Cesarean delivery and Postpartum Acute Kidney Injury

Citation: Potnuru PP, Ganduglia C, Schaefer CM, Suresh M, Eltzschig HK, Jiang Y. Impact of cesarean versus vaginal delivery on the risk of postpartum acute kidney injury: A retrospective database controlled study in 116,876 parturients. J Clin Anesth. 2022;82:110915. DOI: 10.1016/j.jclinane.2022.110915

Study objective: The rate of cesarean delivery is increasing globally but the risk of perioperative organ injury associated with cesarean delivery is not well defined. The objective of this study was to determine the risk of postpartum acute kidney injury, a peripartum complication defined by an acute decrease in kidney function, associated with cesarean delivery compared to vaginal delivery.

Setting: Population-based discharge database.

Patients: The Optum Clinformatics® Data Mart was queried for parturients that underwent cesarean or vaginal delivery between January 2016 to January 2018. Using a propensity score model based on 27 antepartum characteristics, we generated a final matched cohort of 116,876 parturients.

Intervention/exposure: Cesarean delivery as the mode of delivery.

Measurements: The risk of acute kidney injury associated with each delivery mode and the effect of acute kidney injury on the length of hospital stay for parturients.

Main results: The matched cohort consisted of 116,876 deliveries, with 58,438 cases in each group. In the cesarean delivery group, the incidence of postpartum acute kidney injury was 24.5 vs. 7.9 per 10,000 deliveries in the vaginal delivery group (adjusted odds ratio = 3; 95% CI, 2.13-4.22; P < .001). The median of the length of hospital stay [interquartile range] was longer by 50% in parturients who developed postpartum acute kidney injury after vaginal delivery (3 [2-4] days vs. those who did not, 2 [2, 3] days; P < .001) and by 67% after cesarean delivery (5 [4-7] days vs. 3 [3, 4] days; P < .001).

Conclusions: Cesarean delivery is associated with a significantly increased risk of postpartum acute kidney injury as compared to vaginal delivery. The development of postpartum acute kidney injury is associated with prolonged length of hospital stay.


  • Vaginal delivery is a normal physiologic process compared to cesarean delivery, which is major abdominal surgery
    • Recovery from uncomplicated vaginal delivery is significantly shorter than from uncomplicated cesarean delivery
  • The surgical stress response is associated with multiple downstream organ effects (i.e. organ injury)
    • Most of the organ injuries, especially in healthy patients, are subclinical and self-resolving without significant long-term sequelae
    • However, in specific subsets of patients or those prone to organ injury (for whatever reason), this can have a significant impact
  • The findings of this retrospective study suggest that cesarean delivery is associated with a higher risk of postpartum acute kidney injury (AKI).
    • Four sensitivity analyses in clinically relevant subgroups were conducted
    • The most relevant sensitivity analysis was the group with breech presentation as the indication for cesarean delivery.
    • Developing postpartum AKI was also associated with prolonged length of stay in the hospital within the cesarean delivery group (i.e. mom’s that developed postpartum AKI were discharged later compared to moms that did not develop AKI)