Diagnosis of Acute Kidney Injury During Pregnancy

Pregnancy-related acute kidney injury (PrAKI) is a serious complication causing substantial maternal and fetal morbidity and mortality with long-term sequelae including chronic kidney disease (CKD) and cardiovascular disease. PrAKI affects individuals across high- and low-resource settings, though epidemiology, etiologies, and outcomes differ substantially by context. In low-resource settings, PrAKI remains a leading cause of maternal mortality, precipitated by septic abortion, hemorrhage, and hypertensive disorders compounded by limited access to renal replacement therapy. In high-income countries, PrAKI incidence of is rising due to increasing maternal age, cardiometabolic comorbidities, and hypertensive disorders of pregnancy. PrAKI ranges from transient, reversible dysfunction to severe injury necessitating dialysis, with adverse at each stage. Diagnosis is uniquely challenging because physiological adaptations of pregnancy lower serum creatinine, rendering conventional thresholds less reliable. Current AKI definitions and kidney function estimating equations remain unvalidated in pregnant populations and pre-existing CKD may mask superimposed injury when baseline creatinine values are unknown. Management requires a multidisciplinary approach tailored to gestational age and underlying etiology. In this review, we focus on diagnostic strategies for PrAKI-including gestational age-adjusted creatinine trajectories, proteinuria assessment, and emerging kidney and placental biomarkers-alongside clinical management principles, and current gaps in knowledge.