Pregnancy-associated acute kidney injury (PrAKI) is a critical condition traditionally triggered by classic obstetric complications. However, recent clinical observations suggest a shifting landscape. This study investigated the decadal temporal trends of severe PrAKI in a high-income setting, focusing on the changing balance between chronic metabolic vulnerabilities, acute systemic stressors, dialysis utilization, and maternal survival.

We conducted a retrospective cohort study using data from the de-identified TriNetX network spanning 2012 to 2022. Out of 4.1 million pregnancies, severe PrAKI was defined as requiring acute initiation of dialysis or having a first recorded estimated glomerular filtration rate (eGFR) < 15 mL/min/1.73 m² during pregnancy. Temporal changes in baseline health profiles, acute co-morbid stressors (including COVID-19), and short-term renal recovery profiles were tracked biennially.

A total of 8,124 individuals developed severe PrAKI. The incidence increased nearly three-fold from 9.0 per 10,000 pregnancies in 2012–2013 to 27.6 per 10,000 in 2020–2022 (p < 0.001). Multivariable logistic regression revealed that chronic pre-pregnancy conditions were major independent factors, led by cardiometabolic factors and chronic comorbidities including chronic hypertension, obesity, diabetes mellitus, hyperlipidemia, and chronic kidney disease. Meanwhile, traditional pregnancy complications such as HELLP syndrome and placental hemorrhagic disorders significantly declined within the severe PrAKI cohort over time (p < 0.05). During the pandemic era (2020–2022), COVID-19 infection acted as a severe systemic trigger COVID-19 (aOR: 1.12), present in 47.2% of all maternal deaths. Crucially, a "dialysis paradox" was observed: despite a sharp rise in all-cause maternal mortality during 2020–2022 (reaching 3.15%), the proportion of severe PrAKI patients requiring acute dialysis remained stable at 1.6 to 2.3 per 10,000 pregnancies throughout the decade (p-trend = 0.106). For survivors, significant renal recovery was documented, with dialysis dependency falling from 28.2% at 3 months to 4.0% by 13 months post-diagnosis (p < 0.001).

Severe PrAKI has shown a clear shift from an isolated obstetric complication to a strong indicator of systemic multi-organ failure superimposed on pre-existing cardiometabolic vulnerability. Early risk screening and timely multidisciplinary critical care are essential to reduce maternal mortality.