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Piccoli GB, Attini R, Torreggiani M, Chatrenet A, Manzione AM, Masturzo B, Casula V, Longhitano E, Dalmasso E, Biancone L, Pani A, Cabiddu G. Any reduction in maternal kidney mass makes a difference during pregnancy in gestational and fetal outcome. Kidney Int 2024; 105:865-876. [PMID: 38296027 DOI: 10.1016/j.kint.2023.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 11/29/2023] [Accepted: 12/15/2023] [Indexed: 02/19/2024]
Abstract
Little is known about the effect tubulointerstitial nephropathies have in modulating maternal-fetal outcomes in pregnancy. Therefore, we analyzed the main outcomes of pregnancy in these women to gain a better understanding of the role of a reduction in maternal kidney mass. From the Torino Cagliari Observational Study (TOCOS) cohort, we selected 529 patients with a diagnosis of tubulointerstitial disease and focused on 421 patients with chronic kidney disease (CKD) stage 1, without hypertension but with proteinuria less than 0.5 g/day at referral. From a cohort of 2969 singleton deliveries from low-risk pregnancies followed in the same settings we selected a propensity score matched control cohort of 842 pregnancies match 2:1 for age, parity, body mass index, ethnicity, and origin. Time to delivery was significantly shorter in the study cohort 38.0 (Quartile 1-Quartile 3: 37.0-39.0) versus 39.0 (Q1-Q3 38.0-40.0) weeks, with respect to controls. Incidence of delivery of less than 37 gestational weeks significantly increased from controls (7.4%) to women with previous acute pyelonephritis (10.8%), other tubulointerstitial diseases (9.7%) and was the highest in patients with a single kidney (31.1%). Similarly, neonatal birthweight significantly and progressively decreased from controls (3260 g [Q1-Q3: 2980-3530]), previous acute pyelonephritis (3090 g [Q1-Q3: 2868-3405], other tubulointerstitial diseases (3110 g [Q1-Q3: 2840-3417]), and to solitary kidney (2910 g [Q1-Q3: 2480-3240]). Risk of developing preeclampsia was significantly higher in the CKD cohort (3.6% vs 1.7% in low-risk controls). Thus, even a small reduction in functional kidney mass, such as a pyelonephritic scar, is associated with a shorter duration of pregnancy and an increased risk of preterm delivery. The risk is proportional to the extent of parenchymal reduction and is highest in cases with a solitary kidney.
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Affiliation(s)
| | - Rossella Attini
- Department of Obstetrics and Gynecology SC2U, "Città della Salute e della Scienza", Sant'Anna Hospital, Turin, Italy
| | | | - Antoine Chatrenet
- Néphrologie et Dialyse, Centre Hospitalier Le Mans, Le Mans, France; APCoSS-Institute of Physical Education and Sports Sciences (IFEPSA), UCO Angers, Angers, France
| | - Ana Maria Manzione
- Division of Nephrology, Dialysis and Renal Transplantation, Department of Medical Sciences, "Città della Salute e della Scienza di Torino" University Hospital, University of Turin, Turin, Italy
| | - Bianca Masturzo
- Division of Obstetrics and Gynecology, Department of Maternal, Neonatal and Infant Medicine, Nuovo Ospedale Degli Infermi, Biella, Italy
| | - Viola Casula
- Department of Obstetrics and Gynecology SC2U, "Città della Salute e della Scienza", Sant'Anna Hospital, Turin, Italy
| | - Elisa Longhitano
- Néphrologie et Dialyse, Centre Hospitalier Le Mans, Le Mans, France; Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, A.O.U. "G. Martino", University of Messina, Messina, Italy
| | - Eleonora Dalmasso
- Néphrologie et Dialyse, Centre Hospitalier Le Mans, Le Mans, France; Division of Gynecology and Obstetrics, Department of Surgical Sciences, University of Cagliari, Cagliari, Italy
| | - Luigi Biancone
- Division of Nephrology, Dialysis and Renal Transplantation, Department of Medical Sciences, "Città della Salute e della Scienza di Torino" University Hospital, University of Turin, Turin, Italy
| | - Antonello Pani
- Nephrology, Department of Medical Science and Public Health, San Michele Hospital, ARNAS G. Brotzu, University of Cagliari, Cagliari, Italy
| | - Gianfranca Cabiddu
- Nephrology, Department of Medical Science and Public Health, San Michele Hospital, ARNAS G. Brotzu, University of Cagliari, Cagliari, Italy
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Younis D, Mosbah A, Zakaria MM, Awadalla A, El-Kannishy G, Shemies RS. Urinary congophilia in pregnancy: a marker of kidney injury rather than preeclampsia. J Hypertens 2023; 41:1760-1767. [PMID: 37602468 DOI: 10.1097/hjh.0000000000003531] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2023]
Abstract
BACKGROUND The differentiation between preeclampsia and similarly presenting kidney disease in pregnancy is a diagnostic challenge. Although some laboratory tests have been utilized, globally validated tools are yet needed, particularly in resource-limited settings. Congophilic proteins are abundantly detected in the urine of pregnant women who develop preeclampsia that is thought to be a marker of disease process. The present study aimed to assess the diagnostic and predictive utility of urinary congophilia in pregnant women with hypertensive disorders of pregnancy as well as kidney diseases. METHODS This cohort study included 157 pregnant women, classified as healthy controls ( n = 38), preeclampsia/eclampsia ( n = 45), gestational hypertension ( n = 9), chronic hypertension ( n = 8), chronic kidney disease (CKD) ( n = 27), and pregnancy-related acute kidney injury (PR-AKI) ( n = 30). Urinary congophilia was assessed by Congo Red Dot Blot assay. RESULTS Congo red retention (CRR) values were significantly higher in women with preeclampsia/eclampsia ( P ≤ 0.001), chronic hypertension ( P = 0.029), gestational hypertension ( P = 0.017), CKD ( P ≤ 0.001), PR-AKI secondary to preeclampsia ( P ≤ 0.001), and PR-AKI secondary to other causes ( P = 0.001), compared with healthy controls. Women with preeclampsia, CKD, and PR-AKI (non-preeclampsia related) exhibited the highest levels of CRR. CRR positively correlated to proteinuria ( P = 0.006) and serum creatinine ( P = 0.027). CRR did not significantly vary between women who presented antepartum and those presented postpartum after removal of the placenta ( P = 0.707). CRR at a cut-off point of at least 1.272 had 91% specificity and 61.1% sensitivity in predicting renal recovery in PR-AKI patients. CRR had a poor specificity in discriminating preeclampsia from the other clinical presentations. CONCLUSION Urinary congophilia could not discriminate preeclampsia from similarly presenting kidney diseases in pregnancy. Further studies are needed to improve differentiation of these conditions.
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Affiliation(s)
| | | | - Mahmoud M Zakaria
- Clinical Pathology Department, Mansoura Urology and Nephrology Center, Mansoura University, Mansoura City, Egypt
| | - Amira Awadalla
- Clinical Pathology Department, Mansoura Urology and Nephrology Center, Mansoura University, Mansoura City, Egypt
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Fakhouri F, Schwotzer N, Cabiddu G, Barratt J, Legardeur H, Garovic V, Orozco-Guillen A, Wetzels J, Daugas E, Moroni G, Noris M, Audard V, Praga M, Llurba E, Wuerzner G, Attini R, Desseauve D, Zakharova E, Luders C, Wiles K, Leone F, Jesudason S, Costedoat-Chalumeau N, Kattah A, Soto-Abraham V, Karras A, Prakash J, Lightstone L, Ronco P, Ponticelli C, Appel G, Remuzzi G, Tsatsaris V, Piccoli GB. Glomerular diseases in pregnancy: pragmatic recommendations for clinical management. Kidney Int 2023; 103:264-281. [PMID: 36481180 DOI: 10.1016/j.kint.2022.10.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 10/10/2022] [Accepted: 10/18/2022] [Indexed: 12/12/2022]
Abstract
Our understanding of the various aspects of pregnancy in women with kidney diseases has significantly improved in the last decades. Nevertheless, little is known about specific kidney diseases. Glomerular diseases are not only a frequent cause of chronic kidney disease in young women, but combine many challenges in pregnancy: immunologic diseases, hypertension, proteinuria, and kidney tissue damage. An international working group undertook the review of available current literature and elicited expert opinions on glomerular diseases in pregnancy with the aim to provide pragmatic information for nephrologists according to the present state-of-the-art knowledge. This work also highlights areas of clinical uncertainty and emphasizes the need for further collaborative studies to improve maternal and fetal health.
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Affiliation(s)
- Fadi Fakhouri
- Service de Néphrologie et d'Hypertension, Département de Médecine, Centre Hospitalier Universitaire Vaudois, and Université de Lausanne, Lausanne, Switzerland.
| | - Nora Schwotzer
- Service de Néphrologie et d'Hypertension, Département de Médecine, Centre Hospitalier Universitaire Vaudois, and Université de Lausanne, Lausanne, Switzerland
| | - Gianfranca Cabiddu
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy; Department of Nephrology, San Michele Hospital, ARNAS G. Brotzu, Cagliari, Italy
| | - Jonathan Barratt
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Hélène Legardeur
- Gynaecology, Woman Mother Child Department of the Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Vesna Garovic
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA; Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Alejandra Orozco-Guillen
- National Institute of Perinatology Isidro Espinosa de los Reyes (INPER), Department of Nephrology, Ciudad de Mexico, Mexico
| | - Jack Wetzels
- Department of Nephrology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Eric Daugas
- Service de Néphrologie, Hôpital Bichat and Université Paris Cité, Paris, France; Institut national de la santé et de la recherche médicale Inserm U1149, Paris, France
| | - Gabriella Moroni
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; Nephrology and Dialysis Division, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Humanitas Research Hospital, Milan, Italy
| | - Marina Noris
- Istituto di Ricerche Farmacologiche Mario Negri, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Laboratory of Immunology and Genetics of Rare Diseases, Bergamo, Italy
| | - Vincent Audard
- Université Paris Est Créteil, Institut National de la Santé et de la Recherche Médicale (INSERM), Institut Mondor de Recherche Biomédicale (IMRB), Créteil, France; Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Service de Néphrologie et Transplantation, Fédération Hospitalo-Universitaire « Innovative therapy for immune disorders », Créteil, France
| | - Manuel Praga
- Department of Nephrology, Hospital Universitario 12 de Octubre, Complutense University Madrid, Madrid, Spain
| | - Elisa Llurba
- Department of Obstetrics and Gynaecology, Institut d'Investigació Biomèdica Sant Pau - IIB Sant Pau, Hospital de la Santa Creu i Sant Pau, Madrid, Spain; Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Developmental Origin Network (RICORS), Instituto de Salud Carlos III, Madrid, Spain
| | - Grégoire Wuerzner
- Service de Néphrologie et d'Hypertension, Département de Médecine, Centre Hospitalier Universitaire Vaudois, and Université de Lausanne, Lausanne, Switzerland
| | - Rossella Attini
- Department of Obstetrics and Gynecology, University of Turin, Città della Salute e della Scienza, Sant'Anna Hospital, Turin, Italy
| | - David Desseauve
- Gynaecology, Woman Mother Child Department of the Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Elena Zakharova
- Nephrology, Moscow City Hospital n.a. Sergey Petrovich Botkin, Moscow, Russian Federation; Moscow State University of Medicine and Dentistry, Moscow, Russian Federation
| | - Claudio Luders
- Centro de Nefrologia e Dialise, Hospital Sirio-Libanes, São Paulo, Brazil
| | - Kate Wiles
- Department of Women's Health, Barts Health NHS Trust, London, UK
| | - Filomena Leone
- Clinical Nutrition Unit, S. Anna Hospital, Città della Salute e della Scienza, Turin, Italy
| | - Shilpanjali Jesudason
- Central Northern Adelaide Renal and Transplantation Service (CNARTS), Royal Adelaide Hospital, Adelaide, South Australia, Australia; Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Nathalie Costedoat-Chalumeau
- Centre de Référence Maladies Auto-Immunes et Systémiques Rares de l'île de France, Cochin Hospital, Université Paris Cité, Paris, France; Unité de l'Institut national de la santé et de la recherche médicale (INSERM) Unité 1153, Center for Epidemiology and Statistics (CRESS), Paris, France
| | - Andrea Kattah
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Virgilia Soto-Abraham
- Pathology Department, Hospital General de México Dr Eduardo Liceaga, México City, México
| | - Alexandre Karras
- Paris University, Paris, France; Renal Division, Georges Pompidou European Hospital, Paris, France
| | - Jai Prakash
- Department of Nephrology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Liz Lightstone
- Imperial Lupus Centre, Department of Medicine, Imperial College London, London, UK; Section of Renal Medicine and Vascular Inflammation, Department of Medicine, Imperial College London, London, UK
| | - Pierre Ronco
- Sorbonne Université, and Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche S1155, Paris, France; Department of Nephrology, Centre Hospitalier du Mans, Le Mans, France
| | | | - Gerald Appel
- Division of Nephrology, Columbia University Medical Center and the New York Presbyterian Hospital, New York, New York, USA
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Laboratory of Immunology and Genetics of Rare Diseases, Bergamo, Italy
| | - Vassilis Tsatsaris
- Maternité Port-Royal, Fédération Hospitalo-Universitaire Prématurité (FHU PREMA), Assistance Publique des Hôpitaux de Paris AP-HP, Hôpital Cochin, AP-HP, Paris, France; Centre-Université de Paris, Université de Paris, Paris, France
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Karge A, Beckert L, Moog P, Haller B, Ortiz JU, Lobmaier SM, Abel K, Flechsenhar S, Kuschel B, Graupner O. Role of sFlt-1/PIGF ratio and uterine Doppler in pregnancies with chronic kidney disease suspected with Pre-eclampsia or HELLP syndrome. Pregnancy Hypertens 2020; 22:160-166. [PMID: 32992124 DOI: 10.1016/j.preghy.2020.09.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 08/01/2020] [Accepted: 09/11/2020] [Indexed: 12/14/2022]
Abstract
PURPOSE Pregnancies of women with chronic kidney disease (CKD) are at higher risk of experiencing adverse perinatal (APO) and maternal outcome (AMO). Mean uterine artery pulsatility index (mUtA-PI) as well as the ratio of soluble fms-like tyrosine kinase-1 (sFlt-1) and placental growth factor (PlGF) are helpful tools in diagnosing pre-eclampsia (PE) in women with CKD. The aim of the study was to evaluate the role of sFlt-1/PIGF ratio and mUtA-PI as predictors for APO, AMO, preterm delivery and decline of kidney function in CKD pregnancies. METHODS A total of 28 CKD pregnancies with suspected PE/HELLP syndrome were retrospectively included, in whom both sFlt-1/PIGF and mUtA-PI were determined during the third trimester. APO was defined as fetal growth restriction, respiratory distress syndrome, intubation, admission to NICU, 5 min Apgar <7 and intracerebral hemorrhage. AMO was defined as the development of PE, HELLP syndrome or resistant hypertension. Decline of kidney function was defined as a 25% increase of creatinine level after delivery. RESULTS Of all included women, eight (28.6%) developed a PE/HELLP syndrome. AMO (28.6%) and APO (32.1%) were frequently observed. ROC analyses revealed a predictive value for AMO and sFlt-1/PIGF or mUtA-PI. Neither sFlt-1/PIGF nor mUtA-PI could predict APO or decline of postnatal kidney function. mUtA-PI was a predictor for preterm delivery. CONCLUSION Uterine Doppler and sFlt-1/PIGF are predictors of AMO in CKD pregnancies. Therefore, both markers might be helpful for an improved risk assessment. However, neither sFlt-1/PIGF nor mUtA-PI were able to predict a decline of postnatal kidney function or APO.
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Affiliation(s)
- Anne Karge
- Department of Obstetrics and Gynecology, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany.
| | - Lina Beckert
- Department of Obstetrics and Gynecology, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | - Philipp Moog
- Department of Nephrology, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | - Bernhard Haller
- Institute for Medical Informatics, Statistics and Epidemiology (IMedIS), University Hospital rechts der Isar, Technical University of Munich, Germany
| | - Javier U Ortiz
- Department of Obstetrics and Gynecology, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | - Silvia M Lobmaier
- Department of Obstetrics and Gynecology, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | - Kathrin Abel
- Department of Obstetrics and Gynecology, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | - Sarah Flechsenhar
- Department of Obstetrics and Gynecology, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | - Bettina Kuschel
- Department of Obstetrics and Gynecology, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
| | - Oliver Graupner
- Department of Obstetrics and Gynecology, University Hospital rechts der Isar, Technical University of Munich, Munich, Germany
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Seah JM, Kam NM, Wong L, Tanner C, MacIsaac RJ, Shub A, Ekinci EI, Houlihan C. The association between maternal renal function and pregnancy outcomes in type 1 and type 2 diabetes. Diabetes Res Clin Pract 2020; 165:108225. [PMID: 32442556 DOI: 10.1016/j.diabres.2020.108225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 04/02/2020] [Accepted: 05/14/2020] [Indexed: 10/24/2022]
Abstract
AIMS To investigate the prognostic value of estimated glomerular filtration rate (eGFR) and albuminuria in determining pregnancy outcomes in women with type 1 and type 2 diabetes. METHODS An observational study of pregnant women with type 1 (n = 92) and type 2 diabetes (n = 106) who delivered between 2004 and 2014 at a single tertiary obstetric centre. Clinical and biochemical characteristics were determined and related to major obstetric outcomes: preeclampsia, preterm birth <32 and <37 weeks, and neonatal intensive care admission. We used univariate analyses and multivariable logistic regression models with eGFR using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation and albuminuria as covariates. RESULTS In the pooled diabetes cohort, multivariable logistic regression with eGFR and albuminuria status demonstrated that the presence of albuminuria (albumin-to-creatinine ratio ≥ 3.5 mg/mmol) (OR, 2.7; 95% CI, 1.42-4.99; P = 0.002) was associated with preeclampsia, whilst an eGFR of < 120 mL/min/1.73 m2 was associated with preterm birth < 32 weeks (OR, 1.04; 95% CI, 1.00-1.09; P = 0.02). CONCLUSIONS Despite its recognized limitations in pregnancy, lower eGFR values were associated with increased risk of adverse outcomes. Our exploratory data suggest eGFR, along with albuminuria, can aid in identifying women at high risk of developing adverse obstetric outcomes.
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Affiliation(s)
- Jas-Mine Seah
- Department of Perinatal Medicine, Mercy Health, 163 Studley Road, Heidelberg, VIC 3084, Australia; Department of Endocrinology and Diabetes, Austin Health, 145 Studley Road, Heidelberg, VIC 3084, Australia; Department of Medicine, The University of Melbourne, Grattan Street, Parkville, VIC 3010, Australia
| | - Ning Mao Kam
- Department of Endocrinology and Diabetes, Austin Health, 145 Studley Road, Heidelberg, VIC 3084, Australia; Department of Medicine, The University of Melbourne, Grattan Street, Parkville, VIC 3010, Australia
| | - Lydia Wong
- Department of Endocrinology and Diabetes, Austin Health, 145 Studley Road, Heidelberg, VIC 3084, Australia
| | - Cara Tanner
- Department of Endocrinology and Diabetes, Austin Health, 145 Studley Road, Heidelberg, VIC 3084, Australia; Department of Medicine, The University of Melbourne, Grattan Street, Parkville, VIC 3010, Australia
| | - Richard J MacIsaac
- Department of Medicine, The University of Melbourne, Grattan Street, Parkville, VIC 3010, Australia; Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, 41 Victoria Street, Fitzroy, VIC 3065, Australia.
| | - Alexis Shub
- Department of Perinatal Medicine, Mercy Health, 163 Studley Road, Heidelberg, VIC 3084, Australia; Department of Medicine, The University of Melbourne, Grattan Street, Parkville, VIC 3010, Australia.
| | - Elif I Ekinci
- Department of Endocrinology and Diabetes, Austin Health, 145 Studley Road, Heidelberg, VIC 3084, Australia; Department of Medicine, The University of Melbourne, Grattan Street, Parkville, VIC 3010, Australia.
| | - Christine Houlihan
- Department of Perinatal Medicine, Mercy Health, 163 Studley Road, Heidelberg, VIC 3084, Australia; Department of Endocrinology and Diabetes, Austin Health, 145 Studley Road, Heidelberg, VIC 3084, Australia.
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Kanbay M, Ertuglu LA, Afsar B, Ozdogan E, Kucuksumer ZS, Ortiz A, Covic A, Kuwabara M, Cherney DZI, van Raalte DH, de Zeeuw D. Renal hyperfiltration defined by high estimated glomerular filtration rate: A risk factor for cardiovascular disease and mortality. Diabetes Obes Metab 2019; 21:2368-2383. [PMID: 31297976 DOI: 10.1111/dom.13831] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 06/30/2019] [Accepted: 07/08/2019] [Indexed: 12/22/2022]
Abstract
Renal hyperfiltration, defined as an increased glomerular filtration rate above normal values, is associated with early phases of kidney disease in the setting of various conditions such as obesity and diabetes. Although it is recognized that glomerular hyperfiltration, that is, increased filtration per nephron unit (usually studied at low glomerular filtration levels and often referred to as single nephron hyperfiltration), is a risk factor for the progression of chronic kidney disease, the implications of having renal hyperfiltration for cardiovascular disease and mortality risk are incompletely understood. Recent evidence from diverse populations, including healthy individuals and patients with diabetes or established cardiovascular disease, suggests that renal hyperfiltration is associated with a higher risk of cardiovascular disease and all-cause mortality. In this review, we critically summarize the existing studies, discuss possible mechanisms, and describe the remaining gaps in our knowledge regarding the association of renal hyperfiltration with cardiovascular disease and mortality risk.
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Affiliation(s)
- Mehmet Kanbay
- Department of Medicine, Division of Nephrology, Koç University School of Medicine, Istanbul, Turkey
| | - Lale A Ertuglu
- Department of Medicine, School of Medicine, Koç University, Istanbul, Turkey
| | - Baris Afsar
- Department of Medicine, Division of Nephrology, Suleyman Demirel University School of Medicine, Isparta, Turkey
| | - Elif Ozdogan
- Department of Medicine, School of Medicine, Koç University, Istanbul, Turkey
| | - Zeynep S Kucuksumer
- Department of Medicine, School of Medicine, Koç University, Istanbul, Turkey
| | - Alberto Ortiz
- Dialysis Unit, School of Medicine, IIS-Fundacion Jimenez Diaz, Universidad Autónoma de Madrid, Madrid, Spain
| | - Adrian Covic
- Nephrology Clinic, Dialysis and Renal Transplant Center, 'C.I. PARHON' University Hospital, and 'Grigore T. Popa' University of Medicine, Iasi, Romania
| | | | - David Z I Cherney
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Daniel H van Raalte
- Diabetes Center, Department of Internal Medicine, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Dick de Zeeuw
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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Kreepala C, Srila-On A, Kitporntheranunt M, Anakkamatee W, Lawtongkum P, Wattanavaekin K. The Association Between GFR Evaluated by Serum Cystatin C and Proteinuria During Pregnancy. Kidney Int Rep 2019; 4:854-863. [PMID: 31194092 PMCID: PMC6551540 DOI: 10.1016/j.ekir.2019.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 03/05/2019] [Accepted: 04/01/2019] [Indexed: 11/30/2022] Open
Abstract
Introduction Physiological changes in pregnancy result in increased cardiac output and renal blood flow, with a consequential increase in proteinuria. Data from studies of the relationship between proteinuria caused by isolated proteinuria and glomerular filtration rate (GFR) are still limited. The objective of this study was to investigate the effects of isolated proteinuria on the cystatin C–based GFR in the third trimester of pregnancy. Methods Data were collected from pregnant women in their third trimester whose serum creatinine levels were normal. The GFR of each participant was measured using serum cystatin C levels, and proteinuria was measured using urine protein–creatinine ratios. The participants were divided into 3 groups according to their level of proteinuria: normal (<150 mg/d), physiological (150–300 mg/d), and gestational (>300 mg/d). Changes in GFR were recorded for each group. Results The study included 89 participants, of whom 66.3% had levels of proteinuria that did not differ from that of the normal population (<150 mg/d). The incidence of physiological and gestational proteinuria was 21.4% and 12.4%, respectively. The results demonstrate that proteinuria >101.50 mg/d was significantly associated with declined estimated glomerular filtration rate (eGFR) (r = –0.34, P = 0.01). The analysis found that proteinuria >491.27 mg/d led to a risk of GFR <90 ml/min with an odds ratio of 12.69, P = 0.02 when adjusted for systolic blood pressure (SBP), diastolic blood pressure (DBP), and body mass index. Conclusion This study suggests that the term “physiological proteinuria” is a misnomer. When used in the traditional manner, creatinine level has inadequate sensitivity to estimate GFR in pregnant women. We found that there is a significant decline in GFR when urine protein > 101.5 mg/d, which could be an early biomarker for renal pathology rather than pregnancy physiology, suggesting that further workup and precaution is required.
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Affiliation(s)
- Chatchai Kreepala
- Department of Internal Medicine, Faculty of Medicine, Srinakharinwirot University, Nakornnayok, Thailand
| | - Atitaya Srila-On
- Department of Internal Medicine, Faculty of Medicine, Srinakharinwirot University, Nakornnayok, Thailand
| | - Maethaphan Kitporntheranunt
- Department of Obstetrics and Gynecology, Faculty of Medicine, Srinakharinwirot University, Nakornnayok, Thailand
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Davis S, Dylewski J, Shah PB, Holmen J, You Z, Chonchol M, Kendrick J. Risk of adverse maternal and fetal outcomes during pregnancy in living kidney donors: A matched cohort study. Clin Transplant 2019; 33:e13453. [PMID: 30472740 PMCID: PMC6342653 DOI: 10.1111/ctr.13453] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 10/30/2018] [Accepted: 11/16/2018] [Indexed: 01/11/2023]
Abstract
BACKGROUND We examined the risk of adverse pregnancy outcomes in primiparous kidney donors compared to matched controls. METHODS Fifty-nine women with a history of kidney donation prior to their first pregnancy with normal renal function and no history of kidney disease, diabetes or chronic hypertension were matched 1:4 by age (within 2 years) and race to women with two kidneys using data from an integrated healthcare delivery system. Adverse pregnancy outcomes were defined as preterm delivery (delivery <37 weeks), delivery via cesarean section, gestational hypertension, preeclampsia/eclampsia, gestational diabetes, length of stay in the hospital >3 days, infant death/transfer to acute facility and low birthweight (<2500 g). RESULTS Living kidney donors did not have a higher risk of adverse outcomes compared to matched controls. There was a trend toward an increased risk of preeclampsia/eclampsia in kidney donors but it did not reach statistical significance (Odds ratio [OR]: 2.96, 95% CI: 0.98-8.94, P = 0.06). However, in kidney donors ≤30 years of age, there was a fourfold increased risk of preeclampsia/eclampsia (OR: 4.09, 95% CI: 1.07-15.59, P = 0.04). CONCLUSION Overall, the risk of pregnancy-associated complications following kidney donation is small but potential female kidney donors should be counseled on the possible increased risk of preeclampsia.
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Affiliation(s)
- Scott Davis
- Division of Renal Diseases and Hypertension, University of Colorado School of Medicine, Aurora, CO
| | - James Dylewski
- Division of Renal Diseases and Hypertension, University of Colorado School of Medicine, Aurora, CO
| | - Pratik B Shah
- Division of Renal Diseases and Hypertension, University of Colorado School of Medicine, Aurora, CO
| | - John Holmen
- Homer Warner Center, Intermountain Health Care, Salt Lake City, UT
| | - Zhiying You
- Division of Renal Diseases and Hypertension, University of Colorado School of Medicine, Aurora, CO
| | - Michel Chonchol
- Division of Renal Diseases and Hypertension, University of Colorado School of Medicine, Aurora, CO
| | - Jessica Kendrick
- Division of Renal Diseases and Hypertension, University of Colorado School of Medicine, Aurora, CO
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9
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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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10
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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] [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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11
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The role of renal response to amino acid infusion and oral protein load in normal kidneys and kidney with acute and chronic disease. Curr Opin Nephrol Hypertens 2018; 27:23-29. [DOI: 10.1097/mnh.0000000000000380] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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12
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Kendrick J, Holmen J, You Z, Smits G, Chonchol M. Association of Unilateral Renal Agenesis With Adverse Outcomes in Pregnancy: A Matched Cohort Study. Am J Kidney Dis 2017; 70:506-511. [PMID: 28396109 PMCID: PMC5610923 DOI: 10.1053/j.ajkd.2017.02.367] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 02/24/2017] [Indexed: 11/11/2022]
Abstract
BACKGROUND Data regarding the effect of a solitary kidney during pregnancy have come from studies of living kidney donors. We evaluated the risk for adverse pregnancy outcomes in women with a single kidney from renal agenesis. STUDY DESIGN Matched cohort study. SETTING & PARTICIPANTS Using data from 7,079 childbirths from an integrated health care delivery system from 1996 through 2015, we identified births from women with renal agenesis. Only first pregnancies and singleton births were included. After excluding those with diabetes and kidney disease, 200 women with renal agenesis were matched 1:4 by age (within 2 years), race, and history of hypertension to women with 2 kidneys. PREDICTOR Renal agenesis defined by International Classification of Diseases, Ninth Revision (ICD-9) codes prior to pregnancy. OUTCOMES The primary outcome was adverse maternal outcomes, including preterm delivery, delivery by cesarean section, preeclampsia/eclampsia, and hospital length of stay. Adverse neonatal end points were considered as a secondary outcome and included low birth weight (<2,500g) and infant death/transfer to acute inpatient facility. RESULTS Mean gestational age at delivery was 37.9±2.1 weeks for women with renal agenesis compared to 38.6±1.8 weeks for women with 2 kidneys. Compared with women with 2 kidneys, those with renal agenesis had increased risk for preterm delivery (OR, 2.88; 95% CI, 1.86-4.45), delivery by cesarean section (OR, 2.11; 95% CI, 1.49-2.99), preeclampsia/eclampsia (OR, 2.41; 95% CI, 1.23-4.72), and length of stay longer than 3 days (OR, 1.81; 95% CI, 1.18-2.78). Renal agenesis was not significantly associated with increased risk for infant death/transfer to acute facility (OR, 2.60; 95% CI, 0.57-11.89) or low birth weight after accounting for preterm delivery (OR, 2.11; 95% CI, 0.76-5.88). LIMITATIONS Renal agenesis was identified by ICD-9 code, not by imaging of the abdomen. CONCLUSION Women with unilateral renal agenesis have a higher risk for adverse outcomes in pregnancy.
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Affiliation(s)
- Jessica Kendrick
- Division of Renal Diseases and Hypertension, University of Colorado Denver, Aurora, CO; Denver Health Medical Center, Denver, CO.
| | - John Holmen
- Intermountain Healthcare, Salt Lake City, UT
| | - Zhiying You
- Division of Renal Diseases and Hypertension, University of Colorado Denver, Aurora, CO
| | - Gerard Smits
- Division of Renal Diseases and Hypertension, University of Colorado Denver, Aurora, CO
| | - Michel Chonchol
- Division of Renal Diseases and Hypertension, University of Colorado Denver, Aurora, CO
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13
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14
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Park S, Lee SM, Park JS, Hong JS, Chin HJ, Na KY, Kim DK, Oh KH, Joo KW, Kim YS, Lee H. Midterm eGFR and Adverse Pregnancy Outcomes: The Clinical Significance of Gestational Hyperfiltration. Clin J Am Soc Nephrol 2017; 12:1048-1056. [PMID: 28611078 PMCID: PMC5498359 DOI: 10.2215/cjn.12101116] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Accepted: 03/23/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND OBJECTIVES Although hemodynamic adaptation plays a crucial role in maintaining gestation, the clinical significance of midterm renal hyperfiltration (MRH) on pregnancy outcomes is unknown. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This was an observational cohort study. Women with a singleton pregnancy and a serum creatinine measurement during their second trimester were followed at two university hospitals in Korea between 2001 and 2015. Those with substantial renal function impairment or who delivered during the second trimester were not considered. MRH was represented by the highest eGFR, which was calculated using the Chronic Kidney Disease Epidemiology Collaboration method. An adverse pregnancy event was defined by the composition of preterm birth (gestational age <37 weeks), low birth weight (<2.5 kg), and preeclampsia. RESULTS Data from 1931 pregnancies were included. The relationship between midterm eGFR and adverse pregnancy outcomes, which occurred in 538 mothers, was defined by a nonlinear U-shaped curve. The adjusted odds ratio and associated 95% confidence interval (95% CI) of an adverse pregnancy outcome for eGFR levels below and above the reference level of 120-150 ml/min per 1.73 m2 were 1.97 (95% CI, 1.34 to 2.89; P<0.001) for ≥150 ml/min per 1.73 m2; 1.57 (95% CI, 1.23 to 2.00; P<0.001) for 90-120 ml/min per 1.73 m2; and 4.93 (95% CI, 1.97 to 12.31; P<0.001) for 60-90 ml/min per 1.73 m2. Moreover, among mothers without baseline CKD, women with adverse pregnancy outcomes had less prominent MRH than those without (P<0.001). CONCLUSIONS We identified a unique U-shaped relationship between midterm eGFR and adverse pregnancy outcomes, and the optimal range of midterm eGFR levels was 120-150 ml/min per 1.73 m2. In those without evident functional renal impairment, the absence of prominent MRH might be a significant risk factor for poor pregnancy outcomes.
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Affiliation(s)
- Sehoon Park
- Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, Korea
| | - Seung Mi Lee
- Department of Obstetrics and Gynecology, Seoul National College of Medicine, Seoul, Korea
| | - Joong Shin Park
- Department of Obstetrics and Gynecology, Seoul National College of Medicine, Seoul, Korea
| | | | - Ho Jun Chin
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Korea
- Kidney Research Institute, Seoul National University College of Medicine, Seoul, Korea College of Medicine, Seoul, Korea; and
| | - Ki Young Na
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Korea
- Kidney Research Institute, Seoul National University College of Medicine, Seoul, Korea College of Medicine, Seoul, Korea; and
| | - Dong Ki Kim
- Kidney Research Institute, Seoul National University College of Medicine, Seoul, Korea College of Medicine, Seoul, Korea; and
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Kook-Hwan Oh
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Kwon Wook Joo
- Kidney Research Institute, Seoul National University College of Medicine, Seoul, Korea College of Medicine, Seoul, Korea; and
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Yon Su Kim
- Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, Korea
- Kidney Research Institute, Seoul National University College of Medicine, Seoul, Korea College of Medicine, Seoul, Korea; and
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Hajeong Lee
- Kidney Research Institute, Seoul National University College of Medicine, Seoul, Korea College of Medicine, Seoul, Korea; and
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
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15
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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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16
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Anghebem‐Oliveira MI, Webber S, Alberton D, de Souza EM, Klassen G, Picheth G, Rego FGDM. The GCKR Gene Polymorphism rs780094 is a Risk Factor for Gestational Diabetes in a Brazilian Population. J Clin Lab Anal 2017; 31:e22035. [PMID: 27554451 PMCID: PMC6817084 DOI: 10.1002/jcla.22035] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 07/19/2016] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The glucokinase regulatory protein (GCKR) regulates the activity of the glucokinase (GCK), which plays a key role in glucose homeostasis. Genetic variants in GCK have been associated with diabetes and gestational diabetes (GDM). Due to the relationship between GCKRP and GCK, polymorphisms in GCKR are also candidates for genetic association with GDM. The aim of this study was to evaluate the association between the GCKR rs780094 polymorphism and GDM in a Brazilian population. METHODS 252 unrelated Euro-Brazilian pregnant women were classified as control (healthy pregnant women, n = 125) and GDM (pregnant women with GDM, n = 127) age-matched groups. Clinical and anthropometric data were obtained from all subjects. The GCKR rs780094 polymorphism was genotyped using fluorescent probes (TaqMan® , code C_2862873_10). RESULTS Both groups were in Hardy-Weinberg equilibrium. The GCKR rs780094 polymorphism was associated with GDM in codominant and dominant models (P = 0.022 and P = 0.010, respectively). The minor allele (T) frequency for the control group in the study was 38.4% (95% CI: 32-44%), similar to frequencies reported for other Caucasian populations. CONCLUSION Carriers of the C allele of rs780094 were 1.41 (odds ratio, 95% CI, 0.97-2.03) times more likely to develop GDM.
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Affiliation(s)
- Mauren Isfer Anghebem‐Oliveira
- Department of Clinical AnalysisFederal University of ParanaCuritibaBrazil
- Health and Biosciences SchoolPontifical Catholic University of ParanaCuritibaBrazil
| | - Susan Webber
- Department of Clinical AnalysisFederal University of ParanaCuritibaBrazil
| | - Dayane Alberton
- Department of Clinical AnalysisFederal University of ParanaCuritibaBrazil
| | | | - Giseli Klassen
- Department of Basic PathologyFederal University of ParanaCuritibaBrazil
| | - Geraldo Picheth
- Department of Clinical AnalysisFederal University of ParanaCuritibaBrazil
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17
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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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18
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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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19
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Berry C, Atta MG. Hypertensive disorders in pregnancy. World J Nephrol 2016; 5:418-28. [PMID: 27648405 PMCID: PMC5011248 DOI: 10.5527/wjn.v5.i5.418] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 05/31/2016] [Accepted: 06/27/2016] [Indexed: 02/06/2023] Open
Abstract
Renal injury or failure may occur in the context of pregnancy requiring special considerations with regard to fetal and maternal health. The condition of pregnancy itself may be a major factor in such injuries. In addition, for many young women previously known to be healthy, pregnancy may be the first presentation for routine urine and blood testing which may yield previously subclinical renal disease. As such, pregnancy may add complexity to considerations in the management of renal disease presenting coincidentally requiring knowledge of the physiologic changes and potential renal disorders that may be encountered during pregnancy.
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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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