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Saunders J, Callejas Salgado AM, Ting JY, Mammen C, Terry J, Bush JW. Quantifying Proximal Collecting Tubule Deficiency in Angiotensin-Converting Enzyme Inhibitor and Angiotensin II Receptor Blocker Fetopathy. Pediatr Dev Pathol 2021; 24:438-444. [PMID: 34082612 DOI: 10.1177/10935266211018922] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Angiotensin-Converting Enzyme Inhibitors and Angiotensin II Receptor Blockers (AAs) are used for several indications, with cessation recommended in pregnancy due to toxic effects. AA fetopathy phenotype is similar to renal tubular dysgenesis including reduced proximal convoluted tubules (PCTs). Our study aimed to quantify the reduction of PCTs in fetuses and infants with prenatal exposure to AAs. MATERIALS AND METHODS We identified 5 fetal AA exposure cases that underwent autopsy at our institution between 2011 and 2018 and compared with 5 gestational age-matched controls. Immunohistochemistry with CD10 and epithelial membrane antigen (EMA) was utilized. RESULTS CD10 and EMA identified a median PCT density of 19.0% ± 12.3% in AA fetopathy patients, significantly less than controls (52.8% ± 4.4%; p < 0.0001). One case with in utero cessation had a PCT density of 34.2% ± 0.2%. Among other AA fetopathy findings, 1 case demonstrated unilateral renal vein thrombosis and 4 had hypocalvaria. CONCLUSIONS We have quantified the reduction in AA fetopathy PCT density, and demonstrated in utero cessation may recover PCT differentiation. Future studies may benefit from calculating PCT percentage as a potential biomarker to correlate with post-natal renal function and maternal factors including medication type, dosage, duration, and time from medication cessation.
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Affiliation(s)
- Jessica Saunders
- Division of Anatomical Pathology, British Columbia Children's Hospital and Women's Hospital and Health Center, Vancouver, Canada.,Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada
| | | | - Joseph Y Ting
- Section of Neonatology, British Columbia Children's Hospital and Women's Hospital and Health Center, Vancouver, Canada.,Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Cherry Mammen
- Department of Pediatrics, University of British Columbia, Vancouver, Canada.,Division of Nephrology, British Columbia Children's Hospital and Women's Hospital and Health Center, Vancouver, Canada
| | - Jefferson Terry
- Division of Anatomical Pathology, British Columbia Children's Hospital and Women's Hospital and Health Center, Vancouver, Canada.,Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada
| | - Jonathan W Bush
- Division of Anatomical Pathology, British Columbia Children's Hospital and Women's Hospital and Health Center, Vancouver, Canada.,Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada
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Petch S, O'Connor E, McGrath A, Daly S. Valsartan exposure in pregnancy with resultant anhydramnios and chronic kidney disease in a late preterm infant. BMJ Case Rep 2021; 14:e240810. [PMID: 34011666 PMCID: PMC8137155 DOI: 10.1136/bcr-2020-240810] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2021] [Indexed: 11/04/2022] Open
Abstract
In utero exposure to angiotensin II receptor blockers (ARBs) has fetotoxic effects including renal failure, oligohydramnios and lung hypoplasia. We present the case of a 24-year-old woman who presented to the maternity services in the 34th week of her first pregnancy. She was taking valsartan for hypertension. Ultrasound showed a structurally normal fetus with anhydramnios. The patient was admitted and valsartan was discontinued. She had spontaneous preterm delivery at 35 weeks' gestation of a baby girl. The baby's urine output was minimal in the first week of life and she was transferred to a paediatric hospital for specialist nephrology input. At 6 months of age, she requires ongoing nephrology follow-up and she remains on treatment for hypertension and anaemia. This case demonstrates the serious adverse effects resulting from ARB exposure in utero, and highlights the importance of avoiding fetotoxic medications in women of childbearing age.
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Affiliation(s)
- Sarah Petch
- Obstetrics and Gynaecology, Coombe Women and Infants University Hospital, Dublin, Ireland
| | - Emily O'Connor
- Obstetrics and Gynaecology, Coombe Women and Infants University Hospital, Dublin, Ireland
| | - Ailbhe McGrath
- Molecular, Genetic and Population Health Science, The University of Edinburgh Edinburgh Medical School, Edinburgh, UK
- General Paediatrics, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Sean Daly
- Maternal Fetal Medicine, Coombe Women and Infants University Hospital, Dublin, Ireland
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Postmortem blood concentrations of sartans measured by liquid chromatography-tandem mass spectrometry. Forensic Toxicol 2016. [DOI: 10.1007/s11419-016-0308-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Reversible Fetal Renal Impairment following Angiotensin Receptor Blocking Treatment during Third Trimester of Pregnancy: Case Report and Review of the Literature. Case Rep Obstet Gynecol 2016; 2016:2382031. [PMID: 27672462 PMCID: PMC5031874 DOI: 10.1155/2016/2382031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 08/17/2016] [Accepted: 08/22/2016] [Indexed: 11/23/2022] Open
Abstract
Background. Late pregnancy usage of angiotensin converting enzyme inhibitors (ACE-I) and angiotensin II receptor blockers (ARB) may cause severe oligohydramnios due to fetal renal impairment. Affected neonates will often suffer from fatal, renal, and respiratory failure. Case. A 39-year-old multigravida admitted due to anhydramnios secondary to valsartan (ARB) exposure at 30 weeks' gestation. Following secession of treatment amniotic fluid volume returned to normal. Delivery was induced at 34 weeks' gestation following premature rupture of membranes and maternal fever. During the two-year follow-up, no signs of renal insufficiency were noted. Conclusions. This description of reversible fetal renal damage due to ARB intake during pregnancy is the first to show no adverse renal function in a two-year follow-up period. This case may help clinicians counsel patients with pregnancies complicated by exposure to these drugs.
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Marchetto L, Sordino D, De Bernardo G, Trevisanuto D. Postnatal acute renal failure after fetal exposure to angiotensin receptor blockers. BMJ Case Rep 2015; 2015:bcr-2014-207450. [PMID: 26139648 DOI: 10.1136/bcr-2014-207450] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Maternal hypertensive treatment with angiotensin receptor blockers (ARBs) during the second and third trimester of pregnancy is associated with several fetal and neonatal complications, and potential adverse outcomes. We report a neonate presenting with transient renal acute failure during the first days of life after maternal treatment with ARBs. Women who became pregnant while taking one of these drugs must modify antihypertensive therapy with a different class drug as soon as pregnancy is recognised.
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Affiliation(s)
- Luca Marchetto
- Children and Women's Health Department, Medical School University of Padua, Padua, Italy
| | | | | | - Daniele Trevisanuto
- Children and Women's Health Department, Medical School University of Padua, Padua, Italy
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Rodríguez-Castaño M, Corredera A, Aleo E, Arruza L. Prenatal Exposure to Angiotensin II Receptor Blockers and Hemodynamic Effects on the Newborn. Fetal Pediatr Pathol 2015; 34:117-9. [PMID: 25394297 DOI: 10.3109/15513815.2014.976685] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Angiotensin II receptor blockers (ARBs) are potent antihypertensive agents that block the renin angiotensin aldosterone system (RAS). Their use in pregnancy may cause malformations, oligoanuria, hypotension, and death. Hypotension is observed up to 15% of cases and is described as refractory to volume and inotropic support, although its pathophysiology is unknown. We present a case of prenatal exposure to ARBs in order to characterize the hemodynamic compromise in the newborn, help in decision-making, and guide the therapeutic approach to these patients.
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Shimada C, Akaishi R, Cho K, Morikawa M, Kaneshi Y, Yamda T, Minakami H. Outcomes of 83 fetuses exposed to angiotensin receptor blockers during the second or third trimesters: a literature review. Hypertens Res 2015; 38:308-13. [DOI: 10.1038/hr.2015.12] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Revised: 10/29/2014] [Accepted: 11/01/2014] [Indexed: 11/09/2022]
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Bullo M, Tschumi S, Bucher BS, Bianchetti MG, Simonetti GD. Pregnancy Outcome Following Exposure to Angiotensin-Converting Enzyme Inhibitors or Angiotensin Receptor Antagonists. Hypertension 2012; 60:444-50. [DOI: 10.1161/hypertensionaha.112.196352] [Citation(s) in RCA: 206] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Marina Bullo
- From the Department of Pediatrics and Division of Pediatric Nephrology, University Hospital (Inselspital), Berne, Switzerland (M.B., S.T., B.S.B., G.D.S.); Division of Pediatrics, Hospitals Bellinzona and Mendrisio, Bellinzona, Switzerland (M.G.B.)
| | - Sibylle Tschumi
- From the Department of Pediatrics and Division of Pediatric Nephrology, University Hospital (Inselspital), Berne, Switzerland (M.B., S.T., B.S.B., G.D.S.); Division of Pediatrics, Hospitals Bellinzona and Mendrisio, Bellinzona, Switzerland (M.G.B.)
| | - Barbara S. Bucher
- From the Department of Pediatrics and Division of Pediatric Nephrology, University Hospital (Inselspital), Berne, Switzerland (M.B., S.T., B.S.B., G.D.S.); Division of Pediatrics, Hospitals Bellinzona and Mendrisio, Bellinzona, Switzerland (M.G.B.)
| | - Mario G. Bianchetti
- From the Department of Pediatrics and Division of Pediatric Nephrology, University Hospital (Inselspital), Berne, Switzerland (M.B., S.T., B.S.B., G.D.S.); Division of Pediatrics, Hospitals Bellinzona and Mendrisio, Bellinzona, Switzerland (M.G.B.)
| | - Giacomo D. Simonetti
- From the Department of Pediatrics and Division of Pediatric Nephrology, University Hospital (Inselspital), Berne, Switzerland (M.B., S.T., B.S.B., G.D.S.); Division of Pediatrics, Hospitals Bellinzona and Mendrisio, Bellinzona, Switzerland (M.G.B.)
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Polifka JE. Is there an embryopathy associated with first-trimester exposure to angiotensin-converting enzyme inhibitors and angiotensin receptor antagonists? A critical review of the evidence. ACTA ACUST UNITED AC 2012; 94:576-98. [PMID: 22807387 DOI: 10.1002/bdra.23027] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Revised: 03/23/2012] [Accepted: 04/11/2012] [Indexed: 11/06/2022]
Abstract
Drugs that interfere with the renin-angiotensin system, such as angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs), are widely used to manage hypertension and heart failure. Adequate functioning of the RAS is essential for normal fetal kidney development. The potential for ACEIs and ARBs to impair fetal and neonatal renal function if taken after the first trimester of pregnancy has been well documented. Although these drugs were not found to be teratogenic in animals, until recently little was known about the teratogenic effects of ACEIs and ARBs in humans when exposure was limited to the first trimester of pregnancy. New evidence from epidemiologic studies indicates that there may be an elevated teratogenic risk when these drugs are taken during the first trimester of pregnancy. However, this elevated risk does not appear to be specific to ACEIs and ARBs, but is instead related to maternal factors and diseases that typically coexist with hypertension in pregnancy, such as diabetes, advanced maternal age, and obesity. Women who become pregnant while being treated with an ACEI or ARB should be advised to avoid exposure to these drugs during the second and third trimesters of pregnancy by switching to a different class of antihypertensive drugs between weeks 8 and 10 after conception.
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Affiliation(s)
- Janine E Polifka
- Department of Pediatrics, University of Washington, Seattle, Washington, USA.
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Georgaki-Angelaki E, Stergiou N, Naoum E, Papassotiriou I, Anagnostakou M. Olmesartan medoxomil-induced acute renal failure in a premature newborn following maternal exposure during pregnancy: a case report and review of the literature. NDT Plus 2009; 2:295-7. [PMID: 25984019 PMCID: PMC4421235 DOI: 10.1093/ndtplus/sfp045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2009] [Accepted: 04/03/2009] [Indexed: 11/14/2022] Open
Abstract
Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II (AT II) receptor blockers (ARBs) are widely used antihypertensives with well-recognized renoprotective and cardioprotective effects. Although treatment with these agents generally does not result in adverse metabolic consequences, their use during human pregnancy has been associated with negative reactions. Here we report a premature baby with a history of oligohydramnios and maternal exposure to the ARB olmesartan medoxomil who was transferred to our institution with acute renal failure. Conservative treatment with diuretics and meticulous management of fluids and electrolytes resulted in an improvement in renal function in the patient. We conclude that olmesartan medoxomil may cause reversible renal failure in premature neonates.
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Affiliation(s)
| | | | | | - Ioannis Papassotiriou
- Department of Clinical Biochemistry , 'Aghia Sophia' Children's Hospital , Athens 11527 , Greece
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