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Plant-Based Diets Improve Maternal-Fetal Outcomes in CKD Pregnancies. Nutrients 2022; 14:nu14194203. [PMID: 36235855 PMCID: PMC9573150 DOI: 10.3390/nu14194203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 10/01/2022] [Accepted: 10/02/2022] [Indexed: 11/05/2022] Open
Abstract
Reducing protein intake in patients with chronic kidney disease (CKD) limits glomerular stress induced by hyperfiltration and can prevent the progression of kidney disease; data in pregnancy are limited. The aim of this study is to analyze the results obtained in CKD patients who followed a plant-based moderately protein-restricted diet during pregnancy in comparison with a propensity-score-matched cohort of CKD pregnancies on unrestricted diets. A total of 52 CKD pregnancies followed up with a protein-restricted plant-based diet (Torino, Italy) were matched with a propensity score based on kidney function and proteinuria with CKD pregnancies with unrestricted protein intake (Cagliari Italy). Outcomes included preterm (<37 weeks) and very preterm (<34 weeks) delivery and giving birth to a small-for-gestational-age baby. The median age in our cohort was 34 years, 63.46% of women were primiparous, and the median body mass index (BMI) was 23.15 kg/m2 with 13.46% of obese subjects. No statistical differences were found between women on a plant-based diet and women who were not in terms of age, parity, BMI, obesity, CKD stage, timing of referral, or cause of CKD. No differences were found between the two groups regarding the week of delivery. However, the combined negative outcome (birth before 37 completed gestational weeks or birth-weight centile <10) occurred less frequently in women following the diet than in women in the control group (61.54% versus 80.77%; p = 0.03). The lower risk was confirmed in a multivariable analysis adjusted for renal function and proteinuria (OR: 0.260 [Q1:0.093-Q3:0.724]; p = 0.010), in which the increase in proteinuria from the first to the last check-up before delivery was lower in patients on plant-based diets (median from 0.80 to 1.87 g/24 h; p: ns) than in controls (0.63 to 2.39 g/24 h p <0.0001). Plant-based, moderately protein-restricted diets in pregnancy in patients with CKD are associated with a lower risk of preterm delivery and small-for-gestational-age babies; the effect may be mediated by better stabilization of proteinuria.
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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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Molina-Pérez CJ, Nolasco-Leaños AG, Carrillo-Juárez RI, Leaños-Miranda A. Clinical usefulness of angiogenic factors in women with chronic kidney disease and suspected superimposed preeclampsia. J Nephrol 2022; 35:1699-1708. [PMID: 35353367 DOI: 10.1007/s40620-022-01299-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 01/11/2022] [Indexed: 12/21/2022]
Abstract
BACKGROUND Preeclampsia is a condition often superimposed to CKD. OBJECTIVE The purpose of this study was to evaluate the clinical characteristics and outcomes of pregnant women with chronic kidney disease (CKD) with suspected superimposed preeclampsia, stratified according to the degree of their angiogenic imbalance, as assessed by the soluble fms-like tyrosine kinase-1 (sFlt-1)/placental growth factor (PlGF) ratio. METHODS Using a cross-sectional design, we studied 171 pregnancies in patients with CKD and with suspected superimposed preeclampsia, admitted to a teaching hospital. Patients were divided into three groups based on their degree of angiogenic imbalance, evaluated by the sFlt-1/PlGF ratio: no angiogenic imbalance (sFlt-1/PlGF ratio≤ 38), mild angiogenic imbalance (sFlt-1/PlGF ratio> 38 to < 85), and severe angiogenic imbalance (sFlt-1/PlGF ratio≥ 85). Superimposed preeclampsia and preeclampsia-related adverse outcomes were defined according to The American College of Obstetricians and Gynecology criteria. Measurements of sFlt-1 and PlGF were performed on single serum samples using the Elecsys sFlt-1 and PlGF assays (Roche Diagnostics). Serum soluble endoglin (sEng) levels were also determined (ELISA R&D Systems, Minneapolis, MN). Glomerular filtration rate (GFR) was calculated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula, whenever possible on pre-prengancy data. RESULTS Patients with severe angiogenic imbalance had higher rates of confirmed superimposed preeclampsia and preeclampsia-related adverse maternal and perinatal outcomes (p < 0.001) when compared to patients with no or mild angiogenic imbalance. A significant trend towards higher serum sEng levels was observed as the degree of angiogenic imbalance increased. Interestingly, the rate of progression to superimposed preeclampsia increased progressively as the degree of angiogenic imbalance increased (no 11.8%, mild 60.0%, and severe 100%). CONCLUSION In women with CKD and suspected superimposed preeclampsia, severe angiogenic imbalance was associated with confirmed superimposed preeclampsia or progression to superimposed preeclampsia. Patients with no angiogenic imbalance displayed lower rates of progression to superimposed preeclampsia, whereas outcomes were intermediate, supporting a systematic use of sFlt-1/PlGF ratio, and other biomarkers in the clinical management of CKD pregnacies.
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Affiliation(s)
- Carlos José Molina-Pérez
- Medical Research Unit in Reproductive Medicine, Unidad de Investigación Médica en Medicina Reproductiva, UMAE-Hospital de Ginecología y Obstetricia "Dr. Luis Castelazo Ayala", Instituto Mexicano del Seguro Social (IMSS), Don Luis # 111, Col. Nativitas, D.F., 03500, Mexico, Mexico
| | - Ana Graciela Nolasco-Leaños
- Medical Research Unit in Reproductive Medicine, Unidad de Investigación Médica en Medicina Reproductiva, UMAE-Hospital de Ginecología y Obstetricia "Dr. Luis Castelazo Ayala", Instituto Mexicano del Seguro Social (IMSS), Don Luis # 111, Col. Nativitas, D.F., 03500, Mexico, Mexico.,Posgrado e Investigación Biomedicina y Biotecnología Molecular, Instituto Politécnico Nacional, Ciudad de México, Mexico
| | - Reyes Ismael Carrillo-Juárez
- Medical Research Unit in Reproductive Medicine, Unidad de Investigación Médica en Medicina Reproductiva, UMAE-Hospital de Ginecología y Obstetricia "Dr. Luis Castelazo Ayala", Instituto Mexicano del Seguro Social (IMSS), Don Luis # 111, Col. Nativitas, D.F., 03500, Mexico, Mexico
| | - Alfredo Leaños-Miranda
- Medical Research Unit in Reproductive Medicine, Unidad de Investigación Médica en Medicina Reproductiva, UMAE-Hospital de Ginecología y Obstetricia "Dr. Luis Castelazo Ayala", Instituto Mexicano del Seguro Social (IMSS), Don Luis # 111, Col. Nativitas, D.F., 03500, Mexico, Mexico.
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Verlohren S, Brennecke SP, Galindo A, Karumanchi SA, Mirkovic LB, Schlembach D, Stepan H, Vatish M, Zeisler H, Rana S. Clinical interpretation and implementation of the sFlt-1/PlGF ratio in the prediction, diagnosis and management of preeclampsia. Pregnancy Hypertens 2021; 27:42-50. [PMID: 34915395 DOI: 10.1016/j.preghy.2021.12.003] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 11/12/2021] [Accepted: 12/03/2021] [Indexed: 11/16/2022]
Abstract
Preeclampsia is associated with significant morbidity and mortality for mother and baby. Although around 30% of all pregnancies are evaluated for preeclampsia, diagnosis is difficult, especially in patients who have overlying symptoms from other diseases. Discovery of circulating angiogenic factors in the pathogenesis of preeclampsia has been a major advance for both diagnosis and prognosis. The anti-angiogenic factor, soluble fms-like tyrosine kinase 1 (sFlt-1) and the pro-angiogenic factor, placental growth factor (PlGF), can be measured in plasma and serum and are usually reported as a ratio, which specifically relates to the onset and severity of preeclampsia. The sFlt-1/PlGF ratio has a very high negative predictive value in ruling out the development of preeclampsia within 7 days among women with suspected preeclampsia. Currently, there is no clear consensus on the practical use of angiogenic biomarkers in the detection and management of preeclampsia in routine clinical practice. While major international clinical guidelines exist, they do not define which specific parameters signal patient admission, or outpatient evaluation of suspected preeclampsia, and most clinicians follow local practices. Better guidance is needed on risk stratification among women with suspected preeclampsia, as well as among women at high risk for preeclampsia. Prediction of adverse outcomes in women, after the clinical diagnosis of preeclampsia, is also important. This report has been developed following a meeting of international experts and aims to guide clinicians in the management of pregnant women at risk of preeclampsia using the sFlt-1/PlGF ratio test.
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Affiliation(s)
| | - Shaun P Brennecke
- University of Melbourne/Royal Women's Hospital, Melbourne, Australia
| | - Alberto Galindo
- Department of Obstetrics and Gynecology, University Hospital 12 de Octubre, Research Institute (imas12), Complutense University, Madrid, Spain
| | | | | | - Dietmar Schlembach
- Vivantes Network of Health GmbH, Clinicum Berlin-Neukoelln, Clinic of Obstetric Medicine, Berlin, Germany
| | | | - Manu Vatish
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, UK
| | | | - Sarosh Rana
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Chicago, Chicago, IL, USA.
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Kornacki J, Boroń D, Gutaj P, Mantaj U, Wirstlein P, Wender-Ozegowska E. Diagnosis of preeclampsia in women with diabetic kidney disease. Hypertens Pregnancy 2021; 40:322-329. [PMID: 34697978 DOI: 10.1080/10641955.2021.1987454] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Objective: assessing the incidence of preeclampisa (PE) in women with diabetic kidney disease (DKD) and analyzing the significance of clinical characteristics and changes in laboratory findings throughout the pregnancy on the onset of PE.Methods: the study included 79 patients with DKD. All patients had elevated urinary protein loss (30-299 mg/24 h) or proteinuria (≥300 mg/24 h) in the first trimester of pregnancy. PE was diagnosed in 22,8% patients with DKD.Results: women with proteinuria and/or proliferative retinopathy at the admission developed preeclampsia significantly more frequently than those without these findings. The degree of proteinuria was significantly associated with the risk of PE development in each trimester of pregnancy. Patients with chronic hypertension developed PE significantly more frequently than those who had no chronic hypertension.Conclusion: chronic hypertension and the degree of primary kidney injury and dysfunction are crucial determinants of PE development in women with DKD. Proteinuria seems to be the best renal predictive factors of PE.
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Affiliation(s)
- Jakub Kornacki
- Department of Reproduction, Chair of Obstetrics, Gynecology, and Gynecologic Oncology, Poznan University of Medical Sciences, Poznan, Poland
| | - Daniel Boroń
- Department of Reproduction, Chair of Obstetrics, Gynecology, and Gynecologic Oncology, Poznan University of Medical Sciences, Poznan, Poland
| | - Paweł Gutaj
- Department of Reproduction, Chair of Obstetrics, Gynecology, and Gynecologic Oncology, Poznan University of Medical Sciences, Poznan, Poland
| | - Urszula Mantaj
- Department of Reproduction, Chair of Obstetrics, Gynecology, and Gynecologic Oncology, Poznan University of Medical Sciences, Poznan, Poland
| | - Przemysław Wirstlein
- Department of Reproduction, Chair of Obstetrics, Gynecology, and Gynecologic Oncology, Poznan University of Medical Sciences, Poznan, Poland
| | - Ewa Wender-Ozegowska
- Department of Reproduction, Chair of Obstetrics, Gynecology, and Gynecologic Oncology, Poznan University of Medical Sciences, Poznan, Poland
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Hong X, Rosenberg AZ, Zhang B, Binns-Roemer E, David V, Lv Y, Hjorten RC, Reidy KJ, Chen TK, Wang G, Ji Y, Simpson CL, Davis RL, Kopp JB, Wang X, Winkler CA. Joint Associations of Maternal-Fetal APOL1 Genotypes and Maternal Country of Origin With Preeclampsia Risk. Am J Kidney Dis 2020; 77:879-888.e1. [PMID: 33359152 DOI: 10.1053/j.ajkd.2020.10.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 10/24/2020] [Indexed: 12/25/2022]
Abstract
RATIONALE & OBJECTIVES Preeclampsia, which disproportionately affects Black women, is a leading cause of preterm delivery and risk for future hypertension and chronic kidney disease (CKD). Apolipoprotein L1 (APOL1) kidney risk alleles, common among Black individuals, contribute substantially to CKD disparities. Given the strong link between preeclampsia and CKD, we investigated whether maternal and fetal APOL1 risk alleles can jointly influence preeclampsia risk, and explored potential modifiers of the association between APOL1 and preeclampsia. STUDY DESIGN Nested case-control study. SETTING & PARTICIPANTS 426 Black mother-infant pairs (275 African Americans and 151 Haitians) from the Boston Birth Cohort. EXPOSURE Maternal and fetal APOL1 risk alleles. OUTCOMES Preeclampsia. ANALYTICAL APPROACH Logistic regression models with adjustment for demographic characteristics were applied to analyze associations between fetal and maternal APOL1 risk alleles and risk of preeclampsia and to investigate the effects of modification by maternal country of origin. RESULTS Fetal APOL1 risk alleles tended to be associated with an increased risk of preeclampsia, which was not statistically significant in the total genotyped population. However, this association was modified by maternal country of origin (P<0.05 for interaction tests): fetal APOL1 risk alleles were significantly associated with an increased risk of preeclampsia among African Americans under recessive (odds ratio [OR], 3.6 [95% CI, 1.3-9.7]; P=0.01) and additive (OR, 1.7 [95% CI, 1.1-2.6]; P=0.01) genetic models but not in Haitian Americans. Also, maternal-fetal genotype discordance at the APOL1 locus was associated with a 2.6-fold higher risk of preeclampsia (P<0.001) in African Americans. LIMITATIONS Limited sample size in stratified analyses; self-reported maternal country of origin; pre-pregnancy estimated glomerular filtration rate (eGFR) and proteinuria data in mothers were not collected; unmeasured confounding social and/or environmental factors; no replication study. CONCLUSIONS This study supports the hypothesis that fetal APOL1 kidney risk alleles are associated with increased risk for preeclampsia in a recessive mode of inheritance in African Americans and suggests that maternal-fetal genotype discordance is also associated with this risk. These conclusions underscore the need to better understand maternal-fetal interaction and their genetic and environmental factors as contributors to ethnic disparities in preeclampsia.
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Affiliation(s)
- Xiumei Hong
- Department of Population, Family and Reproductive Health, Center for the Early Life Origins of Disease, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Avi Z Rosenberg
- Department of Pathology, Johns Hopkins University, Baltimore, MD
| | - Boyang Zhang
- Department of Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Elizabeth Binns-Roemer
- Molecular Genetic Epidemiology Section, Frederick National Laboratory for Cancer Research in the Basic Research Laboratory, National Cancer Institute, Frederick, MD
| | - Victor David
- Basic Research Laboratory, Center for Cancer Research, National Cancer Institute, Frederick, MD
| | - Yiming Lv
- Department of Population, Family and Reproductive Health, Center for the Early Life Origins of Disease, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Rebecca C Hjorten
- Department of Medicine, Division of Nephrology, University of Washington, Seattle, WA
| | - Kimberly J Reidy
- Department of Pediatrics, Division of Pediatric Nephrology, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY
| | - Teresa K Chen
- Department of Medicine, Division of Nephrology and Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Guoying Wang
- Department of Population, Family and Reproductive Health, Center for the Early Life Origins of Disease, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Yuelong Ji
- Department of Population, Family and Reproductive Health, Center for the Early Life Origins of Disease, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Claire L Simpson
- Department of Genetics, Genomics, and Informatics, University of Tennessee Health Science Center, Memphis, TN
| | - Robert L Davis
- Center for Biomedical Informatics, Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN
| | - Jeffrey B Kopp
- Kidney Diseases Section, National Institute of Diabetes and Digestive and Kidney Disease, National Institutes of Health, Bethesda, MD
| | - Xiaobin Wang
- Department of Population, Family and Reproductive Health, Center for the Early Life Origins of Disease, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD; Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Cheryl A Winkler
- Molecular Genetic Epidemiology Section, Frederick National Laboratory for Cancer Research in the Basic Research Laboratory, National Cancer Institute, Frederick, MD.
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Abstract
PURPOSE OF REVIEW Preeclampsia and chronic kidney disease have a complex, bidirectional relationship. Women with kidney disease, with even mild reductions in glomerular filtrate rate, have an increased risk of developing preeclampsia. Preeclampsia, in turn, has been implicated in the subsequent development of albuminuria, chronic kidney disease, and end-stage kidney disease. We will discuss observational evidence and mechanisms linking the two disease processes. RECENT FINDINGS Preeclampsia is characterized by an imbalance in angiogenic factors that causes systemic endothelial dysfunction. Chronic kidney disease may predispose to the development of preeclampsia due to comorbid conditions, such as hypertension, but is also associated with impaired glycocalyx integrity and alterations in the complement and renin-angiotensin-aldosterone systems. Preeclampsia may lead to kidney disease by causing acute kidney injury, endothelial damage, and podocyte loss. Preeclampsia may be an important sex-specific risk factor for chronic kidney disease. Understanding how chronic kidney disease increases the risk of preeclampsia from a mechanistic standpoint may open the door to future biomarkers and therapeutics for all women.
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Moresi S, Martino C, Salvi S, Del Sordo G, Fruci S, Garofalo S, Lanzone A, De Carolis S, Ferrazzani S. Perinatal outcome in gestational hypertension: Which role for developing preeclampsia. A population-based cohort study. Eur J Obstet Gynecol Reprod Biol 2020; 251:218-222. [PMID: 32559606 DOI: 10.1016/j.ejogrb.2020.05.064] [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: 02/15/2020] [Revised: 05/27/2020] [Accepted: 05/29/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To analyze perinatal outcome in singleton pregnancies complicated by gestational hypertension (GH), to investigate the rate of women developing preeclampsia (PE) and to describe maternal features associated with progression to PE. STUDY DESIGN This is a population-based retrospective cohort-study involving 514 singleton pregnancies with a diagnosis of GH at admission. RESULTS In pregnancies with GH, a poorer pregnancy outcome in comparison to healthy controls was observed in terms of gestational age at delivery, birthweight and birthweight percentile. The observed overall rate of developing PE was 11.7 %. Of all pregnancies with GH at admission, two different groups were identified based on the diagnosis at delivery: GHPE, i.e. women who developed PE (60/514; 11.7 %), and GHnoPE, i.e. women who did not develop PE (454/514; 88.3 %). In the GHPE group it was observed that the 62 % of the women with diagnosis of GH earlier than 28 weeks developed PE while only 2% developed PE if the diagnosis of GH was performed later than 36 weeks. The observed rate of developing PE was 14.7 % in pharmacologically treated hypertensive women, whereas the diagnosis of PE has been made in only 3% of non-treated women. CONCLUSION Pregnant women with raised blood pressure are at risk of having a less favourable perinatal outcome. The risk is mainly associated with the progression to PE. Major determinants of the risk of developing PE are the earlier gestational age at diagnosis of GH, the necessity of treatment and the number of anti-hypertensive drugs needed for controlling blood pressure.
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Affiliation(s)
- Sascia Moresi
- UOC di Patologia Ostetrica, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168, Roma, Italy.
| | - Carmelinda Martino
- UOC di Patologia Ostetrica, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168, Roma, Italy.
| | - Silvia Salvi
- UOC di Patologia Ostetrica, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168, Roma, Italy.
| | - Gelsomina Del Sordo
- UOC di Patologia Ostetrica, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168, Roma, Italy.
| | - Stefano Fruci
- Istituto di Clinica Ostetrica e Ginecologica, Università Cattolica del Sacro Cuore, L.go Francesco Vito 1, Roma, Italy.
| | - Serafina Garofalo
- UOC di Patologia Ostetrica, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168, Roma, Italy.
| | - Antonio Lanzone
- UOC di Patologia Ostetrica, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168, Roma, Italy; Istituto di Clinica Ostetrica e Ginecologica, Università Cattolica del Sacro Cuore, L.go Francesco Vito 1, Roma, Italy.
| | - Sara De Carolis
- UOC di Patologia Ostetrica, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168, Roma, Italy; Istituto di Clinica Ostetrica e Ginecologica, Università Cattolica del Sacro Cuore, L.go Francesco Vito 1, Roma, Italy.
| | - Sergio Ferrazzani
- UOC di Patologia Ostetrica, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo A. Gemelli 8, 00168, Roma, Italy; Istituto di Clinica Ostetrica e Ginecologica, Università Cattolica del Sacro Cuore, L.go Francesco Vito 1, Roma, Italy.
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Clinical Predictors of Preeclampsia in Pregnant Women with Chronic Kidney Disease. ACTA ACUST UNITED AC 2020; 56:medicina56050213. [PMID: 32349458 PMCID: PMC7279325 DOI: 10.3390/medicina56050213] [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: 03/11/2020] [Revised: 04/22/2020] [Accepted: 04/24/2020] [Indexed: 12/05/2022]
Abstract
Background and Objectives: Pregnant women with chronic kidney disease (CKD) are at high risk of adverse maternal and fetal outcomes. Preeclampsia (PE) superimposed on CKD is estimated to occur in 21%–79% of pregnancies. Both conditions share common features such as proteinuria and hypertension, making differential diagnosis difficult. Objective: The aim of this study was to evaluate the incidence and the clinical-biological predictors of preeclampsia in pregnant women with CKD. Material and Methods: We retrospectively analyzed 34 pregnant women with pre-existing CKD admitted to our department between 2008 and 2017. Results: Among the 34 patients, 19 (55.8%) developed PE and the mean time of occurrence was 31.26 ± 2.68 weeks of gestation. The median value of 24-h proteinuria at referral was 0.87 g/day (interquartile range 0.42–1.50) and 47.1% of patients had proteinuria of ≥1 g/day. Patients with PE tended to be more hypertensive, with a more decreased renal function at referral and had significantly higher proteinuria (1.30 vs. 0.63 g/day, p = 0.02). Cox multivariate analysis revealed that proteinuria ≥1 g/day at referral and pre-existing hypertension were independently associated with PE (adjusted hazard ratio = 4.10, 95% confidence interval: 1.52–11.02, p = 0.005, adjusted hazard ratio = 2.62, 95% confidence interval: 1.01–6.77, p = 0.04, respectively). The cumulative risk of PE was significantly higher in pregnant women with proteinuria ≥1 g/day at referral (log-rank, p = 0.003). Proteinuria ≥ 1 g/day at referral and pre-exiting hypertension predicted PE development with accuracies of 73.5% and 64.7%, respectively. Conclusions: Pregnant patients with pre-existing CKD are at high risk of developing preeclampsia, while proteinuria ≥ 1 g/day at referral and pre-existing hypertension were independent predictors of superimposed preeclampsia.
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Wiles K, Chappell LC, Lightstone L, Bramham K. Updates in Diagnosis and Management of Preeclampsia in Women with CKD. Clin J Am Soc Nephrol 2020; 15:1371-1380. [PMID: 32241779 PMCID: PMC7480554 DOI: 10.2215/cjn.15121219] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
It is estimated that women with CKD are ten times more likely to develop preeclampsia than women without CKD, with preeclampsia affecting up to 40% of pregnancies in women with CKD. However, the shared phenotype of hypertension, proteinuria, and impaired excretory kidney function complicates the diagnosis of superimposed preeclampsia in women with CKD who have hypertension and/or proteinuria that predates pregnancy. This article outlines the diagnoses of preeclampsia and superimposed preeclampsia. It discusses the pathogenesis of preeclampsia, including abnormal placentation and angiogenic dysfunction. The clinical use of angiogenic markers as diagnostic adjuncts for women with suspected preeclampsia is described, and the limited data on the use of these markers in women with CKD are presented. The role of kidney biopsy in pregnancy is examined. The management of preeclampsia is outlined, including important advances and controversies in aspirin prophylaxis, BP treatment targets, and the timing of delivery.
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Affiliation(s)
- Kate Wiles
- Division of Women and Children's Health, King's College London, London, United Kingdom.,Department of Renal Medicine, Royal London Hospital, Barts Health National Health Service Trust, London, United Kingdom
| | - Lucy C Chappell
- Division of Women and Children's Health, King's College London, London, United Kingdom.,Department of Obstetrics and Gynaecology, Guy's and St. Thomas' National Health Service Foundation Trust, London, United Kingdom
| | - Liz Lightstone
- Centre for Inflammatory Disease, Faculty of Medicine, Imperial College London, London, United Kingdom; and
| | - Kate Bramham
- Division of Women and Children's Health, King's College London, London, United Kingdom; .,Department of Renal Medicine, King's Kidney Care Centre, King's College Hospital National Health Service Foundation Trust, London, United Kingdom
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11
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Huhn EA, Hoffmann I, Martinez De Tejada B, Lange S, Sage KM, Roberts CT, Gravett MG, Nagalla SR, Lapaire O. Maternal serum glycosylated fibronectin as a short-term predictor of preeclampsia: a prospective cohort study. BMC Pregnancy Childbirth 2020; 20:128. [PMID: 32093623 PMCID: PMC7041257 DOI: 10.1186/s12884-020-2809-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 02/12/2020] [Indexed: 02/04/2023] Open
Abstract
Background Preeclampsia is a major pregnancy complication that results in significant maternal and infant mortality, most of which occurs in low and middle-income countries. The accurate and timely diagnosis of preeclampsia is critical in management of affected pregnancies to reduce maternal and fetal/neonatal morbidity and mortality, yet difficulties remain in establishing the rigorous diagnosis of preeclampsia based on clinical parameters alone. Biomarkers that detect biochemical disease have been proposed as complements or alternatives to clinical criteria to improve diagnostic accuracy. This cohort study assessed the performance of several biomarkers, including glycosylated fibronectin (GlyFn), to rule-in or rule-out preeclampsia within 4 weeks in a cohort of women at increased risk for preeclampsia. Methods 151 women with risk factors for or clinical signs and symptoms of preeclampsia were selected from a prospective cohort. Maternal serum samples were collected between 20 and 37 weeks of gestation. Clinical suspicion of preeclampsia was defined as presence of new-onset proteinuria, or clinical symptoms of preeclampsia. Subjects with a clinical diagnosis of preeclampsia at the time of enrollment were excluded. GlyFn, pregnancy-associated plasma protein-A2 (PAPPA2), placental growth factor (PlGF), and soluble fms-like tyrosine kinase-1 (sFlt-1) were measured by immunoassay. GlyFn was also determined using a rapid point-of care (POC) test format. Receiver-operating characteristic (ROC) curves derived from logistic regression analysis were used to determine the classification performance for each analyte. Results 32 of 151 (21%) women developed a clinical diagnosis of preeclampsia within 4 weeks. All biomarkers exhibited good classification performance [GlyFn (area under the curve (AUROC) = 0.94, 91% sensitivity, 86% specificity); PAPPA2 AUC = 0.92, 87% sensitivity, 77% specificity; PlGF AUC = 0.90, 81% sensitivity, 83% specificity; sFlt-1 AUC = 0.92, 84% sensitivity, 91% specificity. The GlyFn immunoassay and the rapid POC test showed a correlation of r = 0.966. Conclusions In this prospective cohort, serum biomarkers of biochemical disease were effective in short-term prediction of preeclampsia, and the performance of GlyFn in particular as a POC test may meet the needs of rapid and accurate triage and intervention.
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Affiliation(s)
- Evelyn A Huhn
- Department of Obstetrics and Gynaecology, University Hospital Basel, Basel, Switzerland.
| | - Ina Hoffmann
- Department of Obstetrics and Gynaecology, University Hospital Basel, Basel, Switzerland
| | - Begoña Martinez De Tejada
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Soeren Lange
- Department of Obstetrics and Gynecology, Institutions Hospital du Nord Vaudois, Yverdon-les-Bains, Switzerland
| | - Kylie M Sage
- DiabetOmics, Inc, Hillsboro, OR, 97006, USA.,Biostatistics and Design Program, School of Public Health, Oregon Health & Science University, Portland, OR, 97239, USA
| | | | - Michael G Gravett
- Department of Obstetrics and Gynecology, University of Washington Medical Center, Seattle, WA, 98195, USA
| | | | - Olav Lapaire
- Department of Obstetrics and Gynaecology, University Hospital Basel, Basel, Switzerland
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12
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Stepan H, Hund M, Andraczek T. Combining Biomarkers to Predict Pregnancy Complications and Redefine Preeclampsia: The Angiogenic-Placental Syndrome. Hypertension 2020; 75:918-926. [PMID: 32063058 PMCID: PMC7098437 DOI: 10.1161/hypertensionaha.119.13763] [Citation(s) in RCA: 105] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Placental dysfunction underlies a spectrum of perinatal pathologies, including preeclampsia and fetal growth restriction. Angiogenesis-related factors, including sFlt-1 (soluble fms-like tyrosine kinase 1) and PlGF (placental growth factor), play an important role in placental dysfunction; altered levels are detectable several weeks before onset of pregnancy complications. In vitro diagnostic tests for these biomarkers can improve early diagnosis and facilitate prediction of maternal and fetal outcomes. We assessed evidence for combining angiogenic biomarkers with other biomarkers or clinical parameters to predict maternal/fetal outcomes in pregnant women with placental dysfunction. Pooled information on placental perfusion (ultrasonography, mean arterial pressure), clinical characteristics, and biomarker levels (PlGF) can improve first-trimester prediction and preeclampsia diagnosis. Angiogenic factors (sFlt-1/PlGF ratio; PlGF alone) with or without clinical characteristics can facilitate second-/third-trimester prediction of early-onset and late-onset preeclampsia. A combination of increased sFlt-1/PlGF ratio and ultrasound can rule out early fetal growth restriction. The sFlt-1/PlGF ratio is also a reliable tool for discriminating between pregnancy-related hypertensive disorders, including superimposed preeclampsia and gestational hypertension. Analysis of angiogenic factors with or without uterine Doppler substantially improves sensitivity and specificity for predicting adverse outcomes and iatrogenic preterm delivery. We propose to extend the American College of Obstetricians and Gynecologists definition of preeclampsia in the future to include the combination of new-onset hypertension and new-onset of altered angiogenic factors (sFlt-1/PlGF ratio or PlGF alone). In summary, altered angiogenic biomarkers indicate placental dysfunction, and their implementation into clinical practice will help reduce the considerable burden of morbidity and mortality associated with adverse pregnancy outcomes as a consequence of angiogenic-placental syndrome.
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Affiliation(s)
- Holger Stepan
- From the Department of Obstetrics, Leipzig University, Leipzig, Germany (H.S., T.A.)
| | - Martin Hund
- Roche Diagnostics International, Ltd, Rotkreuz, Switzerland (M.H.)
| | - Theresa Andraczek
- From the Department of Obstetrics, Leipzig University, Leipzig, Germany (H.S., T.A.)
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13
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Massimiani M, Lacko LA, Burke Swanson CS, Salvi S, Argueta LB, Moresi S, Ferrazzani S, Gelber SE, Baergen RN, Toschi N, Campagnolo L, Stuhlmann H. Increased circulating levels of Epidermal Growth Factor-like Domain 7 in pregnant women affected by preeclampsia. Transl Res 2019; 207:19-29. [PMID: 30620888 PMCID: PMC6486846 DOI: 10.1016/j.trsl.2018.12.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 11/30/2018] [Accepted: 12/19/2018] [Indexed: 11/23/2022]
Abstract
Proper placental development is crucial to establish a successful pregnancy. Defective placentation is the major cause of several pregnancy complications, including preeclampsia (PE). We have previously demonstrated that the secreted factor Epidermal Growth Factor-like Domain 7 (EGFL7) is expressed in trophoblast cells of the human placenta and that it regulates trophoblast migration and invasion, suggesting a role in placental development. In the present study, we demonstrate that circulating levels of EGFL7 are undetectable in nonpregnant women, increase during pregnancy and decline toward term. Close to term, circulating levels of EGFL7 are significantly higher in patients affected by PE when compared to normal pregnancies. Consistent with these results, villus explant cultures obtained from placentas affected by PE display increased release of EGFL7 in the culture medium when compared to those from normal placentas. Our results suggest that increased release of placenta-derived EGFL7 and increased circulating levels of EGFL7 are associated with the clinical manifestation of PE.
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Affiliation(s)
- Micol Massimiani
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Lauretta A Lacko
- Department of Cell and Developmental Biology, Weill Cornell Medical College, New York, New York
| | - Clare S Burke Swanson
- Department of Cell and Developmental Biology, Weill Cornell Medical College, New York, New York
| | - Silvia Salvi
- Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Lissenya B Argueta
- Department of Cell and Developmental Biology, Weill Cornell Medical College, New York, New York
| | - Sascia Moresi
- Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Sergio Ferrazzani
- Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Shari E Gelber
- Department of ObGyn, Weill Cornell Medical College, New York, New York
| | - Rebecca N Baergen
- Department of Pathology and Laboratory Medicine, Weill Cornell Medical College, New York, New York
| | - Nicola Toschi
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy; Department of Radiology, "Athinoula A. Martinos" Center for Biomedical Imaging, and Harvard Medical School, Boston, Massachusetts
| | - Luisa Campagnolo
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy.
| | - Heidi Stuhlmann
- Department of Cell and Developmental Biology, Weill Cornell Medical College, New York, New York.
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14
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[Potential value of placental angiogenic factors as biomarkers in preeclampsia for clinical physicians]. Nephrol Ther 2019; 15:413-429. [PMID: 30935786 DOI: 10.1016/j.nephro.2018.10.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 10/10/2018] [Accepted: 10/14/2018] [Indexed: 12/20/2022]
Abstract
The role of angiogenic factors in the onset of clinical manifestations of preeclampsia was demonstrated in 2003 by the implication of sFlt-1, PlGF and VEGF, and in 2006 by the implication of soluble endoglin. Placental ischemia and inflammation observed in preeclampsia alter both the production and progression of angiogenic factors during pregnancy. During the first trimester, the combination of PlGF with clinical, biophysical and biological factors results in a better test than the conventional one. However, the clinical value of this method remains to be confirmed. During the second and third trimesters, the sFlt-1/PlGF ratio may be used, with or without pre-existing renal disease, for short-term prediction, diagnosis, and prognosis, and to evaluate the effectiveness of preeclampsia treatment. While a sFlt-1/PlGF ratio<38 and≤33, respectively, rules out the short-term onset and diagnosis of preeclampsia, a sFlt-1/PlGF ratio≥85 between 20 and 34 weeks of pregnancy and≥110 beyond 34 weeks of pregnancy confirms a diagnosis of preeclampsia. Angiogenic and non-angiogenic preeclampsia are identified by a sFlt-1PlGF≥85 and<85, respectively, with the risk of maternal and fetal complications at two weeks differing between the two. Similarly, a sFlt-1/PlGF ratio>665 and>205, respectively, is a good short-term predictor of adverse outcomes of early and late-onset preeclampsia. These values could be incorporated into future guidelines for better clinical management of preeclampsia.
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15
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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: 14] [Impact Index Per Article: 2.8] [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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16
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Piccoli GB, Zakharova E, Attini R, Ibarra Hernandez M, Covella B, Alrukhaimi M, Liu ZH, Ashuntantang G, Orozco Guillen A, Cabiddu G, Li PKT, Garcia-Garcia G, Levin A. Acute Kidney Injury in Pregnancy: The Need for Higher Awareness. A Pragmatic Review Focused on What Could Be Improved in the Prevention and Care of Pregnancy-Related AKI, in the Year Dedicated to Women and Kidney Diseases. J Clin Med 2018; 7:jcm7100318. [PMID: 30275392 PMCID: PMC6210235 DOI: 10.3390/jcm7100318] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 09/18/2018] [Accepted: 09/19/2018] [Indexed: 12/14/2022] Open
Abstract
Pregnancy-related acute kidney injury (pAKI), preeclampsia (PE), and the hypertensive disorders of pregnancy are closely related conditions, which are, in turn, frequently linked to pre-existing and often non-diagnosed chronic kidney disease (CKD). The current literature and research mainly underline the effects of pregnancy complications on the offspring; this review strongly emphasizes the maternal health as well. These conditions not only negatively affect pregnancy outcomes, but have a relevant effect on the future health of affected mothers and their children. Therefore, dedicated diagnostic and follow-up programs are needed, for optimizing materno-foetal health and reducing the impact of pregnancy-related problems in the mothers and in the new generations. This narrative review, performed on the occasion of the 2018 World Kidney Day dedicated to women’s health, focuses on three aspects of the problem. Firstly, the risk of AKI in the hypertensive disorders of pregnancy (the risk is the highest in developing countries; however PE is the main cause of pregnancy related AKI worldwide). Secondly, the effect of AKI and the hypertensive disorders of pregnancy on the development of CKD in the mother and offspring: long-term risks are increased; the entity and the trajectories are still unknown. Thirdly, the role of CKD in the pathogenesis of AKI and the hypertensive disorders of pregnancy: CKD is a major risk factor and the most important element in the differential diagnosis; pregnancy is a precious occasion for early diagnosis of CKD. Higher awareness on the importance of AKI in pregnancy is needed to improve short and long term outcomes in mothers and children.
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Affiliation(s)
- Giorgina Barbara 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, 44100 Guadalajara Jal, Mexico.
| | - Bianca Covella
- Néphrologie, Centre Hospitalier Le Mans, 72000 Le Mans, France.
| | - 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.
| | | | | | - Philip Kam Tao Li
- Prince of Wales Hospital, Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong.
| | - Gulliermo Garcia-Garcia
- Nephrology Service, Hospital Civil de Guadalajara "Fray Antonio Alcalde", University of Guadalajara Health Sciences Center, 44100 Guadalajara Jal, Mexico.
| | - Adeera Levin
- Department of Medicine, Division of Nephrology, University of British Columbia, Vancouver, BC V6T 1Z4, Canada.
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17
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A Systematic Review on Materno-Foetal Outcomes in Pregnant Women with IgA Nephropathy: A Case of "Late-Maternal" Preeclampsia? J Clin Med 2018; 7:jcm7080212. [PMID: 30103519 PMCID: PMC6111833 DOI: 10.3390/jcm7080212] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Revised: 08/09/2018] [Accepted: 08/10/2018] [Indexed: 02/07/2023] Open
Abstract
Background: IgA nephropathy is the most common primary glomerulonephritis in pregnancy and shares with other immunologic diseases and kidney diseases a relationship with adverse maternal outcomes, whose entity and pattern is only partially quantified. Recent studies provide new information and a systematic review regarded progression of kidney disease. The discussion of the outcomes with respect to low-risk pregnancies may help to perfect the estimation of the risks, and to identify specific research needs. Methods: A search strategy was built on Medline, EMBASE and the Cochrane review for the period January 2000–April 2017, aimed at retrieving both case series (defined as with at least 6 pregnancies in women with IgA nephropathy) and case reports, to look into rare occurrences. All papers, with or without control groups, were selected if they reported on at least one pregnancy outcome, or on long-term kidney function. Search strategy, paper selection and data extraction were done in duplicate (PROSPERO N 42016042623). Meta-analysis of case series was performed with Metanalyst Beta 3.13. Case reports were analysed narratively. Results: The search retrieved 556 papers, of which 27 were included (13 series and 14 case-reports). The case series report on 581 women with 729 pregnancies. The analysis was performed in comparison to the available control groups: 562 non-pregnant controls were available for the analysis of progression of kidney disease. As for pregnancy related outcomes (preeclampsia (PE), pregnancy induced hypertension (PIH), preterm birth, small babies), we meta-analyzed the data with respect to the only series of low-risk pregnancies (1418 pregnancies). When compared with women who never got pregnant after diagnosis of IgA nephropathy, in the present meta-analysis pregnancy in women with IgA nephropathy was not associated with a higher risk of progression of kidney disease, possibly due to the overall preserved kidney function at baseline: end-stage kidney disease (OR 0.68; CI 0.28–1.65). Conversely, the incidence of adverse pregnancy-related outcomes was increased compared to low-risk controls: PE and PIH were more than ten-fold increased (OR 11.80; CI 7.53–18.48 and OR 10.39; CI 5.45–19.80), while the increase in risk of preterm birth and “low birth weight babies” was less marked (OR 3.37; CI 1.91–5.95 and OR 2.36; CI 1.52–3.66), a discrepancy suggesting the occurrence of “late” or “maternal” PE, that may affect less severely foetal growth or shorten gestation. In conclusion, in the present meta-analysis IgA nephropathy was not associated with an increased progression of kidney disease. The more than ten-fold increased risk of PIH and PE, in combination with a doubled risk of small babies, suggests the occurrence of “late” or “maternal” PE, usually less affecting early foetal growth. This finding may be of help in defining control policies, while further research is needed to guide clinical management.
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18
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Abstract
Preeclampsia continues to afflict 5% to 8% of all pregnancies throughout the world and is associated with significant morbidity and mortality to the mother and the fetus. Although the pathogenesis of the disorder has not yet been fully elucidated, current evidence suggests that imbalance in angiogenic factors is responsible for the clinical manifestations of the disorder, and may explain why certain populations are risk. In this review, we begin by demonstrating the roles that angiogenic factors play in pathogenesis of preeclampsia and its complications in the mother and the fetus. We then continue to report on the use of angiogenic markers as biomarkers to predict and risk-stratify disease. Strategies to treat preeclampsia by correcting the angiogenic balance, either by promoting proangiogenic factors or by removing antiangiogenic factors in both animal and human studies, are discussed. We end the review by summarizing status of the current preventive strategies and the long-term cardiovascular outcomes of women afflicted with preeclampsia.
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Affiliation(s)
- Belinda Jim
- Division of Nephrology, Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY.
| | - S Ananth Karumanchi
- Departments of Medicine, Obstetrics, and Gynecology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
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19
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Nava J, Moran S, Figueroa V, Salinas A, Lopez M, Urbina R, Gutierrez A, Lujan JL, Orozco A, Montufar R, Piccoli GB. Successful pregnancy in a CKD patient on a low-protein, supplemented diet: an opportunity to reflect on CKD and pregnancy in Mexico, an emerging country. J Nephrol 2017; 30:877-882. [PMID: 28918595 DOI: 10.1007/s40620-017-0428-4] [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: 05/02/2017] [Accepted: 08/03/2017] [Indexed: 12/13/2022]
Abstract
Pregnancy is probably the most important challenge in young women with chronic kidney disease (CKD). The challenge is greater in developing countries, in which access to dialysis is uneven, and prenatal care for CKD patients is not uniformly available. This case report summarizes some of the challenges faced by pregnant CKD women in a developing country. A 35-year-old woman, affected by an undiagnosed kidney disease, experienced preeclampsia at 24 years of age, and started dialysis in emergency at age 31 in the context of severe preeclampsia in her second pregnancy. Following slow recovery of kidney function, after 18 months of dialysis she started a moderately restricted, supplemented, low-protein diet, which allowed her to discontinue dialysis. A few months after dialysis discontinuation, she started a new pregnancy in the presence of severely reduced kidney function (serum creatinine 4.6 mg/dl at the last pre-pregnancy control). Interestingly, she discontinued nephrology and nutritional follow-up, mainly because she was worried that she would be discouraged from continuing the pregnancy, but also because she continued to feel well. She self-managed her diet in pregnancy and delivered a healthy baby, with normal intrauterine growth, at term; while the last laboratory data confirmed the presence of severe kidney function impairment, she is still dialysis-free at the time of the present report. Her story, with its happy ending, underlines the importance of dedicated programs for CKD pregnancies in developing countries and confirms the safety of moderately protein-restricted diets in pregnancy.
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Affiliation(s)
- Julia Nava
- Centro de Atencion Nutricional Fresenius Kabi, Dante 36, 3er Piso, Colonia Anzures, Delegacion Miguel Hidalgo, Ciudad de Mexico, Mexico
| | - Silvia Moran
- Centro de Atencion Nutricional Fresenius Kabi, Dante 36, 3er Piso, Colonia Anzures, Delegacion Miguel Hidalgo, Ciudad de Mexico, Mexico
| | - Veronica Figueroa
- Centro de Atencion Nutricional Fresenius Kabi, Dante 36, 3er Piso, Colonia Anzures, Delegacion Miguel Hidalgo, Ciudad de Mexico, Mexico
| | - Adriana Salinas
- Centro de Atencion Nutricional Fresenius Kabi, Dante 36, 3er Piso, Colonia Anzures, Delegacion Miguel Hidalgo, Ciudad de Mexico, Mexico
| | - Margy Lopez
- Centro de Atencion Nutricional Fresenius Kabi, Dante 36, 3er Piso, Colonia Anzures, Delegacion Miguel Hidalgo, Ciudad de Mexico, Mexico
| | - Rocio Urbina
- Centro de Atencion Nutricional Fresenius Kabi, Dante 36, 3er Piso, Colonia Anzures, Delegacion Miguel Hidalgo, Ciudad de Mexico, Mexico
| | - Abril Gutierrez
- Centro de Atencion Nutricional Fresenius Kabi, Dante 36, 3er Piso, Colonia Anzures, Delegacion Miguel Hidalgo, Ciudad de Mexico, Mexico
| | - Jose Luis Lujan
- Centro de Atencion Nutricional Fresenius Kabi, Dante 36, 3er Piso, Colonia Anzures, Delegacion Miguel Hidalgo, Ciudad de Mexico, Mexico
| | - Alejandra Orozco
- Instituto Nacional de Perinatología Isidro Espinosa de los Reyes (INPER), Calle Montes Urales 800, Ciudad de Mexico, Mexico
| | - Rafael Montufar
- Centro de Atencion Nutricional Fresenius Kabi, Dante 36, 3er Piso, Colonia Anzures, Delegacion Miguel Hidalgo, Ciudad de Mexico, Mexico.
| | - Giorgina B Piccoli
- Dipartimento di Scienze Cliniche e Biologiche, Università di Torino, Turin, Italy.
- Nephrologie, Centre Hospitalier Le Mans, Avenue Roubillard, 72000, Le Mans, France.
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20
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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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21
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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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22
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Phipps E, Prasanna D, Brima W, Jim B. Preeclampsia: Updates in Pathogenesis, Definitions, and Guidelines. Clin J Am Soc Nephrol 2016; 11:1102-1113. [PMID: 27094609 PMCID: PMC4891761 DOI: 10.2215/cjn.12081115] [Citation(s) in RCA: 340] [Impact Index Per Article: 42.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Preeclampsia is becoming an increasingly common diagnosis in the developed world and remains a high cause of maternal and fetal morbidity and mortality in the developing world. Delay in childbearing in the developed world feeds into the risk factors associated with preeclampsia, which include older maternal age, obesity, and/or vascular diseases. Inadequate prenatal care partially explains the persistent high prevalence in the developing world. In this review, we begin by presenting the most recent concepts in the pathogenesis of preeclampsia. Upstream triggers of the well described angiogenic pathways, such as the heme oxygenase and hydrogen sulfide pathways, as well as the roles of autoantibodies, misfolded proteins, nitric oxide, and oxidative stress will be described. We also detail updated definitions, classification schema, and treatment targets of hypertensive disorders of pregnancy put forth by obstetric and hypertensive societies throughout the world. The shift has been made to view preeclampsia as a systemic disease with widespread endothelial damage and the potential to affect future cardiovascular diseases rather than a self-limited occurrence. At the very least, we now know that preeclampsia does not end with delivery of the placenta. We conclude by summarizing the latest strategies for prevention and treatment of preeclampsia. A better understanding of this entity will help in the care of at-risk women before delivery and for decades after.
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Affiliation(s)
- Elizabeth Phipps
- Department of Nephrology/Medicine, Jacobi Medical Center at Albert Einstein College of Medicine, Bronx, New York; and
| | - Devika Prasanna
- Department of Nephrology/Medicine, Jacobi Medical Center at Albert Einstein College of Medicine, Bronx, New York; and
| | - Wunnie Brima
- Department of Medicine, James J. Peters Veterans Affairs Medical Center, New York, New York
| | - Belinda Jim
- Department of Nephrology/Medicine, Jacobi Medical Center at Albert Einstein College of Medicine, Bronx, New York; and
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23
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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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Diagnostic and predictive biomarkers for pre-eclampsia in patients with established hypertension and chronic kidney disease. Kidney Int 2016; 89:874-85. [PMID: 26924064 DOI: 10.1016/j.kint.2015.10.012] [Citation(s) in RCA: 99] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 10/01/2015] [Accepted: 10/15/2015] [Indexed: 01/28/2023]
Abstract
Women with chronic kidney disease (CKD) and chronic hypertension (CHT) frequently develop superimposed pre-eclampsia, but distinction from pre-existing disease is challenging. Plasma placental growth factor (PlGF), B-type natriuretic peptide (BNP), neutrophil gelatinase-associated lipocalin (NGAL), and serum relaxin concentrations were quantified in a longitudinal prospective cohort of 121 women with CKD: 44 with chronic hypertension, and 79 healthy controls. Biomarker concentrations were compared with 32 women with pre-eclampsia without pre-existing disease. Test performance was evaluated for diagnosis of superimposed pre-eclampsia requiring delivery within 14 days of sampling. PlGF was evaluated as a promising marker in a validation cohort of women with suspected pre-eclampsia (29 with CKD; 94 with chronic hypertension; 29 with superimposed pre-eclampsia requiring delivery within 14 days) and compared with women without pre-existing disease (290 with no pre-eclampsia and 176 with pre-eclampsia requiring delivery within 14 days). From 20 and up to 42 weeks of gestation, lower maternal PlGF concentrations had high diagnostic accuracy for superimposed pre-eclampsia requiring delivery within 14 days (receiver operator characteristic 0.85) and confirmed in the validation cohort. The other plasma and serum biomarkers were not discriminatory. Thus, plasma PlGF concentrations could potentially help guide clinical decision making regarding admission and delivery for superimposed pre-eclampsia.
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Nartita T, Ichihara A, Matsuoka K, Takai Y, Bokuda K, Morimoto S, Itoh H, Seki H. Placental (pro)renin receptor expression and plasma soluble (pro)renin receptor levels in preeclampsia. Placenta 2016; 37:72-8. [DOI: 10.1016/j.placenta.2015.11.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Revised: 10/21/2015] [Accepted: 11/18/2015] [Indexed: 10/22/2022]
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Zhang JJ, Ma XX, Hao L, Liu LJ, Lv JC, Zhang H. A Systematic Review and Meta-Analysis of Outcomes of Pregnancy in CKD and CKD Outcomes in Pregnancy. Clin J Am Soc Nephrol 2015; 10:1964-78. [PMID: 26487769 DOI: 10.2215/cjn.09250914] [Citation(s) in RCA: 171] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 08/10/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES We undertook a systematic review and meta-analysis of published cohort studies and case-control studies to estimate (1) the risk of pregnancy complications among patients with CKD versus those without CKD and (2) the risk of CKD progression among pregnant patients versus nonpregnant controls with CKD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We searched electronic databases for studies published between 1946 and 2014, and we reviewed articles using validity criteria. Random-effects analytical methods were used. RESULTS Twenty-three studies (14 with data for adverse pregnancy outcomes and 9 for renal outcomes) with 506,340 pregnancies were included. Pregnancy with CKD had greater odds of preeclampsia (odds ratio [OR], 10.36; 95% confidence interval [95% CI], 6.28 to 17.09), premature delivery (OR, 5.72; 95% CI, 3.26 to 10.03), small for gestational age/low birth weight (OR, 4.85; 95% CI, 3.03 to 7.76), cesarean section (OR, 2.67; 95% CI, 2.01 to 3.54), and failure of pregnancy (OR, 1.80; 95% CI, 1.03 to 3.13). Subgroup analysis showed that odds of preeclampsia (P<0.01) and premature delivery (P<0.01) were higher in women with nondiabetic nephropathy compared with diabetic nephropathy, and the odds of preeclampsia (P=0.01) and premature delivery (P<0.01) were higher in women with macroproteinuria compared with microproteinuria. The median for follow-up time for renal events was 5 years (interquartile range, 5-14.7 years). There were no significant differences in the occurrence of renal events between CKD pregnant women and those without pregnancy (OR, 0.96; 95% CI, 0.69 to 1.35). Subgroup analysis showed that publication year, sample size, follow-up years, type of primary disease, CKD classification, level of serum creatinine at baseline, proteinuria, and level of systolic BP did not modify the renal outcomes. CONCLUSIONS The risks of adverse maternal and fetal outcomes in pregnancy are higher for women with CKD versus pregnant women without CKD. However, pregnancy was not a risk factor for progression of renal disease in women with CKD before pregnancy.
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Affiliation(s)
- Jing-Jing Zhang
- Renal Division, Peking University First Hospital, Institute of Nephrology, Peking University, Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China; and Department of Nephrology, Second Hospital of Anhui Medical University, Hefei, China
| | - Xin-Xin Ma
- Renal Division, Peking University First Hospital, Institute of Nephrology, Peking University, Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China; and
| | - Li Hao
- Department of Nephrology, Second Hospital of Anhui Medical University, Hefei, China
| | - Li-Jun Liu
- Renal Division, Peking University First Hospital, Institute of Nephrology, Peking University, Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China; and
| | - Ji-Cheng Lv
- Renal Division, Peking University First Hospital, Institute of Nephrology, Peking University, Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China; and
| | - Hong Zhang
- Renal Division, Peking University First Hospital, Institute of Nephrology, Peking University, Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China; and
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27
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Piccoli GB, Cabiddu G, Attini R, Vigotti FN, Maxia S, Lepori N, Tuveri M, Massidda M, Marchi C, Mura S, Coscia A, Biolcati M, Gaglioti P, Nichelatti M, Pibiri L, Chessa G, Pani A, Todros T. Risk of Adverse Pregnancy Outcomes in Women with CKD. J Am Soc Nephrol 2015; 26:2011-22. [PMID: 25766536 DOI: 10.1681/asn.2014050459] [Citation(s) in RCA: 206] [Impact Index Per Article: 22.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2014] [Accepted: 10/19/2014] [Indexed: 01/09/2023] Open
Abstract
CKD is increasingly prevalent in pregnancy. In the Torino-Cagliari Observational Study (TOCOS), we assessed whether the risk for adverse pregnancy outcomes is associated with CKD by comparing pregnancy outcomes of 504 pregnancies in women with CKD to outcomes of 836 low-risk pregnancies in women without CKD. The presence of hypertension, proteinuria (>1 g/d), systemic disease, and CKD stage (at referral) were assessed at baseline. The following outcomes were studied: cesarean section, preterm delivery, and early preterm delivery; small for gestational age (SGA); need for neonatal intensive care unit (NICU); new onset of hypertension; new onset/doubling of proteinuria; CKD stage shift; "general" combined outcome (preterm delivery, NICU, SGA); and "severe" combined outcome (early preterm delivery, NICU, SGA). The risk for adverse outcomes increased across stages (for stage 1 versus stages 4-5: "general" combined outcome, 34.1% versus 90.0%; "severe" combined outcome, 21.4% versus 80.0%; P<0.001). In women with stage 1 CKD, preterm delivery was associated with baseline hypertension (odds ratio [OR], 3.42; 95% confidence interval [95% CI], 1.87 to 6.21), systemic disease (OR, 3.13; 95% CI, 1.51 to 6.50), and proteinuria (OR, 3.69; 95% CI, 1.63 to 8.36). However, stage 1 CKD remained associated with adverse pregnancy outcomes (general combined outcome) in women without baseline hypertension, proteinuria, or systemic disease (OR, 1.88; 95% CI, 1.27 to 2.79). The risk of intrauterine death did not differ between patients and controls. Findings from this prospective study suggest a "baseline risk" for adverse pregnancy-related outcomes linked to CKD.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Alessandra Coscia
- Neonatology, Department of Surgical Sciences, University of Torino, Torino, Italy
| | | | | | - Michele Nichelatti
- Biostatistics Service, Department of Hematology, Niguarda Ca' Granda Hospital, Milan, Italy
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Erman Akar M, Ozekinci M, Sanhal C, Kececioglu N, Mendilcioglu I, Senol Y, Dirican K, Kocak H, Dinckan A, Suleymanlar G. A Retrospective Analysis of Pregnancy Outcomes after Kidney Transplantation in a Single Center. Gynecol Obstet Invest 2014; 79:13-8. [DOI: 10.1159/000365815] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Accepted: 07/09/2014] [Indexed: 11/19/2022]
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Chaiworapongsa T, Chaemsaithong P, Korzeniewski SJ, Yeo L, Romero R. Pre-eclampsia part 2: prediction, prevention and management. Nat Rev Nephrol 2014; 10:531-40. [PMID: 25003612 PMCID: PMC5898797 DOI: 10.1038/nrneph.2014.103] [Citation(s) in RCA: 98] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
An antiangiogenic state might constitute a terminal pathway for the multiple aetiologies of pre-eclampsia, especially those resulting from placental abnormalities. The levels of angiogenic and antiangiogenic proteins in maternal blood change prior to a diagnosis of pre-eclampsia, correlate with disease severity and have prognostic value in identifying women who will develop maternal and/or perinatal complications. Potential interventions exist to ameliorate the imbalance of angiogenesis and, hence, might provide opportunities to improve maternal and/or perinatal outcomes in pre-eclampsia. Current strategies for managing pre-eclampsia consist of controlling hypertension, preventing seizures and timely delivery of the fetus. Prediction of pre-eclampsia in the first trimester is of great interest, as early administration of aspirin might reduce the risk of pre-eclampsia, albeit modestly. Combinations of biomarkers typically predict pre-eclampsia better than single biomarkers; however, the encouraging initial results of biomarker studies require external validation in other populations before they can be used to facilitate intervention in patients identified as at increased risk. Angiogenic and antiangiogenic factors might also be useful in triage of symptomatic patients with suspected pre-eclampsia, differentiating pre-eclampsia from exacerbations of pre-existing medical conditions and performing risk assessment in asymptomatic women. This Review article discusses the performance of predictive and prognostic biomarkers for pre-eclampsia, current strategies for preventing and managing the condition and its long-term consequences.
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Affiliation(s)
- Tinnakorn Chaiworapongsa
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, 31 Center Drive, Bethesda, MD 20892, USA and 3990 John R Street, Detroit, MI 48201, USA
| | - Piya Chaemsaithong
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, 31 Center Drive, Bethesda, MD 20892, USA and 3990 John R Street, Detroit, MI 48201, USA
| | - Steven J Korzeniewski
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, 31 Center Drive, Bethesda, MD 20892, USA and 3990 John R Street, Detroit, MI 48201, USA
| | - Lami Yeo
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, 31 Center Drive, Bethesda, MD 20892, USA and 3990 John R Street, Detroit, MI 48201, USA
| | - Roberto Romero
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, 31 Center Drive, Bethesda, MD 20892, USA and 3990 John R Street, Detroit, MI 48201, USA
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30
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Lurie S, Weiner E, Golan A, Sadan O. Total and Differential Leukocyte Count Percentiles in Healthy Singleton Term Women during the First Stage of Labor. Gynecol Obstet Invest 2014; 78:251-4. [DOI: 10.1159/000365084] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Accepted: 06/04/2014] [Indexed: 11/19/2022]
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31
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Liu L, Zhang M, Li L, Li C, Min X, Zheng M. Expression and clinical significance of ATP-binding cassette transporter 1 in serum and placental tissue in Chinese patients with preeclampsia. Gynecol Obstet Invest 2014; 78:194-200. [PMID: 25139615 DOI: 10.1159/000362551] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Accepted: 03/24/2014] [Indexed: 11/19/2022]
Abstract
AIM To investigate the expression and clinical significance of ATP-binding cassette transporter 1 (ABCA1) in pregnant women with preeclampsia (PE). METHODS 52 pregnant women with PE who were admitted for delivery were enrolled in the study, while 30 normal pregnant inpatients were chosen as controls. Blood lipid and serum ABCA1 concentrations were assayed by enzymatic analysis and ELISA, respectively, and the expression of the ABCA1 gene and its encoded protein were detected and quantified by RT-PCR and Western blotting. RESULTS In the study group, blood lipid levels were significantly higher than those in the control group (p < 0.01), while the ABCA1 gene and its encoded protein expression in both serum and placental tissue were lower than that of controls. These differences were highly correlated with disease severity (p < 0.05). In PE patients, serum ABCA1 concentration was positively correlated with ABCA1 protein expression in placental tissue (r = 0.384, p < 0.01) and high-density lipoprotein level (r = 0.318, p < 0.05), but negatively correlated with low-density lipoprotein level (r = -0.279, p < 0.05). CONCLUSION In PE women, expression of ABCA1 was decreased, suggesting that ABCA1 may play an important role in onset of PE by altering blood lipid metabolism.
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Affiliation(s)
- Lixing Liu
- Department of Anatomy, Fujian Medical University, Fuzhou, China
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32
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Polsani S, Phipps E, Jim B. Emerging new biomarkers of preeclampsia. Adv Chronic Kidney Dis 2013; 20:271-9. [PMID: 23928393 DOI: 10.1053/j.ackd.2013.01.001] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2012] [Accepted: 01/02/2013] [Indexed: 01/23/2023]
Abstract
Preeclampsia continues to plague some of the most vulnerable women and fetuses. It is surprisingly prevalent in developing and developed nations. According to the World Health Organization, hypertension during pregnancy is a leading cause of maternal mortality in industrialized countries at 16% and up to 25% in developing countries. As the pathogenesis of this disease is being unraveled, we are afforded new opportunities to develop novel biomarkers for early identification and prevention of disease. The angiogenic markers including soluble fms-like tyrosine kinase 1, placental growth factor, and soluble endoglin have demonstrated to be the most promising, perhaps in conjunction with traditional markers such as plasma protein-13 and uterine artery Doppler studies. There is also increasing evidence that the podocyte is shed during the course of preeclampsia, which may be useful for diagnosis. Systems biology approaches to biomarker discovery such as proteomics and metabolomics are also gaining more attention and will most certainly open new avenues of research. In this review, we present the best studied biomarkers of preeclampsia to date.
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Vellanki K. Pregnancy in chronic kidney disease. Adv Chronic Kidney Dis 2013; 20:223-8. [PMID: 23928386 DOI: 10.1053/j.ackd.2013.02.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Revised: 02/07/2013] [Accepted: 02/07/2013] [Indexed: 11/11/2022]
Abstract
Despite vast improvements in fetal outcomes, pregnancy in women with CKD is fraught with hazards; worsening of renal function and complications like preeclampsia and premature delivery are common. To date, there is no accurate formula to calculate glomerular filtration rate (GFR). Also, whether the current CKD classification is better than the older classification at predicting outcomes in pregnant women with CKD is unknown. Women with an estimated GFR ≥1.4 mg/dL are at increased risk of progressive worsening of renal function regardless of the cause of the underlying kidney disease. Preeclampsia is difficult to diagnose in pregnant women with underlying CKD, and serum markers such as soluble fms-like tyrosine kinase 1 (sFlt1) and placental growth factor (PIGF) may lead the way for definitive diagnosis. New-onset lupus or lupus flare is an indication for kidney biopsy during pregnancy; cyclosporine is safe and is the most effective agent that can be used during pregnancy. Women with adult polycystic kidney disease are at increased risk of hypertension and preeclampsia during pregnancy, as well as hepatic cysts later in life, the latter occurring with multiple pregnancies. Strict blood pressure control is important in pregnant women with diabetic nephropathy. A multidisciplinary team that includes nephrologists and obstetricians who deal with high-risk pregnancies should be involved in the care of pregnant women with CKD for successful pregnancy outcomes.
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Jia RZ, Qian YJ, Zhang X, Ding HJ, Wu HQ, Shao KM. Contribution of Dysfunction of Maternal Hemodynamics to Renal Impairment in Preeclampsia. Gynecol Obstet Invest 2013; 76:95-9. [DOI: 10.1159/000353275] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2013] [Accepted: 05/27/2013] [Indexed: 11/19/2022]
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35
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Nordström A, Birkhed D. Fluoride Retention in Proximal Plaque and Saliva Using Two NaF Dentifrices Containing 5,000 and 1,450 ppm F with and without Water Rinsing. Caries Res 2009; 43:64-9. [DOI: 10.1159/000201592] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2007] [Accepted: 12/22/2008] [Indexed: 11/19/2022] Open
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