Objective ·To investigate the incidence and clinical features of pregnancy-related acute kidney injury (Pr-AKI) in high-risk populations and its correlation with adverse pregnancy outcomes. Methods ·This retrospective single-center cohort study included 17 468 singleton pregnancies delivered at Renji Hospital, Shanghai Jiao Tong University School of Medicine between January 2018 and December 2023. General demographic characteristics, comorbidities, pregnancy complications, serum creatinine levels, and pregnancy outcomes were collected. Pr-AKI was diagnosed according to Kidney Disease: Improving Global Outcomes criteria. Adverse pregnancy outcomes, including stillbirth, early preterm birth (gestational age < 34 weeks at delivery), and low birth weight (birth weight<2 500 g), were defined as the primary observation endpoints. Univariate and multivariate Logistic regression analyses were used to assess the impact of Pr-AKI on adverse pregnancy outcomes. Results ·The incidence of Pr-AKI was 0.3% (61/17 468). Compared with the non-AKI group, patients in the AKI group had higher rates of chronic hypertension, chronic kidney disease, and autoimmune diseases (P<0.05). Additionally, the risks of stillbirth, early preterm birth, low birth weight, and preeclampsia of the patients in the AKI group were increased (P<0.001). Multivariate Logistic regression analysis confirmed Pr-AKI as an independent risk factor for adverse pregnancy outcomes (adjusted OR=5.868, 95% CI 3.142—10.957, P<0.001). Conclusion ·Pr-AKI significantly contributes to adverse pregnancy outcomes in high-risk pregnant populations, underscoring the need for early monitoring and intervention.