Kidney disease is an independent risk factor for adverse fetal and maternal outcomes in pregnancy

Any reduction in maternal kidney mass makes a difference during pregnancy in gestational and fetal outcome

Little is known about the effect tubulointerstitial nephropathies have in modulating maternal-fetal outcomes in pregnancy. Therefore, we analyzed the main outcomes of pregnancy in these women to gain a better understanding of the role of a reduction in maternal kidney mass. From the Torino Cagliari Observational Study (TOCOS) cohort, we selected 529 patients with a diagnosis of tubulointerstitial disease and focused on 421 patients with chronic kidney disease (CKD) stage 1, without hypertension but with proteinuria less than 0.5 g/day at referral. From a cohort of 2969 singleton deliveries from low-risk pregnancies followed in the same settings we selected a propensity score matched control cohort of 842 pregnancies match 2:1 for age, parity, body mass index, ethnicity, and origin. Time to delivery was significantly shorter in the study cohort 38.0 (Quartile 1-Quartile 3: 37.0-39.0) versus 39.0 (Q1-Q3 38.0-40.0) weeks, with respect to controls. Incidence of delivery of less than 37 gestational weeks significantly increased from controls (7.4%) to women with previous acute pyelonephritis (10.8%), other tubulointerstitial diseases (9.7%) and was the highest in patients with a single kidney (31.1%). Similarly, neonatal birthweight significantly and progressively decreased from controls (3260 g [Q1-Q3: 2980-3530]), previous acute pyelonephritis (3090 g [Q1-Q3: 2868-3405], other tubulointerstitial diseases (3110 g [Q1-Q3: 2840-3417]), and to solitary kidney (2910 g [Q1-Q3: 2480-3240]). Risk of developing preeclampsia was significantly higher in the CKD cohort (3.6% vs 1.7% in low-risk controls). Thus, even a small reduction in functional kidney mass, such as a pyelonephritic scar, is associated with a shorter duration of pregnancy and an increased risk of preterm delivery. The risk is proportional to the extent of parenchymal reduction and is highest in cases with a solitary kidney.

Consensus recommendations on fasting during Ramadan for patients with kidney disease: review of available evidence and a call for action (RaK Initiative)

Ramadan fasting (RF) involves abstaining from food and drink during daylight hours; it is obligatory for all healthy Muslims from the age of puberty. Although sick individuals are exempt from fasting, many will fast anyway. This article explores the impact of RF on individuals with kidney diseases through a comprehensive review of existing literature and consensus recommendations. This study was conducted by a multidisciplinary panel of experts.The recommendations aim to provide a structured approach to assess and manage fasting during Ramadan for patients with kidney diseases, empowering both healthcare providers and patients to make informed decisions while considering their unique circumstances.

Long-term Course of Kidney Function in Uterus Transplant Recipients Under Treatment With Tacrolimus and After Transplantectomy: Results of the First Clinical Cohort

Background

Chronic kidney disease is common after non-renal solid organ transplantation, mainly secondary to calcineurin inhibitors toxicity. Uterus transplantation (UTx) is an innovative treatment for women with absolute uterine factor infertility. UTx is exclusive because it is transient with the absence of lifelong immunosuppression and is performed in young healthy participants. Therefore, UTx provides a unique setting for evaluating the effect of time-limited calcineurin inhibitors treatment on recipients' kidney function.

Methods

In the first UTx cohort worldwide, we studied kidney function using estimated glomerular filtration rate (eGFR) in 7 women over a median follow-up of 121 (119-126) mo.

Results

Median eGFR (mL/min/1.73 m2) of the cohort was 113 at UTx, which declined to 74 during month 3, 71 at months 10-12, 76 at hysterectomy (HE), and 83 at last follow-up. Median duration of tacrolimus exposure was 52 (22-83) mo, and median trough levels (µg/L) were 10 during month 3 and 5.8 at HE. Between UTx and month 3, decline in kidney function was observed in all 7 participants with a median eGFR slope for the whole cohort of -24 mL/min/1.73 m2, which declined further by -4 mL/min/1.73 m2 until months 10-12. Thereafter, eGFR slope improved in 3 participants, remained stable in 3, and worsened in 1 until HE/tacrolimus discontinuation, after which it improved in 2. Eventually, between UTx and last follow-up, 4 of 7 participants had a decline in their eGFR, the median annual eGFR slope being negative at -1.9 mL/min/1.73 m2/y for the whole group.

Conclusions

Kidney function declined in all recipients early after UTx followed by a persistent long-term decrease in majority, despite transplantectomy and discontinuation of immunosuppression. Thus, UTx may incur an increased risk of chronic kidney disease even in this young and healthy population, highlighting the importance of close surveillance of kidney function and minimization of tacrolimus exposure.

Pre-Pregnancy eGFR and the Risk of Adverse Maternal and Fetal Outcomes: A Population-Based Study

SIGNIFICANCE STATEMENT

Pregnancies in women with CKD carry greater risk than pregnancies in the general population. The small number of women in prior studies has limited estimates of this risk, especially among those with advanced CKD. We report the results of a population-based cohort study in Ontario, Canada, that assessed more than 500,000 pregnancies, including 600 with a baseline eGFR < 60 ml/min per 1.73 m 2 . The investigation demonstrates increases in risk of different adverse maternal and fetal outcomes with lower eGFR and further risk elevation with baseline proteinuria.

BACKGROUND

CKD is a risk factor for pregnancy complications, but estimates for adverse outcomes come largely from single-center studies with few women with moderate or advanced stage CKD.

METHODS

To investigate the association between maternal baseline eGFR and risk of adverse pregnancy outcomes, we conducted a retrospective, population-based cohort study of women (not on dialysis or having had a kidney transplant) in Ontario, Canada, who delivered between 2007 and 2019. The study included 565,907 pregnancies among 462,053 women. Administrative health databases captured hospital births, outpatient laboratory testing, and pregnancy complications. We analyzed pregnancies with serum creatinine measured within 2 years of conception up to 30 days after conception and assessed the impact of urine protein where available.

RESULTS

The risk of major maternal morbidity, preterm delivery, and low birthweight increased monotonically across declining eGFR categories, with risk increase most notable as eGFR dropped below 60 ml/min per 1.73 m 2 . A total of 56 (40%) of the 133 pregnancies with an eGFR <45 ml/min per 1.73 m 2 resulted in delivery under 37 weeks, compared with 10% of pregnancies when eGFR exceeded 90 ml/min per 1.73 m 2 . Greater proteinuria significantly increased risk within each eGFR category. Maternal and neonatal deaths were rare regardless of baseline eGFR (<0.3% of all pregnancies). Only 7% of women with an eGFR <45 ml/min per 1.73 m 2 received dialysis during or immediately after pregnancy.

CONCLUSIONS

We observed higher rates of adverse pregnancy outcomes in women with low eGFR with concurrent proteinuria. These results can help inform health care policy, preconception counseling, and pregnancy follow-up in women with CKD.

Correlations between Maternal and Fetal Outcomes in Pregnant Women with Kidney Failure

BACKGROUND

Kidney function impairment in pregnancy is challenging, with incidence and prognosis only partially known. Studies concerning maternal and fetal outcomes in pregnancies occurring in patients with renal injury and the therapeutic strategies for improving the prognosis of these patients are scarce due to the limited number of cases reported.

OBJECTIVES

We aimed to establish correlations between the main maternal and fetal outcomes in patients with severe CKD or AKI in pregnancy to improve the prognosis, referring to a control group of patients with mild kidney impairment.

METHODS

For this purpose, we conducted a retrospective study, at University Emergency Hospital in Bucharest, Romania, from January 2019 until December 2021, selecting 38 patients with AKI and 12 patients diagnosed with advanced CKD, compared to 42 patients displaying borderline values of serum creatinine (0.8-1 mg/dL), reflecting the presence of milder kidney impairment.

RESULTS

The probability of having a child that is premature and small for gestational age, with a lower Apgar score and more frequent neonatal intensive care unit admissions, delivered by cesarean section, is higher in patients with highly reduced kidney function.

CONCLUSION

Severe kidney function impairment is associated with a grim fetal prognosis and obstetrical complications.

Identification of Structural and Molecular Signatures Mediating Adaptive Changes in the Mouse Kidney in Response to Pregnancy

Pregnancy is characterized by adaptations in the function of several maternal body systems that ensure the development of the fetus whilst maintaining health of the mother. The renal system is responsible for water and electrolyte balance, as well as waste removal. Thus, it is imperative that structural and functional changes occur in the kidney during pregnancy. However, our knowledge of the precise morphological and molecular mechanisms occurring in the kidney during pregnancy is still very limited. Here, we investigated the changes occurring in the mouse kidney during pregnancy by performing an integrated analysis involving histology, gene and protein expression assays, mass spectrometry profiling and bioinformatics. Data from non-pregnant and pregnant mice were used to identify critical signalling pathways mediating changes in the maternal kidneys. We observed an expansion of renal medulla due to proliferation and infiltration of interstitial cellular constituents, as well as alterations in the activity of key cellular signalling pathways (e.g., AKT, AMPK and MAPKs) and genes involved in cell growth/metabolism (e.g., Cdc6, Foxm1 and Rb1) in the kidneys during pregnancy. We also generated plasma and urine proteomic profiles, identifying unique proteins in pregnancy. These proteins could be used to monitor and study potential mechanisms of renal adaptations during pregnancy and 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.

Evaluation of obstetric outcomes and prognostic factors in pregnancies with chronic kidney disease

Objective: To evaluate the obstetric outcomes of pregnancies with chronic kidney disease (CKD) and to assess the prognostic factors on adverse obstetric outcomes. Methods: We retrospectively reviewed 101 singleton pregnancies with CKD. Obstetric outcomes were explored according to CKD stages. The composite adverse obstetric outcome was defined as at least one of stillbirth, neonatal death and delivery <34 weeks due to preeclampsia or fetal distress. Results: The incidences of preeclampsia, fetal growth restriction, perinatal mortality and composite adverse obstetric outcome were 40.5%, 26.7%, 14.8% and 37.6% respectively in pregnancies with CKD. Composite obstetric adverse outcome was significantly higher in pregnancies with CKD stage 4-5 than the other stages (p < 0.01). CKD stage 4-5 and baseline proteinuria >3 g/24 h were associated with composite obstetric adverse outcome (OR 43.2, p = 0.005 and OR 6.08, p = 0.01 respectively) comparing to stage 1 and proteinuria <0.5 g/24 h. Conclusion: Incidences of adverse obstetric outcomes are high even in early stages of CKD. CKD stage 4-5 and baseline proteinuria >3 g/24 h are poor prognostic factors.

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.

Evaluating the association between neonatal mortality and maternal high blood pressure, heart disease and gestational diabetes: A case control study

Background:

Prevention of noncommunicable diseases (NCDs) during pregnancy is recommended due to severe complications for mothers and infants. Considering that NCDs have a significant impact on infant mortality, this study was conducted to investigate the relationship between mothers' underlying diseases and gestational diabetes and infant mortality in Iran.

Materials and Methods:

Mothers who referred to the health centers in nine provinces of Iran were included. This case–control study used data collected from pregnant women. There were 1162 cases and 1624 controls. The required data were collected from mothers' health records and through interviews.

Results:

The chances of neonatal mortality in women with a body mass index (BMI) of 30–35, 1.7 times (odds ratio [OR] = 1.7, confidence interval [CI]: 1.19–2.44, P = 0.003) was higher compared with women with a normal BMI. The chance of neonatal mortality among mothers with high blood pressure was three times higher compared with healthy mothers (OR = 3.04, 95% CI: 1.98–4.65, P < 0.001). The chance of neonatal mortality in women with kidney disease was also 1.64 times higher than mothers without kidney problems (OR = 1.64, 95% CI: 1.1–2.45, P = 0.015). In the study of gestational diabetes, the chance of neonatal mortality among the mothers who had at risk was 1.63 times higher than mothers without gestational diabetes (OR = 1.63, 95% CI: 0.84–3.16, P = 0.014). Furthermore, the chance of neonatal mortality among the mothers who had heart disease was 1.10 times higher than mothers without heart disease (OR = 2.10, 95% CI: 0.88–4.99, P = 0.014).

Conclusion:

This study showed that undiagnosed underlying diseases were related to neonatal mortality, which highlights the importance of caring for and counseling about the underlying diseases, screening, and controlling blood sugar levels before and during pregnancy to prevent infant mortality by all means possible.

Renal biopsy findings during and after pregnancy

Background

Chronic kidney disease is estimated to affect up to 6% of women of reproductive age. Maternity care represents an opportunity for early diagnosis but there is limited understanding of chronic kidney disease aetiology occurring in or revealed by pregnancy.

Methods

A retrospective evaluation of renal biopsies during and after pregnancy between 2000 and 2015 was undertaken. A large academic health centre pathology database was searched for free text pregnancy-related terms, restricted to typology code 71000 (kidney). Indications and findings of postpartum renal biopsies were reviewed.

Results

Sixty-three renal biopsy reports were identified. Of 45 biopsies performed postpartum, 34 (75.6%) investigated persistent postpartum proteinuria. 20/34 (70.6%) of these biopsies yielded a primary renal disease, and 6/34 (17.6%) women had progressed to end stage renal disease at latest follow-up.

Conclusion

Renal biopsy findings of women investigated for persistent postpartum proteinuria revealed a high incidence of histological diagnosis of de novo renal disease.

Association Between Hypertensive Disorders During Pregnancy and the Subsequent Risk of End-Stage Renal Disease: A Population-Based Follow-Up Study

OBJECTIVE

To assess whether hypertensive disorders during pregnancy (HDPs) are associated with the subsequent development of end-stage renal disease (ESRD).

METHODS

The present study included 1 598 043 women who delivered in Canadian hospitals between April 1993 and March 2003. The baseline information was from the Canadian Institute for Health Information's Discharge Abstract Database. Women with chronic kidney disease, diabetes mellitus, and other specific conditions were excluded. A follow-up study was conducted through a record linkage on their hospitalizations as of the 13th month after the delivery discharge through March 31, 2013. The primary outcome of interest was subsequent hospitalization due to ESRD. Cox model was used to quantify the association between HDPs and ESRD hospitalization.

RESULTS

There occurred 9.9 and 1.7 ESRD hospitalizations per 100 000 person-years in the follow-up of HDPs and non-HDP women, respectively. An increased risk of ESRD hospitalization was observed in pregnant women with pre-eclampsia/eclampsia (adjusted hazard ratio [aHR] = 4.7, 95% CI 3.6-6.0), unspecified HDPs (aHR = 4.6, 95% CI 2.8-7.7), or gestational hypertension (aHR = 3.3, 95% CI 2.1-5.1). Caesarean delivery, preterm delivery, IUGR, and deep vein thrombosis were identified as significant correlates with the subsequent ESRD hospitalization. The risk of subsequent ESRD hospitalization appeared to be lower for women who had ≥2 deliveries compared with those who had one delivery during the study period.

CONCLUSION

Pregnancy complicated with HDPs was significantly associated with an increased risk of ESRD hospitalization in later life, and this association varied by HDP subtype and frequency of delivery.

Establishment of a model to predict the prognosis of pregnancy-related acute kidney injury

BACKGROUND

Our aim was to investigate the prognostic factors of pregnancy related acute kidney injury (PR-AKI), establish the prognosis prediction model and evaluate predictability with the model.

METHODS

Serum creatinine (SCr), placental growth factor (PLGF), endothelin-1 (ET-1), urinary kidney injury molecule-1 (KIM-1), and β2-microglobulin (β2-MG) levels in 122 patients with PR-AKI were measured at 1 month, 3 months, 6 months, and 1 year after delivery and the logistic backward stepwise regression method was used to screen the factors associated with the prognosis, establish the model to predict the prognosis of patients 1 year after delivery, and evaluate predictability with the model.

RESULTS

1) At 1 month, 3 months, 6 months, and 1 year after delivery, SCr was not significantly different in the poor prognosis group (P˃0.05); ET-1, KIM-1 and β2-MG were decreased significantly, and PLGF was significantly increased (P˂0.05); all testing indicators in the good prognosis group were significantly different and returned to normal within 1 year (P˂0.05). By comparing the two groups, there were no significant differences in SCr, PLGF and β2-MG levels at 1 month after delivery (P˃0.05), while there were significant differences in the remaining testing indicators at each time point (P˂0.05). 2) Logistic backward stepwise regression analysis showed that SCr, KIM-1, ET-1, and time were related to the prognosis of patients with PR-AKI, and the above screening indicators were used to fit the model Logit.

CONCLUSIONS

The logistic regression model fitting-effect was good, its accuracy of predicting renal injury prognosis was high. SCr, KIM-1, and ET-1 can be used for PR-AKI screening and are important for monitoring the disease condition of patients, intervention, and evaluation of prognosis.

Chronic hypertension: first-trimester blood pressure control and likelihood of severe hypertension, preeclampsia, and small for gestational age

BACKGROUND

There is extensive evidence that prepregnancy chronic hypertension is associated with a high risk of development of severe hypertension and preeclampsia and birth of small-for-gestational-age neonates. However, previous studies have not reported whether antihypertensive use, blood pressure control, or normalization of blood pressure during early pregnancy influences the rates of these pregnancy complications.

OBJECTIVE

The purpose of this study was to stratify women with prepregnancy chronic hypertension according to the use of antihypertensive medications and level of blood pressure control at the first hospital visit during the first trimester of pregnancy and to examine the rates of severe hypertension, preeclampsia, and birth of small-for-gestational-age neonates according to such stratification.

STUDY DESIGN

We conducted a prospective study of 586 women with prepregnancy chronic hypertension, in the absence of renal or liver disease, that was booked at a dedicated clinic for the management of hypertension in pregnancy. The patients had singleton pregnancies and were subdivided according to findings in their first visit: group 1 (n=199), blood pressure <140/90 mm Hg without antihypertensive medication; group 2 (n=220), blood pressure <140/90 mm Hg with antihypertensive medication; and group 3 (n=167), systolic blood pressure ≥140 mm Hg and/or diastolic blood pressure ≥90 mm Hg, despite antihypertensive medication. In the subsequent management of these pregnancies, our policy was to maintain the blood pressure at 130-140/80-90 mm Hg with the use of antihypertensive medication; antihypertensive drugs were stopped if the blood pressure was persistently <130/80 mm Hg. The outcome measures were severe hypertension (systolic blood pressure ≥160 mm Hg and/or diastolic blood pressure ≥110 mm Hg), preterm and term preeclampsia (in addition to hypertension at least 1 of renal involvement, liver impairment, neurologic complications, or thrombocytopenia), and birth of small-for-gestational-age neonates (birthweight <5th percentile for gestational age). The incidence of these complications was compared in the 3 strata.

RESULTS

The median gestational age at presentation was 10.0 weeks (interquartile range, 9.1-11.0 weeks). In groups 2 and 3, compared with group 1, there was a significantly higher body mass index, incidence of black racial origin, and history of preeclampsia in a previous pregnancy. There was a significant increase from group 1 to group 3 in the incidence of severe hypertension (10.6%, 22.2%, and 52.1%), preterm preeclampsia with onset at <37 weeks of gestation (7.0%, 15.9%, and 20.4%), and small for gestational age (13.1%, 17.7%, and 21.1%), but not term preeclampsia with onset at ≥37 weeks of gestation (9.5%, 9.1%, and 6.6%).

CONCLUSIONS

In women with prepregnancy chronic hypertension, the rates of development of severe hypertension, preterm preeclampsia, and small for gestational age are related to the use of antihypertensive medications and the level of blood pressure control at the first hospital visit during the first trimester of pregnancy.

Outcome of pregnancy after renal transplantation

AIM

The aim of our study was to compare the outcome of pregnancy in patients who became pregnant within 24 months of renal transplantation and patients who became pregnant more than 24 months after renal transplantation.

MATERIALS AND METHODS

The sample population of our prospective cohort study comprised of 44 patients who became pregnant following renal transplantation. In all cases, living donors were used for renal transplantation. The patients were allocated into either group A, which included 24 patients who became pregnant more than 24 months after renal transplantation, or group B, which included 20 patients who inadvertently became pregnant within 24 months of renal transplantation. Serum creatinine and 24-hour urinary protein concentration were measured each trimester. The incidences of preeclampsia and gestational diabetes, the timing and mode of delivery, the rate of preterm labor, and the mean fetal birth weight were determined.

RESULTS

The mean gestational ages in groups A and B were 35.8±3 weeks and 34.1±2.5 weeks, respectively. The mean fetal birth weights in groups A and B were 2,480±316 g and 2,284.5±262 g, respectively. These differences were statistically significant. The incidence of preterm labor was 45.8% in group A and 55% in group B. Proteinuria was significantly higher in group B during the third trimester of pregnancy. Preeclampsia occurred in 25% of the cases in group A and 30% of the cases in group B; this difference was not statistically significant. Gestational diabetes occurred in 2 out of 24 cases in group A and 2 out of 20 cases in group B. For group A and group B, normal vaginal delivery occurred in 58.3% and 55% of cases, respectively, and cesarean section was performed in 41.6% and 45% of cases, respectively.

CONCLUSION

A longer interval between renal transplantation and pregnancy is associated with better pregnancy outcome.

Kidney Function After a Hypertensive Disorder of Pregnancy: A Longitudinal Study

BACKGROUND

Registry-based studies report an increased risk for end-stage kidney disease after hypertensive disorders of pregnancy (HDPs). It is unclear whether HDPs lead to an increased incidence of chronic kidney disease (CKD) and/or progression of kidney function decline.

STUDY DESIGN

Subanalysis of the Prevention of Renal and Vascular Endstage Disease (PREVEND) Study, a Dutch population-based cohort with follow-up of 5 visits approximately 3 years apart.

SETTING & PARTICIPANTS

Women without and with patient-reported HDPs (non-HDP, n=1,805; HDP, n=977) were identified. Mean age was 50 years at baseline and median follow-up was 11 years.

FACTOR

An HDP.

OUTCOMES

(1) The incidence of CKD using Cox regression and (2) the course of kidney function (estimated glomerular filtration rate [eGFR] and 24-hour albuminuria) over 5 visits using generalized estimating equation analysis adjusted for age, mean arterial pressure, and renin-angiotensin system (RAS) blockade. CKD was defined as eGFR<60mL/min/1.73m² and/or 24-hour albuminuria with albumin excretion > 30mg, and end-stage kidney disease was defined as receiving dialysis or kidney transplantation.

RESULTS

During follow-up, none of the women developed end-stage renal disease and the incidence of CKD during follow-up was similar across HDP groups (HR, 1.04; 95% CI, 0.79-1.37; P=0.8). Use of RAS blockade was higher after HDP at all visits. During a median of 11 years, we observed a decrease in eGFR in both groups, with a slightly steeper decline in the HDP group (98±15 to 88±16 vs 99±17 to 91±15mL/min/1.73m²; P_group<0.01, P_group*visit<0.05). The group effect remained significant after adjusting for mean arterial pressure, but disappeared after adjusting for RAS blockade. The 24-hour albuminuria did not differ between groups.

LIMITATIONS

No obstetric records available. HDPs defined by patient report rather than health records.

CONCLUSIONS

HDPs did not detectably increase the incidence of CKD. During follow-up, we observed no differences in albuminuria, but observed a marginally lower eGFR after HDP that was no longer statistically significant after adjusting for the use of RAS blockers. In this population, we were unable to identify a significant risk for kidney function decline after patient-reported HDP.

Emerging understanding and measurement of plasma volume expansion in pregnancy

Plasma volume expansion is an important component of a successful pregnancy. The failure of maternal plasma volume expansion has been implicated in adverse obstetric outcomes such as pre-eclampsia, fetal growth restriction, and preterm birth. Altered iron homeostasis and elevated maternal hemoglobin concentrations have also been associated with adverse pregnancy outcomes; limited data have suggested that these effects may be mediated by inadequate plasma volume expansion. In addition, it has been noted that pregnant, obese women, compared with lean subjects, have decreased plasma volume expansion along with impaired iron homeostasis and increased inflammation. Current estimates of plasma volume expansion are outdated and do not necessarily reflect contemporary obstetric populations. Moreover, the validation of clinically applicable methods of plasma volume determination as well as enhanced methodologies should be a priority. Further study is needed to characterize diminished plasma volume expansion during pregnancy and to understand the potential role of impaired iron homeostasis and inflammation in adverse obstetric outcomes, especially in obese women.

Factors related to deterioration of renal function after singleton delivery in pregnant women with chronic kidney disease

OBJECTIVE

This study is designed to evaluate which factors would relate to deterioration of renal function (DRF) after delivery in pregnant women with chronic kidney disease (CKD).

MATERIALS AND METHODS

This study included 156 singleton pregnancies of 139 women with CKD at our institution from 2001 to 2010. DRF was defined as the shift of CKD stage into another more severe stage. The relevant variables were compared between women who had DRF (n = 39) and the controls (n = 117).

RESULTS

The number of transplantation or dialysis cases after delivery was 5.8%. DRF occurred in 25% of the study patients. From a logistic regression model, the factors that influence DRF were the presence of glomerulonephritis [odds ratio (OR) 3.56, 95% confidence interval (CI) 1.18-10.81], significant proteinuria prior to pregnancy (≥3 g/d or 3+ more dipstick; OR 3.43, 95% CI 1.14-10.33), and treatment with antiplatelet agents (OR 0.30, 95% CI 0.09-0.94). Receiver-operating characteristic curve analysis confirmed that the estimated glomerular filtration rate (eGFR) of 75 mL/min/1.73 m(2) or more before conception is not a risk factor for DRF after delivery (negative predictive value 0.788).

CONCLUSION

This was the first report to reveal a clear cutoff value regarding DRF in pregnant woman with CKD. There is an almost 78% risk of developing DRF after delivery in patients showing eGFR of 75 mL/min/1.73 m(2) or more before conception.

Pregnancy as a critical window for blood pressure regulation in mother and child: programming and reprogramming

Pregnancy is a critical time for long-term blood pressure regulation in both mother and child. Pregnancies complicated by placental insufficiency, resulting in pre-eclampsia and intrauterine growth restriction, are associated with a threefold increased risk of the mother to develop hypertension later in life. In addition, these complications create an adverse intrauterine environment, which programmes the foetus and the second generation to develop hypertension in adult life. Female offspring born to a pregnancy complicated by placental insufficiency are at risk for pregnancy complications during their own pregnancies as well, resulting in a vicious circle with programmed risk for hypertension passing from generation to generation. Here, we review the epidemiology and mechanisms leading to the altered programming of blood pressure trajectories after pregnancies complicated by placental insufficiency. Although the underlying mechanisms leading to hypertension remain the subject of investigation, several abnormalities in angiotensin sensitivity, sodium handling, sympathetic activity, endothelial function and metabolic pathways are found in the mother after exposure to placental insufficiency. In the child, epigenetic modifications and disrupted organ development play a crucial role in programming of hypertension. We emphasize that pregnancy can be viewed as a window of opportunity to improve long-term cardiovascular health of both mother and child, and outline potential gains expected of improved preconceptional, perinatal and post-natal care to reduce the development of hypertension and the burden of cardiovascular disease later in life. Perinatal therapies aimed at reprogramming hypertension are a promising strategy to break the vicious circle of intergenerational programming of hypertension.

Two Pregnancies with a Different Outcome in a Patient with Alport Syndrome

BACKGROUND

Alport syndrome is a genetic disease that progresses to chronic kidney failure, with X-linked, autosomal dominant or autosomal recessive type of inheritance. Women are generally carriers of the mutation and have a milder form of the disease. During pregnancy, they have an increased risk of impaired kidney function and preeclampsia.

CASE PRESENTATION

A 27-year old woman, gravida 1, para 0, in her 23rd gestational week came to the outpatient unit of the University Clinic of Nephrology for the first time because of slowly progressing proteinuria and Alport syndrome. She was admitted to the gynaecological ward in her 29th gw for proteinuria which increased from 3.8 g/day up to 20 g/day and the serum creatinine increased to 120- 150 micromol/l. She was delivered in the 30th gestational week due to obstetrical indications with a cesarian section and delivered a baby with a birth weight of 880 g. After delivery, proteinuria decreased to 2 g/d within 2 months and an angiotensin-converting enzyme inhibitor (ACEI) was started. Her second pregnancy, after 2 years, had an uneventful course and she delivered a healthy baby weighing 3000 g in the 39th week. Six months after the second delivery, her renal function remained normal and her proteinuria was 2 g/d.

CONCLUSIONS

Pre-pregnancy counselling and frequent controls during pregnancy are necessary for women with Alport syndrome, as well as regular monitoring after delivery. Recent reports are more in favour of good pregnancy and nephrological outcomes in women with Alport syndrome when renal disease is not advanced.

Effect of dialysis on fetal heart rate: is inpatient admission for fetal monitoring necessary?

OBJECTIVE

Pregnant patients receiving hemodialysis (HD) have long hospital stays for the purpose of electronic fetal monitoring (EFM) during HD, which allows for monitoring of fetal well-being. However, more frequent dialysis allows for smaller fluid shifts, preventing maternal hypotension. Our aim was to determine differences in rates of EFM abnormalities during HD versus non-stress testing (NST) off dialysis for gravid women with renal failure.

METHODS

Retrospective cohort study over a 13-year period (2000-2013) identified five patients with renal failure in pregnancy. EFM tracings were reviewed during HD (cases) and routine inpatient NST off HD (controls). Standardized nomenclature was used to identify EFM abnormalities. The rate of abnormalities per hour of EFM was calculated. Kruskal-Wallis test was used and statistical significance was set at p < 0.05.

RESULTS

There were no significant differences in late decelerations (p = 0.2) between cases and controls. Significantly fewer variable decelerations (p = 0.01) and contractions (p ≤0.001) were noted during dialysis compared to controls. Significantly more prolonged decelerations (p = 0.02) were noted during HD compared to controls.

CONCLUSION

There may be no fetal benefit of EFM during HD for gravid women with renal disease attributed to hypertensive and diabetic nephropathy. There may be cost savings by shifting HD to the outpatient setting.

An Overview on Fertility Outcome in Renal Transplant Recipients

BACKGROUND

The number of patients undergoing renal transplant are increasing with time. Most of these patients fall in the reproductive age group, who are going to conceive sooner or later. But there are few recipients who either are infertile before transplant or became infertile due to underlying renal pathology responsible for transplantation.

OBJECTIVE

To study fertility outcome in female renal transplant recipients.

MATERIALS AND METHODS

STUDY DESIGN

This is a retrospective study conducted at tertiary health center in Ahmedabad, from 2004 to 2014.

INCLUSION CRITERIA

Renal transplant recipients in the reproductive age group (20-40 years of age) were followed up in gynecology outdoor patient department.

SAMPLE SIZE

There were 211 female renal transplant recipients, out of which 113 (53.5 %) patients had complete family, 3 (1.41 %) patients were infertile, 16 (7.58 %) patients have conceived, 33 (15.63 %) patients were lost to follow-up and remaining 46 (21.8 %) did not try for pregnancy.

EXCLUSION CRITERIA

Unmarried patients, divorced and widow patients were excluded.

RESULTS

Out of 19 patients, 16 patients conceived and 3 were infertile. The main cause of infertility in these patients was ovarian factor in 2 patients and tubal factor in 1 patient. Among 16 patients, 8 patients had missed abortion, 2 patients had preterm deliveries and 6 patients had term deliveries.

CONCLUSION

Peritransplant and preconceptional counseling plays an important role for renal transplant recipients to help them understand the effect of renal pathology and transplantation on their fertility. They can have good fertility and pregnancy outcome with optimum functioning graft.

Pregnancy outcomes among renal transplant recipients and patients with end-stage renal disease on dialysis

AIM

The purpose of our study is to compare pregnancy outcomes between women with a functioning renal transplant and women with end-stage renal disease (ESRD).

METHODS

We carried out a population-based retrospective cohort study using the Healthcare Cost and Utilization Project Nationwide Inpatient Sample database from 2006 to 2011. Logistic regression analysis was used to estimate the age-adjusted effect of functioning renal transplant vs. ESRD requiring dialysis on pregnancy outcomes.

RESULTS

We identified 264 birth records to women with a functional renal transplant and 267 birth records to women with ESRD on dialysis among 5,245,452 births. As compared to women with ESRD on dialysis, renal transplant recipients were less likely to have placental abruption [odds ratio, OR 0.23 (95% confidence interval, CI 0.08-0.70)], to receive blood transfusions [OR 0.17 (95% CI 0.09-0.30)], and to have growth-restricted and small-for-gestational-age babies [OR 0.45 (95% CI 0.23-0.85)]. Renal transplant recipients were more likely to have an instrumental delivery [OR 15.38 (95% CI 1.92-123.3)]. Among renal transplant women, there was a trend towards delivery by cesarean section as compared to patients with ESRD [OR 1.31 (95% CI 0.93-1.85)]. However, these results were not statistically significant. Fetal deaths were less likely to occur in women with a renal transplant [OR 0.41 (95% CI 0.17-0.96)]. There were four maternal deaths among patients with ESRD on dialysis and no maternal deaths among renal transplant patients.

CONCLUSION

Patients with a functional renal graft had an overall lower rate of morbidity and adverse pregnancy complications when compared to patients with ESRD on dialysis.

Alport syndrome and pregnancy: Good obstetric and nephrological outcomes in a pregnant woman with homozygous autosomal recessive Alport syndrome

We describe the course of pregnancy in a 27-year-old woman with homozygous autosomal recessive Alport syndrome. Genetic analysis revealed a homozygous COL4A4 mutation in exon 36 (c.3307G > A) with p.G1102R inherited from her parents (who were parallel cousins) 1 year before conception. Before pregnancy, the patient's renal function and blood pressure were normal, and her urinary protein excretion was below 2 g/day. The pregnancy course was uneventful in the first and second trimesters. She was detected to have nephrotic-range proteinuria during the third trimester, but was observed closely on an outpatient basis without any medications, as her general condition was good, her renal function and blood pressure remained stable, and the fetal well-being was maintained. At 39(+0) weeks of pregnancy, she vaginally gave birth to an appropriate-birthweight infant and her urinary protein excretion returned to pre-pregnancy level. This is the first report of pregnancy in a patient with autosomal recessive Alport syndrome with good obstetric and nephrological outcomes in the absence of any treatment or hospitalization.

Pregnancy in patients with chronic kidney disease: Maternal and fetal outcomes

Chronic kidney diseases (CKD) adversely affects fetal and maternal outcomes during pregnancy. We retrospectively reviewed the renal, maternal and fetal outcomes of 51 pregnancies in women with CKD between July 2009 and January 2012. Of the 51 subjects (mean age 27.8 ± 7.04), 32 had 19 had estimated glomerular filtration rate (eGFR) <60 ml/min. There was significantly greater decline in eGFR at 6 weeks (55.8 ± 32.7 ml/min) after delivery as compared to values at conception (71.7 ± 27.6 [P < 0.001]). The average decline of GFR after 6 weeks of delivery was faster in patients with GFR < 60 ml/min/1.73 m(2) at -18.8 ml/min (stage 3, n = 13, -20.2 ml/min; stage 4, n = 6, -15.8 ml/min) as compared to -15.1 ml/min in patients with GFR ≥ 60 ml/min/1.73 m(2). Three of the six patients (50%) in stage 4 CKD were started on dialysis as compared to none in earlier stages of CKD (P = 0.002). At the end of 1 year, all patients in stage 4 were dialysis dependent, while only 2/13 in stage 3 were dialysis dependent (Odds ratio 59.8, 95% confidence interval 2.8-302, P = 0.001). Preeclampsia (PE) was seen in 17.6%. Only 2/32 (6.25%) patients with GFR ≥ 60 ml/min/1.73 m(2) developed PE while 7/19 (36.84%) patients with GFR < 60 ml/min developed PE. Of the 51 pregnancies, 15 ended in stillbirth and 36 delivered live births. Eleven (21.56%) live-born infants were delivered preterm and 7 (13.72%) weighed < 2,500 g. The full-term normal delivery was significantly high (50%) in patients with GFR ≥ 60 ml/min/1.73 m(2) (P = 0.006) and stillbirth was significantly high - 9/19 (47.36%) patients with GFR < 60 ml/min/1.73 m(2). To conclude, women with CKD stage 3 and 4 are at greater risk of decline in GFR, PE and adverse maternal and fetal outcomes as compared to women with earlier stages of CKD.

Risk of Adverse Pregnancy Outcomes in Women with CKD

CKD is increasingly prevalent in pregnancy. In the Torino-Cagliari Observational Study (TOCOS), we assessed whether the risk for adverse pregnancy outcomes is associated with CKD by comparing pregnancy outcomes of 504 pregnancies in women with CKD to outcomes of 836 low-risk pregnancies in women without CKD. The presence of hypertension, proteinuria (>1 g/d), systemic disease, and CKD stage (at referral) were assessed at baseline. The following outcomes were studied: cesarean section, preterm delivery, and early preterm delivery; small for gestational age (SGA); need for neonatal intensive care unit (NICU); new onset of hypertension; new onset/doubling of proteinuria; CKD stage shift; "general" combined outcome (preterm delivery, NICU, SGA); and "severe" combined outcome (early preterm delivery, NICU, SGA). The risk for adverse outcomes increased across stages (for stage 1 versus stages 4-5: "general" combined outcome, 34.1% versus 90.0%; "severe" combined outcome, 21.4% versus 80.0%; P<0.001). In women with stage 1 CKD, preterm delivery was associated with baseline hypertension (odds ratio [OR], 3.42; 95% confidence interval [95% CI], 1.87 to 6.21), systemic disease (OR, 3.13; 95% CI, 1.51 to 6.50), and proteinuria (OR, 3.69; 95% CI, 1.63 to 8.36). However, stage 1 CKD remained associated with adverse pregnancy outcomes (general combined outcome) in women without baseline hypertension, proteinuria, or systemic disease (OR, 1.88; 95% CI, 1.27 to 2.79). The risk of intrauterine death did not differ between patients and controls. Findings from this prospective study suggest a "baseline risk" for adverse pregnancy-related outcomes linked to CKD.

Blood pressure goals and treatment in pregnant patients with chronic kidney disease

As the age of pregnant women and prevalence of obesity and diabetes are increasing, so is the prevalence of medical disorders during pregnancy, particularly hypertension and the associated CKD. Pregnancy can worsen kidney function in women with severe disease, and hypertension puts them at risk for pre-eclampsia and the associated complications. There are no specific guidelines for hypertension management in this population, and tight control will not prevent pre-eclampsia. Women with end-stage kidney disease should be placed on intense dialysis regimens to improve obstetric outcomes, and angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are best avoided. This article will review the rationale for a management plan that includes a multidisciplinary team to discuss risks and develop a plan before conception, antepartum monitoring for maternal and fetal morbidity, individualization of medical management using medications with established records during pregnancy, and balancing the level of blood pressure control proved to protect kidney function against the potential effects that aggressive blood pressure control could have on the fetal-placental unit.

Kidney disease and maternal and fetal outcomes in pregnancy

BACKGROUND

Pregnancy in kidney disease is considered high risk, but the degree of this risk is unclear. We tested the hypothesis that kidney disease in pregnancy is associated with adverse maternal and fetal outcomes.

STUDY DESIGN

Retrospective study comparing pregnant women with and without kidney disease.

SETTING & PARTICIPANTS

Using data from an integrated health care delivery system from 2000 through 2013, a total of 778 women met the criteria for kidney disease. Using a pool of 74,105 women without kidney disease, we selected 778 women to use for matches for the women with kidney disease. These women were matched 1:1 by age, race, and history of diabetes, chronic hypertension, liver disease, and connective tissue disease.

PREDICTOR

Kidney disease was defined using the NKF-KDOQI definition for chronic kidney disease or International Classification of Diseases, Ninth Revision codes prior to pregnancy or serum creatinine level > 1.2mg/dL and/or proteinuria in the first trimester.

OUTCOMES & MEASUREMENTS

Maternal outcomes included preterm delivery, delivery by cesarean section, preeclampsia/eclampsia, length of stay at hospital (>3 days), and maternal death. Fetal outcomes included low birth weight (weight < 2,500g), small for gestational age, number of admissions to neonatal intensive care unit, and infant death.

RESULTS

Compared with women without kidney disease, those with kidney disease had 52% increased odds of preterm delivery (OR, 1.52; 95% CI, 1.16-1.99) and 33% increased odds of delivery by cesarean section (OR, 1.33; 95% CI, 1.06-1.66). Infants born to women with kidney disease had 71% increased odds of admission to the neonatal intensive care unit or infant death compared with infants born to women without kidney disease (OR, 1.71; 95% CI, 1.17-2.51). Kidney disease also was associated with 2-fold increased odds of low birth weight (OR, 2.38; 95% CI, 1.64-3.44). Kidney disease was not associated with increased risk of maternal death.

LIMITATIONS

Data for level of kidney function and cause of death not available.

CONCLUSIONS

Kidney disease in pregnancy is associated independently with adverse maternal and fetal outcomes when other comorbid conditions are controlled by matching.

Association of low-protein supplemented diets with fetal growth in pregnant women with CKD

BACKGROUND AND OBJECTIVES

Women affected by CKD increasingly choose to get pregnant. Experience with low-protein diets is limited. The aim of this study was to review results obtained from pregnant women with CKD on supplemented vegan-vegetarian low-protein diets.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This was a single-arm, open intervention study between 2000-2012 of a low-protein diet in pregnant patients with stages 3-5 CKD or severe proteinuria (>1 g/d in the first trimester or nephrotic at any time). Stages 3-5 CKD patients who were not on low-protein diets for clinical, psychologic, or logistic reasons served as controls. The setting was the Obstetrics-Nephrology Unit dedicated to kidney diseases in pregnancy. The treated group included 24 pregnancies--21 singleton deliveries, 1 twin pregnancy, 1 abortion, and 1 miscarriage. Additionally, there were 21 controls (16 singleton deliveries, 5 miscarriages). The diet was a vegan-vegetarian low-protein diet (0.6-0.8 g/kg per day) with keto-acid supplementation and 1-3 protein-unrestricted meals allowed per week.

RESULTS

Treated patients and controls were comparable at baseline for median age (35 versus 34 years), referral week (7 versus 8), eGFR (59 versus 54 ml/min), and hypertension (43.5% versus 33.3%); median proteinuria was higher in patients on the low-protein diet (1.96 [0.1-6.3] versus 0.3 [0.1-2.0] g/d; P<0.001). No significant differences were observed in singletons with regard to gestational week (34 versus 36) or Caesarean sections (76.2% versus 50%). Kidney function at delivery was not different, but proteinuria was higher in the diet group. Incidence of small for gestational age babies was significantly lower in the diet group (3/21) versus controls (7/16; chi-squared test; P=0.05). Throughout follow-up (6 months to 10 years), hospitalization rates and prevalence of children below the third percentile were similar in both groups.

CONCLUSION

Vegan-vegetarian supplemented low-protein diets in pregnant women with stages 3-5 CKD may reduce the likelihood of small for gestational age babies without detrimental effects on kidney function or proteinuria in the mother.

A brief overview of preeclampsia

Preeclampsia (PE) is a leading cause of maternal mortality and morbidity worldwide. It occurs in women with first or multiple pregnancies and is characterized by new onset hypertension and proteinuria. Improper placentation is mainly responsible for the disease. If PE remains untreated, it moves towards more serious condition known as eclampsia. Hypertension, diabetes mellitus, proteinuria, obesity, family history, nulliparity, multiple pregnancies and thrombotic vascular disease contribute as the risk factors for PE. PE triggered metabolic stress causes vascular injury, thus contributing to the development of cardiovascular disease (CVD) and/or chronic kidney disease (CKD) in future. This risk appears to be increased especially in women with a history of recurrent PE and eclampsia. Clinically increased serum levels of sFlt-1 and decreased placental growth factor (PIGF) and vascular endothelial growth factor (VEGF) represent the severe condition of PE. The clinical findings of sever PE are assorted by the presence of systemic endothelial dysfunction, microangiopathy, the liver (hemolysis, elevated liver function tests and low platelet count, namely HELLP syndrome) and the kidney (proteinuria). The early detection of PE is one of the most important goals in obstetrics.

Chronic kidney disease in pregnancy

Parturients with renal insufficiency or failure present a significant challenge for the anesthesiologist. Impaired renal function compromises fertility and increases both maternal and fetal morbidity and mortality. Close communication amongst medical specialists, including nephrologists, obstetricians, neonatologists and anesthesiologists is required to ensure the safety of mother and child. Pre-existing diseases should be optimized and close surveillance of maternal and fetal condition is required. Kidney function may deteriorate during pregnancy, necessitating early intervention. The goal is to maintain hemodynamic and physiologic stability while the demands of the pregnancy change. Drugs that may adversely affect the fetus, are nephrotoxic or are dependent on renal elimination should be avoided.

Pregnancy in CKD: whom should we follow and why?

BACKGROUND

Chronic kidney disease (CKD) has a high prevalence in pregnancy. In a period of cost constraints, there is the need for identification of the risk pattern and for follow-up.

METHODS

Patients were staged according to K-DOQI guidelines. The analysis was prospective, January 2000-June 2011. Two hundred and forty-nine pregnancies were observed in 225 CKD patients; 176 singleton deliveries were recorded. The largest group encompasses stage 1 CKD patients, with normal renal function, in which 127 singleton deliveries were recorded. No hard outcomes occurred (death; dialysis); therefore, surrogate outcomes were analysed [caesarean section, prematurity, need for neonatal intensive care unit (NICU)]. Stage 1 patients were compared with normal controls (267 low-risk pregnancies followed in the same setting) and with patients with CKD stages 2-4 (49 singleton deliveries); two referral patterns were also analysed (known diagnoses; new diagnoses).

RESULTS

The risk for adverse pregnancy rises significantly in stage 1 CKD, when compared with controls: odds ratios were caesarean section 2.73 (1.72-4.33); preterm delivery 8.50 (4.11-17.57); NICU 16.10 (4.42-58.66). The risks rise in later stages. There is a high prevalence of new CKD diagnosis (overall: 38.6%; stage 1: 43.3%); no significant outcome difference was found across the referral patterns. Hypertension and proteinuria are confirmed as independent risk factors.

CONCLUSIONS

CKD is a risk factor in pregnancy; all patients should be followed within dedicated programmes from stage 1. There is need for dedicated interventions and educational programmes for maximizing the diagnostic and therapeutic potentials in early CKD stages.

Pregnancy outcomes in women with chronic kidney disease: a systematic review

BACKGROUND AND OBJECTIVES

Pregnant women with chronic kidney disease (CKD) are at risk of adverse maternal and fetal outcomes. We conducted a systematic review of observational studies that described this risk.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We searched several databases from their date of inception through June 2010 for eligible articles published in any language. We included any study that reported maternal or fetal outcomes in at least five pregnant women in each group with or without CKD. We excluded pregnant women with a history of transplantation or maintenance dialysis.

RESULTS

We identified 13 studies. Adverse maternal events including gestational hypertension, pre-eclampsia, eclampsia, and maternal mortality were reported in 12 studies. There were 312 adverse maternal events among 2682 pregnancies in women with CKD (weighted average of 11.5%) compared with 500 events in 26,149 pregnancies in normal healthy women (weighted average of 2%). One or more adverse fetal outcomes such as premature births, intrauterine growth restriction, small for gestational age, neonatal mortality, stillbirths, and low birth weight were reported in nine of the included studies. Overall, the risk of developing an adverse fetal outcome was at least two times higher among women with CKD compared with those without.

CONCLUSIONS

This review summarizes current available evidence to guide physicians in their decision-making, advice, and care for pregnant women with CKD. Additional studies are needed to better characterize the risks.

Medically indicated--iatrogenic prematurity

Premature delivery of an infant is occasionally performed because of complications of pregnancy. This article reviews common medical indications for preterm delivery and the available evidence supporting delivery before 37 weeks of gestation. In many conditions, few data exist to guide optimal timing of delivery and management is guided by expert opinion. Ultimately, an individual assessment must be made in each case to weigh the risks that pregnancy continuation poses to the mother and/or fetus with the risks of prematurity and its associated morbidities.

Fertility considerations in the management of gynecologic malignancies

GOALS

Gynecologic cancers represent a significant proportion of malignancies affecting women. Historically, cancer treatment focused primarily on eradicating disease, irrespective of the impact on fertility. The implementation of early detection protocols and advanced treatment regimens has resulted in improved prognosis for gynecologic cancer patients. With this improvement, more attention is now paid to quality-of-life issues. Fertility preservation (FP) has become an integral component in the selection and execution of gynecological cancer management. In this report we address gynecologic malignancies as they relate to future fertility potential.

METHODS

We review reproductive principles such as ovarian reserve, uterine function, cervical competence, and early obstetrical management, as well as available FP methods. In addition, we discuss the potential damage that cancer and cancer treatments can impart on the female reproductive system. We offer general recommendations regarding baseline screening tests useful in assessing the feasibility of FP. Lastly, cancer-specific FP methods are presented.

RESULTS

Oocyte quantity and quality naturally decline with advancing age. In most patients, the slope of decline steepens significantly after the age of 35. Reliable ovarian reserve measures exist and should be utilized to assess and triage potential candidates for FP. Advancements in FP, particularly in oocyte cryopreservation (OC), have improved the success rates associated with the techniques available to cancer patients. Currently, where successfully available, OC appears to be the preferred method for single women diagnosed with a gynecologic malignancy as it affords reproductive autonomy, whereas embryo cryopreservation using a donor gamete remains an alternative.

CONCLUSIONS

In gynecologic oncology, effective treatments to achieve cancer survival can compromise the ability to subsequently conceive and/or carry a child. Therefore, as the field of oncofertility continues to expand, a discussion regarding FP should be initiated when tailoring a cancer treatment protocol.

Vegetarian supplemented low-protein diets. A safe option for pregnant CKD patients: report of 12 pregnancies in 11 patients

BACKGROUND

Pregnancy in CKD is an increasing challenge, considering also the paucity of therapeutic tools available in pregnant women. While theoretically interesting, the experience with low protein diets in pregnancy is limited. Aim of this feasibility study is to review our experience with supplemented vegetarian low protein diets in pregnancy, as a "rescue treatment" for severe CKD and/or proteinuria.

METHODS

Data were gathered prospectively. Diet schema: proteins: 0.6-0.7 g/Kg/day, amino and chetoacid supplementation, 1-3 free meals/week. Compliance, side effects, biochemical data recorded at each visit (at least twice monthly).

RESULTS

Between January 2000 and February 2010, out of 168 pregnancies referred, 12 were managed by the diet (11 patients; median age 33, range 20-38). One pregnancy was terminated (patient's choice); the other 10 patients delivered 11 healthy babies. At referral, 2 patients were in stage 4 CKD, 4 in stage 3, 4 had nephrotic proteinuria (3.6-6.3 g/day). One patient doubled serum creatinine; none needed renal replacement therapy within 6 months from delivery. No patient complained of side effects, nor developed hyperkalemia or hypercalcaemia. Two babies from mothers in CKD stage 4 were small for gestational age; 9/11 were delivered by caesarean section (median gestational age 33 weeks: range 28-37; birth weight 935-2620 g) within a policy of delivery in the presence of foetal growth impairment and/or worsening of proteinuria, GFR, hypertension or foetal conditions. All babies are well, 1 month, 7.5 years from delivery.

CONCLUSION

Our report suggests considering vegetarian diets as an additional tool in the management of pregnant CKD patients.

Pregnancy and chronic kidney disease: a challenge in all CKD stages

BACKGROUND AND OBJECTIVES

Chronic kidney disease (CKD) is a challenge for pregnancy. Its recent classification underlines the importance of its early phases. This study's aim was to evaluate outcomes of pregnancy according to CKD stage versus low-risk pregnancies followed in the same center.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

The prospective analysis was conducted from January 2000 to May 2009 with the start of observation at referral and end of observation 1 month after delivery. Ninety-one singleton deliveries were studied; 267 "low-risk" singleton pregnancies served as controls. Because of the lack of hard end points (death, start of dialysis), surrogate end points were analyzed (cesarean section, prematurity, neonatal intensive care).

RESULTS

CKD outcome was worse than physiologic pregnancies: preterm delivery (44% versus 5%); cesarean section (44% versus 25%); and need for neonatal intensive care (26% versus 1%). The differences were highly significant in stage 1 CKD (61 cases) versus controls (CKD stage 1: cesarean sections = 57%, preterm delivery = 33%, intensive care = 18%). In CKD, proteinuria and hypertension were correlated with outcomes [proteinuria dichotomized at 1 g/24 h at referral: need for intensive care, relative risk (RR) = 4.16 (1.05 to 16.46); hypertension: preterm delivery, RR = 7.24 (2.30 to 22.79); cesarean section, RR = 5.70 (1.69 to 19.24)]. Statistical significance across stages was reached for preterm delivery [RR = 3.32 (1.09 to 10.13)].

CONCLUSIONS

CKD is a challenge for pregnancy from early stages. Strict follow-up is needed for CKD patients, even when there is normal renal function.

Long-term neurodevelopment of children exposed in utero to ciclosporin after maternal renal transplant

BACKGROUND

Immunosuppressant therapy is essential in the prevention of organ transplant rejection.

OBJECTIVE

To evaluate the long-term neurodevelopmental outcomes of children following in utero ciclosporin (cyclosporine) exposure after maternal renal transplantation.

METHODS

A cohort study with matched controls using a prospectively collected database was conducted to assess neurocognitive and behavioral outcomes using standardized measures. Thirty-nine children exposed in utero to ciclosporin therapy following maternal renal transplantation were assessed (15 single pregnancies, 24 multiple pregnancies) and compared with 38 matched unexposed children. Intelligence, visuomotor abilities, and psychologic adjustment were measured using the Wechsler Preschool and Primary Scale of Intelligence-Revised (WPPSI-R), the Beery Developmental Test of Visual-Motor Integration (VMI-4) and the Wide Range Assessment of Visual Motor Abilities (WRAVMA), and the Child Behavior Checklist (CBCL), respectively. Statistical analysis, including regression, was performed to determine the significant predictors for the main outcome, full-scale IQ (FIQ).

RESULTS

There were no significant differences in FIQ, verbal IQ (VIQ), performance IQ (PIQ) or behavioral outcomes between exposed and unexposed children or between single and multiple delivery groups. Thirty-three percent of exposed children were premature versus 0.5% in unexposed controls (p < 0.01). Prematurity was associated with low birthweight, high rates of perinatal complications, and instrumental deliveries. Relative to full-term children, premature, low birthweight children in the ciclosporin-exposed group had significantly lower FIQ and VIQ scores (101.04 vs 111.31 [p = 0.008] and 102.31 vs 113.08 [p = 0.021], respectively). Maternal IQ and socioeconomic status were positive and significant predictors for children's IQ (p < 0.001 and p = 0.03, respectively). There were no statistically significant differences in exposed children's IQ who were and were not breastfed.

CONCLUSION

In this cohort, there was no association between in utero exposure to ciclosporin and long-term neurocognitive and behavioral development in children after maternal renal transplantation. Maternal IQ and socioeconomic status are positive predictors for children's intelligence. However, maternal renal transplantation and associated co-morbidity is associated with higher rates of premature delivery and consequent poorer neurocognitive and behavioral outcomes. Proper management of maternal morbidity and improved obstetric care may improve the child's profile.

Kidney function and future risk for adverse pregnancy outcomes: a population-based study from HUNT II, Norway

BACKGROUND

Current knowledge on prepregnancy reduced kidney function and the risk of adverse pregnancy outcomes mainly relies on small studies in selected populations. We aim to investigate whether reduced kidney function is associated with the risk of adverse pregnancy-related outcomes in the general population.

METHODS

A population-based study linking all women attending the Second Health Study in Nord-Trøndelag, Norway (1995-97) and subsequent pregnancies registered in the Medical Birth Registry. Multivariable random-effect logistic regression analysis was used to explore the association between renal function and study outcome.

RESULTS

The mean eGFR among 3405 women was 107.6 +/- 19.4 ml/min/1.73 m(2) at baseline; 18.8% and 0.1% had eGFR of 60-89 and <60, respectively. Over the next 11 years, they gave birth to 5655 singletons of whom 885 (17.7%) were complicated with preeclampsia, small for gestational age (SGA) or preterm birth. Women with eGFR 60-89 were not at increased risk for this combined outcome compared to women with eGFR > or =90, although women with eGFR 60-74 tended to have an increased risk. Neither was reduced kidney function a risk factor among women with microalbuminuria, but those with an eGFR of 60-89 plus hypertension had a significantly increased risk: odds ratios for preeclampsia, SGA or preterm birth were 2.58 (95% CI 1.40-4.75, P < 0.001) and 10.09 (95% CI 2.38-42.87, P < 0.001) in hypertensive women with eGFR 75-89 and 60-74, respectively. Relative excess risk due to interaction between reduced kidney function and hypertension was 2.23 (95% CI 1.35-3.10, P < 0.001). Women with a reduced kidney function were not at increased risk for other pregnancy complications like caesarean section, maternal bleeding, dystocia, pre-labour rupture of membranes, Apgar score < or =7, stillbirth or congenital malformations.

CONCLUSIONS

Women with eGFR 60-89 ml/min/1.73 m(2) were not at increased risk for preeclampsia, SGA or preterm birth unless they were also hypertensive.