Chronic Kidney Disease and Pregnancy

Pregnancy and Family Planning in Women With Kidney Disease

Introduction

Females with kidney disease are at increased risk for pregnancy complications. Few studies have examined pregnancy perspectives of people with kidney disease. Our objective was to examine kidney patients' perspectives on family planning.

Methods

We conducted an online survey of female patients with kidney disease from the University of Colorado Hospital between the ages of 18 and 50 years from August to October 2022. The survey asked questions on previous and current pregnancies with kidney disease, family planning, and reproductive health discussions with their nephrologists. Perspectives on how kidney disease influences pregnancies were also explored.

Results

A total of 136 participants completed the survey. The majority of participants were White (71.3%) with a mean (SD) age of 37 ± 10 years. The majority of participants self-characterized their kidney disease as moderate (n = 57, 43.5%) with 16 participants (12.2%) receiving dialysis. Fifty-two participants (38.5%) experienced a pregnancy with a diagnosis of kidney disease, which were largely planned (n = 33, 61.1%). The majority of participants were able to conceive within 6 months (64.8%). Nearly half of participants reported that kidney disease influenced their family planning decisions with the majority (n = 91, 66.5%) believing that kidney disease increased their risk for pregnancy complications. More than half of participants never discussed the health risks of a potential pregnancy (54.0%), desire to have children (58.0%), pregnancy prevention (57.0%), and/or optimizing their health prior to pregnancy (68.1%) with their nephrologist.

Conclusion

Although kidney disease influenced family planning decisions, few participants had family planning discussions with their nephrologists.

Pre-gestational counselling for women living with CKD: starting from the bright side

Pregnancy in women living with chronic kidney disease (CKD) was often discouraged due to the risk of adverse maternal-fetal outcomes and the progression of kidney disease. This negative attitude has changed in recent years, with greater emphasis on patient empowerment than on the imperative 'non nocere'. Although risks persist, pregnancy outcomes even in advanced CKD have significantly improved, for both the mother and the newborn. Adequate counselling can help to minimize risks and support a more conscious and informed approach to those risks that are unavoidable. Pre-conception counselling enables a woman to plan the most appropriate moment for her to try to become pregnant. Counselling is context sensitive and needs to be discussed also within an ethical framework. Classically, counselling is more focused on risks than on the probability of a successful outcome. 'Positive counselling', highlighting also the chances of a favourable outcome, can help to strengthen the patient-physician relationship, which is a powerful means of optimizing adherence and compliance. Since, due to the heterogeneity of CKD, giving exact figures in single cases is difficult and may even be impossible, a scenario-based approach may help understanding and facing favourable outcomes and adverse events. Pregnancy outcomes modulate the future life of the mother and of her baby; hence the concept of 'post partum' counselling is also introduced, discussing how pregnancy results may modulate the long-term prognosis of the mother and the child and the future pregnancies.

Placental and Renal Pathways Underlying Pre-Eclampsia

Pre-eclampsia is a serious complication of pregnancy characterized by a state of multiorgan hypertensive disorders, with or without proteinuria and possible multiorgan dysfunction. Chronic kidney disease is an established risk factor for the development of pre-eclampsia, as angiogenic homeostasis is altered and the maternal circulation is already hypertensive. Facing pre-eclampsia in the context of chronic kidney disease is a challenging emergency for both the mother and the fetus. The clinical features and the management of this multi-organ disorder are clearly defined in the modern literature but the underlying pathophysiologic mechanisms remain not fully elucidated. Understanding the pathophysiology that mediates the onset of pre-eclampsia itself and in synergy with chronic kidney disease is fundamental for developing prompt prevention strategies, treatment planning, and patient counseling. This review aims to summarize the main molecular mechanisms involved in the process of pre-eclampsia, with a particular focus on the role of the kidneys and hormonal pathways related to renal function in normal pregnancy and pre-eclamptic syndromes.

Association between proteinuria and adverse pregnancy outcomes: a retrospective cohort study

Proteinuria during pregnancy is closely related to the occurrence of adverse pregnancy outcomes. One hundred and forty-two women with proteinuria during pregnancy and followed between January 2018 and December 2020 were evaluated. Based on the 24-h proteinuria value, they were divided as mild (n = 76, 300-1000 mg/day), moderate (n = 39, 1000-3500 mg/day) and severe (n = 27, >3500 mg/day) proteinuria. The rates of prematurity, low birth weight and neonatal asphyxia were significantly higher in the severe proteinuria group than in the mild and moderate groups, while the rates of foetal growth restriction and neonatal intensive care unit admission were significantly higher in the severe compared with the mild proteinuria group (all p < .05). Logistic regression analysis showed that moderate proteinuria (OR = 97.2, 95%CI: 7.1-1334.2, p = .001) and severe proteinuria (OR = 34.0, 95%CI: 1.6-711.0, p = .023) were associated with adverse perinatal outcomes. Compared with mild proteinuria, moderate and severe proteinuria are associated with adverse pregnancy outcomes in perinatal infants.Impact StatementWhat is already known on this subject? The production of proteinuria is closely related to the filtration function of the glomerulus, the reabsorption and secretion function of the renal tubules. For women with normal renal function before pregnancy, such physiological changes are less likely to cause adverse symptoms; however, for women with chronic kidney disease before pregnancy, especially those with significantly impaired renal function, the kidneys often cannot compensate for these physiological changes, which can lead to serious complications for both mother and infant.What do the results of this study add? In our study, logistic regression analysis showed that the severity of proteinuria was independently associated with adverse perinatal outcomes. The ROC curve showed that 24-h proteinuria had a predictive value for adverse perinatal outcomes. Therefore, for patients with urine protein quantification ≥0.3 g/24 h, regular 24-h urine protein quantification during pregnancy could help predict adverse perinatal outcomes and improve prognosis.What are the implications of these findings for clinical practice and/or further research? Proteinuria quantification can be used as one of the factors predicting adverse pregnancy outcomes. Thus, monitoring of urinary protein quantification in women during pregnancy should be strengthened for early detection of renal impairment, then interventions be used to improve maternal and infant outcomes.

Protective Role of Taurine on Rat Offspring Hypertension in the Setting of Maternal Chronic Kidney Disease

Taurine is a natural antioxidant with antihypertensive properties. Maternal chronic kidney disease (CKD) has an impact on renal programming and increases the risk of offspring hypertension in later life. The underlying mechanisms cover oxidative stress, a dysregulated hydrogen sulfide (H2S) system, dysbiotic gut microbiota, and inappropriate activation of the renin-angiotensin-aldosterone system (RAAS). We investigated whether perinatal taurine administration enables us to prevent high blood pressure (BP) in offspring complicated by maternal CKD. Before mating, CKD was induced through feeding chow containing 0.5% adenine for 3 weeks. Taurine was administered (3% in drinking water) during gestation and lactation. Four groups of male offspring were used (n = 8/group): controls, CKD, taurine-treated control rats, and taurine-treated rats with CKD. Taurine treatment significantly reduced BP in male offspring born to mothers with CKD. The beneficial effects of perinatal taurine treatment were attributed to an augmented H2S pathway, rebalance of aberrant RAAS activation, and gut microbiota alterations. In summary, our results not only deepen our knowledge of the mechanisms underlying maternal CKD-induced offspring hypertension but also afford us the impetus to consider taurine-based intervention as a promising preventive approach for future clinical translation.

Prevalence of chronic kidney disease in women of reproductive age and observed birth rates

INTRODUCTION

Women of reproductive age with chronic kidney disease (CKD) are recognised to have decreased fertility and a higher risk of adverse pregnancy outcomes. How often CKD afflicts women of reproductive age is not well known. This study aimed to evaluate the burden of CKD and associated birth rates in an entire region.

METHODS

This was a retrospective cohort study including women of childbearing age in Stockholm during 2006-2015. We estimated the prevalence of "probable CKD" by the presence of an ICD-10 diagnosis of CKD, a single estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2 or history of maintenance dialysis. By linkage with the Swedish Medical Birth Register we identified births during the subsequent three years from study inclusion and evaluated birth rates.

RESULTS

We identified 817,730 women in our region, of whom 55% had at least one creatinine measurement. A total of 3938 women were identified as having probable CKD, providing an age-averaged CKD prevalence of 0.50%. Women with probable CKD showed a lower birth rate 3 years after the index date (35.7 children per 1000 person years) than the remaining women free from CKD (46.5 children per 1000 person years).

CONCLUSION

As many as 0.50% of individuals in this cohort had probable CKD, defined on the basis of at least one eGFR<60 ml/min1.73 m2 test result, dialysis treatment (i.e. CKD stages 3-5) or an ICD-10 diagnosis of CKD. This prevalence is lower than previous estimates. Women with probable CKD, according to a study mainly capturing CKD 3-5, had a lower birth rate than those without CKD, illustrating the challenges of this population to successfully conceive.

Literature Review: The sFlt1/PlGF Ratio and Pregestational Maternal Comorbidities: New Risk Factors to Predict Pre-Eclampsia

One of the main causes of maternal and neonatal morbidity and mortality is pre-eclampsia. It is characterized by a high sFlt1/PlGF ratio, according to prior research. Pregestational diseases in mothers may increase the risk of developing pre-eclampsia. Only a few studies have looked at the connection between maternal comorbidities before conception and the sFlt1/PlGF ratio. The most recent information regarding the association between maternal pregestational diseases and the ratio of sFlt1/PlGF is described in this review. The paper also examines current research suggesting that changes in pregnancy hormones and metabolites are related to a high sFlt1/PlGF ratio. Certain maternal disorders have been found to dramatically raise sFlt-1 and sFlt1/PlGF levels, according to an analysis of the literature. There is still debate about the data on the association between the sFlt1/PlGF ratio and maternal disorders such as HIV, acute coronary syndromes, cardiovascular function in the mother between 19 and 23 weeks of pregnancy, thyroid hormones, diabetes, and cancer. Additional research is needed to confirm these findings.

The Impact of Nutrient Intake and Metabolic Wastes during Pregnancy on Offspring Hypertension: Challenges and Future Opportunities

Hypertension can have its origin in early life. During pregnancy, many metabolic alterations occur in the mother that have a crucial role in fetal development. In response to maternal insults, fetal programming may occur after metabolic disturbance, resulting in programmed hypertension later in life. Maternal dietary nutrients act as metabolic substrates for various metabolic processes via nutrient-sensing signals. Different nutrient-sensing pathways that detect levels of sugars, amino acids, lipids and energy are integrated during pregnancy, while disturbed nutrient-sensing signals have a role in the developmental programming of hypertension. Metabolism-modulated metabolites and nutrient-sensing signals are promising targets for new drug discovery due to their pathogenic link to hypertension programming. Hence, in this review, we pay particular attention to the maternal nutritional insults and metabolic wastes affecting fetal programming. We then discuss the role of nutrient-sensing signals linking the disturbed metabolism to hypertension programming. This review also summarizes current evidence to give directions for future studies regarding how to prevent hypertension via reprogramming strategies, such as nutritional intervention, targeting nutrient-sensing signals, and reduction of metabolic wastes. Better prevention for hypertension may be possible with the help of novel early-life interventions that target altered metabolism.

Iodomethylcholine Inhibits Trimethylamine-N-Oxide Production and Averts Maternal Chronic Kidney Disease-Programmed Offspring Hypertension

Chronic kidney disease (CKD) affects 10% of the global population, including pregnant women. Adverse maternal conditions determine the developmental programming of many diseases later in life. We previously demonstrated that adult rat offspring born to dams with CKD developed hypertension and renal hypertrophy. Trimethylamine-N-oxide (TMAO), a uremic toxin derived from the gut microbiota, has been linked to hypertension. This study assesses the effects of TMAO inhibition by iodomethylcholine (IMC) treatment on offspring hypertension programmed by maternal CKD. Female rats were fed either a control or a 0.5% adenine diet before conception, with or without IMC treatment during pregnancy and lactation. Maternal IMC treatment averted maternal CKD-primed offspring hypertension and renal hypertrophy in 12-week-old offspring. Offspring hypertension is associated with increases in the plasma TMAO concentration and oxidative stress and shifts in gut microbiota. The beneficial effects of IMC are related to a reduction in TMAO; increases in genera Acetatifactor, Bifidobacterium, and Eubacterium; and decreases in genera Phocacecola and Bacteroides. Our findings afford insights into the targeting of the gut microbiota to deplete TMAO production, with therapeutic potential for the prevention of offspring hypertension programmed by maternal CKD, although these results still need further clinical translation.

Associations between female birth sex and risk of chronic kidney disease development among people with HIV in the USA: A longitudinal, multicentre, cohort study

Background

Women represent a meaningful proportion of new HIV diagnoses, with Black women comprising 58% of new diagnoses among women. As HIV infection also increases risk of chronic kidney disease (CKD), understanding CKD risk among women with HIV (WWH), particularly Black women, is critical.

Methods

In this longitudinal cohort study of people with HIV (PWH) enrolled in CFAR Network of Integrated Clinical Systems (CNICS), a multicentre study comprised of eight academic medical centres across the United States from Jan 01, 1996 and Nov 01, 2019, adult PWH were excluded if they had ≤2 serum creatinine measurements, developed CKD prior to enrollment, or identified as intersex or transgendered, leaving a final cohort of 33,998 PWH. The outcome was CKD development, defined as estimated glomerular filtration rate (eGFR) <60 mL/min/1·73 m2 calculated using the CKD-EPI equation, for ≥90 days with no intervening higher values.

Findings

Adjusting for demographic and clinical characteristics, WWH were 61% more likely to develop CKD than men (adjusted hazard ratio [aHR]: 1·61, 95% CI: 1·46-1·78, p<0·001). This difference persisted after further adjustment for APOL1 risk variants (aHR female sex: 1·92, 95% CI: 1·63-2·26, p<0·001) and substance abuse (aHR female sex: 1·70, 95% CI: 1·54-1·87, p<0·001).

Interpretation

WWH experienced increased risk of CKD. Given disparities in care among patients with end-stage kidney disease, efforts to engage WWH in nephrology care to improve chronic disease management are critical.

Funding

US National Institutes of Health.

The experience of being a mother with end stage renal disease: A qualitative study of women receiving treatment at an ambulatory dialysis unit

Background

End-stage kidney disease (ESKD) has considerable effects on the quality of life, impairing daily activities and leading to lifestyle changes. The purpose of this study was therefore to explore the experience of motherhood and taking care of children in women with ESKD.

Methods

A qualitative exploratory study was conducted based on an interpretive framework. Participants were recruited using non-probabilistic purposeful sampling. In total, 14 women with ESKD were included, who were treated at the dialysis unit of a Spanish hospital. In-depth interviews (unstructured and semi-structured interviews) and researchers’ field notes were used to collect the data. A systematic text condensation analysis was performed. The techniques performed and application procedures used to control trustworthiness were credibility, transferability, dependability, and confirmability.

Results

Three themes emerged from the data. “Coping with being a mother” described how women are faced with the decision to become mothers and assess the risks of pregnancy. The second theme, called “Children and the experience of illness”, highlighted the women’s struggle to prevent the disease from affecting their children emotionally or disrupting their lives. The third theme, “Fear of genetic transmission”, was based on the women’s fear of passing the disease on to their children.

Conclusions

Deciding to become a mother and taking care of children represents a challenge for women with ESKD, coupled with the losses in their lives caused by the disease. These findings are only relevant to women on dialysis.

Reproductive concerns and associated factors among female chronic kidney diseases patients: a Multi-Center Cross-Sectional Study

AIM

The study aimed to investigate the current status of reproductive concerns and explore the associated factors among young female chronic kidney disease (CKD) patients.

DESIGN

A multi-center cross-sectional study was designed.

METHODS

The study was conducted in six representative tertiary hospitals across southwest China. A total of 295 female Chronic kidney disease patients between 18-45 years of age completed a 20 min, web-based survey, which included demographics and disease-related information questionnaire, Reproductive Concerns Scale, Generalized Anxiety Disorder 7 (GAD-7) instrument and Patient Health Questionnaire 9 (PHQ-9) instrument.

RESULT

The survey total collected 270 valid questionnaires. The mean reproductive concern score was 54.39 ± 10.90 (out of a maximum of 90), with the mean scores for sub-scales ranging from 7.80 ± 1.69 to 10.44 ± 1.85. Multiple regression analysis showed that those with higher reproductive concerns were more likely to have pregnancy intentions, to be in Chronic kidney disease stages 1-3, and to have a higher GAD-7 score. This study offered further evidence of the need for improved education and emotional support surrounding reproductive concerns among young Chinese women with Chronic kidney disease.

Maternal and fetal outcomes of pregnancy in chronic kidney disease: diagnostic challenges, surveillance and treatment throughout the spectrum of kidney disease

Pregnancy requires several physiological adaptations from the maternal organism, including modifications in the glomerular filtration rate and renal excretion of several products. Chronic kidney disease (CKD) can negatively affect these modifications and consequently is associated with several adverse maternal and fetal adverse outcomes (gestational hypertension, progression of renal disease, pre-eclampsia, fetal growth restriction, and preterm delivery). A multidisciplinary vigilance of these pregnancies is essential in order to avoid and/or control the harmful effects associated with this pathology. Dialysis and transplantation can decrease the risks of maternal and fetal complications, nonetheless, the rates of complications remain high comparing with a normal pregnancy. Several recent developments in this area have improved quality and efficacy of treatment of pregnant women with CKD. This article summarizes the most recent literature about CKD and pregnancy.

Animal Models for DOHaD Research: Focus on Hypertension of Developmental Origins

Increasing evidence suggests that fetal programming through environmental exposure during a critical window of early life leads to long-term detrimental outcomes, by so-called developmental origins of health and disease (DOHaD). Hypertension can originate in early life. Animal models are essential for providing convincing evidence of a causal relationship between diverse early-life insults and the developmental programming of hypertension in later life. These insults include nutritional imbalances, maternal illnesses, exposure to environmental chemicals, and medication use. In addition to reviewing the various insults that contribute to hypertension of developmental origins, this review focuses on the benefits of animal models in addressing the underlying mechanisms by which early-life interventions can reprogram disease processes and prevent the development of hypertension. Our understanding of hypertension of developmental origins has been enhanced by each of these animal models, narrowing the knowledge gap between animal models and future clinical translation.

Perinatal Resveratrol Therapy Prevents Hypertension Programmed by Maternal Chronic Kidney Disease in Adult Male Offspring: Implications of the Gut Microbiome and Their Metabolites

The gut microbiota plays a critical role in kidney disease and hypertension; however, whether maternal chronic kidney disease (CKD)-induced offspring hypertension is associated with alterations of the microbiota and microbial metabolites remains elusive. Using rat as an animal model, we conducted a maternal adenine-induced CKD model to examine whether adult male offspring develop hypertension and kidney disease. As resveratrol has antioxidant and prebiotic properties, we also aimed to elucidate whether its use in pregnancy and lactation can benefit hypertension programmed by maternal CKD via mediation of the gut microbiota and oxidative stress. Female Sprague-Dawley rats received regular chow (C) or chow supplemented with 0.5% adenine (CKD) from 3 weeks before pregnancy until lactation. One group of the adenine-induced CKD pregnant rats received resveratrol (R; 50 mg/L) in drinking water during gestation and lactation. Male offspring were divided into three groups: C, CKD, and CKD+R. The microbial metabolites analyzed were short chain fatty acids (SCFAs) in feces and trimethylamine (TMA)/trimethylamine N-oxide (TMAO) in plasma. We found perinatal resveratrol therapy protected against maternal CKD-induced hypertension in adult male offspring. The overall microbial compositions and diversity of bacterial community in the three groups were different. Resveratrol therapy increased α-diversity, decreased the Firmicutes to Bacteroidetes ratio, and increased the abundance of the genera Lactobacillus and Bifidobacterium. Perinatal resveratrol therapy increased plasma TMA levels but decreased the plasma TMAO-to-TMA ratio. Although resveratrol had negligible effect on fecal concentrations of SCFAs, it increased G-protein coupled receptor-41 (GPR41) protein levels in the offspring’s kidneys. Additionally, resveratrol therapy increased plasma levels of L-arginine and the L-arginine-to-ADMA ratio (AAR), and decreased oxidative stress. Overall, the protective effects of resveratrol against programmed hypertension are related to gut microbiome remodeling, including an increased abundance of beneficial microbes, mediation of the TMA-TMAO pathway, and alterations of SCFA receptors. Our results highlighted that targeting the microbiome and their metabolites might be potential therapeutic strategies to prevent maternal CKD-induced adverse pregnancy and offspring outcomes.

Sexual Dysfunction in Women With Kidney Disease

Sexual health is inversely associated with estimated glomerular filtration rate and is associated with adverse cardiovascular outcomes, depression, poor self-image, and impaired quality of life. Many women with chronic kidney disease (CKD) and ESKD experience symptoms of sexual dysfunction which is underrecognized secondary to a variety of factors including physicians' discomfort in discussing sexual health, patients' reluctance to bring up sexual health, difficulty in the assessment of sexual health in comparison to men, and the overall lack of well-conducted clinical studies in women. The pathophysiology is not fully understood but likely involves changes in sex hormones throughout the hypothalamic-pituitary-ovarian axis. Proper evaluation of this axis is necessary as treatment is tailored to these findings and can improve outcomes. A comprehensive assessment of sexual dysfunction inclusive of women with varying gender identification and sexual orientation, partnered with recognition and treatment of contributing factors as well as identifying the underlying cause, is paramount. With the lack of studies, particularly in women with CKD, treatment options, in some cases, can be considered unchartered territory. In this article, we will review available evidence on the pathophysiology, clinical manifestations, and treatment for sexual dysfunction in women with CKD and ESKD.

Maternal Adenine-Induced Chronic Kidney Disease Programs Hypertension in Adult Male Rat Offspring: Implications of Nitric Oxide and Gut Microbiome Derived Metabolites

Maternal chronic kidney disease (CKD) during pregnancy causes adverse fetal programming. Nitric oxide (NO) deficiency, gut microbiota dysbiosis, and dysregulated renin-angiotensin system (RAS) during pregnancy are linked to the development of hypertension in adult offspring. We examined whether maternal adenine-induced CKD can program hypertension and kidney disease in adult male offspring. We also aimed to identify potential mechanisms, including alterations of gut microbiota composition, increased trimethylamine-N-oxide (TMAO), reduced NO bioavailability, and dysregulation of the RAS. To construct a maternal CKD model, female Sprague-Dawley rats received regular chow (control group) or chow supplemented with 0.5% adenine (CKD group) for 3 weeks before pregnancy. Mother rats were sacrificed on gestational day 21 to analyze placentas and fetuses. Male offspring (n = 8/group) were sacrificed at 12 weeks of age. Adenine-fed rats developed renal dysfunction, glomerular and tubulointerstitial damage, hypertension, placental abnormalities, and reduced fetal weights. Additionally, maternal adenine-induced CKD caused hypertension and renal hypertrophy in adult male offspring. These adverse pregnancy and offspring outcomes are associated with alterations of gut microbiota composition, increased uremic toxin asymmetric and symmetric dimethylarginine (ADMA and SDMA), increased microbiota-derived uremic toxin TMAO, reduced microbiota-derived metabolite acetate and butyrate levels, and dysregulation of the intrarenal RAS. Our results indicated that adenine-induced maternal CKD could be an appropriate model for studying uremia-related adverse pregnancy and offspring outcomes. Targeting NO pathway, microbiota metabolite TMAO, and the RAS might be potential therapeutic strategies to improve maternal CKD-induced adverse pregnancy and offspring outcomes.

Role of sFlt-1/PIGF ratio and uterine Doppler in pregnancies with chronic kidney disease suspected with Pre-eclampsia or HELLP syndrome

PURPOSE

Pregnancies of women with chronic kidney disease (CKD) are at higher risk of experiencing adverse perinatal (APO) and maternal outcome (AMO). Mean uterine artery pulsatility index (mUtA-PI) as well as the ratio of soluble fms-like tyrosine kinase-1 (sFlt-1) and placental growth factor (PlGF) are helpful tools in diagnosing pre-eclampsia (PE) in women with CKD. The aim of the study was to evaluate the role of sFlt-1/PIGF ratio and mUtA-PI as predictors for APO, AMO, preterm delivery and decline of kidney function in CKD pregnancies.

METHODS

A total of 28 CKD pregnancies with suspected PE/HELLP syndrome were retrospectively included, in whom both sFlt-1/PIGF and mUtA-PI were determined during the third trimester. APO was defined as fetal growth restriction, respiratory distress syndrome, intubation, admission to NICU, 5 min Apgar <7 and intracerebral hemorrhage. AMO was defined as the development of PE, HELLP syndrome or resistant hypertension. Decline of kidney function was defined as a 25% increase of creatinine level after delivery.

RESULTS

Of all included women, eight (28.6%) developed a PE/HELLP syndrome. AMO (28.6%) and APO (32.1%) were frequently observed. ROC analyses revealed a predictive value for AMO and sFlt-1/PIGF or mUtA-PI. Neither sFlt-1/PIGF nor mUtA-PI could predict APO or decline of postnatal kidney function. mUtA-PI was a predictor for preterm delivery.

CONCLUSION

Uterine Doppler and sFlt-1/PIGF are predictors of AMO in CKD pregnancies. Therefore, both markers might be helpful for an improved risk assessment. However, neither sFlt-1/PIGF nor mUtA-PI were able to predict a decline of postnatal kidney function or APO.

Maternal Tryptophan Supplementation Protects Adult Rat Offspring against Hypertension Programmed by Maternal Chronic Kidney Disease: Implication of Tryptophan-Metabolizing Microbiome and Aryl Hydrocarbon Receptor

Hypertension and chronic kidney disease (CKD) can originate during early-life. Tryptophan metabolites generated by different pathways have both detrimental and beneficial effects. In CKD, uremic toxins from the tryptophan-generating metabolites are endogenous ligands of the aryl hydrocarbon receptor (AHR). The interplay between AHR, nitric oxide (NO), the renin–angiotensin system (RAS), and gut microbiota is involved in the development of hypertension. We examined whether tryptophan supplementation in pregnancy can prevent hypertension and kidney disease programmed by maternal CKD in adult offspring via the aforementioned mechanisms. Sprague–Dawley (SD) female rats received regular chow or chow supplemented with 0.5% adenine for 3 weeks to induce CKD before pregnancy. Pregnant controls or CKD rats received vehicle or tryptophan 200 mg/kg per day via oral gavage during pregnancy. Male offspring were divided into four groups (n = 8/group): control, CKD, tryptophan supplementation (Trp), and CKD plus tryptophan supplementation (CKDTrp). All rats were sacrificed at the age of 12 weeks. We found maternal CKD induced hypertension in adult offspring, which tryptophan supplementation prevented. Maternal CKD-induced hypertension is related to impaired NO bioavailability and non-classical RAS axis. Maternal CKD and tryptophan supplementation differentially shaped distinct gut microbiota profile in adult offspring. The protective effect of tryptophan supplementation against maternal CKD-induced programmed hypertension is relevant to alterations to several tryptophan-metabolizing microbes and AHR signaling pathway. Our findings support interplay among tryptophan-metabolizing microbiome, AHR, NO, and the RAS in hypertension of developmental origins. Furthermore, tryptophan supplementation in pregnancy could be a potential approach to prevent hypertension programmed by maternal CKD.

The predictive value of sonographic placental markers for adverse pregnancy outcome in women with chronic kidney disease

OBJECTIVE

To determine the rate of sonographic placental markers and their predictive value for preeclampsia and fetal growth restriction in women with chronic kidney disease (CKD).

STUDY DESIGN

A retrospective cohort study of women with CKD followed at a tertiary referral center between 2016 and 2019 (n = 86). All women underwent 2nd trimester sonographic placental examinations that included assessment of placental morphology, umbilical cord, and uterine artery Doppler. Continuous placental markers were converted to multiples on medians (MoM).

MAIN OUTCOME MEASURES

Predictive value of sonographic markers for preeclampsia and birthweight < 10th percentile.

RESULTS

Women in the cohort had a high rate of preeclampsia (24.4%), birthweight < 10th% (26.7%), and preterm birth (30.2%). The most important markers were placental volume and uterine artery Doppler: the risk of preeclampsia was elevated in women with low placental volume (51.7% vs. 10.9%; OR = 8.79 [2.70-28.59] for preeclampsia; and 40.0% vs. 9.1%; OR = 6.67 [1.85-24.04] for preterm preeclampsia), and in women with bilateral uterine artery notching (62.5% vs. 20.8%; OR = 6.35 [1.37-29.45] for preeclampsia; and 62.5% vs. 10.4%; OR = 14.38 [1.29-71.75] for preterm preeclampsia). The combination of both markers had the strongest predictive value for preeclampsia (positive likelihood ratio = 8.25 [6.84-9.95]). Low placental volume and bilateral uterine notching were also associated with birthweight < 10th percentile.

CONCLUSION

A 2nd-trimester sonographic placental study can identify a subgroup of women with CKD who are at most risk of preeclampsia and fetal growth restriction. Such data may inform their subsequent perinatal care and assist care providers in the often challenging distinction between preeclampsia flare of underlying CKD.

Chronic kidney disease in pregnant mothers affects maternal and fetal disposition of mercury

Chronic kidney disease (CKD) affects over 15 % of the adults in the United States. Pregnant women with CKD present an additional challenge in that they are at increased risk for adverse events such as preterm birth. Exposure to environmental toxicants, such as methylmercury, may exacerbate maternal disease and increase the risk of adverse fetal outcomes. We hypothesized that fetuses of mothers with CKD are more susceptible to accumulation of methylmercury than fetuses of healthy mothers. The current data show that when mothers are in a state of renal insufficiency, uptake of mercury in fetal kidneys is enhanced significantly. Accumulation of Hg in fetal kidneys may be related to the flow of amniotic fluid, maternal handling of Hg, and/or underdeveloped mechanisms for cellular export and urinary excretion. The results of this study indicate that renal insufficiency in mothers leads to significant alterations in the way toxicants such as mercury are handled by maternal and fetal organs.

Confidence in Women's Health: A Cross Border Survey of Adult Nephrologists

A range of women’s health issues are intimately related to chronic kidney disease, yet nephrologists’ confidence in counseling or managing these issues has not been evaluated. The women’s health working group of Cure Glomerulonephropathy (CureGN), an international prospective cohort study of glomerular disease, sought to assess adult nephrologists’ training in, exposure to, and confidence in managing women’s health. A 25-item electronic questionnaire was disseminated in the United States (US) and Canada via CureGN and Canadian Society of Nephrology email networks and the American Society of Nephrology Kidney News. Response frequencies were summarized using descriptive statistics. Responses were compared across provider age, gender, country of practice, and years in practice using Pearson’s chi-squared test or Fisher’s exact test. Among 154 respondents, 53% were women, 58% practiced in the US, 77% practiced in an academic setting, and the median age was 41–45 years. Over 65% of respondents lacked confidence in women’s health issues, including menstrual disorders, preconception counseling, pregnancy management, and menopause. Most provided contraception or preconception counseling to less than one woman per month, on average. Only 12% had access to interdisciplinary pregnancy clinics. Finally, 89% felt that interdisciplinary guidelines and/or continuing education seminars would improve knowledge. Participants lacked confidence in both counseling and managing women’s health. Innovative approaches are warranted to improve the care of women with kidney disease and might include the expansion of interdisciplinary clinics, the development of case-based teaching materials, and interdisciplinary treatment guidelines focused on this patient group.