Acute kidney injury associated with acute fatty liver of pregnancy - An update on a rare clinical entity

Sep 28, 2026

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Acute fatty liver of pregnancy (AFLP) is a rare, potentially life-threatening mitochondrial disorder characterized by microvesicular hepatic steatosis, usually in the third trimester and occasionally postpartum. AFLP overlaps with thrombotic microangiopathy features and is clinically linked to preeclampsia-like manifestations, while acute kidney injury (AKI) occurs in the majority of cases. The review synthesizes epidemiology, pathophysiology, clinical presentation, and management of AFLP-associated AKI, including tubular injury related to free fatty acids and limited evidence for therapeutic plasma exchange.

LanguageEnglish

CategoryHealthcare

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Pages12

Reading Time30 min

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Abstract

Core Tip

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Introduction

Pregnancy complications and diagnostics

Key Words

| W | J | N | World Journal of
Nephrology | | --- | --- | --- | --- | Submit a Manuscript: [https://www.f6publishing.com](https://www.f6publishing.com) World J Nephrol 2025 December 25; 14(4): 110414 DOI: 10.5527/wjn.v14.i4.110414 ISSN 2220-6124 (online) MINIREVIEWS Acute kidney injury associated with acute fatty liver of pregnancy: An update on a rare clinical entity Meenakshi Rajput, Sumitra Bachani, Jyotsna Suri, Rekha Bharti, Adarsh Kumar, Rajesh Kumar, Himanshu Verma, Pallavi Prasad Specialty type: Urology and nephrology Provenance and peer review: Invited article; Externally peer reviewed. Peer-review model: Single blind Peer-review report’s classification Scientific Quality: Grade B, Grade B Novelty: Grade A, Grade B Creativity or Innovation: Grade A, Grade B Scientific Significance: Grade A, Grade B P-Reviewer: Yuan Z, PhD, Assistant Professor, China Received: June 9, 2025 Revised: July 15, 2025 Accepted: October 24, 2025 Published online: December 25, 2025 Processing time: 200 Days and 0.9 Hours Meenakshi Rajput, Sumitra Bachani, Jyotsna Suri, Rekha Bharti, Department of Obstetrics and Gynaecology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi 110029, Delhi, India Adarsh Kumar, Rajesh Kumar, Himanshu Verma, Pallavi Prasad, Department of Nephrology and Renal Transplant Medicine, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi 110029, Delhi, India Co-first authors: Meenakshi Rajput and Sumitra Bachani. Corresponding author: Adarsh Kumar, DM, MD, Associate Professor, Department of Nephrology and Renal Transplant Medicine, Vardhman Mahavir Medical College and Safdarjung Hospital, Ansari Nagar East, Near AIIMS Metro Station, New Delhi 110029, Delhi, India. [adarshnephro081@gmail.com](adarshnephro081@gmail.com) Abstract Acute fatty liver of pregnancy (AFLP) is a rare but potentially life-threatening liver disease associated with mitochondrial dysfunction. It is characterized by microvesicular hepatic steatosis and typically occurs in the third trimester, though it may rarely present postpartum. AFLP is considered a non-thrombotic microangiopathy (TMA) but may present with overlapping TMA features. Its incidence ranges from 1 in 7000 to 1 in 20000 pregnancies, although milder cases may go unrecognized. AFLP can rapidly progress to acute liver failure and 20% to 40% of affected women exhibit clinical features of preeclampsia. Acute kidney injury (AKI) is a frequent complication, observed in 55% to 75% of AFLP cases, which is significantly higher than the 7% to 20% occurrence seen in preeclampsia or hemolysis, elevated liver enzymes, and low platelets syndrome. The exact mechanism behind AKI in AFLP remains unclear, but renal histology has shown tubular deposits of free fatty acids, which correlate with current theories regarding liver pathology. While AFLP-associated AKI is often reversible after delivery, some patients may develop persistent AKI that requires dialysis. Therapeutic plasma exchange (TPE) has been explored in these cases, but available evidence is limited. This review summarizes the current understanding of the epidemiology, pathophysiology, clinical features, and management of AKI in the context of AFLP, and discusses the potential role of adjunctive therapies such as TPE. Key Words: Acute kidney injury; Acute tubular necrosis; Acute fatty liver of pregnancy; WJN [https://www.wjgnet.com](https://www.wjgnet.com) 1 December 25, 2025 Volume 14 Issue 4 Rajput M et al. AKI Associated with AFLP Pregnancy complications; Therapeutic plasma exchange ©The Author(s) 2025. Published by Baishideng Publishing Group Inc. All rights reserved. Core Tip: Acute kidney injury (AKI) associated with acute fatty liver of pregnancy (AFLP) occurs more frequently than AKI related to preeclampsia or hemolysis, elevated liver enzymes, and low platelets syndrome; however, it is generally nonoliguric and of relatively low severi

FAQs

How common is acute kidney injury in acute fatty liver of pregnancy compared with preeclampsia-related syndromes?

AKI is reported in about 55% to 75% of AFLP cases, which is higher than the 7% to 20% occurrence seen in preeclampsia or hemolysis, elevated liver enzymes, and low platelets syndrome.

What mechanism is proposed for AFLP-associated AKI?

The exact mechanism is unclear, but renal histology shows tubular deposits of free fatty acids that align with current theories about liver-derived pathology contributing to kidney injury.

Can AFLP-associated AKI persist after delivery and what treatments are discussed?

AKI is often reversible after delivery, but some patients develop persistent AKI requiring dialysis. Therapeutic plasma exchange has been explored, though available evidence remains limited, and rapid recognition with prompt delivery is emphasized.

Sep 28, 2026

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