Assessment of Point-of-care Creatinine testing In Pregnancy: A prospective cohort study in Sierra Leone

Introduction
Pregnancy-associated acute kidney injury (PrAKI) is a major cause of maternal and perinatal morbidity and mortality in low- and middle-income countries, where detection is often delayed by limited access to creatinine testing. Point-of-care creatinine (POC-Cr) devices may offer a promising alternative.

Methods
We conducted a prospective observational study of pregnant or postpartum women at high risk of PrAKI admitted to a tertiary hospital in Freetown, Sierra Leone (April–August 2023).
Eligibility criteria were systolic blood pressure ≥140 mmHg, diastolic ≥90 mmHg, and/or shock index ≥0.9. Women underwent POC-Cr testing at enrolment, 24, and 48 hours. PrAKI was defined as POC-Cr >77 μmol/l when no baseline was available, or a change ≥26 μmol/l, and staged by KDIGO criteria where possible. Associations with maternal (death, eclampsia, major surgery) and perinatal (stillbirth, neonatal death) composite outcomes were evaluated. Multivariable logistic regression identified risk factors, and optimal POC-Cr thresholds were explored. Feasibility was measured by proportion of women who refused or had failed tests.

Results
Of 1,746 eligible women, POC-Cr testing was completed in 1,669 (96%); only two (0.1%) declined, and one had (0.06%) failed tests. PrAKI (or chronic kidney disease, CKD) was identified in 427 (25.6%). Affected women had significantly higher maternal (14.5% vs.8.7%) and perinatal (19.3% vs. 4.8%) adverse outcomes compared with those without PrAKI (both P<0.001). At discharge, 47% had unresolved kidney injury, or underlying CKD. Independent risk factors included age, mean arterial pressure, and preeclampsia/ eclampsia. The optimal POC-Cr threshold for predicting adverse outcomes was
>77 μmol/l, supporting prior definitions.

Conclusions
One in four high-risk pregnancies in this setting was complicated by kidney dysfunction, associated with maternal and perinatal morbidity. POC-Cr testing is feasible, enabling earlier detection of PrAKI or CKD without laboratory infrastructure. Wider implementation could improve detection, guide prevention, and inform maternal health policy in resource-limited settings.