Renal histopathology of prolonged acute kidney injury in HELLP syndrome: a case series and literature review

  • Wenling Ye
  • Hong Shu
  • Yubing Wen
  • Wei Ye
  • Hang Li
  • Yan Qin
  • Limeng Chen
  • Xuemei LiEmail author
Nephrology - Original Paper



Acute kidney injury (AKI) is a severe complication of hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome. However, renal pathological investigation of AKI in this syndrome has rarely been reported. We aimed to evaluate the renal pathological changes of persistent AKI and its relationship with renal outcomes in HELLP syndrome.


Women with HELLP syndrome who had a renal biopsy because of persistent AKI were investigated. The cases describing renal pathology of AKI in HELLP syndrome reported in PubMed were also reviewed.


Among the 41 patients diagnosed with AKI complicated by HELLP syndrome, 6 patients had renal biopsy. Four of these patients had anuria and required renal replacement therapy. Renal histopathology showed thrombotic microangiopathy (TMA) that coexisted with acute tubular necrosis (ATN) (3), acute renal cortical necrosis (ARCN) (1), and glomerular disease (2). Two patients who had ARCN and ATN with TMA lesions developed chronic renal dysfunction. Ten cases reported in the literature showed ATN (4), TMA (1), TMA with ATN (1), ARCN (2) and mesangial proliferative glomerulonephritis (1). All of them required temporary renal replacement therapy. Two patients developed chronic renal dysfunction including one patient with ARCN.


ATN was the most common finding for persistent AKI in HELLP syndrome. Patients with ARCN or TMA with ATN may have the potential to develop chronic renal dysfunction. Renal biopsy should be performed in patients with prolonged AKI to determine the renal prognosis and guide the appropriate treatment.


HELLP syndrome Acute kidney injury Renal pathology Outcome Pregnancy 



We are indebted to staff from the Department of Gynaecology and Obstetrics at the Peking Union Medical College Hospital for treatment and diagnostic support. We also thank Jodi Smith, Ph.D., from Liwen Bianji, Edanz Editing China (, for editing the English text of a draft of this manuscript.

Compliance with ethical standards

Conflict of interest

All authors declare that they have no conflict of interest.

Ethics approval

The research protocol was approved by the Ethics Committee at PUMCH. All procedures performed in this study were in accordance with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. For this type of study, formal consent was not required.


  1. 1.
    Gedik E, Yucel N, Sahin T, Koca E, Colak YZ, Togal T (2017) Hemolysis, elevated liver enzymes, and low platelet syndrome: outcomes for patients admitted to intensive care at a tertiary referral hospital. Hypertens Pregnancy 36(1):21–29. CrossRefGoogle Scholar
  2. 2.
    Sibai BM, Ramadan MK, Usta I, Salama M, Mercer BM, Friedman SA (1993) Maternal morbidity and mortality in 442 pregnancies with hemolysis, elevated liver enzymes, and low platelets (HELLP syndrome). Am J Obstet Gynecol 169(4):1000–1006CrossRefGoogle Scholar
  3. 3.
    Erdemoglu M, Kuyumcuoglu U, Kale A, Akdeniz N (2010) Factors affecting maternal and perinatal outcomes in HELLP syndrome: evaluation of 126 cases. Clin Exp Obstet Gynecol 37(3):213–216Google Scholar
  4. 4.
    Gul A, Aslan H, Cebeci A, Polat I, Ulusoy S, Ceylan Y (2004) Maternal and fetal outcomes in HELLP syndrome complicated with acute renal failure. Ren Fail 26(5):557–562CrossRefGoogle Scholar
  5. 5.
    Abraham KA, Connolly G, Farrell J, Walshe JJ (2001) The HELLP syndrome, a prospective study. Ren Fail 23(5):705–713CrossRefGoogle Scholar
  6. 6.
    Huang C, Chen S (2017) Acute kidney injury during pregnancy and puerperium: a retrospective study in a single center. BMC Nephrol 18(1):146. CrossRefGoogle Scholar
  7. 7.
    Selcuk NY, Odabas AR, Cetinkaya R, Tonbul HZ, San A (2000) Outcome of pregnancies with HELLP syndrome complicated by acute renal failure (1989–1999). Ren Fail 22(3):319–327CrossRefGoogle Scholar
  8. 8.
    Abraham KA, Kennelly M, Dorman AM, Walshe JJ (2003) Pathogenesis of acute renal failure associated with the HELLP syndrome: a case report and review of the literature. Eur J Obstet Gynecol Reprod Biol 108(1):99–102CrossRefGoogle Scholar
  9. 9.
    Fang JT, Chen YC, Huang CC (2000) Unusual presentation of mesangial proliferative glomerulonephritis in HELLP syndrome associated with acute renal failure. Ren Fail 22(5):641–646CrossRefGoogle Scholar
  10. 10.
    Gupta A, Ferguson J, Rahman M, Weber-Shrikant E, Venuto R (2012) Acute oliguric renal failure in HELLP syndrome: case report and review of literature. Ren Fail 34(5):653–656. CrossRefGoogle Scholar
  11. 11.
    Mohaupt MG (1998) Anuria after delivery. Therapeutische Umschau Revue therapeutique 55(9):579–582Google Scholar
  12. 12.
    Sheikh IA, Shaheen FA (1998) Acute renal failure and HELLP syndrome: a single center's experience. Saudi J Kidney Dis Transpl 9(3):290–293Google Scholar
  13. 13.
    Sibai BM (2004) Diagnosis, controversies, and management of the syndrome of hemolysis, elevated liver enzymes, and low platelet count. Obstet Gynecol 103(5 Pt 1):981–991. CrossRefGoogle Scholar
  14. 14.
    Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group (2012) KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney Int 2(Suppl):1–138Google Scholar
  15. 15.
    Brocklebank V, Wood KM, Kavanagh D (2018) Thrombotic microangiopathy and the kidney. Clin J Am Soc Nephrol 13(2):300–317. CrossRefGoogle Scholar
  16. 16.
    George JN, Nester CM (2014) Syndromes of thrombotic microangiopathy. N Engl J Med 371(7):654–666. CrossRefGoogle Scholar
  17. 17.
    Vigil-De Gracia P, Rojas-Suarez J, Ramos E, Reyes O, Collantes J, Quintero A, Huertas E, Calle A, Turcios E, Chon VY (2015) Incidence of eclampsia with HELLP syndrome and associated mortality in Latin America. Int J Gynaecol Obstet 129(3):219–222. CrossRefGoogle Scholar
  18. 18.
    Karumanchi SA, Maynard SE, Stillman IE, Epstein FH, Sukhatme VP (2005) Preeclampsia: a renal perspective. Kidney Int 67(6):2101–2113. CrossRefGoogle Scholar
  19. 19.
    Abildgaard U, Heimdal K (2013) Pathogenesis of the syndrome of hemolysis, elevated liver enzymes, and low platelet count (HELLP): a review. Eur J Obstet Gynecol Reprod Biol 166(2):117–123. CrossRefGoogle Scholar
  20. 20.
    Drakeley AJ, Le Roux PA, Anthony J, Penny J (2002) Acute renal failure complicating severe preeclampsia requiring admission to an obstetric intensive care unit. Am J Obstet Gynecol 186(2):253–256CrossRefGoogle Scholar
  21. 21.
    Ghosh AK, Vashisht K, Varma S, Khullar D, Sakhuja V (1994) Acute renal failure in a patient with HELLP syndrome–an unusual complication of eclampsia. Ren Fail 16(2):295–298CrossRefGoogle Scholar
  22. 22.
    Beller FK, Dame WR, Ebert C (1985) Pregnancy induced hypertension complicated by thrombocytopenia, haemolysis and elevated liver enzymes (HELLP) syndrome. Renal biopsies and outcome. Austr N Z J Obstet Gynaecol 25 (2):83–86Google Scholar
  23. 23.
    Martin JN Jr (2013) Milestones in the quest for best management of patients with HELLP syndrome (microangiopathic hemolytic anemia, hepatic dysfunction, thrombocytopenia). Int J Gynaecol Obstet 121(3):202–207. CrossRefGoogle Scholar
  24. 24.
    Erkurt MA, Berber I, Berktas HB, Kuku I, Kaya E, Koroglu M, Nizam I, Bakirhan FA, Ozgul M (2015) A life-saving therapy in Class I HELLP syndrome: therapeutic plasma exchange. Transfus Apheresis Sci 52(2):194–198. CrossRefGoogle Scholar
  25. 25.
    Simetka O, Klat J, Gumulec J, Dolezalkova E, Salounova D, Kacerovsky M (2015) Early identification of women with HELLP syndrome who need plasma exchange after delivery. Transfus Apheresis Sci 52(1):54–59. CrossRefGoogle Scholar
  26. 26.
    Ospina-Tascon GA, Nieto Calvache AJ, Quinones E, Madrinan HJ, Valencia JD, Bermudez WF, Carvajal J, Escobar MF, de Backer D (2017) Microcirculatory blood flow derangements during severe preeclampsia and HELLP syndrome. Pregnancy Hypertens 10:124–130. CrossRefGoogle Scholar
  27. 27.
    Kahra K, Draganov B, Sund S, Hovig T (1998) Postpartum renal failure: a complex case with probable coexistence of hemolysis, elevated liver enzymes, low platelet count, and hemolytic uremic syndrome. Obstet Gynecol 92(4 Pt 2):698–700Google Scholar

Copyright information

© Springer Nature B.V. 2019

Authors and Affiliations

  • Wenling Ye
    • 1
  • Hong Shu
    • 2
  • Yubing Wen
    • 1
  • Wei Ye
    • 1
  • Hang Li
    • 1
  • Yan Qin
    • 1
  • Limeng Chen
    • 1
  • Xuemei Li
    • 1
    Email author
  1. 1.Department of Nephrology, Peking Union Medical College HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
  2. 2.Department of NephrologySecond Hospital of Lanzhou UniversityLanzhouChina

Personalised recommendations