1
|
Moss EM, Brewster UC. Kidney Biopsy in a Pregnant Patient with Suspected Glomerular Disease: CON. KIDNEY360 2023; 4:1356-1358. [PMID: 37578478 PMCID: PMC10617793 DOI: 10.34067/kid.0000000000000243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 01/30/2023] [Indexed: 08/15/2023]
Affiliation(s)
- Emily M Moss
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | | |
Collapse
|
2
|
Naipaul R, Marques C, Ng J, Barbour S, Lo C, Hildebrand AM, Siu V, Prasad B, Laurin LP, Wazny LD, Armstrong S, Tran J, Sheffield M, Jauhal A, Hladunewich MA. Focused Jurisdictional Scan of Glomerulonephritis Medication Access in Canada: A Program Report. Can J Kidney Health Dis 2023; 10:20543581231190227. [PMID: 37581108 PMCID: PMC10423446 DOI: 10.1177/20543581231190227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 06/23/2023] [Indexed: 08/16/2023] Open
Abstract
Purpose of Program Glomerulonephritis (GN) is a group of rare kidney diseases that is increasingly being managed with higher cost immunosuppressive (IS) agents in Canada. Ontario Health's Ontario Renal Network (ORN) oversees the management and delivery of GN services in the province. Stakeholder surveys previously conducted by ORN identified that both clinicians and patients do not perceive access to GN medications as comprehensive or timely. The program conducted a focused jurisdictional scan among 7 provinces to inform ORN initiatives to improve access to GN medications. Specifically, the program examined clinician experience with GN access, public drug coverage criteria, and timelines for public coverage for select IS agents (ie, tacrolimus, cyclosporine, mycophenolate mofetil [MMF], mycophenolate sodium, rituximab, and eculizumab) used to manage GN in adults who live in Canada. Methods For the selected IS agents, a focused jurisdictional scan on medication access was conducted by ORN in 2018 and updated in July 2022. Information was obtained by searching the gray literature and/or credible online sources for public funding policies and eligibility criteria. Findings were supplemented by personal communications with provincial drug programs and consulting GN clinical experts from 7 provinces (ie, Alberta, British Columbia, Saskatchewan, Manitoba, Ontario, Nova Scotia, and Quebec). Key Findings Clinicians from different provinces prescribe IS agents similarly for GN indications, despite distinctions in public drug funding policies. While patients can obtain public funding for many IS agents, for GN, most provinces rely on case-by-case review processes. In addition, provinces can vary in their funding criteria and which IS agents are listed on the public formulary. For IS agents that require prior authorization or case-by-case review, timelines vary by province with decisions taking a few days to weeks. British Columbia, with a GN-specific drug formulary, had the most integrated and efficient system for patients and prescribers. Limitations This scan primarily relied on publicly available information for drug coverage criteria and clinician experience with access in their province. Since this scan was conducted, public drug coverage criteria and/or application processes may have changed. Implications While patients in most provinces have similar needs and nephrologists similar prescribing patterns, gaps still exist for publicly funded GN medications. Interprovincial differences in the drugs funded, funding criteria, and application process may affect timely and equitable access to GN medications across Canada. Given the rarity of GN, a pan-Canadian funding approach may be warranted to improve the current state.
Collapse
Affiliation(s)
| | | | - Jenny Ng
- Division of Nephrology, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Nanji Family Kidney Centre, Sunnybrook Health Sciences Center, Toronto, ON, Canada
| | - Sean Barbour
- Division of Nephrology, Department of Medicine, University of British Columbia, BC Renal, Vancouver, BC, Canada
| | - Clifford Lo
- Division of Nephrology, Department of Medicine, University of British Columbia, BC Renal, Vancouver, BC, Canada
| | - Ainslie M. Hildebrand
- Division of Nephrology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Valerie Siu
- Pharmacy Services, Alberta Health Services, University of Alberta Hospital, Edmonton, AB, Canada
| | - Bhanu Prasad
- Division of Nephrology, Department of Medicine, Regina General Hospital, Regina, SK, Canada
| | - Louis-Philippe Laurin
- Division of Nephrology, Department of Medicine, Maisonneuve-Rosemont Hospital, University of Montreal, Montreal, QB, Canada
| | - Lori D. Wazny
- Manitoba Renal Program and Winnipeg Regional Health Authority, Winnipeg, MB, Canada
| | - Sean Armstrong
- Manitoba Renal Program and Winnipeg Regional Health Authority, Winnipeg, MB, Canada
| | - Jaclyn Tran
- Central Zone, Nova Scotia Health Renal Program, Halifax, NS, Canada
| | - Maneka Sheffield
- Central Zone, Nova Scotia Health Renal Program, Halifax, NS, Canada
| | - Arenn Jauhal
- Division of Nephrology, Department of Medicine, University Health Network, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Michelle A. Hladunewich
- Ontario Health (Ontario Renal Network), Toronto, Canada
- Division of Nephrology, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Nanji Family Kidney Centre, Sunnybrook Health Sciences Center, Toronto, ON, Canada
| |
Collapse
|
3
|
Kidney biopsy during pregnancy: a difficult decision. A case series reporting on 20 patients from Mexico. J Nephrol 2022; 35:2293-2300. [PMID: 35994230 DOI: 10.1007/s40620-022-01366-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 05/23/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND Kidney biopsy is a routine procedure in the diagnosis of kidney disease, but during pregnancy it carries potential adverse effects for both mother and child, aside from the challenges of obtaining adequate tissue samples. Nevertheless, a precise diagnosis is necessary when specific and potentially toxic treatments are to be used during pregnancy. The present report presents our experience with regard to the usefulness and safety of kidney biopsies during pregnancy. METHODS Retrospective analysis of clinical indications, complications, histopathological diagnoses, and treatment of patients who had kidney biopsies done at a single academic center during gestation weeks 11-30 between January 2015 and January 2019. RESULTS Kidney biopsies were carried out in 20 pregnant patients with nephrotic proteinuria. Biopsy was adequate in all patients. The histological diagnoses included focal segmental glomerulosclerosis (collapsing, tip and perihiliar varieties), membranous lupus nephropathy, diabetic nephropathy, and IgA nephropathy. Treatment was associated with reduction of proteinuria in 17 patients and reduction of serum creatinine in 9 out of 11 patients who had serum creatinine ≥ 1 mg/dl at the time of biopsy. There was one major bleeding complication that required transfusion of one unit of blood. There was a high incidence of preeclampsia, preterm delivery, and low birth weight despite appropriate kidney disease therapy. CONCLUSIONS Kidney biopsy may be done during pregnancy when therapeutic decisions depend on a precise pathologic diagnosis.
Collapse
|
4
|
Preservation of Renal Function. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00017-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
|
5
|
Bu Y, Yuan L, Tian C, Zhao C, Ji C, Gao X, Cai Y, Sun D, Liu Y. 24 h urinary creatinine excretion during pregnancy and its application in appropriate estimation of 24 h urinary iodine excretion. J Trace Elem Med Biol 2021; 66:126751. [PMID: 33836494 DOI: 10.1016/j.jtemb.2021.126751] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 03/11/2021] [Accepted: 03/22/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Urinary creatinine can be used to adjust urinary iodine to evaluate iodine nutritional status during pregnancy. However, the reference intervals and impact factors of urinary creatinine are unknown. METHODS 24 h urine creatinine concentration (24 hUCr) and spot UCr at four different time periods of the day of pregnant women from Part 1 (n = 743) were measured. Linear regression analysis was performed to identify the impact factors of 24 h urinary creatinine excretion (24 hUCrE) and obtain the estimated 24 h urinary creatinine excretion (24 hUCrEest). Then measured urinary iodine concentration (UIC) of 24 h and at fasting of pregnant women from Part 2 (n = 325), used spot urinary iodine to creatinine concentration ratio (UIC/UCr) and 24 hUCrEest to calculate the estimated 24 h urinary iodine excretion (24 hUIEest), finally checked the consistency and correlation of 24 hUIEest and 24 h urinary iodine excretion (24 hUIE). RESULTS In Part 1, the median 24 hUCrE was 1.24(IQR0.98-1.76)g, and the reference interval was 0.61-2.93 g. The median 24 hUCr was 0.76 (IQR0.57-1.01)g/L, and the reference interval was 0.36-1.88 g/L. Multiple linear regression results showed that pregnancy weight was an influencing factor to 24 hUCrE after adjusting by gestational weeks, age, pre-pregnancy BMI, and percentage of body fat (F = 45.029, p<0.001). In Part 2, there was no statistically significant difference between 24 hUIEest and 24 hUIE (Z =-0.767, p = 0.443). Using 24hUIE as the gold standard, the relative average difference in 24hUIEest was 4.2 %, the relative average differences for UIC and UIC/UCr were 32.4 % and 37.2 %. The reference interval of 24 hUIE and 24 hUIEest were 88.43-585.90 μg and 50.97-700.39 μg, respectively. CONCLUSIONS The reference intervals of 24 hUCrE, spot UCr, 24 hUIE, and 24 hUIEest during pregnancy were established. 24 hUCrE has important application value in iodine nutrition evaluation to gain more lead time for pregnant women with iodine nutrition-related diseases.
Collapse
Affiliation(s)
- Ye Bu
- Center for Endemic Disease Control, Chinese Center for Disease Control and Prevention, Harbin Medical University, National Health and Family Planning Commission & Education Bureau of Heilongjiang Province, Key Laboratory of Etiology and Epidemiology (23618504), Heilongjiang Provincial Key Laboratory of Trace Elements and Human Health, Harbin, 150086 Heilongjiang, China; The Fourth Affiliated Hospital of Harbin Medical University, Department of Obstetrics and Gynecology, Harbin, 150001 Heilongjiang, China.
| | - Lin Yuan
- The Fourth Affiliated Hospital of Harbin Medical University, Department of Obstetrics and Gynecology, Harbin, 150001 Heilongjiang, China.
| | - Chunyuan Tian
- Center for Endemic Disease Control, Chinese Center for Disease Control and Prevention, Harbin Medical University, National Health and Family Planning Commission & Education Bureau of Heilongjiang Province, Key Laboratory of Etiology and Epidemiology (23618504), Heilongjiang Provincial Key Laboratory of Trace Elements and Human Health, Harbin, 150086 Heilongjiang, China.
| | - Chunyan Zhao
- The Fourth Affiliated Hospital of Harbin Medical University, Department of Obstetrics and Gynecology, Harbin, 150001 Heilongjiang, China.
| | - Chunlei Ji
- The Fourth Affiliated Hospital of Harbin Medical University, Department of Obstetrics and Gynecology, Harbin, 150001 Heilongjiang, China.
| | - Xiaoxu Gao
- The Fourth Affiliated Hospital of Harbin Medical University, Department of Obstetrics and Gynecology, Harbin, 150001 Heilongjiang, China.
| | - Yan Cai
- The Fourth Affiliated Hospital of Harbin Medical University, Department of Obstetrics and Gynecology, Harbin, 150001 Heilongjiang, China.
| | - Dianjun Sun
- Center for Endemic Disease Control, Chinese Center for Disease Control and Prevention, Harbin Medical University, National Health and Family Planning Commission & Education Bureau of Heilongjiang Province, Key Laboratory of Etiology and Epidemiology (23618504), Heilongjiang Provincial Key Laboratory of Trace Elements and Human Health, Harbin, 150086 Heilongjiang, China.
| | - Ying Liu
- Center for Endemic Disease Control, Chinese Center for Disease Control and Prevention, Harbin Medical University, National Health and Family Planning Commission & Education Bureau of Heilongjiang Province, Key Laboratory of Etiology and Epidemiology (23618504), Heilongjiang Provincial Key Laboratory of Trace Elements and Human Health, Harbin, 150086 Heilongjiang, China.
| |
Collapse
|
6
|
TOK A, GÜZEL FB, OZTURK İ, ERKEN E, ALTUNÖREN O, GÜNGÖR Ö. Gebelikte Ödem ve Proteinürinin Çok Nadir Görülen Bir Nedeni: Mirror Sendromu. KAHRAMANMARAŞ SÜTÇÜ İMAM ÜNIVERSITESI TIP FAKÜLTESI DERGISI 2021. [DOI: 10.17517/ksutfd.874803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
|
7
|
Gleeson S, Lightstone L. Glomerular Disease and Pregnancy. Adv Chronic Kidney Dis 2020; 27:469-476. [PMID: 33328063 DOI: 10.1053/j.ackd.2020.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 08/04/2020] [Accepted: 08/04/2020] [Indexed: 12/28/2022]
Abstract
Nephrologists are routinely involved in the care of pregnant women with glomerulonephritis. Prepregnancy counseling is vital to inform women of the potential risks of pregnancy and to reduce those risks by optimizing clinical status and medications. In general, for all glomerulonephritides, the best pregnancy outcomes are achieved when the disease is in remission and the woman has preserved renal function with no proteinuria or hypertension. Each glomerulonephritis has specific considerations, for example in lupus nephritis, mycophenolate is teratogenic and must be stopped at least 6 weeks before conception, hydroxychloroquine is recommended for all pregnant women, and flares are frequently encountered and must be treated appropriately. De novo glomerulonephritis should be considered when significant proteinuria is found early in pregnancy or an acute kidney injury with active urine is encountered. Biopsy can be safely undertaken in the first trimester. Treatment is often with corticosteroids, azathioprine, and/or tacrolimus. Rituximab is increasingly used for severe disease. Women with glomerulonephritis should ideally be managed in a joint renal-obstetric clinic. This review details the approach to the care of women with glomerulonephritis from prepregnancy counseling, through antenatal care and delivery, to the postpartum period. Special attention is given to medications and treatment of glomerulonephritis in pregnancy.
Collapse
|
8
|
Farrington CA. Kidney Imaging and Biopsy in Pregnancy. Adv Chronic Kidney Dis 2020; 27:525-530. [PMID: 33328069 DOI: 10.1053/j.ackd.2020.05.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/13/2020] [Accepted: 05/14/2020] [Indexed: 12/21/2022]
Abstract
Physiologic glomerular, tubular, and structural changes related to pregnancy may complicate the detection of underlying kidney disease in pregnant patients. Imaging studies may provide important clinical information to assist in the diagnosis and treatment of kidney disease during pregnancy. Furthermore, in select patients who develop new or worsening kidney disease in pregnancy, kidney biopsy may be essential to ensure the accuracy of diagnosis and guide treatment choices. This review article will discuss the risks and benefits of various modalities used to image the kidneys and urinary tract during pregnancy to aid in the judicious selection of appropriate imaging studies that are likely to maximize clinical benefit while minimizing fetal risk. It will also highlight the potential benefits and harms associated with antepartum kidney biopsy and will offer strategies for identifying patients who are most likely to benefit from kidney biopsy during pregnancy.
Collapse
|
9
|
Sachdeva M, Beck LH, Miller I, Bijol V, Fishbane S. Phospholipase A 2 Receptor Antibody-Positive Pregnancy: A Case Report. Am J Kidney Dis 2020; 76:586-589. [PMID: 32093980 DOI: 10.1053/j.ajkd.2019.11.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 11/27/2019] [Indexed: 11/11/2022]
Abstract
Renal course and clinical outcomes in pregnant women with primary membranous nephropathy are not completely understood. In addition, the use of autoantibodies to M-type phospholipase A2 receptor (PLA2R) as a serologic marker throughout pregnancy and postpartum in the mother and baby is not yet fully elucidated. We followed up a pregnant woman with primary membranous nephropathy during pregnancy and postpartum and describe the clinical course and outcomes of mother and baby and the course of PLA2R antibody titers. We show evidence of transplacental transfer of PLA2R antibody from mother to fetus. In addition, we observe the effect of breastfeeding in a PLA2R antibody-positive pregnancy and describe the transfer of this antibody into breast milk. Although pregnancy in women with underlying PLA2R antibody-positive membranous nephropathy is possible, there is an increase in risk to both mother and fetus, requiring a multidisciplinary team approach and careful monitoring of both neonate and mother during pregnancy and postpartum.
Collapse
Affiliation(s)
- Mala Sachdeva
- Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY.
| | - Laurence H Beck
- Renal Section, Boston University School of Medicine, Boston, MA
| | - Ilene Miller
- Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY
| | - Vanesa Bijol
- Department of Pathology, North Shore University Hospital and Long Island Jewish Medical Center, Manhasset, NY
| | - Steven Fishbane
- Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY
| |
Collapse
|
10
|
Rao S, Jim B. Acute Kidney Injury in Pregnancy: The Changing Landscape for the 21st Century. Kidney Int Rep 2018; 3:247-257. [PMID: 29725629 PMCID: PMC5932309 DOI: 10.1016/j.ekir.2018.01.011] [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: 01/12/2018] [Revised: 01/26/2018] [Accepted: 01/28/2018] [Indexed: 12/27/2022] Open
Abstract
Pregnancy-related acute kidney injury (Pr-AKI) remains a large public health problem, with decreasing incidences in developing countries but seemingly increasing incidences in the United States and Canada. These epidemiologic changes are reflective of the advances in medical and obstetric care, as well as changes in underlying maternal risk factors. The risk factors associated with advanced maternal age, such as hypertension, diabetes, chronic kidney disease, and those associated with reproductive technologies such as multiple gestations, are increasing. Traditional causes of Pr-AKI, such as septic abortions and puerperal sepsis, have been replaced by hypertensive diseases, such as preeclampsia and thrombotic microangiopathies comprising thrombotic thrombocytopenic purpura (TTP) and atypical hemolytic uremic syndrome (aHUS). In this review, we discuss the global impact of Pr-AKI on maternal and fetal outcomes, the predominant etiologies, and key clinical features to distinguish diagnoses, such as preeclampsia/hemolysis elevated liver function test and low platelet (HELLP) syndrome, acute fatty liver disease of pregnancy (AFLP), and other thrombotic microangiopathies. New insights into the pathogenesis of preeclampsia, TTP/aHUS, and AFLP that have unearthed possible therapeutic targets are summarized. We also delve into special consideration needed to give to pyelonephritis and postobstructive causes of Pr-AKI. With each diagnosis, we offer the latest treatment recommendations, such as the positive reports from the use of eculizumab to treat aHUS. In the end, we hope to arm the clinician with the best tools to understand and address this morbid problem that does not seem to be disappearing.
Collapse
Affiliation(s)
- Swati Rao
- Division of Nephrology, Department of Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania, USA
| | - Belinda Jim
- Division of Nephrology, Department of Medicine, Jacobi Medical Center at Albert Einstein College of Medicine, Bronx, New York, USA
| |
Collapse
|
11
|
Blom K, Odutayo A, Bramham K, Hladunewich MA. Pregnancy and Glomerular Disease: A Systematic Review of the Literature with Management Guidelines. Clin J Am Soc Nephrol 2017; 12:1862-1872. [PMID: 28522651 PMCID: PMC5672957 DOI: 10.2215/cjn.00130117] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
During pregnancy, CKD increases both maternal and fetal risk. Adverse maternal outcomes include progression of underlying renal dysfunction, worsening of urine protein, and hypertension, whereas adverse fetal outcomes include fetal loss, intrauterine growth restriction, and preterm delivery. As such, pregnancy in young women with CKD is anxiety provoking for both the patient and the clinician providing care, and because the heterogeneous group of glomerular diseases often affects young women, this is an area of heightened concern. In this invited review, we discuss pregnancy outcomes in young women with glomerular diseases. We have performed a systematic review in attempt to better understand these outcomes among young women with primary GN, we review the studies of pregnancy outcomes in lupus nephritis, and finally, we provide a potential construct for management. Although it is safe to say that the vast majority of young women with glomerular disease will have a live birth, the counseling that we can provide with respect to individualized risk remains imprecise in primary GN because the existing literature is extremely dated, and all management principles are extrapolated primarily from studies in lupus nephritis and diabetes. As such, the study of pregnancy outcomes and management strategies in these rare diseases requires a renewed interest and a dedicated collaborative effort.
Collapse
Affiliation(s)
- Kimberly Blom
- Division of Nephrology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; and
| | - Ayodele Odutayo
- Division of Nephrology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; and
| | - Kate Bramham
- Department of Renal Medicine, Division of Transplantation Immunology and Mucosal Biology, King’s College, London, United Kingdom
| | - Michelle A. Hladunewich
- Division of Nephrology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; and
| |
Collapse
|