026thinsp;8)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eaHUS(n\u0026thinsp;=\u0026thinsp;2)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePE (n\u0026thinsp;=\u0026thinsp;6)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32.12\u0026thinsp;\u0026plusmn;\u0026thinsp;5.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29.50\u0026thinsp;\u0026plusmn;\u0026thinsp;9.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33.00\u0026thinsp;\u0026plusmn;\u0026thinsp;4.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.68\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGestational age\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28.75\u0026thinsp;\u0026plusmn;\u0026thinsp;8.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37.50\u0026thinsp;\u0026plusmn;\u0026thinsp;0.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32.83\u0026thinsp;\u0026plusmn;\u0026thinsp;5.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.07\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHTN Rate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6/8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1/2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5/6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.46\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePLT (*109/l)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e93.63\u0026thinsp;\u0026plusmn;\u0026thinsp;86.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28.50\u0026thinsp;\u0026plusmn;\u0026thinsp;6.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e117.17\u0026thinsp;\u0026plusmn;\u0026thinsp;89.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHGB (g/l)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75.75\u0026thinsp;\u0026plusmn;\u0026thinsp;33.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52.50\u0026thinsp;\u0026plusmn;\u0026thinsp;16.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e86.33\u0026thinsp;\u0026plusmn;\u0026thinsp;33.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLDH (U/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100.57\u0026thinsp;\u0026plusmn;\u0026thinsp;895.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2369\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e779.50\u0026thinsp;\u0026plusmn;\u0026thinsp;727.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD-dimer(mg/l)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.82\u0026thinsp;\u0026plusmn;\u0026thinsp;6.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.56\u0026thinsp;\u0026plusmn;\u0026thinsp;6.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.46\u0026thinsp;\u0026plusmn;\u0026thinsp;5.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.36\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ehematuria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6/8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2/2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4/6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003esCr(umol/l)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e366.58\u0026thinsp;\u0026plusmn;\u0026thinsp;275.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e674.00\u0026thinsp;\u0026plusmn;\u0026thinsp;79.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e264.10\u0026thinsp;\u0026plusmn;\u0026thinsp;232.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC3 (g/l)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.81\u0026thinsp;\u0026plusmn;\u0026thinsp;0.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.67\u0026thinsp;\u0026plusmn;\u0026thinsp;0.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.85\u0026thinsp;\u0026plusmn;\u0026thinsp;0.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.41\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC4 (g/l)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.16\u0026thinsp;\u0026plusmn;\u0026thinsp;0.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.12\u0026thinsp;\u0026plusmn;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.18\u0026thinsp;\u0026plusmn;\u0026thinsp;0.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.36\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProportion of RRT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2/8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2/2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0/6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.04\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProportion of PE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4/8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2/2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2/6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.43\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003esCr(discharge)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e195.25\u0026thinsp;\u0026plusmn;\u0026thinsp;163.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e304.50\u0026thinsp;\u0026plusmn;\u0026thinsp;67.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e171.16\u0026thinsp;\u0026plusmn;\u0026thinsp;69.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003ePregnancy-associated TMA is a rare but critical illness and is a key cause of severe obstetric complications. Its pathogenesis is endothelial injury that varies by etiology. The incidence rates for pregnancy-associated TMA are: preeclampsia (PE) 1/20, thrombotic thrombocytopenic purpura (TTP) 1/200,000, and atypical hemolytic uremic syndrome (aHUS) 1/25,000. In our study, PE accounted for 6/8 cases and aHUS for 2/8, with no TTP cases. PE is a common cause of pregnancy-associated TMA, often occurring in mid-to-late pregnancy with frequent hypertension. Pregnancy-associated TMA typically arises in mid-to-late pregnancy or postpartum, presenting with abdominal pain, vaginal bleeding, placental abruption, hypertension, proteinuria, hematuria, and variable renal dysfunction. Clinical manifestations and prognoses differ by etiology. For example, PE-related TMA often improves post-pregnancy termination with a favorable prognosis. In contrast, TTP and aHUS-related TMAs have more pronounced thrombocytopenia and severe renal damage, especially aHUS, which may progress despite pregnancy termination, necessitating early etiological diagnosis and specific treatment.\u003c/p\u003e \u003cp\u003eTMA is a syndrome with diverse etiologies (hereditary and acquired), characterized by microangiopathic hemolytic anemia, thrombocytopenia, and organ involvement from platelet thrombi in microvasculature. Pregnancy-associated TMA broadly refers to TMA that occurs in pregnant patients. Diagnosis requires confirming TMA and determining the cause as PE, TTP, and aHUS, three distinct etiologies of pregnancy-associated TMA, have different treatments and prognoses. PE often progresses from hypertensive disorders of pregnancy to renal damage and TMA. Measuring serum soluble fms-like tyrosine kinase-1/placental growth factor ratios aids PE diagnosis, and prompt pregnancy termination improves PE-related TMA prognosis. TTP-related pregnancy-associated TMA is rare (1/17,000\u0026ndash;200,000 pregnancies), with more significant thrombocytopenia and milder renal injury. Plasma exchange with hormone therapy is the first choice for treatment. Finally, aHUS-related pregnancy-associated TMA may be triggered by pregnancy, with underlying complement system gene abnormalities causing unchecked complement activation and microvascular endothelial damage.\u003c/p\u003e \u003cp\u003eA French database study found 19% of TMA with acute kidney injury cases were pregnancy-triggered. Fadi Fakhouri et al., using a global aHUS registry, found similar complement abnormalities in pregnancy and nonpregnancy-related aHUS, supporting complement-mediated pathogenesis. In our study, one aHUS patient had decreased H factor and TMA-related gene mutations, indicating complement system involvement. Pregnancy may trigger aHUS in those with pre-existing complement abnormalities.\u003c/p\u003e \u003cp\u003eAccurate etiological diagnosis of pregnancy-associated TMA is challenging. Our study used clinical features, autoimmune markers, post-pregnancy termination TMA changes, ADAMTS13 activity, complement H factor, and genetic testing for diagnosis, though some patients had delayed confirmation. Pregnancy-associated TMA primarily affects the kidneys, causing hematuria, proteinuria, and acute renal failure. Renal pathology typically shows glomerular and vascularendothelial swelling, with half having interstitial damage, and immunofluorescence usually reveals nonspecific deposits. Few prior systematic analyses of renal biopsy pathology in pregnancy-associated TMA exist, due to high biopsy risks in pregnant patients and inadequate communication with nephrologists.\u003c/p\u003e \u003cp\u003eRenal impairment severity correlates with TMA etiology. aHUS patients have higher initial serum creatinine and higher rates of renal replacement therapy. PE patients often improve post-pregnancy termination, with some suffering no renal damage. aHUS patients have worse renal recovery than PE patients, but timely plasma exchange can hasten renal function improvement. Our study suggests that if, three days post-pregnancy termination, thrombocytopenia persists and renal function doesn\u0026rsquo;t improve, TTP/aHUS or PE combined with TTP/aHUS should be suspected. Early plasma exchange can enhance overall and renal prognoses, with more exchanges correlating with better outcomes. Given the unavailability of eculizumab, plasma exchange was used in our study and it improved patient outcomes. PE combined with TTP/aHUS is possible, so early combined plasma exchange and pregnancy termination may benefit patients with unclear etiology.\u003c/p\u003e \u003cp\u003eTreatment varies by etiology. PE/HELLP syndrome requires prompt pregnancy termination, even before 28 weeks\u0026rsquo; gestation, combined with plasma exchange if needed, while monitoring platelet and LDH recovery. Pregnancy-associated aHUS treatment options include plasma exchange (not always effective) and anti-C5 monoclonal antibody (eculizumab) to inhibit complement activation. Studies show plasma exchange alone doesn\u0026rsquo;t reduce the risk of end-stage renal disease, however. For pregnancy-associated TTP, plasma exchange is preferred. Early pregnancy TTP cases may consider timely termination, and mid-to-late pregnancy cases may undergo plasma exchange with close fetal monitoring. If plasma exchange fails, prompt termination is advised. In our study, two pregnancy-associated aHUS patients received plasma exchange without anti-C5 monoclonal antibodies, but we recommend adding this test for better diagnosis and treatment.\u003c/p\u003e \u003cp\u003eIn conclusion, pregnancy-associated TMA is a complex, critical condition that requires multidisciplinary collaboration. Nephrologists play a key role in diagnosis and treatment given the significant renal involvement. Recommendations for standardized management include: enhancing TMA recognition and diagnostic awareness, improving etiological diagnostic capabilities, and implementing tailored treatment strategies. Combined plasma exchange and pregnancy termination is advocated to ensure maternal safety.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLZ and MYH designed the study. LZ, LTH, ZYF, WY, and HJ performed data Collection. LZ , FF and ZB analyzed the data. LZ and MYH drafted and revised the paper. All authors approved the fnal manuscript as submitted.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was supported by National High Level Hospital Clinical Research Funding ( BJ-2022-105、BJ-2024-194); All funding bodies had no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript. Availability of data and materials The data used to support the fndings of this study are available from the corresponding author upon reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEthics approval and consent to participate\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study was approved by the institutional ethics committee of Beijing Hospital (2025BJYYEC-KY296-01) . This study was carried out in accordance with the code of ethics of the World Medical Association Declaration of Helsinki. This study was approved by the Ethics Review Committee of Beijing Hospital with a waiver of informed consent.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no confict of interest to declare\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eZununi, Vahed, et al. Thromb microangiopathy Dur pregnancy Microvascular Res. 2021;138:10422.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGupta M, et al. Thrombotic microangiopathies of pregnancy: Differential diagnosis. Pregnancy Hypertens. 2018;12:29\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInkeri Lokki A, Heikkinen-Eloranta J, et al. Pregnancy induced TMA in severe preeclampsia results from complement-mediated thromboinflammation. Hum Immunol. 2021;82:371\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eScully M, et al. Thrombotic thrombocytopenic purpura and atypical hemolytic uremic syndrome microangiopathy in pregnancy. Semin Thromb Hemost. 2016;42(7):774\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMegha, Gupta et al. january. Pregnancy-Associated Atypical Hemolytic Uremic Syndrome. obstetrics \u0026amp; gynecology vol. 135, no.1, 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFremeaux-Bacchi V, Fakhouri F, Garnier A, et al. Genetics and outcome of atypical hemolytic uremic syndrome: a nationwide French series comparing children and adults. Clin J Am Soc Nephrol. 2013;8:554.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFadi, Fakhouri, et al. Pregnancy-triggered atypical hemolytic uremic syndrome (aHUS): a Global aHUS. Registry Anal J Nephrol. 2021;34:1581\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFadi, Fakhouri et al. Management of thrombotic microangiopathy in pregnancy and postpartum: report from an international working group.Blood 5 november 2020 | volume 136, number 19.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEslick R, McLintock C. Managing ITP and thrombocytopenia in pregnancy. Platelets. 2020;31(3):300\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNeave L, Scully M. Microangiopathic hemolytic anemia in pregnancy. Transfus Med Rev. 2018;32(4):230\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarie Scully. How to evaluate and treat the spectrum of TMA syndromes in pregnancy Hematology 2021 ASH Education Program 545\u0026ndash;551.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReese JA, Peck JD, Deschamps DR, et al. Platelet counts during pregnancy. N Engl J Med. 2018;379(1):32\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVahed SZ. Yalda Rahbar Saadat,Mohammadreza Ardalan. Thrombotic microangiopathy during pregnancy. Microvasc Res 2021 Nov:138:104226. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.mvr.2021.104226\u003c/span\u003e\u003cspan address=\"10.1016/j.mvr.2021.104226\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nephrology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bnep","sideBox":"Learn more about [BMC Nephrology](http://bmcnephrol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bnep/default.aspx","title":"BMC Nephrology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Pregnancy, Acute Kidney Injury (AKI), Thrombotic Microangiopathy (TMA), Plasma Exchange (PE)","lastPublishedDoi":"10.21203/rs.3.rs-8195195/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8195195/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eThis study investigates the characteristics of pregnancy-related thrombotic microangiopathy (TMA) and its renal manifestations, with a focus on factors that affect renal prognosis.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eClinical data, renal involvement, treatment regimens, and prognosis were collected for patients diagnosed with pregnancy-related TMA who were admitted to the Nephrology Department of the National Center of Geriatrics at Beijing Hospital from 2014 to 2023.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eEight clinically and/or pathologically diagnosed cases of pregnancy-related TMA were identified. The average age was (32.12\u0026thinsp;\u0026plusmn;\u0026thinsp;5.14) years, and the onset of TMA during pregnancy occurred at an average of (28.75\u0026thinsp;\u0026plusmn;\u0026thinsp;8.73) weeks. Common peripartum symptoms included abdominal pain, placental abruption, and postpartum hemorrhage. Causes of TMA included pre-eclampsia (PE) in 6 cases, among which 1 case was complicated by systemic lupus erythematosus (SLE) and 1 case by malignant hypertension, and atypical hemolytic uremic syndrome (aHUS) in 2 cases. Laboratory findings revealed significantly elevated levels of LDH and D-dimer, with platelet counts at (93.63\u0026thinsp;\u0026plusmn;\u0026thinsp;86.39)\u0026times;10\u003csup\u003e9\u003c/sup\u003e/l and hemoglobin at (75.75\u0026thinsp;\u0026plusmn;\u0026thinsp;33.36) g/l. Renal manifestations showed varying degrees of proteinuria and hematuria in all 8 patients, with 6 patients experiencing different degrees of renal impairment and 2 patients showing no renal function impairment. The highest serum creatinine recorded was (366.58\u0026thinsp;\u0026plusmn;\u0026thinsp;275.06) umol/l, with 2 cases of aHUS patients requiring renal replacement therapy and 4 patients (2 cases of aHUS patients, 1 case of PE patient, and 1 case of PE combined with SLE patient.) needing plasma exchange treatment (\u0026ge;\u0026thinsp;1time). Among the 6 patients who underwent renal biopsy, 50% exhibited glomerular capillary endothelial cell swelling (83.3%), capillary lumen opening disparity (66.7%), small vessel endothelial cell swelling (66.7%), or brush border loss of renal tubules (66.7%). Four cases of patients had electron microscopy results: 1 case showed endothelial cell proliferation and segmental widening of the basal membrane's loose layer; 1 case showed a large number of fragmented red blood cells within the capillary loops; and 2 cases did not exhibit typical TMA electron microscopy findings. Comparisons between aHUS and PE groups revealed significant differences in serum creatinine levels and the proportion of patients requiring renal replacement therapy (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Patients with aHUS tended to develop the condition later in pregnancy and also had lower platelet counts. Prognosis results showed that 1 patient remained on hemodialysis, 1 patient came off dialysis, 1 patient was discharged automatically, and 3 patients exhibited a significant decrease in serum creatinine upon discharge among the 6 patients with kidney function impairment.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003ePregnancy-related TMA mostly manifests in mid to late pregnancy, with PE being the most common cause and renal manifestations primarily presenting as proteinuria, hematuria, and acute renal failure. Furthermore, patients with pregnancy-related aHUS tend to develop the condition later in pregnancy, experience more severe renal function impairments, have lower platelet levels, and require renal replacement therapy at a higher rate. Once diagnosed with aHUS as the cause of pregnancy-related TMA, promptly terminating the pregnancy and actively engaging in plasma exchange treatment may improve prognosis.\u003c/p\u003e","manuscriptTitle":"Renal Manifestations in Pregnancy-Associated Thrombotic Microangiopathy (TMA)","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-10 21:55:08","doi":"10.21203/rs.3.rs-8195195/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-01T14:44:18+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-13T18:32:40+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-10T07:20:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"38484069115893849517692261808292744899","date":"2026-02-01T13:54:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"214337870264095718238962432946482390542","date":"2026-02-01T13:35:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"115639613232370983398848436478343275517","date":"2026-02-01T08:59:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"150198793255860925110491460693360581390","date":"2025-12-19T02:17:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"12652647833686016452473313487868440040","date":"2025-12-17T20:21:21+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-08T08:53:23+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-25T11:25:56+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-25T11:23:24+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nephrology","date":"2025-11-24T15:37:19+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nephrology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bnep","sideBox":"Learn more about [BMC Nephrology](http://bmcnephrol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bnep/default.aspx","title":"BMC Nephrology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c5bd4b16-652e-4361-a8ea-dd9cb8f98ffb","owner":[],"postedDate":"December 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-14T15:09:15+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-10 21:55:08","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8195195","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8195195","identity":"rs-8195195","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}