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Nakai K, Sato K, Nohara N, Takagi M, Kihara M, Ueda S, Gohda T, Suzuki Y. Successful Pregnancy and Delivery in a Chronic Renal Failure Patient with Membranoproliferative Glomerulonephritis and Preeclampsia-related Nephrotic Syndrome. Intern Med 2024; 63:2035-2042. [PMID: 38008458 PMCID: PMC11309875 DOI: 10.2169/internalmedicine.1972-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 10/01/2023] [Indexed: 11/28/2023] Open
Abstract
A 37-year-old woman with chronic kidney disease (CKD) stage G4 with membranoproliferative glomerulonephritis was hospitalized for nephrotic syndrome and hypertension due to superimposed preeclampsia at 27 weeks into her third pregnancy. Proteinuria did not worsen significantly after pulse steroid therapy. Delivery was induced at 30 weeks' gestation due to the maternal renal function and fetal growth. No obvious fetal complications other than preterm delivery were observed. In this case, we successfully managed a high-risk patient with membranoproliferative glomerulonephritis complicated by advanced CKD, nephrotic syndrome, and hypertension, which are independent risk factors for pregnancy complications.
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Affiliation(s)
- Kumi Nakai
- Department of Nephrology, Juntendo University Faculty of Medicine, Japan
| | - Koji Sato
- Department of Nephrology, Juntendo University Faculty of Medicine, Japan
| | - Nao Nohara
- Department of Nephrology, Juntendo University Faculty of Medicine, Japan
| | - Miyuki Takagi
- Department of Nephrology, Juntendo University Faculty of Medicine, Japan
| | - Masao Kihara
- Department of Nephrology, Juntendo University Faculty of Medicine, Japan
| | - Seiji Ueda
- Department of Nephrology, Juntendo University Faculty of Medicine, Japan
| | - Tomohito Gohda
- Department of Nephrology, Juntendo University Faculty of Medicine, Japan
| | - Yusuke Suzuki
- Department of Nephrology, Juntendo University Faculty of Medicine, Japan
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Verma PR, Patil P. Nephrotic Syndrome: A Review. Cureus 2024; 16:e53923. [PMID: 38465146 PMCID: PMC10924861 DOI: 10.7759/cureus.53923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 02/09/2024] [Indexed: 03/12/2024] Open
Abstract
Nephrotic syndrome (NS) is characterized by hypoalbuminemia, severe proteinuria, and peripheral edema, frequently in conjunction with hyperlipidemia. Individuals usually show symptoms of weariness and swelling, but no signs of serious liver damage or cardiac failure. With characteristic medical symptoms and evidence of hypoalbuminemia and severe proteinuria, NS can be diagnosed. The majority of NS episodes are classified as unexplained or primary; the most prevalent histopathological subgroups of primary NS in people are focal segmental glomerulosclerosis and membraneous nephropathy. Thrombosis of the veins with high cholesterol levels is a significant NS risk. Acute renal damage and infection are further possible side effects. The pathobiochemistry of NS involves alterations in genes that affect the selectivity of the kidneys and abnormalities in proteins related to podocytes. Understanding the molecular mechanisms that influence these processes is crucial to developing specific and targeted therapeutic approaches. The need for invasive renal biopsies throughout the diagnosis process may be lessened by the development of non-invasive nephrotic syndrome biomarkers, such as microRNAs. Corticosteroids are frequently used as the initial line of defense in NS treatment. However, some individuals need other treatments since a resistant type of NS also exists. The use of calcineurin inhibitors, mycophenolate mofetil, and rituximab is mentioned in the text, along with current research to identify safer and more efficient therapeutic choices. The complicated kidney condition NS has several underlying causes and symptoms. For the diagnosis of this ailment as well as the creation of focused therapies, an understanding of the pathophysiology and the identification of possible biomarkers are essential.
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Affiliation(s)
- Priyanshu R Verma
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Praful Patil
- Microbiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Yazici H, Dirim AB, Garayeva N, Safak S, Ozluk Y, Hurdogan O, Oto OA, Artan AS, Turkmen A. Diagnostic yield and safety of percutaneous native kidney biopsy in pregnancy: 20-years of single-center experience. J Nephrol 2023; 36:2507-2517. [PMID: 37665527 DOI: 10.1007/s40620-023-01753-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 07/31/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND Percutaneous kidney biopsy is a fundamental procedure in nephrology. Although pregnancy is not a contraindication, a careful risk-benefit assessment is mandatory in pregnancy. We aimed to evaluate safety and diagnostic accuracy of percutaneous kidney biopsy in pregnancy in a single-center retrospective study. METHODS Percutaneous kidney biopsy was performed in 19 pregnant patients. Demographics, estimated glomerular filtration rates, serum albumin levels, and proteinuria levels at the time of biopsy were evaluated. Biopsy-related complications, diagnoses, and treatments during the follow-up were analyzed. In addition, delivery success, preeclampsia, early delivery, low birth weight rates, and long-term outcomes of the patients were retrieved and analyzed. RESULTS Mean patient age was 27 (range 16-41) years. Median gestational week at kidney biopsy was 20th. All but one biopsies were diagnostic. Median gestational week of delivery was 35 (range 23-39) gestational weeks. Preterm delivery (< 37 gestational weeks) and low birth weight (< 2500 mg) occurred in 73.7% and 52.6% of cases, respectively. Median weight at birth was 2500 mg. The incidence of preeclampsia was 57.9%. Overall 89.5% of the children survived. Median post-biopsy follow-up was 64 months. Maternal mortality was not observed during the follow-up period. End stage kidney disease developed in one patient. The results of percutaneous kidney biopsy led to therapeutic decisions in 73.7% of cases. CONCLUSIONS Although percutaneous kidney biopsy is not frequently performed during pregnancy, it is relatively safe and usually diagnostic, and may guide further follow-up.
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Affiliation(s)
- Halil Yazici
- Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, 34134, Istanbul, Turkey
| | - Ahmet Burak Dirim
- Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, 34134, Istanbul, Turkey.
| | - Nurana Garayeva
- Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, 34134, Istanbul, Turkey
| | - Seda Safak
- Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, 34134, Istanbul, Turkey
| | - Yasemin Ozluk
- Department of Pathology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ozge Hurdogan
- Department of Pathology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ozgur Akin Oto
- Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, 34134, Istanbul, Turkey
| | - Ayse Serra Artan
- Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, 34134, Istanbul, Turkey
| | - Aydin Turkmen
- Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, 34134, Istanbul, Turkey
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Fang L, Shen B, Zhang H, Yin N, Cai J, Zhang J, Zhao H. Clinical features and prognosis of pregnancy-related renal damage and pregnancy after chronic kidney disease. BMC Pregnancy Childbirth 2023; 23:619. [PMID: 37644467 PMCID: PMC10466819 DOI: 10.1186/s12884-023-05941-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 08/21/2023] [Indexed: 08/31/2023] Open
Abstract
OBJECTIVE To explore the clinical features of renal damage related to pregnancy and pregnancy after chronic kidney disease (CKD), providing clinical evidence for the relationship between renal damage and pregnancy. METHODS A retrospective analysis was performed on patients admitted to our hospital between March 2013 and February 2021 who had both pregnancy and kidney damage. The study collected pathology results from renal biopsies, 24-hour urinary protein quantity, albumin (Alb), serum creatinine (Scr), blood lipids, coagulation function, blood routine, and other indicators during and after pregnancy. RESULTS This study included 82 cases, with 48 cases in the pregnancy-related renal damage group. Thirty-four cases were in the post-CKD pregnancy group. Of the patients, 30 cases (88.24%) had CKD stage 1-2. Results showed better pregnancy and fetal outcomes in the post-CKD pregnancy group compared to the pregnancy-related renal damage group (Ρ was 0.029 and 0.036, respectively). Renal biopsy pathology revealed that 16 cases (33.33%) in the pregnancy-related renal damage group mainly had focal segmental glomerulosclerosis (FSGS), while the post-CKD pregnancy group was dominated by 14 cases (43.75%) of IgA nephropathy. The first blood test indicators revealed that the pregnancy-related renal damage group had lower estimated glomerular filtration (eGFR) and Alb levels compared to the post-CKD pregnancy group (Ρ was 0.003 and 0.000, respectively). Additionally, 24-hour urinary protein quantity, total cholesterol (Tch), triglyceride (TG), and platelet (PLT) counts were higher in the pregnancy-related renal damage group compared to the post-CKD pregnancy group (Ρ was 0.005, 0.001, 0.008, and 0.031, respectively). The abnormal rate of Scr during pregnancy was 41.67% (20/48) in the pregnancy-related renal damage group and 17.39% (4/23) in the post-CKD pregnancy group, with a statistically significant difference (Ρ was 0.043). CONCLUSION The pregnancy-related renal damage group is mainly associated with FSGS, while the post-CKD pregnancy group is characterized by IgA nephropathy. Patients with CKD1-2 can have a successful pregnancy after achieving good control of eGFR, albumin, 24-hour urinary protein quantity and other indicators, resulting in better pregnancy and fetal outcomes. Abnormal Scr levels during pregnancy of pregnancy-related renal damage can be improved within 3 months after delivery.
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Affiliation(s)
- Li Fang
- Department of Nephrology, First affiliated hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Bingbing Shen
- Department of Nephrology, First affiliated hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
- Department of Nephrology, Chongqing University Central Hospital, Chongqing Emergency Medical Center, NO.1 Jiankang Street,Yuzhong District, Chongqing, 400014, China
| | - Huhai Zhang
- Department of Nephrology, First affiliated hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Na Yin
- Department of Nephrology, First affiliated hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Juan Cai
- Department of Nephrology, First affiliated hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Jun Zhang
- Department of Nephrology, First affiliated hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China.
| | - Hongwen Zhao
- Department of Nephrology, First affiliated hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China.
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Alekseeva MV, Kozlovskaya NL, Korotchaeva YV, Demyanova KA, Chegodaeva AG, Apresyan SV. [Nephrotic syndrome during pregnancy. Is it chronic glomerulonephritis or preeclampsia? Case report]. TERAPEVT ARKH 2023; 95:500-504. [PMID: 38158970 DOI: 10.26442/00403660.2023.06.202264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 08/14/2023] [Indexed: 01/03/2024]
Abstract
Nephrotic syndrome (NS) during pregnancy is a fairly rare pathology and its descriptions in the literature are few. For a long time, NS was associated only with an exacerbation of chronic glomerulonephritis or de novo nephritis, however, the experience of recent years has shown that NS can be a manifestation of the classical obstetric pathology - preeclampsia (PE). The appearance of massive proteinuria with the development of NS is most typical for early PE, which, of course, makes diagnosis difficult, especially if PE develops at an unusually early time (up to 20 weeks). To describe PE that does not fit into the classical criteria, the term "atypical" PE is now used, the development of which can be promoted by both obstetric and somatic risk factors. The presented clinical observation describes the development of early (within 14 weeks) severe PE with the NS at the onset of the disease in a patient with the first multiple pregnancy and complete hydatidiform mole (HM) of one of the fetuses. The progression of nephropathy with the addition of thrombotic microangiopathy and HELLP syndrome made it possible to assume the diagnosis of PE with a high probability. The rapid relief of all clinical manifestations after delivery confirmed this assumption. The role of HM as the main trigger of unusually early PE is discussed. Apparently, the patient's trophoblast disease in the form of hydatidiform mole caused the formation of a severe angiogenic imbalance already in the early stages of pregnancy, which led to the development of PE, which manifested NS as a consequence of podocytopathy due to VEGF deficiency. Thus, the development of NS in a pregnant patient without a history of kidney disease dictates, first of all, the exclusion of PE, until proven otherwise.
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Affiliation(s)
- M V Alekseeva
- People's Friendship University of Russia (RUDN University)
| | - N L Kozlovskaya
- People's Friendship University of Russia (RUDN University)
- Yeramishantsev City Clinical Hospital
| | - Y V Korotchaeva
- Yeramishantsev City Clinical Hospital
- Sechenov First Moscow State Medical University (Sechenov University)
| | - K A Demyanova
- People's Friendship University of Russia (RUDN University)
- Yeramishantsev City Clinical Hospital
| | | | - S V Apresyan
- People's Friendship University of Russia (RUDN University)
- Yeramishantsev City Clinical Hospital
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Saleem M, Iftikhar H. Anti-phospholipase A2 Receptor Antibody-Negative Membranous Nephropathy in Pregnancy. Cureus 2023; 15:e42827. [PMID: 37664313 PMCID: PMC10473257 DOI: 10.7759/cureus.42827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2023] [Indexed: 09/05/2023] Open
Abstract
Nephrotic syndrome in pregnancy is associated with challenges for both patients and physicians. Early recognition is crucial, and when appropriate, renal biopsy should be considered to differentiate preeclampsia from other causes of glomerulopathies. Pregnancy in a woman with nephrotic syndrome is high risk, and more data are needed to highlight pregnancy outcomes.
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Affiliation(s)
- Maryam Saleem
- Nephrology, Ohio Valley Nephrology Associates, Owensboro, USA
- Nephrology, Washington University School of Medicine, St. Louis, USA
- Internal Medicine, Waterbury Hospital, Waterbury, USA
| | - Hassaan Iftikhar
- Nephrology, Ohio Valley Nephrology Associates, Owensboro, USA
- Nephrology, Washington University School of Medicine, St. Louis, USA
- Internal Medicine, Saint Francis Medical Center, Trenton, USA
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7
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Lv Y, Zhou Y, Hu R, Liang Y, Lian Y, Wang J, Wei Y, Zhang Y, Qiao Y, He T. Association between hypoproteinaemia with massive proteinuria and small for gestational age in pre-eclampsia: a single-centre, retrospective cohort study using propensity score matching. BMJ Open 2023; 13:e071835. [PMID: 37463811 PMCID: PMC10357757 DOI: 10.1136/bmjopen-2023-071835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/20/2023] Open
Abstract
OBJECTIVE To investigate the association between hypoproteinaemia with massive proteinuria and the incidence of small for gestational age in pre-eclampsia. DESIGN Retrospective cohort study using propensity score matching. SETTING Northwest Women's and Children's Hospital in Shaanxi Province, China, using data from January 2016 to December 2021. PARTICIPANTS Patients diagnosed with pre-eclampsia were grouped into the massive proteinuria group if the maximum proteinuria was >3.5 g/day and the minimum serum albumin was <30 g/L; otherwise, they were placed in the control group. OUTCOME MEASURES The primary outcome was the incidence of small for gestational age infants. Secondary outcomes included fetal death, admission to the neonatal intensive care unit, a 5 min APGAR score <7, severe small for gestational age, fetal growth restriction, birth weight, premature birth, and maternal outcomes such as eclampsia, encephalopathy, placental abruption, haemolysis, elevated liver enzymes and low platelet syndrome, heart failure and retinal detachment. RESULTS In total, 468 patients (234 from each group) were included, and the groups were well matched. The incidences of small for gestational age (33.76% vs 20.51%, OR 1.646, 95% CI 1.208 to 2.243, p=0.001), severe small for gestational age (14.70% vs 7.69%, OR 1.833, 95% CI 1.063 to 3.162, p=0.026), fetal growth restriction (23.93% vs 16.24%, OR 1.474, 95% CI 1.018 to 2.133, p=0.038), and the numbers of infants admitted to the neonatal intensive care unit (67.52% vs 58.55%, OR 1.153, 95% CI 1.003 to 1.326, p=0.044) were significantly higher in patients with hypoproteinaemia and massive proteinuria than in the control group. In addition, the median birth weight was significantly lower in the massive proteinuria group. There were no significant differences in maternal outcomes except for renal parameters, which were worse in the massive proteinuria group. CONCLUSION Hypoproteinaemia with massive proteinuria was associated with fetal growth and a higher incidence of small for gestational age infants in pre-eclampsia.
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Affiliation(s)
- Yanxiang Lv
- Obstetrics and Gynecology Intensive Care Unit, Northwest Women's and Children's Hospital, Xi'an, Shaanxi, China
| | - Ying Zhou
- Obstetrics and Gynecology Intensive Care Unit, Northwest Women's and Children's Hospital, Xi'an, Shaanxi, China
| | - Rui Hu
- Obstetrics and Gynecology Intensive Care Unit, Northwest Women's and Children's Hospital, Xi'an, Shaanxi, China
| | - Yan Liang
- Obstetrics and Gynecology Intensive Care Unit, Northwest Women's and Children's Hospital, Xi'an, Shaanxi, China
| | - Yanan Lian
- Obstetrics and Gynecology Intensive Care Unit, Northwest Women's and Children's Hospital, Xi'an, Shaanxi, China
| | - Jun Wang
- Obstetrics and Gynecology Intensive Care Unit, Northwest Women's and Children's Hospital, Xi'an, Shaanxi, China
| | - Yang Wei
- Obstetrics and Gynecology Intensive Care Unit, Northwest Women's and Children's Hospital, Xi'an, Shaanxi, China
| | - Yanmei Zhang
- Obstetrics and Gynecology Intensive Care Unit, Northwest Women's and Children's Hospital, Xi'an, Shaanxi, China
| | - Yuan Qiao
- Obstetrics and Gynecology Intensive Care Unit, Northwest Women's and Children's Hospital, Xi'an, Shaanxi, China
| | - Tongqiang He
- Obstetrics and Gynecology Intensive Care Unit, Northwest Women's and Children's Hospital, Xi'an, Shaanxi, China
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8
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Moroni G, Calatroni M, Donato B, Ponticelli C. Kidney Biopsy in Pregnant Women with Glomerular Diseases: Focus on Lupus Nephritis. J Clin Med 2023; 12:jcm12051834. [PMID: 36902621 PMCID: PMC10003332 DOI: 10.3390/jcm12051834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/14/2023] [Accepted: 02/22/2023] [Indexed: 03/02/2023] Open
Abstract
Despite significant improvements of renal and obstetrical management, pregnancies in women with glomerular diseases and with lupus nephritis continue to be associated with increased complications both for the mother and the fetus as compared to those of pregnancies in healthy women. To reduce the risk of these complications, planning pregnancy in a phase of stable remission of the underlining disease is necessary. A kidney biopsy is an important event in any phase of pregnancy. A kidney biopsy can be of help during counselling before pregnancy in cases of incomplete remission of the renal manifestations. In these situations, histological data may differentiate active lesions that require the reinforcement of therapy from chronic irreversible lesions that may increase the risk of complications. In pregnant women, a kidney biopsy can identify new-onset systemic lupus erythematous (SLE) and necrotizing or primitive glomerular diseases and distinguish them from other, more common complications. Increasing proteinuria, hypertension, and the deterioration of kidney function during pregnancy may be either due to a reactivation of the underlying disease or to pre-eclampsia. The results of the kidney biopsy suggest the need to initiate an appropriate treatment, allowing the progression of the pregnancy and the fetal viability or the anticipation of delivery. Data from the literature suggest avoiding a kidney biopsy beyond 28 weeks of gestation to minimize the risks associated with the procedure vs. the risk of preterm delivery. In case of the persistence of renal manifestations after delivery in women with a diagnosis of pre-eclampsia, a renal kidney assessment allows the final diagnosis and guides the therapy.
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Affiliation(s)
- Gabriella Moroni
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
- Nephrology and Dialysis Division, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
- Correspondence: ; Tel.: +39-345-872-1910
| | - Marta Calatroni
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
- Nephrology and Dialysis Division, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Beatriz Donato
- Nephrology Department, Hospital Beatriz Ângelo, 2674-514 Loures, Portugal
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9
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Fakhouri F, Schwotzer N, Cabiddu G, Barratt J, Legardeur H, Garovic V, Orozco-Guillen A, Wetzels J, Daugas E, Moroni G, Noris M, Audard V, Praga M, Llurba E, Wuerzner G, Attini R, Desseauve D, Zakharova E, Luders C, Wiles K, Leone F, Jesudason S, Costedoat-Chalumeau N, Kattah A, Soto-Abraham V, Karras A, Prakash J, Lightstone L, Ronco P, Ponticelli C, Appel G, Remuzzi G, Tsatsaris V, Piccoli GB. Glomerular diseases in pregnancy: pragmatic recommendations for clinical management. Kidney Int 2023; 103:264-281. [PMID: 36481180 DOI: 10.1016/j.kint.2022.10.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 10/10/2022] [Accepted: 10/18/2022] [Indexed: 12/12/2022]
Abstract
Our understanding of the various aspects of pregnancy in women with kidney diseases has significantly improved in the last decades. Nevertheless, little is known about specific kidney diseases. Glomerular diseases are not only a frequent cause of chronic kidney disease in young women, but combine many challenges in pregnancy: immunologic diseases, hypertension, proteinuria, and kidney tissue damage. An international working group undertook the review of available current literature and elicited expert opinions on glomerular diseases in pregnancy with the aim to provide pragmatic information for nephrologists according to the present state-of-the-art knowledge. This work also highlights areas of clinical uncertainty and emphasizes the need for further collaborative studies to improve maternal and fetal health.
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Affiliation(s)
- Fadi Fakhouri
- Service de Néphrologie et d'Hypertension, Département de Médecine, Centre Hospitalier Universitaire Vaudois, and Université de Lausanne, Lausanne, Switzerland.
| | - Nora Schwotzer
- Service de Néphrologie et d'Hypertension, Département de Médecine, Centre Hospitalier Universitaire Vaudois, and Université de Lausanne, Lausanne, Switzerland
| | - Gianfranca Cabiddu
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy; Department of Nephrology, San Michele Hospital, ARNAS G. Brotzu, Cagliari, Italy
| | - Jonathan Barratt
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Hélène Legardeur
- Gynaecology, Woman Mother Child Department of the Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Vesna Garovic
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA; Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Alejandra Orozco-Guillen
- National Institute of Perinatology Isidro Espinosa de los Reyes (INPER), Department of Nephrology, Ciudad de Mexico, Mexico
| | - Jack Wetzels
- Department of Nephrology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Eric Daugas
- Service de Néphrologie, Hôpital Bichat and Université Paris Cité, Paris, France; Institut national de la santé et de la recherche médicale Inserm U1149, Paris, France
| | - Gabriella Moroni
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; Nephrology and Dialysis Division, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Humanitas Research Hospital, Milan, Italy
| | - Marina Noris
- Istituto di Ricerche Farmacologiche Mario Negri, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Laboratory of Immunology and Genetics of Rare Diseases, Bergamo, Italy
| | - Vincent Audard
- Université Paris Est Créteil, Institut National de la Santé et de la Recherche Médicale (INSERM), Institut Mondor de Recherche Biomédicale (IMRB), Créteil, France; Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Service de Néphrologie et Transplantation, Fédération Hospitalo-Universitaire « Innovative therapy for immune disorders », Créteil, France
| | - Manuel Praga
- Department of Nephrology, Hospital Universitario 12 de Octubre, Complutense University Madrid, Madrid, Spain
| | - Elisa Llurba
- Department of Obstetrics and Gynaecology, Institut d'Investigació Biomèdica Sant Pau - IIB Sant Pau, Hospital de la Santa Creu i Sant Pau, Madrid, Spain; Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Developmental Origin Network (RICORS), Instituto de Salud Carlos III, Madrid, Spain
| | - Grégoire Wuerzner
- Service de Néphrologie et d'Hypertension, Département de Médecine, Centre Hospitalier Universitaire Vaudois, and Université de Lausanne, Lausanne, Switzerland
| | - Rossella Attini
- Department of Obstetrics and Gynecology, University of Turin, Città della Salute e della Scienza, Sant'Anna Hospital, Turin, Italy
| | - David Desseauve
- Gynaecology, Woman Mother Child Department of the Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Elena Zakharova
- Nephrology, Moscow City Hospital n.a. Sergey Petrovich Botkin, Moscow, Russian Federation; Moscow State University of Medicine and Dentistry, Moscow, Russian Federation
| | - Claudio Luders
- Centro de Nefrologia e Dialise, Hospital Sirio-Libanes, São Paulo, Brazil
| | - Kate Wiles
- Department of Women's Health, Barts Health NHS Trust, London, UK
| | - Filomena Leone
- Clinical Nutrition Unit, S. Anna Hospital, Città della Salute e della Scienza, Turin, Italy
| | - Shilpanjali Jesudason
- Central Northern Adelaide Renal and Transplantation Service (CNARTS), Royal Adelaide Hospital, Adelaide, South Australia, Australia; Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Nathalie Costedoat-Chalumeau
- Centre de Référence Maladies Auto-Immunes et Systémiques Rares de l'île de France, Cochin Hospital, Université Paris Cité, Paris, France; Unité de l'Institut national de la santé et de la recherche médicale (INSERM) Unité 1153, Center for Epidemiology and Statistics (CRESS), Paris, France
| | - Andrea Kattah
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Virgilia Soto-Abraham
- Pathology Department, Hospital General de México Dr Eduardo Liceaga, México City, México
| | - Alexandre Karras
- Paris University, Paris, France; Renal Division, Georges Pompidou European Hospital, Paris, France
| | - Jai Prakash
- Department of Nephrology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Liz Lightstone
- Imperial Lupus Centre, Department of Medicine, Imperial College London, London, UK; Section of Renal Medicine and Vascular Inflammation, Department of Medicine, Imperial College London, London, UK
| | - Pierre Ronco
- Sorbonne Université, and Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche S1155, Paris, France; Department of Nephrology, Centre Hospitalier du Mans, Le Mans, France
| | | | - Gerald Appel
- Division of Nephrology, Columbia University Medical Center and the New York Presbyterian Hospital, New York, New York, USA
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Laboratory of Immunology and Genetics of Rare Diseases, Bergamo, Italy
| | - Vassilis Tsatsaris
- Maternité Port-Royal, Fédération Hospitalo-Universitaire Prématurité (FHU PREMA), Assistance Publique des Hôpitaux de Paris AP-HP, Hôpital Cochin, AP-HP, Paris, France; Centre-Université de Paris, Université de Paris, Paris, France
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10
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Kidney biopsy during pregnancy: a difficult decision. A case series reporting on 20 patients from Mexico. J Nephrol 2022; 35:2293-2300. [PMID: 35994230 DOI: 10.1007/s40620-022-01366-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 05/23/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND Kidney biopsy is a routine procedure in the diagnosis of kidney disease, but during pregnancy it carries potential adverse effects for both mother and child, aside from the challenges of obtaining adequate tissue samples. Nevertheless, a precise diagnosis is necessary when specific and potentially toxic treatments are to be used during pregnancy. The present report presents our experience with regard to the usefulness and safety of kidney biopsies during pregnancy. METHODS Retrospective analysis of clinical indications, complications, histopathological diagnoses, and treatment of patients who had kidney biopsies done at a single academic center during gestation weeks 11-30 between January 2015 and January 2019. RESULTS Kidney biopsies were carried out in 20 pregnant patients with nephrotic proteinuria. Biopsy was adequate in all patients. The histological diagnoses included focal segmental glomerulosclerosis (collapsing, tip and perihiliar varieties), membranous lupus nephropathy, diabetic nephropathy, and IgA nephropathy. Treatment was associated with reduction of proteinuria in 17 patients and reduction of serum creatinine in 9 out of 11 patients who had serum creatinine ≥ 1 mg/dl at the time of biopsy. There was one major bleeding complication that required transfusion of one unit of blood. There was a high incidence of preeclampsia, preterm delivery, and low birth weight despite appropriate kidney disease therapy. CONCLUSIONS Kidney biopsy may be done during pregnancy when therapeutic decisions depend on a precise pathologic diagnosis.
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11
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Drapeau L, Beaumier M, Esbelin J, Comoz F, Figueres L, Piccoli GB, Kervella D. Complex Management of Nephrotic Syndrome and Kidney Failure during Pregnancy in a Type 1 Diabetes Patient: A Challenging Case. J Clin Med 2022; 11:jcm11195725. [PMID: 36233591 PMCID: PMC9571482 DOI: 10.3390/jcm11195725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 09/23/2022] [Accepted: 09/24/2022] [Indexed: 11/18/2022] Open
Abstract
Pregnancy with chronic kidney disease is challenging, and patients with diabetic nephropathy are at particular risk of a rapid kidney function decline during pregnancy. While indications for the management of pregnant patients with initial diabetic nephropathy are widely available in the literature, data on patients with severe nephrotic syndrome and kidney function impairment are lacking, and the decision on whether and when dialysis should be initiated is not univocal. We report a type 1 diabetes patient who started pregnancy with a severe nephrotic syndrome and shifted from CKD stage 3b to stage 5 during pregnancy. The management was complicated by a fetal heart malformation and by poorly controlled diabetes. The evidence for and against starting dialysis was carefully evaluated, and the choice of strict nephrological and obstetrical monitoring, nutritional management, and diuretic treatment made it possible to avoid dialysis in pregnancy, after ruling out pre-eclampsia. This experience enables examination of some open issues and contributes to the discussion of when to start dialysis in pregnancy.
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Affiliation(s)
- Leo Drapeau
- Néphrologie et Immunologie Clinique, CHU de Nantes, Nantes Université, 44000 Nantes, France
| | - Mathilde Beaumier
- Néphrologie, Centre Hospitalier Public du Cotentin, 50100 Cherbourg, France
| | - Julie Esbelin
- Service de Gynécologie-Obstétrique, CHU de Nantes, 44000 Nantes, France
| | - François Comoz
- Anatomie et Cytologie Pathologiques, CHU Caen Normandie, 14033 Caen, France
| | - Lucile Figueres
- Néphrologie et Immunologie Clinique, CHU de Nantes, Nantes Université, 44000 Nantes, France
| | | | - Delphine Kervella
- Center for Research in Transplantation and Translational Immunology, UMR 1064, ITUN, Inserm, CHU de Nantes, Nantes Université, F-44000 Nantes, France
- Correspondence:
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12
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Sagar PS, Fischer E, Gangadharan Komala M, Bose B. A case of minimal change disease during pregnancy - benefits of early diagnosis and use of corticosteroids. Obstet Med 2022; 15:198-200. [PMID: 36262820 PMCID: PMC9574446 DOI: 10.1177/1753495x21990214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 12/27/2020] [Accepted: 01/02/2021] [Indexed: 09/03/2023] Open
Abstract
Nephrotic syndrome presenting in pregnancy is rare and poses a diagnostic and therapeutic challenge. Timing of renal biopsy is important given the increased risk of bleeding and miscarriage, and the choice of immunosuppression is limited due to the teratogenicity profiles of standard drugs. We report and discuss a case of minimal change disease diagnosed by renal biopsy during early pregnancy and treated with corticosteroids throughout the pregnancy. Prompt diagnosis and treatment of glomerular disease in pregnancy are vital to prevent poor maternal and fetal outcomes.
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Affiliation(s)
- Priyanka S Sagar
- Department of Renal Medicine, Nepean
Hospital, Penrith, NSW, Australia
| | - Eddy Fischer
- Department of Renal Medicine, Nepean
Hospital, Penrith, NSW, Australia
| | | | - Bhadran Bose
- Department of Renal Medicine, Nepean
Hospital, Penrith, NSW, Australia
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13
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To Explore the Application Effect and Value of Evidence-Based Nursing in Patients with Pregnancy-Induced Hypertension Syndrome. CONTRAST MEDIA & MOLECULAR IMAGING 2022; 2022:6476031. [PMID: 36101809 PMCID: PMC9439890 DOI: 10.1155/2022/6476031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 07/21/2022] [Accepted: 07/26/2022] [Indexed: 11/17/2022]
Abstract
Objective The objective is to explore the nursing methods of evidence-based nursing in preventing serious complications in patients with pregnancy-induced hypertension. Methods A total of 80 patients with pregnancy-induced hypertension from April 2020 to April 2022 were selected and randomly divided into a control group and a research group, with 40 cases in each group. The blood pressure, Self-Efficacy Scale score, Disease Uncertainty Scale score, the incidence of maternal and infant complications, the improvement of mental state, and the patients' satisfaction with the nursing program were observed and compared between the two groups. Results Compared with before the intervention, the self-efficacy scores of the two groups were significantly improved, and the blood pressure, disease uncertainty score, SAS, and SDS scores were significantly decreased, and the indicators in the study group were better than those before the intervention. In the control group, the difference was statistically significant (P < 0.05). After the intervention, among the 40 patients in the study group, 10 cases (25.00%) of cesarean section were significantly lower than 19 cases (47.50%) in the control group, and the nursing work satisfaction in the study group was significantly higher than that in the control group (P < 0.05). Conclusion The application of evidence-based nursing interventions and smart medical nursing interventions to patients with pregnancy-induced hypertension syndrome has significant effect and can effectively improve the blood pressure control effect of patients during pregnancy.
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14
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Tsani Z, Ntafos A, Toumanidou V, Dastiridou A, Ploumi I, Androudi S. Vision loss in a pregnant woman with nephrotic syndrome. Eur J Ophthalmol 2021; 33:11206721211054731. [PMID: 34664511 DOI: 10.1177/11206721211054731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To report acute visual acuity loss in a pregnant woman with nephrotic syndrome. CASE REPORT A 34-year-old pregnant woman was referred to our service for acute, bilateral visual impairment, associated with bilateral below knee edema (BKE). Best-corrected visual acuity (BCVA) was hand motion in the right eye and 20/200 in the left eye. Dilated fundus exam disclosed multiple pigment epithelium detachments involving the macula in both eyes. After consultation with a nephrologist a diagnosis of nephrotic syndrome was made. Unfortunately, a week later she lost the fetus. At follow-up evaluation, 20 days after the miscarriage, BCVA improved to 20/25 in both eyes with near normal restoration of the retinal anatomy. CONCLUSION In nephrotic syndrome, sequestration of interstitial fluids, which leads to classic generalized edema, could be the origin of interstitial accumulation of fluids in the retinal and subretinal layers. Increased awareness by the gynaecologists and prompt treatment may prevent fetus miscarriage.
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Affiliation(s)
- Zoi Tsani
- Department of Ophthalmology, 393317University of Thessaly, Larissa, Greece
| | - Antonios Ntafos
- Department of Ophthalmology, 393317University of Thessaly, Larissa, Greece
| | | | - Anna Dastiridou
- Department of Ophthalmology, 393317University of Thessaly, Larissa, Greece
| | - Ioanna Ploumi
- 195088Northeastern University, College of Science, Boston, MA, USA
| | - Sofia Androudi
- Department of Ophthalmology, 393317University of Thessaly, Larissa, Greece
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15
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Filler G, Bhayana V, Schott C, Díaz‐González de Ferris ME. How should we assess renal function in neonates and infants? Acta Paediatr 2021; 110:773-780. [PMID: 32869283 DOI: 10.1111/apa.15557] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 08/20/2020] [Accepted: 08/24/2020] [Indexed: 11/28/2022]
Abstract
AIM Review of current knowledge on assessing renal function in term and preterm neonates. METHODS Literature review and analysis of own data. RESULTS Prematurity, genetic, environmental and maternal factors may alter peak nephron endowment and life-long renal function. Nephrogenesis continues until 34-36 weeks of gestation, but it is altered with premature delivery. Variability of nephron endowment has a substantial impact on the clearance of renally excreted drugs. Postnatally, glomerular function rate (GFR) increases daily, doubles by two weeks, and slowly reaches full maturity at 18 months of age. Ideally, renal function biomarkers should be expressed as age-independent z-scores, and evidence suggests indexing these values to post-conceptual age rather than chronological age. Newborn and maternal serum creatinine correlate tightly for more than 72 hours after delivery, rendering this biomarker unsuitable for the assessment of neonatal renal function. Cystatin C does not cross the placenta and may be the preferred biomarker in the neonate. Here, we provide preliminary data on the natural evolution of the cystatin C eGFR in infancy. CONCLUSION Cystatin C may be superior for GFR estimation in neonates, but the best approach to drug dosing of renally excreted drugs remains to be established.
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Affiliation(s)
- Guido Filler
- Departments of Paediatrics, Medicine, and The Lilibeth Caberto Kidney Clinical Research Unit Western University London ON Canada
- Department of Pathology and Laboratory Medicine University of Western Ontario London Ontario Canada
| | - Vipin Bhayana
- Department of Pathology and Laboratory Medicine University of Western Ontario London Ontario Canada
| | - Clara Schott
- Schulich School of Medicine and Dentistry University of Western Ontario London Ontario Canada
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16
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A case of minimal change nephrotic syndrome with pregnancy. CEN Case Rep 2021; 10:315-319. [PMID: 33405175 DOI: 10.1007/s13730-020-00568-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 12/13/2020] [Indexed: 10/22/2022] Open
Abstract
A 32-year-old Japanese woman at 8 weeks of gestation was admitted to our hospital for systemic edema, hypoalbuminemia, and severe proteinuria. The patient had a history of generalized alopecia and migraine. We diagnosed nephrotic syndrome, and renal biopsy revealed minimal change nephrotic syndrome (MCNS). We administered 1000 mg/day of methylprednisolone for 3 days. Oral corticosteroid therapy was followed by 40 mg of prednisolone daily. We carefully selected concomitant medication after considering organogenesis. Before and after renal biopsy, we administered heparin, antithrombin III, and immunoglobulin agents as appropriate. The patient achieved complete remission on day 8 of treatment and gave birth to a boy at 37 weeks of gestation without recurrence. MCNS during pregnancy is rare, and there is no established treatment. In conclusion, we present a case of a pregnant woman with MCNS during organogenesis. Early treatment initiation can provide a good prognosis for both mother and child.
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17
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Lobbes H, Mainbourg S, Lega JC. Prevention of venous thromboembolism in nephrotic syndrome: the quest towards precision medicine. Nephrol Dial Transplant 2020; 36:gfaa337. [PMID: 33367807 DOI: 10.1093/ndt/gfaa337] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Indexed: 12/30/2022] Open
Affiliation(s)
| | - Sabine Mainbourg
- Service de médecine interne et médecine vasculaire, Hôpital Lyon Sud, Hospices Civils de Lyon, Lyon, France
- Equipe Evaluation et Modélisation des Effets Thérapeutiques, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, CNRS, Claude Bernard University Lyon 1, Lyon, France
| | - Jean-Christophe Lega
- Service de médecine interne et médecine vasculaire, Hôpital Lyon Sud, Hospices Civils de Lyon, Lyon, France
- Equipe Evaluation et Modélisation des Effets Thérapeutiques, UMR 5558, Laboratoire de Biométrie et Biologie Evolutive, CNRS, Claude Bernard University Lyon 1, Lyon, France
- Groupe d'Etude Multidisciplinaire en Maladie Thrombotique (GEMMAT), Hospices Civils de Lyon, Lyon, France
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18
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Wiles K, Webster P, Seed PT, Bennett-Richards K, Bramham K, Brunskill N, Carr S, Hall M, Khan R, Nelson-Piercy C, Webster LM, Chappell LC, Lightstone L. The impact of chronic kidney disease Stages 3-5 on pregnancy outcomes. Nephrol Dial Transplant 2020; 36:2008-2017. [PMID: 33313680 PMCID: PMC8577624 DOI: 10.1093/ndt/gfaa247] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Indexed: 12/16/2022] Open
Abstract
Background Contemporaneous data are required for women with chronic kidney disease (CKD) Stages 3–5 to inform pre-pregnancy counselling and institute appropriate antenatal surveillance. Methods A retrospective cohort study in women with CKD Stages 3–5 after 20 weeks’ gestation was undertaken in six UK tertiary renal centres in the UK between 2003 and 2017. Factors predicting adverse outcomes and the impact of pregnancy in accelerating the need for renal replacement therapy (RRT) were assessed. Results There were 178 pregnancies in 159 women, including 43 women with renal transplants. The live birth rate was 98%, but 56% of babies were born preterm (before 37 weeks’ gestation). Chronic hypertension was the strongest predictor of delivery before 34 weeks’ gestation. Of 121 women with known pre-pregnancy hypertension status, the incidence of delivery before 34 weeks was 32% (31/96) in women with confirmed chronic hypertension compared with 0% (0/25) in normotensive women. The risk of delivery before 34 weeks doubled in women with chronic hypertension from 20% [95% confidence interval (CI) 9–36%] to 40% (95% CI 26–56%) if the gestational fall in serum creatinine was <10% of pre-pregnancy concentrations. Women with a urinary protein:creatinine ratio >100 mg/mmol prior to pregnancy or before 20 weeks’ gestation had an increased risk for birthweight below the 10th centile (odds ratio 2.57, 95% CI 1.20–5.53). There was a measurable drop in estimated glomerular filtration rate (eGFR) between pre-pregnancy and post-partum values (4.5 mL/min/1.73 m2), which was greater than the annual decline in eGFR prior to pregnancy (1.8 mL/min/1.73 m2/year). The effect of pregnancy was, therefore, equivalent to 1.7, 2.1 and 4.9 years of pre-pregnancy renal disease in CKD Stages 3a, 3b and 4–5, respectively. The pregnancy-associated decline in renal function was greater in women with chronic hypertension and in those with a gestational fall in serum creatinine of <10% of pre-pregnancy concentrations. At 1 year post-partum, 46% (58/126) of women had lost ≥25% of their pre-pregnancy eGFR or required RRT. Most women with renal transplants had CKD Stage 3 and more stable renal function prior to pregnancy. Renal transplantation was not independently associated with adverse obstetric or renal outcomes. Conclusions Contemporary pregnancies in women with CKD Stages 3–5 are complicated by preterm delivery, low birthweight and loss of maternal renal function. Chronic hypertension, pre- or early pregnancy proteinuria and a gestational fall in serum creatinine of <10% of pre-pregnancy values are more important predictors of adverse obstetric and renal outcome than CKD Stages 3–5. Pregnancy in women with CKD Stages 3–5 advances the need for dialysis or transplantation by 2.5 years.
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Affiliation(s)
- Kate Wiles
- Department of Women and Children's Health, Kings College London, London, UK
| | | | - Paul T Seed
- Department of Women and Children's Health, Kings College London, London, UK
| | | | - Kate Bramham
- Department of Women and Children's Health, Kings College London, London, UK.,King's Kidney Care, King's College NHS Foundation Trust, London, UK
| | - Nigel Brunskill
- Department of Cardiovascular Sciences, College of Life Sciences, University of Leicester, Leicester, UK
| | - Sue Carr
- Department of Renal Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Matt Hall
- Department of Renal Medicine, Nottingham University Hospitals NHS Trust, Leicester, UK
| | - Rehan Khan
- Department of Obstetrics and Gynaecology, Barts Health NHS Trust and Women's Health Research Unit, Barts and the London School of Medicine and Dentistry, London, UK
| | - Catherine Nelson-Piercy
- Department of Women and Children's Health, Kings College London, London, UK.,Department of Obstetric Medicine, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Louise M Webster
- Department of Women and Children's Health, Kings College London, London, UK
| | - Lucy C Chappell
- Department of Women and Children's Health, Kings College London, London, UK
| | - Liz Lightstone
- Imperial College Healthcare NHS Trust, London, UK.,Centre for Inflammatory Disease, Faculty of Medicine, Imperial College London, London, UK
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19
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Siligato R, Gembillo G, Cernaro V, Torre F, Salvo A, Granese R, Santoro D. Maternal and Fetal Outcomes of Pregnancy in Nephrotic Syndrome Due to Primary Glomerulonephritis. Front Med (Lausanne) 2020; 7:563094. [PMID: 33363180 PMCID: PMC7758435 DOI: 10.3389/fmed.2020.563094] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 11/12/2020] [Indexed: 12/18/2022] Open
Abstract
Chronic kidney disease (CKD) affects 3% of pregnancies, impacting on maternal and fetal outcomes, and at the same time, a recurrent question in nephrology regards gestation impact on kidney function. Observational studies stated that CKD stage, pre-existent hypertension, and proteinuria are the main predictors of possible complications, such as maternal CKD progression, maternal or fetal death, prematurity, small for gestational age (SGA) newborn, or admission to the neonatal intensive care unit. In this regard, given the prominence of proteinuria among other risk factors, we focused on primary nephrotic syndrome in pregnancy, which accounts for 0.028% of cases, and its impact on materno-fetal outcomes and kidney survival. Data extracted from literature are scattered because of the small cohorts investigated in each trial. However, they showed different outcomes for each glomerular disease, with membranous nephropathy (MN) having a better maternal and fetal prognosis than focal and segmental glomerulosclerosis (FSGS), membranoproliferative glomerulonephritis (MPGN), or minimal change disease (MCD). Nephrotic syndrome does not have to discourage women to undertake a pregnancy, but the correct management may include a specific evaluation of risk factors and follow-up for adverse materno-fetal events and/or maternal kidney disease progression.
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Affiliation(s)
- Rossella Siligato
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Guido Gembillo
- Department of Biomedical, Dental, Morphological and Functional Imaging Sciences, University of Messina, Messina, Italy
| | - Valeria Cernaro
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Francesco Torre
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Antonino Salvo
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Roberta Granese
- Unit of Gynecology, Department of Human Pathology of Adult and Childhood "G. Barresi", University of Messina, Messina, Italy
| | - Domenico Santoro
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
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20
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Gleeson S, Lightstone L. Glomerular Disease and Pregnancy. Adv Chronic Kidney Dis 2020; 27:469-476. [PMID: 33328063 DOI: 10.1053/j.ackd.2020.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 08/04/2020] [Accepted: 08/04/2020] [Indexed: 12/28/2022]
Abstract
Nephrologists are routinely involved in the care of pregnant women with glomerulonephritis. Prepregnancy counseling is vital to inform women of the potential risks of pregnancy and to reduce those risks by optimizing clinical status and medications. In general, for all glomerulonephritides, the best pregnancy outcomes are achieved when the disease is in remission and the woman has preserved renal function with no proteinuria or hypertension. Each glomerulonephritis has specific considerations, for example in lupus nephritis, mycophenolate is teratogenic and must be stopped at least 6 weeks before conception, hydroxychloroquine is recommended for all pregnant women, and flares are frequently encountered and must be treated appropriately. De novo glomerulonephritis should be considered when significant proteinuria is found early in pregnancy or an acute kidney injury with active urine is encountered. Biopsy can be safely undertaken in the first trimester. Treatment is often with corticosteroids, azathioprine, and/or tacrolimus. Rituximab is increasingly used for severe disease. Women with glomerulonephritis should ideally be managed in a joint renal-obstetric clinic. This review details the approach to the care of women with glomerulonephritis from prepregnancy counseling, through antenatal care and delivery, to the postpartum period. Special attention is given to medications and treatment of glomerulonephritis in pregnancy.
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21
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Govsyeyev N, Malgor RD, Hoffman C, Sturman E, Siada S, Al-Musawi M, Malgor EA, Jacobs DL, Nehler M. A systematic review of diagnosis and treatment of acute limb ischemia during pregnancy and postpartum period. J Vasc Surg 2020; 72:1793-1801.e1. [DOI: 10.1016/j.jvs.2020.04.516] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 04/23/2020] [Indexed: 01/01/2023]
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22
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Abstract
PURPOSE OF REVIEW We focus on the current understanding of preeclampsia (PE) in order to examine how it mediates glomerular injury and affects the course of glomerulonephritis (GNs). In addition, this review discusses the role of GNs on the development of PE. RECENT FINDINGS In PE, the dysfunctional utero-placental perfusion causes the release into the mother's circulation of anti-angiogenic substances, leading to systemic endotheliosis. In preeclamptic patients, the imbalance between pro- and anti-angiogenic factors is responsible for the kidney injury, and PE may reveal a silent pre-existent GN or may induce the development of the disease. Moreover, in women with chronic kidney disease (CKD), it could accelerate the disease progression. In any case, GNs compromise renal function, making the kidney less responsive to physiological changes that occur during pregnancy and, at the same time, cause maternal vascular inflammation, representing a risk factor for PE development. Although a bidirectional correlation between GNs and PE has been demonstrated, the data are limited, and further large studies are warranted. Close collaboration between a multidisciplinary team of obstetricians and nephrologists is essential to establish the correct diagnosis and safely manage these vulnerable women and their fetuses.
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23
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Sachdeva M, Beck LH, Miller I, Bijol V, Fishbane S. Phospholipase A 2 Receptor Antibody-Positive Pregnancy: A Case Report. Am J Kidney Dis 2020; 76:586-589. [PMID: 32093980 DOI: 10.1053/j.ajkd.2019.11.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 11/27/2019] [Indexed: 11/11/2022]
Abstract
Renal course and clinical outcomes in pregnant women with primary membranous nephropathy are not completely understood. In addition, the use of autoantibodies to M-type phospholipase A2 receptor (PLA2R) as a serologic marker throughout pregnancy and postpartum in the mother and baby is not yet fully elucidated. We followed up a pregnant woman with primary membranous nephropathy during pregnancy and postpartum and describe the clinical course and outcomes of mother and baby and the course of PLA2R antibody titers. We show evidence of transplacental transfer of PLA2R antibody from mother to fetus. In addition, we observe the effect of breastfeeding in a PLA2R antibody-positive pregnancy and describe the transfer of this antibody into breast milk. Although pregnancy in women with underlying PLA2R antibody-positive membranous nephropathy is possible, there is an increase in risk to both mother and fetus, requiring a multidisciplinary team approach and careful monitoring of both neonate and mother during pregnancy and postpartum.
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Affiliation(s)
- Mala Sachdeva
- Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY.
| | - Laurence H Beck
- Renal Section, Boston University School of Medicine, Boston, MA
| | - Ilene Miller
- Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY
| | - Vanesa Bijol
- Department of Pathology, North Shore University Hospital and Long Island Jewish Medical Center, Manhasset, NY
| | - Steven Fishbane
- Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY
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24
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Wiles K, Chappell L, Clark K, Elman L, Hall M, Lightstone L, Mohamed G, Mukherjee D, Nelson-Piercy C, Webster P, Whybrow R, Bramham K. Clinical practice guideline on pregnancy and renal disease. BMC Nephrol 2019; 20:401. [PMID: 31672135 PMCID: PMC6822421 DOI: 10.1186/s12882-019-1560-2] [Citation(s) in RCA: 88] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 09/16/2019] [Indexed: 01/13/2023] Open
Affiliation(s)
- Kate Wiles
- NIHR Doctoral Research Fellow in Obstetric Nephrology, Guy's and St. Thomas' NHS Foundation Trust and King's College London, London, UK.
| | - Lucy Chappell
- Guy's and St. Thomas' NHS Foundation Trust and King's College London, London, UK
| | | | - Louise Elman
- Expert Patient, c/o The Renal Association, Bristol, UK
| | - Matt Hall
- Nottingham University Hospital, Nottingham, UK
| | - Liz Lightstone
- Imperial College London and Imperial College Healthcare NHS Trust, London, UK
| | | | | | - Catherine Nelson-Piercy
- Guy's and St. Thomas' NHS Foundation Trust and Imperial College Healthcare NHS Trust, London, UK
| | | | | | - Kate Bramham
- King's College Hospital NHS Foundation Trust and King's College London, London, UK
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25
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Orozco Guillén OA, Velazquez Silva RI, Gonzalez BM, Becerra Gamba T, Gutiérrez Marín A, Paredes NR, Cardona Pérez JA, Soto Abraham V, Piccoli GB, Madero M. Collapsing Lesions and Focal Segmental Glomerulosclerosis in Pregnancy: A Report of 3 Cases. Am J Kidney Dis 2019; 74:837-843. [PMID: 31378644 DOI: 10.1053/j.ajkd.2019.04.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Accepted: 04/10/2019] [Indexed: 01/18/2023]
Abstract
The relationship between focal segmental glomerulosclerosis (FSGS) and pregnancy is complex and not completely elucidated. Pregnancy in patients with FSGS poses a high risk for complications, possibly due to hemodynamic factors, imbalance between angiogenic and antiangiogenic factors, and hormonal conditioning. Although poor clinical outcomes associated with collapsing FSGS are common outside of pregnancy, the prognosis during pregnancy is not well documented. We report 3 patients who developed collapsing FSGS during pregnancy, 2 of whom had presumed underlying FSGS. Two patients underwent biopsy during pregnancy, and 1, during the puerperium. None of the 3 patients improved spontaneously after delivery, and 1 experienced a rapid deterioration in kidney function and proteinuria after delivery. Aggressive immunosuppressive therapy led to a full response in 1 case (without chronic lesions) and to partial responses in the remaining 2 cases. These cases suggest that collapsing lesions should be considered in patients with FSGS who develop a rapid increase in serum creatinine level or proteinuria during pregnancy and that these lesions may at least partially respond to treatment.
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Affiliation(s)
| | | | - Bernardo Moguel Gonzalez
- Department of Nephrology, National Institute of Cardiology "Ignacio Chávez", Mexico City, Mexico
| | - Tomas Becerra Gamba
- Department of Nephrology, National Institute of Cardiology "Ignacio Chávez", Mexico City, Mexico
| | - Alfredo Gutiérrez Marín
- Departments of Critical Care, National Institute of Perinatology "Isidro Espinoza de los Reyes", Mexico City, Mexico
| | - Norberto Reyes Paredes
- Gynaecology and Obstetrics, National Institute of Perinatology "Isidro Espinoza de los Reyes", Mexico City, Mexico
| | - Jorge Arturo Cardona Pérez
- Neonatologist Critical Care, National Institute of Perinatology "Isidro Espinoza de los Reyes", Mexico City, Mexico
| | - Virgilia Soto Abraham
- Department of Pathology, National Institute of Cardiology "Ignacio Chávez," Mexico City, Mexico
| | - Giorgina Barbara Piccoli
- Department of Clinical and Biological Sciences, University of Torino, Turin, Italy; Néphrologie, Centre Hospitalier Le Mans, Le Mans, France
| | - Magdalena Madero
- Department of Nephrology, National Institute of Cardiology "Ignacio Chávez", Mexico City, Mexico
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Piccoli GB, Zakharova E, Attini R, Ibarra Hernandez M, Orozco Guillien A, Alrukhaimi M, Liu ZH, Ashuntantang G, Covella B, Cabiddu G, Li PKT, Garcia-Garcia G, Levin A. Pregnancy in Chronic Kidney Disease: Need for Higher Awareness. A Pragmatic Review Focused on What Could Be Improved in the Different CKD Stages and Phases. J Clin Med 2018; 7:E415. [PMID: 30400594 PMCID: PMC6262338 DOI: 10.3390/jcm7110415] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Revised: 10/28/2018] [Accepted: 10/31/2018] [Indexed: 02/07/2023] Open
Abstract
Pregnancy is possible in all phases of chronic kidney disease (CKD), but its management may be difficult and the outcomes are not the same as in the overall population. The prevalence of CKD in pregnancy is estimated at about 3%, as high as that of pre-eclampsia (PE), a better-acknowledged risk for adverse pregnancy outcomes. When CKD is known, pregnancy should be considered as high risk and followed accordingly; furthermore, since CKD is often asymptomatic, pregnant women should be screened for the presence of CKD, allowing better management of pregnancy, and timely treatment after pregnancy. The differential diagnosis between CKD and PE is sometimes difficult, but making it may be important for pregnancy management. Pregnancy is possible, even if at high risk for complications, including preterm delivery and intrauterine growth restriction, superimposed PE, and pregnancy-induced hypertension. Results in all phases are strictly dependent upon the socio-sanitary system and the availability of renal and obstetric care and, especially for preterm children, of intensive care units. Women on dialysis should be aware of the possibility of conceiving and having a successful pregnancy, and intensive dialysis (up to daily, long-hours dialysis) is the clinical choice allowing the best results. Such a choice may, however, need adaptation where access to dialysis is limited or distances are prohibitive. After kidney transplantation, pregnancies should be followed up with great attention, to minimize the risks for mother, child, and for the graft. A research agenda supporting international comparisons is highly needed to ameliorate or provide knowledge on specific kidney diseases and to develop context-adapted treatment strategies to improve pregnancy outcomes in CKD women.
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Affiliation(s)
- Giorgina B Piccoli
- Department of Clinical and Biological Sciences, University of Torino, 10100 Torino, Italy.
- Néphrologie, Centre Hospitalier Le Mans, 72000 Le Mans, France.
| | - Elena Zakharova
- Nephrology, Moscow City Hospital n.a. S.P. Botkin, 101000 Moscow, Russia.
- Nephrology, Moscow State University of Medicine and Dentistry, 101000 Moscow, Russia.
- Nephrology, Russian Medical Academy of Continuous Professional Education, 101000 Moscow, Russia.
| | - Rossella Attini
- Obstetrics, Department of Surgery, University of Torino, 10100 Torino, Italy.
| | - Margarita Ibarra Hernandez
- Nephrology Service, Hospital Civil de Guadalajara "Fray Antonio Alcalde", University of Guadalajara Health Sciences Center, Guadalajara, Jal 44100, Mexico.
| | | | - Mona Alrukhaimi
- Department of Medicine, Dubai Medical College, P.O. Box 20170, Dubai, UAE.
| | - Zhi-Hong Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing 210000, China. zhihong--
| | - Gloria Ashuntantang
- Yaounde General Hospital & Faculty of Medicine and Biomedical Sciences, University of Yaounde I, P.O. Box 337, Yaounde, Cameroon.
| | - Bianca Covella
- Néphrologie, Centre Hospitalier Le Mans, 72000 Le Mans, France.
| | | | - Philip Kam Tao Li
- Prince of Wales Hospital, Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong.
| | - Guillermo Garcia-Garcia
- Nephrology Service, Hospital Civil de Guadalajara "Fray Antonio Alcalde", University of Guadalajara Health Sciences Center, Guadalajara, Jal 44100, Mexico.
| | - Adeera Levin
- Department of Medicine, Division of Nephrology, University of British Columbia, Vancouver, BC V6T 1Z4, Canada.
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Morton A, Teasdale S. Review article: Investigations and the pregnant woman in the emergency department - part 1: Laboratory investigations. Emerg Med Australas 2018; 30:600-609. [PMID: 29656593 DOI: 10.1111/1742-6723.12957] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 02/07/2018] [Indexed: 12/17/2022]
Abstract
Accurate assessment of the pregnant patient in the ED depends on knowledge of physiological changes in pregnancy, and how these changes may impact on pathology tests, appearance on point-of-care ultrasound and electrocardiography. In addition the emergency physician needs to be cognisant of disorders that are unique to or more common in pregnancy. Part 1 of this review addresses potential deviations in laboratory investigation reference intervals resulting from physiological alterations in pregnancy, and the important causes of abnormal laboratory results in pregnancy. Part 2 will address the role of point-of-care ultrasound in pregnancy, physiological changes that may affect interpretation of point-of-care ultrasound, physiological changes in electrocardiography, and the safety of radiological procedures in the pregnant patient.
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Affiliation(s)
- Adam Morton
- Mater Health and The University of Queensland, Brisbane, Queensland, Australia
| | - Stephanie Teasdale
- Mater Health and The University of Queensland, Brisbane, Queensland, Australia
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28
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Colla L, Diena D, Rossetti M, Manzione AM, Marozio L, Benedetto C, Biancone L. Immunosuppression in pregnant women with renal disease: review of the latest evidence in the biologics era. J Nephrol 2018; 31:361-383. [DOI: 10.1007/s40620-018-0477-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 02/03/2018] [Indexed: 02/07/2023]
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29
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Ibarra-Hernández M, Orozco-Guillén OA, de la Alcantar-Vallín ML, Garrido-Roldan R, Jiménez-Alvarado MP, Castro KB, Villa-Villagrana F, Borbolla M, Gallardo-Gaona JM, García-García G, Reyes-Paredes N, Piccoli GB. Acute kidney injury in pregnancy and the role of underlying CKD: a point of view from México. J Nephrol 2017; 30:773-780. [DOI: 10.1007/s40620-017-0444-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 09/06/2017] [Indexed: 11/28/2022]
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