Postpartum kidney assessment after hypertensive disorders of pregnancy: A practical framework for obstetric care

Hypertensive disorders of pregnancy, particularly pre-eclampsia, are recognized not only as major obstetric complications but also as early indicators of future maternal cardiovascular and renal risk. Despite this, postpartum care remains centered on blood pressure surveillance, whereas kidney assessment is not consistently incorporated into routine obstetric follow-up. This narrative review examines the renal implications of hypertensive disorders of pregnancy beyond delivery and translates guidance and observational evidence into a practical obstetric approach to postpartum kidney assessment. Available data indicate that a clinically meaningful subgroup of women have persistent renal abnormalities in the early postpartum period, most often as albuminuria or proteinuria rather than as overt reduction in estimated glomerular filtration rate. Reliance on blood pressure or serum creatinine alone may therefore fail to identify incomplete renal recovery, pregnancy-unmasked chronic kidney disease, or women requiring closer reassessment. We also emphasize pregnancy-associated acute kidney injury as a high-priority phenotype, operationalized by creatinine rise or oliguria using Kidney Disease: Improving Global Outcomes (KDIGO)-type criteria and interpreted against pregnancy-specific creatinine physiology. Patients meriting greater attention include those with severe or preterm disease, persistent hypertension, antenatal renal abnormalities, pregnancy-associated acute kidney injury, or relevant pre-existing comorbidity. We propose a feasible postpartum framework based on blood pressure measurement, serum creatinine with estimated glomerular filtration rate, and urinary assessment of albuminuria or proteinuria, with repeat testing or specialist evaluation guided by postpartum findings and clinical risk. Rather than creating a parallel nephrology pathway, this approach supports obstetric services in identifying women whose renal recovery may be incomplete.