Kidney disease and maternal and fetal outcomes in pregnancy

Evaluation of maternal and fetal outcomes in pregnancies with maternal solitary kidney: A case-control study from a tertiary center

INTRODUCTION

There exists a prevailing concern regarding the heightened susceptibility of women with a solitary kidney to unfavorable consequences during pregnancy. Irrespective of the underlying etiology, individuals with a solitary kidney are advised to have regular annual screenings for blood pressure and urinalysis due to their increased susceptibility to developing proteinuria, hypertension, and renal failure.

OBJECTIVE

To investigate the risk of adverse pregnancy outcomes in women with a maternal solitary kidney by comparing maternal and fetal outcomes to those of healthy pregnant women.

METHODS

This retrospective, single-center study was conducted with 29 pregnant women with maternal solitary kidney and 60 healthy controls at a tertiary hospital. Obstetric data such as gestational hypertension, preeclampsia, preterm labor, birth week, mode of delivery, Apgar scores, and neonatal intensive care requirements, were compared between the groups. A binary logistic regression analysis was performed to determine the obstetric complications increased by the presence of maternal solitary kidney.

RESULTS

The number of spontaneous abortions, serum creatinine and blood urea nitrogen levels were significantly higher in the patients with solitary kidney (p < 0.05). The birth week was earlier among the patients with a solitary kidney compared to the controls (p = 0.013). The preterm and cesarean delivery rates were also higher in the case group (p = 0.002 and p = 0.035, respectively). The pregnant women with solitary kidney were found to have higher rates of gestational hypertension, preeclampsia, and maternal intensive care requirements (p = 0.008, p = 0.015, and p = 0.008, respectively). Logistic regression analysis revealed a seven-fold increase in the rate of preterm labor (1.45-37.64) and a three-fold increase in preeclampsia (1.27-22.08) among the pregnant women with a solitary kidney.

CONCLUSION

Patients with solitary kidney are at high risk of encountering pregnancy complications, such as gestational hypertension, preeclampsia, and preterm labor. These pregnant women should be followed up carefully, starting from the first prenatal visit.

Adverse pregnancy outcomes in pregnant women with chronic kidney disease: A systematic review and meta-analysis

BACKGROUND

Chronic kidney disease (CKD) is associated with an increased risk of adverse pregnancy outcomes, but the risk at different stages of CKD (defined by estimated glomerular filtration rate, eGFR) compared with women without CKD has not been quantified in large cohorts.

OBJECTIVES

To quantify the association between CKD and adverse pregnancy outcomes according to CKD definition, CKD stage and presence or absence of diabetes.

SEARCH STRATEGY

A systematic search of EMBASE and MEDLINE from inception to 5 January 2023.

SELECTION CRITERIA

English-language randomised controlled trials as well as cohort and case-control studies investigating adverse pregnancy outcomes in pregnant women with CKD.

DATA COLLECTION AND ANALYSIS

Two reviewers conducted independent data extractions. A random-effects model was used to estimate risk.

MAIN RESULTS

We included 19 studies with 3 251 902 women. Defining CKD using eGFR or serum creatinine produced results with greater effect size but wider confidence intervals. Compared with CKD stages 1-2, women with CKD stages 3-5 have a greater risk, but also greater imprecision in the risk estimate, of the following outcomes: pre-eclampsia (OR 55.18, 95% CI 2.63-1157.68, vs OR 24.74, 95% CI 1.75-348.70), preterm birth (OR 20.24, 95% CI 2.85-143.75, vs OR 8.18, 95% CI 1.54-43.46) and neonatal intensive care unit admission (OR 19.32, 95% CI 3.07-121.68, vs OR 9.77, 95% CI 2.49-38.39). Women with diabetic kidney disease, compared with women without diabetic kidney disease, have higher risks of maternal mortality, small-for-gestational-age neonates, pre-eclampsia and gestational hypertension.

CONCLUSIONS

There is heterogeneity in the definition of CKD in pregnancy. Future studies should consider ways to standardise its definition and measurement in pregnancy.

Association between Liver and Kidney Function and Birth Outcomes in Pregnant Surinamese Women Exposed to Mercury and Lead in the Caribbean Consortium for Research in Environmental and Occupational Health (CCREOH) Environmental Epidemiologic Cohort Study

Exposure to mercury (Hg) and lead (Pb), in combination with liver and kidney impairment, may result in adverse birth outcomes. From 408 women in the age range of 16 to 46 years, living in rural and urban areas in the interior of Suriname, we looked at the association between adverse birth outcomes and exposure to Hg and Pb in combination with liver and kidney function. This group of women represented a subcohort of pregnant women who participated in the Caribbean Consortium for Research in Environmental and Occupational Health (CCREOH)-Meki Tamara study. Liver function was assessed by measuring aspartate amino transferase (AST), alanine amino transferase (ALT), and gamma-glutamyl transferase (GGT). Kidney function was assessed by measuring creatinine, urea, and cystatin C. We defined preterm births as birth before 37 weeks of gestation, low birthweight as birthweight < 2500 g, and low Apgar score as a score < 7 at 5 min, and these were used as indicators for adverse birth outcomes. Small size for gestational age was defined as gestational age < -2SD weight for GA. We found significant statistical associations between biomarkers for liver and kidney functions and adverse birth outcomes Apgar score and gestational age. No significant association was found between heavy metals Hg and lead and adverse birth outcomes.

Pregnancy in women with nephrotic-range proteinuria: A retrospective cohort study

Background

Obstetric and kidney outcomes following detection of nephrotic-range proteinuria in early pregnancy have not been well described.

Methods

A retrospective cohort study of chronic kidney disease (CKD) in pregnancy between 2008 and 2018. Outcomes in those with nephrotic-range proteinuria before 20 weeks' gestation were compared to those without nephrotic-range proteinuria.

Results

The study included 37 women with nephrotic-range proteinuria and 62 women without. Pre-pregnancy estimated glomerular filtration rate (eGFR) was similar. Nephrotic-range proteinuria was associated with higher rates of preterm (odds ratio [OR] 1.77, 95% confidence interval [CI]: 1.07-2.92) and early preterm delivery (OR 2.63, 95% CI: 1.12-6.2), and with a requirement for renal replacement therapy at 3 years post-partum (OR 10.72, 95% CI: 2.58-44.47). Tubulointerstitial scarring on kidney biopsy was associated with early preterm delivery and progression to advanced CKD, independent of pre-pregnancy eGFR.

Conclusion

Compared to CKD without nephrotic-range proteinuria, nephrotic-range proteinuria early in pregnancy is associated with higher rates of pre-term delivery and progression to advanced CKD.

Reassuring pregnancy outcomes in women with mild COL4A3-5-related disease (Alport syndrome) and genetic type of disease can aid personalized counseling

Individualized pre-pregnancy counseling and antenatal care for women with chronic kidney disease (CKD) require disease-specific data. Here, we investigated pregnancy outcomes and long-term kidney function in women with COL4A3-5 related disease (Alport Syndrome, (AS)) in a large multicenter cohort. The ALPART-network (mAternaL and fetal PregnAncy outcomes of women with AlpoRT syndrome), an international collaboration of 17 centers, retrospectively investigated COL4A3-5 related disease pregnancies after the 20th week. Outcomes were stratified per inheritance pattern (X-Linked AS (XLAS)), Autosomal Dominant AS (ADAS), or Autosomal Recessive AS (ARAS)). The influence of pregnancy on estimated glomerular filtration rate (eGFR)-slope was assessed in 192 pregnancies encompassing 116 women (121 with XLAS, 47 with ADAS, and 12 with ARAS). Median eGFR pre-pregnancy was over 90ml/min/1.73m2. Neonatal outcomes were favorable: 100% live births, median gestational age 39.0 weeks and mean birth weight 3135 grams. Gestational hypertension occurred during 23% of pregnancies (reference: 'general' CKD G1-G2 pregnancies incidence is 4-20%) and preeclampsia in 20%. The mean eGFR declined after pregnancy but remained within normal range (over 90ml/min/1.73m2). Pregnancy did not significantly affect eGFR-slope (pre-pregnancy β=-1.030, post-pregnancy β=-1.349). ARAS-pregnancies demonstrated less favorable outcomes (early preterm birth incidence 3/11 (27%)). ARAS was a significant independent predictor for lower birth weight and shorter duration of pregnancy, next to the classic predictors (pre-pregnancy kidney function, proteinuria, and chronic hypertension) though missing proteinuria values and the small ARAS-sample hindered analysis. This is the largest study to date on AS and pregnancy with reassuring results for mild AS, though inheritance patterns could be considered in counseling next to classic risk factors. Thus, our findings support personalized reproductive care and highlight the importance of investigating kidney disease-specific pregnancy outcomes.

Neutrophil Gelatinase-Associated Lipocalin (NGAL) as a potential early biomarker for diabetic nephropathy: a meta-analysis

BACKGROUND

Diabetic nephropathy (DN) is a prevalent and chronic, severe complication of diabetes, representing a serious global health concern. Early detection of DN is essential for initiating timely and effective therapeutic interventions and accurately assessing prognosis. Neutrophil Gelatinase-Associated Lipocalin (NGAL), a low molecular weight protein, has emerged as a potential biomarker for DN due to its association with renal injury and its ability to provide early indications of kidney damage. NGAL levels in both serum and urine are elevated in individuals with renal damage, making it a valuable biomarker for detecting early signs of kidney impairment in the context of diabetes. This study aims to investigate the utility of NGAL as an early biomarker for DN and explore its correlation with various clinical parameters associated with the disease. Understanding the relationship between NGAL levels and clinical parameters such as glycemic control, renal function, blood pressure, and duration of diabetes is crucial for comprehensively evaluating the potential of NGAL as a diagnostic and prognostic tool for DN. Furthermore, assessing the sensitivity and specificity of NGAL in detecting early-stage DN will provide valuable insights into its clinical applicability and reliability.

METHODOLOGY

A planned meta-analysis was conducted following PRISMA and MOOSE guidelines. The PubMed database was searched from January 2016 to June 2023 for English-language studies on DN and NGAL. Fifteen eligible studies were included as per the criteria. Data on serum NGAL levels in DN patients and healthy controls were analyzed using Stata 16.0 software.

RESULT

The study revealed a significantly higher mean serum NGAL level in DN patients (168.08 ng/ml, 95% CI: 105.50-230.67) compared to healthy controls (75.02 ng/ml, 95% CI: 43.02-107.03), demonstrating NGAL's potential as a biomarker (P=0.01).

CONCLUSION

NGAL offers a powerful tool for DN diagnosis, staging, and monitoring, surpassing traditional markers in sensitivity. Challenges include defining universal threshold values and ensuring consistent test performance across diverse clinical settings. The study underscores NGAL's potential in transforming DN diagnosis and management.

Thoracic organ transplantation and pregnancy outcomes: systematic review and meta-analysis

PURPOSE

Pre-conceptual comorbidities, an inherent risk of graft loss, rejection during pregnancy, and the postpartum period in women with thoracic lung transplant may predispose them to increased risk of adverse feto-maternal outcomes. The study aimed to systematically analyze and assess the risk of adverse pregnancy outcomes in women with thoracic organ transplant.

METHODS

MEDLINE, EMBASE, and Cochrane library were searched for publication between January 1990 and June 2020. Risk of bias was assessed using Joanna Briggs critical appraisal tool for case series. The primary outcomes included maternal mortality and pregnancy loss. The secondary outcomes were maternal complications, neonatal complications, and adverse birth outcomes. The analysis was performed using the DerSimonian-Laird random effects model.

RESULTS

Eleven studies captured data from 275 parturient with thoracic organ transplant describing 400 pregnancies. The primary outcomes included maternal mortality {pooled incidence (95% confidence interval) 4.2 (2.5-7.1) at 1 year and 19.5 (15.3-24.5) during follow-up}. Pooled estimates yielded 10.1% (5.6-17.5) and 21.8% (10.9-38.8) risk of rejection and graft dysfunction during and after pregnancy, respectively. Although 67% (60.2-73.2) of pregnancies resulted in live birth, total pregnancy loss and neonatal death occurred in 33.5% (26.7-40.9) and 2.8% (1.4-5.6), respectively. Prematurity and low birth weight were reported in 45.1% (38.5-51.9) and 42.7% (32.8-53.2), respectively.

CONCLUSIONS

Despite pregnancies resulting in nearly 2/3rd of live births, high incidence of pregnancy loss, prematurity and low birth weight remain a cause of concern. Focused pre-conceptual counseling to avoid unplanned pregnancy, especially in women with transplant-related organ dysfunctions and complications, is vital to improve pregnancy outcomes.

PROSPERO NUMBER

CRD42020164020.

Paternal age and perinatal outcomes: an observational study

OBJECTIVES

The study's primary aim was to examine the relationship between paternal age and perinatal outcomes.

METHODS

This study used data from two hospital birth registries to examine the association between paternal age and adverse perinatal outcomes. The sample included all live singleton births between 2010 and 2022. The primary exposure was paternal age, and the following perinatal outcomes were considered: mode of conception, mode of delivery, pregnancy complications, and neonatal outcomes.

RESULTS

A total of 15,232 pregnant women were considered. Maternal and paternal ages were 31.9 ± 5.3 and 36.5 ± 6.5 years, respectively. Independent of maternal, paternal age was associated with lower odds of spontaneous conceptions (OR 0.930, 95 % CI 0.968/0.993; p=0.003) and higher odds of intracytoplasmatic sperm injection (OR 1.054, 95 % CI 1.045/1.062; p=0.0001), respectively. In contrast to maternal age, paternal age decreased the odds of any (OR 0.922, 95 % CI 0.985/0.999; p=0.032) and urgent/emergent (OR 0.984, 95 % CI 0.975/0.993; p=0.0001) cesarean delivery. Paternal age did not affect the gestation length, placental or neonatal weight, blood loss during delivery, and neonatal 5th-minute Apgar score.

CONCLUSIONS

Paternal age is associated with perinatal outcomes. These findings suggest that advanced paternal age may have implications for reproductive counseling and prenatal care.

Proteinuria among Pregnant Women Admitted to the Department of Obstetrics and Gynaecology of a Tertiary Care Centre

Introduction

Proteinuria is usually related with preeclampsia during pregnancy, although it can also be caused by other conditions such as renal disease or isolated proteinuria. Proteinuria during pregnancy can result in adverse fetomaternal outcomes. The study aimed to find the prevalence of proteinuria among pregnant women admitted to the Department of Obstetrics and Gynaecology of a tertiary care centre.

Methods

A descriptive cross-sectional study was carried out among pregnant women in the Department of Obstetrics and Gynaecology after obtaining ethical approval from the Institutional Review Committee. Data of 14 April 2022 to 13 April 2023 was collected from 9 June 2023 to 9 September 2023 from medical records. The study included pregnant women aged 18-45 years, who were past 28 weeks of gestation and had a 24-hour urine protein measurement. Pregnant women who had insufficient medical records were excluded from the study. A convenience sampling method was used. The point estimate was calculated at a 95% Confidence Interval.

Results

Among 3,914 pregnant women, proteinuria was seen in 61 (1.56%) (1.17-1.95, 95% Confidence Interval). The mean proteinuria in the study group was 1.5±2.75 gm/24 hr. In pregnant women with proteinuria, maternal complications were seen in 51 (83.60%) and foetal complications in 34 (55.73%) cases. A total of 47 (77.05%) underwent emergency lower-section caesarean section.

Conclusions

The prevalence of proteinuria among pregnant women was found to be similar as compared to studies done in similar settings.

Keywords

preeclampsia; pregnancy complications; proteinuria.

Contraceptive Use in Females With Advanced CKD: A Qualitative Study

Rationale & Objective

Pregnancy in females with kidney disease is not uncommon and is associated with adverse maternal and fetal outcomes. The use of contraception in females with chronic kidney disease remains low. We sought to describe the perspectives of female patients with advanced chronic kidney disease on the use of contraception.

Study Design

Qualitative study.

Setting & Participants

We conducted 5 focus group interviews involving 16 adult female patients with advanced chronic kidney disease (n = 3 nondialysis nontransplant chronic kidney disease, n = 9 kidney transplant, and n = 4 kidney failure receiving dialysis) in the United States, following which thematic saturation was reached.

Analytical Approach

Interview transcripts were analyzed thematically.

Results

We identified the following 5 themes: 1) variable knowledge regarding reproductive health with kidney disease, 2) inadequate counseling about contraceptive use, 3) lack of interdisciplinary coordination regarding contraceptive use, 4) insufficient educational resources available to guide the contraceptive discussion, and 5) need for research to better understand reproductive needs in females with kidney disease.

Limitations

Patients were from a single center in the United States, and the study is limited by the transferability of findings to other settings.

Conclusions

Patients with chronic kidney disease report emotional challenges with reproductive health, lack of counseling and care coordination, and insufficient resources for contraceptive use. Strategies to strengthen these factors may improve the quality of reproductive care and increase contraceptive use for females with chronic kidney disease.

Plain-Language Summary

Pregnancy in females with kidney disease is common and associated with a higher risk of adverse maternal and fetal outcomes, but the use of contraception remains low. Little is known about female patients' experiences in contraceptive use that may contribute to low contraceptive use in this high-risk population. In the present study using focus group interviews, patients with chronic kidney disease reported emotional challenges with reproductive health, lack of counseling and care coordination, and insufficient resources for contraceptive use. Interventions are needed to strengthen these factors to improve the quality of reproductive care and increase contraceptive use for females with chronic kidney disease.

Metabolomic profiling of preterm birth in pregnant women living with HIV

BACKGROUND

Preterm birth is a leading cause of death in children under the age of five. The risk of preterm birth is increased by maternal HIV infection as well as by certain antiretroviral regimens, leading to a disproportionate burden on low- and medium-income settings where HIV is most prevalent. Despite decades of research, the mechanisms underlying spontaneous preterm birth, particularly in resource limited areas with high HIV infection rates, are still poorly understood and accurate prediction and therapeutic intervention remain elusive.

OBJECTIVES

Metabolomics was utilized to identify profiles of preterm birth among pregnant women living with HIV on two different antiretroviral therapy (ART) regimens.

METHODS

This pilot study comprised 100 mother-infant dyads prior to antiretroviral initiation, on zidovudine monotherapy or on protease inhibitor-based antiretroviral therapy. Pregnancies that resulted in preterm births were matched 1:1 with controls by gestational age at time of sample collection. Maternal plasma and blood spots at 23-35 weeks gestation and infant dried blood spots at birth, were assayed using an untargeted metabolomics method. Linear regression and random forests classification models were used to identify shared and treatment-specific markers of preterm birth.

RESULTS

Classification models for preterm birth achieved accuracies of 95.5%, 95.7%, and 80.7% in the untreated, zidovudine monotherapy, and protease inhibitor-based treatment groups, respectively. Urate, methionine sulfone, cortisone, and 17α-hydroxypregnanolone glucuronide were identified as shared markers of preterm birth. Other compounds including hippurate and N-acetyl-1-methylhistidine were found to be significantly altered in a treatment-specific context.

CONCLUSION

This study identified previously known as well as novel metabolomic features of preterm birth in pregnant women living with HIV. Validation of these models in a larger, independent cohort is necessary to ascertain whether they can be utilized to predict preterm birth during a stage of gestation that allows for therapeutic intervention or more effective resource allocation.

Baseline proteinuria level and adverse outcomes in pregnant women with chronic kidney disease: new evidence and a note of caution

About 3% of all pregnancies occur in patients with some degree of chronic kidney disease (CKD) and, in turn, CKD is a risk factor for developing hypertensive disorders of pregnancies (HDP) and unfavorable pregnancy outcomes, at both the maternal and fetal level. CKD is often characterized by proteinuria and proteinuria is a risk factor for HDP. However, even if the positive correlation between proteinuria and unfavorable pregnancy outcomes is well acknowledged, the degree of proteinuria associated with adverse outcomes is still a matter of debate. In this issue of the Journal, Li et al. present a retrospective study that shows that >1 g of proteinuria/day is associated with worse maternal outcomes while >2 g/day with worse fetal ones. This study gives proteinuria thresholds for unfavorable outcomes in pregnant CKD patients, but it should be kept in mind that there is a linear correlation between proteinuria and worse pregnancy outcomes, thus a strict surveillance during the entire gestation should be advised independently of the proteinuria level.

Female Reproductive Health and Contraception Use in CKD: An International Mixed-Methods Study

Rationale & Objective

Female reproductive health is recognized as a predictor of morbidity, mortality, and quality of life, although data in the setting of chronic kidney disease (CKD) are limited.

Study Design

A mixed-methods study was employed. Phase 1 was an anonymous, internet-based survey. Phase 2 was semistructured interviews offered to all respondents upon survey completion.

Setting & Participants

The survey was disseminated internationally from October 4, 2021, to January 7, 2022, to individuals aged 18-50 years with both a uterus and CKD diagnosis.

Outcomes

Menstrual health and contraceptive use by CKD stage (dialysis, nondialysis CKD, and transplant).

Analytical Approach

Survey data were analyzed using descriptive statistics. Interview data were analyzed using the framework method of analysis.

Results

Of 152 respondents, 98 (mean age 33 ± 0.7 years; n = 20 dialysis, n = 59 nondialysis CKD, n = 19 transplant) satisfied the inclusion criteria, representing 3 continents. The most common causes of CKD among survey respondents were hereditary causes in dialysis (n = 6, 30%) and glomerulonephritis in nondialysis CKD (n = 22, 37%) and transplant (n = 6, 32%). The majority reported heavy menstrual bleeding (n = 12, 86% dialysis; n = 46, 94% nondialysis CKD; n = 14, 100% transplant). Less than half of participants were consistently able to afford period products. Condoms were the most common contraceptive reported. Most participants reported no contraceptive use (n = 10, 50% dialysis; n = 37, 63% nondialysis CKD; n = 7, 37% transplant), primarily because of "fear". Interviews (n = 6) revealed a perception of a relationship between kidney function and menstrual health, concerns about contraceptive use, and a desire for greater multidisciplinary care to improve kidney and reproductive health.

Limitations

Self-reported outcomes, need for internet access and a device.

Conclusions

Abnormal menstruation and period poverty (ie, inability to afford period products and the socioeconomic consequences of menstruation) were common, and contraceptive use was low among female individuals with CKD, highlighting an important gap in the sex-specific care of this population.

Plain-Language Summary

Chronic kidney disease (CKD) in female individuals is accompanied by menstrual disorders and low contraceptive use. However, most data are limited to the dialysis and transplant populations. Therefore, this mixed-methods study aimed to describe self-assessed menstruation and contraceptive use across all stages of CKD. People aged 18-50 years with a uterus and CKD diagnosis were invited to participate in an online survey shared internationally as well as an optional telephone interview. Abnormal menstruation and period poverty (ie, inability to afford period products and the socioeconomic consequences of menstruation) were common, and contraceptive use was low among female individuals with CKD, highlighting an important gap in the sex-specific care of this population.

Kidney damage on fertility and pregnancy: A Mendelian randomization

BACKGROUND

Low fertility and adverse pregnancy outcomes are commonly observed in women with chronic kidney disease (CKD). However, a causal relationship between low fertility and adverse pregnancy outcomes with CKD remains unclear. Besides, whether mild kidney dysfunction can affect fertility and pregnancy still needs exploration. Hence, this study aimed to investigate the causal effect of kidney damage on fertility and pregnancy using Mendelian randomization (MR).

METHODS

We first used two-sample MR to examine the effects of kidney damage on fertility and pregnancy. Next, we introduced the Bayesian model averaging MR analysis to detect major causal relationships and render the results robust. The genetic instruments and outcome data were derived from various large genome-wide association studies.

RESULTS

Adverse pregnancy outcomes: Our analyses supported a suggestive causal effect of CKD and estimated glomerular filtration rate (eGFR) rapid on stillbirth, with CKD having an odds ratio (OR) of 1.020 [95% confidence interval (CI) 1.002 to 1.038] and eGFR rapid having an OR of 1.026 (95% CI 1.004-1.048). We also discovered a suggestive causal effect of eGFR on spontaneous abortion, with an OR of 2.63 (95% CI 1.269 to 5.450). Moreover, increased urinary albumin-to-creatinine ratio (UACR) was regarded as a potential risk factor for pre-eclampsia (OR = 1.936; 95% CI 1.065 to 3.517) and gestational hypertension (OR = 1.700; 95% CI 1.002 to 2.886). Fertility assessment: The results indicated that eGFR and UACR had a suggestive causal relationship with the anti-Müllerian hormone level (eGFR beta: 1.004; UACR beta: 0.405).

CONCLUSIONS

Our study used MR to demonstrate a suggestive causal relationship between kidney damage and fertility and pregnancy. We reported that mild kidney dysfunction might be a risk factor for reduced fertility and adverse pregnancy outcomes. Dynamic renal detection may help preserve fertility and reduce the risk of pregnancy loss.

Long-Term Kidney and Maternal Outcomes After Pregnancy in Living Kidney Donors

For counseling it is important to know if pregnancy after Living Kidney Donation (LKD) affects long-term outcomes of the mono-kidney and the mother. Therefore, we performed a retrospective multicenter study in women ≤45 years who donated their kidney between 1981 and 2017. Data was collected via questionnaires and medical records. eGFR of women with post-LKD pregnancies were compared to women with pre-LKD pregnancies or nulliparous. eGFR before and after pregnancy were compared in women with post-LKD pregnancies. Pregnancy outcomes post-LKD were compared with pre-LKD pregnancy outcomes. 234 women (499 pregnancies) were included, of which 20 with pre- and post-LKD pregnancies (68) and 26 with only post-LKD pregnancies (59). Multilevel analysis demonstrated that eGFR was not different between women with and without post-LKD pregnancies (p = 0.23). Furthermore, eGFR was not different before and after post-LKD pregnancy (p = 0.13). More hypertensive disorders of pregnancy (HDP) occurred in post-LKD pregnancies (p = 0.002). Adverse fetal outcomes did not differ. We conclude that, despite a higher incidence of HDP, eGFR was not affected by post-LKD pregnancy. In line with previous studies, we found an increased risk for HDP after LKD without affecting fetal outcome. Therefore, a pregnancy wish alone should not be a reason to exclude women for LKD.

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.

Perinatal Outcomes in Women with Chronic Kidney Diseases

OBJECTIVE

 To assess maternal and neonatal outcomes in women with chronic kidney disease (CKD) at a referral center for high-risk pregnancy.

METHODS

 A retrospective cohort of pregnant women with CKD was followed at the Women's Hospital of Universidade Estadual de Campinas, Brazil, between 2012 and 2020. Variables related to disease etiology, treatment duration, sociodemographic variables, lifestyle, other associated diseases, obstetric history, and perinatal outcomes were assessed. The causes of CKD were grouped into 10 subgroups. Subsequently, we divided the sample according to gestational age at childbirth, as preterm and term births, comparing maternal and neonatal outcomes, and baseline characteristics as well as outcomes among such groups.

RESULTS

 A total of 84 pregnancies were included, in 67 women with CKD. Among them, six pregnancies evolved to fetal death, five to miscarriage, and one was a twin pregnancy. We further analyzed 72 single pregnancies with live births; the mean gestational age at birth was 35 weeks and 3 days, with a mean birth weight of 2,444 g. Around half of the sample (51.39%) presented previous hypertension, and 27.7% developed preeclampsia. Among the preterm births, we observed a higher frequency of hypertensive syndromes, longer maternal intensive care unit (ICU) stay in the postpartum period, higher incidence of admission to the neonatal ICU, higher neonatal death, lower 5-minute Apgar score, and lower birth weight.

CONCLUSION

 This study demonstrates increased adverse outcomes among pregnancies complicated by CKD and expands the knowledge on obstetric care among such women in an attempt to reduce maternal risks and identify factors related to prematurity in this population.

A multi-institutional study of renal outcomes and renal-related pregnancy outcomes in uterus transplant recipients

Uterus transplantation (UTx) is an effective treatment option for uterine factor infertility. However, the need for immunosuppression and congenital renal anomalies that coexist with uterine agenesis in about 30% of women with Mayer-Rokitansky-Kuster-Hauser syndrome create a risk for renal dysfunction. We therefore examined renal function trajectory and related pregnancy complications in an international cohort of 18 UTx recipients from September 2016-February 2020 who had at least one live birth. All UTx recipients had a diminution in their renal function that was apparent starting at 30 days posttransplant and in half the reduction in eGFR was at least 20%; the decrease in eGFR persisted into the early post-partum period. Half met criteria for Stage 1 acute kidney injury (AKI) as defined by the AKI Network criteria during their pregnancy. Overall, 28% of UTx recipients developed pre-eclampsia. eGFR was lower at embryo transfer and throughout pregnancy among those who developed pre-eclampsia, reaching statistical significance at week 16 of pregnancy. This effect was independent of tacrolimus levels. Mean eGFR remained significantly lower in the first 1-3 months after delivery. In the subgroup who reached 12 months of postpartum follow up and had a graft hysterectomy (n = 4), there was no longer a statistical difference in eGFR (pretransplant 106.7 ml/m ± 17.7 vs. 12 mos postpartum 92.6 ml/m ± 21.7, p = .13) but the number was small. Further study is required to delineate long term renal risks for UTx recipients, improve patient selection, and make decisions regarding a second pregnancy.

Development and Testing Requirements for an Integrated Maternal and Child Health Information System in Iran: A Design Thinking Case Study

BACKGROUND

 Management of child health care can be negatively affected by incomplete recording, low data quality, and lack of data integration of health management information systems to support decision making and public health program needs. Given the importance of identifying key determinants of child health via capturing and integrating accurate and high-quality information, we aim to address this gap through the development and testing requirements for an integrated child health information system.

SUBJECTS AND METHODS

 A five-phase design thinking approach including empathizing, defining, ideation, prototyping, and testing was applied. We employed observations and interviews with the health workers at the primary health care network to identify end-users' challenges and needs using tools in human-centered design and focus group discussion. Then, a potential solution to the identified problems was developed as an integrated maternal and child health information system (IMCHIS) prototype and tested using Software Quality Requirements and Evaluation Model (SQuaRE) ISO/IEC 25000.

RESULTS

 IMCHIS was developed as a web-based system with 74 data elements and seven maternal and child health care requirements. The requirements of "child disease" with weight (0.26), "child nutrition" with weight (0.20), and "prenatal care" with weight (0.16) acquired the maximum weight coefficient. In the testing phase, the highest score with the weight coefficient of 0.48 and 0.73 was attributed to efficiency and functionality characteristics, focusing on software capability to fulfill the tasks that meet users' needs.

CONCLUSION

 Implementing a successful child health care system integrates both maternal and child health care information systems to track the effect of maternal conditions on child health and support managing performance and optimizing service delivery. The highest quality score of IMCHIS in efficiency and functionality characteristics confirms that it owns the capability to identify key determinants of child health.

Gestational Outcomes of Pregnant Women with Unilateral Congenital Renal Agenesis

ObjectiveWe evaluated if there were more adverse gestational outcomes of pregnant women with unilateral congenital renal agenesis (UCRA). Study design: This single center retrospective case-control study compared maternal complications and neonatal outcomes from 25 women with UCRA to the outcomes of 125 women with two kidneys. Results: UCRA women had lower gestational weeks at birth and higher rates of preterm delivery (p = 0.004 and <0.001; respectively). Mothers had higher rates of preeclampsia and newborns with congenital anomalies and neonatal intensive care unit (NICU) admission (p = 0.009, 0.042, and 0.039; respectively). Unadjusted odds ratios were significantly higher for preterm delivery and for any APGAR score of <7 at the first 10 min and preeclampsia [OR (95% CI):13.5 (4.66-39.05), 31 (3.44-279.32) and 5.76 (1.33-24.84), respectively]. Conclusion: Maternal UCRA is a risk factor for less optimal obstetric and neonatal outcomes.

Case Report: Anesthesia for Cesarean Section in Parturients With Chronic Renal Failure Requiring Hemodialysis: Case Reports and Literature Review

Pregnancies are rare in women with chronic renal failure requiring hemodialysis. Although a chance of successful pregnancy and delivery in hemodialysis women has increased over the years, it is still very low, and with high maternal and fetal mortality and morbidity rate compared to normal population. And cesarean section is usually used for delivery. The first case was a 32-year-old Chinese woman with chronic kidney disease stage V undergoing maintenance hemodialysis for six years. The second case was also a 32-year-old patient with a 6-year history of hemodialysis for chronic glomerulonephritis. And due to a history of atrial septal defect and hypertension she received intensive hemodialysis during pregnancy. Both cases were scheduled for cesarean delivery under epidural anesthesia. To help develop reasonable anesthetic methods and management objectives for such patients, we described our anesthetic management and performed a literature search on published cases of cesarean section with chronic renal failure undergoing hemodialysis.

Chronic kidney disease and adverse pregnancy outcomes: a systematic review and meta-analysis

OBJECTIVE

Limited evidence exists on the role that the cause of chronic kidney disease plays in determining pregnancy outcomes. The aim of this systematic review and meta-analysis was to examine the association between chronic kidney disease and adverse pregnancy outcomes by the cause and severity of chronic kidney disease where reported. The protocol was registered under the International Prospective Register of Systematic Reviews (CRD42020211925).

DATA SOURCES

PubMed, Embase, and Web of Science were searched until May 24, 2021, supplemented with reference list checking.

STUDY ELIGIBILITY CRITERIA

Studies that compared the pregnancy outcomes in women with or without chronic kidney disease were included. Two reviewers independently screened titles, abstracts, and full-text articles according to a priori defined inclusion criteria.

METHODS

Data extraction and quality appraisal were performed independently by 3 reviewers. The grading of recommendations, assessment, development, and evaluation approach was used to assess the overall certainty of the evidence. Random-effects meta-analyses were used to calculate the pooled estimates using the generic inverse variance method. The primary outcomes included preeclampsia, cesarean delivery, preterm birth (<37 weeks' gestation), and small for gestational age babies.

RESULTS

Of 4076 citations, 31 studies were included. Prepregnancy chronic kidney disease was significantly associated with a higher odds of preeclampsia (pooled crude odds ratio, 8.13; [95% confidence interval, 4.41-15], and adjusted odds ratio, 2.58; [1.33-5.01]), cesarean delivery (adjusted odds ratio, 1.65; [1.21-2.25]), preterm birth (adjusted odds ratio, 1.73; [1.31-2.27]), and small for gestational age babies (adjusted odds ratio, 1.93; [1.06-3.52]). The association with stillbirth was not statistically significant (adjusted odds ratio, 1.67; [0.96-2.92]). Subgroup analyses indicated that different causes of chronic kidney disease might confer different risks and that the severity of chronic kidney disease is associated with a risk of adverse pregnancy outcomes, as pregnancies with later stages of chronic kidney disease had higher odds of preeclampsia, preterm birth, and small for gestational age babies than those at earlier stages. The grading of recommendations, assessment, development, and evaluation certainty of the evidence overall was "very low".

CONCLUSION

This meta-analysis quantified the associations between prepregnancy chronic kidney disease and adverse pregnancy outcomes, both overall and according to the cause and severity of the disease. These findings might support the clinicians aiming to counsel women having chronic kidney disease by allowing them to tailor their advice according to cause and severity of the chronic kidney disease. We identified the gaps in the literature, and further studies examining the effect of specific kidney diseases and other clinical characteristics (eg, proteinuria, hypertension) on adverse pregnancy outcomes are warranted.

Parenthood with kidney failure: Answering questions patients ask about pregnancy

Achieving parenthood can be an important priority for women and men with kidney failure. In recent decades, the paradigm has shifted toward greater support of parenthood, with advances in our understanding of risks related to pregnancy and improvements in obstetrical and perinatal care. This review, codesigned by people with personal experience of kidney disease, provides guidance for nephrologists on how to answer the questions most asked by patients when planning for parenthood. We focus on important issues that arise in preconception counseling for women receiving dialysis and postkidney transplant. We summarize recent studies reflecting pregnancy outcomes in the modern era of nephrology, obstetrical, and perinatal care in developed countries. We present visual aids to help clinicians and women navigate pregnancy planning and risk assessment. Key principles of pregnancy management are outlined. Finally, we explore outcomes of fatherhood in males with kidney failure.

History of Adverse Pregnancy on Subsequent Maternal-Fetal Outcomes in Patients with Immunoglobulin A Nephropathy: A Retrospective Cohort Study from a Chinese Single Center

BACKGROUND

Gestation complications have a recurrence risk and could predispose to each other in the next pregnancy. We aimed to evaluate the relationship between a history of adverse pregnancy and maternal-fetal outcomes in subsequent pregnancy in patients with Immunoglobulin A nephropathy (IgAN).

METHODS

A retrospective cohort study from a Chinese single center was conducted. Pregnant women with biopsy-proven primary IgAN and aged ≥18 years were enrolled and divided into the 2 groups by a history of adverse pregnancy. The primary outcome was adverse pregnancy outcome, which included maternal-fetal outcomes. Logistical regression model was used to evaluate the association of a history of adverse pregnancy with subsequent adverse maternal and fetal outcomes.

RESULTS

Ninety-one women with 100 pregnancies were included, of which 54 (54%) pregnancies had a history of adverse pregnancy. IgAN patients with adverse pregnancy history had more composite maternal outcomes (70.4% vs. 45.7%, p = 0.012), while there was no difference in the composite adverse fetal outcomes between the 2 groups (55.6% vs. 45.7%). IgAN patients with a history of adverse pregnancy were associated with an increased risk of subsequent adverse maternal outcomes (adjusted odds ratio [OR], 2.64; 95% CI, 1.07-6.47). Similar results were shown in those with baseline serum albumin <3.5 g/dL, 24 h proteinuria ≥1 g/day, and a history of hypertension. There was no association between a history of adverse pregnancy and subsequent adverse fetal outcomes in IgAN patients (adjusted OR, 1.56; 95% CI, 0.63-3.87).

CONCLUSION

A history of adverse pregnancy was associated with an increased risk of subsequent adverse maternal outcomes, but not for adverse fetal outcomes in IgAN patients.

The diagnostic value of angiogenic and antiangiogenic factors in differential diagnosis of preeclampsia

The definition of preeclampsia is changing. However, with the addition of organ symptoms to the presence of hypertension in pregnancy instead of relying only on proteinuria, a more precise detection of women at risk of preeclampsia-associated adverse events has not been achieved. Instead, under the new definitions of the American College of Obstetricians and Gynecologists and of the International Society for the Study of Hypertension in Pregnancy, more women are classified as preeclamptic, with a tendency to milder disease. Furthermore, angiogenic and antiangiogenic factors have emerged as essential tools for predicting and diagnosing preeclampsia at high accuracies. Next to being rooted in the pathophysiology of the disease, they have been proven to be reliable tools for predicting and diagnosing the disease. In addition, 2 cutoffs have been evaluated for the clinical setting. As shown in the Prediction of Short-Term Outcome in Pregnant Women With Suspected Preeclampsia Study, at the soluble fms-like tyrosine kinase-1-to-placental growth factor ratio cutoff of 38, a preeclampsia can be ruled out for 1 week with a negative predictive value of 99.3% (95% confidence interval, 97.9-99.9) and ruled in with a positive predictive value of 36.7% (95% confidence interval, 28.4-45.7). The diagnostic cutoff of 85 has been shown to accurately identify women with preeclampsia, with a sensitivity of up to 88% and a specificity of 99.5%. In this review, we highlight the central role of angiogenic and antiangiogenic factors in the differential diagnosis of women presenting at high risk of the disease, such as patients with chronic hypertension or chronic kidney disease. We will focus on their ability to predict preeclampsia-associated adverse fetal and maternal outcomes. This is only possible when critically reviewing the evolution of the definition of "preeclampsia." We show how changes in this definition shape our clinical picture of the condition and how angiogenic and antiangiogenic biomarkers might be included to better identify women destined to develop preeclampsia-related adverse outcomes.

Chronic kidney disease and pregnancy outcomes

Pregnancy complicated by CKD is currently not fully understood topic. Outcome of pregnancy in patients with CKD is related to impaired glomerular filtration rate and the degree of proteinuria. In our study we evaluated the association of serum creatinine level and proteinuria with both maternal and fetal outcomes in the cohort of 84 pregnant patients with CKD. In CKD group we confirmed negative correlation of highest serum creatinine level in pregnancy to fetal weight (p value < 0.001) and gestation period (p value < 0.001). Likewise, negative correlation of preconception serum creatinine to fetal weight (p value < 0.001) and gestation period (p value 0.002). Negative correlation of proteinuria to gestation period (p value < 0.001) and fetal weight (p value < 0.001) was also demonstrated. CKD is serious risk factor for pregnancy outcome. Proteinuria and serum creatinine level should be examined before pregnancy and regularly monitored during pregnancy. Higher serum creatinine levels and higher proteinuria predispose to shorter gestation period and lower birth weight of the neonate.

The effect of preexisting medical comorbidities on the preeclamptic phenotype: a retrospective cohort study

Objective:To compare the effect of comorbidities on the phenotype and outcomes of preeclampsia.Methods: A matched retrospective cohort study of women delivering at a tertiary maternity center following a diagnosis of preeclampsia. We collected data on signs and symptoms, biochemical markers, and maternal and perinatal outcomes.Results:We studied 474 women; 158 women with and 316 without comorbidities. Compared to women without comorbidities, women with comorbidities delivered earlier. They suffered fewer maternal but more neonatal complications.Conclusion: Women with comorbidities receive earlier intervention than women without comorbidities, which may lead to fewer maternal complications but worse neonatal outcomes.

Association between time of delivery and composite adverse outcomes in pregnancies complicated by hypertensive disorders

INTRODUCTION

A potential manner to lower the morbidity with the hypertensive disoreders of pregancy is to explore the time of day of delivery.

OBJECTIVE

To compare composite neonatal adverse outcomes among term women with hypertensive disorders.

METHODS

This population-based cohort study used the U.S. vital statistics dataset from 2013 to 2017. Time of delivery was categorized into three shifts. The primary outcome was composite neonatal adverse outcome..

RESULTS

Compared to neonates delivered at the first shift, the risk of composite neonatal adverse outcome was higher at the third shift (aRR = 1.19, 95% CI = 1.13-1.25).

CONCLUSION

the risk of composite neonatal adverse outcome is higher if the delivery occurs at the third (23:00-7:00) shift.

Low-dose aspirin for the prevention of severe preeclampsia in patients with chronic kidney disease: a retrospective study : This is the study for kidney and pregnancy

OBJECTIVE

The objective of the study was to investigate the effects of low-dose aspirin (LDA) during pregnancy on the prevention of preeclampsia in patients with chronic kidney disease (CKD).

METHODS

The clinical data of pregnant women with CKD were retrospectively analyzed at Peking University First Hospital between January 2013 and January 2020. Among 287 pregnant women with stage 1-2 CKD, 63 patients who were treated with LDA were included in study group 1, and 63 patients who were not treated with aspirin were allocated to control group 1. Among 41 pregnant women with stage 3-5 CKD, 22 patients who were treated with LDA were included in study group 2, and 19 patients were allocated to control group 2. Pregnancy outcomes of the patients with stage 1-2 and stage 3-5 CKD who received LDA during pregnancy and those who did not were compared.

RESULTS

No significant difference was observed in the incidence of preeclampsia or severe preeclampsia between study and control group 1. The patients in study group 2 had a lower incidence of severe preeclampsia than those in control group 2 (3/22 [13.6%] vs. 8/19 [42.1%], P = 0.04). Among the patients with stage 3-5 CKD, LDA therapy during pregnancy was associated with a lower risk of severe preeclampsia (odds ratio = 0.22, 95% confidence interval: 0.074-0.993; P = 0.049).

CONCLUSIONS

LDA therapy during pregnancy can reduce the risk of severe preeclampsia in patients with stage 3-5 CKD. Prospective studies are  needed to further explore the preventive effects of aspirin on preeclampsia in patients with stage 1-2 CKD.

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.

Contraceptive Use Among Women With End-Stage Kidney Disease on Dialysis in the United States

Rationale & Objective

Although end-stage kidney disease (ESKD) adversely affects fertility, pregnancies can occur among women receiving dialysis. ESKD increases the risk for adverse pregnancy outcomes and little is known about contraceptive use in women undergoing dialysis.

Study Design

Retrospective cohort study.

Setting & Participants

Using the US Renal Data System covering January 1, 2005, through December 31, 2014, we evaluated for each calendar year women who for the entire year were aged 15 to 44 years, receiving dialysis, and with Medicare as the primary payer.

Predictors

Age, race/ethnicity, and calendar year of prevalent ESKD.

Outcome

Contraceptive use.

Analytic Approach

We determined rates of contraceptive use and used multivariable logistic regression to identify factors associated with contraceptive use.

Results

The study cohort included 35,732 women and represented 115,713 person-years. The rate of contraceptive use was 5.30% of person-years (95% CI, 5.17%-5.42%). Overall, contraceptive use increased from 2005 to 2014 (4.21%; 95% CI, 3.84%-4.59% vs 6.54%, 95% CI, 6.10%-6.99%). Compared with women aged 25 to 29 years, contraceptive use was higher in women aged 15 to 24 years (OR, 1.30; 95% CI, 1.18-1.43) and lower in women aged 30 to 34 years (OR, 0.74; 95% CI, 0.68-0.81), 35 to 39 years (OR, 0.46; 95% CI, 0.42-0.50), and 40 to 44 years (OR, 0.30; 95% CI, 0.27-0.34). Compared with White women, contraceptive use was higher in Black (OR, 1.12; 95% CI, 1.02-1.24) and Native American women (OR, 1.60; 95% CI, 1.25-2.05). Women with ESKD due to glomerulonephritis had a higher likelihood of contraceptive use than women with ESKD due to diabetes (OR, 1.22; 95% CI, 1.06-1.42). Women receiving peritoneal dialysis had a lower likelihood of contraceptive use than women receiving hemodialysis (OR, 0.85; 95% CI, 0.78-0.93). Compared with women without predialysis nephrology care, contraceptive use was higher in women who received predialysis nephrology care for 12 or fewer months (OR, 1.22; 95% CI, 1.09-1.37) and more than 12 months (OR, 1.33; 95% CI, 1.20-1.47).

Limitations

Retrospective design and use of administrative data.

Conclusions

Among women with ESKD undergoing dialysis, contraceptive use remains low at 5.30%. Younger age, Native American and Black race/ethnicity, ESKD due to glomerulonephritis, hemodialysis, and predialysis nephrology care are associated with a higher likelihood of contraceptive use. The study highlights the importance of prepregnancy counseling for contraceptive use in women receiving dialysis.

Exposure to Per- and Polyfluoroalkyl Substances and Adiposity at Age 12 Years: Evaluating Periods of Susceptibility

Per- and polyfluoroalkyl substances (PFAS) exposure may increase adiposity and obesity risk in children. However, no studies have extended these findings into adolescence or identified periods of heightened susceptibility. We estimated associations of repeated pre- and postnatal serum PFAS concentrations with adolescent adiposity and risk of overweight/obesity. We studied 212 mother-offspring pairs from the HOME Study. We quantified serum concentrations of four PFAS in mothers at ∼16 week gestation and their children at birth and ages 3, 8, and 12 years. We assessed adiposity at 12 years using anthropometry and dual-energy X-ray absorptiometry. Using multiple informant models, we estimated covariate-adjusted associations of an interquartile range (IQR) increase in log2-transformed PFAS for each time period with adiposity measures and tested differences in these associations. Serum perfluorooctanoate (PFOA) and perfluorohexane sulfonate (PFHxS) concentrations during pregnancy were associated with modest increases in central adiposity and risk of overweight/obesity, but there was no consistent pattern for postnatal concentrations. We observed nonlinear associations between PFOA in pregnancy and some measures of adiposity. Overall, we observed a pattern of modest positive associations of gestational PFOA and PFHxS concentrations with central adiposity and the risk of obesity in adolescents, while no pattern was observed for postnatal PFAS concentrations.

Contraception in Kidney Disease

Unplanned pregnancies account for a large number of encountered pregnancies. One of the reasons for this is the lack of counseling surrounding contraception and subsequently lack of contraception use. A conversation during a regular CKD office visit of simply asking a woman what her plans are regarding pregnancy can lead to further discussion on timing of pregnancy and contraception and eventually safer outcomes for both the mother and fetus. Individual preference, as well as comorbid conditions, should be taken into account when deciding on optimal contraceptive methods. One must remember that contraception counseling and initiation of contraception should not be wrapped up in a single office visit, and there must be continued follow-up to ensure that the woman is using the contraceptive method correctly to prevent any future unplanned pregnancy.

Chronic Kidney Disease and Pregnancy

Women with chronic kidney disease (CKD) are at high risk for adverse outcomes in pregnancy. In the United States, pregnancy rates in women with risk factors for CKD such as obesity and advanced maternal age are increasing; thus, more pregnancies are likely to be affected by CKD. Strategies that involve coordinated multidisciplinary care to optimize preconception health, perform meticulous antenatal monitoring, and provide continued care in the postpartum "fourth trimester" appear to be most beneficial for both the mother and baby. Discussions surrounding preconception risk stratification should be individualized based on CKD stage/serum creatinine level, degree of hypertension and proteinuria, and comorbid conditions. Preparation for pregnancy should include optimization of comorbidities and medication adjustments to those compatible with pregnancy. Unless contraindicated, all women with CKD should be prescribed low-dose aspirin in pregnancy to reduce risk of preeclampsia. After delivery, women with CKD may benefit from an early postpartum visit (within 7-10 days) for blood pressure check and may require serial monitoring of serum creatinine and proteinuria as appropriate. Breastfeeding is safe and can be recommended for most women with CKD. A contraceptive plan that includes patients' preferences, feasibility, medical eligibility, duration, and effectiveness of the contraceptive method should be implemented.

The association between maternal renal function and pregnancy outcomes in type 1 and type 2 diabetes

AIMS

To investigate the prognostic value of estimated glomerular filtration rate (eGFR) and albuminuria in determining pregnancy outcomes in women with type 1 and type 2 diabetes.

METHODS

An observational study of pregnant women with type 1 (n = 92) and type 2 diabetes (n = 106) who delivered between 2004 and 2014 at a single tertiary obstetric centre. Clinical and biochemical characteristics were determined and related to major obstetric outcomes: preeclampsia, preterm birth <32 and <37 weeks, and neonatal intensive care admission. We used univariate analyses and multivariable logistic regression models with eGFR using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation and albuminuria as covariates.

RESULTS

In the pooled diabetes cohort, multivariable logistic regression with eGFR and albuminuria status demonstrated that the presence of albuminuria (albumin-to-creatinine ratio ≥ 3.5 mg/mmol) (OR, 2.7; 95% CI, 1.42-4.99; P = 0.002) was associated with preeclampsia, whilst an eGFR of < 120 mL/min/1.73 m² was associated with preterm birth < 32 weeks (OR, 1.04; 95% CI, 1.00-1.09; P = 0.02).

CONCLUSIONS

Despite its recognized limitations in pregnancy, lower eGFR values were associated with increased risk of adverse outcomes. Our exploratory data suggest eGFR, along with albuminuria, can aid in identifying women at high risk of developing adverse obstetric outcomes.

Nutritional Challenges in Pregnant Women with Renal Diseases: Relevance to Fetal Outcomes

Pregnancy in women affected by chronic kidney disease (CKD) has become more common in recent years, probably as a consequence of increased CKD prevalence and improvements in the care provided to these patients. Management of this condition requires careful attention since many clinical aspects have to be taken into consideration, including the reciprocal influence of the renal disease and pregnancy, the need for adjustment of the medical treatments and the high risk of maternal and obstetric complications. Nutrition assessment and management is a crucial step in this process, since nutritional status may affect both maternal and fetal health, with potential effects also on the future development of adult diseases in the offspring. Nevertheless, few data are available on the nutritional management of pregnant women with CKD and the main clinical indications are based on small case series or are extrapolated from the general recommendations for non-pregnant CKD patients. In this review, we discuss the main issues regarding the nutritional management of pregnant women with renal diseases, including CKD patients on conservative treatment, patients on dialysis and kidney transplant patients, focusing on their relevance on fetal outcomes and considering the peculiarities of this population and the approaches that could be implemented into clinical practice.

Kidney function, blood pressure and proteinuria were associated with pregnancy outcomes of pregnant women with chronic kidney disease: a single-center, retrospective study in the Asian population

BACKGROUND

Studies among pregnant Asian women with chronic kidney disease (CKD) have not been widely performed; therefore, clinical criteria for these patients have not been well established.

METHODS

We conducted a retrospective study among pregnant women with CKD who received prenatal care at our institution for 8 consecutive years. Primary outcome was the development of severe adverse events (SAEs). We analyzed correlations between primary outcome and CKD parameters [age, body mass index (BMI), estimated glomerular filtration rate (eGFR), urinary protein-creatinine ratio (UP), systolic blood pressure (SBP), diastolic blood pressure (DBP), and not normal blood pressure (non-NBP)] at the time of referral. Secondary outcomes were low birth weight (LBW), preterm delivery (PreD), and small for gestational age (SGA). We divided into two categories, CKD stage G1, and G2 or higher according to eGFR, and proteinuria negative and proteinuria positive according to UP, respectively.

RESULTS

We observed 89 pregnancies. SAE was observed in 28 pregnancies. In live birth cases, there were 28 PreD, 28 LBW and 13 SGA. Major SAEs included preeclampsia, superimposed preeclampsia, unscheduled cesarean section, neonatal intensive care unit admission, and fetal death. Stepwise logistic regression analysis selected eGFR (OR = 0.847, p = 0.026), SBP (OR = 1.897, p = 0.006) and proteinuria positive (OR = 2.96, p = 0.046) as the significant predictors of SAEs. There were no significant differences among the baseline characteristics stratified by SGA.

CONCLUSIONS

This is the first study to report pregnancy outcomes among Japanese non-disease-oriented patients with CKD. In Asians, especially in the Japanese population, kidney function, blood pressure and proteinuria might affect pregnancy outcomes.

Differential effects of delivery hospital on mortality and morbidity in minority premature and low birth weight neonates

OBJECTIVE

To describe variation in mortality and morbidity effects of high-level, high-volume delivery hospital between racial/ethnic groups and insurance groups.

STUDY DESIGN

Retrospective cohort including infants born at 24-32 weeks gestation or birth weights ≤2500 g in California, Missouri, and Pennsylvania between 1995 and 2009 (n = 636,764). Multivariable logistic random-effects models determined differential effects of birth hospital level/volume on mortality and morbidity through an interaction term between delivery hospital level/volume and either maternal race or insurance status.

RESULT

Compared to non-Hispanic white neonates, odds of complications of prematurity were 14-25% lower for minority infants in all gestational age and birth weight cohorts delivering at high-level, high-volume centers (odds ratio (ORs) 0.75-0.86, p < 0.001-0.005). Effect size was greatest for Hispanic infants. No difference was noted by insurance status.

CONCLUSIONS

Neonates of minority racial/ethnic status derive greater morbidity benefits than non-Hispanic white neonates from delivery at hospitals with high-level, high-volume neonatal intensive care units.

Phospholipase A2 Receptor Antibody-Positive Pregnancy: A Case Report

Renal course and clinical outcomes in pregnant women with primary membranous nephropathy are not completely understood. In addition, the use of autoantibodies to M-type phospholipase A₂ receptor (PLA₂R) as a serologic marker throughout pregnancy and postpartum in the mother and baby is not yet fully elucidated. We followed up a pregnant woman with primary membranous nephropathy during pregnancy and postpartum and describe the clinical course and outcomes of mother and baby and the course of PLA₂R antibody titers. We show evidence of transplacental transfer of PLA₂R antibody from mother to fetus. In addition, we observe the effect of breastfeeding in a PLA₂R antibody-positive pregnancy and describe the transfer of this antibody into breast milk. Although pregnancy in women with underlying PLA₂R antibody-positive membranous nephropathy is possible, there is an increase in risk to both mother and fetus, requiring a multidisciplinary team approach and careful monitoring of both neonate and mother during pregnancy and postpartum.

Maternal and environmental risk factors for neonatal AKI and its long-term consequences

Acute kidney injury (AKI) is a common and life-threatening complication in critically ill neonates. Gestational risk factors for AKI include premature birth, intrauterine growth restriction and low birthweight, which are associated with poor nephron development and are often the consequence of pre-gestational and gestational factors, such as poor nutritional status. Our understanding of how to best optimize renal development and prevent AKI is in its infancy; however, the identification of pre-gestational and gestational factors that increase the risk of adverse neonatal outcomes and the implementation of interventions, such as improving nutritional status early in pregnancy, have the potential to optimize fetal growth and reduce the risk of preterm birth, thereby improving kidney health. The overall risk of AKI among critically ill and premature neonates is exacerbated postnatally as these infants are often exposed to dehydration, septic shock and potentially nephrotoxic medications. Strategies to improve outcomes - for example, through careful evaluation of nephrotoxic drugs - may reduce the incidence of AKI and its consequences among this population. Management strategies and updated technology that will support neonates with AKI are greatly needed. Extremely premature infants and those who survive an episode of AKI should be screened for chronic kidney disease until early adulthood. Here, we provide an overview of our current understanding of neonatal AKI, focusing on its relationship to preterm birth and growth restriction. We describe factors that prevent optimal nephrogenesis during pregnancy and provide a framework for future explorations designed to maximize outcomes in this vulnerable population.

Acute air pollution exposure and NICU admission: a case-crossover analysis

PURPOSE

Neonatal intensive care unit (NICU) admission rates have increased over time. Air pollution is associated with adverse pregnancy outcomes, but the relationship between prenatal air pollution exposure and NICU admission has not been investigated.

METHODS

In the Consortium on Safe Labor (2002-2008), 27,189 singletons were admitted to the NICU. Modified Community Multiscale Air Quality models estimated exposures for criteria air pollutants and constituents of particles less than or equal to 2.5 microns (PM_2.5). Case-crossover analyses calculated odds ratios and 95% confidence intervals for interquartile range increases in pollutant exposure, comparing exposures during the week of delivery to control periods before and after delivery.

RESULTS

In models that adjusted for PM_2.5, exposure to PM_2.5 constituents during the week before delivery was significantly associated with increased odds of NICU admission: elemental carbon (35%), ammonium ions (37%), nitrate compounds (16%), organic compounds (147%), and sulfate compounds (35%). Odds were also significantly increased by day of and day before delivery exposures to carbon monoxide (4%-5%), nitrogen dioxide (13%), nitrogen oxides (4%-8%), particles less than or equal to 10 microns (2%), particles less than or equal to 2.5 microns (2%), and sulfur dioxide (3%-6%). No associations were observed for ozone.

CONCLUSIONS

Acute exposures to PM_2.5 constituents and several traffic-related pollutants during the week before delivery, the day of delivery, and day before delivery appear to increase the odds of NICU admissions. These novel associations suggest infants exposed in utero to common air pollutants may require additional care during the newborn hospital admission.

Serious kidney disease in pregnancy: an Australian national cohort study protocol

BACKGROUND

Maternal kidney disease (acute kidney injury (AKI), advanced chronic kidney disease (CKD), dependence on dialysis or a kidney transplant) has a substantial impact on pregnancy, with risks of significant perinatal morbidity. These pregnancies require integrated multidisciplinary care to manage a complex and often challenging clinical situation. The ability to deliver optimal care is currently hindered by a lack of understanding around prevalence, management and outcomes in Australia. This study aims to expand an evidence base to improve clinical care of women with serious kidney impairment in pregnancy.

METHODS/DESIGN

The "Kidney Disease in Pregnancy Study" is a national prospective cohort study of women with stage 3b-5 CKD (including dialysis and transplant) and severe AKI in pregnancy, using the Australasian Maternity Outcomes Surveillance System (AMOSS). AMOSS incorporates Australian maternity units with > 50 births/year (n = 260), capturing approximately 96% of Australian births. We will identify women meeting the inclusion criteria who give birth in Australia between 1st August 2017 and 31st July 2018. Case identification will occur via monthly review of all births in Australian AMOSS sites and prospective notification to AMOSS via renal or obstetric clinics. AMOSS data collectors will capture key clinical data via a web-based data collection tool. The data collected will focus on the prevalence, medical and obstetric clinical care, and maternal and fetal outcomes of these high-risk pregnancies.

DISCUSSION

This study will increase awareness of the issue of serious renal impairment in pregnancy through engagement of 260 maternity units and obstetric and renal healthcare providers across the country. The study results will provide an evidence base for pre-pregnancy counselling and development of models of optimal clinical care, clinical guideline and policy development in Australia. Understanding current practices, gaps in care and areas for intervention will improve the care of women with serious renal impairment, women with high-risk pregnancies, their babies and their families.

Delayed Initiation of Hemodialysis in Pregnant Women with Chronic Kidney Disease: Logistical Problems Impact Clinical Outcomes. An Experience from an Emerging Country

BACKGROUND

Chronic kidney disease (CKD) is associated with reduction of fertility and increased complications during pregnancy. The aim of this work is to analyze the clinical outcomes and risk factors in pregnant women who needed to start dialysis with different schedules in a public hospital in Mexico City, with particular attention on the interference of social and cultural elements as well as resource limitations.

MATERIAL AND METHODS

CKD women who needed dialysis in pregnancy over the period 2002⁻2014 and had with complete demographic and outcome data were included in this retrospective study. Clinical background, renal function during pregnancy, dialysis schedule, and clinical outcomes were reviewed.

RESULTS

Forty pregnancies in women with CKD who needed dialysis in pregnancy (39 singleton and one twin pregnancy) were studied: All patients were treated with hemodialysis. Thirty-nine patients had CKD stages 4 or 5 at referral; only one patient was of stage 3b. Dialysis was considered as indicated in the presence of fluid overload, unresponsive hypertension in the setting of advanced CKD, or when blood urea nitrogen values were increased to around 50 mg/dL. However, the initiation of dialysis was often delayed by days or weeks. The main reason for delaying the initiation of dialysis was patient (and family) refusal to start treatment. All patients were treated with thrice weekly dialysis, in 3⁻5 hour sessions, with a target urea of <100 mg/dL. The number of hours on dialysis did not impact pregnancy outcomes. Ten pregnancies ended in miscarriages (8 spontaneous), 29 in pre-term delivery, and 1 in term delivery. Fifteen women were diagnosed with preeclampsia, one with eclampsia, and one with HELLP (hemolysis, elevated liver enzymes, low platelets,) syndrome. Twenty-four of the neonates survived (77.4% of live births); six singletons and one twin died as a consequence of prematurity. Two neonates displayed malformations: cleft palate with ear anomalies and duodenal atresia.

CONCLUSIONS

CKD requiring hemodialysis in pregnancy is associated with a high frequency of complications; in the setting of delayed start and of thrice-weekly hemodialysis, dialysis schedules do not appear to influence outcomes.

Renal disease in pregnancy: Fetal, neonatal and long-term outcomes

Renal disease in women of childbearing age is estimated to be approximately 3%; consequently, renal disease is not an uncommon comorbidity in pregnancy. There has been considerable evidence published over the last 20 years to suggest that renal disease in pregnancy is associated with higher maternal, fetal, and offspring morbidity. Studies published are largely heterogeneous; include unmatched cohort studies; and focus on early neonatal outcomes such as prematurity, small for gestational age, and neonatal unit admission. There appears to be an inverse relationship between maternal renal function and likelihood of neonatal morbidity using these outcome measures. Overall though, data regarding medium-to long-term outcomes for children born to mothers with renal disease are scarce. However, in view of emerging epidemiological evidence regarding cardiovascular programming in intrauterine life in those born premature or small for gestational age, it is likely that this population of children remain at high risk of cardiovascular disease as adults. The scope of this review is to amalgamate and summarize existing evidence regarding the outcomes of infants born to mothers with renal disease. Focus will be given to pregnancy-related acute kidney injury, chronic kidney disease, dialysis, and transplantation.

Dialysis or a Plant-Based Diet in Advanced CKD in Pregnancy? A Case Report and Critical Appraisal of the Literature

Pregnancy is increasingly reported in chronic kidney disease (CKD), reflecting higher awareness, improvements in materno-foetal care, and a more flexible attitude towards “allowing” pregnancy in the advanced stages of CKD. Success is not devoid of problems and an important grey area regards the indications for starting dialysis (by urea level, clinical picture, and residual glomerular filtration rate) and for dietary management. The present case may highlight the role of plant-based diets in dietary management in pregnant CKD women, aimed at retarding dialysis needs. The case. A 28-year-old woman, affected by glomerulocystic disease and unilateral renal agenesis, in stage-4 CKD, was referred at the 6th week of amenorrhea: she weighed 40 kg (BMI 16.3), was normotensive, had no sign of oedema, her serum creatinine was 2.73 mg/dL, blood urea nitrogen (BUN) 35 mg/dL, and proteinuria 200 mg/24 h. She had been on a moderately protein-restricted diet (about 0.8 g/kg/real body weight, 0.6 per ideal body weight) since childhood. Low-dose acetylsalicylate was added, and a first attempt to switch to a protein-restricted supplemented plant-based diet was made and soon stopped, as she did not tolerate ketoacid and aminoacid supplementation. At 22 weeks of pregnancy, creatinine was increased (3.17 mg/dL, BUN 42 mg/dL), dietary management was re-discussed and a plant-based non-supplemented diet was started. The diet was associated with a rapid decrease in serum urea and creatinine; this favourable effect was maintained up to the 33rd gestational week when a new rise in urea and creatinine was observed, together with signs of cholestasis. After induction, at 33 weeks + 6 days, she delivered a healthy female baby, adequate for gestational age (39th centile). Urea levels decreased after delivery, but increased again when the mother resumed her usual mixed-protein diet. At the child’s most recent follow-up visit (age 4 months), development was normal, with normal weight and height (50th–75th centile). In summary, the present case confirms that a moderate protein-restricted diet can be prescribed in pregnancies in advanced CKD without negatively influencing foetal growth, supporting the importance of choosing a plant-based protein source, and suggests focusing on the diet’s effects on microcirculation to explain these favourable results.

Pre-pregnancy kidney function and subsequent adverse pregnancy outcomes

BACKGROUND

Renal insufficiency is associated with pregnancy complications including fetal growth restriction, preterm birth (PTB), and pre-eclampsia.

OBJECTIVE

To determine the effect of preconception kidney function within the normal range on pregnancy outcome.

METHOD

1043 (50% black, 50% white) women who participated in the CARDIA study who had kidney function and biochemical analyses measured before at least one pregnancy delivered during the 20 years post-baseline period were included in analysis. Kidney function estimated as glomerular filtration rate (eGFR) via modified CKD-EPI equations, serum creatinine, and urinary albumin/creatinine ratio were evaluated as predictors of infant birthweight, gestational age, birthweight-for-gestational-age, and hypertensive disorders of pregnancy via self-report, using multiple regression with adjustment for confounders (age, race, smoking, BMI, center, parity, systolic blood pressure at baseline). Serum uric acid was also examined at both baseline and year 10.

RESULTS

Unadjusted pre-pregnancy eGFR (baseline) was associated with lower average birthweight-for-gestational-age, but this disappeared after adjustment for confounders. A decline in GFR from baseline to year 10 was associated with lower birthweight (adjusted estimate -195 g, p = 0.03 overall), especially among whites. After adjustment for confounders, no association was found with gestational age or hypertensive disorders.

CONCLUSIONS

No strong evidence for an association between preconception kidney function in the normal range and birthweight or gestational age was found. Possible racial differences in these relationships warrant further examination.