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Li Z, Chen S, Tan Y, Lv J, Zhao M, Chen Q, He Y. Twenty-four-hour proteinuria levels are associated with adverse pregnancy outcomes among women with CKD. Clin Kidney J 2023; 16:1634-1643. [PMID: 37779840 PMCID: PMC10539237 DOI: 10.1093/ckj/sfad044] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Indexed: 10/03/2023] Open
Abstract
Background Proteinuria is commonly measured to assess the renal status of chronic kidney disease (CKD) patients before the 20th week of gestation during pregnancy. High levels of proteiuria have been associated with adverse pregnancy outcomes. However, researchers have not clearly determined what baseline proteinuria levels would be associated with adverse pregnancy outcomes. This study aimed to analyse associations between proteinuria levels and adverse pregnancy outcomes among CKD patients treated with or without steroids/immunosuppressive therapy in early pregnancy. Methods This retrospective study included the clinical information of 557 pregnant patients with CKD from 1 January 2009 to 31 December 2021. A multivariable logistic regression analysis was conducted to evaluate the risk of adverse pregnancy outcomes across various proteinuria ranges, which were further stratified by whether the patients were receiving steroids/immunosuppressive therapy. Results (i) Proteinuria was assessed on 24-h urine collection. The median (quartile) baseline proteinuria levels were 0.83 g (0.20, 1.92) and 0.25 g (0.06, 0.80) in the steroids/immunosuppressive therapy and therapy-free groups, respectively. (ii) CKD patients with adverse pregnancy outcomes had significantly higher proteinuria levels in the first trimester than patients without adverse pregnancy outcomes. (iii) The risk of adverse pregnancy outcomes increased with increasing baseline proteinuria levels (P < .001). (iv) In the early-pregnancy steroids/immunosuppressive therapy group, the risk of severe preeclampsia was higher in patients with higher baseline proteinuria levels (P < .007) [odds ratio (OR) 30.86 for proteinuria ≥5.00 g/24 h]; in the therapy-free group, the risks of severe preeclampsia, very-low-birth-weight infants, early preterm birth and foetal-neonatal death were higher in patients with higher baseline proteinuria levels (OR 53.16 for proteinuria ≥5.00 g/24 h; OR 37.83 for proteinuria ≥5.00 g/24 h; OR 15.30 for proteinuria ≥5.00 g/24 h; and OR 18.83 for proteinuria ≥5.00 g/24 h, respectively; P < .001, P < .001, P < .001 and P = .006, respectively). Conclusions As shown in the present study, a baseline 24-h proteinuria level >1.00 g was associated with adverse maternal outcomes. Furthermore, a 24-h proteinuria level >2.00 g increased the incidence of adverse foetal events among CKD patients.
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Affiliation(s)
- Zheng Li
- Department of Obstetrics and Gynecology, Peking University, First Hospital, Beijing, P.R. China
| | - Shi Chen
- Department of Obstetrics and Gynecology, Peking University, First Hospital, Beijing, P.R. China
| | - Ying Tan
- Renal Division, Department of Medicine, Peking University, First Hospital, Peking University Institute of Nephrology, Beijing, P.R. China
| | - Jicheng Lv
- Renal Division, Department of Medicine, Peking University, First Hospital, Peking University Institute of Nephrology, Beijing, P.R. China
| | - Minghui Zhao
- Renal Division, Department of Medicine, Peking University, First Hospital, Peking University Institute of Nephrology, Beijing, P.R. China
| | - Qian Chen
- Department of Obstetrics and Gynecology, Peking University, First Hospital, Beijing, P.R. China
| | - Yingdong He
- Department of Obstetrics and Gynecology, Peking University, First Hospital, Beijing, P.R. China
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2
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de Jong MF, van Hamersvelt HW, van Empel IW, Nijkamp EJ, Lely AT. Summary of the Dutch Practice Guideline on Pregnancy Wish and Pregnancy in CKD. Kidney Int Rep 2022; 7:2575-2588. [PMID: 36506226 PMCID: PMC9727525 DOI: 10.1016/j.ekir.2022.09.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 09/21/2022] [Accepted: 09/26/2022] [Indexed: 11/11/2022] Open
Affiliation(s)
- Margriet F.C. de Jong
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, Groningen, the Netherlands,Correspondence: Margriet F. C. de Jong, Department of Internal Medicine, division of Nephrology, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, the Netherlands.
| | | | - Inge W.H. van Empel
- Department of Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Ellen J.W. Nijkamp
- Department of Obstetrics and Gynecology, Utrecht University Medical Center, Utrecht, the Netherlands
| | - A. Titia Lely
- Department of Obstetrics and Gynecology, Utrecht University Medical Center, Utrecht, the Netherlands
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3
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Pregnancy in patients with stage 3–5 CKD: Maternal and fetal outcomes. Pregnancy Hypertens 2022; 29:86-91. [DOI: 10.1016/j.preghy.2022.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 06/19/2022] [Accepted: 06/29/2022] [Indexed: 11/17/2022]
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4
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Piccoli GB, Torreggiani M, Crochette R, Cabiddu G, Masturzo B, Attini R, Versino E. What a paediatric nephrologist should know about preeclampsia and why it matters. Pediatr Nephrol 2022; 37:1733-1745. [PMID: 34735598 DOI: 10.1007/s00467-021-05235-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 07/06/2021] [Accepted: 07/13/2021] [Indexed: 12/24/2022]
Abstract
Preeclampsia is a protean syndrome causing a kidney disease characterised by hypertension and proteinuria, usually considered transitory and reversible after delivery. Its prevalence ranges from 3-5 to 10% if all the related disorders are considered. This narrative review, on behalf of the Kidney and Pregnancy Study Group of the Italian Society of Nephrology, focuses on three reasons why preeclampsia should concern paediatric nephrologists and how they can play an important role in its prevention, as well as in the prevention of future kidney and cardiovascular diseases. Firstly, all diseases of the kidney and urinary tract diagnosed in paediatric age are associated with a higher risk of adverse pregnancy-related outcomes, including preeclampsia. Secondly, babies with low birth weights (small for gestational age, born preterm, or both) have an increased risk of developing the full panoply of metabolic diseases (obesity, hypertension, early-onset cardiopathy and chronic kidney disease) and girls are at higher risk of developing preeclampsia when pregnant. The risk may be particularly high in cases of maternal preeclampsia, highlighting a familial aggregation of this condition. Thirdly, pregnant teenagers have a higher risk of developing preeclampsia and the hypertensive disorders of pregnancy, and should be followed up as high risk pregnancies. In summary, preeclampsia has come to be seen as a window on the future health of both mother and baby. Identification of subjects at risk, early counselling and careful follow-up can contribute to reducing the high morbidity linked with this disorder.
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Affiliation(s)
- Giorgina Barbara Piccoli
- Néphrologie Et Dialyse, Centre Hospitalier Le Mans, 194 Avenue Rubillard, 72000, Le Mans, France.
| | - Massimo Torreggiani
- Néphrologie Et Dialyse, Centre Hospitalier Le Mans, 194 Avenue Rubillard, 72000, Le Mans, France
| | - Romain Crochette
- Néphrologie Et Dialyse, Centre Hospitalier Le Mans, 194 Avenue Rubillard, 72000, Le Mans, France
| | | | - Bianca Masturzo
- Department of Obstetrics and Gynecology, Città della Salute e della Scienza, Ospedale Sant'Anna, University of Torino, Turin, Italy
| | - Rossella Attini
- Department of Obstetrics and Gynecology, Città della Salute e della Scienza, Ospedale Sant'Anna, University of Torino, Turin, Italy
| | - Elisabetta Versino
- Epidemiology, Department of Clinical and Biological Sciences, University of Torino, Turin, Italy
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5
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Gouveia IF, Silva JR, Santos C, Carvalho C. Maternal and fetal outcomes of pregnancy in chronic kidney disease: diagnostic challenges, surveillance and treatment throughout the spectrum of kidney disease. ACTA ACUST UNITED AC 2021; 43:88-102. [PMID: 33460427 PMCID: PMC8061969 DOI: 10.1590/2175-8239-jbn-2020-0055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 08/31/2020] [Indexed: 01/01/2023]
Abstract
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.
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Affiliation(s)
- Inês Filipe Gouveia
- Serviço de Ginecologia e Obstetrícia do Centro Hospitalar de Vila Nova de Gaia e Espinho, Portugal
| | - Joana Raquel Silva
- Serviço de Ginecologia e Obstetrícia do Centro Hospitalar de Vila Nova de Gaia e Espinho, Portugal
| | - Clara Santos
- Serviço de Nefrologia do Centro Hospitalar de Vila Nova de Gaia e Espinho, Portugal
| | - Claudina Carvalho
- Serviço de Ginecologia e Obstetrícia do Centro Hospitalar de Vila Nova de Gaia e Espinho, Portugal
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Amir N, McCarthy HJ, Tong A. A working partnership: A review of shared decision-making in nephrology. Nephrology (Carlton) 2021; 26:851-857. [PMID: 34010487 DOI: 10.1111/nep.13902] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 05/14/2021] [Indexed: 11/28/2022]
Abstract
Patients with chronic kidney disease are required to make difficult decisions, negotiating between the risks, burdens and benefits for any proposed course. This process can be extremely challenging, since these decisions involve inherent risks, which can impact on survival and quality of life. Shared decision-making offers a patient-centred approach in partnering with patients to make decisions about their treatment, which reflect their values and preferences. Shared decision-making can improve patient preparedness, motivation, satisfaction, and adherence to the treatment or decision agreed upon. In this review article, we outline the key principles of shared decision-making, and provide a framework with communication strategies to facilitate shared decision-making. We highlight the broad range and context of decisions faced by patients in several areas of nephrology care and discuss patient-important outcomes, priorities and motivations that underpin their decision-making. Preserving patient autonomy through shared decision-making ensures close consideration of patient preferences to enhance satisfaction with the decision reached and optimize outcomes important to patients.
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Affiliation(s)
- Noa Amir
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Hugh J McCarthy
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Allison Tong
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
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7
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Abstract
Sexual and reproductive function are impacted negatively in individuals with chronic kidney disease and end-stage renal disease. Disruption of the hypothalamic-pituitary-gonadal axis plays a pivotal role in contributing to these manifestations as a result of decreasing kidney function and the development of uremia. Early menopause is encountered commonly in women with reduced kidney function, and treatment is problematic as a result of reduced kidney function changing the half-life of medications. Kidney transplantation corrects some of these abnormalities, but medications required after transplantation as well as the persistence of other comorbidities are barriers to normal restoration of gonadal dysfunction.
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Affiliation(s)
- Rebecca Rojas
- Department of Medicine, Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Deborah J Clegg
- Departments of Research and Internal Medicine, Texas Tech Health Sciences Center, El Paso, TX
| | - Biff F Palmer
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX.
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8
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Wang ML, He YD, Yang HX, Chen Q. Successful pregnancy after protective hemodialysis for chronic kidney disease: A case report. World J Clin Cases 2020; 8:4521-4526. [PMID: 33083413 PMCID: PMC7559658 DOI: 10.12998/wjcc.v8.i19.4521] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 08/10/2020] [Accepted: 08/25/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) affects almost 3% of females of child-bearing age, who have a high risk of adverse maternal and fetal outcomes. Additionally, high renal burden as a result of pregnancy may lead to deterioration of renal function. An increasing number of women with CKD stages 3 to 5 have a strong desire to conceive, and both obstetricians and nephrologists are faced with enormous challenges in terms of their treatment and management.
CASE SUMMARY The case of a 35-year-old pregnant woman with a 10-year history of mild mesangial proliferative glomerulonephritis is described here. CKD progressed from stage 3 to stage 5 rapidly during pregnancy, and protective hemodialysis was started at 28 wk of gestation. Due to preeclampsia at 34 wk of gestation, cesarean section was performed and a healthy baby was delivered. Hemodialysis was discontinued at 4 wk postpartum. After 1 year of follow-up, her renal function was stable, and her baby exhibited good growth and development.
CONCLUSION Protective hemodialysis during pregnancy can prolong gestational age and improve maternal and fetal outcomes in women with advanced CKD.
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Affiliation(s)
- Meng-Lu Wang
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing 100034, China
| | - Ying-Dong He
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing 100034, China
| | - Hui-Xia Yang
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing 100034, China
| | - Qian Chen
- Department of Obstetrics and Gynecology, Peking University First Hospital, Beijing 100034, China
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9
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McBride L, Wilkinson C, Jesudason S. Management of Autosomal Dominant Polycystic Kidney Disease (ADPKD) During Pregnancy: Risks and Challenges. Int J Womens Health 2020; 12:409-422. [PMID: 32547249 PMCID: PMC7261500 DOI: 10.2147/ijwh.s204997] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 03/20/2020] [Indexed: 01/29/2023] Open
Abstract
Autosomal dominant polycystic kidney disease (ADPKD) affects up to 1 in 1000 people. The disease is characterized by the progressive development of cysts throughout the renal parenchyma due to inherited pathogenic variants in genes including PKD1 or PKD2 and eventually leads to gradual loss of renal function, along with manifestations in other organ systems such as hepatic cysts and intracranial aneurysms. ADPKD management has advanced considerably in recent years due to genetic testing availability, pre-implantation genetic diagnosis technology and new therapeutic agents. Renal disease in pregnancy is recognised as an important risk factor for adverse maternal and fetal outcome. Women with ADPKD and health professionals face multiple challenges in optimising outcomes during the pre-pregnancy, pregnancy and post-partum periods.
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Affiliation(s)
- Lucy McBride
- Women’s and Babies’ Division, Women’s and Children’s Hospital, Adelaide, SA, Australia
| | - Catherine Wilkinson
- Central and Northern Adelaide Renal and Transplantation Services (CNARTS), Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Shilpanjali Jesudason
- Central and Northern Adelaide Renal and Transplantation Services (CNARTS), Royal Adelaide Hospital, Adelaide, SA, Australia
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia
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10
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Attini R, Cabiddu G, Montersino B, Gammaro L, Gernone G, Moroni G, Santoro D, Spotti D, Masturzo B, Gazzani IB, Menato G, Donvito V, Paoletti AM, Piccoli GB. Contraception in chronic kidney disease: a best practice position statement by the Kidney and Pregnancy Group of the Italian Society of Nephrology. J Nephrol 2020; 33:1343-1359. [PMID: 32166655 PMCID: PMC7701165 DOI: 10.1007/s40620-020-00717-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Accepted: 02/25/2020] [Indexed: 01/09/2023]
Abstract
Even though fertility is reduced, conception and delivery are possible in all stages of CKD. While successful planned pregnancies are increasing, an unwanted pregnancy may have long-lasting deleterious effects, hence the importance of birth control, an issue often disregarded in clinical practice. The evidence summarized in this position statement is mainly derived from the overall population, or other patient categories, in the lack of guidelines specifically addressed to CKD. Oestroprogestagents can be used in early, non-proteinuric CKD, excluding SLE and immunologic disorders, at high risk of thromboembolism and hypertension. Conversely, progestin only is generally safe and its main side effect is intramestrual spotting. Non-medicated intrauterine devices are a good alternative; their use needs to be carefully evaluated in patients at a high risk of pelvic infection, even though the degree of risk remains controversial. Barrier methods, relatively efficacious when correctly used, have few risks, and condoms are the only contraceptives that protect against sexually transmitted diseases. Surgical sterilization is rarely used also because of the risks surgery involves; it is not definitely contraindicated, and may be considered in selected cases. Emergency contraception with high-dose progestins or intrauterine devices is not contraindicated but should be avoided whenever possible, even if far preferable to abortion. Surgical abortion is invasive, but experience with medical abortion in CKD is still limited, especially in the late stages of the disease. In summary, personalized contraception is feasible, safe and should be offered to all CKD women of childbearing age who do not want to get pregnant.
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Affiliation(s)
- Rossella Attini
- Department of Obstetrics and Gynecology, Città della Salute e della Scienza, Ospedale Sant'Anna, Turin, Italy
| | | | - Benedetta Montersino
- Department of Obstetrics and Gynecology, Città della Salute e della Scienza, Ospedale Sant'Anna, Turin, Italy
| | - Linda Gammaro
- Nephrology Ospedale Fracastoro San Bonifacio, San Bonifacio, Italy
| | | | - Gabriella Moroni
- Nephrology, Fondazione Ca' Granda Ospedale Maggiore, Milan, Italy
| | - Domenico Santoro
- Nephrology and Dialysis, Azienda Ospedaliera Universitaria "G. Martino", Messina, Italy
| | - Donatella Spotti
- Nephrology and Dialysis, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Bianca Masturzo
- Department of Obstetrics and Gynecology, Città della Salute e della Scienza, Ospedale Sant'Anna, Turin, Italy
| | - Isabella Bianca Gazzani
- Department of Obstetrics and Gynecology, Città della Salute e della Scienza, Ospedale Sant'Anna, Turin, Italy
| | - Guido Menato
- Department of Obstetrics and Gynecology, Città della Salute e della Scienza, Ospedale Sant'Anna, Turin, Italy
| | - Valentina Donvito
- Department of Internal Medicine, Ospedale Sant'Anna, Città della Salute e della Scienza, Turin, Italy
| | - Anna Maria Paoletti
- Department of Surgical Sciences, Obstetrics and Gynecology, University Hospital of Cagliari, Cagliari, Italy
| | - Giorgina Barbara Piccoli
- Department of Clinical and Biological Sciences, Università di Torino, Turin, Italy. .,Nephrology and Dialysis, Centre Hospitalier Le Mans, Le Mans, France.
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Abstract
Chronic kidney disease represents a heterogeneous group of disorders characterized by alterations in the structure and function of the kidney. Chronic kidney disease significantly increases the risk of adverse maternal and perinatal outcomes, and these risks increase with the severity of the underlying renal dysfunction, degree of proteinuria, as well as the frequent coexistence of hypertension. Further, renal anatomic changes result in dilatation of the collecting system, and physiologic adaptations include alterations in the balance of vasodilatory and vasoconstrictive hormones, resulting in decreased systemic and renal vascular resistance, increased glomerular filtration rate, and modifications in tubular function. These alterations have important clinical implications and can make the diagnosis of renal compromise challenging. The effect of pregnancy on kidney disease may manifest as a loss of renal function, particularly in the context of concomitant hypertension and proteinuria, and chronic kidney disease, even when mild, contributes to the high risk of adverse pregnancy outcomes, including increased risks of preeclampsia, preterm delivery, and small-for-gestational age neonates. Strategies for optimization of pregnancy outcomes include meticulous management of hypertension and proteinuria where possible and the initiation of preeclampsia prevention strategies, including aspirin. Avoidance of nephrotoxic and teratogenic medications is necessary, and renal dosing of commonly used medications must also be considered. Mode of delivery in women with chronic kidney disease should be based on usual obstetric indications, although more frequent prenatal assessments by an expert multidisciplinary team are desirable for the care of this particularly vulnerable patient population. Obstetricians represent a critical component of this team responsible for managing each stage of pregnancy to optimize both maternal and neonatal outcomes, but collaboration with nephrology colleagues in combined clinics wherein both specialists can make joint management decisions is typically very helpful.
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12
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Chronic kidney disease in pregnant mothers affects maternal and fetal disposition of mercury. Reprod Toxicol 2020; 93:137-145. [PMID: 32084500 DOI: 10.1016/j.reprotox.2020.02.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 01/23/2020] [Accepted: 02/10/2020] [Indexed: 11/22/2022]
Abstract
Chronic kidney disease (CKD) affects over 15 % of the adults in the United States. Pregnant women with CKD present an additional challenge in that they are at increased risk for adverse events such as preterm birth. Exposure to environmental toxicants, such as methylmercury, may exacerbate maternal disease and increase the risk of adverse fetal outcomes. We hypothesized that fetuses of mothers with CKD are more susceptible to accumulation of methylmercury than fetuses of healthy mothers. The current data show that when mothers are in a state of renal insufficiency, uptake of mercury in fetal kidneys is enhanced significantly. Accumulation of Hg in fetal kidneys may be related to the flow of amniotic fluid, maternal handling of Hg, and/or underdeveloped mechanisms for cellular export and urinary excretion. The results of this study indicate that renal insufficiency in mothers leads to significant alterations in the way toxicants such as mercury are handled by maternal and fetal organs.
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13
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Chronic kidney disease in preeclamptic patients: not found unless searched for—Is a nephrology evaluation useful after an episode of preeclampsia? J Nephrol 2019; 32:977-987. [DOI: 10.1007/s40620-019-00629-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 07/08/2019] [Indexed: 12/13/2022]
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14
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Pillay C, Clark K. Postpartum care of women with renal disease. Best Pract Res Clin Obstet Gynaecol 2019; 57:89-105. [PMID: 31122756 DOI: 10.1016/j.bpobgyn.2019.03.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 03/25/2019] [Indexed: 10/26/2022]
Abstract
Twenty-three percent of women with known chronic kidney disease (CKD) have been reported to demonstrate the first decline in kidney function between giving birth and six-weeks postpartum. As such, these women warrant close monitoring during the postpartum period irrespective of their pregnancy journey. Substantial haemodynamic variability during pregnancy and postpartum renders estimated glomerular filtration rate inaccurate, and poorly defined normal ranges of markers of kidney function at this time pose challenges for accurate assessment of renal complications. Multi-disciplinary specialist care is therefore essential, with consideration of specific implications of any known renal diagnosis and with observation for the development of postpartum complications of pregnancy. Furthermore, the postpartum period affords time to further investigate and diagnose kidney disease revealed by pregnancy. Good care planning and communication in the postpartum period has the potential to improve long-term health outcomes for women with known or new CKD and will be discussed in this review.
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Affiliation(s)
- Camilla Pillay
- Department of Renal Medicine, King's College Hospital, Denmark Hill, London, SE5 9RS, UK.
| | - Katherine Clark
- Antental Hypertension Clinic, King's College Hospital, 16-20, Windsor Walk, London, SE5 8BB, UK.
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15
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Rivera JCH, Pérez López MJ, Corzo Bermúdez CH, García Covarrubias L, Bermúdez Aceves LA, Chucuan Castillo CA, Mendoza MS, Piccoli GB, Sierra RP. Delayed Initiation of Hemodialysis in Pregnant Women with Chronic Kidney Disease: Logistical Problems Impact Clinical Outcomes. An Experience from an Emerging Country. J Clin Med 2019; 8:E475. [PMID: 30965626 PMCID: PMC6518183 DOI: 10.3390/jcm8040475] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 03/21/2019] [Accepted: 04/03/2019] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
| | | | | | | | | | | | - Mariana Salazar Mendoza
- Emergency Service, Hospital Regional "Lic. Adolfo López Mateos", ISSSTE, 01030 CdMx, México.
| | - Giorgina Barbara Piccoli
- Centre Hospitalier Le Mans, 72000 Le Mans, France.
- Department of Clinical and Biological Sciences, University of Torino, 10100 Torino, Italy.
| | - Ramón Paniagua Sierra
- Unidad de Investigación Médica en Enfermedades Nefrológicas, CMN Siglo XXI, 06720 CdMx, México.
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Wiles K, Bramham K, Seed PT, Kurlak LO, Mistry HD, Nelson-Piercy C, Lightstone L, Chappell LC. Diagnostic Indicators of Superimposed Preeclampsia in Women With CKD. Kidney Int Rep 2019; 4:842-853. [PMID: 31194119 PMCID: PMC6551530 DOI: 10.1016/j.ekir.2019.03.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 02/11/2019] [Accepted: 03/11/2019] [Indexed: 12/23/2022] Open
Abstract
Introduction Diagnosis of superimposed preeclampsia in women with chronic kidney disease (CKD) is complicated by the presence of hypertension and proteinuria due to renal disease. The aims of this study were to determine mechanistic links between superimposed preeclampsia and renin-angiotensin system activation, endothelial pathology, complement dysfunction, and tubular injury, and to explore the role of diagnostic indicators of superimposed preeclampsia. Methods Plasma and urinary biomarkers derived from the renin-angiotensin system (active renin, angiotensinogen), endothelial glycocalyx (hyaluronan, intercellular adhesion molecule, vascular cell adhesion molecule [VCAM], P-selectin, E-selectin), complement activation (C3a, C5a, complement factor H, C5b-9), and tubular injury (kidney injury molecule-1, urinary lipocalin-2) were quantified in 60 pregnant women with CKD including 15 women at the time of superimposed preeclampsia diagnosis and 45 women who did not develop superimposed preeclampsia, 18 women with preeclampsia, and 20 normal pregnancies. Correlation with placental growth factor was assessed. Results Plasma concentrations of hyaluronan (67.5 ng/ml vs. 27.5 ng/ml, P = 0.0017, receiver operating characteristic area 0.80) and VCAM (1132 ng/ml vs. 659 ng/ml, P < 0.0001, receiver operating characteristic area 0.86) distinguished women with CKD and superimposed preeclampsia from those without superimposed preeclampsia, and correlated with placental growth factor concentration. The diagnostic discrimination of markers of the renin-angiotensin system was reduced by adjustment for chronic hypertension, antihypertensive drug use, and black ethnicity. Other markers offered limited or no diagnostic discrimination for superimposed preeclampsia. Conclusion This study suggests that endothelial dysfunction contributes to the pathophysiology of superimposed preeclampsia and a diagnostic role for plasma hyaluronan and VCAM is hypothesized.
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Affiliation(s)
- Kate Wiles
- Department of Women and Children's Health, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - Kate Bramham
- Department of Renal Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Paul T Seed
- Department of Women and Children's Health, King's College London, London, UK
| | - Lesia O Kurlak
- Division of Child Health, Obstetrics & Gynaecology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Hiten D Mistry
- Division of Child Health, Obstetrics & Gynaecology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Catherine Nelson-Piercy
- Guy's and St Thomas' NHS Foundation Trust and Imperial College Healthcare NHS Trust, London, UK
| | - Liz Lightstone
- Imperial College London and Imperial College Healthcare NHS Trust, London, UK
| | - Lucy C Chappell
- Department of Women and Children's Health, King's College London, London, UK
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17
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Haseler E, Melhem N, Sinha MD. Renal disease in pregnancy: Fetal, neonatal and long-term outcomes. Best Pract Res Clin Obstet Gynaecol 2019; 57:60-76. [PMID: 30930143 DOI: 10.1016/j.bpobgyn.2019.01.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 12/19/2018] [Accepted: 01/21/2019] [Indexed: 12/17/2022]
Abstract
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.
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Affiliation(s)
- Emily Haseler
- Department of Paediatric Nephrology, Evelina London Children's Hospital, Guys & St Thomas NHS Foundation Trust, Westminster Bridge Road, London SE1 7EH, UK
| | - Nabil Melhem
- Department of Paediatric Nephrology, Evelina London Children's Hospital, Guys & St Thomas NHS Foundation Trust, Westminster Bridge Road, London SE1 7EH, UK
| | - Manish D Sinha
- Department of Paediatric Nephrology, Evelina London Children's Hospital, Guys & St Thomas NHS Foundation Trust, Westminster Bridge Road, London SE1 7EH, UK; Kings College London, UK.
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18
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Attini R, Montersino B, Leone F, Minelli F, Fassio F, Rossetti MM, Colla L, Masturzo B, Barreca A, Menato G, Piccoli GB. Dialysis or a Plant-Based Diet in Advanced CKD in Pregnancy? A Case Report and Critical Appraisal of the Literature. J Clin Med 2019; 8:jcm8010123. [PMID: 30669543 PMCID: PMC6352283 DOI: 10.3390/jcm8010123] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Revised: 01/07/2019] [Accepted: 01/08/2019] [Indexed: 02/07/2023] Open
Abstract
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.
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Affiliation(s)
- Rossella Attini
- Department of Obstetrics and Gynecology SC2U, Città della Salute e della Scienza-O.I.R.M., Sant'Anna Hospital, 10100 Turin, Italy.
| | - Benedetta Montersino
- Department of Obstetrics and Gynecology SC2U, Città della Salute e della Scienza-O.I.R.M., Sant'Anna Hospital, 10100 Turin, Italy.
| | - Filomena Leone
- Department of Surgery, Città della Salute e della Scienza-O.I.R.M., Sant'Anna Hospital, 10100 Turin, Italy.
| | - Fosca Minelli
- Department of Obstetrics and Gynecology SC2U, Città della Salute e della Scienza-O.I.R.M., Sant'Anna Hospital, 10100 Turin, Italy.
| | - Federica Fassio
- Department of Obstetrics and Gynecology SC2U, Città della Salute e della Scienza-O.I.R.M., Sant'Anna Hospital, 10100 Turin, Italy.
| | - Maura Maria Rossetti
- SCDU Nephrology, Città della Salute e della Scienza, University of Torino, 10100 Torino, Italy.
| | - Loredana Colla
- SCDU Nephrology, Città della Salute e della Scienza, University of Torino, 10100 Torino, Italy.
| | - Bianca Masturzo
- Department of Obstetrics and Gynecology SC2U, Città della Salute e della Scienza-O.I.R.M., Sant'Anna Hospital, 10100 Turin, Italy.
| | - Antonella Barreca
- Department of Medical Sciences, University of Torino, 10100 Torino, Italy.
| | - Guido Menato
- Department of Obstetrics and Gynecology SC2U, Città della Salute e della Scienza-O.I.R.M., Sant'Anna Hospital, 10100 Turin, Italy.
| | - Giorgina Barbara Piccoli
- Department of Biological and Clinical Sciences, University of Torino, 10100 Torino, Italy.
- Nephrology, Centre Hospitalier Le Mans, 72000 Le Mans, France.
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19
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Adverse maternal and fetal outcomes in pregnant patients with chronic kidney disease. Presentation of two cases in our clinic and literature review. GINECOLOGIA.RO 2019. [DOI: 10.26416/gine.24.2.2019.2373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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20
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Harville EW, Catov J, Lewis CE, Bibbins-Domingo K, Gunderson EP. Pre-pregnancy kidney function and subsequent adverse pregnancy outcomes. Pregnancy Hypertens 2019; 15:195-200. [PMID: 30825922 PMCID: PMC6484837 DOI: 10.1016/j.preghy.2019.01.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 01/09/2019] [Accepted: 01/28/2019] [Indexed: 01/07/2023]
Abstract
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.
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Affiliation(s)
- Emily W Harville
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, United States.
| | - Janet Catov
- University of Pittsburgh, Departments of OB/GYN and Epidemiology, Pittsburgh, PA, United States.
| | - C Elizabeth Lewis
- Department of Epidemiology, School of Public Health University of Alabama at Birmingham, Birmingham, AL, United States.
| | - Kirsten Bibbins-Domingo
- Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, CA, United States.
| | - Erica P Gunderson
- Cardiovascular and Metabolism Section, Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States.
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21
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Piccoli GB, Zakharova E, Attini R, Ibarra Hernandez M, Orozco Guillien A, Alrukhaimi M, Liu ZH, Ashuntantang G, Covella B, Cabiddu G, Li PKT, Garcia-Garcia G, Levin A. Pregnancy in Chronic Kidney Disease: Need for Higher Awareness. A Pragmatic Review Focused on What Could Be Improved in the Different CKD Stages and Phases. J Clin Med 2018; 7:E415. [PMID: 30400594 PMCID: PMC6262338 DOI: 10.3390/jcm7110415] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Revised: 10/28/2018] [Accepted: 10/31/2018] [Indexed: 02/07/2023] Open
Abstract
Pregnancy is possible in all phases of chronic kidney disease (CKD), but its management may be difficult and the outcomes are not the same as in the overall population. The prevalence of CKD in pregnancy is estimated at about 3%, as high as that of pre-eclampsia (PE), a better-acknowledged risk for adverse pregnancy outcomes. When CKD is known, pregnancy should be considered as high risk and followed accordingly; furthermore, since CKD is often asymptomatic, pregnant women should be screened for the presence of CKD, allowing better management of pregnancy, and timely treatment after pregnancy. The differential diagnosis between CKD and PE is sometimes difficult, but making it may be important for pregnancy management. Pregnancy is possible, even if at high risk for complications, including preterm delivery and intrauterine growth restriction, superimposed PE, and pregnancy-induced hypertension. Results in all phases are strictly dependent upon the socio-sanitary system and the availability of renal and obstetric care and, especially for preterm children, of intensive care units. Women on dialysis should be aware of the possibility of conceiving and having a successful pregnancy, and intensive dialysis (up to daily, long-hours dialysis) is the clinical choice allowing the best results. Such a choice may, however, need adaptation where access to dialysis is limited or distances are prohibitive. After kidney transplantation, pregnancies should be followed up with great attention, to minimize the risks for mother, child, and for the graft. A research agenda supporting international comparisons is highly needed to ameliorate or provide knowledge on specific kidney diseases and to develop context-adapted treatment strategies to improve pregnancy outcomes in CKD women.
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Affiliation(s)
- Giorgina B Piccoli
- Department of Clinical and Biological Sciences, University of Torino, 10100 Torino, Italy.
- Néphrologie, Centre Hospitalier Le Mans, 72000 Le Mans, France.
| | - Elena Zakharova
- Nephrology, Moscow City Hospital n.a. S.P. Botkin, 101000 Moscow, Russia.
- Nephrology, Moscow State University of Medicine and Dentistry, 101000 Moscow, Russia.
- Nephrology, Russian Medical Academy of Continuous Professional Education, 101000 Moscow, Russia.
| | - Rossella Attini
- Obstetrics, Department of Surgery, University of Torino, 10100 Torino, Italy.
| | - Margarita Ibarra Hernandez
- Nephrology Service, Hospital Civil de Guadalajara "Fray Antonio Alcalde", University of Guadalajara Health Sciences Center, Guadalajara, Jal 44100, Mexico.
| | | | - Mona Alrukhaimi
- Department of Medicine, Dubai Medical College, P.O. Box 20170, Dubai, UAE.
| | - Zhi-Hong Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing 210000, China. zhihong--
| | - Gloria Ashuntantang
- Yaounde General Hospital & Faculty of Medicine and Biomedical Sciences, University of Yaounde I, P.O. Box 337, Yaounde, Cameroon.
| | - Bianca Covella
- Néphrologie, Centre Hospitalier Le Mans, 72000 Le Mans, France.
| | | | - Philip Kam Tao Li
- Prince of Wales Hospital, Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong.
| | - Guillermo Garcia-Garcia
- Nephrology Service, Hospital Civil de Guadalajara "Fray Antonio Alcalde", University of Guadalajara Health Sciences Center, Guadalajara, Jal 44100, Mexico.
| | - Adeera Levin
- Department of Medicine, Division of Nephrology, University of British Columbia, Vancouver, BC V6T 1Z4, Canada.
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22
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Carosso A, Zonca M, Colla L, Borella F, Daniele L, Benedetto C. Pregnancy in a woman with recurrent immunoglobulin a nephropathy: A case report. Case Rep Womens Health 2018; 20:e00074. [PMID: 30225199 PMCID: PMC6138941 DOI: 10.1016/j.crwh.2018.e00074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Revised: 08/08/2018] [Accepted: 08/15/2018] [Indexed: 12/15/2022] Open
Abstract
Immunoglobulin A nephropathy (IgAN) is the most common form of primary glomerulonephritis and is increasingly encountered in pregnancy. The obstetric and renal outcomes of pregnancy are controversial, however. Women with IgAN are at higher risk of hypertension, preeclampsia and foetal loss; the prognosis is worse for those who have advanced chronic kidney disease and proteinuria. Here we report the case of a 32-year-old nulliparous woman with chronic hypertension who conceived during an active phase of her IgAN, which had been diagnosed 8 years earlier. Antihypertensive therapies and a low-protein diet were key to her reaching 34 weeks' gestation with acceptable kidney function. Rupture of membranes occurred at 34 weeks 3 days' gestation and a healthy boy was delivered the next day. This report aims to provide clinicians with useful information for the management of patients with IgAN during pregnancy.
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Affiliation(s)
- A. Carosso
- Department of Obstetrics and Gynaecology, Sant'Anna Hospital, University of Torino, Torino, Italy
| | - M. Zonca
- Department of Obstetrics and Gynaecology, Sant'Anna Hospital, University of Torino, Torino, Italy
| | - L. Colla
- SCDU Nephrology, Department Città della Salute e della Scienza, University of Torino, Torino, Italy
| | - F. Borella
- Department of Obstetrics and Gynaecology, Sant'Anna Hospital, University of Torino, Torino, Italy
| | - L. Daniele
- Pathology Unit, Mauriziano Hospital, Torino, Italy
| | - C. Benedetto
- Department of Obstetrics and Gynaecology, Sant'Anna Hospital, University of Torino, Torino, Italy
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23
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Cabiddu G, Spotti D, Gernone G, Santoro D, Moroni G, Gregorini G, Giacchino F, Attini R, Limardo M, Gammaro L, Todros T, Piccoli GB. A best-practice position statement on pregnancy after kidney transplantation: focusing on the unsolved questions. The Kidney and Pregnancy Study Group of the Italian Society of Nephrology. J Nephrol 2018; 31:665-681. [PMID: 29949013 PMCID: PMC6182355 DOI: 10.1007/s40620-018-0499-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 04/30/2018] [Indexed: 12/15/2022]
Abstract
Kidney transplantation (KT) is often considered to be the method best able to restore fertility in a woman with chronic kidney disease (CKD). However, pregnancies in KT are not devoid of risks (in particular prematurity, small for gestational age babies, and the hypertensive disorders of pregnancy). An ideal profile of the potential KT mother includes "normal" or "good" kidney function (usually defined as glomerular filtration rate, GFR ≥ 60 ml/min), scant or no proteinuria (usually defined as below 500 mg/dl), normal or well controlled blood pressure (one drug only and no sign of end-organ damage), no recent acute rejection, good compliance and low-dose immunosuppression, without the use of potentially teratogen drugs (mycophenolic acid and m-Tor inhibitors) and an interval of at least 1-2 years after transplantation. In this setting, there is little if any risk of worsening of the kidney function. Less is known about how to manage "non-ideal" situations, such as a pregnancy a short time after KT, or one in the context of hypertension or a failing kidney. The aim of this position statement by the Kidney and Pregnancy Group of the Italian Society of Nephrology is to review the literature and discuss what is known about the clinical management of CKD after KT, with particular attention to women who start a pregnancy in non-ideal conditions. While the experience in such cases is limited, the risks of worsening the renal function are probably higher in cases with markedly reduced kidney function, and in the presence of proteinuria. Well-controlled hypertension alone seems less relevant for outcomes, even if its effect is probably multiplicative if combined with low GFR and proteinuria. As in other settings of kidney disease, superimposed preeclampsia (PE) is differently defined and this impairs calculating its real incidence. No specific difference between non-teratogen immunosuppressive drugs has been shown, but calcineurin inhibitors have been associated with foetal growth restriction and low birth weight. The clinical choices in cases at high risk for malformations or kidney function impairment (pregnancies under mycophenolic acid or with severe kidney-function impairment) require merging clinical and ethical approaches in which, beside the mother and child dyad, the grafted kidney is a crucial "third element".
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Affiliation(s)
| | | | | | | | | | | | | | | | - Monica Limardo
- Azienda Ospedaliera della Provincia di Lecco, Lecco, Italy
| | | | - Tullia Todros
- Department of Surgery, Università di Torino, Turin, Italy
| | - Giorgina Barbara Piccoli
- Department of Clinical and Biological Sciences, Università di Torino, Turin, Italy.
- Centre Hospitalier Le Mans, Le Mans, France.
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24
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Leaños-Miranda A, Campos-Galicia I, Ramírez-Valenzuela KL, Berumen-Lechuga MG, Isordia-Salas I, Molina-Pérez CJ. Urinary IgM excretion: a reliable marker for adverse pregnancy outcomes in women with chronic kidney disease. J Nephrol 2018; 32:241-251. [PMID: 30206800 PMCID: PMC6423310 DOI: 10.1007/s40620-018-0536-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 08/22/2018] [Indexed: 02/06/2023]
Abstract
Objective Chronic kidney disease (CKD) pregnancies are at high risk of developing adverse outcomes. In non-pregnant subjects with CKD, higher urinary IgM levels are associated with poor renal survival and higher rates of cardiovascular deaths. In this study, we assessed whether urinary IgM levels are associated with an increased risk of adverse pregnancy outcomes (APO) in CKD pregnancies. Methods We performed a nested case–control study within a cohort of CKD patients with singleton pregnancies attended at a tertiary care hospital. The study included 90 CKD patients who eventually developed one or more APO and 77 CKD patients who did not. Urinary IgM excretion was determined from the 24-h urine samples at enrollment by an ultrasensitive enzyme immunoassay. Results The risk for combined APO and for preeclampsia (PE) was higher among women with urinary IgM and proteinuria levels values in the highest quartile or with CKD stages 4–5 (odds ratios, OR ≥ 2.9), compared with the lowest quartile or with CKD stage 1. Urinary IgM levels were more closely associated with the risk of either combined or specific APO (PE, preterm birth, and for having a small-for-gestational-age infant; OR ≥ 5.9) than either the degree of total proteinuria or CKD stages. Among patients with CKD stage 1, the risk of combined APO, PE, and preterm birth was higher in women with urinary IgM levels values in the highest quartile (OR ≥ 4.8), compared with the three lower quartiles, independently of proteinuria. Conclusion In CKD pregnancies, at the time of initial evaluation, proteinuria and CKD stage are associated with increased risk of combined APO. However, urinary IgM concentrations appear to be better predictors of an adverse outcome and may be useful for risk stratification in CKD pregnancies.
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Affiliation(s)
- Alfredo Leaños-Miranda
- Medical Research Unit in Reproductive Medicine, UMAE-Hospital de Ginecología y Obstetricia "Luis Castelazo Ayala", Instituto Mexicano del Seguro Social (IMSS), Don Luis # 111, Col. Nativitas, 03500, Mexico City, DF, Mexico.
| | - Inova Campos-Galicia
- Medical Research Unit in Reproductive Medicine, UMAE-Hospital de Ginecología y Obstetricia "Luis Castelazo Ayala", Instituto Mexicano del Seguro Social (IMSS), Don Luis # 111, Col. Nativitas, 03500, Mexico City, DF, Mexico
| | - Karla Leticia Ramírez-Valenzuela
- Division of Maternal-Fetal Medicine, UMAE-Hospital de Ginecología y Obstetricia "Luis Castelazo Ayala", Instituto Mexicano del Seguro Social (IMSS), Mexico City, Mexico
| | | | - Irma Isordia-Salas
- Medical Research Unit in Thrombosis, Hemostasia and Atherogenesis, H.G.R. No. 1 "Dr. Carlos Mac Gregor", IMSS, Mexico City, Mexico
| | - Carlos José Molina-Pérez
- Department of Obstetrics and Gynecology, Hospital General Regional No. 251 Metepec, IMSS, Metepec, Estado de México, Mexico
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25
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Piccoli GB, Alrukhaimi M, Zhi-Hong L, Zakharova E, Levin A. [What we do and do not know about women and kidney diseases; Questions unanswered and answers unquestioned: Reflection on World Kidney Day and International Woman's Day]. TERAPEVT ARKH 2018; 90:4-14. [PMID: 32598653 DOI: 10.26442/terarkh20189064-14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Indexed: 11/22/2022]
Abstract
On behalf of the World Kidney Day Steering Committee Chronic kidney disease affects approximately 10% of the world's adult population: it is within the top 20 causes of death worldwide, and its impact on patients and their families can be devastating. World Kidney Day and International Women's Day in 2018 coincide, thus offering an opportunity to reflect on the importance of women's health and specifically their kidney health, on the community, and the next generations, as well as to strive to be more curious about the unique aspects of kidney disease in women so that we may apply those learnings more broadly. Girls and women, who make up approximately 50% of the world's population, are important contributors to society and their families. Gender differences continue to exist around the world in access to education, medical care, and participation in clinical studies. Pregnancy is a unique state for women, offering an opportunity for diagnosis of kidney disease, but also a state where acute and chronic kidney diseases may manifest, and which may impact future generations with respect to kidney health. There are various autoimmune and other conditions that are more likely to impact women with profound consequences for child bearing, and on the fetus. Women have different complications on dialysis than men, and are more likely to be donors than recipients of kidney transplants. In this editorial, we focus on what we do and do not know about women, kidney health, and kidney disease, and what we might learn in the future to improve outcomes worldwide.
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Affiliation(s)
- G B Piccoli
- Department of Clinical and Biological Sciences, University of Torino, Torino, Italy.,Nephrology department, Centre Hospitalier Le Mans, Le Mans, France
| | - M Alrukhaimi
- Department of Medicine, Dubai Medical College, Dubai, United Arab Emirates
| | - L Zhi-Hong
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - E Zakharova
- Nephrology department, S.P. Botkin Moscow City Hospital, Moscow, Russia.,Department of Nephrology, A.I. Evdokimov Moscow State University of Medicine and Dentistry, Ministry of Health of Russia, Moscow, Russia.,Department of Nephrology, Russian Medical Academy of Continuous Professional Education, Ministry of Health of Russia
| | - A Levin
- Department of Medicine, Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
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26
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Piccoli G, Al Rukhaimi M, Liu ZH, Zakharova E, Levin A. What we know and do not know about women and kidney diseases; Questions unanswered and answers unquestioned: Reflection on World Kidney Day and International Woman's Day. Braz J Med Biol Res 2018; 51:e7315. [PMID: 29791583 PMCID: PMC5972021 DOI: 10.1590/1414-431x20177315] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 11/27/2017] [Indexed: 01/08/2023] Open
Abstract
Chronic kidney disease affects approximately 10% of the world's adult population: it is within the top 20 causes of death worldwide, and its impact on patients and their families can be devastating. World Kidney Day and International Women's Day in 2018 coincide, thus offering an opportunity to reflect on the importance of women's health and specifically women's kidney health on the community and the next generations, as well as to strive to be more curious about the unique aspects of kidney disease in women so that we may apply those learnings more broadly. Girls and women, who make up approximately 50% of the world's population, are important contributors to society and their families. Gender differences continue to exist around the world in access to education, medical care, and participation in clinical studies. Pregnancy is a unique state for women, offering an opportunity for diagnosis of kidney disease, but also a state in which acute and chronic kidney diseases may manifest, and which may impact future generations with respect to kidney health. Various autoimmune and other conditions are more likely to impact women, with profound consequences for child bearing and the fetus. Women have different complications on dialysis than men, and are more likely to be donors than recipients of kidney transplants. In this editorial, we focus on what we know and do not know about women, kidney health, and kidney disease, and what we might learn in the future to improve outcomes worldwide.
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Affiliation(s)
- G.B. Piccoli
- Department of Clinical and Biological Sciences, University of
Torino, Torino, Italy
- Nephrology, Centre Hospitalier Le Mans, Le Mans, France
| | - M. Al Rukhaimi
- Department of Medicine, Dubai Medical College, Dubai, United
Arab Emirates
| | - Zhi-Hong Liu
- National Clinical Research Center of Kidney Diseases, Jinling
Hospital, Nanjing University School of Medicine, Nanjing, China
| | - E. Zakharova
- Nephrology, Moscow City Hospital n.a. S.P. Botkin, Moscow,
Russian Federation
- Nephrology, Moscow State University of Medicine and Dentistry,
Moscow, Russian Federation
- Nephrology, Russian Medical Academy of Continuous Professional
Education, Moscow, Russian Federation
| | - A. Levin
- Department of Medicine, Division of Nephrology, University of
British Columbia, Vancouver, British Columbia, Canada
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Abstract
Women with chronic kidney disease (CKD) are at risk for adverse pregnancy-associated outcomes, including progression of their underlying renal dysfunction, a flare of their kidney disease, and adverse pregnancy complications such as preeclampsia and preterm delivery. Earlier-stage CKD, as a rule, is a safer time to have a pregnancy, but even women with end-stage kidney disease have attempted pregnancy in recent years. As such, nephrologists need to be comfortable with pregnancy preparation and management at all stages of CKD. In this article, we review the renal physiologic response to pregnancy and the literature with respect to both expected maternal and fetal outcomes among young women at various stages of CKD, including those who attempt to conceive while on dialysis. The general management of young women with CKD and associated complications, including hypertension and proteinuria are discussed. Finally, the emotional impact these pregnancies may have on young women with a chronic disease and the potential benefits of care in a multidisciplinary environment are highlighted.
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Piccoli GB, Alrukhaimi M, Liu ZH, Zakharova E, Levin A. What we do and do not know about women and kidney diseases: Questions unanswered and answers unquestioned : Reflection on World Kidney Day and International Woman's Day. Pediatr Nephrol 2018; 33:529-540. [PMID: 29497823 DOI: 10.1007/s00467-018-3917-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 01/23/2018] [Indexed: 10/17/2022]
Affiliation(s)
- Giorgina B Piccoli
- Department of Clinical and Biological Sciences, University of Torino, Torino, Italy.,Nephrology, Centre Hospitalier Le Mans, Le Mans, France
| | - Mona Alrukhaimi
- Department of Medicine, Dubai Medical College, Dubai, United Arab Emirates
| | - Zhi-Hong Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Elena Zakharova
- Nephrology, Moscow City Hospital n.a. S.P. Botkin, Moscow, Russian Federation.,Nephrology, Moscow State University of Medicine and Dentistry, Moscow, Russian Federation.,Nephrology, Russian Medical Academy of Continuous Professional Education, Moscow, Russian Federation
| | - Adeera Levin
- Department of Medicine, Division of Nephrology, University of British Columbia, Vancouver, BC, Canada.
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29
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Piccoli GB, Alrukhaimi M, Liu ZH, Zakharova E, Levin A. What we do and do not know about women and kidney diseases; Questions unanswered and answers unquestioned: Reflection on World Kidney Day and International Woman’s Day. Physiol Int 2018; 105:1-18. [DOI: 10.1556/2060.105.2018.1.6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Chronic kidney disease (CKD) affects approximately 10% of the world’s adult population; it is within the top 20 causes of death worldwide, and its impact on patients and their families can be devastating. World Kidney Day and International Women’s Day in 2018 coincide, thus offering an opportunity to reflect on the importance of women’s health and specifically their kidney health, on the community, and the next generations, as well as to strive to be more curious about the unique aspects of kidney disease in women so that we may apply those learnings more broadly. Girls and women, who make up approximately 50% of the world’s population, are important contributors to society and their families. Gender differences continue to exist around the world in access to education, medical care, and participation in clinical studies. Pregnancy is a unique state for women, which not only offers an opportunity for diagnosis of kidney disease, but also states where acute and chronic kidney diseases may manifest, and which may impact future generations with respect to kidney health. There are various autoimmune and other conditions that are more likely to impact women with profound consequences for childbearing, and on the fetus. Women have different complications on dialysis than men and are more likely to be donors than recipients of kidney transplants. In this editorial, we focus on what we do and do not know about women, kidney health, and kidney disease and what we might learn in the future to improve outcomes worldwide.
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Affiliation(s)
- GB Piccoli
- 1 Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
- 2 Department of Nephrology, Centre Hospitalier Le Mans, Le Mans, France
| | - M Alrukhaimi
- 3 Department of Medicine, Dubai Medical College, Dubai, United Arab Emirates
| | - Z-H Liu
- 4 National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - E Zakharova
- 5 Department of Nephrology, Moscow City Hospital n.a. S.P. Botkin, Moscow, Russian Federation
- 6 Department of Nephrology, Moscow State University of Medicine and Dentistry, Moscow, Russian Federation
- 7 Department of Nephrology, Russian Medical Academy of Continuous Professional Education, Moscow, Russian Federation
| | - A Levin
- 8 Division of Nephrology, Department of Medicine, The University of British Columbia, Vancouver, BC, Canada
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30
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Piccoli GB, Alrukhaimi M, Liu ZH, Zakharova E, Levin A. What we do and do not know about women and kidney diseases; questions unanswered and answers unquestioned: reflection on World Kidney Day and International Woman's Day. BMC Nephrol 2018; 19:66. [PMID: 29544451 PMCID: PMC5856379 DOI: 10.1186/s12882-018-0864-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 03/05/2018] [Indexed: 12/30/2022] Open
Abstract
Chronic Kidney Disease affects approximately 10% of the world's adult population: it is within the top 20 causes of death worldwide, and its impact on patients and their families can be devastating. World Kidney Day and International Women's Day in 2018 coincide, thus offering an opportunity to reflect on the importance of women's health and specifically their kidney health, on the community, and the next generations, as well as to strive to be more curious about the unique aspects of kidney disease in women so that we may apply those learnings more broadly.Girls and women, who make up approximately 50% of the world's population, are important contributors to society and their families. Gender differences continue to exist around the world in access to education, medical care, and participation in clinical studies. Pregnancy is a unique state for women, offering an opportunity for diagnosis of kidney disease, but also a state where acute and chronic kidney diseases may manifest, and which may impact future generations with respect to kidney health. There are various autoimmune and other conditions that are more likely to impact women with profound consequences for child bearing, and on the fetus. Women have different complications on dialysis than men, and are more likely to be donors than recipients of kidney transplants.In this editorial, we focus on what we do and do not know about women, kidney health, and kidney disease, and what we might learn in the future to improve outcomes worldwide.
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Affiliation(s)
- Giorgina B Piccoli
- Department of Clinical and Biological Sciences, University of Torino, Torino, Italy.,Nephrology, Centre Hospitalier Le Mans, Le Mans, France
| | - Mona Alrukhaimi
- Department of Medicine, Dubai Medical College, Dubai, United Arab Emirates
| | - Zhi-Hong Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Elena Zakharova
- Nephrology, Moscow City Hospital n.a. S.P. Botkin, Moscow, Russian Federation.,Nephrology, Moscow State University of Medicine and Dentistry, Moscow, Russian Federation.,Nephrology, Russian Medical Academy of Continuous Professional Education, Moscow, Russian Federation
| | - Adeera Levin
- Department of Medicine, Division of Nephrology, University of British Columbia, Vancouver, BC, Canada.
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31
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Piccoli GB, Alrukhaimi M, Liu ZH, Zakharova E, Levin A. What We Do and Do Not Know About Women and Kidney Diseases; Questions Unanswered and Answers Unquestioned: Reflection on World Kidney Day and International Woman's Day. Can J Kidney Health Dis 2018; 5:2054358118761656. [PMID: 29552348 PMCID: PMC5846917 DOI: 10.1177/2054358118761656] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 12/08/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Chronic kidney disease affects approximately 10% of the world's adult population: It is within the top 20 causes of death worldwide, and its impact on patients and their families can be devastating. World Kidney Day and International Women's Day in 2018 coincide, thus giving an occasion to reflect on open questions on the importance of kidney health in women for the present and the future generations. OBJECTIVES In this review, we summarize some aspects that are unique to women's kidney health, offering an opportunity to reflect on the importance of women's health and specifically their kidney health, on the community, and the next generations, as well as to strive to be more curious about the unique aspects of kidney disease in women so that we may apply those learnings more broadly. FINDINGS Girls and women, who make up approximately 50% of the world's population, are important contributors to society and their families. Gender differences continue to exist around the world in access to education, medical care, and participation in clinical studies. Pregnancy is not only a unique state for women, offering an opportunity for diagnosis of kidney disease, but also a state where acute and chronic kidney diseases may manifest, and which may impact future generations with respect to kidney health. There are various autoimmune and other conditions that are more likely to impact women with profound consequences for childbearing, and on the fetus. Women have different complications on dialysis than men, and are more likely to be donors than recipients of kidney transplants. CONCLUSION Improving knowledge on women, kidney health, and kidney disease, may be a way to improve outcomes of kidney diseases worldwide.
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Affiliation(s)
- Giorgina B. Piccoli
- Department of Clinical and Biological Sciences, University of Turin, Italy
- Nephrology, Centre Hospitalier–Le Mans, France
| | - Mona Alrukhaimi
- Department of Medicine, Dubai Medical College, United Arab Emirates
| | - Zhi-Hong Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, China
| | - Elena Zakharova
- Nephrology, Moscow City Hospital n.a. S.P. Botkin, Moscow, Russian Federation
- Nephrology, Moscow State University of Medicine and Dentistry, Russian Federation
- Nephrology, Russian Medical Academy of Continuous Professional Education, Moscow, Russian Federation
| | - Adeera Levin
- Department of Medicine, Division of Nephrology, University of British Columbia, Vancouver, Canada
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32
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Piccoli GB, Alrukhaimi M, Liu ZH, Zakharova E, Levin A. What We Do and Do Not Know about Women and Kidney Diseases: Questions Unanswered and Answers Unquestioned: Reflection on World Kidney Day and International Women's Day. Indian J Nephrol 2018; 28:87-96. [PMID: 29861556 PMCID: PMC5952463 DOI: 10.4103/ijn.ijn_81_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Affiliation(s)
- G. B. Piccoli
- Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
- Centre Hospitalier Le Mans, Le Mans, France
| | - M. Alrukhaimi
- Department of Medicine, Dubai Medical College, Dubai, United Arab Emirates
| | - Z. H. Liu
- National Clinical Research Center of Kidney Diseases, School of Medicine, Jinling Hospital, Nanjing University, Nanjing, China
| | - E. Zakharova
- Moscow City Hospital n.a. S.P. Botkin
- Moscow State University of Medicine and Dentistry
- Russian Medical Academy of Continuous Professional Education, Moscow, Russian Federation
| | - A. Levin
- Department of Medicine, Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
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33
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Piccoli GB, Alrukhaimi M, Liu ZH, Zakharova E, Levin A. Women and Kidney Diseases: Questions Unanswered and Answers Unquestioned. Kidney Int Rep 2018; 3:225-235. [PMID: 29725625 PMCID: PMC5932302 DOI: 10.1016/j.ekir.2018.01.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Giorgina B. Piccoli
- Department of Clinical and Biological Sciences, University of Torino, Italy
- Nephrology, Centre Hospitalier Le Mans, Le Mans, France
| | - Mona Alrukhaimi
- Department of Medicine, Dubai Medical College, Dubai, United Arab Emirates
| | - Zhi-Hong Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Elena Zakharova
- Nephrology, Moscow City Hospital n.a. S.P. Botkin, Moscow, Russian Federation
- Nephrology, Moscow State University of Medicine and Dentistry, Moscow, Russian Federation
- Nephrology, Russian Medical Academy of Continuous Professional Education, Moscow, Russian Federation
| | - Adeera Levin
- Department of Medicine, Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
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34
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Piccoli GB, Alrukhaimi M, Liu ZH, Zakharova E, Levin A. What we do and do not know about women and kidney diseases - questions unanswered and answers unquestioned: Reflection on World Kidney Day and International Woman’s Day. Nephrology (Carlton) 2018; 23:199-209. [DOI: 10.1111/nep.13193] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2017] [Indexed: 12/11/2022]
Affiliation(s)
- Giorgina B Piccoli
- Department of Clinical and Biological Sciences; University of Torino; Torino Italy
- Nephrology; Centre Hospitalier Le Mans; Le Mans France
| | - Mona Alrukhaimi
- Department of Medicine; Dubai Medical College; Dubai United Arab Emirates
| | - Zhi-Hong Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital; Nanjing University School of Medicine; Nanjing China
| | - Elena Zakharova
- Nephrology Department; Moscow City Hospital n.a. S.P. Botkin; Moscow Russian Federation
- Chair of Nephrology; Moscow State University of Medicine and Dentistry; Moscow Russian Federation
- Chair of Nephrology; Russian Medical Academy of Continuous Professional Education; Moscow Russian Federation
| | - Adeera Levin
- Division of Nephrology, Department of Medicine; University of British Columbia; Vancouver British Columbia Canada
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35
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Piccoli GB, Alrukhaimi M, Liu ZH, Zakharova E, Levin A. What We Do and Do Not Know about Women and Kidney Diseases; Questions Unanswered and Answers Unquestioned: Reflection on World Kidney Day and International Women's Day. Am J Nephrol 2018; 47:103-114. [PMID: 29455210 DOI: 10.1159/000486408] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Chronic kidney disease affects approximately 10% of the world's adult population: it is within the top 20 causes of death worldwide, and its impact on patients and their families can be devastating. World Kidney Day and International Women's Day in 2018 coincide, thus offering an opportunity to reflect on the importance of women's health and specifically their kidney health, on the community and the next generations, as well as to strive to be more curious about the unique aspects of kidney disease in women so that we may apply those learnings more broadly. Girls and women, who make up approximately 50% of the world's population, are important contributors to society and their families. Gender differences continue to exist around the world in access to education, medical care, and participation in clinical studies. Pregnancy is a unique state for women, offering an opportunity for diagnosis of kidney disease, but also a state where acute and chronic kidney diseases may manifest, and which may impact future generations with respect to kidney health. There are various autoimmune and other conditions that are more likely to have an impact on women, with profound consequences for child bearing, and on the fetus. Women have different complications on dialysis than men, and are more likely to be donors than recipients of kidney transplants. In this editorial, we focus on what we do and do not know about women, kidney health, and kidney disease, and what we might learn in the future to improve outcomes worldwide.
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Affiliation(s)
- Giorgina B Piccoli
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
- Nephrology, Centre Hospitalier Le Mans, Le Mans, France
| | - Mona Alrukhaimi
- Department of Medicine, Dubai Medical College, Dubai, United Arab Emirates
| | - Zhi-Hong Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Elena Zakharova
- Nephrology, Moscow City Hospital n.a. S.P., Moscow, Russian Federation
- Nephrology, Moscow State University of Medicine and Dentistry, Moscow, Russian Federation
- Nephrology, Russian Medical Academy of Continuous Professional Education, Moscow, Russian Federation
| | - Adeera Levin
- Division of Nephrology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| |
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36
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Piccoli GB, Alrukhaimi M, Liu ZH, Zakharova E, Levin A. What we do and do not know about women and kidney diseases; questions unanswered and answers unquestioned: reflection on World Kidney Day and International Women's Day. J Nephrol 2018; 31:173-184. [PMID: 29464527 DOI: 10.1007/s40620-018-0474-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 01/15/2018] [Indexed: 02/08/2023]
Abstract
Chronic Kidney Disease affects approximately 10% of the world's adult population: it is within the top 20 causes of death worldwide, and its impact on patients and their families can be devastating. World Kidney Day and International Women's Day in 2018 coincide, thus offering an opportunity to reflect on the importance of women's health and specifically their kidney health, on the community, and the next generations, as well as to strive to be more curious about the unique aspects of kidney disease in women so that we may apply those learnings more broadly. Girls and women, who make up approximately 50% of the world's population, are important contributors to society and their families. Gender differences continue to exist around the world in access to education, medical care, and participation in clinical studies. Pregnancy is a unique state for women, offering an opportunity for diagnosis of kidney disease, but also a state where acute and chronic kidney diseases may manifest, and which may impact future generations with respect to kidney health. There are various autoimmune and other conditions that are more likely to impact women with profound consequences for child bearing, and on the fetus. Women have different complications on dialysis than men, and are more likely to be donors than recipients of kidney transplants. In this editorial, we focus on what we do and do not know about women, kidney health, and kidney disease, and what we might learn in the future to improve outcomes worldwide.
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Affiliation(s)
- Giorgina Barbara Piccoli
- Department of Clinical and Biological Sciences, University of Torino, Turin, Italy.,Nephrology, Centre Hospitalier Le Mans, Le Mans, France
| | - Mona Alrukhaimi
- Department of Medicine, Dubai Medical College, Dubai, United Arab Emirates
| | - Zhi-Hong Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Elena Zakharova
- Nephrology, Moscow City Hospital n.a. S.P. Botkin, Moscow, Russian Federation.,Nephrology, Moscow State University of Medicine and Dentistry, Moscow, Russian Federation.,Nephrology, Russian Medical Academy of Continuous Professional Education, Moscow, Russian Federation
| | - Adeera Levin
- Division of Nephrology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
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37
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Piccoli GB, Alrukhaimi M, Liu ZH, Zakharova E, Levin A. What We Do and Do Not Know about Women and Kidney Diseases; Questions Unanswered and Answers Unquestioned: Reflection on World Kidney Day and International Woman's Day. Blood Purif 2018; 45:364-375. [PMID: 29478067 DOI: 10.1159/000484686] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 10/31/2017] [Indexed: 12/18/2022]
Abstract
Chronic kidney disease affects approximately 10% of the world's adult population: it is within the top 20 causes of death worldwide, and its impact on patients and their families can be devastating. World Kidney Day and International Women's Day in 2018 coincide, thus offering an opportunity to reflect on the importance of women's health and specifically their kidney health, on the community and the next generations, as well as to strive to be more curious about the unique aspects of kidney disease in women so that we may apply those learnings more broadly. Girls and women, who make up approximately 50% of the world's population, are important contributors to society and their families. Gender differences continue to exist around the world in access to education, medical care, and participation in clinical studies. Pregnancy is a unique state for women, offering an opportunity for diagnosis of kidney disease, but also a state where acute and chronic kidney diseases may manifest, and which may impact future generations with respect to kidney health. There are various autoimmune and other conditions that are more likely to have an impact on women, with profound consequences for child bearing, and on the fetus. Women have different complications on dialysis than men, and are more likely to be donors than recipients of kidney transplants. In this editorial, we focus on what we do and do not know about women, kidney health, and kidney disease, and what we might learn in the future to improve outcomes worldwide.
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Affiliation(s)
- Giorgina B Piccoli
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy.,Nephrology, Centre Hospitalier Le Mans, Le Mans, France
| | - Mona Alrukhaimi
- Department of Medicine, Dubai Medical College, Dubai, United Arab Emirates
| | - Zhi-Hong Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Elena Zakharova
- Nephrology, Moscow City Hospital n.a. S.P., Moscow, Russian Federation.,Nephrology, Moscow State University of Medicine and Dentistry, Moscow, Russian Federation.,Nephrology, Russian Medical Academy of Continuous Professional Education, Moscow, Russian Federation
| | - Adeera Levin
- Division of Nephrology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | | |
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38
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Piccoli GB, Alrukhaimi M, Liu ZH, Zakharova E, Levin A. What We Do and Do Not Know About Women and Kidney Diseases; Questions Unanswered and Answers Unquestioned: Reflection on World Kidney Day and International Woman's Day. Am J Hypertens 2018; 31:375-384. [PMID: 29438477 DOI: 10.1093/ajh/hpx218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Giorgina B Piccoli
- Department of Clinical and Biological Sciences, University of Torino, Turin, Italy
- Nephrology, Centre Hospitalier Le Mans, Le Mans, France
| | - Mona Alrukhaimi
- Department of Medicine, Dubai Medical College, Dubai, United Arab Emirates
| | - Zhi-Hong Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Elena Zakharova
- Department of Nephrology, Moscow City Hospital n.a. S.P. Botkin, Moscow, Russian Federation
- Department of Nephrology, Moscow State University of Medicine and Dentistry, Moscow, Russian Federation
- Department of Nephrology, Russian Medical Academy of Continuous Professional Education, Moscow, Russian Federation
| | - Adeera Levin
- Department of Medicine, Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
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39
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Piccoli GB, Alrukhaimi M, Liu ZH, Zakharova E, Levin A. What we know and do not know about women and kidney diseases: questions unanswered and answers unquestioned: reflection on World Kidney Day and International Women's Day. Intern Med J 2018; 48:113-123. [PMID: 29415356 DOI: 10.1111/imj.13694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 11/20/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Giorgina B Piccoli
- Department of Clinical and Biological Sciences, University of Torino, Torino, Italy.,Department of Nephrology, Centre Hospitalier Le Mans, Le Mans, France
| | - Mona Alrukhaimi
- Department of Medicine, Dubai Medical College, Dubai, United Arab Emirates
| | - Zhi-Hong Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Elena Zakharova
- Department of Nephrology, Moscow City Hospital S.P. Botkin, Moscow, Russia.,Department of Nephrology, Moscow State University of Medicine and Dentistry, Moscow, Russia.,Department of Nephrology, Russian Medical Academy of Continuous Professional Education, Moscow, Russia
| | - Adeera Levin
- Department of Medicine, Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
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40
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Piccoli GB, Alrukhaimi M, Liu ZH, Zakharova E, Levin A. What We Do and Do Not Know about Women and Kidney Diseases; Questions Unanswered and Answers Unquestioned: Reflection on World Kidney Day and International Women's Day. KIDNEY DISEASES (BASEL, SWITZERLAND) 2018; 4:37-48. [PMID: 29594141 PMCID: PMC5848484 DOI: 10.1159/000485269] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Chronic kidney disease affects approximately 10$ of the world's adult population: it is within the top 20 causes of death worldwide, and its impact on patients and their families can be devastating. World Kidney Day and International Women's Day in 2018 coincide, thus offering an opportunity to reflect on the importance of women's health and specifically their kidney health, on the community and the next generations, as well as to strive to be more curious about the unique aspects of kidney disease in women so that we may apply those learnings more broadly. Girls and women, who make up approximately 50$ of the world's population, are important contributors to society and their families. Gender differences continue to exist around the world in access to education, medical care, and participation in clinical studies. Pregnancy is a unique state for women, offering an opportunity for diagnosis of kidney disease, but also a state where acute and chronic kidney diseases may manifest, and which may impact future generations with respect to kidney health. There are various autoimmune and other conditions that are more likely to have an impact on women, with profound consequences for child bearing, and on the fetus. Women have different complications on dialysis than men, and are more likely to be donors than recipients of kidney transplants. In this editorial, we focus on what we do and do not know about women, kidney health, and kidney disease, and what we might learn in the future to improve outcomes worldwide.
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Affiliation(s)
- Giorgina B. Piccoli
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
- Nephrology, Centre Hospitalier Le Mans, Le Mans, France
| | | | - Zhi-Hong Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Elena Zakharova
- Nephrology, Moscow City Hospital n.a. S.P. Botkin, Moscow State University of Medicine and Dentistry, Moscow, Russia
- Nephrology, Moscow State University of Medicine and Dentistry, Moscow, Russia
- Nephrology, Russian Medical Academy of Continuous Professional Education, Moscow, Russia
| | - Adeera Levin
- Division of Nephrology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
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Attini R, Leone F, Montersino B, Fassio F, Minelli F, Colla L, Rossetti M, Rollino C, Alemanno MG, Barreca A, Todros T, Piccoli GB. Pregnancy, Proteinuria, Plant-Based Supplemented Diets and Focal Segmental Glomerulosclerosis: A Report on Three Cases and Critical Appraisal of the Literature. Nutrients 2017; 9:E770. [PMID: 28753930 PMCID: PMC5537884 DOI: 10.3390/nu9070770] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Revised: 07/06/2017] [Accepted: 07/10/2017] [Indexed: 11/16/2022] Open
Abstract
Chronic kidney disease (CKD) is increasingly recognized in pregnant patients. Three characteristics are associated with a risk of preterm delivery or small for gestational age babies; kidney function reduction, hypertension, and proteinuria. In pregnancy, the anti-proteinuric agents (ACE-angiotensin converting enzyme-inhibitors or ARBS -angiotensin receptor blockers) have to be discontinued for their potential teratogenicity, and there is no validated approach to control proteinuria. Furthermore, proteinuria usually increases as an effect of therapeutic changes and pregnancy-induced hyperfiltration. Based on a favourable effect of low-protein diets on proteinuria and advanced CKD, our group developed a moderately protein-restricted vegan-vegetarian diet tsupplemented with ketoacids and aminoacids for pregnant patients. This report describes the results obtained in three pregnant patients with normal renal function, nephrotic or sub-nephrotic proteinuria, and biopsy proven diagnosis of focal segmental glomerulosclerosis, a renal lesion in which hyperfiltration is considered of pivotal importance (case 1: GFR (glomerular filtration rate): 103 mL/min; proteinuria 2.1 g/day; albumin 3.2 g/dL; case 2: GFR 86 mL/min, proteinuria 3.03 g/day, albumin 3.4 g/dL; case 3: GFR 142 mL/min, proteinuria 6.3 g/day, albumin 3.23 g/dL). The moderately restricted diet allowed a stabilisation of proteinuria in two cases and a decrease in one. No significant changes in serum creatinine and serum albumin were observed. The three babies were born at term (38 weeks + 3 days, female, weight 3180 g-62th centile; 38 weeks + 2 days, female, weight 3300 g-75th centile; male, 38 weeks + 1 day; 2770 g-8th centile), thus reassuring us of the safety of the diet. In summary, based on these three cases studies and a review of the literature, we suggest that a moderately protein-restricted, supplemented, plant-based diet might contribute to controlling proteinuria in pregnant CKD women with focal segmental glomerulosclerosis. However further studies are warranted to confirm the potential value of such a treatment strategy.
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Affiliation(s)
- Rossella Attini
- Materno-Foetal Unit, Department of Surgery, University of Torino, 10100 Turin, Italy.
| | - Filomena Leone
- Materno-Foetal Unit, Department of Surgery, University of Torino, 10100 Turin, Italy.
| | - Benedetta Montersino
- Materno-Foetal Unit, Department of Surgery, University of Torino, 10100 Turin, Italy.
| | - Federica Fassio
- Materno-Foetal Unit, Department of Surgery, University of Torino, 10100 Turin, Italy.
| | - Fosca Minelli
- Materno-Foetal Unit, Department of Surgery, University of Torino, 10100 Turin, Italy.
| | - Loredana Colla
- SCDU Nephrology, Città della Salute e della Scienza, University of Torino, 10100 Turin, Italy.
| | - Maura Rossetti
- SCDU Nephrology, Città della Salute e della Scienza, University of Torino, 10100 Turin, Italy.
| | - Cristiana Rollino
- SCDU Nephrology, Giovanni Bosco Hospital, University of Torino, 10100 Turin, Italy.
| | - Maria Grazia Alemanno
- Materno-Foetal Unit, Department of Surgery, University of Torino, 10100 Turin, Italy.
| | - Antonella Barreca
- Department of Medical Sciences, University of Torino, 10100 Turin, Italy.
| | - Tullia Todros
- Materno-Foetal Unit, Department of Surgery, University of Torino, 10100 Turin, Italy.
| | - Giorgina Barbara Piccoli
- Department of Biological and Clinical Sciences, University of Torino, 10100 Turin, Italy.
- Nephrology, Centre Hospitalier Le Mans, 72000 Le Mans, France.
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Maternal-foetal outcomes in pregnant women with glomerulonephritides. Are all glomerulonephritides alike in pregnancy? J Autoimmun 2017; 79:91-98. [DOI: 10.1016/j.jaut.2017.01.008] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Revised: 01/27/2017] [Accepted: 01/31/2017] [Indexed: 11/23/2022]
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Piccoli GB, Cabiddu G, Castellino S, Gernone G, Santoro D, Moroni G, Spotti D, Giacchino F, Attini R, Limardo M, Maxia S, Fois A, Gammaro L, Todros T. A best practice position statement on the role of the nephrologist in the prevention and follow-up of preeclampsia: the Italian study group on kidney and pregnancy. J Nephrol 2017; 30:307-317. [PMID: 28434090 DOI: 10.1007/s40620-017-0390-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 03/09/2017] [Indexed: 02/07/2023]
Abstract
Preeclampsia (PE) is a protean syndrome causing a transitory kidney disease, characterised by hypertension and proteinuria, ultimately reversible after delivery. Its prevalence is variously estimated, from 3 to 5% to 10% if all the related disorders, including also pregnancy-induced hypertension (PIH) and HELLP syndrome (haemolysis, increase in liver enzyme, low platelets) are included. Both nephrologists and obstetricians are involved in the management of the disease, according to different protocols, and the clinical management, as well as the role for each specialty, differs worldwide. The increased awareness of the role of chronic kidney disease in pregnancy, complicating up to 3% of pregnancies, and the knowledge that PE is associated with an increased risk for development of CKD later in life have recently increased the interest and redesigned the role of the nephrologists in this context. However, while the heterogeneous definitions of PE, its recent reclassification, an emerging role for biochemical biomarkers, the growing body of epidemiological data and the new potential therapeutic interventions lead to counsel long-term follow-up, the lack of resources for chronic patients and the increasing costs of care limit the potential for preventive actions, and suggest tailoring specific interventional strategies. The aim of the present position statement of the Kidney and Pregnancy Study Group of the Italian Society of Nephrology is to review the literature and to try to identify theoretical and pragmatic bases for an agreed management of PE in the nephrological setting, with particular attention to the prevention of the syndrome (recurrent PE, presence of baseline CKD) and to the organization of the postpartum follow-up.
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Affiliation(s)
- Giorgina Barbara Piccoli
- Department of Clinical and Biological Sciences, University of Torino, Turin, Italy. .,Nephrologie, Centre Hospitalier Le Mans, Avenue Roubillard, 72000, Le Mans, France.
| | | | | | | | | | - Gabriella Moroni
- Nephrology, Fondazione Ca' Granda Ospedale Maggiore, Milan, Italy
| | - Donatella Spotti
- Nephrology and Dialysis, IRCCS Ospedale San Raffaele, Milano, Italy
| | | | - Rossella Attini
- Obstetrics, Department of Surgery, University of Torino, Turin, Italy
| | - Monica Limardo
- Nephrology, Azienda Ospedaliera della Provincia di Lecco, Lecco, Italy
| | | | - Antioco Fois
- Nephrology, Azienda Ospedaliera Brotzu, Cagliari, Italy
| | - Linda Gammaro
- Nephrology Ospedale Fracastoro San Bonifacio, San Bonifacio, Italy
| | - Tullia Todros
- Obstetrics, Department of Surgery, University of Torino, Turin, Italy
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Hypertension in CKD Pregnancy: a Question of Cause and Effect (Cause or Effect? This Is the Question). Curr Hypertens Rep 2016; 18:35. [PMID: 27072828 DOI: 10.1007/s11906-016-0644-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Chronic kidney disease (CKD) is increasingly encountered in pregnancy, and hypertension is frequently concomitant. In pregnancy, the prevalence of CKD is estimated to be about 3%, while the prevalence of chronic hypertension is about 5-8%. The prevalence of hypertension and CKD in pregnancy is unknown. Both are independently related to adverse pregnancy outcomes, and the clinical picture merges with pregnancy-induced hypertension and preeclampsia. Precise risk quantification is not available, but risks linked to CKD stage, hypertension, and proteinuria are probably multiplicative, each at least doubling the rates of preterm and early preterm delivery, small for gestational age babies, and related outcomes. Differential diagnosis (based upon utero-placental flows, fetal growth, and supported by serum biomarkers) is important for clinical management. In the absence of guidelines for hypertension in CKD pregnancies, the ideal blood pressure goal has not been established; we support a tailored approach, depending on compliance, baseline control, and CKD stages, with strict blood pressure monitoring. The choice of antihypertensive drugs and the use of diuretics and of erythropoiesis-stimulating agents (ESAs) are still open questions which only future studies may clarify.
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Piccoli GB, Cabiddu G, Attini R, Gerbino M, Todeschini P, Perrino ML, Manzione AM, Piredda GB, Gnappi E, Caputo F, Montagnino G, Bellizzi V, Di Loreto P, Martino F, Montanaro D, Rossini M, Castellino S, Biolcati M, Fassio F, Loi V, Parisi S, Versino E, Pani A, Todros T. Pregnancy outcomes after kidney graft in Italy: are the changes over time the result of different therapies or of different policies? A nationwide survey (1978–2013). Nephrol Dial Transplant 2016; 31:1957-1965. [DOI: 10.1093/ndt/gfw232] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Attini R, Leone F, Parisi S, Fassio F, Capizzi I, Loi V, Colla L, Rossetti M, Gerbino M, Maxia S, Alemanno MG, Minelli F, Piccoli E, Versino E, Biolcati M, Avagnina P, Pani A, Cabiddu G, Todros T, Piccoli GB. Vegan-vegetarian low-protein supplemented diets in pregnant CKD patients: fifteen years of experience. BMC Nephrol 2016; 17:132. [PMID: 27649693 PMCID: PMC5029029 DOI: 10.1186/s12882-016-0339-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 08/29/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Pregnancy in women with advanced CKD becoming increasingly common. However, experience with low-protein diets in CKD patients in pregnancy is still limited. Aim of this study is to review the results obtained over the last 15 years with moderately restricted low-protein diets in pregnant CKD women (combining: CKD stages 3-5, proteinuria: nephrotic at any time, or > =1 g/24 at start or referral; nephrotic in previous pregnancy). CKD patients on unrestricted diets were employed for comparison. METHODS STUDY PERIOD January, 2000 to September, 2015: 36 on-diet pregnancies (31 singleton deliveries, 3 twin deliveries, 1 pregnancy termination, 1 miscarriage); 47 controls (42 singleton deliveries, 5 miscarriages). The diet is basically vegan; since occasional milk and yoghurt are allowed, we defined it vegan-vegetarian; protein intake (0.6-0.8 g/Kg/day), keto-acid supplementation, protein-unrestricted meals (1-3/week) are prescribed according to CKD stage and nutritional status. Statistical analysis was performed as implemented on SPSS. RESULTS Patients and controls were similar (p: ns) at baseline with regard to age (33 vs 33.5), referral week (7 vs 9), kidney function (CKD 3-5: 48.4 % vs 64.3 %); prevalence of hypertension (51.6 % vs 40.5 %) and proteinuria >3 g/24 h (16.1 % vs 12.2 %). There were more diabetic nephropathies in on-diet patients (on diet: 31.0 % vs controls 5.3 %; p 0.007 (Fisher)) while lupus nephropathies were non-significantly higher in controls (on diet: 10.3 % vs controls 23.7 %; p 0.28 (Fisher)). The incidence of preterm delivery was similar (<37 weeks: on-diet singletons 77.4 %; controls: 71.4 %). The incidence of other adverse pregnancy related outcomes was non-significantly lower in on-diet patients (early preterm delivery: on diet: 32.3 % vs controls 35.7 %; birth-weight = <1.500 g: on diet: 9.7 % vs controls 23.8 %). None of the singletons in the on-diet series died, while two perinatal deaths occurred among the controls (p = 0.505). The incidence of small for gestational age (SGA <10th centile) and/or extremely preterm babies (<28th week) was significantly lower in singletons from on-diet mothers than in controls (on diet: 12.9 % vs controls: 33.3 %; p: 0.04 (Fisher)). CONCLUSION Moderate protein restriction in the context of a vegan-vegetarian supplemented diet is confirmed as a safe option in the management of pregnant CKD patients.
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Affiliation(s)
- Rossella Attini
- SS Nephrology, SCDU Urology, AOU San Luigi, Orbassano, Italy
- SS Epidemiology, University of Torino, Torino, Italy
- SSD Clinical Nutrition, Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
- SCD Nephrology, Brotzu Hospital, Cagliari, Italy
- SCDU Nephrology, Department Città della Salute e della Scienza, University of Torino, Torino, Italy
- SS Nephrology, Department of Clinical and Biological Sciences, University of Torino, Regione Gonzole 10, Orbassano, Torino 10100 Italy
- Nèphrologie, CH du Mans, Le Mans, France
| | - Filomena Leone
- SS Nephrology, SCDU Urology, AOU San Luigi, Orbassano, Italy
- SS Epidemiology, University of Torino, Torino, Italy
- SSD Clinical Nutrition, Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
- SCD Nephrology, Brotzu Hospital, Cagliari, Italy
- SCDU Nephrology, Department Città della Salute e della Scienza, University of Torino, Torino, Italy
- SS Nephrology, Department of Clinical and Biological Sciences, University of Torino, Regione Gonzole 10, Orbassano, Torino 10100 Italy
- Nèphrologie, CH du Mans, Le Mans, France
| | - Silvia Parisi
- SS Nephrology, SCDU Urology, AOU San Luigi, Orbassano, Italy
- SS Epidemiology, University of Torino, Torino, Italy
- SSD Clinical Nutrition, Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
- SCD Nephrology, Brotzu Hospital, Cagliari, Italy
- SCDU Nephrology, Department Città della Salute e della Scienza, University of Torino, Torino, Italy
- SS Nephrology, Department of Clinical and Biological Sciences, University of Torino, Regione Gonzole 10, Orbassano, Torino 10100 Italy
- Nèphrologie, CH du Mans, Le Mans, France
| | - Federica Fassio
- SS Nephrology, SCDU Urology, AOU San Luigi, Orbassano, Italy
- SS Epidemiology, University of Torino, Torino, Italy
- SSD Clinical Nutrition, Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
- SCD Nephrology, Brotzu Hospital, Cagliari, Italy
- SCDU Nephrology, Department Città della Salute e della Scienza, University of Torino, Torino, Italy
- SS Nephrology, Department of Clinical and Biological Sciences, University of Torino, Regione Gonzole 10, Orbassano, Torino 10100 Italy
- Nèphrologie, CH du Mans, Le Mans, France
| | - Irene Capizzi
- SS Nephrology, SCDU Urology, AOU San Luigi, Orbassano, Italy
| | | | - Loredana Colla
- SCDU Nephrology, Department Città della Salute e della Scienza, University of Torino, Torino, Italy
| | - Maura Rossetti
- SCDU Nephrology, Department Città della Salute e della Scienza, University of Torino, Torino, Italy
| | - Martina Gerbino
- SS Nephrology, SCDU Urology, AOU San Luigi, Orbassano, Italy
- SS Epidemiology, University of Torino, Torino, Italy
- SSD Clinical Nutrition, Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
- SCD Nephrology, Brotzu Hospital, Cagliari, Italy
- SCDU Nephrology, Department Città della Salute e della Scienza, University of Torino, Torino, Italy
- SS Nephrology, Department of Clinical and Biological Sciences, University of Torino, Regione Gonzole 10, Orbassano, Torino 10100 Italy
- Nèphrologie, CH du Mans, Le Mans, France
| | | | - Maria Grazia Alemanno
- SS Nephrology, SCDU Urology, AOU San Luigi, Orbassano, Italy
- SS Epidemiology, University of Torino, Torino, Italy
- SSD Clinical Nutrition, Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
- SCD Nephrology, Brotzu Hospital, Cagliari, Italy
- SCDU Nephrology, Department Città della Salute e della Scienza, University of Torino, Torino, Italy
- SS Nephrology, Department of Clinical and Biological Sciences, University of Torino, Regione Gonzole 10, Orbassano, Torino 10100 Italy
- Nèphrologie, CH du Mans, Le Mans, France
| | - Fosca Minelli
- SS Nephrology, SCDU Urology, AOU San Luigi, Orbassano, Italy
- SS Epidemiology, University of Torino, Torino, Italy
- SSD Clinical Nutrition, Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
- SCD Nephrology, Brotzu Hospital, Cagliari, Italy
- SCDU Nephrology, Department Città della Salute e della Scienza, University of Torino, Torino, Italy
- SS Nephrology, Department of Clinical and Biological Sciences, University of Torino, Regione Gonzole 10, Orbassano, Torino 10100 Italy
- Nèphrologie, CH du Mans, Le Mans, France
| | - Ettore Piccoli
- SS Nephrology, SCDU Urology, AOU San Luigi, Orbassano, Italy
- SS Epidemiology, University of Torino, Torino, Italy
- SSD Clinical Nutrition, Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
- SCD Nephrology, Brotzu Hospital, Cagliari, Italy
- SCDU Nephrology, Department Città della Salute e della Scienza, University of Torino, Torino, Italy
- SS Nephrology, Department of Clinical and Biological Sciences, University of Torino, Regione Gonzole 10, Orbassano, Torino 10100 Italy
- Nèphrologie, CH du Mans, Le Mans, France
| | - Elisabetta Versino
- SS Epidemiology, University of Torino, Torino, Italy
- SSD Clinical Nutrition, Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
| | - Marilisa Biolcati
- SS Nephrology, SCDU Urology, AOU San Luigi, Orbassano, Italy
- SS Epidemiology, University of Torino, Torino, Italy
- SSD Clinical Nutrition, Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
- SCD Nephrology, Brotzu Hospital, Cagliari, Italy
- SCDU Nephrology, Department Città della Salute e della Scienza, University of Torino, Torino, Italy
- SS Nephrology, Department of Clinical and Biological Sciences, University of Torino, Regione Gonzole 10, Orbassano, Torino 10100 Italy
- Nèphrologie, CH du Mans, Le Mans, France
| | - Paolo Avagnina
- SS Nephrology, Department of Clinical and Biological Sciences, University of Torino, Regione Gonzole 10, Orbassano, Torino 10100 Italy
- Nèphrologie, CH du Mans, Le Mans, France
| | | | | | - Tullia Todros
- SS Nephrology, SCDU Urology, AOU San Luigi, Orbassano, Italy
- SS Epidemiology, University of Torino, Torino, Italy
- SSD Clinical Nutrition, Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
- SCD Nephrology, Brotzu Hospital, Cagliari, Italy
- SCDU Nephrology, Department Città della Salute e della Scienza, University of Torino, Torino, Italy
- SS Nephrology, Department of Clinical and Biological Sciences, University of Torino, Regione Gonzole 10, Orbassano, Torino 10100 Italy
- Nèphrologie, CH du Mans, Le Mans, France
| | - Giorgina B. Piccoli
- SS Nephrology, Department of Clinical and Biological Sciences, University of Torino, Regione Gonzole 10, Orbassano, Torino 10100 Italy
- Nèphrologie, CH du Mans, Le Mans, France
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Cabiddu G, Castellino S, Gernone G, Santoro D, Moroni G, Giannattasio M, Gregorini G, Giacchino F, Attini R, Loi V, Limardo M, Gammaro L, Todros T, Piccoli GB. A best practice position statement on pregnancy in chronic kidney disease: the Italian Study Group on Kidney and Pregnancy. J Nephrol 2016; 29:277-303. [PMID: 26988973 PMCID: PMC5487839 DOI: 10.1007/s40620-016-0285-6] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 02/08/2016] [Indexed: 01/09/2023]
Abstract
Pregnancy is increasingly undertaken in patients with chronic kidney disease (CKD) and, conversely, CKD is increasingly diagnosed in pregnancy: up to 3 % of pregnancies are estimated to be complicated by CKD. The heterogeneity of CKD (accounting for stage, hypertension and proteinuria) and the rarity of several kidney diseases make risk assessment difficult and therapeutic strategies are often based upon scattered experiences and small series. In this setting, the aim of this position statement of the Kidney and Pregnancy Study Group of the Italian Society of Nephrology is to review the literature, and discuss the experience in the clinical management of CKD in pregnancy. CKD is associated with an increased risk for adverse pregnancy-related outcomes since its early stage, also in the absence of hypertension and proteinuria, thus supporting the need for a multidisciplinary follow-up in all CKD patients. CKD stage, hypertension and proteinuria are interrelated, but they are also independent risk factors for adverse pregnancy-related outcomes. Among the different kidney diseases, patients with glomerulonephritis and immunologic diseases are at higher risk of developing or increasing proteinuria and hypertension, a picture often difficult to differentiate from preeclampsia. The risk is higher in active immunologic diseases, and in those cases that are detected or flare up during pregnancy. Referral to tertiary care centres for multidisciplinary follow-up and tailored approaches are warranted. The risk of maternal death is, almost exclusively, reported in systemic lupus erythematosus and vasculitis, which share with diabetic nephropathy an increased risk for perinatal death of the babies. Conversely, patients with kidney malformation, autosomal-dominant polycystic kidney disease, stone disease, and previous upper urinary tract infections are at higher risk for urinary tract infections, in turn associated with prematurity. No risk for malformations other than those related to familiar urinary tract malformations is reported in CKD patients, with the possible exception of diabetic nephropathy. Risks of worsening of the renal function are differently reported, but are higher in advanced CKD. Strict follow-up is needed, also to identify the best balance between maternal and foetal risks. The need for further multicentre studies is underlined.
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Affiliation(s)
| | | | | | | | - Gabriella Moroni
- Nephrology, Fondazione Ca' Granda Ospedale Maggiore, Milano, Italy
| | | | | | | | - Rossella Attini
- Obstetrics, Department of Surgery, University of Torino, Torino, Italy
| | - Valentina Loi
- Nephrology, Azienda Ospedaliera Brotzu, Cagliari, Italy
| | - Monica Limardo
- Nephrology, Azienda Ospedaliera della Provincia di Lecco, Lecco, Italy
| | - Linda Gammaro
- Nephrology, Ospedale Fracastoro, San Bonifacio, Italy
| | - Tullia Todros
- Obstetrics, Department of Surgery, University of Torino, Torino, Italy
| | - Giorgina Barbara Piccoli
- Nephrology, ASOU San Luigi, Department of Clinical and Biological Sciences, University of Torino, Torino, Italy.
- Nephrologie, Centre Hospitalier du Mans, Le Mans, France.
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Hladunewich MA, Melamed N, Bramham K. Pregnancy across the spectrum of chronic kidney disease. Kidney Int 2016; 89:995-1007. [PMID: 27083278 DOI: 10.1016/j.kint.2015.12.050] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2015] [Revised: 12/06/2015] [Accepted: 12/18/2015] [Indexed: 01/14/2023]
Abstract
Management of the pregnant woman with chronic kidney disease is difficult for both nephrologists and obstetricians. Prepregnancy counselling with respect to risk stratification, optimization of maternal health prior to pregnancy, as well as management of the many potential pregnancy-associated complications in this complex patient population remains challenging due to the paucity of large, well-designed clinical studies. Furthermore, the heterogeneity of disease and the relative infrequency of pregnancy, particularly in more advanced stages of chronic kidney disease, leaves many clinicians feeling ill prepared to manage these pregnancies. As such, counselling is imprecise and management varies substantially across centers. All pregnancies in women with chronic kidney disease can benefit from a collaborative multidisciplinary approach with a team that consists of nephrologists experienced in the management of kidney disease in pregnancy, maternal-fetal medicine specialists, high-risk pregnancy nursing staff, dieticians, and pharmacists. Further access to skilled neonatologists and neonatal intensive care unit support is essential given the risks for preterm delivery in this patient population. The goal of this paper is to highlight some of the data that currently exist in the literature, provide management strategies for the practicing nephrologist at all stages of chronic kidney disease, and explore some of the knowledge gaps where future multinational collaborative research efforts should concentrate to improve pregnancy outcomes in women with kidney disease across the globe.
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Affiliation(s)
- Michelle A Hladunewich
- Division of Nephrology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.
| | - Nir Melamed
- Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Kate Bramham
- Division of Transplantation, Immunology and Mucosal Biology, Department of Renal Medicine, King's College, London, UK
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50
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Piccoli GB, De Pascale A, Randone O, Vigotti FN, Priola AM, Naretto C, Ferraresi M, Aroasio E, Gonella S, Mongilardi E, Scognamiglio S, Consiglio V, Roggero S, Piga A, Roccatello D, Veltri A. Revisiting nephrocalcinosis: A single-centre perspective. A northern Italian experience. Nephrology (Carlton) 2016; 21:97-107. [DOI: 10.1111/nep.12535] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2015] [Indexed: 01/19/2023]
Affiliation(s)
- Giorgina Barbara Piccoli
- SS Nephrology; ASOU San Luigi; Department of Clinical and Biological Sciences; University of Torino; Torino Italy
| | - Agostino De Pascale
- Radiology; ASOU San Luigi; Department of Oncology; University of Torino; Torino Italy
| | - Olga Randone
- SS Nephrology; ASOU San Luigi; Department of Clinical and Biological Sciences; University of Torino; Torino Italy
| | - Federica Neve Vigotti
- SS Nephrology; ASOU San Luigi; Department of Clinical and Biological Sciences; University of Torino; Torino Italy
| | | | - Carla Naretto
- Interregional Center for Rare Diseases; G Bosco Hospital; Department of Clinical and Biological Sciences; University of Torino; Torino Italy
| | - Martina Ferraresi
- SS Nephrology; ASOU San Luigi; Department of Clinical and Biological Sciences; University of Torino; Torino Italy
| | - Emiliano Aroasio
- Laboratory; ASOU San Luigi; Department of Clinical and Biological Sciences; University of Torino; Torino Italy
| | - Silvana Gonella
- Laboratory; ASOU San Luigi; Department of Clinical and Biological Sciences; University of Torino; Torino Italy
| | - Elena Mongilardi
- SS Nephrology; ASOU San Luigi; Department of Clinical and Biological Sciences; University of Torino; Torino Italy
| | - Stefania Scognamiglio
- SS Nephrology; ASOU San Luigi; Department of Clinical and Biological Sciences; University of Torino; Torino Italy
| | - Valentina Consiglio
- SS Nephrology; ASOU San Luigi; Department of Clinical and Biological Sciences; University of Torino; Torino Italy
| | - Simona Roggero
- Microcythemia Unit; ASOU San Luigi; Department of Clinical and Biological Sciences; University of Torino; Torino Italy
| | - Antonio Piga
- Microcythemia Unit; ASOU San Luigi; Department of Clinical and Biological Sciences; University of Torino; Torino Italy
| | - Dario Roccatello
- Interregional Center for Rare Diseases; G Bosco Hospital; Department of Clinical and Biological Sciences; University of Torino; Torino Italy
| | - Andrea Veltri
- Radiology; ASOU San Luigi; Department of Oncology; University of Torino; Torino Italy
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